Iraqi Postgraduate Medical Journal

BACKGROUND:
Peptic ulcers are defects in the gastrointestinal mucosa that extend through the muscularis mucosae. They
persist as a function of the acid or peptic activity in gastric juice. The natural history of peptic ulcer
ranges from resolution without intervention to the development of complications with the potential for
significant morbidity and mortality, such as bleeding and perforation.
OBJECTIVE:
Reviewing the incidence, types, complications and surgical indications for chronic gastric ulcer in Iraq
and comparing it with other world reports.
METHODS:
Retrospective study of the data base for 5166 patients with chronic peptic ulcer disease operated upon
between 1965-2000. The incidence of chronic gastric ulcer, their age, sex, race, clinical presentation,
diagnosis, types, size of ulcers and the indications of surgery during the period 1965-1980 (Group A) and
1981-2000 (Group B) were reviewed.
RESULTS:
Among the 5166 patients with peptic ulcer disease,111(2.15%) had chronic gastric ulcer.86 (77.5%) were
male and 25 (22.5%) were females. 97 (87%) were Arabs and 14 (12.6%) were Kurds, a ratio: 8.1/1. Age
ranges (mean) 19-79 (53.9) years. Duration of illness ranges (mean) 6 months to 9 years ( 4.2 years).
68.5% of patients were among the low socioeconomic classes. 77.9% of males were smokers. Barium
study showed the ulcer in the 89 patients examined. Malignancy was excluded by endoscopy and biopsy
in 91 and frozen section biopsy during surgery in 49 patients. Types of ulcer were; Type I: 47 (42.3%),
Type II: 44 (39.6%), Type III: 14 (12.6%) and Type IV 6 (5.4%) patients. The Size of ulcers was; < 2 cm
23 (20.7%), 2-4 cm 57 (51.4%) and > 4 cm 31 (27.9%) patients. Indications for surgery in Group A (67
patients) versus Group B (44 patients) were; dyspepsia 51 (67.1%) v 11 (25%), gastric outlet obstruction
9 (13.4%) v 18 (40.9%), bleeding 6 (9%) v 13 (29.5%) and perforation one (1.5%) v 2 (4.5%) patients.
Surgical procedures were; vagotomy and drainage in 77 (69.4%) and B-I partial gastrectomy in 34
(30.6%) patients. 2 (1.8%) died post-operatively, 11 lost to follow after 6-9 months and 98 patients were
followed for 5-32 years. Evidence of recurrent stomal ulcer in one patient.
CONCLUSION:
The incidence of chronic gastric ulcer in Iraq is low compared to chronic DU a ratio 1/45.5. Mean age
53.9 years. Male/female: 3.4/1 .Arabs/Kurds: 6.9/1 . Coexistence of chronic duodenal ulcer with chronic
gastric ulcer was 39.6%. The indications for surgery during the period 1965-1980 versus the period 1981-
2000 were; elective in 51 (76%) v 11 (25%) and urgent or emergency in 16 (24%) v 33 (75%) patients.
Operations were; vagotomy and drainage in 69.4% and resection in 30.6% of patients.

BACKGROUND:
Lipomas arise as soft tissue tumors almost, every where in the body and follow the distribution of the
fat Those presenting in the hand are uncommon slowly growing masses within the hand spaces..
OBJECTIVE:
To highlight the various presentations of large sized lipomas growing in the palm with different
clinical pictures.
PATIENTS AND METHODS:
Five patients with hand lipomas , ages (7-45) years,pesented with palmar swellings , three were
diagnosed clinically and two were diagnosed with magnetic resonance. The lipomas were surgically
excised under general anesthesia.
RESULTS:
Compressive neuropathy was elicited in three patients, one patient had mild motor weakness due to
muscle stretching. All patients had marginal excisions, histopathology proved to b lipomas. The
paresthesia in three patients improved postoperatively ,all patients had full recovery of hand
function during the follow up period of one year .
CONCLUSION:
The palm has limited spaces ,yet lipomas can grow for some time with minimal ill effect, surgical
excision is the only remedy.

THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL.7, NO. 4, 2008
INTRODUCTION:
ABSTRACT:
BACKGROUND:
Compound comminuted fractures of lower tibia and fibula are very common in Iraq these days due
to missile injuries (bullets and blasts), it could be associated with bone loss and neurovascular injury
this will interfere with the patients rehabilitation and leads to major social and economic burden on
the patient, , his family and the community.
OBJECTIVE:
To prove that primary below knee amputation in management of compound comminuted fracture
lower tibia and fibula due to high velocity missile injury and complete tibial nerve injury is superior
to limb salvage.
PATIENT AND METHODS:
This is a prospective comparative study including 25 patients age 30-60 years presented to the
emergency department in Medical City with a history of missile injury during the period 2005-2007
they had compound comminuted fractures of lower tibia and fibula (Gustilo grade II, III) all of them
had different degrees of bone loss (more than 5 cm) and all of them had complete tibial nerve injury
and 10 of them had associated posterior tibial artery injury which is irreparable. We divided our
patients in to two groups the first one (9 patients four of them had also associated vascular injury) we
did primary below knee amputation, while the second group (16 patients six of them had vascular
injury) who refused amputation we did wound exsion and application of external fixation. Both
groups followed up clinically and radiologically for one year.
RESULTS:
Group I the patients rehabilitated early and a prosthesis were used after one and a half month and the
patients return to their original work or changing their work and have almost normal life, group II all
of them had prolonged course of treatment with economic and social problems.
CONCLUSION:
Primary below knee amputation is a very good option for patients with history of compound
comminuted fractures of lower tibia and fibula (grade II and III) associated with bone loss and tibial
nerve injury. Decreasing rehabilitation time and early return back to work also less cost and less
social problems.

BACKGROUND:
Tibia is the most commonly fractured long bone in the body, because its particular blood supply and
high complications rate we always try to find out the
best method to manage such fracture with minimal disturbance to its blood supply and early
mobilizations. The fracture brace is one of the best methods of treatment of fractures regarding safety
and early mobilization. We used the brace in closed and
compound ( Gustillo I and II ) in adult, and shows its advantage over other methods regarding safety,
mobility, and low complication rate.
PATIENTS AND METHODS:
Nineteen patient with tibial shaft fracture was investigated during the treatment with tibial castbrace
Fractures were classified according to AO/ASIF classification.
Patients were treated primarily by back slab followed by plaster application from toes to above the
knee Fracture brace was applied after the pain and swelling had subsided. Serial x-ray films were
taken regularly in a fixed dates to observe and prevent any unacceptable misalignment cast brace
was discarded after union, when it found safe to walk independently.
RESULTS:
The average time needed for application of the cast after injury was (4.8) weeks for closed fractures
and (6.1) weeks for open Fractures. Union occurred in an average of (17.2) weeks for type A1
(AO/ASIF), (16.2) weeks for A2, and the longest healing time (22.2) weeks was obtained in type C
.Neither a significant shortening was obtained with a range of (8.6-13.4 mm.) nor an angulations
range of (1-7.5°) if compared with the acceptable figures .
CONCLUSION:
Functional bracing is another method in accomplishing the goal of early introduction of function after
bone union . It does not replace other methods of treatment which have its specific indications.
Functional bracing is successful in type A, and can be used in type B and C of AO/ASIF
classification .The misalignments obtained are mostly within acceptable range if compared with the
standard figures.

BACKGROUND:
Congenital lower intestinal tract anomalies are significant cause of morbidity and mortality in children,
classified in two groups, major one is anorectal malformation, other one Hirchsprung’s disease, usually
associated with other anomalies and should be treated as early as possible.
OBJECTIVE:
To show the prevalence and our experience with congenital lower intestinal tract anomalies in AL-Najaf
city.
PATIENTS AND METHODS:
A total 50 patients had various types of congenital lower intestinal tract anomalies , 22 of them high types
(anorectal) treated by 3 stages operations(preliminary colostomy, nearly new definitive surgery
infracoccygeal approach and closure colostomy), minor surgery for low types (12) and for Hirchsprung's
disease treated by usual pull through operation(Swenson’s).
RESULTS:
The anorectal anomalies (A.R.M) are the most common anomalies of lower intestinal tract , high type
cases were 25 , low type were 12 cases and Hirchsprung’s disease were13 cases . Male were 30 cases and
female were 20 cases , age of presentation between first day of life and 18 years of life .
CONCLUSION:
Infracoccygeal approach was the safe and non complicated operation in dealing with high type of
anorectal malformation and the good results obtained when the operation was done early period of life
(around one year).

