Colorectal tuberculosis

Our objective was to evaluate the incidence of colorectal tuberculosis in our series and to study its radiological spectrum. A total of 684 cases of proven gastrointestinal tuberculosis with positive barium contrast findings seen over a period of more than one decade were evaluated. The study did not include cases where colon was involved in direct contiguity with ileo-caecal tuberculosis. Seventy-four patients (10.8%) had colorectal tuberculosis. Commonest site involved was transverse colon, closely followed by rectum and ascending colon. Radiological findings observed were in the form of strictures (54%), colitis (39%) and polypoid lesions (7%). Complications noted were in the form of perforations and fistulae in 18.9% of cases. Colorectal tuberculosis is a very common site for gastrointestinal tuberculosis. Typical findings of colorectal tuberculosis are strictures, signs of colitis and polypoid lesions. Common complications are perforation and fistulae.

Imaging of esophageal tuberculosis: a review of 23 cases

PURPOSE

To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

MATERIAL AND METHODS

The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

RESULTS

Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Perforations and fistulae in gastrointestinal tuberculosis

BACKGROUND

Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies.

MATERIAL AND METHODS

A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae.

RESULTS

Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression.

CONCLUSION

Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.

Celiac disease presenting as iron-deficiency anemia in northern India

BACKGROUND

Adult celiac disease is infrequent in India. Iron-deficiency anemia as its presenting manifestation is still rarer.

METHODS

We investigated patients with refractory iron-deficiency anemia attending the hematology clinic of a tertiary-care hospital for celiac disease. The diagnosis of celiac disease was based on histology, serology and response to treatment.

RESULTS

Of 19 patients with refractory iron-deficiency anemia seen from April 1998 to March 2000, 11 were diagnosed to have celiac disease. Four of these had abnormal D-xylose test and 3 had fat malabsorption. All 11 patients responded to gluten-free diet with improvement in hematological parameters.

CONCLUSION

Patients with refractory iron-deficiency anemia of unknown cause should be investigated for subclinical celiac disease.

Lactose intolerance in different types of irritable bowel syndrome in north Indians

BACKGROUND

Twenty-five patients of irritable bowel syndrome (IBS) and 25 normal healthy individuals serving as controls, were studied for lactose intolerance.

METHODS

Hydrogen breath test was used as an investigation after giving 50 g of oral lactose. Clinically, the patients were classified into 3 types of IBS.

RESULTS

Eleven (44%) out of 25 patients belonged to diarrhoeal type of IBS, 7 (28%) of 25 patients to spastic and rest 7 (28%) of 25 patients had features of both types of symptoms. Lactose hydrogen breath test was abnormal in 9 cases (82%) of 11 diarrhoeal type of IBS which was significantly higher (p < 0.02) than controls. However, the difference of abnormal hydrogen breath test between spastic type of IBS and patients with features of both types was not significant as compared to controls.

CONCLUSIONS

These results suggest that patients with diarrhoeal type of IBS have a higher incidence of lactose intolerance as compared to spastic type as well as patients with features of both types.

Primary small bowel tumors: a radiologic-pathologic correlation

BACKGROUND

Primary small bowel tumors are rare and their preoperative diagnosis is unsatisfactory. The cornerstone of diagnosis remains contrast radiography. The present study was done to evaluate the radiologic findings of primary small bowel tumors as shown on enteroclysis and to correlate these observations with surgical and histopathologic findings.

METHODS

Seventy two patients with primary small bowel tumors identified by enteroclysis were evaluated. All the patients were subjected to jejunal biopsy or surgery. The diagnosis was established by histopathologic examination in all cases.

RESULTS

Radiologic findings were suggestive of benign tumors in 19 patients and malignant tumors in 31 patients. Nonspecific findings in the form of diffuse involvement of the small bowel were noted in 22 patients. There was 100% radiologic-surgical correlation. Leiomyomas and lymphomas were the most common benign and malignant tumors, respectively. Tumor specificities were 89.5% for benign tumors and 41.5% for malignant tumors.

CONCLUSION

Distinctive morphologic patterns as shown on enteroclysis are highly suggestive of specific tumor types in the majority of cases.

