Case Sheets

CASE NO.-1 Name Gugulothu Somla Age 50 yrs Sex Male ResidenceNalsyagal thanda Kodakandla mandal Occupation Farmer Complaints 1.Pain abdomen since 9 hrs

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease

DOA 12/1/2008 DOO 12/1/2008 8.30 pm DOD 25/1/2008 Result Relieved Regd.No. 1448

Acute since 9 hrs situated at first in epigastrium radiated to all over the abdomen dull aching continuos no vomitings

once only nil nil nil nil Present 6 yrs Present relieved after food brufen tab on and off for body pains nil nil nil nil no no no no no

PERSONAL HISTORY 1.Appetite 2.Diet 3.Micturition 4.Bowels 5.Sleep 6.Addictions a)alcoholism b)smoking c)chewing tobacco FAMILY HISTORY TREATMENT HISTORY

Good Non vegetetarian and chilly food Normal regular disturbed due to pain on and off ten cigarettes daily since 30 yrs no Nil particular takes Digene syrup and tab Rantac at the time of pain GENERAL EXAMINATION

A.General Appearance 1.Built Moderate 2.Pallor Absent 3.Dehydration Severe 4.Eyes Sunken 5.Tongue Pink 6.Teeth Normal VITAL DATA 1.Pulse 98 /min Regular 2.Temparature Normal 3.Respiration 31 /min 4.B.P. 15/90 mmHg B.Abdominal examination INSPECTION a)Shape of abdomen Distended b)Movement of abdominal wall with respiration Restricetd in the upper part c)Hernia sites Normal PALPATION a)Tenderness All over the abdomen b)Gaurding All over the abdomen c)Muscular rigidity In epigastrium.rt.hypochondrium d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION a)Heart S 1 S 2 Heart normal b)Lungs Clinically clear c)CNS No neurological deficit d)Spine normal e)Scrotum normal PROVISIONAL DIAGNOSISPeritonitis due to duodenal ulcer perforation INVESTIGATIONS 1.Urine a)Albumin Trace b)Sugar Nil 2.Hb% 76% 3.Blood urea 18 mg 4.Blood sugar 90 mg Random 5.Blood group AB + ve 6.Plain X-ray abdomen erect posture Gas under diaphragm No 3852 Date 12/1/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper mid line Laporotomy b)Findings 1.Exudate 800 ml of frank pus 2.Perforation In anterior wall of First part of Duodenum Size 3 mm Shape Round PROCEDURE Perforation is closed with 3 simple intermittent 2-0 silk sutures and reinforced with omental patch.Peritoneal toilet done with normal saline .Compleete haemostasis secured. Wound closed in layers after keeping in flanks bilateral abdominal drains. POST OPERATIVE PERIOD Uneventful Naso Gasric aspiration,antibiotics,analgesics,and I V Fluids Recovery from Paralytic Ileus48 Hrs Drains removed 5 th day

COMPLICATIONS Post operative fever Nil Wound infection Nil Post operative vomitings Nil Suture removal 10 th post operative day Discharged on 13 th post operative day Hospital stay 12 days Interval between onset of symptoms and surgery Eleven hours Follow up Followed up for one and half yrs,and patient was problem free

CASE NO.-2 Name P.Narender DOA 18/1/2008 Age 33 yrs DOO 19/1/2008 1.50 am Sex Male DOD 29/1/2008 ResidenceKagipally Result Relieved Jayapur Mandal,Adilabad Regd.No. 2180 Occupation Farmer Complaints Pain since evening of 18/1/08

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease PERSONAL HISTORY 1.Appetite 2.Diet 3.Micturition 4.Bowels 5.Sleep 6.Addictions

Sudden Since 6 hrs started in epigastrium later on To all over abdomen Piercing and constant Continuos

No vomitings

Nil Nil Nil Nil Absent Nil Nil Analgesics for five days prior to admission Nil Nil Nil Nil Nil Nil Nil Nil Nil

Loss of appetite since one week Mostly vegetarian with plenty of chillies 4/1 normal Regular Normal

a)alcoholism b)smoking c)chewing tobacco FAMILY HISTORY TREATMENT HISTORY

Occasionally Beer & whisky No No Nil particular Irregular use of antacids and H 2 receptor antagonist GENERAL EXAMINATION

A.General Appearance 1.Built Moderate 2.Pallor No 3.Dehydration Severe 4.Eyes Sunken 5.Tongue Dry & pink 6.Teeth Normal VITAL DATA 1.Pulse 110 mm Regular 2.Temparature Normal 3.Respiration 32 / min 4.B.P. 150 /90 B.Abdominal examination INSPECTION a)Shape of abdomen Distended b)Movement of abdominal wall with respiration Normal c)Hernia sites Normal PALPATION a)Tenderness All over abdomen b)Gaurding All over abdomen c)Muscular rigidity Rt.Hypochondrium d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs clinically clear c)CNS Normal d)Spine NAD e)Scrotum Normal PROVISIONAL DIAGNOSISAcute perforation of Duodenal ulcer with Peritonitis INVESTIGATIONS 1.Urine a)Albumin Nil b)Sugar Nil 2.Hb% 78% 3.Blood urea 24 mg 4.Blood sugar 86 mg