BACKGROUND:
Maxillary sinus ultrasound has been found useful in diagnosis of maxillary sinus diseases.
OBJECTIVE:
Is to compare the usefulness of diagnostic ultrasound, radiography of the maxillary sinuses with the
results of he diagnostic wash out in detection of the maxillary sinus diseases.
PATIENTS AND METHODS:
Fifty-five patients (109 maxillary sinuses) with suspected sinus diseases on clinical evaluation
examined by ultrasonography, plain radiography and followed by diagnostic antral washout.
RESULTS:
The positive returns were 48.6% (53/109). The sensitivity of the ultrasonography and plain
radiography were (92.5%), (90.5%) respectively. The specificity of the ultrasonography and the plain
radiography were (55%, 41%) respectively. The accuracy of the ultrasonography was (73.4) while of
the radiography was (65%).
CONCLUSION:
Sinus ultrasonography is harmless (no radiation), less expensive and can be used safely in childhood
and pregnancy, and gives comparable results with plain radiography and antral washout in diagnosis
of sinus diseases.

BACKGROUND:
Rotavirus is the main cause of diarrhea in <5 years children causing high rates of hospitalizations and
high mortality.
OBJECTIVE:
To estimate the burden of rotavirus gastroenteritis among less than five years children attending AlAlwaiya Pediatric Hospital. To examin the validity of ELISA and Latex screening tests and to find
out the concordane rates.
METHODS:
Across sectional study involved under five years(1-59months) children with acute gastroenteritis
attending Al-Alwaiya Pediatric Hospital for the period from 1st of January 2008 to 31st of May 2008.
The questionnaire used depended on WHO protocol of the National Rotavirus Gastroenteritis
Surveillance Program. LATEX and ELISA tests were used for diagnosis. The period of study
included two seasons: Winter and Spring.
RESULTS:
Stool samples of 342 children with acute gastroenteritis were investigated by general stool
examination, stool culture, LATEX and ELISA tests for the presence of any parasite, bacteria and/ or
rotavirus antigen respectively. Rotavirus was detected in 162(47.4%) of children with acute
gastroenteritis either by LATEX, ELISA or both. Total concordance rate between the two tests was
as high as 85.4%. Females were 61(37.7%) and males were 101(62.3%). Age group mostly affected
was (>6-12) months which was (31.4%).
CONCLUSION:
Rotavirus cause 47.4% of acute gastroenteritis cases of the studied sample with no significant
statistical difference between rotavirus and other causes of gastroenteritis regarding demographic
features (except for gender, more in males), clinical features, and type of treatment and course of
disease (except time of onset).Concordance rate between ELISA and Latex was found to be high
confirming their validity.

BACKGROUND:
Hydatid disease is a widely distributed disease caused by the larval stage of the Cestode Echinococcus.
Inflammation increases the synthesis of immunoglobulins and complement components (C3 and C4)
presumably through the action of interleukin 1& gamma interferon.
OBJECTIVE:
Assessment of immunopathotogical response of scrum immnnoglobulins and complement components fC3
and C4)in Iraqi patients that might be a fleeted as inflammatory response to hydatid disease.
SUBJECT AND METHOD:
A total number of 50 patients with radiological diagnosis of HD wore studied. Surgical interference had been
done to 20 out of 50 patients and the results of surgery gave a clinical confirmation of the diagnosis of HD.
Sera from patients with HD and 38 apparently healthy controls were obtained for measurement of
immunoglobulins (lgG. IgM and IgA) and complement components (C3 and C4) by Radial Immunodiffuision
Assay ( Biomaghreb).
RESULTS AND DISCUSSION:
Hydatid patients showed increases of IgG (P value < 0.001) IgM and IgA levels (p value <0.05) in
comparison to the control group, but these variables start to decrease after surgical treatment that is
significant only in case of IgM (P value <0.05). and this might be due to activation of humoral immunity
against HD. Complement components were found to be insignificantly lower in patients with HD in
comparison to control group (P value > 0.05) and higher in one week postoperative period in
comparsion preoperative period (P value > 0.05). This might mean consumption of complement and it's
activation or it might be due to anticomplementary action of the hydatid cyst.
CONCLUSION:
The picture that has emerged from this study is that HC wall might have anticomplementary action. And
serum complement component tend to increase in postoperative period.

