Resection of leaking aneurysms of abdominal aorta (10.5 cms. in diameter) and right common iliac artery and replacement with a synthetic bilateral aortofemoral bypass graft was undertaken as an urgent procedure under general anesthesia at Indus Hospital. His hospital course was excellent with the exception of anterolateral myocardial ischemia in the immediate post-operative period which responded to medical therapy. Patient survived to live more than three years after which he died of some abdominal malignancy according to his family.

A 68 years old house wife was admitted to Indus Hospital on April 17, 2000 with 30 days history of generalized swelling of the entire body with progressive shortness of breath , restriction of activity, insomnia , nausea and decreasing urinary output despite treatment by a medical specialist at Pathankot who diagnosed her as a case of hypothyroidism. She had history of coronary artery disease with old myocardial infarction in 1985 and cholecystectomy for calculus disease in 1997.

Poisoning from consumption of Argemone Mexicana contaminated mustard oil was suspected. She had history of coronary artery disease with old myocardial infarction in 1985 and cholecystectomy for calculus disease in 1997. There was no history of congestive heart failure , liver , kidney or thyroid disease in the past .

Physical examination on admission revealed normal vital signs , orthopnea and generalized anasarca with clothes soaking wet due to water oozing from the entire body without sweating. Heart sounds were muffled and breath sounds were reduced at the lung bases , bilaterally. Jugular venous pressure was raised. Massive ascites and third degree uterine prolapse were noted.

LAB. DATA :
Pertinent investigations revealed cardiomegaly with massive bilateral pleural effusions , marked pericardial effusion and ascites. Kidneys and liver parenchymas were hyperechoic . EKG showed low voltage and sinus tachycardia. Hgb. 7.5 g/dL, Hct. 23% , WBC 15,400/cu. mm. , Polymorphs. 78% , Platelets 1,20,000/ cu. mm., Sed rate 22/ hr. , Total Proteins 7.6 g/dL, Albumin 5.2 g/dL, Fasting Blood Sugar 95 mg/dL. Liver , Kidney, Cardiac and Coagulation Profiles as well as Serum Electrolytes and Urinalysis were normal. Stools were positive for occult blood. Thyroid function tests showed normal TSH , near normal T₃ ( 2.29 pg/mL ) and reduced Free T₄ levels (0.66 ng/dL ). Anti 38 kDa, Mycobacterium and Anti Nuclear Antibody were negative. Peritoneal and Pleural fluid analysis showed transudative characteristics with negative cytology, bacterial smears and cultures . Polymorphs 70%, Lymphocytes 30%. Pericardial Fluid : Proteins 3.1 g/dL , Cholesterol 50 mg/dL , Polymorphs 13%, Lymphocytes 87% , Gram Stain and Routine Culture Negative , AFB Smear Negative .

PROVISIONAL DIAGNOSES : 1. Epidemic Dropsy, Rule Out Tubercular Pericarditis 2. Subclinical Hypothyroidism 3. Coronary Artery Disease with Old Myocardial Infarction 4. Status Post-operative Cholecystectomy

HOSPITAL COURSE :
Patient was started on oxygen by face mask and a lifeline with D5W. She was continuously monitored in the Critical Care Unit. Soon after admission, there was no urine output for 2 hours after which dopamine infusion was started for hypotension (BP 80/60). She was hypovolemic despite being water logged. Patient responded to dopamine infusion which was gradually tapered off over the next five days. Human albumin, parenteral amino acids , furosemide and mannitol were carefully administered. Patient was digitalized and started on thyroxin (0.1 mg./day) and anti-tubercular regimen with prednisone @ 0.75 mg./Kg body weight. Supportive therapy was continued. 300 C.Cs of clear yellowish fluid was removed with pericardiocentesis and several liters of straw colored fluid was removed from the peritoneal and pleural cavities by repeated paracentesis and thoracentesis to help the patient breathe better . Pleural effusions were seen to re-accumulate quite fast, requiring insertion of bilateral chest tubes in stages for continuous drainage and chemical pleurodysis. Packed RBCs were transfused twice in order to improve the oxygen carrying capacity. Intensive diuresis was continued with spironolactone and furosemide administered twice a day along with supportive and symptomatic treatment. Steroids were changed to alternate day therapy. Patient was discharged home on the 38th Hospital day for out-patient follow-up with residual ascites and pericardial effusion, both of which cleared completely over the next four months. Patient remains asymptomatic one year after the hospital discharge.

A 70 years old , chronic heavy smoker man with history of alcohol abuse was admitted to Indus Hospital on June 23, 1998 , with five years history of progressive pain in the left scapular reason . Pain was almost continuous and unbearable for six months despite medical treatment for many years from a local civil hospital. He also complained of anorexia and epigastric abdominal pain for six days prior to admission . Rest of the history was non-contributory.

On physical examination, his vital signs were normal . The patient was afebrile, acyanotic , non-icteric without edema or lymphadenopathy. Clinical examinations of heart , extremities and neck was unremarkable. Breath sounds were diminished in the left scapular area , otherwise , lungs were clear to auscultation. There was epigastric tenderness without abdominal organomegaly, ascites or palpable masses .

