Scope of Homoeopathy in Surgical Diseases – A New Methodological Approach

Navin Pawaskar, Reetha Krishnan, Ramya Krishna,  SVNS Vani, Fatiha Sultana Saba

A Homoeopathic clinician is often requested for an opinion to check if homoeopathy can help when a surgery is advised to a patient?  The conventional thought process of the homoeopathic clinician is to check if homoeopathic Materia Medica has remedies to offer for a required clinical condition.

The other common method used is to classify the diseases as “true surgical” & “so called surgical’ diseases. These approaches are too simplistic and lacking in depth to apply in clinical practice. This is so because, any given disease is not static or inert, it is dynamic and progressive and hence, a clinical decision in such situations is not always fixed but relative and multi-dimensional.

Diseases will always advance either ‘evidently or imperceptibly’. There are variations in advancement patterns; pace could differ, morphological stage may vary or its progress could be indiscernible to the naked eyes yet, the progress is inevitable.  In short, it is only a ‘matter of time’.

Given these medically observed facts, it will be too naive to discount dynamism of the disease and adopt a static classification as “true and so called surgical” diseases. Today’s ‘so called’ case may progress into ‘true zone’ tomorrow and the ‘true surgical’ case can revert without a surgical intervention with the right medication alone.  Therefore, in a practical sense, the criteria to decide the scope of homeopathy is far and wide beyond this conservative thought process.

Disease is a complex phenomenon resultant of numerous interactions of bio-psycho-social factors like: inheritance, environmental exposure, life style, personality factors, exposure to risk factors, and end organ or specific tissue weakness. Each disease has a generic ‘road map for its progress’ evident from its clinical progress descriptions noted in medical literature which, is based on observations.

A specific case always determines its path within the realms of generic roadmap but not without its own individualised trademark. This individualised progress is based on the sum total of genetic predispositions, maintaining causes, inborn or acquired vulnerabilities and reactivity of that individual. Hence, a homoeopathic physician should factor in all the above mentioned components in his decision to decide the scope of homoeopathy in a given case be it surgical or otherwise.

Having discussed the progressive and dynamic nature of the surgical diseases to understand its Homoeopathic management one needs to refer, ‘Organon of Medicine’ by Dr Samuel Hahnemann from aphorisms $ 185 through $ 203 as the starting point. The summary of the detailed guidelines for treatment states that even though the signs of the malady may be present only locally, the disease itself shall not occur without the internal dynamic disturbance.

The local malady is often the singular representation of the internal dynamic disturbance of the sick individual. Therefore, the approach to treat these, should never be local alone. The solution has to be mainly dynamic aimed at correction of the primary source that, in the first place caused the local signs.

The local intervention if required should be used with discretion for short term benefits to help healing or remove the maintaining cause for that period. The examples provided in the guidelines though indicative are apt. There is a loud and clear warning in the guidelines about the harm caused by treating local signs by localized treatment alone.

The local signs if thrashed without treating “the origin” may often lead to reappearance of the disease with rebound vigour at the same site or metastatic expression of disease at another location with profound consequences. It is evident from the guidelines that short term and long term measures have to be incorporated in the individualised treatment plan for a patient to offer a swift and permanent solution.

Based on the above understanding the orthodox approach to classify though rational is, too simplistic. This rather simple approach needs a review because the variety of diseases where, surgery can be used as a treatment in modern times has increased sizeably. Due to minimally invasive surgeries and robotics, the tissue handling has become precise and limited leading to swift postoperative hemodynamic stabilization, early mobilization and reduced hospitalization.

As a result, the rate of post-operative complications leading to mortality and morbidity have also reduced.  In brief, the entire paradigm of surgeries has changed rapidly thanks to improved techniques, technology and better infection control.

Thus, in current times, the role of homoeopathy in cases requiring surgical procedures to either avert a surgery or complete the healing and recovery in an individual is a multi-dimensional subject. There are no easy customary answers. From a generic perspective there is no single criteria that decides the scope of homeopathy in surgical cases. In most instances the generic criteria applied to the specifics of a case powers the final decision.

Hence, we should approach this topic with a fresh cognizance and build upon the simplistic, yet broad outline mentioned in the Organon of Medicine. As these decisions are multi-dimensional a decision framework as a part of solution to this problem is warranted.  A homoeopathic clinician may benefit if he/she can use a framework formulated on broad rules to decide the scope of homeopathy in a given case.

 The Decision Framework

A frame work is a basic conceptual structure supported by a system of rules and ideas of something that gives it a shape. In general, a framework is structure intended to serve as a support or guide for the building of something or to arrive at decisions in complex matters. It helps one to decide what to do. There are hypothetical, conceptual and decision frameworks. A clinician uses a combination of hypothetical, conceptual and decision frameworks in his daily practice, often without conscious cognizance.

In a clinical scenario, often a clinician is challenged to choose what is best for his patient? The choice in the given context is based on; a diagnosis, of stage of the disease, age, co morbidities, lack availability of full information about disease due to limited investigations, lack of skills, social and economic constraints.

He is expected to weigh the risks and benefits and often provide least harmful solution. It may be noted that a choice a clinician makes is not purely clinical it is a mix of clinical, techno- socio-economic and cultural elements.

In a surgical decision, there are two sets of ideas for a homoeopathic doctor. Seemingly these ideas are almost always opposite to each other. What a good decision maker should do is to understand the ideas, and integrate them, and come up with a third idea. This third or new idea is a unique combination of the best parts of the original, opposing ideas. The question now is how to do this? This is where the decision-making framework comes into application.

The starting point for building a framework is its “Goal”. What does one want to achieve? In a clinical scenario it could be rapid gentle and permanent cure or palliation whichever, is possible in the given context using the optimal resources available.

Frameworks generally provide transparency about goals, information, and decision processes. The framework can adapt decisions over time to new challenges, changing circumstances, new data and new knowledge. The frameworks are thus, dynamic and can be adapted to a complex and dynamic phenomenon like a disease. This malleability of frameworks is relevant in a complex decision making process like, clinical decisions.

A decision-making framework helps analyze the situation and discard ideas with the worst effects. It analyses the cause and effect relationship and helps a person make the best possible decision in the scenario and facilitate an idea that has the least harmful consequences.

The framework if, incorporated as a tool in clinical decision process will provide objectivity and avoid conjectural influence.  This in turn in the long run will improve the treatment outcome and help the patients, eventually creating a win-win situation for the patient, clinician and the homoeopathic science. A combination of decision and conceptual framework, with a decision support tool, underpinned by the real time data will help a homoeopathic clinician overcome this complex dilemma with improved accuracy.

All the decision frameworks are based on the objectives to be achieved. To use the framework, one has to first set the optimal goals of the treatment in the current clinical and social context. The time line of the case bears prime importance while setting goals for long term and short term outcomes in a given case.

Goals of a treatment (GOAT).

There are several goals of any treatment. For the sake of discussion as per the scope of this paper we shall limit to surgical cases. Twelve goals are listed below as a suggestive list to help a clinician in decision process of surgical cases. Thou empirical in nature they are based on sound clinical experiences. In short, a surgery is performed to achieve at least one or more of the goals.

Table 1 Depicting Goals of Treatment

#	Goals of Intervention/Therapy
1	Save a life
2	Save an individual from life threatening complication
3	Prevent permanent loss of tissue
4	Restore alignment and hence improve functional & structural effectiveness.
5	Restore physiological efficiency of an organ
6	Relive pain & distress
7	Improve quality of life
8	Improve aesthetics
9	Prevent relapse or reoccurrence of pathology
10	Reduce existing drug load on permanent basis
11	Help post-op recovery
12	Provide better healing

Set the Time Line & Weigh the Risks & Benefits

To address the next issue, it is important to study why, in the first place a patient is advised surgery? What is the illness, what is its stage and what are we trying to achieve by offering treatment. The approach should be based on goal of interventions, risks of intervention and short term and long term benefits , and the cost of intervention.

This should be weighed against goals of non-intervention, risks of non-intervention, and risks of not intervening in time, additional benefits of not intervening and long term cost of the treatment. The table below indicates the outline.

Table 2 Risk & Benefit Analysis

Intervention Vs. Non-Intervention Risk Benefit Analysis
Goal of interventions	Goals of non-intervention
Risks of intervention	Risks of non-intervention,
Short term benefits of intervention	Risks of not intervening in time
Long term benefits of intervention	Additional benefits of not intervening
Cost of intervention	Long term cost of the treatment

If, homoeopathy can offer comparable benefits then the need for surgery is eliminated. If homoeopathy can offer additional assistance then surgery is indicated, but consuming homoeopathy pre-operatively or post -operatively will offer patients that extra benefit.

The quantum of benefits or outcomes in favour of the patient tilts the decision in favour of or against the surgery. The same will hold true for use of homeopathy instead of surgery as standalone or as an adjuvant.

To check the operational usefulness of these criteria we have listed real life examples. The surgeries are listed as indicative examples and the role of homoeopathy is also mentioned next to it. We have tried to provide graphical presentation for ease of comprehension indicating weights of surgery and homoeopathy in given example.

Table 3 Examples of Goals of Treatment Indicating role of Surgery & Homoeopathy

#	Goals of Intervention/ Therapy	Indicative Example	Homoeopathy	Surgery
1	Save a life itself	Angioplasty in a case of unstable angina
2	Save an individual from life threatening complication	Coiling of a Cerebral aneurysm before developing a SAH. Subarachnoid haemorrhage is an uncommon cause of stroke mortality but occurs at a young age, producing a relatively large burden of premature mortality, comparable with ischemic stroke. Subarachnoid haemorrhage accounts for 4.4% of stroke mortality but 27.3% of all stroke-related years of potential life lost before age 65, a measure of premature mortality.
3	Prevent permanent loss of tissues and function.	Grade II & III soft tissue injury. Grade II injury results in some joint instability. While many injuries can heal on their own, the most severe ones involving tears may require surgery. A Grade III, the worst soft tissue injury, results in a complete tear that will require surgery.
4	Restore alignment & help healing	Long bone fractures requiring nailing or plating.
5	Restore physiological efficiency of an organ	Removing a ureteric stone causing hydronephrosis and back pressure impacting the filtration.
6	Relive pain & distress	Stereotactic radiosurgery to relive Trigeminal Neuralgia
7	Improve quality of life	Obstructive sleep apnea. To improve sleep and reduce risk of Diabetes type II , Hypertension , Brain damage and Cardiac Arrhythmias
8	Improve aesthetics of the body.	tummy tuck (abdominoplasty), breast augmentation, breast reduction, eyelid surgery, nose reshaping (rhinoplasty), face lift and removal of fat (liposuction).
9	Prevent relapse or recurrence of pathology	Prevent relapse of malignant tumour Prevent recurrence of per-anal fistula
10	Reduce existing drug load on permanent basis	Thymectomy, may sometimes be recommended for myasthenia gravis. This has been shown to improve myasthenia symptoms in some people with an unusually large thymus & reduce the dose of steroids , reduce the chances of needing immune-suppressants, reduce the chances of needing to go into hospital because of worsening symptoms for at least 3 years after surgery.
11	Help post-op recovery	Use of minimally invasive surgeries have helped early post-operative recovery
12	Help in wound healing	Debridement of infected wound for e.g Bed sore or Non-healing ulcer.

_{Diagnostic intervention such as biopsies are not included in this discussion as they are not meant for therapeutic outcomes.}

It may also be noted that a multiple of these 12 criteria’s may be used to chart out long term and short term goals of a single case. In example 1 (refer table 1) use of angioplasty to preserve life is the short term goal. The long term goal is also to prevent reoccurrence of pathology, where homeopathy may have a strong role. In example 4, surgery of fractured long bone may be indicated for better apposition and alignment, but if homoeopathy is offered post operatively it may provide additional benefit of early healing.

How do we apply this in an individual case?

To apply this in an individual case, a clinician has to follow the steps in the framework mentioned below. Diagnose the case and set immediate and long term goals. Align the goals with timeline of the case. Weigh the risks of surgery. Consider the pros and cons of three different options a) standalone surgery, b) standalone homoeopathy c) integrative care.

Assess skill levels and technical support required to deliver the desired care to achieve the goals. Last but not the least assess socio-economic background. Make a decision, provide clinical care and treatment. Assess outcome and perform gap analysis.

The decision to undergo surgery or skip the surgery and use homoeopathy is also based on other factors like: patient refusing for personal reasons like unaffordability due to cost barrier, severe anxiety to undergo intervention, co-morbidities leading to risk of administering anaesthesia, lack of surgical facility in residing geographical location and lack of skilled surgeons to perform complex surgeries in a given locality. Though the reasons for not opting for surgery are a mix of clinical and socio-cultural, patients may benefit if, offered homoeopathy.

The steps to use decision framework in clinical scenario in surgical patients for a homoeopathic doctor are as follows.

Table 4 Steps for using Decision Framework.

