Kauverian Medical Journal

Editor's Message

Dr. Venkita S. Suresh — 2026-04-08

Editor's Message

Indications, outcomes, and complications of endoscopic retrograde cholangiopancreatography: A retrospective analysis of 750 procedures from Kauvery hospitals, Trichy

R Rajakumari — 2026-04-08

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an established therapeutic modality for the management of pancreaticobiliary disorders. Although highly effective, ERCP is associated with procedure-related complications.

Aim: To evaluate the clinical indications, procedural outcomes, and complications of ERCP performed in Kauvery Hospitals, Trichy. Methods: This retrospective observational study included 750 ERCP procedures performed at Kauvery Hospitals, Trichy. Demographic details, indications for ERCP, interventions performed, stent placement, procedural success, and complications were analysed. Statistical analysis was performed and the results were expressed as mean ± standard deviation or frequency with percentage.

Results: A total of 750 ERCP procedures were included. The mean patient age was 55.9 ± 17.7 years, with male predominance (56%). The most common indication was choledocholithiasis (72.7%), followed by malignant biliary obstruction and benign biliary strictures. The overall procedural success rate was 94.9%. Procedure-related complications occurred in approximately 5–6% of cases, with post-ERCP pancreatitis being the most frequent complication, followed by bleeding and cholangitis. Statistical analysis did not demonstrate significant associations between sex and disease type or between diagnosis type and complication rate.

Conclusion: ERCP remains a safe and effective therapeutic procedure for pancreaticobiliary diseases when performed in experienced centres, with high success rates and acceptable complication rates.

Clinical profile and therapeutic outcomes of yellow phosphorus (Ratol) poisoning: A retrospective analysis at Kauvery Hospital, Trichy

Johnson A — 2026-04-08

Background: Ingestion of yellow phosphorus (YP), primarily in the form of "Ratol" paste, is a leading cause of toxic hepatitis and fulminant hepatic failure (FHF) in Southern India. Despite the 2022 ban on 3% YP paste in Tamil Nadu, cases continue to present at tertiary centers.

Methods: A retrospective study of 67 patients admitted over one year in multispecialty tertiary care hospitals of Kauvery (Pan-Kauvery audit) was conducted. Data on demographics, formulation types, treatment (NAC and Plasmapheresis), and survival outcomes were analyzed.

Results: Of 67 cases, 67% were male (n=45). The "Paste" formulation was the primary toxicant (n=37). Management included N-acetylcysteine (NAC) and therapeutic plasma exchange (PLEX). The overall survival rate was 70.1%, with a 9% mortality rate and 21% discharged AMA.

Conclusion: Early initiation of NAC and PLEX as a "bridge to recovery" significantly improves survival in resource-limited settings where liver transplantation is not immediately available.

Grown-up Congenital Heart (GUCH) Disease: Clinical challenges and role of electronic registries (GUCH & Heart Transplant)

Shirlin M. S — 2026-04-08

Background: Adult Congenital Heart Disease (ACHD), also known as Grown Up Congenital Heart Disease, .(GUCH) is increasingly recognized due to improved survival from childhood, but its clinical presentation can be highly variable, often mimicking common adult cardiovascular conditions. Early recognition, appropriate management, and long-term follow-up are essential.

Case Presentation: We report three adult patients with congenital heart disease. The first involved a 43-year-old male with Ebstein anomaly, presenting with breathlessness, abdominal distension, palpitations, and swelling of both legs, complicated by atrial fibrillation and acute kidney injury. Echocardiography revealed pulmonary hypertension severe tricuspid regurgitation with right ventricular failure and preserved left ventricular function. He was managed with oxygen, IV diuretics, electrolyte correction, antiarrhythmics, and supportive care, resulting in clinical improvement. The second patient was a 57-year-old female with type 2 diabetes mellitus, presenting with chest pain mimicking unstable angina. ECG showed ST depression, while echocardiography and coronary angiography revealed normal epicardial coronaries, pulmonary hypertension and normal left ventricular function. She was managed with antiplatelets, statins, beta-blockers, proton pump inhibitors, and supportive therapy and discharged in stable condition. The third patient was a 37 years old female patient with large ASD(OS) and PAH admitted with chest pain and breathlessness. ECG showed biventricular hypertrophy with sinus tachycardia and chest –ray showed dense lung infiltrates. She was treated with bronchodilator and systemic steroids and BiPAP support discharged in stable condition.