Isolated gastric tuberculosis presenting as massive hematemesis: report of a case

Tuberculous involvement of the stomach is rare. We report herein the unusual case of a 25-year-old man in whom a benign gastric ulcer was found along the lesser curvature after he presented with massive upper gastrointestinal bleeding. Histopathological examination helped to confirm a diagnosis of tuberculosis. The granulomas typical of tuberculosis were caseation with epithelioid and giant cells. The patient was successfully treated by a combination of appropriate surgical therapy and prompt institution of antituberculosis medication.

Cholangiopathy in extrahepatic portal venous obstruction. Radiological appearances

PURPOSE

To evaluate cholangiographic abnormalities resulting from extrahepatic portal venous obstruction (EHPVO) by sonography and endoscopic retrograde cholangiopancreaticography (ERCP).

MATERIAL AND METHODS

Forty-three patients with an established diagnosis of EHPVO were subjected to duplex Doppler sonography and ERCP. Of these, 8 patients had obstructive jaundice.

RESULTS

Dilated common bile duct with pericholedochal varices showing a continuous type of flow pattern was seen in 5 EHPVO patients with obstructive jaundice. ERCP revealed cholangiographic abnormalities in 40 patients (93%). Extrahepatic bile ducts were involved in 100% of cases compared to intrahepatic bile ducts (57%). Abnormalities noted were contour irregularity with indentations, displacement and angulation, strictures and filling defects in the extrahepatic ductal system. Intrahepatic bile ducts showed dilatation with areas of narrowing and filling defects.

CONCLUSION

Cholangiographic abnormalities are very common in patients with EHPVO, even without clinical manifestations of biliary disease. Extrahepatic bile ducts are far more often involved compared to intrahepatic bile ducts. Extrinsic compression with contour irregularity is the most common cholangiographic finding. Sonographic findings are not diagnostic. Dilated common bile duct with pericholedochal varices was seen in only 5 patients.

Clostridium difficile toxin and faecal lactoferrin assays in adult patients

Clostridium difficile is the primary aetiological agent of antibiotic-associated diarrhoea. The faecal lactoferrin (FL) assay is a simple in vitro test which is highly sensitive to the presence of a marker of polymorphonuclear cells. We evaluated the use of the FL assay in conjunction with the C. difficile toxin assay in faecal samples obtained from 231 adult patients. The relationship between C. difficile toxin and FL in both negative and positive status was highly significant statistically (P < 0.001). Therefore, the FL assay performed simultaneously with the C. difficile toxin assay can help rule out asymptomatic carriage of C. difficile.

Cholangiopathy in extrahepatic portal venous obstruction. Radiological appearances

PURPOSE

To evaluate cholangiographic abnormalities resulting from extrahepatic portal venous obstruction (EHPVO) by sonography and endoscopic retrograde cholangiopancreaticography (ERCP).

MATERIAL AND METHODS

Forty-three patients with an established diagnosis of EHPVO were subjected to duplex Doppler sonography and ERCP. Of these, 8 patients had obstructive jaundice.

RESULTS

Dilated common bile duct with pericholedochal varices showing a continuous type of flow pattern was seen in 5 EHPVO patients with obstructive jaundice. ERCP revealed cholangiographic abnormalities in 40 patients (93%). Extrahepatic bile ducts were involved in 100% of cases compared to intrahepatic bile ducts (57%). Abnormalities noted were contour irregularity with indentations, displacement and angulation, strictures and filling defects in the extrahepatic ductal system. Intrahepatic bile ducts showed dilatation with areas of narrowing and filling defects.

CONCLUSION

Cholangiographic abnormalities are very common in patients with EHPVO, even without clinical manifestations of biliary disease. Extrahepatic bile ducts are far more often involved compared to intrahepatic bile ducts. Extrinsic compression with contour irregularity is the most common cholangiographic finding. Sonographic findings are not diagnostic. Dilated common bile duct with pericholedochal varices was seen in only 5 patients.

Paterson-Kelly syndrome and celiac disease--a rare combination

Paterson-Kelly syndrome is characterized by an association of iron deficiency with dysphagia. We describe a patient with this syndrome who was later diagnosed to have celiac disease.