#	Steps	Description of Activity
1	Set the goal of the treatment (Long term and Short term) Using 1a & 1b.	Saving life Preventing life threatening complication Preventing permanent loss of tissue or function. Improving efficiency of organ and its physiology. Improving Aesthetics Improving alignment & healing Preventing relapse
1a	Arrive at provisional diagnosis	History of Patient Clinical Examination Preliminary Investigations Assess co morbidities
1b	Confirm Diagnosis	Specialized specific investigation Expert/Second Opinion ( if required)
3	Set a Time scale	Prognosticate disease based on current clinical staging, co morbidities, exposure to risk factors, inheritance, past history of the patient, response to non-surgical medications. If left untreated what is the outcome? In how much time? If surgery is denied what is the outcome? In how much time?
4	Weighing up risks	Assess risk of complications Assess risk of death Assess risk of permanent loss of tissue Assess risk of permanent loss of function.
5	Weigh Pros & Cons Surgery (A)	Assess implications of going in for surgery e.g. anaesthesia risk, Cost, LOS, Intra operative death, risk of infection, risk of post-operative complications. Cost of the surgery, availability of skilled surgeon, availability of operative infrastructure.
6	Weigh Pros & Cons Homoeopathy ( B)	Assess probability of success if, treated with Homoeopathy based on possibility of finding the correct simillimum and patients ability to respond to it. This should be based on General condition of patient, age, comorbidities, stage of disease reversibility or irreversibility, Miasm, Presence of homoeopathic characteristics in the given case.
7	Weigh Pros & Cons of Integrative approach	Based on Goals + A + B.
8	Assess level of care delivery possible in a Hospital/Nursing home/Home-based etc.	Assess socio-cultural-economic. Assess skill levels and technology required for safe care.
9	Make a decision	State Reasons Watch the outcome
10	Evaluate your decision	Review the set goals against outcomes. Perform a gap analysis.

An individual case has to be processed through the above framework. To stay objective as a clinician following a scoring chart as a tool might help. Scope of surgery should be scored independently in chart 1 and so also scope of homoeopathy in chart 2.  The charts have to be mirrored in each case. The mirroring process will lead to emergence different scenarios.

0	No Scope
1	Least Scope
2	Modest Scope
3	Reasonable Scope
4	Sufficient Scope
5	Definite Scope

Table 5 & 6 Measure & Comparison of Scope of Interventions

			Score
#	Goals of Surgery/ Intervention	0	1	2	3	4	5	Total
1	Save a life						5	5
2	Save an individual from life threatening complication			2				2
3	Prevent permanent loss of tissue				3			3
4	Restore alignment and hence improve functional & structural effectiveness.					4		4
5	Restore physiological efficiency of an organ	0						0
6	Relive pain & distress		1					1
7	Improve quality of life			2				2
8	Improve aesthetics				3			3
9	Prevent relapse or reoccurrence of pathology					4		4
10	Reduce existing drug load on permanent basis				3			3
11	Help post-op recovery	0						0
12	Provide better healing			3				3
								30
			Score
#	Goals of Homoeopathy	0	1	2	3	4	5	Total
1	Save a life	0						0
2	Save an individual from life threatening complication		1					1
3	Prevent permanent loss of tissue			2				2
4	Restore alignment and hence improve functional & structural effectiveness.			2				2
5	Restore physiological efficiency of an organ			2				2
6	Relive pain & distress				3			3
7	Improve quality of life					3		3
8	Improve aesthetics		1					1
9	Prevent relapse or reoccurrence of pathology					3		3
10	Reduce existing drug load on permanent basis				3			3
11	Help post-op recovery					4		4
12	Provide better healing					4		4
	Total							28

It may be noted that, the numbers in the table above are only indicative used to demonstrate the model.

Once the mirroring process is complete the overall scenario of the scope of homoeopathy and surgical intervention for that case will emerge (Refer Graph 1).

Graph 1

As the case moves on from time T1 to time T2 the scope of different interventions may change based on the progress of the case.

Graph 2

This is only half of the solution and further analysis will help zero down on precise roles of surgery and homoeopathy in a given case (Refer Graph 2)

Graph 3

As scoring and mirroring process is done repeatedly in multiple cases, the broad yet definitive scope will get defined for different types of cases based on the data inputs of previous cases (refer graph 3).

Table 7 Assessment of Generic Scope of Surgery & Homoeopathy

#	Goals of Intervention/Therapy	Homoeopathy	Surgery
1	Save a life itself	10%	90%
2	Save an individual from life threatening complication	20%	80%
3	Prevent permanent loss of tissues	30%	70%
4	Restore alignment & help healing	25%	75%
5	Restore physiological efficiency of an organ	50%	50%
6	Relive pain & distress	50%	50%
7	Improve quality of life	50%	50%
8	Improve aesthetics	10%	90%
9	Prevent relapse or reoccurrence of pathology	75%	25%
10	Reduce existing drug load on permanent basis	50%	50%
11	Help post-op recovery	75%	25%
12	Provide better healing	90%	10%

Graph 4

At a generic level we have indicated role of surgical intervention and role of homeopathy. Though the indications are empirical they are based on pragmatic experience. There could be a few exceptions where, homoeopathy has averted a need for surgery or homoeopathy expected to prevent recurrence has failed to do so.

The trend as represented in the graph 4 suggests that the scope varies across the spectrum indicating there is no fixed answer in “yes or no”. There is supposedly a better scope for homoeopathy in post-operative healing & prevention of recurrence.

The scope for surgery is dominant when it comes to saving life or averting a life threatening complication, preventing permanent loss of tissue or function. There is shared scope if, surgery is done to improve physiological efficiency, relieve mere pain or improve just the overall quality of life.

We shall now apply these criteria as a case study in cases of paediatrics where surgery was indicated. For the sake of discussion, we are using 7 cases of various clinical diagnosis of paediatric age group to demonstrate the scope of homoeopathy and the algorithm.

CASE- 1

A 2-month-old female, a known case of acyanotic heart disease with cardiomegaly came with the complaints of cough, fever and dyspnea since 3 days, cough aggravating at 3-4 am, taken allopathic treatment for the same, but not better.

On examination findings

Temp – 102 F

Pulse rate – 160/min

RR- 80/pm

Chest examination –

Bilateral Crepitations

Bilateral intercostal retraction

Sub costal retraction

Per abdominal examination –

Liver 3 and half fingers palpable,

Tender spleen just palpable

CVS – systolic murmur present.

Investigations:

Hb – 13

TLC – 10800

N – 56

L – 42

E – 2

M – 0

X-ray CHEST : Right Para- cardiac Pneumonitis with Cardiomegaly.

Diagnosis

Acyanotic heart disease with Cardiomegaly with Right Paracardiac Pneumonitis in CCF

Discussion:

In heart failure, the heart may not provide tissues with adequate blood for metabolic needs. The cardiac-related elevation of pulmonary or systemic venous pressures may result in organ congestion. This condition can result from abnormalities of systolic or diastolic function or, commonly, both. The primary abnormality can be a change in cardiomyocyte function &reduced O2 with lower systemic blood pressure. This activates arterial baro-reflexes, increasing sympathetic tone and decreasing parasympathetic tone. As a result, heart rate and myocardial contractility increase, arterioles in selected vascular beds constrict, veno-constriction occurs, and sodium and water are retained. These changes compensate for reduced ventricular performance and help maintain hemodynamic homeostasis in the early stages of heart failure. Until this time when heart is still compensating and homoeopathy has fair scope to heal the failing heart.

 Pulmonary congestion with dilated capillaries and leakage of blood into alveolar spaces leads to an increase in hemosiderin-laden macrophages. Brown granules of hemosiderin from break down of RBC’s appear in the macrophage cytoplasm. These macrophages are sometimes called “heart failure cells” because of their association with pulmonary congestion with congestive heart failure. This is the reason why we often see blood streaked frothy sputum.

  However as time passes, these compensatory changes increase cardiac work, preload, and afterload; reduce coronary and renal perfusion; cause fluid accumulation resulting in congestion; increase potassium excretion; and may cause cardiomyocyte necrosis and arrhythmias. In this phase the system decompensates and hence it becomes that much difficult for dynamic homoeopathic doses to stimulate the system.

Short-term Goals include relieving symptoms and improving hemodynamics; avoiding  hypokalemia, renal dysfunction, and symptomatic hypotension; and correcting neurohumoral activation.

Discussion:

The child had congenital agenesis of the heart. The structural agenesis needed further evaluation and mainly a surgical intervention. The child had developed a lower respiratory illness with pneumonia. Children with congenital heart disease are more prone to respiratory infections. If the infection is severe they may land up intocardiac failure due to high output secondary to infection. So, in this case the scope of homoeopathy was mainly to treat the pneumonia which had set in a cardio-respiratory compromise and failure. Once the failure is controlled and pneumonia treated the child should be referred for surgical evaluation of the heart and further management. Surgical correction of the congenital agenesis shall prevent such and similar episodes and also contribute to overall growth of the child. Also, the hospital where case was treated had the intensive care unit but did not have cardiac surgery facility.

 Totality

Cough < 3-4 am

Pneumonia (Inflammation) contributing to early heart failure (Odema & pulmonary congestion) Affection of heart with lungs

 Discussion:

 Being a pediatric case totality was formed by correlating key note of Cough worst at 3-4 am with the pathology of pneumonia and failing heart.

 After reading the pathophysiological response it is evident that the heart and the lung get congested turgid and edematous leading to blood streaked transudates. Hence, we need a remedy with retention, accumulation turgidity and fatigue of tissue as its core genus.

 KALI CARB has 3-4 am aggravation but the heart is irritable and accelerated. In addition, the fluid collection is usually localized as in between the serous membranes in lungs unlike generalized in this case.

 ANTIM TART also has the same aggravation time but usually has bronchi and alveoli full of exudates, hence the rattle. The lung fatigue is more prominent than the heart. Lung infection is more the seat of illness than the congestive and edematous failure of heart and lung.

 STROPHANTHUS has heart failure and is usually used to run off the dropiscal affection. But the seat of pathology is degenerative changes in arteries & valves leading to failure. The heart beats rapidly to the extent that patient can experience palpitations and throb.

 AMMONIUM CARB is slow, sluggish, exhausted congested and edematous especially with cardio pulmonary pathogenesis. There are transudates mixed with blood. This is the genius of ammonium represented by general symptoms and its core pathological expressions. In addition it has 3-4 am aggravation. Therefore, based on key note of 3-4 general aggravation and genesis of pathology Ammonium Carb was selected.

 Remedy

Ammonium carb 30 multiple doses

Follow up

Within 1 hour cough was better by 50% patient was comfortable and slept peacefully. Discharged within 24 hours as cough and respiratory rate settled. Referred to tertiary care for further surgical evaluation

 Discussion:

In this case homoeopathy was used to manage life-threatening medical complication of a primarily a congenital surgical disorder. To achieve short term goals homoeopathy was used and to achieve long-term goals the surgery.

 Primary information of CHD.

Introduction

Congenital heart disease includes abnormalities in heart structure that occur before birth. Such defects occur in the foetus while it is developing in the uterus during pregnancy

Incidence

About 500,000 adults have congenital heart disease in USA. 1 in every 100 children has defects in their heart due to genetic or chromosomal abnormalities, such as Down syndrome.

Etiology

There is no obvious etiology but well recognized association includes:

1. Maternal illness
2. Systemic lupus
3. Diabetes
4. Rubella
5. Alcohol abuse
6. Certain drugs
7. Chromosomal anomalies
8. Trisomy 21
9. Trisomy 13 and 18
10. Turner’s syndrome

Classification

Congenital heart disease is broadly classified into cyanotic and a-cyanotic heart disease though no distinction is clear cut.

A-cyanotic congenital heart diseases

Persistent ductus arteriosus

• This anomaly accounts for 5-10 percent of congenital heart disease.
• Following birth, the ductus arteriosus, which facilitates the transfer of oxygenated blood in the fetal circulation from the pulmonary artery to the aorta, begins to close.
• In the isolated case of patent ductus, there is left to right stunt of blood resulting in high pulmonary blood flow.
• This may lead to respiratory difficulties in preterm child in addition to heart failure.
• If medical treatment to close the ductus is unsuccessful the lesion may be treated by interventional cardiology (i.e umbrella occlusion device inserted percutaneous) or by surgery via a left thoracotomy.
• Asymptomatic persistent ductus should be treated at any age because of the risk of infective endocarditis

Coarctation of aorta

• This accounts for 5 percent of congenital heart disease
• In this condition the arch of aorta around the ductus arteriosus is narrowed.
• This coarctation puts a pressure load on the left ventricle which will ultimately fail
• The upper body is well perfused leading to fluid overload, kidneys is poorly perfused leading to fluid overload excess renin secretion and acidosis.
• There is radio femoral delay when examining the pulses.
• Emergency treatment includes the administration of indomethacin to reopen the ductus and general resuscitation before corrective treatment which includes ballon dilatation or open operation via a left thoracotomy
• Operative options include resection of the coarctation and end to end anastomosis or the use of left subclavian artery as an onlay flap.

Investigations

• In a child suspected with congenital heart disease a through history need to be taken from the parents and specific information regarding the maternal history and drug intake during pregnancy is to be asked for.
• A proper family history is also important as some defects are familial.
• Evaluation of various presenting signs and symptoms along with various investigational modalities available which include oxygen saturation, echocardiography along with conventional electrocardiography and chest roentgenography and newer axial views of cineangiography have made it possible to arrive at a precise diagnosis

CASE- 2

A 7-month old child was brought by her mother in the evening at 4pm with complaints of excessive crying since 2 days. Child suddenly started crying without any reason. They took treatment from a general physician with temporary relief.  After a while child started crying again for around 1-1½ hours & become asymptomatic in sometime. Child would crouch while crying due to abdominal pain.

Since last one day, the child started with loose stools. They are initially scanty, semisolid, with mucous, yellowish green. Later, it became reddish mixed with mucus.

Examination findings:

Child cranky⁺⁺

Bending double while crying

Temp- 97⁰ F,

Pulse – 120/min

Respiratory System– clear

Per Abdomen: soft, lump palpable in Rt. Lumbar region. Tenderness⁺⁺

Bowel sounds++

Cardio-Vascular System– S1,S2 normal.