5.Blood group O +ve 6.Plain X-ray abdomen erect posture Gas under diaphragm No. 4217 Date 18/1/08 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Mid line Laporatomy b)Findings 1.ExudateOne Litre bile stained fluid in peritoneal cavity 2.Perforation 0.5 cm size oval shaped in anterior wall of first part of duodenum. PROCEDURE Simple closure of perforation with omental patch of Graham method with 2-0 Mersilk sutures.Peritoneal toilet done ,compleete haemostasis secured. Wound closed in layers after keeping bilateral abdominal drains in flanks POST OPERATIVE PERIOD Naso gastric Aspiration,Antibiotics,Analgesics,and IV Fluids Recovery from Paralytic Ileus48 hrs Drain removed 4 th post operative fluid COMPLICATIONS Post operative fever No Wound infection No Post operative vomitings Present 4 th & 5 th days,relieved with RTA and anti emetics Suture removal 7 th post operative day Discharged on 11 th post operative day Hospital stay 11 days Interval between onset of symptoms and surgeryseven hours Follow up For one and half years with out complications

CASE NO.-3 Name Allepu Ballaiah DOA 21/2/2008 Age 55 yrs DOO 22/2/08 1.00am Sex Male DOD 28/2/2008 ResidenceKannure Result Relieved Kamalapure,Mandal,Karimnagar(Dist) Regd.No. 6437 Occupation Agriculture Labour Complaints Pain abdomen 10 and half hours

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease PERSONAL HISTORY 1.Appetite 2.Diet 3.Micturition 4.Bowels

Acute Since 10 &1/2 hrs Rt hypochondrium initially referring to Rt shoulder To all over abdomen Burning initially,dragging later on Continuos

No vomitings

No No No No Present 3 yrs Present Relieved after taking food Brufen on & off for body pains H/O bronchial ashma on anti ashmatics for 15 yrs Nil Nil Nil Nil Nil Nil Nil Nil Nil

Normal Vegetarian with plenty of chillies Normal Normal

5.Sleep Normal 6.Addictions a)alcoholism 500 ml country liquor for 25 yrs b)smoking 5 chuttas daily c)chewing tobacco No FAMILY HISTORY Nil particular TREATMENT HISTORY Antacids and Rantac tabs for past 3 yrs. GENERAL EXAMINATION A.General Appearance 1.Built Thin 2.Pallor No 3.Dehydration Severe 4.Eyes Sunken 5.Tongue Dry & pink 6.Teeth normal VITAL DATA 1.Pulse 90 min 2.Temparature Normal 3.Respiration 22 /min 4.B.P. 110 /60 mmHg B.Abdominal examination INSPECTION a)Shape of abdomen Distended b)Movement of abdominal wall with respiration Restricted c)Hernia sites Normal PALPATION a)Tenderness Diffuse tenderness all over abdomen b)Gaurding All over abdomen c)Muscular rigidity All over abdomen d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Absent

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Cl.Clear c)CNS Normal d)Spine Normal e)Scrotum Normal PROVISIONAL DIAGNOSISPeritonitis due to duodenal ulcer Perforation INVESTIGATIONS 1.Urine a)Albumin Nil

b)Sugar

Nil

2.Hb% 76% 3.Blood urea 24 mg 4.Blood sugar 146 mg 5.Blood group AB +ve 6.Plain X-ray abdomen erect posture Gas under diaphragm No. 2461 Date 21/2/08 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate2 Litres of yellowish green fluid 2.Perforation 4 mm Size perforation on the anterior wall of first part of duodenum PROCEDURE Perforation closed by Graham's omental patch using 2-0 silk sutures.Peritoneal toilet done with 2 litres of normal saline.After securing haemostasis wound closed in layers after keeping abdominal drains in both the flanks POST OPERATIVE PERIOD Naso gastric Aspiration,Antibiotics,Analgesics,and IV Fluids Recovery from Paralytic Ileus48 hrs Drain removed

5 th post operative fluid

COMPLICATIONS Post operative fever 3 rd & 4th th POD,relieved with anti-pyretics Wound infection No Post operative vomitings No Suture removal 8 th POD Discharged on 9th POD Hospital stay 9days Interval between onset of symptoms and surgery21 hours Follow up For one and half year,Patient had stich abscess one month after discharge ,drained wound healed well,asymptomatic after that.

