Odysseys of George

This 50 plus year old gentleman was admitted to the ward for having this painfull swelling over his nape which he has been having for the last 5 days. The swelling was getting bigger and more painful and started discharging some yellowish fluid just the day prior to admission. He is a diabetic and his sugar control was poor.

So, any takers, any guesses?

From : A Lethal Rare Event

This is a rare event. It is usually due to sudden reduction of blood flow to the intestine. The reason for it could either be from a blood clot that has shifted away(emboli) and impacted an artery that carries blood to the intestine or a blood clot forming at the site of the artery(thrombosis).An emboli’s source are usually from the heart or a abnormal dilatation of the aorta, e.g. irregular pulses (arryhtmias), a disease involving the valves of the heart, a dilated and failing heart, or an aneurysm. A thrombus however usually occurs when there is stasis of the blood flow, some blood disorders which causes the blood to clot or a damage to the internal lining of the vessel.This damage is usually due to changes which we call artherosclerotic changes which is secondary to diabetes mellitus, hypertension or high cholesterol levels(hyperlipidaemia), smoking and aging. Mesenteric artery stenosis is found in 17.5% of independent elderly adults.

So, upon seeing this, I recalled the history. His complaints and of his wife fits correctly. He had all the risk factors. The problem is that it has been a few days now and he is very ill and also very septic. The figures were running in my mind. Because of the delay in diagnosis, mortality rate is of 45-65%. When more than half the bowel is removed, mortality rates of up to 80% have been reported The studies have shown that mortality rates are highest for patients with arterial thrombosis (70-87%), followed by nonocclusive mesenteric ischemia (70-80%), arterial embolism (66-71%), and venous thrombosis (44%).

I rechecked his bowels again making sure that it is no more viable and assessed the length involved - which was approximately half the length of his small bowel.

Now came the next dilemma — to call it the quits and close the abdomen or remove the dead intestine? To close, he will surely die. To resect, well he will have that 20% chance but it will take a little longer. This would increase his risk of developing other complications, the commonest with a background of diabetes and hypertension ( artherosclerosis), would be a heart attack (myocardial infarction, MI) and the other is renal failure. Other possible complications include bleeding, infection,further bowel infarction and prolonged ileus.

So with a decision made, I informed my anaesthetist and proceeded to resect the involved segment. As he was ill, the bowel perfusion is in question and time is of the essence, so I brought out the ends as a stoma rather than to sew (anastomose) the ends together.

He was placed in ICU after surgery. However, he did not look any better. The ileus set in and his kidneys started to shut down. Sadly on the night, three days after surgery he developed the most feared about complication - heart attack - and expired.

Over the past 20 years, diagnosis and treatment of mesenteric ischemia has advanced only minimally. In a review of 57 cases, only 18% of patients were properly diagnosed with mesenteric ischemia before operation or death. Of the 57 patients in this review, 46 died.

From: A news that made me sad……

I just came back from Teluk Intan Hospital. En.Jaafar was admitted there from the second day of Raya. He look wasted, cachetic and his eyes were tainted yellow of we call jaundice. He had a tube which was inserted through the nose to drain the contents of his stomach as he was vomiting persistently. He had fluids running into his veins. I was impressed to see the MO still there talking to him at 3pm on a weekend.

He was extremely happy and comforted to see me. I was happy he recognised me - there he was losing weight and I am gaining. I was dissappointed he did not consult me earlier. He had pancreatic cancer which had infiltrated the duodenum causing obstructon and there is also evidence of liver involvement. He is presently obstructed at the least the duodenum and bile duct. Usually, this would also mean obstruction to the pancreatic duct. I will see how I can help him despite being advanced in nature.

For those who are unsure what I am talking about, let me explain a little.

Definition

Uncontrolled growth of abnormal cells that tends to form a mass and destroys the normal cells and invade neighouring structures or move(spread) to other areas of the body.

Signs and Symptoms

Often then not, it is absent - no symptoms or subtle. Thus I termed it the silent killer. By the time there is symptoms, it is usually late. The common symptoms are abdominal pain, nausea, loss of appetite, unexplained weight loss, and jaundice. These are symptoms that could also be a presentation of other cancers.

Test

There are no spesific laboratory tests available for the early detection or diagnosis of pancreatic cancer.

The common laboratory tests that can be done but non spesific are:

1. CA 19-9 (Cancer Antigen 19-9): a tumor marker for pancreatic cancer; it may be used to monitor for cancer recurrence but is not useful for detection or diagnosis.

2. Other metabolic test - Liver function, kidney function, glucose levels, and the rarer test for pancreatic function - fecal fat, stool trypsin, trypsinogen, amylase, and lipase

Radiological investigations like

Surgical methods are laparoscopic staging - looking for invasion and spread and assess for possibility of surgery.

Prevention

But there are many who do get pancreatic cancer have none of these risk factors.

Treatment & Outcome

Once diagnosed and staged (that is to assess how far the cancer has evolved), then there are 2 options - resectable or non-resectable.