 Investigations:

• USG at 4.30pm: Ileo-caecal intussusception of size 4.8×5.2 cms.
• Stool routine: Color- reddish brown, Mucus+RBCs: 50-60/ hpf, Pus Cell- 5-6per/hpf

 Differential Diagnosis

The commonly considered differential diagnosis are; Abdominal hernias, Appendicitis, Blunt abdominal trauma in emergency medicine, Colic, Cycling vomiting syndrome, Bacillary dysentery, Gastroenteritis, Volvulus, Testicular torsion.

Discussion:

Any two classical symptoms out of the four are sufficient to arrive at the diagnosis. In this case, we do have abdominal pain, abdominal mass and most important sign the rectal bleeding for easy diagnosis.

Although, we do have abdominal pain, vomiting, and stool with blood and mucus occur in acute gastroenteritis or bacillary dysentery as well, but in these cases diarrhea is the leading symptom.

Similarly, in rectal prolapse expect projecting mucosa that can be felt in continuity with the perianal skin, whereas in Intussusception, the finger may pass indefinitely into the depth of the sulcus

Diagnosis:

Classical symptoms of intussusception are; Stool mixed with blood and mucus — sometimes referred to as currant jelly stool because of its appearance. Vomiting and a lump in the abdomen. Weakness or lack of energy. Diarrhoea & pain in abdomen

 Discussion:

The only outcome a homoeopathic physician can aim for in this case is to avert surgery in the shortest period of time. If surgery is avoided the hemodynamic, anesthesia and post-surgery recovery risks can be avoided. Besides, it will save the agony for the patient’s parents and off course the cost of the treatment.

The time factor is critical to determine the thin line between vascularity and a- vascularity of the affected tissue. Once this line is crossed it will progress into zone of irreversibility and will complicate into avascular necrosis and peritonitis and sepsis. The life of the child will be further endangered at that moment with poor prognosis.

To avoid taking unwarranted risk patient and to achieve this critical balance between homoeopathic conservative & timely surgical intervention there is a need for the child to be monitored by an integrative team of surgeon and homoeopathic clinician.The ancillary care of fluid and electrolyte balance is important to maintain the vitals of the child.  The hospital should have facility for emergency pediatric surgery including an aesthesia.

The homoeopathic clinician has to base his judgment of accepting the case on availability of homoeopathic characteristic, clear cut homoeopathic totality, assessment of susceptibility & vitality of the patient.

 Prognosis:

Timely management of intussusception is critical to avoid complications, including perforation, bowel necrosis, and rarely short bowel syndrome. The prognosis for intussusception is excellent if treated quickly, but if untreated it can lead to death within two to five days. The longer the intestine segment is prolapsed and the longer it goes without a blood supply, the less effective a non-surgical reduction. Prolonged intussusception increases bowel ischemia and necrosis, requiring surgical resection.

 Discussion:

So to summarize the above information, “time is essence” in diagnosis and treating intussusception. The more we lose time the lesser the chance of recovery without surgery.

The approach to the case in pediatric emergency and acute care is usually based on correlation of key notes observed by the physician or reported by the mother and its co relation of pathophysiology.

From a pathophysiological angle we need a drug which will have dys-motility of hollow tubular organ, constrictive sensation and pathology both. The drug should have sphere of action on nerves specially ANS and sensory nerves causing hypersensitive pain response.

The keynote of bending double should be the peculiar differentiator.

Discussion of the remedies:

Some of the Drugs which may help us in such Situations:

ACONITE: They cry and complain much, are sleepless and restless. There is obvious panic on the face. The main action is on sensory nerves and vasomotor response is strong in aconite. Vomiting, bilious mucous and bloody, greenish. Pressure in stomach with dyspepsia. Hot, tense, tympanitic Abdomen. Sensitive to touch. Colic, no position relieves. Watery diarrhoea in children.

ARSENICUM ALBUM:  Vomiting of blood, bile, green mucus, or brown-black mixed with blood. Stomach extremely irritable; seems raw, as if torn. Dysentery dark, bloody, very offensive. Cholera, with intense agony, prostration, and burning thirst. Arsenic is usually indicated when there is an  infection but may get indicated in late stage of intussusception when necrosis of intestine sets in.

BELLADONA: Belladonna stands for violence of attack and suddenness of onset. Great children’s remedy. Spasms of stomach. Empty retching. Uncontrollable vomiting. Transverse colon protrudes like a pad. Tender, swollen. Pain as if clutched by a hand; worse, jar, pressure. Thin, green, dysenteric; in lumps like chalk. Shuddering during stool. Comes close to the case from colic perspective but rarely has the centrality of dys-motility.

BRYONIA: Vomiting of bile and water immediately after eating. Worse, warm drinks, which are vomited. Stomach sensitive to touch. Pressure in stomach after eating, as of a stone. Burning pain, stitches; worse, pressure, coughing, breathing. Tenderness of abdominal walls. This remedy though has symptoms that may come up when there is peritonitis secondary to infection of a tubular organ like appendix. The onset is usually slow as well.

COLCHICUM: Vomiting of mucus, bile and food; worse, any motion. Caecum and ascending colon much distended. Fullness and continuous rumbling. Painful, scanty, transparent, jelly-like mucus; stools contain while shreddy particles in large quantities. Ineffectual pressing; feels feces in rectum, but cannot expel them. The closest of all except the fact that it does not have the keynote of the case.

COLOCYNTH: The remedy acts on intestine & ANS causing spasm, constrictions, sudden jerks and loss of synchronized motility of hollow organs like intestines and ureters. Agonizing cutting pain in abdomen causing patient to bend over double, and pressing on the abdomen. Sensation as if stones were being ground together in the abdomen, and would burst. Intestines feel as if bruised. Each paroxysm is attended with general agitation, chill and jerks.. Dysenteric stool renewed each time by the least food or drink. Jelly-like stools.

MERCURIUS SOLUBILIS: Is indicated when colon has ulcers that bleed. Infective bacterial etiology or autoimmune in nature. The symptoms are for colo-rectal origin specially involving the sigmoid colon and rectum causing tenusmus as key pathological expression along with blood. Flatulent distention, with pain. Greenish, bloody and slimy Stools, worse at night, with pain and tenesmus. Never-get-done feeling. Discharge accompanied by chilliness, sick stomach, cutting colic, and tenesmus.

MERCURIUS CORROSIVUS: A mercurious with violent action more blood and intense tenesmus. Intense feeling of constriction of rectum and along with that of neck of bladder as well. Never get done feeling even after evacuating. Bruised sensation; cecal region and transverse colon painful. Bloated Abdomen; very painful to least touch. Dysentery; tenesmus, not relieved by stool; incessant. Stool hot, bloody, slimy, offensive, with cutting pains and shreds of mucous membrane.

OPIUM: Opium is indicated when key presentation is obstipation, loss of peristalsis due to paralysis of bowels and altered sensorium. Multi organ involvement due to sepsis in intestinal obstruction with anuria due to loss of bladder tone and loss of bowel sounds on examination. Vomiting, with colic and convulsions. Fecal vomiting. hard, bloated, tympanitic. Remember opium is dry and hot.

PLUMBUM METALLICUM: The remedy of contraction, restriction, constriction and convulsions. The pulling sensation and retraction towards spine is hall mark. Has strong spheres of action on nerves spinal, ANS, and Muscles of intestine. Contraction and colic caused mainly due to sclerotic pathology is hall mark. Slow ischemia causing necrotic and sclerotic tissues. Contraction in œsophagus and stomach; pressure and tightness. Gastralgia. causing constant vomiting. Excessive colic, radiating to all parts of body. Abdominal wall feels drawn by a string to spine. Although is better by pressure pain causes desire to stretch. Intussusception; strangulated hernia.  Abdomen retracted and drawn in to uneven lumps which move..Anus feels drawn up with obstructed flatus, obstinate constipation and intense colic.

Remedy:

Depending on the attitude of crouching attained by the child & seat of action of the remedy i.e  hollow organs and ANS acuity of disease, Colocynth 200 pills stat dose given and repeated ½ hourly

Follow up:

Follow up after 2 hours was as follows: Child slept within 15 minutes. She had not slept the whole night yesterday. But intermittently would wake, cry for few minutes and again sleep.

USG FINDINGS: Intussusception 4.4×5.0cms. Peristaltic waves seen inside the intussusception.

Follow up after 3 hours was as follows: Intussusception 2.8×2.4 cms in size. Peristalsis was present.

The potency of Colocynth was stepped up to 1000C 1 dose stat.

Follow up after 10 hours: Child slept peacefully at night. Did not wake up whole night. Stool passed once yellow, small. Urine-passed

USG FINDINGS: Normal

Discussion:

In this case an integrative team of doctors used homoeopathy along with close monitoring to manage the case conservatively and avert a surgery.

Intussusception

Intussusception is one of the most frequent causes of acute bowel obstruction in infants and toddlers. It most commonly occurs in a proximal to distal direction. The most common area to be affected is the ileum intussuscepting into the cecum and ascending colon.

It occurs throughout the world with an incidence of approximately 1 to 4 in 2000 infants and children. The incidence is highest in infants between the ages of 4 and 10 months, but it can also be found in neonates and adults. The male: female ratio is 3: 1.

Intussusception can be categorized into four main types: general, specific, anatomic, and other.

(1) The two general types are permanent (fixed, 80%) and transient (spontaneous reduction, 20%);

(2) the specific types can be described as idiopathic (no pathologic lead point [PLP], 95%), PLP (4%), and postoperative (1%)

(3) when classified by anatomic types, their actual occurrence is ileocolic (85%); ileoileocolic (10%); appendicocolic, cecocolic, or colocolic (2.5%) jejunojejunal, ileoileal (2.5%); and those occurring around indwelling tubes; and

(4) the fourth type is “other”. Under this category are recurrent (5%) and neonatal (0.3%) intussusception.

Pathophysiology

The part that prolapses into the other is called the intussusceptum. The part that receives it is called the intussuscipiens. An anatomic lead point occurs in approximately 10% of intussusceptions. Almost all intussusceptions occur with the intussusceptum having been located proximally to the intussuscipiens. This is because a peristaltic action of the intestine pulls the proximal segment into the distal segment. Usually, the ileum enters the cecum. Rarely does a part of the ileum or jejunum prolapse into itself.

The trapped section of the bowel may have its blood supply cut off, which causes ischemia. The mucosa is sensitive to ischemia and responds by causing sloughing off into the gut. This creates a “red currant jelly” stool, which sloughed mucosa, blood, and mucus.

“Red currant jelly” occurs in a minority of cases of intussusception and should be considered in the differential diagnosis of children passing any bloody stool. The trapping of the bowel loop and ischemia creates urgency, hence needs immediate intervention earlier on a medical and in advanced stages a surgical.

It should be suspected with any of the two classic symptoms (abdominal pain or vomiting) or two classic signs (abdominal mass or rectal bleeding). Severe intermittent cramping abdominal pain occurring at intervals every 15 to 20 minutes in an infant or toddler is a hallmark of intussusceptions.

The sudden onset of severe, colicky, intermittent abdominal pain, which makes infants pull up their legs, is the most common classic symptom of pediatric intussusception in about 85% of patients. The child will initially be well in between spasms but will later become pale and lethargic. As intestinal obstruction develops, the vomiting will become bilious.

Bright red rectal bleeding mixed with mucous, the so-called “red currant jelly stool,” will be seen in up to 25% of cases and more frequently if digital rectal examination is performed. Rectal bleeding is usually the last sign to occur. A palpable mass is felt in the right upper quadrant or epigastrium along with a distinguishable feeling of emptiness in the right iliac fossa (Dance’s sign).

The most serious complication is stretching and constriction of the mesentery resulting in venous obstruction, causing engorgement and bleeding from the bowel mucosa, fluid loss, and subsequently bowel perforation, peritonitis and gut necrosis.

Ultrasound has a sensitivity of approximately 98-100% and a specificity of approximately 98% in diagnosing intussusception. The diagnostic findings of intussusception on ultrasound include a tubular mass in longitudinal views and a doughnut or target appearance in transverse images

Treatment of an infant or child with an intussusception must start in the emergency department, and the surgeon should be involved from the initial presentation. Spontaneous reduction of intussusception occurs in approximately 4-10% of patients. Untreated intussusception in infants is usually fatal.

CASE-3

A one and half year-old male child was brought into emergency room with excessive crying for more than 48 hours. The child did not pass stools and there was severe distention of abdomen since 3 days which was not better after using allopathic medication.

History of complaints:

There was a history of upper respiratory tract infection 7 days back which, was better by allopathic treatment. The child had excessive crying and had not slept since 3 days. He had to be continuously carried on shoulder and moved about. The symptoms would stop intermittently and reoccur. Urine frequency had decreased since 3 days and so was the appetite. History of similar episode 6 months back which was better with allopathic medicine.

Examination findings

Weight – 6 kgs

Large head, anterior fontanelles open

Child was cranky while examination.

Temp – 100.4℉

Pulse rate – 130/pm

Respiratory system – Bilateral Crepitations

Per abdomen – Distended and tense, umbilicus everted, tenderness, bowel sounds present.

