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Profile of non traumatic surgical disorders found in the pilgrims/ trekkers travelling to Shri Amarnath Ji cave.

Background & objectives: The "Shri Amarnath Ji Yatra" is an annual congregation in which the devotees trek a difficult route of around 40 km to reach to a cave at a height of approximately 14,000 feet at Pahalgam in the State of Jammu & Kashmir, India. These trekkers are subjected to stress and strain of the long mountainous route and difficult security scenario as a result of which they are prone to develop some surgical disorders. We ascertained the profile of non-traumatic surgical conditions met in these people at the various medical aid centres and the base hospital Pahalgam so that a policy could be framed to prevent these conditions.

Methods: This study was conducted at the Government Base Hospital Pahalgam, Kashmir, between June and August 2006. The patients with non traumatic surgical conditions attending the hospital were included in this study. Necessary investigations were done and patients requiring surgical intervention were operated upon.

Results: Of the 1,54,000 devotees who undertook the "yatra', in 2006 the personnel of the Directorate of Health Services, Kashmir, extended medical aid to 40,082 pilgrims. Of these 40,082 pilgrims, 172 were admitted on the surgical side for various non traumatic surgical disorders. The commonest cause for admission was exacerbation of acid peptic diseases. Nine emergency surgical procedures were conducted at the base hospital and the commonest cause for intervention was perforation of a duodenal ulcer. There was no mortality and the patients responded well to conservative ulcer procedures.

Interpretation & conclusions: The stress of high altitude trekking and assembly of a large gathering of people during the annual "Amarnath Ji yatra" can pose a number of health related problems especially in the old and infirm people as was observed in the study. Pilgrims who intend taking up the yatra in future should seek medical advice prior to their departure. If a person is diagnosed to have peptic ulcer disease he or she should be put on anti-ulcer therapy to prevent potential complications.

Key words Amarnath yatra-stress-surgical profile

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The devotees from all over India come for an annual congregation in the State of Jammu & Kashmir, India, in the months of July and August to visit the holy cave of Lord Amarnath situated at a height of about 14,000 feet and trek a difficult mountainous route of about 40 km. In 2006, around 1,50,000 registered devotees reached the base camp situated at Nunwan near Pahalgam by various routes. They trekked a difficult mountainous route of over 40 km in area around 14000 feet above the sea level especially at the famous Mahagunus Pass and the holy cave. Due to the stress and strain of this unusual physical and psychological exercise the pilgrims are at a risk to develop some surgical disorders. Even though the incidence of traumatic injuries after falls along with cold induced injuries like frostbite (1,2) are common at high altitudes, a review of literature revealed that sigmoid volvulus and megacolon occurred at an increased incidence at 13,000 feet (3,4). However, there are no published reports about the occurrence of surgical disorders in large congregations. We ascertained the profile of non-traumatic surgical conditions seen in these travellers at the various medical aid centres and the base hospital Pahalgam in 2006.

Material & Methods

This study was mainly conducted at the Government Base Hospital Pahalgam, which is the first referral centre manned by the personnel of the Directorate of Health Services, Kashmir between June-August 2006. The study protocol was approved by the Director, Health Services Kashmir. All patients with non traumatic surgical conditions were included in this study who either presented at this hospital on their own or were referred from various medical aid centres which are set up on temporary basis en route the holy cave.

The patients were examined by the surgeon specialist at the base hospital Pahalgam which is a 30 bedded hospital with the basic investigative set up and a surgical theatre. A detailed history was taken and a clinical examination was conducted in the outpatient department. The patients with acute surgical disorders were admitted in the hospital for further investigation. Patients with history of trauma requiting admission were excluded from this study. Necessary investigations were done and the patients requiring any surgical intervention were operated upon in the base hospital Pahalgam. The patients were carefully followed up during postoperative period fill their discharge from the hospital.

Results

The total number of devotees registered for 2006 was 1,54,000. The doctors and the paramedical staff of the Directorate of Health Services, Kashmir, examined 40,082 patients at the various medical aid camps set up en route to the holy cave. The total number of patients admitted for various non traumatic surgical conditions at the base hospital Pahalgam was 172. There was no mortality in the hospital though the number of deaths reported by various medical aid centres due to different causes was 22.