CASE NO.-4 Name kammala Narayana DOA 24/2/2008 Age 60 yrs DOO 25/2/08 3.PM Sex Male DOD 5/3/2008 ResidenceMenazipet,Muttaram(mandal) Result Relieved Karimnagar(Dist) Regd.No. 6768 Occupation Agriculture Complaints 1.Pain abdomen since 5 days 2.Not passing urine since 1 day

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease PERSONAL HISTORY 1.Appetite 2.Diet 3.Micturition 4.Bowels 5.Sleep 6.Addictions

Acute For the past five days Initially in epigastrium all over the abdomen Piercing and aching Constant

Absent

Nil Nil Nil Nil Old case of chronic duodenal ulcer 6 yrs Present Relieved after food intake Rantac tabs antacid syrup Nil Nil Nil Nil Nil Nil Nil Nil Nil

Normal Veg & Non-Veg ,plenty of chillies Oliguria since 1 day,before normal Regular Normal

a)alcoholism Toddy 1 litre once in 4 days since 35 yrs b)smoking 2-3 cigerattes per day c)chewing tobacco yes FAMILY HISTORY Nil Particular TREATMENT HISTORY Antacids irregular GENERAL EXAMINATION A.General Appearance Patient is in shock,peripheries cold 1.Built Average 2.Pallor No 3.Dehydration severe 4.Eyes Sunken 5.Tongue Dry 6.Teeth Normal VITAL DATA 1.Pulse 128 /min feeble 2.Temparature 98 ⁰F 3.Respiration 38/min shallow 4.B.P. 80/60 mmHg B.Abdominal examination INSPECTION a)Shape of abdomen Grossly distended,skin shiny b)Movement of abdominal wall with respiration Diminished Movement c)Hernia sites Normal PALPATION a)Tenderness Present in all quadrants more in Rt.Hypochondrium b)Gaurding Present c)Muscular rigidity Present in all quadrants more in Rt.Hypochondrium d)Rebound tenderness Present PERCUSSION 1.Liver dullness Not obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Absent

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Bilateral crepts and wheeze present c)CNS Normal d)Spine Normal e)Scrotum Normal PROVISIONAL DIAGNOSISDuodenal ulcer perforation with peritonitis INVESTIGATIONS 1.Urine a)Albumin Nil b)Sugar Nil 2.Hb% 78% 3.Blood urea 26 mg 4.Blood sugar 86 mg

5.Blood group O + ve 6.Plain X-ray abdomen erect posture Gas under dome of diaphragm No. 880 Date 24/2/08 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate 5 litres bile stained purulent fluid 2.Perforation 1.5 cm in size on the anterior surface of first part of duodenum PROCEDURE After draining peritoneal fluid ,perforation was closed with 2-0 mersilk with omental patch.Peritoneal toilet done with normal saline ,haemostasis secured. wound closed after keeping abdominal drains in both flanks. POST OPERATIVE PERIOD Resuscitation of shock NG Aspiration,High Antibiotics,IV Fluids Recovery from Paralytic Ileus48 hrs Drain removed On 7 th post operative day COMPLICATIONS Post operative fever Present Wound infection No Post operative vomitings No Suture removal Alternate sutures on 7 th day,remaining on 9 th post operaive Discharged on 10 th post op day Hospital stay 10 days Interval between onset of symptoms and surgeryFive and half days Follow up For one and half yrs,without complications

CASE NO.-5 Name B.Janardhan Age 45 yrs Sex Male ResidenceLaxmidevpet,Venkatapure(mandal) WarangalDist. Occupation Agriculture Complaints 1.Pain abdomen since 3 days 2.Distension of abdomen since 3 days 3.constipation since 2 days

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease PERSONAL HISTORY 1.Appetite 2.Diet 3.Micturition 4.Bowels 5.Sleep 6.Addictions

DOA 5/3/2008 DOO 6/3/2008 12.40am DOD 11/4/2008 Result Relieved Regd.No. 8117

Sudden onset since 3/3/08 3 days First in epigasrium Rt hypochondrium later to Rt.iliac fossa Piercing continuos increasing inn intensity

no vomitings Constipated since 2 days No No No No No No No No No No No No No No No No Pulmonary TB 5 yrs back No

Normal Mixed with plenty of chillies Normal constipated for 2 days Normal

a)alcoholism b)smoking c)chewing tobacco FAMILY HISTORY TREATMENT HISTORY

Toddy 1 litre per day since 10 yrs 10 beedies daily 10 yrs No Nil particular Nil particular GENERAL EXAMINATION

A.General Appearance 1.Built Average 2.Pallor No 3.Dehydration Severe 4.Eyes Sunken 5.Tongue Dry & pink 6.Teeth Normal VITAL DATA 1.Pulse 100 min Regular 2.Temparature Normal 3.Respiration 34 /min 4.B.P. 110 /90 B.Abdominal examination INSPECTION a)Shape of abdomen Distension of abdomen present b)Movement of abdominal wall with respiration Less in upper abdomen c)Hernia sites Normal PALPATION a)Tenderness In all quardrants b)Gaurding Rt Hypochondrium c)Muscular rigidity Rt.Iliac fossa d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds absent

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Cl.Clear c)CNS Normal d)Spine Normal e)Scrotum Normal PROVISIONAL DIAGNOSISAcute Duodenal ulcer Perforation with Peritonitis INVESTIGATIONS 1.Urine a)Albumin Trace b)Sugar Nil 2.Hb% 80% 3.Blood urea 28 mg 4.Blood sugar 72 mg