BACKGROUND:
The incidence of nosocomial bacteremia continues to increase despite antimicrobial therapy and
supportive care; it remains a major cause of death in hospitalized patients who are undergoing
chemotherapy. The prolonged survival of leukemia patients who have disturbance in their innate
immune system increased the factors of risk.
OBJECTIVE:
This study was conducted to assess the epidemiological features of Bacteremia in adult patients with
leukemia and the species distribution and antimicrobial susceptibilities of causative pathogens. In
addition, nosocomial bacteremia was compared to community acquired bacteremia.
METHODS:
A total of (84) adult leukemic patients more than 15 years old, males and females, feverish or with
hypothermia and leukopenic. Bacteremic cases were obtained by culturing blood samples aerobically
and anaerobically. The identification of blood isolates and susceptibility testing were performed by
the routine methods in use at the affiliated laboratories.
RESULTS:
It has been found that 15 out of 28 (53.57%) patients with bacteremia acquired the infection during
hospitalization, while the 13 (46.42%) patients acquired the infection out side the hospital. Table (1)
CONCLUSION:
High incidence rate of nosocomial infection (hospital acquired infections) in leukopenic leukemic
patients with bacteremia.

BACKGROUND:
A quantitative relationships between circulating leukocytes and infection was established in patients
with leukemia, in particular, the probability of being infected is proportional to the severity and
duration of leukopenia (1). Infection with gram- negative as well as gram-positive microorganisms may
lead to septic shock and death (2, 3) . The major functional activities of cytokines are concerned with the
regulation of the development and behavior of the immune effector cells. IL-1 is one of proximal
cytokines. IL-1 act to stimulate the release of distal cytokines, such as IL-6 and IL-8, IL-8 is most
closely related to the severity of the physiological response to infection and systemic inflammation.
OBJECTIVE:
This study was conducted to detect the levels of IL-1 and IL-8 during Gram negative and Gram positive
bacteremia. That could be useful in determining an appropriate choice for antimicrobial drug depending
on the antimicrobial susceptibility pattern.
METHODS:
IL-1α and IL-8 was studied in (28) adult leukopenic patient with bacteremia, males and females, more
than 15 years old. The study was including (20) healthy control. The bacteremic cases were obtained by
culturing blood samples aerobically and anaerobically.
The isolates were identified on the basis of their morphological, cultural and biochemical
characteristics. Interleukin-1α and interleukin-8 cocentration were measured by using a commercially
available enzyme-linked immunosorbent assay (ELISA).
RESULTS:
Statistical analysis show no significant difference in IL-1α levels between Gram-negative and Grampositive bacteremia in leukopenic leukemia patients (P=0.803). While statistical analysis show
significant difference between patient with Gram-negative and Gram-positive bacteremia in leukopenic
leukemia patients (P=0.037).
CONCLUSION:
In leukopenic leukemia patients with bacteremia we may could determining an appropriate choice for
treatment depending on IL-8 levels in the circulation of those patients and the antimicrobial
susceptibility pattern.

BACKGROUND:
Despite the advances in treatment of acute lymphoblastic leukemia(ALL), CNS relapse remains an
obstacle to successful treatment. This study was performed to determine the frequency of CNS
relapse in ALL patients and to study risk factors and outcome after CNS relapse.
PATIENTS AND METHODS:
A retrospective study done on 364 patients diagnosed as ALL in Central Teaching Hospital for
Children-Baghdad for the period from 1st Jan 2000 to 31st Mar 2005. ALL patients whom diagnosed
after 1st Jan 2004 received CTHC 2004 protocol .The following parameters were studied: gender, age,
hepatomegaly, splenomegaly, LAP, mediastinal mass, initial WBC count, platelets count, FAB
morphology, initial CNS involvement and if the patient received radiotherapy.
RESULTS:
35 patients were excluded from the study. Out of 329 eligible patients, 76 patients (23.1%) had CNS
relapse(isolated or combined), with mean duration before CNS relapse 12.30±8.28 months and
median of 11 months. The following factors were significantly associated with development of CNS
relapse: male gender, age <2 years, massive hepatomegaly, massive splenomegaly,
lymphadenopathy, mediastinal mass, initial WBC count≥50000/mm, initial CNS involvement, and
patients who did not receive prophylactic CNS radiation. The study shows that frequency of CNS
relapse decreased significantly after addition of three intrathecal doses during induction). Shorter
duration between diagnosis of ALL and CNS relapse was associated with higher mortality.
CONCLUSION:
Frequency of CNS relapse and mortality rate still higher than globally-accepted figures.
Intensification of systemic and CNS-directed therapy, significantly decreased these figures in our
patients.