Investigations

Hb – 8gm%

WBC Count – 12200

Neutrophils – 58

Lymphocytes – 36

Eosinophils -4

Monocytes -2

ESR – 4

Serum calcium – 9.2

Serum creatinine – 0.52

Urine routine – Normal

X Ray Abdomen – Distended bowel loops

USG abdomen – Distended bowels

Diagnosis – Chronic intestinal pseudo obstruction

Clinical features of chronic intestinal pseudo obstruction

Group of disorder characterised by signs and symptoms of intestinal obstruction in the absence of anatomic lesion

• Most congenital forms of pseudo obstruction occur sporadically
• Symptoms wax and wane
• Poor nutrition and inter-current illness tends to exacerbate symptoms

 Discussion:

In this case the scope of homoeopathy is enhanced as the diagnosis is established by careful history, examination findings and some basic investigations.

 Once it is with fair amount of certainty established that there is no specific mechanical obstruction the scope of homoeopathy gets boosted as pathology is mostly functional. Thou seemingly it looks like a intestinal obstruction and therefore surgical.

 Rapid symptomatic relief is the short term goal. If, the symptoms are resolved rapidly the need for further exploration is curtailed. Prevention of future such and similar episodes becomes the long term goal of the case.

 Homoeopathic therapeutics

 ALUMINA- Constipation in alumina is mostly due to dryness of intestinal tract. There is diminished peristaltic movement and complete inertia of the rectum. Even soft stool is expelled with great difficulty, Dry mouth and irritated looking tongue lead to the selection of this remedy. A thin child, highly inactive as if paralysed. Inactive rectum and bladder both. Must strain to pass stool or urinate.

SULPHUR has an ineffectual urge to stool, with a sensation of heat and discomfort in rectum, there is a general uneasy feeling all through the intestinal tract due to abdominal plethora or passive portal congestion. Great straining to stool, the first effort to stool being extremely painful. There is much twitching and burning of the anus. The orifices are red with fissures. The child is lean and lanky lethargic, dirty. At times could be peevish and excitable.

OPIUM– There is an absolute inaction of the intestines, a regular paralysis of the peristaltic movements. There is an absence of desire, absolutely no urge to stool, faeces become impacted in the bowels, when passed at all come in little, hard, dry, black balls. Flatus accumulates in the upper parts of intestine.

The child is usually sleepy or drowsy. The pain factor is less but toxicity is high with altered respiratory rhythm. The head is hot to touch and sweat also is warm. Child searches for a cold place to get relief. Child will have unexplained twitching of muscles.

GRAPHITES- There is no urge with constipation of days together. The patient goes days without passing the stool, when it does come it is composed of little round balls, knotted, together with shreds of mucus, slimy stools and accompanied by great pain when passing. Abdomen is distended with incarcerated flatus. Child passes lumpy thick and hard stools. Child is listless, lax, flabby, chilly and confused.

PLATINA- There is torpor of the whole intestinal tract, unsuccessful urging to stool and great dryness of rectum. Hard black scant stool, difficult to pass. The stools seem to adhere to rectum like glue. There is great weakness in the abdomen and sensation as if there were a load in the rectum which could not be expelled.

There is violent cramping and congestion with hypersensitive reaction reaching hysterical amplitude. This is usually followed by the opposite state of numbness. The child has foul mood is abrupt and unkind.

CINA- Hunger alternating with loss of appetite. Twisting pain at the navel, distended and hard abdomen. Stool is white watery, itching at the anus, unpleasant warm feeling in the abdomen. Child has excessive incessant crying only better by moving around and carrying the child on the shoulder or rocked. Child is usually in ugly mood, cross with everyone and difficult to please. Stiffens out if spoken to or even looked at.

Treatment given – Cina 200C – 4 hourly

Ancillary measures

Abdominal girth 4 hourly

Nil by mouth

TPR 2 hourly

Pass flatus tube 4 hourly

Discussion:

Cina was chosen based on the behaviour and mental state of the child. There was a peculiar modality of moving around and carrying on shoulder that would ameliorate the cry. This mental state accompanied by distension of abdomen and location of large bowel point towards Cina. The other half of the management is auxiliary which, is equally important as homoeopathic medicine.

Follow up

Within half an hour child slept peacefully after 3 days After 1 hour passed stool in moderate quantity. Fever settled after 12 hours. There was no crankiness. Abdominal distention better.

After 24 hours no further improvement in abdominal distention, stool not passed again.

Cina 1000C – single dose given. After 1 hour passed moderate quantity of stool. Later passed 2-3 stools in the next 6 hours. Abdominal distention was nil.

Discussion:

Once the diagnosis was established the need for surgical intervention was ruled out the entire scope of management was homoeopathic. It is thus, imperative that the diagnosis of surgical cases are well established to understand the level of functional and structural impairment in the case.

 Intestinal Obstruction

Intestinal obstruction is a common surgical emergency, because of its severity it demands early diagnosis and speedy relief. It is classified into two main types

1. Dynamic; peristalsis is against an obstructing agent in the lumen, in the wall or outside the wall.
2. Adynamic: In this condition, peristalsis ceases no true propulsive waves occur

Pseudo-obstruction

It is a type of intestinal obstruction presenting with classic signs and symptoms but with no mechanical cause. It usually affects the colon and occasionally involves the ileum

Incidence

CIPO can develop in children and adults. Many patients with CIPO also have underlying degenerative neuropathic and myopathic conditions. It is estimated that 20% of patients on home parenteral nutrition have CIPO. Limited epidemiological studies characterised CIPO in the U.S. Studies from Japan have reported a prevalence of 0.8 and 1.0 and an incidence of 0.21 and 0.24 cases per 100,000 adult men and women, respectively.

Etiology

The causes associated with pseudo-obstruction could include:

1. Idiopathic
2. Retroperitoneal irritation by blood, urine, enzymes, tumour
3. Idiosyncratic drug reaction – tricyclics, phenothiazines, levodopa
4. Metabolic disorders – diabetes, hypokalemia, uraemia, myxoedema
5. Severe trauma especially to lumbar spine and pelvis
6. Shock from severe burns, myocardial infarct or stroke
7. Septicaemia

When it comes to the idiopathic group many present with abnormal nerve tissue in the wall of the bowels. Correction of it may cure the obstruction.

Clinical features

The classic presentation of chronic intestinal pseudo obstruction depicts abdominal distention, recurrent episodes of abdominal pain, inability to defecate, with or without episodes of vomiting mimicking a mechanical sub occlusion.

Acute episodes last only for a few hours but in most severe cases there is chronic distention and air filled levels in the intestinal loops which is detectable.

Nausea, vomiting and weight loss are the predominant symptoms when it is involving the upper gastrointestinal tract, diffuse abdominal pain, abdominal distention and constipation are more of lower gastrointestinal tract involvement.

Urinary symptoms associated with urinary tract distention are also frequent.

Diagnosis

Diagnosis of chronic intestinal pseudo obstruction is mainly clinical, supported by radiological evidence of dilated bowels with air fluid levels after exclusion of organic lesions in the lumen, mechanical occlusion, and any possible causes of secondary forms.

1. Radiology – plain abdominal films depict distended bowel loops with air fluid levels when the patient is in upright position. Entero-CTscan allows internal and external views of the gut wall, abdominal CT and MR scans are important in investigating possible causes of gut compression.³
2. Endoscopy – the Upper GI endoscopy is done to rule out any mechanical occlusions in the gastro-jejunal or ileo-colonic regions
3. Laboratory tests – tests are useful to monitor hydro-electrolyte balance and circulating levels of essential elements in patients on parenteral nutrition or, in general, with a severe malnutrition.
4. Manometry – Small bowel manometry is invariably abnormal in CIPO patients, however, the test is not of diagnostic value due to its low specificity. It can play a supportive role in defining the diagnosis, as to differentiate mechanical from functional obstruction.

Ogilvie syndrome is an Acute colonic pseudo obstruction (ACPO) which is a rare condition first reported in 1948 by Sir William Ogilvie. It is characterised by acute colonic dilatation in the absence of an intrinsic mechanical obstruction or an extrinsic inflammatory process (toxic megacolon).

Acute mesenteric ischemia occurs when narrowed or blocked arteries restrict blood flow to your small intestine. Decreased blood flow can permanently damage the small intestine.

Diverticulitis is a general term that refers to the presence of diverticula, small pouches in the large intestinal (colonic) wall. These outpouchings arise when the inner layers of the colon push through weaknesses in the outer muscular layers.

Hirschsprung disease is a developmental disorder characterised by the absence of ganglia in the distal colon, resulting in a functional obstruction. Most cases of Hirschsprung disease are diagnosed in the newborn period. Hirschsprung disease should be considered in any newborn who fails to pass meconium within 24-48 hours of birth.

Chronic megacolon as well as megarectum, is a descriptive term. It denotes dilatation of the colon that is not caused by a mechanical obstruction. Although the definition of megacolon has varied in the literature, most researchers use the measurement of greater than 12 cm for the cecum as the standard.

 Management

Patients with suspected obstruction should receive intravenous fluids and electrolyte replacement with placement of nasogastric tube to decompress the stomach.

A complete blood count should be obtained because the presence of leukocytosis with a left shift in the differential count should raise suspicion of compromised intestines.

If there is complete obstruction with fever, pain, and no passage of flatus or stool, the child needs immediate exploration. Observation is warranted if there is a partial bowel obstruction in the absence of fever, leukocytosis, and localised abdominal pain. Observation should include frequent abdominal examinations, serial abdominal radiographs, and frequent measurement of serum electrolytes.

CASE-4

An 8-year-old male child was brought to the hospital complaining of frank and large hematemesis. He was a single child of educated parents brought to the hospital carried by father. Child had never taken homoeopathy before. Details of the complaints were as follows:

• Gets similar episode every year around same time.
• Frank profuse bright red bloody vomiting 3- 4 vomiting/day.
• Passing dark tarry stool 3-4 days prior vomiting.
• No history of abdominal pain.
• No history of having consumed any substance.
• History of 3 similar episodes in which child had collapsed and was dyspnoeic. Had to be revived, given blood transfusion & life support system. Each episode lasted for three to four days. Not better with sclerotherapy.

Past history:

Deep obstructive jaundice at the age of 1 yr.

Milestones delayed

General Physical Examination:

General condition unsatisfactory, cold clammy skin

Heart rate 130/min

Respiratory rate 43/min

Hypotension

Per abdomen: Liver hard and spleen palpable.

Investigation:

• Total WBC Count :10,000
• Hb: 4 gm%
• Platelet: 1.4 Lakhs
• B.T: 4.14/sec.
• C.T: 3.10/sec.

Ultrasound examination of the previous admissions shows nodular liver enlarged with splenomegaly.

Differential Diagnosis

• Haemorrhagic and Erosive Gastropathy which, differs as there is sub-epithelial haemorrhage and erosions no major blood vessels are involved hence no major bleeding.
• Erosions reports around 2-10% of patients more prevailing in neonatal intensive care unit (NICU). Most common cause is NSAID -nonsteroidal anti-inflammatory drug use and stress.
• Peptic ulcers where bleeding is rare compared to adults. One third patients found to have active bleeding require surgery. Hematemesis and perforation are secondary to peptic ulcer.
• Mallory- Weiss tear is ruled out as it occurs at the Gastro-oesophageal junction primarily the gastric side, resulting from retching or coughing followed by Hematemesis less frequently seen in Children.

Diagnosis: As the patient had the symptoms like bloody vomiting 3-4 /day with dark tarry stools 3-4/day, palpable liver & spleen. There were similar episodes earlier leading to collapsed state indicating hypovolemic shock due to torrential bleeding. Based on above clinical history the diagnosed case as Oesophageal Varices.

Gr. II – III Oesophageal varices with portal hypertension due to cirrhosis of liver and splenomegaly presenting with hematemesis with impending hypovolemic shock.

Discussion:

There was a substantial blood loss in this episode and the haemoglobin also was significantly low. This patient had collapsed thrice in the past and hence there is a possibility of the same occurring once again.

 The best short-term scope in this case is to stop bleeding as soon as possible and maintain patient in hemodynamic stable conditions.

 If, the conservative measures fail then patient will have to undergo surgical intervention to stop bleeding like Balloon Tamponade/ Endoscopic Variceal Ligation or Sclerotherapy. 

 The long term goal is to prevent further reoccurrence of bleeding episodes and prevent further progress of cirrhosis. If conservative treatment does not help then patient may be subjected to venous graft or liver transplant.

 TOTALITY

• Annual aggravation
• Sudden ness
• Pathology
• Degeneration
• Destruction
• Haemorrhage
• Shock

Location

4) Craving sweets

Discussion:

The case had sufficient homoeopathic characteristics like annual aggravation plus the pattern of disease was recurrent and similar for e.g. Haemorrhage followed by sudden shock. In each of the shock episode the vitality was low and child faced a near death situation. The seat of disease was gland i.e. Liver and its blood vessels, the pathology was rapidly progressing fibrosis. The case had moved from reversible to irreversible pathological zone rather quickly. From a homoeopathic perspective all this would translate into indications of tubercular to syphilitic miasm..

 Susceptibility assessment was based on the pace of disease which is moderate to fast paced changes with compromised vitality. There is a degenerative liver- irreversible pathology with complication of varices & haemorrhage. There are very few homoeopathic characteristic symptoms. The totality was formed on basis of discharges, pathological generals and location. There was only one general modality of annual aggravation.

Differential group of remedies.

 PHOSPHORUS: This remedy is indicated where there is bright red blood present in vomiting. Patient craves cold drink which is vomited after little while. Patient has regurgitation by mouthfuls there is spasm of oesophagus at the cardiac end. Patient has ravenous hunger in spite of vomiting. Pain in the stomach is better by cold drink. Patient has empty hollow feeling in the stomach. very fetid stools and flatus. Long, narrow, hard, granular stools.