5.Blood group A + ve 6.Plain X-ray abdomen erect posture Gas under dome of Diaphragm No. 1062 Date 5/3/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate 2 Litres of purulent bile stained fluid 2.Perforation 5 mm Size perforation on the anterior wall of 1 st part of Doudenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains. POST OPERATIVE PERIOD NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus

After 72 hrs

COMPLICATIONS Post operative fever No Wound infection Present,Pus for C/S,E.Coli grown, sensitive to ciprofloxacin Post operative vomitings No Suture removal 9 th post op day,wound gaping closed by secondary suturing Discharged on 11/4/2008 Hospital stay 34 days Interval between onset of symptoms and surgery 82 hrs Follow up Monthly follow up for six months ,with no problems,lost for further follow up

CASE NO.-6 Name Chintala Keshavulu DOA 7/3/2008 Age 30 Yrs DOO 7/3/2008 12.00pm Sex Male DOD 20/3/08 ResidenceJangalapally,Mulugu(mandal) Result Relieved Dist.Warangal Regd.No. 8270 Occupation Agriculture Complaints 1.pain abdomen since 2 days 2.Vomiting since morning 3.Distension of abdomen since morning

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease PERSONAL HISTORY 1.Appetite 2.Diet 3.Micturition 4.Bowels 5.Sleep 6.Addictions

sudden and spontaneous since 48 hrs First in epigastrium To all over abdomen Dull aching continuous Twice Yellowish white Non projectile 30 ml each time Once only No No No No Present 3 yrs Present Relieved after food intake No Nil Nil Nil Nil Nil Nil Nil Nil Nil

Normal Mixed diet and spicy Normal Regular Disturbed since 2 days

a)alcoholism occassionally coutry liqour and toddy since 5 yrs b)smoking 10-15 cigarettes per day since 10 yrs c)chewing tobacco yes FAMILY HISTORY Nil particular TREATMENT HISTORY Antacids,H2 receptor antagonists GENERAL EXAMINATION A.General Appearance Drowsy and in shock 1.Built Well 2.Pallor No 3.Dehydration Severe 4.Eyes Sunken 5.Tongue Dry & pink 6.Teeth Normal VITAL DATA 1.Pulse 94 min 2.Temparature normal 3.Respiration 26/min 4.B.P. 84/60 mm B.Abdominal examination INSPECTION a)Shape of abdomen grossly distended b)Movement of abdominal wall with respiration Restricted over upper abdomen c)Hernia sites Normal PALPATION a)Tenderness Diffuse in all quadrants b)Gaurding Present c)Muscular rigidity Present d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness present AUSCULTATION 1.Bowel sounds Absent

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)Scrotum Normal PROVISIONAL DIAGNOSISAcute Duodenal ulcer Perforation with Peritonitis INVESTIGATIONS 1.Urine a)Albumin Nil b)Sugar Nil 2.Hb% 76% 3.Blood urea 25mg 4.Blood sugar 89 mg

5.Blood group AB + ve 6.Plain X-ray abdomen erect posture Free air under domes of Diaphragm No. 1079 Date 7/3/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate 7 litres of greenish yellow thick fluid in peritoneal cavity 2.Perforation 1 cm Size on anterior surface of 1 st part of duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains. POST OPERATIVE PERIODUneventful NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus 48 hrs COMPLICATIONS UTI treated with Norfloxacin Post operative fever Absent Wound infection No Post operative vomitings No Suture removal 8 th post op day Discharged on 13 th post op day Hospital stay 13 days Interval between onset of symptoms and surgery 65 hrs Follow up One year without complications

CASE NO.-7 Name P.Raju Age 50 yrs Sex Male ResidenceLaxmipuram,Duggondi(mandal) Dist.Warangal Occupation Agriculture Complaints 1.Pain abdommen since 1 day 2.Unable to pass urine since 1 day

HISTORY OF PRESENT ILLNESS A.Pain 1.onset 2.duration 3.location 4.radiation 5.character 6.nature B.Vomitings 1.number 2.colour 3.character 4.quantity C.Bowels 1.frequency 2.diarrhea 3.blood & mucus 4.malena 5.haematemesis PAST HISTORY 1.History suggesting peptic ulcer 2.Duration of symptoms 3.Periodicity 4.Pain in relation to food intake 5.History of drug ingestion 6.Associated symptoms a)vomitings b)haematemesis c)malena 7.Any serious previous illness 8.Operation 9.Loss of weight 10.Diabetes mellitus 11.Enteric fever 12.Cardio vascular disease

DOA 2/4/2008 DOO 2/4/2008 6.00pm DOD 20/4/08 Result Relieved Regd.No. 11559

Sudden Since 26 hrs First in epigastrium To all over abdomen Piercing Constant incresing in intensity

no vomiting once in two days Nil Nil Nil Nil Present 10 yrs Present Relieved after food or soda Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil

PERSONAL HISTORY 1.Appetite Good 2.Diet Mixed & spicy 3.Micturition Oliguria since 12 hrs 4.Bowels Constipated since 3 days 5.Sleep Normal 6.Addictions

a)alcoholism Toddy 1 litre once a week since 25 yrs b)smoking 6 cigars daily since 20 yrs c)chewing tobacco No FAMILY HISTORY Nil particular TREATMENT HISTORY soda ingestion,antacids for 8 yrs GENERAL EXAMINATION A.General Appearance Conscious coherent 1.Built Average 2.Pallor No 3.Dehydration Severe 4.Eyes sunken 5.Tongue Dry & pink 6.Teeth Normal VITAL DATA 1.Pulse 100 min feeble 2.Temparature 98 degree F 3.Respiration 34/min 4.B.P. 70/50 B.Abdominal examination INSPECTION a)Shape of abdomen Distended lower abdomen b)Movement of abdominal wall with respiration Diminished movements c)Hernia sites Normal PALPATION a)Tenderness All over abdomen b)Gaurding All over abdomen c)Muscular rigidity in epigastium d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Absent

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)Scrotum Normal PROVISIONAL DIAGNOSISPeritonoitis due Duodenal ulcer Perforation INVESTIGATIONS 1.Urine a)Albumin Nil b)Sugar Nil 2.Hb% 80% 3.Blood urea 48 mg 4.Blood sugar 98 mg

5.Blood group A +ve 6.Plain X-ray abdomen erect posture free air under diaphragm No. 6883 Date 2/4/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate 2 litre of bile stained fluid 2.Perforation 1 cm Size on the anterior wall of 1 st part of duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains. POST OPERATIVE PERIOD NasoGastric aspiration,Antibiotics,IV Fluids One unit of blood transfusion Recovery from paralytic Ileus 36 hrs Drains removed 5 th POD COMPLICATIONS Loose motions 2 nd POD Post operative fever absent Wound infection No Post operative vomitings No Suture removal 8 th POD Discharged on 18 th POD Hospital stay 18 DAYS Interval between onset of symptoms and surgery 36 hrs Follow up only once after one month later he did not report

CASE NO.-8 Name Jannu Sambaiah Age 50 Yrs Sex Male ResidenceHasanparthy ,(mandal) Dist.Warangal Occupation Rikshaw puller Complaints 1.Pain abdomen since 2 hrs

DOA 4/7/2008 DOO 4/7/08 4.30pm DOD 18/7/08 Result Relieved Regd.No. 23039

HISTORY OF PRESENT ILLNESS A.Pain 1.onset Sudden 2.duration since 2hrs 3.location started in epigastrium 4.radiation to Rt.Iliac fossa 5.character bursting & aching 6.nature continuous B.Vomitings 1.number 2.colour 3.character no vomitings 4.quantity C.Bowels 1.frequency daily once 2.diarrhea nil 3.blood & mucus nil 4.malena nil 5.haematemesis nil PAST HISTORY 1.History suggesting peptic ulcer absent 2.Duration of symptoms nil 3.Periodicity nil 4.Pain in relation to food intake nil 5.History of drug ingestion analgesics on & off for back pain 6.Associated symptoms a)vomitings nil b)haematemesis nil c)malena once 8 months back 7.Any serious previous illnessnil 8.Operation nil 9.Loss of weight nil 10.Diabetes mellitus nil 11.Enteric fever nil 12.Cardio vascular disease nil PERSONAL HISTORY 1.Appetite good 2.Diet Mixed with plenty of chillies 3.Micturition Normal 4.Bowels Regular 5.Sleep Normal 6.Addictions

a)alcoholism Toddy 1 litre a day since 32 yrs b)smoking smokes 2-3 cigarettes daily c)chewing tobacco no FAMILY HISTORY Nil Particular TREATMENT HISTORY Nil Particular GENERAL EXAMINATION A.General Appearance Conscious & coherent 1.Built Thin 2.Pallor No 3.Dehydration Severe 4.Eyes sunken 5.Tongue Dry & Pink 6.Teeth normal VITAL DATA 1.Pulse 100/min Regular 2.Temparature normal 3.Respiration 22/min 4.B.P. 110/60 B.Abdominal examination INSPECTION a)Shape of abdomen Flat b)Movement of abdominal wall with respiration restricted over upper part of abdomen c)Hernia sites Normal PALPATION a)Tenderness Rt.Hypochondrium &Rt.Iliac fossa b)Gaurding Rt.Hypochondrium &Rt.Iliac fossa c)Muscular rigidity Absent d)Rebound tenderness Rt.Iliac fossa PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Absent

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)ScrotumNormal PROVISIONAL DIAGNOSISDuodenal ulcer Perforation INVESTIGATIONS 1.Urine a)Albumin2 + b)Sugar Nil 2.Hb% 80% 3.Blood urea 20 mg 4.Blood sugar 145 mg