Majority of the patients admitted in the base hospital were males (n=172, males 148 and females 24). The age of the patients ranged from 19 to 76 yr maximum number (33.06%) in 51-60 yr age group (Table I). Of the 172 patients admitted, 163 (94.7%) were managed by conservative means only. The commonest cause for admission in these patients was an acute exacerbation of acid peptic disease (Table II). Only nine patients required surgery. Of these, four had perforated duodenal ulcer, two had acute appendicitis, one each had acute pancreatitis, twisted ovarian cyst, and obstructed ingniol hernia.

There was no mortality. One patient who developed mild wound infection required to stay in the hospital for 12 days and responded to antiseptic dressings and third generation cephalosporin antibiotics. There was one case of thrombophelibitis and one patient developed respiratory tract infection which required third generation cephalosporins and chest physiotherapy in the post-operative period.

Most of the patients were discharged on the postoperative day 7-9 after removal of the sutures and were advised to follow up with doctors at their permanent residence.

Discussion

Of the total 172 patients admitted for various non traumatic surgical disorders, 163 were managed by conservative means. The commonest cause found in these patients was acute exacerbation of acid peptic disease. The main complaint of these patients was epigastric pain not radiating to back with or without history of vomiting. The clinical examination usually revealed mild tenderness in the epigastric region. It could not be ascertained with certainty as to how many patients had taken non steroidal anti-inflammatory drugs (NSAIDs) which could have contributed to the development of this acute exacerbation as majority of the patients were sages (sadhus) and illiterate people. The second commonest cause for admission was ureteric colic, followed by abdominal pain. Mild pancreatitis was managed by conservative treatment. Conservative management of pancreatitis has been documented in many studies (5,6). We did not find any case of sigmoid volvulus or megacolon or active medical condition mimicking acute abdomen as has been documented earlier (4,5,7).

The commonest surgical emergency presented was perforation of a viscus (i.e., perforated duodenal ulcer). This is contrary to the experience of others who have established acute appendicitis as the commonest surgical emergency (6,8,9). Four of the 9 patients (44.5%) requiring surgery had perforated ulcer. Only three of these four patients had prior history suggestive of ulcer dyspepsia while one was totally symptom free before this episode. These three patients had taken some form of anti-ulcer therapy in the past but currently were not on any medication. Only one patient had history suggestive of intake of NSAIDs before the episode. The possible reason for the perforation could be the excessive physical and mental stress due to the rough geographical terrain and the prevailing security scenario. All four responded to conservative surgical procedure of the Ceilen Jones technique (10). No patients were subjected to definitive ulcer procedure as there was frank peritonitis in all of them (11). Laparoscopic repair could not be considered as the facilities were not available at the hospital; also there are contradictory reports about this procedure (6,12).

Acute appendicitis is associated with lower mortality, shorter duration of hospital stay and lower morbidity than other intra-abdominal infections (13). Laparoscopic appendectomy could not be done due to non availability of equipment although it has shown better results than open operation (14). Recent reports have demonstrated that antibiotics alone are useful to treat patients with early non perforated appendicitis (15).

Patients were given injectable antibiotics peri-and post-operatively till they tolerated oral diet, when oral antibiotics were switched to. There has not been a consensus about the appropriate duration of treatment for intra-abdominal infections. Some believe that antibiotics can be stopped once fever and leukocytosis have resolved, and gastrointestinal function has returned (16), while others recommend a specific duration of therapy (17). The development of effective oral antimicrobials for the treatment of intra-abdominal infections has led to a number of prospective randomized trials that have advocated switching to oral antibiotics once patients can tolerate a diet (16-18).

The commonest indication for admission in was acute exacerbation of acid peptic disease. The conservative line of management of these patients yielded excellent results. The commonest indication for surgical intervention in patients with non traumatic surgical disorder was perforated duodenal ulcer. If a person is diagnosed to have peptic ulcer prior to journey, it is better to start anti-ulcer therapy to prevent a possible complication from surfacing even though some authors do not favour this regime (19,20), while others support the use of anti-ulcer therapy (21-23).

In conclusion, our results showed that the persons who intend to come for the "yatra" in future should seek medical advice prior to their departure to rule out any pre-existing disorder. If a person is diagnosed to have peptic ulcer it is better to start anti-ulcer therapy to prevent a potential complications during the journey.

Received July 18, 2007

References

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(2.) Hashmi MA, Rashid M, Haleem A, Bokhari SA, Hussain T. Frostbite: epidemiology at high altitude in the Karakoram mountains. Ann R Coll Surg Engl 1998; 80: 91-5.