BACKGROUND:
Cardiac surgery can either induce acute renal failure or improve GFR by improving the cardiac
performance. Acute renal shutdown (urine output <0.5ml/kg/hr.) is an uncommon but fatal
complication which occurs in cases of insufficient cardiac function and may be accompanied with
multi-organ failure. Acute renal failure (ARF) after open heart valve surgery occurs in about 8% of
adult cardiac surgical patients with some preoperative renal impairment and in about 3-4% of
patients with normal preoperative renal function test. This study was done to determine the
frequency of acute renal shutdown after valvular open heart surgery and to detect any suggestive
risk factors.
METHODS:
90 patients undergoing valve replacement (mitral and/ or aortic) were prospectively evaluated in
three time periods: before, 24 hours after surgery and 48 hours after surgery. The association
between preoperative, intra-operative and postoperative variables and the development of ARF was
assessed thoroughly.
RESULTS:
Of the 90 consecutive patients 3 (3.49%) patients developed acute renal failure (serum
creatinine>2.5 mg/dl) and 16 (18.6%) patients developed acute renal dysfunction (serum creatinine
1.6-2.4 mg/dl). The risk factors that were noted in the development of ARF were age, raised
preoperative blood urea and creatinine, low cardiac output state, diabetes mellitus, oligurea, total
cross clamp time total CPB time, and significant hypotension during the procedure or during
intensive care unit (ICU) stay. Mortality rate for established ARF was extremely poor (50 %).
CONCLUSION:
Avoidance of this dangerous outcome looks better than trying to treat once it is fully established.

BACKGROUND:
The aim of this retrospective study is to report the clinical course of children and adolescents with
primary focal segmental glomerulosclerosis (FSGS), and to study their outcome and to identify the
predictors of progression to end stage renal disease (ESRD).
PATIENTS AND METHODS:
This is a retrospective study of 50 patients with biopsy-proven primary FSGS who were admitted
from April 1995 - January 2007, during the study period from May 2005 - June 2007. Clinical,
Laboratory and histopathological data were recorded. The median follow-up time of 4.5 year.
RESULTS:
The commonest age and sex group is male between 1 - 5 year. At presentation all patients had
nephrotic-range proteinuria, hypertension was noted in 22 (44%) of patients, microscopic
haematuria was detected in 20 (40%) of patients, five patients had evidence of abnormal renal
function. The distribution of patients according to steroid responsiveness show that the steroid
sensitive patients were 21 (42%), 8 (38.09%) of them were frequent relapsers and 11 (52.38%) of
them were steroid dependant and 2 (9.52%) of them developed secondary steroid resistance. But
those who had steroid resistance from the start of treatment were 29 (58%) patients. During followup 30 (62%) patients had complete remission, 15 patients (30%) developed chronic kidney disease
(9 of them stage 5).
At the end of follow-up, 24 (80%) of 30 patients with normal renal function had short stature. The
univariate analysis identified the presence of hypertension (P=0.0027), heamaturia (P=0.0107) and
presence of abnormal renal function (P=0.0001) at presentation, also presence of initial steroid
resistance (P=0.0383), resistance to cytotoxic therapy (P=0.0032), capsular adhesions in renal
biopsy (P=0.0066), tubular atrophy (P=0.0027), interstitial fibrosis (P=0.0010), all expect to be
significant predictors of progression to ESRD.
CONCLUSION:
Considering the clinical and histological characteristics of studied patients, apparently our results
are comparable to other published series. The progression to chronic kidney disease (CKD) occurs
in 30% of patients after 5 years follow-up, must of them with ESRD, this is relatively good out
come compared to other studies.