5.Blood group O + ve 6.Plain X-ray abdomen erect posture free air under diaphragm No. 5162 Date 4/7/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate500 ml of bile stained fluid in peritoneal fluid 2.Perforation 3 mm Size on the anterior wall of 1 st part of Duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains. POST OPERATIVE PERIOD Uneventful NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus 48 hrs Drains removed 4th POD COMPLICATIONS Post operative fever Nil Wound infection Nil Post operative vomitings Nil Suture removal 11 th POD Discharged on 14 th POD Hospital stay 14 days Interval between onset of symptoms and surgery nine and half hours Follow upFor one year was asymptomatic

CASE NO.-9 Name D.Vishnu Age 29 Yrs Sex Male ResidenceBhoopalpally,(mandal) Dist.Warangal Occupation Labourer Complaints 1.Pain abdomen for 3 days 2.Vomitings for 1 day

HISTORY OF PRESENT ILLNESS A.Pain 1.onset Sudden 2.duration72 hrs 3.locationFirst in epigastrium 4.radiationto all over abdomen 5.characterPiercing 6.nature Continuous B.Vomitings 1.number3 times 2.colour greenish white 3.characterMixed with food 4.quantity50-100 ml C.Bowels 1.frequency 2.diarrhea Nil 3.blood & mucus Nil 4.malena Nil 5.haematemesis Nil PAST HISTORY 1.History suggesting peptic ulcer Absent 2.Duration of symptoms Nil 3.Periodicity Nil 4.Pain in relation to food intake Nil 5.History of drug ingestion Nil 6.Associated symptoms a)vomitings Nil b)haematemesis Nil c)malena Nil 7.Any serious previous illness Nil 8.Operation Nil 9.Loss of weight Nil 10.Diabetes mellitus Nil 11.Enteric fever Nil 12.Cardio vascular disease Nil PERSONAL HISTORY 1.Appetite Normal 2.Diet Mixed with plenty of chillies 3.Micturition Normal 4.Bowels constipated 5.Sleep disturbed since 3 days 6.Addictions

DOA 11/7/2008 DOO 11/7/2008 8:00 PM DOD 23/7/08 Result Relieved Regd.No. 23985

a)alcoholism 250 ml Gudumba daily since 5 yrs b)smoking 5 beedies daily since 9 yrs c)chewing tobacco no FAMILY HISTORY nil particular TREATMENT HISTORY nil particular GENERAL EXAMINATION A.General Appearance 1.Built Moderate 2.Pallor Absent 3.Dehydration Severe 4.Eyes Sunken 5.Tongue Dry ,coated 6.Teeth normal VITAL DATA 1.Pulse 120/min feeble 2.Temparature Normal 3.Respiration 24/min 4.B.P. 90/60 B.Abdominal examination INSPECTION a)Shape of abdomen Flat b)Movement of abdominal wall with respiration c)Hernia sites Normal PALPATION a)Tenderness All over abdomen b)Gaurding present c)Muscular rigidity present d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Absent

restricted

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)ScrotumNormal PROVISIONAL DIAGNOSISAcute Perforation of Duodenal ulcer with Peritonitis INVESTIGATIONS 1.Urine albumin 2+ b)Sugar Nil 2.Hb% 70% 3.Blood urea 40 mg 4.Blood sugar 78 mg

5.Blood group O +ve 6.Plain X-ray abdomen erect posture free air under diaphragm No. 3161 Date 10/7/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate3 litres straw colored fluid 2.Perforation 3 mm Size round shaped on anterior surface of 1 st part of Duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains.

POST OPERATIVE PERIOD Uneventful NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus 48 hrs Drains removed 5th POD COMPLICATIONS Post operative fever on 5 th POD treated with antipyretic Wound infection Nil Post operative vomitings Nil Suture removal on 10th POD Discharged on 12 th POD Hospital stay 12 days Interval between onset of symptoms and surgery 72 hrs Follow upRepoted only once after one month

CASE NO.-10 Name Vanaparthi Rajaiah DOA 7/8/2008 Age 50 DOO 7/8/2008 9.30 pm Sex Male DOD 30/8/08 Residencepothakapally,Odela(mandal) Result Relieved Dist.Karimnagar Regd.No. 27987 Occupation Toddy Tapper Complaints 1.Distension of abdomen since 3 days 2.Passing small quantities of urine 3 days