 HAMAMELIS: The principal action of the drug is on veins producing congestion and fullness. There is congestive fullness prickling and stinging pain. Vomiting of black blood with large quantity of tar like blood in stool. There is great prostration. There is swelling, enlargement and engorgement of vessel. Hæmorrhoids, bleeding  profusely, with soreness.

 LEPTANDRA: Affects liver and causes bleeding which is worse periodically. There is craving for cold drinks but it aggravates the pain and sinking feeling in pit of the stomach. Stools are black tarry with foetid smell. Also useful in shooting pain in liver with extreme prostration. There is sore pain over the liver near gall bladder extending to navel or left scapula.

 LACHESIS: has easy bleeding which, is thin dark containing particles like charred straw. Acrid and offensive vomiting. Soreness with cramps in epigastrium. Excessive painfulness with sense of constrictions worse by hot drinks. Thirsty but fears to drink. Anus feels tight and pain in the rectum on jarring. Piles protrude on coughing. Constant urging in rectum not for stool.

CROTALUS HORRIDUS: Crotalus has annual aggravation, profuse bleeding with action on blood, vessels, and liver. Sudden collapse due to shock caused by haemorrhage and sepsis with low vitality.

 Based on state of pathology and annual aggravation

 Final Remedy:

Crotalus Horridus 30C was prescribed.

 Follow up: Child was very much better after he received first dose of medicine which was followed up 4 times a day while child was admitted in the hospital.

• No vomiting thereafter
• Heart rate settled
• Peripheral circulation stabilised
• No complaints thereafterChild was discharged after 72 hours.

The same medicine was continued for long term goal.

 

• Followed up for more than one yearNo complaint of annual aggravation and bleeding episodes.
• No signs of progress of disease were noted.
• The cirrhosis did not reverse. The changes that had occurred in liver and portal hypertension before child took homoeopathic treatment remained stable but unchanged.

Discussion:

In this case the best outcome for a child was maintaining hemodynamic stability without surgical intervention. The hospital had facility for providing blood and critical care support. Most important the case was supervised by an expert paediatrician along with a homoeopathic doctor. Thus by providing an integrative care the scope of homoeopathy in surgical case was enhanced and child could be offered a safe rapidly effective, gentle and affordable care with comparable outcome. The case was suitable for homoeopathic treatment because it had well defined homoeopathic totality.

Oesophageal varices:

Definition: Esophageal varices are dilated sub-mucosal distal esophageal veins connecting the portal and systemic circulations.

Esophageal varices form due to portal hypertension, which commonly is a result of cirrhosis, resistance to portal blood flow, and increased portal venous blood inflow (10-12 mm Hg).

Natural Porto-systemic shunts most common site is esophagus. When these varices get enlarged, they rupture producing severe hemorrhage.

Bleeding may manifest at anytime in infancy to adulthood and mean age presentation is 6.3-9.3 years with 1.8-3.1 episodes of bleeding.

Types: Small (<5mm)/medium (5-10mm) / large (>10mm).

Incidence: India portal hypertension in children is caused more often by Extra-hepatic portal vein obstruction 68-76% and is common cause of GI bleeding in children 70%.

Etiology: Portal hypertension, liver cirrhosis NSAID’S, history of febrile illness, Wilson’s disease, Hepatolenticular degeneration.

Signs and symptoms:

• Vomiting of large amount of blood
• Black tarry, bloody stools
• Splenomegaly
• Lightheadedness
• Pain in left upper quadrant
• Loss of consciousness in severe cases
• If liver involved:
• Yellow coloration of skin and eyes (jaundice)
• Easy bleeding or bruising
• Ascites

Investigations: Hemogram, LFT, BUN, USG abdomen. Endoscopy, CT scan

Complications:

• Gastric varices
• Perforation of the esophagus
• Multiorgan failure
• Death

Management: Resuscitation, Identification of the cause of bleeding control of bleeding its prevention. Packed red blood cell transfusion, maintain Hb >8-10 gm%, platelets transfusion if platelets < 50,000/mm

Treatment: Immediate asses of severity and causes.

Establish and maintain the intravascular volume.

Adequate IV access should be established, monitor pulse, BP, intra venous pressure and oxygen to counter hypoxia.

Medication fails then, Balloon Tamponade/ Endoscopic Variceal Ligation or Sclerotherapy, venous graft or liver transplant to be done.

Prognosis: Medication and lifestyle changes reduce risk of recurrence.

CASE-5

A 28 days old neonate was brought into hospital with complaint of vomiting and distension of abdomen since three weeks.

Complaints started with vomiting on the 6^th day after birth. Child used to vomit 4 times a day, once in morning, afternoon, evening and night. Child gradually developed icterus after vomiting, suck was poor, activity decreased, pale yellow to white, stools and yellowish urine.

 Birth history:

Full term normal delivery. Child cried immediately after birth, Birth weight 2.7 kilograms. No complaint immediately postnatal

Family history:

 On examintation:

• Icterus, deep yellow
• Temp- 100.4 F
• HR – 136/ min
• Fontanel- Normal
• Skin turgor – Normal
• Chest – clear
• P/A – soft, Liver 3 finger palpable & firm, Spleen 3 finger palpable firm.

Investigation:

• Total Bilirubin – 21.70
• Indirect- 17.55
• Direct – 4.15
• SGOT – 60
• SGPT – 87
• Alkaline Phosphatase – 496
• USG -NAD

Provisional diagnosis:

Based on the available history and clinical findings & investigations i.e. Jaundice lasting for more than 3 weeks (Hyper-bilirubinemia), decreased activity, vomiting, yellow urine, alcoholic stools, raised Alkaline Phosphatase, raised Total & Indirect Bilirubin with Normal USG the provisional diagnosis of  ‘Intrahepatic Biliary Stasis’ was arrived at. The etiology for the same was not confirmed due to limitations of availability diagnostic facilities.

Discussion:

It may be difficult to clearly differentiate infants with biliary atresia, who require surgical correction, from those with intrahepatic disease (neonatal hepatitis) and patent bile ducts. No single biochemical test or imaging procedure is entirely satisfactory. Idiopathic neonatal hepatitis has a familial incidence of approximately 20%, whereas biliary atresia is unlikely to recur within the same family.

A few infants with fetal onset of biliary atresia have an increased incidence of other abnormalities, such as the polysplenia syndrome with abdominal heterotaxia, malrotation, levocardia, and intraabdominal vascular anomalies. Neonatal hepatitis appears to be more common in infants who are premature or small for gestational age. Persistently acholic stools suggest biliary obstruction (biliary atresia), but patients with severe idiopathic neonatal hepatitis can have a transient severe impairment of bile excretion. Consistently pigmented stools rule against biliary atresia. The finding of bile-stained fluid on duodenal intubation also excludes biliary atresia. Palpation of the liver might find an abnormal size or consistency in patients with biliary atresia; this is less common with idiopathic neonatal hepatitis.

From the discussion above it is evident that the precise diagnosis is difficult to arrive at. There were several limitations like, available diagnostic and imaging facilities in rural settings of India a few years ago. There were socio-economic constraint as patient could not afford the tertiary care referral at higher centers in cities and also did not have social support system in cities. The case hovered on the borderline of surgical and medical management. The physician had to arrive at a reasonable provisional diagnosis and chart his treatment plan and closely monitor by admitting the patient.

The patient was explained about the possibility of outcomes with homoeopathic treatment and also need for surgery in immediate future if, the case did not respond as planned. The general condition of the child was good so far, hence the physician decided to take the calculated risk. To begin with, the scope of homeopathy was unsure hence, physician adopted a cautious approach with close clinical monitoring.

Homoeopathic totality:

• Cyclic vomiting of infants – Time
• Infancy-Time (Epoch)
• Inflammation with plastic exudate-(Discharge)
• Biliary stasis (Pathology)
• Liver (Location)

Homoeopathic Remedies

CHELIDONIUM MAJUS: A prominent liver and portal system remedy, covering many of the pathological indications like pasty, pale yellow stool, enlarged and tender liver and deep jaundice with distension of abdomen. The jaundice is associated with pain and hence the child is not comfortable. Bilious complication during gestation. Jaundice due to hepatic and gall-bladder obstruction. Distention.

CHINA OFFICINALIS: Vomiting of undigested food. Slow digestion. Milk disagrees. Hungry longing for food, which lies undigested. Flatulence; belching or regurgitation of food gives no relief; Hiccough. Bloated but better by movement. Gall-stone colic. Jaundice. Gastro-duodenal catarrh.

CHIONANTHUS VIRGINICA: Hepatic derangements. Jaundice associated with discomfort and abdominal pain. Aching in umbilical region, griping.  Infantile colic feels as if a string were tied in a “slip-knot” around intestines which was suddenly drawn tight and then gradually loosened. Sore; enlarged liver, with jaundice and constipation. Clay-colored stool, also soft, yellow and pasty. Tongue heavily coated. No appetite. Bilious colic. Hepatic region tender.

LEPTANDRA VIRGINICA: A liver remedy, with jaundice and black, tarry stools. Bilious states. Enfeebled portal circulation. Tongue coated yellow. Aching in region of liver extending to spine, which feels chilly. Clay colored stools with jaundice.

LUPULUS: Infantile jaundice. Scarlatina- feels chapped, skin peels. Drowsy during the day. Sopor.

NATRUM SULPHURICA: Duodenal catarrh; hepatitis; icterus and vomiting of bile; liver sore to touch, with sharp, stitching pains; cannot bear tight clothing around waist, worse, lying on left side. Flatulency; wind colic in ascending colon; Diarrhea yellow, watery stools. Loose morning stools, worse, after spell of wet weather. Stools involuntary, when passing flatus. Great size of the fecal mass.

PODOPHYLLINUM: especially adapted to persons of bilious temperament. Liver region painful, better rubbing part colic and bilious vomiting. Torpidity of the liver; portal engorgement with a tendency to hypogastric pain, fullness of superficial veins, jaundice. Can lie comfortably only on stomach.

MERCURIUS DULCIS: A remedy with profound actions on glands like liver, duodenum and bowels. Plastic exudate with obstructive state in narrow tubes like biliary tree and duct. Biliary stasis. Cyclic vomiting of infants. Pallid, flabby catarrhal and bilious child. Nausea and vomiting.  Remittent bilious attacks. Especially indicated in systems disposed to remittent bilious fevers; in peritonitis and meningitis.

Remedy: Merc. Dulcis 30 C 4 doses in a day.

Follow up:

Vomiting stopped in 24Hrs.

	Total .Bilirubin mg/dl	Indirect .Bilirubin mg/dl	Direct. Bilirubin mg/dl
1st week	9.53	9.26	0.27
2nd  week	6.92	6.12	0.80
3rd week	1.8	1.6	0.2

 

Discussion:

In this case there were two time-based characteristics. The first characteristic was cyclical nature of the vomiting indicating periodicity and the other characteristic was infancy indicating stage or epoch of life. The physician based the prescription on available homoeopathic characteristic of Time ‘cyclical vomiting’ in “Infancy” both indicating “time” from a different perspective. This was then correlated with state of pathology “biliary stasis in the liver”. The bile which is semi-viscous in nature has further become viscid and refuses to flow smoothly through the liver’s biliary tree due to inflammatory state hence, the green, plastic exudates. Also, affinity for the glandular organs like liver. The totality emerges when the whole is associated and integrated based on Bogers’s concepts.

An algorithm for clinical analysis of cases of Neonatal Cholestasis. Due to progress of a disease the evolution of a pathology over a time may demonstrate an overlap between the categories and some clinical features might overlap. The algorithm hence, is dynamic and subject to change overtime.

CASE-6

A 4yrs/ male child, residing in small town, a single child was bought for consultation for protrusion of mass per rectum since 1½ year and recurrent colds associated with cough and fever.

History of presenting complaints:

Patient was apparently healthy 1 ½ year back. He suffered with severe dysentery with semisolid stool with no straining, no pain, no bleeding, and no involuntary stools yet developed protrusion of mass per rectum. The child was diagnosed to have prolapse of rectum. Prolapse was seen after defecation and was reduced by manual insertion each time but, would recur.

He also had accompaniment complaint of cold associated with fever, sneezing and cough. There are frequent attacks of cold once or twice a month since the age of 4 months, lasting for a week if, treated. Sneezing and cough in short intervals with & rattling in chest.

Child fails to expectorate develops red face and ends up in vomiting of white sticky mucus. Cough aggravated after getting wet, cold drink, morning, lying down, eating banana, and better by vomiting, fanning and honey. Cough is accompanied by decreased, appetite, increased thirst of small quantities often and irritability better by carrying the child.

Past history:

• Pneumonia twice at 4 months- admitted in ICU
• Dysentery1 ½ year ago have taken allopathy treatment not recovered.

Family history:

• Grandmother suffers from cataract
• Father suffers from Chronic bronchitis
• Mother has Bronchial Asthma

 

Milestones:

• Dentition: 5-6^th month
• Walking:9-10^thmonthwithoutsupport
• Speech, Sentences-11-12^thmonth

Mental symptoms:

 

• Irritable-shouts, fights, beats but cools down easily
• Obstinate, anger violent- throws objects at persons
• Doesn’t mix with strangers
• Quiet most of the time
• Timid
• Neat and systematic with belongings
• Doesn’t like anybody taking his things without his permission

 Physical generals:

• Lean, thin, fair
• Appetite-usually eats less.
• Thirst –increased small quantity often
• Sleep-normal
• Perspiration- scanty on back
• Craving-salty things, banana
• Aversion-milk
• Thermals- chilly

General physical examination:

• lean, thin, undernourished, fair child

 

er abdomen:

·        No Abnormality Detected.