BACKGROUND:
Acute bacterial meningitis [ABM] remains an important cause of death and neurological sequel in
children, the clinical feature of meningitis is often nonspecific may overlap with those of other
infection. Early diagnosis and appropriate treatment are perhaps the most important steps in
management, but published data suggested that fewer than half of the cases of meningitis are identified
at first assessment [1,2] .
OBJECTIVE:
Was to evaluate the clinical indicators of ABM of IMCI [integrated management of childhood illness]
referral criteria of meningitis include [lethargy, unconsciousness, in ability to feed, neck stiffness,
seizures] and other symptoms and sign.
PATIENT AND METHODS:
By prospective study done at central teaching hospital for child for one year from 1st of September
2006-31 0f August 2007,all admission were included, L p was done for 110 cases who got one or more
of meningial signs and IMCI indicators and other symptoms and sign.
RESULTS:
From 110 cases who have one or more of IMCI indicators and other signs,75 got meningitis including
68 only who meet all referral criteria for meningitis sensitivity 90%, specifity 60%,other 13 cases got
one or more of in dependent indicators of meningitis which include, lethargy , impaired consciousness,
in ability to feed, neck stiffness, seizures, anterior fontanel bulging, cyanosis, others, while in
dependent indicators of absence of meningitis were the absence of high fever. .
CONCLUSION:
Not all cases of meningitis meet all IMCI criteria but may have one or more of them and other criteria
as seizure outside febril convulsion age, repeated short fit, diarrhea, and dehydration; however careful
observation and assessment may be the practical way to identify most cases of meningitis

BACKGROUND:
Viral hepatitis may lead to nephropathy as one of its multiple extra hepatic manifestations.
Symptomatic proteinuria as detected by dipstick, and qualitative urine collection are simple tests in
practice as well as useful cardinal test of underlying renal abnormalities. The aim of this study was to
elucidate the impact of hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infections on the
occurrence of symptomatic proteinuria amongst adults and pediatrics.
PATIENTS & METHODS :
A prospective study included (143) adult and pediatric Iraqi patients presented with symptomatic
proteinuria, and 108 (age- and sex-matched) apparently healthy individuals (as control group) who were
serologically screened for HBV & HCV markers using third generation Enzyme linked immunosorbent
assay (ELISA) techniques, screening for HIV by ELISA and other related immunological and
biochemical profile.
RESULTS :
It was found that the prevalence of hepatitis B surface antigen (HBsAg), anti hepatitis B core antibody
(anti-HBc-IgM), anti hepatitis B surface antibody (anti-HBs) and anti hepatitis C antibody (anti-HCV)
in the proteinuria group as compared to control group, were (7.0% vs. 0.9%, P<0.05) for HBsAg,
(2.8% vs. 0% ,P>0.05) for anti-HBc-IgM, (20.3% vs. 23.1%, P>0.05) for anti-HBs antibody, and
(6.3% vs. 0%, P<0.01) for anti-HCV.
CONCLUSION :
Our study demonstrated a significant association between proteinuria and HCV, and HBV infection in
the adult and pediatric population. The interpretation of serological patterns of viral hepatitis markers in
patients with newly diagnosed proteinuria are important, it might suggest that detailed urinalysis and
qualitative urine protein assessment is mandatory when managing patients with HCV or with HBV
infections.

Enucleation is the traditional surgical procedure for
removal of sporadic insulinoma, but this may
associated with recurrence. This is a case report of
thirty-five years old woman, who underwent
enucleation for solitary insulinoma at the head of
pancreases three years ago. Recently, she was
complaining from recurrent attacks of hunger pain,
dizziness, sweating, convulsion, behavioral changes
and loss of consciousness. Endoluminal ultrasound
revealed that there are bilobed mass or probably two
masses related to the head/neck region of the
pancreas about 1.5 cm in diameter. So the diagnosis
of recurrent insulinoma was made and she was
treated by complete resection with 1cm safety margin
by harmonic scalpel guided by intraoperative
ultrasound. The recurrent insulinoma reported in this
article and others may give attention to change the
strategy of treating solitary insulinoma by local
resection with good safety margin rather than by
enucleation to prevent recurrence.