HISTORY OF PRESENT ILLNESS A.Pain 1.onset sudden 2.duration3days 3.locationfirst in epigastrium 4.radiationto all over the abdomen 5.characterdragging 6.nature continuous B.Vomitings 1.number 2.colour 3.character no vomitings 4.quantity C.Bowels 1.frequency once daily 2.diarrhea Nil 3.blood & mucus Nil 4.malena Nil 5.haematemesis Nil PAST HISTORY 1.History suggesting peptic ulcer Present 2.Duration of symptoms 8 yrs 3.Periodicity Present 4.Pain in relation to food intake relieved after food 5.History of drug ingestion Nil 6.Associated symptoms a)vomitings Nil b)haematemesis Nil c)malena Nil 7.Any serious previous illness Nil 8.Operation Nil 9.Loss of weight Nil 10.Diabetes mellitus Nil 11.Enteric fever Nil 12.Cardio vascular disease Nil PERSONAL HISTORY 1.Appetite Normal 2.Diet Mixed with chillies 3.Micturition Normal 4.Bowels Normal 5.Sleep disturbed due to pain 6.Addictions

a)alcoholism 250 ml gudumba daily for 31 yrs b)smoking 2-3 cigars 32 yrs c)chewing tobacco no FAMILY HISTORY Nil particular TREATMENT HISTORY Irregular use of antacids GENERAL EXAMINATION A.General Appearance 1.Built Thin 2.Pallor absent 3.Dehydration present 4.Eyes sunken 5.Tongue dry pink 6.Teeth Normal VITAL DATA 1.Pulse 100/min,low vol. 2.Temparature Normal 3.Respiration 20/min 4.B.P. 120/80 B.Abdominal examination INSPECTION a)Shape of abdomen Distended b)Movement of abdominal wall with respiration restricted in upper abdomen c)Hernia sites Normal PALPATION a)Tenderness Diffuse b)Gaurding Rt.Hypochondrium,epigastrium,Rt.iliac fossa c)Muscular rigidity Rt.Hypochondrium,epigastrium,Rt.iliac fossa d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)ScrotumNormal PROVISIONAL DIAGNOSISAcute Perforation of Duodenal ulcer with Peritonitis INVESTIGATIONS 1.Urine a)Albumin b)Sugar 2.Hb% 3.Blood urea 4.Blood sugar

5.Blood group 6.Plain X-ray abdomen erect posture free air under diaphragm No. 5765 Date 7/8/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate4 litres of yellowish green fluid present 2.Perforation 1 cm Size on anterior surface of 1 st part of Duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains.

POST OPERATIVE PERIOD Uneventful NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus 72 hrs Drains removed 5th POD COMPLICATIONS Post operative fever present treated with anti pyretic Wound infection Present Post operative vomitings Nil Suture removal 10 th POD Discharged on 25 th POD Hospital stay 25Days Interval between onset of symptoms and surgery 80 hrs Follow upFollowed up for 6 months asymptomatic,subsequently did not report for follow up

CASE NO.-11 Name Marepally Ilaiah DOA 10/8/2008 Age 50 yrs DOO 10/8/2008 3.15 pm Sex Male DOD 19/8/08 ResidenceShyampet,(mandal) Result Relieved Dist.Warangal Regd.No. 28288 Occupation Agriculture Complaints 1.Pain abdomen for 1 day 2.Fever since one day 3.Not passing motion since the day before morning

HISTORY OF PRESENT ILLNESS A.Pain 1.onset Sudden 2.duration 24 hrs 3.location first in epigastium 4.radiation to Rt.Iliac fossa 5.character Piercing 6.nature continuous increasing in severity B.Vomitings 1.number 2.colour 3.character no vomiting 4.quantity C.Bowels 1.frequency daily once 2.diarrhea Nil 3.blood & mucus Nil 4.malena Nil 5.haematemesis Nil PAST HISTORY 1.History suggesting peptic ulcer Present 2.Duration of symptoms 4 yrs 3.Periodicity Present 4.Pain in relation to food intake relieved after food 5.History of drug ingestion Taking Aspirin frequently for body pains 6.Associated symptoms a)vomitings Nil b)haematemesis Nil c)malena once one month back 7.Any serious previous illnessNil 8.Operation Nil 9.Loss of weight Nil 10.Diabetes mellitus Nil 11.Enteric fever Nil 12.Cardio vascular disease Nil PERSONAL HISTORY 1.Appetite good 2.Diet Mixed spicy food 3.Micturition Normal 4.Bowels Normal 5.Sleep disturbed due to pain 6.Addictions

a)alcoholism 200 ml of Gudumba since 25 yrs b)smoking 10 beedies daily since 32 yrs c)chewing tobacco occassionally FAMILY HISTORY Nil particular TREATMENT HISTORY irregular use of antacids GENERAL EXAMINATION A.General Appearance 1.Built Moderate 2.Pallor No 3.Dehydration Severe 4.Eyes sunken 5.Tongue dry pink 6.Teeth Normal VITAL DATA 1.Pulse 102 /min Regular 2.Temparature Normal 3.Respiration 24 /min 4.B.P. 110/80 mmHg B.Abdominal examination INSPECTION a)Shape of abdomen Flat b)Movement of abdominal wall with respiration Diminished in upper part c)Hernia sites Normal PALPATION a)Tenderness Diffuse b)Gaurding Rt.hypochondrium,epigastrium c)Muscular rigidity Absent d)Rebound tenderness Rt.iliac fossa PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Present SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)ScrotumNormal

PROVISIONAL DIAGNOSIS Acute Perforation of Duodenal ulcer with Peritonitis INVESTIGATIONS 1.Urine a)Albumintrace b)Sugar nil 2.Hb% 76% 3.Blood urea 50 mg 4.Blood sugar 68 mg

