Background: Acute appendicitis is the most common cause of acute abdomen and subsequent surgery. The diagnosis is essentially based on the clinical grounds and as a result misdiagnosis is a common and crucial problem in general surgery. Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin and C-reactive protein (CRP) have been shown to indicate perforation in appendicitis. Aim: The purpose of this study was to evaluate the role of hyperbilirubinemia, CRP and ultrasonography (USG) as predictors for appendiceal perforation. Materials and Methods: This study consisted of patients admitted with the clinical suspicion of acute appendicitis. The study finally included a group of those 100 patients who had histologically proven appendicitis. Subsequent to hospital admission all patients underwent thorough physical examination and routine lab exams. Preultrasound clinical diagnosis was made based on medical history, physical examination as well as laboratory findings. Real-time, high-resolution (5 MHz, 7.5 MHz) graded compression ultrasound examination was performed by a senior radiologist after a clinical diagnosis was made. Results: Serum bilirubin and CRP were raised in significant number of patients with appendiceal perforation compared to the patients of appendicitis without perforation. Thirty-three of 42 patients with perforated appendix had bilirubin ≥1.5 mg/dl (P < 0.0001). Sensitivity of serum bilirubin in predicting perforation was 78.57%, while as specificity was 89%. Thirty-five of 42 patients with perforated acute appendicitis had raised CRP levels (P < 0.0001). Sensitivity and specificity of CRP in predicting perforation were 83% and 74%, respectively. Abdominal USG in patients with diagnosis of perforated acute appendicitis has a sensitivity of 64.28% and specificity of 79.3% (P < 0.0001). Conclusion: Bilirubin, CRP and ultrasound are effective for differentiation of perforated from nonperforated appendicitis. Bilirubin, CRP and USG are important preoperative biochemical and sonographic markers of perforation, respectively in appendicitis.

Introduction: Lung cancer is the most common cancer in the world operative mortality rates for resection of lung cancer varies with type of resection carried out. Aim: The aim was to study the various causes of 30-day mortality, difference in the 30-day operative mortality between pneumonectomy, lobectomy and lesser resections and overall 30-day operative mortality following lung resection surgery of bronchogenic carcinoma. Materials and Methods: All those patients of bronchogenic carcinoma who were planned for lung resection surgery, from May 2008 to October 2010 in the department of cardiovascular and thoracic surgery, were included in the study protocol prospectively. Results: Lung carcinoma is predominantly a disease of males. The most common finding on X-ray chest is evidence of mass lesion. 91.1% had positive findings on bronchoscopic examination. Squamous cell carcinoma was present in the majority of patients (74.4%). Majority of patients underwent lobectomy (55.6%). Overall 30-day operative mortality was 4.4%. Mortality was more in patients who underwent pneumonectomy. Advanced age was associated with significant mortality. The most common postoperative complication was pneumonia followed by bronchopleural fistula. Conclusion: Surgery for bronchogenic carcinoma is associated with low mortality and morbidity and a good outcome, especially in patients with early stage disease.