(3.) Asbun HJ, Castellanos H, Balderrama B, Ochoa J, Arismendi R, Teran H, et al. Sigmoid volvulus in the high altitude of the Andes. Review of 230 cases. Dis Colon Rectum 1992; 35: 350-2.

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(9.) Jones RS, Claridge JA. Acute abdomen. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery, The biological basis of modern surgical practice, 17th ed. Philadelphia: Elsevier; 2005. p. 1219-40.

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(11.) Boey J, Lee NW, Koo J, Lam PH, Wong J, Ong GB. Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trail. Ann Surg 1982; 196: 338-44.

(12.) Siu WT, Leong HT, Law BK, Chau CH, Li AC, Fung KH, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 2002; 235: 313-9.

(13.) Merlino JI, Malangoni MA, Smith CM, Lange RL. Prospective randomized trials affect the outcomes of intraabdominal infection. Ann Surg 2001; 233: 859-66.

(14.) Nguyen NT, Zainabadi K, Mavandadi S, Paya M, Stevens CM, Root J, et al. Trends in utilization and outcomes of laparoscopic versus open appendectomy. Am J Surg 2004; 188 : 813-20.

(15.) Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, et al. Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial. World J Surg 2006, 30 : 1033-7.

(16.) Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT, et al. Guidelines for the selection of anti-infective agents for the complicated intra-abdominal infection. Clin Infect Dis 2003; 37 : 997-1005.

(17.) Mazuski JE, Sawyer RG, Nathens AB, DiPiro JT, Schein M, Kudsk KA, et al. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary. Surg Infect 2002; 3 : 161-73.

(18.) Malangoni MA, Song J, Herrington J, Choudri S, Pertel P. Randomized control trial of moxifloxacin compared with piperacillin-tazobactam and amoxicillin-clavulanate for the treatment of complicated intra-abdominal infections. Ann Surg 2006; 244 : 204-11.

(19.) Fazili A, Bhat MH, Nazir S. Incidence of duodenal ulcer perforation in patients on anti-ulcer therapy. J Med Sci 2002; 5 : 150-2.

(20.) Rahuman MM, Saha AK, Rahim A. Experience of peptic ulcer perforations in a teaching hospital in Southern Bangladesh. Ceylon Med J 2003; 48 : 53-5.

(21.) Walt R, Katschinski B, Logan R, Ashley J, Langman M. Rising frequency of ulcer perforations in elderly people in the United Kingdom. Lancet 1986; 1 : 489-92.

(22.) Hermansson M, Stael von Holstein C, Zilling T. Peptic ulcer perforation before and after the introduction of H 2-receptor blockers and proton pump inhibitors. Scand J Gastroenterol 1997; 32 : 523-9.

(23.) Davidson G, Kritas S, Butler R. Stressed mucosa. Nestle Nutr Workshop Ser Pediatr Program 2007; 59 : 133-42; discussion 143-6.

I.S. Mir, M. Mir & M. Ahmed *

Government Gousia Hospital, Srinagar, Jammu & Kashmir & * Health Services, Kashmir, India

Reprint requests: Dr Iqbal Saleem Mir, Apex Super Speciality Centre, Gole Market, Karan Nagar, Srinagar 190 010

Jammu & Kashmir, India

e-mail: iqbalsurg@yahoo.com
Table I. Age distribution of the yatrees

 Age (yr) No. (%)

 10-20 13 (7.54)
 21-30 10 (5.41)
 31-40 11 (6.38)
 41-50 44 (25.52)
 51-60 57 (33.06)
 61-70 31 (17.98)
 71 & above 6 (3.48)
 Total 172 (100)

Table II. Break up of the diagnosis in patients managed conservatively

Diagnosis No. (%)

Acute exacerbation of acid peptic disease 69 (42.09)
Ureteric colic 27 (16.47)
Undiagnosed abdominal pain 22 (13.42)
Post acute gastroentetitis pain 16 (9.76)
Acute cholecystites 12 (7.21)
Severe urinary tract infection 7 (4.27)
Bleeding per rectum 4 (2.44)
Acute urinary retention 2 (1.21)
Upper gastrointestinal bleeding 1 (0.61)
Pancreatitis 1 (0.61)
Total 163 (100)
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Author:Mir, I.S.; Mir, M.; Ahmed, M.
Publication:Indian Journal of Medical Research
Article Type:Report
Geographic Code:9INDI
Date:Dec 1, 2008
Words:2436
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