5.Blood group O +ve 6.Plain X-ray abdomen erect posture free air under diaphragm No. 3679 Date 10/8/2008 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate300 ml of purulent fluid in peritoneum 2.Perforation 3 mm Size round shaped anterior aspect of 1 st part of Duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains. POST OPERATIVE PERIOD Uneventful NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus 48 hrs Drains removed 5th POD COMPLICATIONS Post operative feverAbsent Wound infection No Post operative vomitings No Suture removal 7 th POD Discharged on 10 th POD Hospital stay 10 days Interval between onset of symptoms and surgery 36 hrs Follow up One yr follow up with PPI'S asymptomatic

CASE NO.-12 Name T.Komraiah Age 48 yrs Sex Male ResidenceIppagudem,St.Ghanpure(mandal) dist.Warangal Occupation Agriculture Complaints 1.Pain abdomen since 48 hrs 2.Not passing stools for 2 days

DOA 16/12/08 DOO 16/12/08 7.30 pm DOD 25/12/08 Result Relieved Regd.No. 47881

HISTORY OF PRESENT ILLNESS A.Pain 1.onset Sudden 2.duration48 hrs 3.locationFirst In epigasrium 4.radiationto all over abdomen 5.character dragging 6.nature continuous,increasing in severity B.Vomitings 1.number 2.colour 3.character no vomiting 4.quantity C.Bowels 1.frequency constipated for 2 days 2.diarrhea Nil 3.blood & mucus Nil 4.malena Nil 5.haematemesis once 5 ml PAST HISTORY 1.History suggesting peptic ulcer Present 2.Duration of symptoms 2 yrs 3.Periodicity Present 4.Pain in relation to food intake relieved after food 5.History of drug ingestion Nil 6.Associated symptoms a)vomitings Nil b)haematemesis Nil c)malena Nil 7.Any serious previous illness Nil 8.Operation Nil 9.Loss of weight Nil 10.Diabetes mellitus Nil 11.Enteric fever Nil 12.Cardio vascular disease Nil PERSONAL HISTORY 1.Appetite Normal 2.Diet Mixed lot of chillies 3.Micturition Normal 4.Bowels constipated 5.Sleep disturbed during pain 6.Addictions

a)alcoholism Gudumba 250 ml -500 ml daily for 8 yrs b)smoking 2-3 cigars for 28 yrs c)chewing tobacco No FAMILY HISTORY Nil particular TREATMENT HISTORY Nil particular GENERAL EXAMINATION A.General Appearance 1.Built Moderate 2.Pallor No 3.Dehydration Present 4.Eyes Sunken 5.Tongue Dry pink 6.Teeth Normal VITAL DATA 1.Pulse 80 /min regular 2.Temparature Normal 3.Respiration 34 /min 4.B.P. 140/90 mmHg B.Abdominal examination INSPECTION a)Shape of abdomen Distended b)Movement of abdominal wall with respiration restricted in upper abdomen c)Hernia sites Normal PALPATION a)Tenderness Diffuse b)Gaurding Rt.hypochondrium c)Muscular rigidity Present d)Rebound tenderness Present PERCUSSION 1.Liver dullness Obliterated 2.Shifting dullness Present AUSCULTATION 1.Bowel sounds Sluggish

SYSTEMIC EXAMINATION a)Heart Normal b)Lungs Normal c)CNS Normal d)Spine Normal e)ScrotumNormal PROVISIONAL DIAGNOSISAcute Perforation of Duodenal ulcer with Peritonitis INVESTIGATIONS 1.Urine a)Albuminnil b)Sugar nil 2.Hb% 70% 3.Blood urea 30 mg 4.Blood sugar 100 mg

5.Blood group B +ve 6.Plain X-ray abdomen erect posture free air under diaphragm No. 7327 Date 16/12/08 TREATMENT 1.Preoperative a)Nothing by mouth b)Ryel's tube aspiration c)Intravenous fluids d)I.V.Antibiotics e)No enema 2.Anaesthesia General Endo Tracheal 3.Operation text a)Incision Upper Midline Laporatomy b)Findings 1.Exudate4 litres of greenish brown moderately turbid ,fibrinous flakes over intestines 2.Perforation 4 mm Size,circular shape anterior aspect 1st part of duodenum PROCEDURE Simple closure of perforation with 2-0 silk,with omental patch.Peritoneal toilet done with 2 litres of normal saline,Wound closed in layers after keeping bilateral flank drains.

POST OPERATIVE PERIOD Uneventful NasoGastric aspiration,Antibiotics,IV Fluids Recovery from paralytic Ileus48 hrs Drains removed 5th POD COMPLICATIONS Post operative fever Absent Wound infection No Post operative vomitings No Suture removal 9 th POD Discharged on 9 th POD Hospital stay 9 days Interval between onset of symptoms and surgery60 hrs Follow up For one yr,asymptomatic