Resectable would mean that the surgeon will be able to remove the growth. Unfortunately resection (removal) is possible less than 15% of the time. How much surgery is done depends on where the tumor is, its size, how far it has spread, and the patient’s health.

Radiation and chemotherapy also may be used and are often necessary as tiny, undetectable amounts of the tumor have often spread by the time surgery is done. Unfortunately, pancreatic cancer does not respond well to current treatments.

Non-resectable means the only option is for palliative(comfort-oriented) care. Surgery — to relieve an obstructed system by way of bypass or endoscopic stenting, Chemotherapy and radiation for pain relief.

For patients with advanced cancers, the overall survival rate of all stages is <1% at 5 years with most patients dying within 1 year

Next: My dying driver

Reminds me of the “Kegemilangan Kesultanan Melaka” where when the Sultan speaks it is made. So, the Sultan of Selangor, the prince of people, spoke clear and loud. “Resign and bewarned not just Dato Z but all Datos’, that the title can be revoked.” Thus Dato Z of MPK has 10 days left but if it was me I would have resigned even before this.

Then, now the people are protesting asking for the “Istana” to be torn down. So what is a RM24K fine for somebody who can afford a RM6million “Istana”? Is it fair that the MPK goes around demolishing illegal extensions of the most other rakyat and spare this arrogant disrespectful indisciplined power crazy Dato’s “mahligai”? This is people power and why do you think they are powerful now? Why does the rakyat look more intelligent, more alert of the going ons? How did this start? Thanks to the paper even the journalism is better - they have more power and freedom and the people can voice their unhappiness better! This is the evolving Malaysia thanks to our present PM, Pak Lah.

This brings me to the 22 years of fist rule of our previous PM. Don’t get me wrong, I was a fan and he was my idol! What more he was from my prestigious school since primary, secondary and university! But 2 to 3 years before he stepped down he appears to become more incoherent and senile! It was also during that last 2-3 years that he made many last minute deals which were questionable - among which the “crooked” scenic bridge! Now his accusations are contradictory - how can he be prevented from complaining when that is exactly what he has been doing - complaining since he stepped down! And why is that? Simple, the present leadership is aimed to give the rakyat the power and responsibility! Thus the transparency! This is ultimately important if Malaysia is going to survive the globalisation. Is it so difficult to see that the present leadership is having the biggest burden to correct the fumble and discrepancy of the previous leadership. During those years nobody could speak or write anything about the leadership and no freedom of the press! Everybody was either put on a gag order, ISA or be numb and stupid! This over 22 years has created a community which accepted and swallowed everything good, bad and ugly and a group of crony businessmen bailed out consistently everytime they bankrupt. And it is this group of people, the cronies of the previous leadership that is now complaining.

Like what a friend told me recently; ” Now is better than before (the last 5-10years,I suppose), but we must unite and have voice so that we can continue to improve and at the same time be realistic about the goals. Don’t expect to see an overnight change but rather expect to see a more balanced, more empowered and more united Malaysian over a period of time.” I concur.
So what is the rakyat waiting for — now is the time to be part of history not as politicians but as interested and patriotic rakyat to fight for Malaysia, a better Malaysia in every way for every Malaysian.

Got semangat already or not? Care to comment?

As I was diving thru the internet, I thought I will share my findings with you.

Top 10 Dive Sites in the World:

1. Yongala, Australia
2. Thistlegorm, Egyptian Red Sea
3. Blue Corner Wall, Palau, Micronesia
4. Barracuda Point, Sipadan Island
5. Shark and Yolanda Reef, Egyptian Red Sea
6. Navy Pier, Australia
7. Manta Ray Night Dive, Kailua Kona, Hawaii
8. Big Brother, Egyptian Red Sea
9. Liberty, Bali, Indonesia
10. Elphinstone Reef, Egyptian Red Sea

There are another 3 dive sites in Sipadan which have emerged as top 100 - Hanging Garden, South Point and Turtle Tavern. ( 52,69 & 76). Pulau Layang-Layang, The Point, was ranked 44.

The Eygyptian Red Sea appears to be the best site with many of its dive sites emerging above top 50.



Egypt’s Red Sea coast runs from the Gulf of Suez to the Sudanese border. Its mineral-rich red mountain ranges inspired the mariners of antiquity to name the sea Mare Rostrum, or the Red Sea.

Anybody been there?

A 49 year old Indian gentleman presented to my practise with a 5 day complaint of progressively increasing abdominal pain which started around the umblicus and on the day of admission the pain was present all over the abdomen. This was associated with nausea and vomiting. He also noted his abdomen progressively increasing in size and was not able to pass motion. He was having spiking temperature and was very dehydrated. He had diabetes and hypertension and was also a heavy smoker. There has been previous episodes of central abdominal pain which lasted mostly for 2 to 3 days and colicky in nature. However, the wife noted that his abdominal pain increased in frequency recently and worsened after meals. He was resuscitated and an emergency laparotomy was performed. These was what I saw:

Mind to make a guess?

Answer

PS: For those who read “Burnt” , the 17 year old boy passed away yesterday!