Introduction: Gall stone disease is a common cause of acute pancreatitis. At present the pattern of gall stones complication are largely unpredictable. Little research has been done to identify gall stone morphology and biliary tract anatomy in the causation of gall stone induced pancreatitis. Aims and Objectives: The present study was done at IGMC Shimla to study the relationship of gallstone characteristics to the risk of gall stone pancreatitis and to compare and evaluate the biliary tract anatomy in patients of gall stone induced pancreatitis and cholelithiasis by MRCP. Materials and Methods: The prospective study included 25 patients each of symptomatic cholelithiasis and gall stone induced pancreatitis divided into Group A and Group B respectively. All the patients were subjected to MRCP preoperatively. All the patients were operated by laproscopic or open method. Postoperatively the gall stone were collected and analyzed. Results: On MRCP- In Group A Single calculus was present in 11 (44%) patients and 1 (4%) patients had associated sludge, 14 (56%) patients had multiple calculi and 3 (44%) patients had associated sludge.In Group B 22 (88%) patients had multiple calculi and 16 (56%) patients had associated sludge, 3 (12%) patients had single stone, and 2 (8%) patients had associated sludge. In Group A, CBD stones were seen in 3 (12%) patients, cystic duct diameter ranged from 3 mm to 5.2 mm, CBD diameter ranged from 5 mm to 9 mm and pancreatic duct diameter ranged from 2.7 mm to 4 mm.In Group B, CBD stones were seen in 7 (28%) patients, cystic duct diameter ranged from 4 mm to 6.4 mm, CBD diameter ranged from 5 mm to 12 mm and pancreatic duct diameter ranged from 2.6 mm to 4.8 mm In Group A, Common channel was seen in 8 (32%) patients. In Group B, Common channel was seen in 18 (72%) patients Gall Stone Morphology- In Group A, Single calculus present in 11 (44%) patients and 1 (4%) patient had associated sludge. Multiple calculi present in 14 (56%) patients and 3 (12%) patients had associated sludge. In Group B, Single calculus present in 3 (12%) patients and 2 (8%) patients had associated sludge. In group A, 15 (60%) patients had round stones and 14 (56%) patients had multifaceted stones and 6 (24%) patients had associated sludge. In Group B, 5 (20%) patients had round stones and 14 (56%) patients has multifaceted stones and 6 (24%) patients had associated sludge. Sludge <2 mm diameter was present in 6 patients each in Group A and B. Weight ranged from 2 to 3.8 gm in Group A and in Group B from 1.6 to 3.25gm. Conclusion: The present study clearly established an association between multiple, multifaceted stones, sludge, wide cystic duct and presence of common channel with increased incidence of Gallstone induced pancreatitis, MRCP also proved to be an excellent diagnostic modality in Gall stone induced pancreatitis.

Bouveret syndrome is gastric outlet obstruction due to gallstone. It is an extremely rare complication of cholelithiasis. We report a case of an elderly male who presented with epigastric abdominal pain, and gastric outlet obstruction due to migrated gallstone was suggested on computed tomography. He was managed with urgent 'one-stage' surgery with favorable outcome. Bouveret syndrome should be considered as a differential diagnosis, especially in elderly age group presenting with symptoms of gastric outlet obstruction or pancreatitis.

Central odontogenic fibroma (COF) is an uncommon benign neoplasm composed by varying amounts of inactive looking odontogenic epithelium embedded in a neoplastic mature and fibrous stroma. It originates from odontogenic ectomesenchyme and accounts for 0.1% of all odontogenic tumours. It appears as an asymptomatic expansion of the cortical plates of jaws. Radiographically, it appears as unilocular or multilocular radiolucency. It responds well to surgical enucleation. Recurrence is rare. Here is a rare case of recurrence of COF reported in 18-year-old female in the left mandibular posterior region after 1 year.

The localized varicosities of the hands and digits are quite rare with only a handful of cases reported in the literature. The cause of upper and lower limb varicosities are almost the same and the same treatment principles should be followed for both. Here, we report a case of 19-year-old male with localized varicosities of the dorsum of his hand and digits. Diagnosis was confirmed by color Doppler ultrasound scanning. He was managed by multiple ligations and excision of varicose veins with excellent results.

Hypothyroidism can be well-diagnosed with classical clinical signs, but not always. Extradural hematomas (EDH) are usually characterized by a rapidly progressing clinical course within few hours necessitating early surgical intervention. Surgical management of EDH with hypothyroidism is really a challenging issue for treating surgeon in the emergency hour, as the ultimate outcome depends on the further consequences of EDH and the ongoing metabolic stress due to hypothyroidism. A 53-year-old woman presented to us with a h/o head injury with dry, coarse, pale skin, and sunken face but without goiter with computed tomography scan of brain suggestive of right temporoparietal EDH. Clinical suspicion to be a case of hypothyroidism from these uncommon features was confirmed upon thyroid function test (TFT). Without delay, we planned for emergency craniotomy and evacuated the extradural blood clots ↓ local anesthesia avoiding the bad impact of regional anesthesia over hypothyroidism. Postoperatively, we supplemented levothyroxine through Ryle's tube, thus surviving the patient of EDH as well as hypothyroidism. Hence, clinical suspicion of some common comorbidity (e.g. hypothyroidism) can enlighten the treating surgeon to plan for further management strategy as reflected in our case.