Discussion: These patients illustrate the heterogeneous presentation of ACHD in adults, ranging from right heart failure and arrhythmias to angina-like symptoms without coronary obstruction. Management requires a multidisciplinary approach, including medical therapy, surgical intervention, and, when indicated, heart transplantation. Transplant registries are critical for tracking outcomes, guiding clinical decisions, and improving long-term survival in this population.

Conclusion: Adult congenital heart disease requires timely recognition, individualized management, and long-term follow-up. Participation in transplant registries enhances patient outcomes, supports research, and informs evidence-based strategies for managing rare ACHD presentations.

Pathological complete response in breast cancer: A case series

Elakiya — 2026-04-08

Background: Pathological Complete Response (pCR) is an important prognostic indicator in oncology, particularly in breast cancer patients receiving neoadjuvant chemotherapy. It is defined as the absence of invasive cancer in the surgical specimen following systemic therapy. Achieving pCR is associated with improved overall survival and disease-free survival. This article presents a case series of patients with breast cancer who achieved pathological complete response following neoadjuvant chemotherapy and subsequent surgical management. They highlight the importance of systemic therapy in achieving tumor regression and improving treatment outcomes.

Prolonged hypoglycemia leading to irreversible hypoglycemic encephalopathy: A case report

A. Arunagiri — 2026-04-08

Background: Hypoglycemia is a common metabolic emergency in diabetic patients; however, prolonged untreated hypoglycemia can result in irreversible neurological injury. We report the clinical course of a 59-year-old male with Type 2 Diabetes Mellitus who presented with delayed recognition of severe hypoglycemia leading to diffuse cerebral edema and hypoglycemic encephalopathy. Despite early correction of glucose and intensive neurocritical care management, the patient showed no meaningful neurological recovery. Serial neuroimaging demonstrated progression from metabolic brain injury to hypoxic-ischemic sequelae. This case highlights the importance of early recognition and prevention of prolonged hypoglycemia to avoid devastating neurological outcomes.

Ultrasound–guided abdominal wall blocks as sole anesthetic technique in a high-risk patient undergoing CAPD catheter insertion with umbilical hernia repair: A case report

Arivazhagan J. K — 2026-04-08

Background: Patients with End Stage Renal Disease (ESRD) often present with complex comorbidities that significantly increase perioperative morbidity and mortality. General anesthesia in such patients may result in haemodynamic instability, delayed drug clearance and postoperative pulmonary complications. Regional anesthesia techniques in such patients provide an effective alternative with minimal systemic effects. We report a case of a 55-year-old female patient with ESRD on maintenance haemodialysis complicated by ischemic heart disease, right ventricular dysfunction and recurrent episodes of atrial fibrillation and chronic pulmonary embolism was scheduled for CAPD (Continuous Ambulatory Peritoneal Dialysis) catheter placement with concurrent umbilical hernia repair. Considering the high anesthetic risk, the procedure was successfully performed using bilateral rectus sheath block and transversus abdominis plane (TAP) block. The patient remained hemodynamically stable intraoperatively and had an uneventful postoperative recovery with adequate analgesia. This case highlights the feasibility and safety of ultrasound-guided abdominal wall blocks as the sole anesthetic technique in high-risk patients with significant cardiopulmonary comorbidities undergoing abdominal procedures.

Repeat curative liver resection for metachronous HCC in a noncirrhotic liver: Precision surgery in a technically hostile terrain

Senthil Gnanasekaran — 2026-04-08

Background: Hepatocellular carcinoma (HCC) in a non-cirrhotic liver is relatively uncommon, accounting for approximately 10–20% of cases. While primary resection is the standard of care, metachronous recurrence presents a significant surgical challenge due to dense adhesions and altered anatomy from previous major hepatic surgery.

Postpartum thrombotic microangiopathy with acute kidney injury: A diagnostic challenge between TTP and atypical HUS

J. Balasubramaniyan — 2026-04-08

Background: Pregnancy-associated thrombotic microangiopathy (TMA) is a diagnostic challenge because postpartum thrombotic thrombocytopenic purpura (TTP), atypical hemolytic uremic syndrome (aHUS), HELLP syndrome, and secondary TMAs can overlap clinically. ADAMTS13 activity is central to distinguishing TTP from other TMAs, but borderline reductions may not be definitive in pregnancy.