·        Rectal examination: Mass protrusion per rectum post defecation.

 Diagnosis:

 Grade 3 Rectal Prolapse.

Differential diagnosis:

 

• Rectal polyp: A prolapsed rectal polyp looks as a plum- colored mass with a stalk and it does not involve the entire anal circumference.
• Intussusception mass: In this condition, one can insinuate finger between prolapsed mass and anus.
• Hemorrhoids: External hemorrhoids are associated with extreme pain and itching, often due to acute thrombosis. Internal hemorrhoids are located above the dentate line and manifest primarily with bleeding, prolapse, and occasional incarceration.
• Pilonidal disease: It usually manifests in adolescents or young adults with significant hair over the midline sacral and coccygeal areas. It can occur as an acute abscess with a tender, warm, flocculent, erythematous swelling or as draining sinus tracts

 Discussion:

The long-term goal is to prevent further reoccurrence of acute episodes of respiratory system and further progress of Rectal Prolapse.

The objective is to treat the rectal prolapse conservatively and avoid surgery.

 Totality of symptoms:

 

• Anger violent
• Anger violet-throws things
• Shrieking, shouting children in
• Obstinate
• Timid
• Reserved
• Aversion – Milk
• Craving- Salty things, banana
• Easy tendency to infection
• Easy tendency to colds
• Laxity of tissue
• Lean built

 Discussion:

This case can be approached with different ways. One may choose to centre the case on ‘Prolapse of Rectum’ and consider remedies like Podophyllum, Mercurius, Aloes, Lycopodium, Muriatic Acid etc. The other way could be to choose a constitutional remedy based on symptoms of mind and physical generals etc. This case can also be approached by a amalgamation of Borland’s Child Type classification, Boger’s General Pathology and understanding its miasmatic interpretations.

 To understand this, we first need to set the right goals of addressing the recurrent tendencies in the child. What are they? 1. Tendency to catch easy infections. 2. Tendency to Colds. 3. Tendency to and lack of adhesiveness of connective tissue causing laxity.

 The entity in our body which, is supposed to hold or stick things together is, collagen tissue. Collagen is the primary building block of body’s skin, muscles, bones, tendons and ligaments and other connective tissues. It is also found in organs, blood vessels and intestinal lining. Collagen is the most abundant protein in our body. It accounts for about 30% of total protein.

 Lack of collagen or defective causes wrinkling, sagging, shrinking, loss of mobility and thinning of the mucosal and epithelial lining. In young age there is abundance of collagen production as age progresses the collagen production is reduced hence the above effect. Nutrition and absorption of right nutrient is the main cause for early lack of collagen. In short in this child’s case one can with fair certainty say there is lack of good collagen support infrastructure to mucus membranes which is usually due to a subtle nutrient & metabolic insufficiency.

 The second tendency is to catch infections. This child catches infection in respiratory and gastrointestinal system. The Child has recurrent infections since four months of age. For an infection to occur, germs must enter a susceptible person’s body and invade tissues, multiply, and cause a reaction. People with a weak immune system have a higher risk of experiencing frequent infections and severe symptoms.

 Our immune system efficiency is influenced by nutrition, rest, exercise, alcohol, smoking, hygiene etc. It is also influenced by hereditary factors like anatomical malformation of organ or tissues weakness like that of lymph nodes, spleen, and bone marrow, skin and mucus membranes.

 Even the physiological aberrations like; cellular components, protein , amino acid and the component of blood that produce the bank of antibodies against sensitized antigen impacts the performance of immune systems. The tendency to infection is a proof of weakness of immune system.  A combination of hereditary and nutritional dyscrasias.

 The look of the child is lean and under nourished. The child is fed well yet has less appetite and does not seem to assimilate much.

 As we set our eyes on tackling the above mentioned fundamental issues the next step is to check, we have a deeper solution. The deeper solution lies in tacking the miasm which is impacting the constitution of the child.

 The misasmatic fault makes the child more vulnerable to infections and prevents the healing of rectum. It creates the reoccurrence and tendencies to relapse. This in turn prevents his growth the wellbeing. Therefore in this case the strong dominant Miasm needs to be addressed.

 Susceptibility assessment:

Pace of disease: Rapid   paced changes.

Pathology: Recurrent acute infective illness settling deep leading to debility (prolapse).

Fundamental miasm:

 Based on family history a mixed miasmatic influence is evident.

Dominant miasm: Tubercular

 Discussion:

The family history and past history of the patient can give fair indication of tendencies running through the family tree.

 More than the disease name it is important to understand the underlying pace of the disease, stage, complications that occurred in the family members due to the diseases.

 In past of the patient which diseases prevailed and how they prevailed?  It is important to understand physiological makeup of the constitution as well. Also, the individual peculiarities like; cravings, reaction to temperatures, change of weather etc. not to miss the mental makeup and emotional reaction.

 In this case the child had easy tendency to infections indicating weak immune system. The infections settle in respiratory system (pneumonia) and gastrointestinal systems. The pace of all the acute diseases is fast and they often settle deep complicating the situation.

Child has undernourished look with easy satiety. He is lean fair skinned with narrow chest. This indicates nutritional and metabolic dyscrasias. Leading to weakness in connective tissue abilities to hold things together reflecting as weakness, laxity and prolapses.

 Emotionally the child is labile with sudden anger leading to violence in actions and gestures. The reaction is sudden yet short lasting.

He does not tolerate cold weather well. Has liking for salts and cold drinks. Aversion to milk.

 

In nutshell, the weakness of immune system and metabolism leading to easy tendency to infection and debility of tissues causing laxity is strongly indicating of tubercular diathesis.

 Seat of disease is mucus membranes of respiratory and gastrointestinal systems. The pace is rapid and it recurs often leaving the child debilitated.

 There is liking for cold but inability to tolerate it and a weak and frail body to defend the insults which run deep.

 The tubercular miasm runs through the case and dominates it.

 

 PHOSPHORUS: This remedy has tendencies to pneumonia and respiratory infections. The child is lean, delicate, stooped with narrow chest. Weakness is hallmark of this remedy. Child has craving for meat, egg, and salty  taste. The child is loving, compassionate, cosmopolitan and expressive. The basic nature is fearful, sensitive nervous. The child has aversion to be alone, desires company. Great weakness after stool. Discharge of blood from rectum, during stool. White, hard stools. Cough from tickling in throat; worse, cold air, reading, laughing, talking, from going from warm room into cold air. Hard, dry, tight, racking cough. Congestion of lungs. Burning pains, heat and oppression of chest. Tightness across chest; great weight on chest. Pneumonia, with oppression; worse, lying on left side.

SULPHUR: There are two definite children type in Sulphur. One is fairly well- nourished child with big head, rough skin, coarse hair and clumsy sweating easily. The other type is lean with large head. The legs are like spindles, potbellied abdomen, and coarse skin. They are pale, undernourished with a narrow chest. They present with lack of stamina and get exhausted easily even while standing. They are impatient, quarrelsome, censorious & discontented. The child often feel underestimated and hence behave egoistically. They dislike parents if, they interfere and wish that they are left alone so that they can show off. They have well defined appetite with taste for seasoned food, spiced food and sweets. Milk disagrees, nights are troublesome and so are all orifices. Redness around the anus, with itching. Morning diarrhoea, painless, drives out of bed, with prolapsus recti. Oppression and burning sensation in chest. Difficult respiration; wants windows open. Much rattling of mucus. Chest feels heavy; stitches, with heart feeling too large and palpitating pleuritic exudations.

TUBERCULINUM: Restless, hyperactive, discontented, obstinate and irritable children. Breaks things, shrieks, gets violent, impulsive, anger tantrums. Unpredictable, constant desire for change, never happy with constancy. Dissipate themselves due to activity. Romantic longings including sexual fantasies.

Weakness, laxity, protrusions, infections, altered immunity and exhaustions. Erratic tendencies. Early-morning, sudden diarrhea. Stools dark-brown, offensive, discharged with much force. Tabes mesenterica. Hard, dry cough during sleep. Shortness of breath. Sensation of suffocation, even with plenty of fresh air. Longs for cold air. Broncho-pneumonia in children.

Selection of remedy:

Tuberculinum 1000C one dose repeating every week. Tuberculinum was used as a indicated chronic remedy.

Drosera 200 1 dose bed time for 3 days if, an acute cold and cough develops. During acute cold it was advised to stop Tuberculinum.  Tuberculinum to be restarted after the cold subsides.

Discussion:

Considering the child type, pathology, its interpretation of tubercular diathesis, dominant tubercular miasma & the objective of treatment being prevention of recurrence in a chronic illness, tuberculinum was chosen as the indicated remedy.

Follow up:

Single dose of Tuberculinum 1000C was given. With the first dose, the rectal prolapse was 50%better and would reduce on its own and no manual reduction was required.

After 2nd dose. Within a month the rectal prolapse was 80% better

Two months after treatment no rectal prolapse. Child got only one episode of bronchitis which improved with infrequent doses of Drosera 200C.

There after child was observed on placebo. The recurrence of infection and prolapse stopped.

Discussion:

Homoeopathic medicine could achieve the set goals of stopping the recurrences of prolapse thus avoiding the surgery. This was done by addressing the constitutional dyscrasia of the child. The child was not only free of prolapse but also recurrent tendency to infections. Homoeopathy offers better solution for these type of clinical conditions caused due to constitutional tendencies.

Rectal prolapse

It is defined as descent of a few or all layers of the rectal wall through anus. A prolapse limited only to the rectal mucosa (mucous membrane with submucosa approx. 1-4cm) is known as incomplete prolapse or mucosal prolapse where as a protrusion of all layers is known as complete prolapse or Full-thickness prolapse (synonym: procidentia). Rectal prolapse is one of the most common acquired anorectal disorder usually affecting children <4 years.

Demographics:

It seems to have a bimodal pattern in children, appearing in infants and then again in children between 2 and 4 years of age. Boys seem to be affected more often than females.

Etiopathogenesis:

1. The exact etiology of rectal prolapse in children is unknown.
2. Repeated straining with constipation, diarrhea, and laxative use predisposes children to rectal prolapse.
3. Children with associated disorders such as meningomyelocele, cystic fibrosis, and surgical intervention for anorectal malformation are more prone for rectal prolapse.

Higher incidence of rectal prolapse in children can be attributed to various anatomical and precipitating factors.

• Pathologically, rectal prolapse in children is hypothesized to start as mucosal prolapse at the mucocutaneous junction (rectal intussusception) and it eventually progresses to full-thickness prolapse.
• The anatomical factors, which predispose children to rectal prolapse are more vertical or straighter course of the rectum, a flat coccyx with diminished sacral curve and a weak levator ani support. Further, a small pelvis with relatively low position of rectum, increased mobility of the sigmoid colon, and loose attachment of the rectal mucosa to the underlying muscularis in children makes them more prone for prolapse.
• Persistent rectal prolapse leads to a pelvic floor defect with diastasis of levator ani muscle. Prolapse may be precipitated by multiple acquired factors. Children from malnutrition are more prone to develop rectal prolapse due to: (1) repeated bouts of diarrhea and (2) loss of supporting ischiorectal fat.

Clinical Features

• Protrusion of dark- or bright-red mass from the child’s anus after straining.
• Painless with minimal discomfort.
• Prolapse occurs during defecation while sitting on toilet seat or while squatting (in India).
• Floor Musculature becomes more and more lax.
• Prolapse with the slightest of straining or spontaneously even in upright position.

On examination, the     child  is usually comfortable without any pain or findings.

• Physical examination is normal.
• Child should be examined in squatting position or lateral decubitus position while straining.
• Straining produces prolapse of rectum as a pouting and swollen rosette.
• In case of mucosal prolapse (false), the folds are radial, whereas in complete prolapse there are circular mucosal folds.
• On palpation between fingers, one can differentiate between mucosal and full- thickness rectal prolapse.

Altemeier classification of rectal prolapse.

 Type I: Protrusion of redundant mucosa, termed false prolapse; it is usually associated with hemorrhoids

 Type II: Intussusception without sliding hernia of the cul-de-sac it occupies the rectal ampulla but does not continue through the anal canal; themost common symptom is fecal incontinence, but solitary ulcers in the anterior rectal mucosa can be seen.

Type III: Complete prolapse, including full- thickness rectal wall prolapse. It is associated with a sliding hernia of the Douglas pouch and is the most frequent type.

CASE- 7

 A 4years old, female, residing in a metro city came with the following complaints – Pain in abdomen at umbilical and right hypochondrium region with each episode lasting from 2 to 3 hours to 2 days. There were about four episodes of the that have occurred till the date the patient was brought to the physician.

1st episode – June

2nd episode -December same year

3rd episode – January following year4th episode – February same year

The pain was very severe with weakness and an urge to pass stool. It was aggravated more in the morning and the child was better by lying down with legs drawn towards abdomen and also by the use of allopathic medicines.

Pain was accompanied by dullness, thirst increased, every few minutes, and appetite decreased. Peeling of skin since 15-20 days was visible on both the palms and hands. There was a characteristic dryness and rawness with no itching or discharge. Palmar erythema was observed.