Intestinal pseudo-obstruction due to neurofibromatosis responding to cisapride

Gastrointestinal involvement in neurofibromatosis presenting with mechanical obstruction, hemorrhage or intussusception is known. Small bowel dysmotility and intestinal pseudo-obstruction due to neurofibromatosis is rare. A 23-year-old man with classical neurofibromatosis presented with intermittent episodes of intestinal pseudo-obstruction, small bowel bacterial overgrowth and steatorrhea. The patient had good symptomatic improvement with cisapride.

Concurrent renal transitional cell carcinoma and right colon cancer

A 45-year-old man who had undergone right radical nephrectomy for transitional cell carcinoma 3 months earlier was admitted with right colonic tumor. Review of CT done for right kidney tumor was suggestive of right colon pathology. Right hemicolectomy was performed, followed by a course of chemotherapy for mucinous adenocarcinoma, and he is well a year later.

Teratocarcinoma presenting with duodenal metastases diagnosed on endoscopic fine needle aspiration

Upper gastrointestinal bleed as the first symptom of metastatic testicular tumors is rare. We describe a 17-year-old man who presented with upper gastrointestinal bleed; endoscopic fine needle aspiration cytology from a duodenal mass suggested germ cell tumor, which was later confirmed on histology of the testis.

Pregnancy and its outcome in patients with noncirrhotic portal hypertension

There is paucity of data in the literature on the occurrence of pregnancy and its outcome in patients with noncirrhotic portal hypertension. The present study was undertaken to assess the fertility pattern, fetal loss, and consequences of variceal bleeding during pregnancy in these patients. Fifty-five women of child-bearing age with a diagnosis of noncirrhotic portal hypertension (including 32 with noncirrhotic portal fibrosis and 23 with extrahepatic portal venous obstruction) and 44 age-matched controls were studied. A detailed history of obstetric events and bleeding episodes was recorded in all patients. Any complication of portal hypertension was managed accordingly. Patients were classified into three groups for analysis: group 1-obstetric events after the diagnosis of portal hypertension in patients; group II-obstetric events before the diagnosis of portal hypertension in patients; and group III-obstetric events in controls. A total of 116 pregnancies took place in 44 patients. Of these, 36 occurred after and 80 before the diagnosis of portal hypertension was made. In the 44 controls, 118 pregnancies took place. The mean fertility rates of groups I, II and III were 0.20+/-0.24, 0.18+/-0.21, and 0.22+/-0.12 pregnancies per year, respectively, which were not statistically different (P>0.05). The numbers of fetal losses in groups I, II and III were 3/36 (8.3%), 6/80 (7.5%), and 12/118 (10.17%) pregnancies, respectively. Menstrual irregularities were found in 7/55 (12.72%) patients and 6/44 (13.6%) controls (P>0.05). Five episodes of variceal bleeding occurred in 36 pregnancies after the diagnosis of portal hypertension (13.88%). All five were successfully managed with endoscopic sclerotherapy. In conclusion, noncirrhotic portal hypertensive patients have normal fertility and outcome of pregnancy. Variceal bleeding episodes are not common and endoscopic sclerotherapy is safe and effective in pregnancy.

Fine needle aspiration biopsy of the spleen in pyrexia of unknown origin

To evaluate the diagnostic utility, value and potential risk of fine needle aspiration biopsy of spleen (sFNAB) in patients with splenomegaly in pyrexia of unknown origin (PUO), a retrospective analysis of medical records and cytological material of 31 patients on whom FNAB was performed between April 1994 and October 1997 was done. The patients were HIV- and presented with PUO. All other relevant investigations were negative. The spleen was either palpable or detected to have space-occupying lesions on ultrasonography (USG). The splenic aspirates showed tuberculosis in 11 patients (35.4%) and inconclusive or reactive changes in nine patients (25.8%). One case out of this group proved to be Kaposi's sarcoma on autopsy. The other diseases encountered were leishmaniasis (n = 3), non-Hodgkin's lymphoma (n = 4), fungal infections (n = 2), Hodgkin's lymphoma (n = 1). The patients who were diagnosed as having tuberculosis had epithelioid cells, giant cells, necrosis and inflammatory cells in various combinations. AFB positivity was 63.6%. The other cases which showed granulomas but no AFB were diagnosed on empirical grounds and all responded to the anti-tuberculosis therapy. No complications were encountered with the procedure. Therefore the authors conclude that sFNAB is rewarding in patients where all other non-invasive modalities of diagnosis have failed.

Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension

Rectal bleeding due to radiation proctosigmoiditis is often difficult to manage. We had earlier shown the efficacy of short-term therapy with topical sucralfate in controlling bleeding in the radiation proctosigmoiditis. We now report our long-term results with this form of therapy. The study comprised 26 patients with radiation proctosigmoiditis. Sigmoidoscopically, 9 (34.6%) patients had severe changes, 15 (57.69%) had moderate, and 2 (7.69%) had mild changes. Severity of bleeding was graded as severe (> 15 episodes per week), moderate (8-14 episodes per week), mild (2-7 episodes per week), negligible (< or = 1 episode per week), or nil (no bleeding). Ten patients had moderate rectal bleeding, while 16 had severe bleeding. All patients were treated with 20 ml of 10% rectal sucralfate suspension enemas twice a day until bleeding per rectum ceased or failure of therapy was acknowledged. Response to therapy was considered good whenever the severity of bleeding showed improvement by a change of two grades. Rectally administered sucralfate achieved good response in 20 (76.9%) patients at 4 weeks, 22 (84.6%) patients at 8 weeks, and 24 (92.3%) patients at 16 weeks. This change was significant by Wilcoxon matched-pairs signed-ranks test. Two patients required surgery due to poor response. Over a median follow-up of 45.5 months (range 5-73 months) after cessation of bleeding, 17 (70.8%) patients had no further bleeding while 7 (22.2%) had recurrence of bleeding. All recurrences responded to short-term reinstitution of therapy. No treatment-related complications were observed. Ten patients had other associated late toxicity due to pelvic irradiation in the form of asymptomatic rectal stricture (N = 3), rectovaginal fistula (N = 1), intestinal stricture (N = 1), vaginal stenosis (N = 1), and hematuria (N = 6). Three patients had progression of the primary disease in the form of pelvic recurrence (N = 2) and hepatic metastases (N = 1). We conclude that topical sucralfate induces a lasting remission in a majority of patients with moderate to severe rectal bleeding due to radiation proctosigmoiditis.

Watermelon stomach: a rare cause of upper gastrointestinal bleeding

Watermelon stomach is a rare cause of upper gastrointestinal bleeding. We report a middle-aged woman who had been having recurrent bleeding from watermelon stomach. She was treated surgically by gastrectomy and Billroth II anastomosis.

Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures

BACKGROUND

Intralesional corticosteroid injection has been shown to be effective in refractory esophageal strictures of various etiologies. The present study was conducted to determine the efficacy of intralesional triamcinolone in augmenting results of endoscopic dilation in corrosive esophageal strictures.

METHODS

Seventeen patients with corrosive esophageal strictures were treated with endoscopic dilation together with injection of triamcinolone acetonide into the stricture. Fourteen patients were already undergoing dilation; 3 patients were newly recruited. The interval between dilations and frequency of dilation were calculated before and after corticosteroid injections, and periodic dilation index was calculated as number of dilations/number of months.

RESULTS

The mean age of the 17 patients (8 men and 9 women) was 30+/-9.21 (range 13 to 52). Thirteen had strictures due to acid ingestion, four to alkali ingestion. There were 18 strictures in total, involving the upper (n = 2), middle (n = 10), and lower (n = 6) thirds of esophagus. Fourteen patients already on a dilation program had undergone 27.92+/-28.63 (range 6 to 92) dilations over a period of 22.92+/-30.73 months (range 2 to 96) before corticosteroid injections. Nine patients received a single injection of triamcinolone, whereas four each had two and three sessions. The dilation requirement after injections in these 14 patients was reduced to 3.57+/-2.90 (range 0 to 10) dilations over a period of 10.5+/-5.58 (range 4 to 21) months. The median total periodic dilation index irrespective of corticosteroid therapy was 0.33 (range 0.55 to 1.8). In 12 of the 14 patients, periodic dilation index before injections (range 0.91 to 3.0, median 1.67) was higher than the median total periodic dilation index and in all the 14 patients periodic dilation index after corticosteroid therapy (range 0 to 0.83, median 0.32) was less than the median of total periodic dilation index (p < 0.01). In addition three patients received intralesional corticosteroid injections at the time of first dilation. These three patients could be effectively dilated with 5, 3, and 3 dilations.