Case Presentation: A 21-year-old primigravida at 33 weeks gestation presented with intrauterine fetal demise and developed postpartum anuric acute kidney injury, severe thrombocytopenia, and microangiopathic hemolytic anemia. She had no hypertension or neurological symptoms. Laboratory evaluation showed elevated LDH (2576 U/L), thrombocytopenia (30,000/µL), anemia (Hb 5.7 g/dL), schistocytes (1.6%), and ADAMTS13 activity of 23%. Liver enzymes were mildly elevated without features of HELLP syndrome.She was treated with hemodialysis and plasma exchange, with subsequent improvement in platelet count and renal function.

Conclusion: This case highlights the diagnostic challenge of postpartum pregnancyassociated thrombotic microangiopathy when ADAMTS13 activity is reduced but not severely deficient. Early recognition, prompt plasma exchange, and renal support were associated with haematologic and renal recovery, emphasizing the need for timely empiric treatment in similar cases despite uncertainty between TTP and aHUS.

Emergency PTBD for cholangitic shock with severe thrombocytopenia from a retained CBD stent and distal CBD structure

Amalan — 2026-04-08

Background: Acute cholangitis complicated by septic shock carries high mortality and requires urgent biliary decompression. Percutaneous transhepatic biliary drainage (PTBD) remains a life-saving alternative when ERCP is not feasible. We report a 67-year-old patient who presented with severe cholangitic shock, multiorgan dysfunction, early acute respiratory distress syndrome (ARDS) and severe thrombocytopenia secondary to a retained and fractured common bile duct (CBD) stent. Due to failed previous ERCP attempts and distal CBD stricture, emergency PTBD was performed. Following biliary decompression and targeted antibiotic therapy for multidrug-resistant Klebsiella pneumoniae, the patient demonstrated significant clinical recovery. 5th day PTBD was internalised and 7 th day This case highlights the critical role of timely biliary decompression via PTBD in lifethreatening cholangitis when ERCP is not feasible.

Early primary repair of giant omphalocele with favorable neonatal outcome

Sindhu Sivanandan — 2026-04-08

Background: Omphalocele is a congenital midline abdominal wall defect characterized by herniation of abdominal contents (liver and bowel) into a membranous sac. We report a term female neonate with antenatally diagnosed large omphalocele with liver as content. Prenatal evaluation including karyotyping and whole exome sequencing was normal. A high-risk neonatal team attended delivery, and the sac was immediately protected to minimize fluid and heat loss. A temporary silo was placed to facilitate gradual reduction by gravity. The infant underwent elective primary repair on day 2 of life, with successful reduction of contents and closure of a 6 × 6 cm defect. The postoperative course was uneventful with early extubation, successful advancement to full feeds. The infant was discharged in stable condition after an 8-day NICU stay.

When pneumonia becomes complicated- the power of teamwork

Fathima M — 2026-04-08

Background: Complicated pneumonia in the pediatric population remains a significant clinical challenge, often progressing to parapneumonic effusion or empyema despite appropriate vaccination and initial therapy. This case underscores the necessity of a multidisciplinary "teamwork" approach in managing severe, necrotizing-pattern pneumonia.

Bispectral index guided sedation during drug-induced sleep endoscopy: A clinical study towards standardized airway assessment in obstructive sleep apnea

Aruna Manaswini Murugesan — 2026-04-08

Background: Drug-Induced Sleep Endoscopy (DISE) identifies the anatomical level and pattern of airway obstruction in Obstructive Sleep Apnea (OSA). Variations in sedation depth may influence airway findings and recovery. This quality improvement study evaluated whether Bispectral Index (BIS) guided sedation improves procedural consistency and recovery outcomes during DISE.

Methods: A prospective clinical audit compared, Conventional DISE using clinical assessment of sedation with/against DISE performed using Target-Controlled Infusion (TCI) of Injection Propofol guided by BIS monitoring. A BIS range of 65–75 was maintained. Endpoints included total sedative consumption, additional bolus requirement, number of agents per case, airway collapse patterns, recovery time (modified Aldrete score ≥9), and respiratory adverse events.

Results: After implementation of BIS monitoring, total sedative consumption and additional bolus requirements decreased. Fewer cases require multiple sedative agents. Airway collapse patterns were more consistent, and recovery time was shorter in the BIS-guided phase.