Physical characteristics:

• Appearance – lean, sparse hair, broad forehead
• Teeth – caries
• Hunger – easy satiety
• Craving – milk⁺³ sweets⁺³
• Stool – Colour- yellowish brown, Consistency hard initial part, then soft like stuck pellets.
• Perspiration – on scalp
• Thermals – hot patient

Obstetric history of mother

Mother’s health – NAD

Birth type – FTND

Birth weight – 3.5kg

Developmental milestones

Dentition – 6 months

Walking – 9 months

Lisping – since 1 year

Socialization – 1 and half year

Talking in sentences – 1 and half year

 Past history:

Nothing specific

Family history:

Paternal uncle – hypertension

Paternal grandmother – asthma and hypertension

Maternal grandmother – hypertension

Maternal uncle – renal calculi

 Differential Diagnosis:

Recurrent abdominal pain in children is defined as at least 3 episodes of pain over at least 3 months that interfered with function. Abdominal pain without demonstrable evidence of pathologic condition, such as anatomic metabolic, infectious, inflammatory or neoplastic disorder.

 Biliary atresia is commonly associated with Choledochal Cyst and must therefore be ruled out in neonatal obstructive jaundice. However, CBA patients are symptomatic at earlier ages (less than 3 months old), and one-third of CBA patients develop liver failure or require liver transplantation. On ultrasound, CBA cysts appear smaller, with less dilatation of the intrahepatic bile ducts and are associated with an atretic or elongated gallbladder.

 Gallstones that develop between 2 and 12 years of age are primarily composed of mixtures of calcium bilirubinate, with varying amounts of calcium carbonate and cholesterol. Abdominal pain may vary from the typical right upper abdominal location to vague and poorly localized pain, especially in younger children. The diagnosis is usually determined with Ultra-Sound. Unfortunately, the diagnosis may be delayed in this young age group despite abdominal pain, nausea, emesis, and, occasionally, fever.

 Pancreatic pseudocysts are localized collections of pancreatic secretions that do not have an epithelial lining and develop after pancreatic injury, inflammation, or duct obstruction. These cysts typically lie in the lesser sac behind the stomach. The presence of a pancreatic pseudocyst is suggested by a history of blunt abdominal trauma; an illness resembling pancreatitis, possibly followed by a symptom-free interval of weeks to months; or palpation of a mass in the epigastrium or left upper quadrant. Abdominal pain is the most common symptom, with jaundice, chest pain, signs of gastric obstruction, vomiting, gastrointestinal hemorrhage, weight loss, fever, and ascites also being features.

 Mesenchymal hamartoma usually presents as a painless right upper quadrant abdominal mass in a child younger than 2 years. The tumor may present as a predominantly cystic structure that enlarges rapidly because of fluid accumulation, or it may be predominantly vascular and present with congestive heart failure.

 Hepatoblastoma usually presents as a large, asymptomatic abdominal mass. As the disease progresses, fatigue, fever, weight loss, anorexia, vomiting, and abdominal pain may ensue.

Investigations

Complete blood count

Hemoglobin – 12.9gm%,

RBC – 5.03 million cells/cu.mm,

WBC – 12,600 N-39, L-50, B-04, M-03, E-04

Platelet count – 4, 16,000/cu.mm

ESR – 10mm/hr

Liver function tests

Total bilirubin – 0.32

Direct bilirubin – 0.19

Indirect bilirubin – 0.13

Protein – 6.03, Albumin – 4.40, Globulin – 2.23

A/G ratio – 1.97

SGOT – 60

SGPT – 65

Alkaline phosphatase – 469 IU/L

SGGT – 114 IU/L

Ultrasonography abdomen

Impression: Obstructive jaundice showing marked dilatation of the common bile duct(16mm) and minimal dilatation of IHBD

MRCP – Choledocal cyst (type IV) with evidence of calculi in CHD/CBD complex. Evidence of calculi in neck of gall bladder with distension of gall bladder.

 Diagnosis: Choledochal Cyst

 Discussion:

The Patient has frequent episodes of abdomen pain which subsided by medication for time-being. The last episode was so severe with weakness, parents resorted to other mode of treatment. It is evident from the clinic-pathological correlation that, the disease is of chronic nature with intermittent acute exacerbations. Therefore the short term goal is to tackle the acute exacerbation. The long term goal is to prevent further reoccurrence of acute episodes and prevent further progress of disease.

 If, the homoeopathic treatment helps the need for surgery could be postponed or completely averted.

 To approach this case one will have to understand premorbid attributes of the child and also the clinical picture during acute exacerbation and the end organ weakness.

 Premorbid Presentation:

The child was intelligent yet sensitive in nature, had quick perceptive abilities to assess the situations around. Academically the child was doing well and also had the skills to maneuver the social circles in the school. Child had a good mix of belligerence and compliant behavior which the child would adapt based on the reading of the situation. In private he is obstinate, opinionated and also insistent especially with parents and siblings. He presents himself to the society intelligently by concealing his vulnerabilities and sharp edges.

 Totality of symptoms

Mental generals

Obstinate

Dominating

Diplomatic

Intelligent

Physical generals

Hunger – easy satiety

Craving – milk+3, sweets +3

Perspiration – scalp

Thermals – hot

Slow and chronic

Liver Inflammation

Duct Dilatation

Hair Thinning Forehead

Forehead Prominence

Teeth Caries.

Discussion:

For a 3-year-old child there are many pathologies already co-existing together and most are permanent and non-reversible. When we generalised what is happening as a state of this child at the level of mind, behaviour, liver, teeth and hair we see that child is on maturation overdrive. Indicating a mix of sycotic and syphilitic miasm underplay. The crux is the child is ageing too soon and faster than his/her age. This is the central core of the case and the same has to match with the core genus of the remedy.

There is no predetermined approach to a case. The clinician has to respect the symptomatology in the case and use the best possible approach that gets indicated. In this case there are mental generals, physical & pathological generals.

Differential group of remedies:

 CALCAREA CARB: Great chilliness during attack; darting pain from right to left, with profuse sweat, abdominal spasms and colic, cutting colic in epigastrium, has to bend double, clench hands, writhe with agony. In addition, Calcarea Carb has a great syphilitic depth and match of the locations of forehead, teeth, liver and inflammation and degeneration. It is also slow and chronic. What does not match so well is the ability to discriminate and sharply perceive the situation and adapt. To dominate or submit based on the situation to survive is not what Calcarea Carb core is all about. Calcarea Carb has tendency to shrink and freeze unlike in this case where there is alternate dilatation and contractions as seen in symptoms as well as in pathology of liver and bile duct.

SULPHUR: If we look at the repertory alone Sulphur seems plausible but as one dives deep in to Materia Medica one understands the gaps.  It lacks the specificity of the pathology of dilation of duct due to inflammation and the depth of the syphilitic impact on the pathology.

LACHESIS: This remedy comes quiet close but does not demonstrate the adaptability of the child based on discrimination of social situation. Lachesis is foolishly deceptive which is available to the external world. The aggression is uncontrolled and expressed at the drop of a hat. Usually the pace of illness is fast and often expresses as necrotizing black and blue inflammation leading to sepsis and hemorrhagic discharges. Lachesis ulcerates too soon. It is not known to bloat and dilate.

LYCOPODIUM: This remedy ages faster than its chronological age. It bloats, accumulates and dilates.  The bulge and protuberance is obvious be it forehead or the belly. It has slow onset inflammation which impacts, lungs, liver, gall bladder, bile duct, kidneys and intestines. Intellect outgrows the emotions and exhibits better control over behavior of a person. Stay sharp, perceive swiftly, assess the situation control self or control the environment to survive. Controlling to survive and grow is the motto. It also has strong Syco-Syphilitic underplay, long lasting and progressive pathologies tending to be irreversible. Also, is a warm blooded patient, with craving for Sweet. The hairline is its definitive weakness.

NUX MOSCHATA: Enlarged liver, bloody stools, weight about liver; pressure as from a sharp body or stones; swollen feeling, must bend double.

 NUX VOMICA: Jaundice, aversion to food, fainting turns; gall-stones; constipation; cannot bear anything tight around abdomen.

 Remedy prescribed :

Lycopodium 30 CH 1 dose

 Discussion:

The case has enough Mental and Physical Generals, Pathological Generals & Particulars available to define the totality of the patient. Therefore a single Constitutional remedy based on the above totality covering both the acute symptomatology and the chronic state as well as pre-morbidattributes was selected.

For the academic discussion other remedies should kept on hand in the planning like; Carduus Mar. Chelidonium. Chenopodium. China. Chionanthus. These remedies may be useful if the cases progresses or if has acute exacerbations.

 Thou Further, Progress was assessed based on the Follow-ups.

Follow ups:

• In the first week of starting treatment patient experienced an episode of acute abdominal pain. The pain in this episode was relived faster than the earlier episode. All other liver signs were same. Patient was prescribed Lycopodium 30 C 3 doses on alternate days of the week.
• Thereafter for 4 months patient did not have any episode of pain. The palmer erythema reduced and liver size on abdominal palpation was reduced.
• Child was asymptomatic for six consecutive months after starting Lycopodium 30C 3 doses in a week schedule. Ultrasound examination was repeated after six months of starting Lycopodium. Ultrasound examination findings were as follows; no gall stones, No peri-cholecystic fluid, IHBD and CHD are minimally dilated. CBD dilated 10 mm. Liver function tests at the same time were normal. Child was asked to follow same schedule of Lycopodium 30C 3 doses in a week for next 2 months.

Child remained asymptomatic till the last follow up noted in the case record.

 Discussion:

In this case child had four episodes of acute abdominal pain with altered LFT, USG & MRCP suggestive of acute on chronic Choledocal cyst TYPE III-IV. Surgery is required if pain, inflammation and dilatation of bile ducts continue to persists and LFT stays abnormal in spite of conservative treatment. In this case with homoeopathy child’s acute episodes subsided completely, liver functions were maintained normal and ultrasound findings showed good improvement. The indication for surgery was avoided through conservative management and close monitoring. Thus by controlling the progress of disease homoeopathy helped avert need for surgery.

Choledochal Cyst

Choledochal cyst, or congenital biliary dilatation (CBD) is a rare anomaly characterised by cystic or fusiform dilatation of the common bile duct.

Types of choledochal cyst

• Type I – cystic or fusiform.
• Type II – diverticulum of common bile duct.
• Type III – choledochocele (dilatation of the common bile duct within the duodenal wall).
• Type IV – multiple cysts of extrahepatic and intrahepatic ducts or multiple extra hepatic duct cysts.
• Type V – intra hepatic duct cysts (single or multiple [Caroli’s disease]).

Incidence

It is rare anomaly with an incidence of 1:100,000 – 150,000. Though it can be discovered in any age group, 60% of the cases are diagnosed before the age of 10 years. Most commonly affected are the females with a M:F ratio of 1:4. There is a greater prevalence of choledochal cyst in East Asia with a much higher incidence as high as 1:1000 in Japan.

 Etiology

The exact cause of choledochal cysts is unknown and several theories have been proposed to explain its pathogenesis:

• Congenital malformation.
• Weakness of the wall of the bile duct leading to its dilation.
• Obstruction of the distal common bile duct.
• Combination of distal obstruction and weakness of the wall of bile ducts.
• Reflux of pancreatic enzymes into the common bile duct as a result of a anomaly of the pancreaticobiliary junction (APBJ).
• More than 90% of patients with choledochal cysts have an APBJ with the pancreatic duct joining the common bile duct >1 cm proximal to the ampulla.

Pathology

There are three components to the pathology of a choledochal cyst: the cyst, which may be inflamed and thick-walled, and any abnormal bile ducts; the associated liver histology, which varies from normal to fibrotic or cirrhotic; and the existence of pancreaticobiliary-malunion, which is present in most but not all cases.

In the last, the terminal common bile duct and pancreatic duct unite to form a common channel well outside the duodenal wall. Since this common channel is not surrounded by the normal sphincter mechanism, pancreatic juice refluxes into the biliary tree and high concentrations of pancreatic amylase and/or lipase are typically present in the bile. Occasionally, bile refluxes into the pancreatic duct causing pancreatitis.

In most cases, the common channel represents a simple union of the two ducts, but in some patients the anatomy is complex. Rarely, pancreatico-biliary malunion occurs without biliary dilatation.

Clinical features

The classic triad for choledochal cysts is:

• Pain
• Jaundice
• Abdominal mass

This is found in only a minority (20–60%) of children at the time of presentation.

Neonates and young infants usually present :

• abdominal mass
• obstructive jaundice
• acholic stools depending on the degree of obstruction.

Infants commonly present with:

• Elevated conjugated bilirubin (80%)
• Failure to thrive
• An abdominal mass (30%)

In patients older than 2 years of age:

• Abdominal pain is the most common presenting symptom.
• This is usually associated with intermittent jaundice.
• Recurrent cholangitis and pancreatitis.

Complications

The most common complications of a choledochal cyst are:

• Perforation is rare which presents as acute abdomen.
• Cholangitis, pancreatitis, biliary cirrhosis, liver abscess, cholelithiasis, portal hypertension, cyst rupture, malignant degeneration.

The risk of complications increases with age and the most important complication is malignant degeneration, with an incidence of 2.5–26%.

 Diagnosis

• Abdominal ultrasonography – is the best method for detecting CBD.
• Computed tomography (CT) scan is a valuable and accurate investigation in diagnosing choledochal cyst.
• Fetal magnetic resonance imaging (MRI) has additionally been performed to aid in the diagnosis.
• Endoscopic Retrograde Cholangio Pancreatography (ERCP), Percutaneous transhepatic cholangiography (PTC), and MRCP (Magnetic Resonance Cholangio Pancreatography) are reserved for patients in whom confusion remains after evaluation by less invasive investigation.
• A less invasive and reliable investigation is HIDA (Hepatobiliary Iminodiacetic Acid) scan.
• MRCP is helpful in the diagnosis and delineating the anomalous pancreaticobiliary junction.