CONCLUSIONS

Intralesional triamcinolone injections augment the effects of endoscopic dilation in patients with corrosive esophageal strictures.

Detection of Clostridium difficile toxin by an indigenously developed latex agglutination assay

An indigenously developed latex agglutination assay using C. sordelli antitoxin was used to screen 211 stool samples received from hospitalized patients. Of 126 samples from patients receiving single to multiple antibiotics for various ailments, 38 (30%) were positive by the toxin assay, whereas only 6/85 (7%) of samples of patients not receiving antibiotics were also positive. Thus, of 211 samples a total of 44 (20.8%) were positive by our toxin assay, giving titers ranging from 1 in 5 to 1 in 320. The test developed by us is simple, rapid, easy and reliable and can be easily adapted to all microbiology laboratories.

Retained surgical sponge: an unusual cause of malabsorption

Retained surgical sponge is an unpleasant surprise in clinical practice. Intraluminal migration of the retained sponge, though rare, can lead to intestinal obstruction and other complications. We describe two cases of retained surgical sponge, both following gynaecological surgery, presenting several years after surgery with features of subacute intestinal obstruction, malabsorption and several years after surgery with features of subacute intestinal obstruction, malabsorption and sever hypoproteinemia which reverted after surgical removal.

The chronology and sequence of eruption of human permanent teeth in Northern Ireland

OBJECTIVES

To ascertain the average and range of ages and sequence of eruption of human permanent teeth, taking into account the effect of premature loss of primary antecedents.

DESIGN

Longitudinal study.

SETTING

Caucasian subjects in Northern Ireland.

SAMPLE AND METHODS

Study casts at 6-monthly intervals from age 5 to 15 years of 276 children (146 males and 130 females) enrolled in the Belfast Growth Study. The mean and range of ages of eruption of each individual tooth were computed. Comparisons were made between the mean ages of eruption with and without premature loss of primary antecedents, between upper and lower arches, between right and left sides and between males and females. The sequence of eruption was also investigated.

RESULTS

The means and ranges of eruption ages are reported. Premature loss of primary antecedents delayed eruption of permanent successors except for the upper premolars which were accelerated. The differences relating to the upper first premolar and lower canine were not statistically significant. Each lower tooth erupted before its upper counterpart except for the premolars. There was no significant difference in age of eruption between right and left sides. Females tended to erupt teeth before males with the exception of the second molars in both arches; however, the only differences to reach statistical significance related to upper and lower canines and upper lateral incisors. The most frequent orders of eruption were unique to the subject. These occurred in 22% of upper and 33% of lower arches. The classic sequences: first molar-central incisor-lateral incisor-first premolar-canine-second premolar-second molar (M1-I1-I2-PM1-C-PM2-M2) in the upper arch and I1-M1-I2-C-PM1-PM2-M2 in the lower arch occurred in only 16% of upper arches and 13% of lower arches. Males adhered to the textbook sequence (20% upper, 17% lower) more than females (12% upper, 8% lower). In the upper arch of females, the order M1-I1-I2-PM1-PM2-C-M2 in 10% of subjects was almost as frequent as the classic sequence.

CONCLUSION

The ages, ranges and orders of eruption found in this study are more reliable than many which are frequently quoted on account of its longitudinal nature and the fact that the effect of premature loss of primary antecedents is taken into account. The exclusively Caucasian sample makes the data quite precise but limits applicability to patients of this ethnic origin.

Intralesional steroid injections for corrosive induced pyloric stenosis

Gastric outlet obstruction is a well-recognized sequela of corrosive ingestion. Such patients are traditionally treated surgically. We have treated three such patients with intralesional steroid injections combined with through-the-scope balloon dilation. All three patients responded well and are asymptomatic after 12 months, 14 months and 3 years and 3 months of follow-up, respectively. Endoscopic balloon dilation combined with intralesional steroid may be an effective alternative to surgery in such patients.

Hepatosplenic tuberculosis: a cause of persistent fever during recovery from prolonged neutropenia

SETTING

Hepatosplenic abscesses in neutropenic patients, especially during the recovery phase, are almost always attributed to fungal infections. We report similar lesions due to Mycobacterium tuberculosis in neutropenic patients in a tertiary care centre in India.