Conclusion: BIS-guided sedation during DISE improves procedural consistency and recovery characteristics. Objective monitoring may enhance reliability of airway evaluation in OSA.

Early t-cell precursor acute lymphoblastic leukemia presenting as pericardial tamponade

Haridha Devi — 2026-04-08

Background: Acute Lymphoblastic Leukemia (ALL) is a malignant disorder of lymphoid progenitor cells that commonly presents with symptoms related to bone marrow failure. However, extramedullary manifestations may occasionally be the initial presentation. Pericardial effusion leading to cardiac tamponade is a rare but life-threatening complication associated with hematological malignancies. We report the case of a 31-year-old female with no known comorbidities who presented with dry cough for two months and breathlessness for one week. Echocardiography revealed massive pericardial effusion with features of cardiac tamponade, for which emergency pericardiocentesis was performed. Further evaluation with flow cytometry confirmed Early T-cell Precursor Acute Lymphoblastic Leukemia (ETPALL). This case highlights the importance of considering hematological malignancy in patients presenting with unexplained pericardial effusion and mediastinal masses.

Surgical management of neglected anorectal malformation in an adult

Mahesh Sundaram — 2026-04-08

Background: Neglected anorectal malformations in adults, often resulting from failed neonatal repairs and long-term loss of follow-up, present significant surgical challenges, including chronic constipation, megarectum, and fecal incontinence. Management of these rare cases requires a staged surgical approach, utilizing meticulous dissection to navigate hostile tissue and a tailored bowel management program to improve functional outcomes. Detailed radiological findings, such as MRI and contrast studies, are essential for mapping complex anatomy, identifying the sphincter complex, and planning necessary redo surgeries.

A delayed diagnosis of Sheehan syndrome, presenting as chronic hypopituitarism

Priya — 2026-04-08

Background: Sheehan syndrome is a rare but important cause of maternal hypopitutarism resulting from ischemic necrosis of the pituitary gland following severe postpartum hemorrhage. The diagnosis is often delayed due to non-specific clinical manifestations that may appear years after the inciting obstetric event. We report the instance of a middle-aged women presenting with features of chronic hypopituitarism, ultimately diagnosed as Sheehan syndrome. This report highlights the importance of detailed obstetric history and early endocrine evaluation in women presenting with unexplained multi system symptoms.

Unusual case of DRESS syndrome with drug induced liver injury: A challenging overlap of immunology and hepatotoxicity in critical care practice

Harish Mallapura Maheshwarappa — 2026-04-08

Background: A 33-year-old male developed severe Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. The case highlights the critical care challenges of managing the overlap between immunological hypersensitivity and acute metabolic hepatotoxicity, requiring rapid recognition to prevent organ failure.

Motorized transcatheter aortic valve implantation in a high-risk patient with severe aortic stenosis: A case report

Shirlin M.S — 2026-04-08

Background: Transcatheter aortic valve implantation (TAVI) is an effective therapy for severe aortic stenosis, especially in patients with high surgical risk due to complex cardiac history. Motorised valve delivery systems enable precise deployment, improving procedural outcomes.

Case Presentation: We report a 65-year-old male with newly diagnosed diabetes mellitus, a history of coronary artery disease (triple-vessel disease), status postprimary PCI to the left anterior descending artery (LAD) following an evolved anterior wall myocardial infarction (AWMI) with prior cardiac resuscitation, and old multifocal cerebrovascular infarcts. The patient also had recovered from acute decompensated heart failure and moderate left ventricular dysfunction. During follow-up, he was found to have severe calcific aortic stenosis with severe aortic regurgitation. On admission, he was conscious and oriented, pulse 74 bpm, BP 160/90 mmHg, S1/S2 audible, and bilateral air entry normal. He underwent successful transfemoral motorised TAVI under fluoroscopic and ultrasound guidance. Preprocedure gradient was 80/60 mmHg. Following balloon pre-dilatation with an 18 mm Z-MED II balloon, the motorised valve was deployed with optimal positioning. Post-procedure gradient was reduced to 13/6 mmHg with minimal paravalvular leak. The patient had an uneventful recovery and remained asymptomatic at 30-day follow-up.