 Management

• The treatment of choice of choledochal cyst is complete excision. Surgical management varies according to the type of cyst.
• Patients who present late after development of advanced liver cirrhosis and portal hypertension are not good candidates for excisional surgery.
• Appropriate antibiotics therapy and supportive care should be given to patients presenting with cholangitis.
• Recently and with advancement in minimal invasive surgery, laparoscopic complete cyst excision and hepaticoduodenostomy for choledochal cyst were shown to be feasible and safe. This however requires experienced laparoscopic surgeons.

 CASE-8

A 12-year female was carried by parents with complaint of pain in right gluteal region and inability to walk since 1 month. Pain⁺²started gradually but was continuously increasing since onset, now since 3 to 4 days pain become severe and caused stiffness. Patient is unable to turn in bed or walk, there was swelling and high-grade fever. Patient cried with pain when the leg was extended. Pain was aggravated whenever the patient extended hip and flexed and was better when sitting.

The patient was anxious about illness and irritable. Since the complaints started the appetite decreased, thirst low. Patient was constipated.

Examination findings:

Temp:    102°F

Pulse:    130 beats/min

Chest:      clear

Per Abdomen :       Soft

Right Inguinal lymph nodes: palpable solitary small non-tender

Local examination

Right hip: Warmth, Tenderness, Swelling mild.

Range of Movements:  Extension, external rotation, internal rotation painfully restricted

Investigations

Hb: 8.1

TC: 10800    N: 76    L: 19    E:3    M:2

ESR: 58

X-RAY CHEST: Normal

X-RAY: PBH

F/S/O: Active sacroiliac disease with Right Ilio psoas soft tissue swelling S/O? Abscess

USG ABDOMEN: Right Iliopsoas abscess 4.2 X 3.2 cm with partial liquefaction

Treatment offered by surgeon: Injectable antibiotics and painkillers for 5 days followed by oral antibiotics for ten days. Outcome of the treatment was as follows. Pain was status quo and fever persisted. Limp in gait was observed. USG was repeated and the findings were 4 X 3 cm partially liquefied ilio-psoas abscess. Advised for USG guided tapping and physician’s opinion to start AKT but the Sonologist refuses to tap as abscess was partially liquefied. Orthopaedician refers to the homoeopath for further management.

Discussion:

The diagnosis was well established and first line of treatment was offered by the orthopaedic surgeon. The first line of treatment offered insignificant relief in symptoms and there was no resolution of pathology. Further management involved surgical USG guided aspiration. Since, the abscess had not liquefied aspiration would not yield desired result. Culture and sensitivity had to be done to choose the right antibacterial including anti-tuberculosis agents if, indicated. Homoeopathic treatment was an option that could help avoid need for aspiration and also culture and sensitivity test, apart from offering symptomatic relief.

Homoeopathic Symptoms.

The child had become irritable during illness which was not her original premorbid temperament. At base she is a calm child, focused, responsible towards her work and family. She is sincere in her approach in fact at times, she is fastidious. She is anxious about her academic performance hence extremely focused. Off late she has developed constipation. She was sensitive to cold, had cravings for fish. Palms and soles were moist on examination.

Acute Symptoms:

Irritability

Thirst extreme low

Rectum constipation

Extremity pain < motion

Sitting >

Pre-morbid symptoms.

Responsible⁺²

Sincere⁺²

Fastidious⁺²

Calm⁺²

Anxiety about studies

Chilly

Craving fish

Perspiration palm and sole

 Differential remedies:

SEPIA covers the concomitant of irritability to this state of abscess. The premorbid picture of anticipatory anxiety and mild and calm demeanour contradicts typical drug picture of sepia. It is also not known to absorb pus and has no affinity for specific location of Psoas region.

HEPAR SULPHUR is the great homoeopathic remedy for suppurations where the pus is healthy or laudable. It is indicated by these symptoms: chilly sensations, throbbing pains in the parts, or sharp, sticking pains which are worse at night and from cold. If given low potency in threatening suppuration it will favor the formation of pus. The suppurative process will often be aborted by Hepar if given in the higher potencies. Hepar Sulph is fast paced and intense in presentation. It has violent syphilitic dimension and often the pus is liquid and swelling is fluctuant unlike in this case where the pus is not liquefied and clinical presentation suggest slow induration of the local tissue.

LYCOPODIUM comes close on the repertorization. The symptoms of anticipation, anxiety, and slow evolution of disease also match.  The thermal state of the patient however is contradictory and so is the state of pathology.

SULPHUR is also a remedy which may be used with the greatest benefit in abscesses and suppurations; especially is it useful in chronic cases where the discharge is profuse, accompanied with emaciation and hectic fever. Abscesses in scrofulous persons, where there is a marked psoric taint and a tendency to boils, correspond to Sulphur. The pus is acrid and excoriating. Crops of boils in various parts of the body, with unhealthy tendencies, indicate the remedy well.

NITRIC ACID may also come in in suppurations about the glands, especially the inguinal or axillary, in syphilitic subjects, and when the discharge is offensive, excoriating and of a dirty, greenish yellow colour.

SILICEA is the remedy where the suppuration continues and the wound refuses to heal; the pus is thick, and the process is a sluggish and indolent one. Under Silicea the suppurative process takes on a healthy action, the pus becomes laudable, wounds appear granulations. It has a sycotic taint to its inflammation hence, the Silica produces a slow, indurated, granulomatous inflammation leading to pus. Silica has pus which is slow & in deeper tissues, not just the skin deep. It also, covers the specific location of psoas muscles. In addition, Silica covers the acute mental state of irritability as well as the premorbid constitutional features of; anticipatory anxiety, nervousness, responsible, focussed and calm behaviour.

Remedy: Silicea 200 single dose

Follow up after 10 days of treatment.

Pain improved. Able to sit on ground.

Pain only on walking fast. There was no fever

Local Examination: Swelling and tenderness was better. Full range of movement for flexion and extension.

Repeat USG showed abscess size 2 X 1.9 cms.

Progress after 3 weeks of treatment

No complaints.

USG: Normal

Psoas abscess

A psoas abscess is defined as a purulent infectious collection within the psoas muscle.

Etiology

The etiology of primary psoas abscess remains uncertain. literature suggests it results from either hematogenous spread from occult infection or local trauma with resultant intramuscular hematoma formation, which predisposes to abscess formation.

Primary psoas abscess occurs most commonly in patients with a history of diabetes, injection drug use, alcoholism, AIDS, renal failure, hematologic malignancy, immunosuppression, or malnutrition. Additional risk factors include age under 20 years, males (3:1 predominance), and low socioeconomic status.

The predominant organism is Staphylococcus aureus (over 88%), followed by Escherichia coli and Streptococcus.

Secondary psoas abscess is often caused by a mixed flora of enteric bacteria, commonly E. coli and Bacteroides.

 Pathophysiology

 The pathogenetic mechanism for retroperitoneal abscesses varies between adults and the paediatric patients. Occurrence in children tends to be primary in nature rather, as opposed to secondary spread from contagious infectious processes seen in adults.

Though the exact pathophysiology of primary psoas abscess is unknown, it has been suggested that the presence of a transient bacteraemia may be the cause, though primary muscle infection is a rare condition, even in children with septicaemia. Muscle tissue has an inherent resistance to bacterial infection so some form of previous trauma is more likely evident.

Secondary psoas abscesses tend to occur as a result of haematogenous sources, skin penetration, previous viral illness, renal failure or diabetes, appendicitis, bowel disease or retroperitoneal lymphadenitis. Malnutrition has also been suggested as a possible contributing factor

May spread to hip joint causing septic arthritis because of indirect passage via psoas bursa lies between hip joint and psoas or connects psoas directly to hip joint in 15% of cadavers direct passage between the iliofemoral and iliopubic ligaments

 Clinical features

The classic presenting symptoms of a psoas abscess are fever, flank or abdominal pain and limp or flexion deformity of the involved hip. Many patients will present with an insidious onset of nonspecific features such as malaise and low-grade pyrexia which may progress into more specific symptoms, such as abdominal/flank discomfort, a flexed and externally rotated hip, pain on movement of the hip.

Fever is usually the most common symptom to start with but it is a nonspecific symptom, though many patients later on develop specific symptoms such as FFD, flank pain and hip pain. FFD is the most common specific symptom, followed by flank and hip pain. The majority of the patients in this series had the above symptoms. Fever was the most common presenting symptom and FFD was the most common clinical sign.

Physical examination

Inspection- hip rests in a position of flexion Palpation -may have tender mass in iliac fossa

Provocative tests – psoas sign – pain caused by extension and internal rotation of the limb

Diagnosis

Routine laboratory investigations including full blood count, C-reactive protein and erythrocyte sedimentation rate are useful in confirming the diagnosis of an inflammatory mass. Formal imaging is required however not only to confirm the diagnosis, but to plan further treatment.

Radiographs

The recommended views AP and frog-leg lateral pelvic x-rays to rule out septic hip.

Findings- may show loss of definition or enlargement of psoas muscle shadow.

Ultrasound – diagnostic imaging study of choice.

Bone scan – helpful in diagnosis.

CT scan with contrast indications can confirm diagnosis when ultrasound or MRI not available, avoid if possible due to radiation exposure

findings – include the presence of a mass and local attenuation within the involved muscles, with ring enhancement, may be negative in early stages.

MRI can confirm diagnosis if ultrasound not available difficult to obtain expeditiously

findings – will show changes early in the disease process

Treatment

Nonoperative – percutaneous ultrasound or CT-guided drainage

indications- treatment of choice in most cases

Operative – open drainage

indications – useful for secondary psoas abscess e.g. spread from the bowel can simultaneously address intraabdominal source.

Management

The agreed first-line treatment in the literature is broad-spectrum antibiotics that will cover S. aureus and also any possible primary source of the psoas abscess. Traditionally, surgical drainage was the treatment of choice.

Percutaneous drainage is an effective method of treatment for the management of psoas abscesses and an effective alternative to open surgical drainage. It is done under USG-guidance, it does not require general anaesthesia and it is associated with less pain. Percutaneous drainage, i.e. needle aspiration for small abscesses and catheter drainage for large abscesses is a less invasive but equally effective alternative to surgery in paediatric patients.

Open drainage is required if percutaneous drainage fails to completely resolve the abscess and clinical symptoms deteriorate despite antibiotic treatment.

Complications

Septic arthritis – psoas abscess can spread to hip joint

Sepsis

Decision Framework Application in Paediatric Surgical Cases

Conclusion:

The scope of surgery has widened vastly thanks to; improved techniques, precision tools and better infection control. A surgery that seemed impossible a few years ago is now possible with minimum of risk and hospital stay. In the dynamic ever-changing scenario in the surgical field, it is impractical for a homoeopathic clinician to use a static and one-dimensional classification of ‘true and so called ‘surgical diseases’ or ‘Therapeutic’ based approach to decide the scope of homoeopathy.

Homoeopathy has a varying role in surgical cases right from; averting a surgery, symptomatic relief, prevention of recurrence, preventing complications and even saving life. Having said that, there is no definitive generic answer about the scope and limitations of homoeopathy in the surgical cases. The answer about the scope lies in individual and specifics of the case. If, a personalised treatment plan is prepared for individual case the scope gets defined in a precise manner.

Goal of a treatment (GOAT) approach may help pragmatically to define the scope and limitation in a given surgical case. A decision framework if, used as a tool to lay down steps to a clinical decision process may help in objectively defining the scope in a given case.

The decision framework is a tool based on; diagnosis, case and disease time line, goals to be achieved, weighing of risk, efficacy and effectiveness of different treatment options available (Standalone surgery, Standalone Homoeopathy, Integrative approach), assessment of skill and tech support in given geographical settings and socio-economic background. A logical framework with objective scoring system to set goals and scope of each therapy, underpinned by data from past experiences will help build an expert system to guide the clinician’s decisions.

To bring about objectivity in homoeopathic the clinical decision-making process, a student of homoeopathy should be exposed to these concepts and framework early in his/her training. Competency based dynamic curriculum should be built around this concept and introduced in advance and basic training of homoeopathy with varying complexities. After all a good clinical decision can make a difference between life and death or ecstasy or misery of the patient.

Adopting an integrative approach and playing by the proven strengths of each system will not only benefit patients but will also help us bring down the cost of treatment in long run. It may also help the fraternity open new avenues by conducting research to test new treatment methods.

While adopting to this new approach, the sanctity of the wisdom stated in ‘organon of medicine’ need not be compromised. It can be further built upon based on real time, pragmatic experiences of the homeopathic clinicians, patients and researchers.

To build upon the wealth of experiences a centralised and standardised information management system is a must.  Once the data is in place one can aim for the sky and provide newer, improved and pragmatic solutions to patients, teachers, researchers, clinicians and policy makers.

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Authors

Dr. Navin Pawaskar

MD (HOM), MICR (BOM), MHA (USA), CPDM (USA),

Director

Ariv Integrative Healthcare and JIMS Healthcare

Dr. Reetha Krishnan

MD (HOM), MPH (USA)

Director

Ariv Integrative Healthcare

Dr. Ramya Krishna

M.D.(HOM)

Assistant Professor

Department of Paediatrics

JIMS Homoeopathic Medical College & Hospital

Dr. SVNS Vani

M.D.(HOM)

Post-Graduate Scholar

Department of Paediatrics

JIMS Homoeopathic Medical College & Hospital

Dr. Fatiha Sultana Saba

M.D.(HOM)

Post-Graduate Scholar

Department of Paediatrics

JIMS Homoeopathic Medical College & Hospital