LAB. DATA
Hgb. 12.6 gm/ dL , Hct. 38% , R.B.Cs 4.7 m/cu.mm. , WBC 14600 /cu.mm , Polys 82% , Lymph. 16% , Mono. 1% , Eosin. 1% , Platelets 2,20,000/cu.mm., Sed Rate 40 mm/hr. , Urinalysis normal , Stools normal , VDRL non-reactive , Serum Chemistry Profile and Electrolytes were normal , PBS normocytic normochromic , Sputum for AFB Smears negative , Mantaux Skin Test negative , Electrocardiogram and Pulmonary Function Tests were normal, X-rays Chest showed a large patchy radiodensity in the superior segment region of left lower lobe with normal heart size and mediastinal shadows and no free fluid, X-rays of cervical spine showed narrowing of C5-C6 and C6-C7 disc spaces, Ultrasonography of Abdomen was normal , Double Contrast Upper G.I. Barium X-rays with Small Bowel Follow-through Studies showed Pylorospasm with Gastric Dilatation .

Esophagogastroduodenoscopy showed superficial ulcerations in the Prepyloric region along the lesser curvature and in the pyloric channel . Examination of esophagus and duodenum was unremarkable.

Flexible Bronchoscopy showed an endobronchial neoplasm at the superior segmental bronchial orifice of the left lower lobe which proved to be poorly differentiated squamous cell carcinoma by biopsy. Nuclear Bone Scan , CT Scans of head and liver showed no metastatic disease.

DIAGNOSES :
1. Squamous Cell Carcinoma, Left Lower Lobe With Invasion of Chest Wall .
2. Peptic Ulcer Disease.

HOSPITAL COURSE
After one week triple antibiotic and five weeks H₂ blocker and antacid treatment for peptic ulcer disease , the patient was readmitted for left standard posterolateral thoracotomy under general endotracheal anesthesia . A large , bulky tumor mass in the superior segment of lower lobe was found to invade the lingular segment of the upper lobe as well as the structures in the seventh and eighth intercostal spaces posteriorly. Intercostal lymph nodes were also involved. Left lower lobectomy with wedge resection of lingula and wide exicision of chest wall , including the seventh , eighth and ninth ribs , was performed without prosthetic reconstruction of the chest wall. The patient made a slow, but an uneventful recovery and was discharged home on the 21st Hospital day in good condition .

FOLLOW-UP
Patient was readmitted to Indus Hospital nine months after the Hospital discharge with pulmonary tuberculosis involving the upper lobe of the right lung. He was given antitubercular treatment for nine months with complete resolution of the disease . He has been followed at yearly intervals for three years . The patient has gained weight , remained free of metastatic disease , but continues to smoke and abuse alcohol despite instructions to the contrary.

MALIGNANT BRONCHIAL CARCINOID REQUIRING PNEUMONECTOMY

A 34 years old woman with known pregnancy induced systemic arterial hypertension for 2 years was seen at Indus Hospital on July 04 , 2001 with 10 months history of 12 kg weight loss , diarrhoea , dyspepsia and occasional vomiting without hemetemesis , melena or hematochesia . Blood pressure was controlled with 50 mg. Atenelol O.D. She had no other symptoms except scanty menstrual periods . Examinations showed no abnormal physical findings . BP was 130/80 mm. Hg. , Pulse 84 per minute , Weight 56 kg , Respiration 16 per minute . Temperature was normal . Lab Data : Hgb. 12.6 gm % , Hct. 38% , RBC's 4.7 million / cu. mm , WBC 7200/cu. mm. , Sed. Rate 6 mm. , DLC : normal . Urinalysis : 2-3 pus cells / H.P.F. , otherwise normal . Blood Group : O , Rh +ve . Blood Chemistry Profile , Serum Electrolytes and Coagulation Profile were normal . Thyroid Function Tests showed marked hypothyroidism with Free T3 = 1.88 pg./ mL. , Free T4 = 0.49 ng./dL. , TSH = 68.73 uIU / mL. VDRL was non-reactive . HIV Screening Test and Mantaux Skin Test were negative . Stool examination for Ova , Cysts and Occult Blood was negative. 12 lead EKG was normal . Chest X-rays showed right hilar enlargement . CT Scan of Thorax confirmed the presence of a 3.8 cm. soft tissue mass adjacent to the right main bronchus without significant post -contrast enhancement and normal pulmonary parenchymal fields , subcarinal and left hilar areas . Flexible fiber-optic bronchoscopy showed a polypoid mass projecting from the right middle lobe bronchial orifice with intact mucosal lining. Bronchial washings were negative for malignant cells . However , bronchial biopsies showed brochial carcinoid tumor . Although , patient's symptoms of diarrhoea could be explained on the basis of carcinoid syndrome , double contrast upper G.I. and small bowel follow-through Barium x-rays were done which were suspicious for features of inflammatory bowel disease with floculation of barium and thickened mucosa in the small bowel . Esophagus , stomach and duodenum were normal . Patient was treated for hypothyroidism with 75 microgram thyroxine daily and metastatic work- up including CT Scans of brain , abdomen and nuclear bone scan were performed which were all negative for metastatic disease . Treatment for inflammatory bowel disease was withheld pending removal of bronchial carcinoid tumor to see weather carcinoid syndrome was the underlying cause of her diarrhoea . HOSPITAL COURSE: A standard postero-lateral right thoracotomy under general anesthesia was performed on July 21 , 2001 . Although , the right upper lobar bronchus was free of tumor involvement , its venous drainage was involved by the malignant carcinoid , necessitating right pneumonectomy for complete removal of the tumor . Patient tolerated the procedure well and made an uneventful recovery . FINAL HISTOPATHOLOGICAL DIAGNOSIS : Central Carcinoid tumor ( lung) with capsular invasion and surrounding lung parenchyma free from invasion . Reactive hyperplasia of mediastinal lymph nodes . She , however, continued to have symptoms of diarrhoea on and off after removal of the tumor . In view of the high incidence of small bowel tuberculosis in India , the patient was , empirically , started on anti-tubercular treatment with excellent symptomatic response . She continues to do well and remains asymptomatic