Conclusion: This case illustrates the feasibility, safety, and efficacy of motorised TAVI in patients with severe aortic stenosis and multiple high-risk comorbidities, including prior myocardial infarction, PCI, cerebrovascular disease, and moderate LV dysfunction.

Spectrum of supraventricular and ventricular arrhythmia: A case series highlighting AVNRT and arrhythmogenic right ventricular dysplasia

Shirlin M.S — 2026-04-08

Background: Supraventricular tachycardia (SVT) and ventricular arrhythmia’s are common causes of palpitations and syncope, with variable clinical presentations and outcomes. Radiofrequency (RF) ablation and cardioversion remain mainstays of definitive therapy in selected cases.

Case Series: We report three cases highlighting the clinical spectrum of arrhythmias. Case 1 involved a 44-year-old female with AVNRT and comorbid hypertension and hypothyroidism, successfully treated with RF ablation using 3-D electro anatomical mapping (EAM). Case 2 described a 38-year-old male with drug-refractory AVNRT and mild mitral valve prolapse, also successfully managed with RF ablation. Case 3 involved a 15-year-old boy with arrhythmogenic right ventricular dysplasia (ARVD) presenting with ventricular tachycardia; arrhythmia was refractory to antiarrhythmic therapy but reverted to normal rhythm after synchronized DC cardioversion.

Conclusion: This series illustrates the diverse presentation of supraventricular and ventricular arrhythmias, the role of advanced electrophysiologic interventions, and the importance of individualized management strategies to achieve optimal outcomes.

The pre-infarction ECG pattern: A case report of wellens syndrome

Shirlin M.S — 2026-04-08

Background: Wellens syndrome represents a high-risk ECG pattern in unstable angina or NSTE-ACS patients, signaling critical proximal LAD stenosis and impending anterior myocardial infarction. This report highlights two cases emphasizing that prompt recognition and immediate invasive intervention are necessary, as traditional stress testing is hazardous for these patients.

SVT in children: Case study

Shirlin M.S — 2026-04-08

Background: Supraventricular tachycardia (SVT) in children can be refractory to medical management, necessitating definitive intervention. Atrioventricular reentrant tachycardia (AVRT) mediated by a concealed accessory pathway is a common mechanism that can present with significant symptoms or tachycardiomyopathy.

Carcinoma hypopharynx: A case report

Abdul Kalam — 2026-04-08

Background: Hypopharyngeal cancer is a relatively uncommon but aggressive malignancy of the upper aerodigestive tract. It often presents late due to vague early symptoms. We report a case of a 52-year-old female with a long history of tobacco chewing who presented with dysphagia and throat discomfort. Detailed clinical evaluation and imaging revealed carcinoma of the hypopharynx involving the postcricoid region. The patient was planned for radical concurrent chemoradiotherapy. This case highlights the importance of early diagnosis and multidisciplinary management in hypopharyngeal carcinoma.

Double primary malignancy: Bilateral breast carcinoma in a patient with past history of papillary thyroid carcinoma

Ranjith Kumar. R — 2026-04-08

Background: Double primary malignancy is defined as the occurrence of two independent primary cancers in the same individual. With improved cancer survival and better diagnostic techniques, the incidence of multiple primary malignancies has increased. We report a case of a 50-year-old female with a past history of papillary thyroid carcinoma who later developed bilateral invasive breast carcinoma. The patient presented with a right breast lump and was diagnosed with bilateral breast malignancy on imaging and biopsy. She received neoadjuvant chemotherapy followed by bilateral modified radical mastectomy with axillary lymph node dissection. Final histopathology revealed invasive carcinoma of no special type (NST) in both breasts with residual cancer burden class II. This case highlights the importance of multidisciplinary management in patients with complex oncological conditions involving multiple primary tumors.

Diagnostic Images: CT abdomen–GIT spotters

Meenakshi Paramasivan — 2026-04-08

Diagnostic Images: CT abdomen–GIT spotters

Siderosis and spinal CSF leaks

Meena Nedunchelian — 2026-04-08

Background: A 39-year-old male presenting with syncope was found to have superficial siderosis on initial imaging, prompting a comprehensive repeat MRI to rule out vascular causes, as spinal CSF leaks are a recognized cause of this condition. The evaluation, including non-contrast MRA/MRV and ASL, was initiated after initial images were unavailable, highlighting the need for thorough investigation to identify potential underlying dural defects.