OBJECTIVE

To characterize the features of hepatosplenic tuberculosis in neutropenic patients.

DESIGN

Retrospective comparison of disease pattern and response to treatment of hepatosplenic tuberculosis in febrile neutropenia patients (four of 30 with severe prolonged neutropenia) and in non neutropenic patients diagnosed during the same 12-month period (n = 4, control group).

RESULTS

The disease in the neutropenic patients typically presented during the recovery phase of neutropenia, with ultrasonic abnormalities similar to those seen in hepatosplenic fungal infections. In contrast to the marked organomegaly and typical granulomatous response found in the control group, the disease in the neutropenic patients was characterised by an absence of organomegaly, non-involvement of other sites, poor inflammatory response and a high bacillary load. The initial response to therapy was satisfactory in both groups.

CONCLUSION

Tuberculosis needs to be considered in the diagnostic work-up of hepatosplenic abscesses that occur during the recovery phase of neutropenia.

Endotoxemia predicts outcome in acute pancreatitis

The incidence of complications of acute pancreatitis is high in patients with endotoxemia, and so we determined the endotoxin levels in the blood and peritoneal fluid of patients with acute severe pancreatitis to correlate the levels with any sequelae. Fourteen patients with acute severe pancreatitis were examined with regard to clinical features, biochemical tests, and laparotomy (n = 9). In all coagulation profiles, blood gas analysis, chest and abdominal x-rays, ultrasound, and abdominal computed tomography scan (n = 10) were performed. Qualitative estimation of endotoxin levels was done in peripheral blood and peritoneal and peripancreatic fluid. Ten (71.42%) of 14 patients had endotoxin in the blood, and 9 (64.28%) had it in the peritoneal fluid. Twelve (85.7%) had pulmonary involvement, with hypoxia being the most common (85.7%); among them endotoxin was found in the blood of 10 (83.32%) and in the peritoneal fluid of 8 (66.66%) patients. Renal dysfunction was found in 4 (28.57%) patients; endotoxin was present in the blood of all 4 patients and in the peritoneal fluid of 3 (75%) patients. Cardiovascular abnormality was detected in 8 (57.14%) patients, and endotoxin was present in the blood and peritoneal fluid of all patients. Metabolic abnormality was present in 8 (57.14%) patients; endotoxin was present in the blood of all 8 patients and in the peritoneal fluid of 7 (87.6%) patients. Eight (88.88%) of the 9 patients who required surgery had endotoxemia. Three (30%) patients with endotoxemia survived, whereas all 4 patients without endotoxemia survived. Mean hospital stay was 61.2 days and 46.7 days for endotoxin-positive and endotoxin-negative patients, respectively. We conclude that the presence of endotoxin in blood and peritoneal fluid correlates with the severity, systemic complications, and mortality rates of acute pancreatitis. Endotoxin estimation can identify patients at risk in the early stages of acute pancreatitis.

Enteroclysis-guided fine-needle aspiration cytology of focal small-bowel lesions

PURPOSE

To study the role of enteroclysis-guided percutaneous fine-needle aspiration cytology (FNAC) of focal small-bowel lesions.

MATERIAL AND METHODS

Twenty patients with non-palpable circumscribed small-bowel lesions found on enteroclysis underwent FNAC after confirmation of needle position under fluoroscopy.

RESULTS

Positive diagnosis was obtained in 18 (90%) of the patients. Thirteen patients with positive FNAC and one with inconclusive cytology underwent surgery. In all, the cytological diagnosis was confirmed by histopathology. No complications were seen.

CONCLUSION

Enteroclysis-guided FNAC of focal small-bowel lesions is a safe and accurate diagnostic method.

Sclerotherapy in noncirrhotic portal fibrosis

Endoscopic sclerotherapy has emerged as an effective and safe mode of treatment for long-term management of esophageal varices due to cirrhosis of liver and extrahepatic portal venous obstruction. There are few studies that have evaluated the role of sclerotherapy in the management of esophageal varices in patients with noncirrhotic portal fibrosis (NCPF). We report our results of long-term sclerotherapy in patients with NCPF. Seventy-two consecutive patients (men 29, women 43; age 32.9 +/- 11.8 years) with recurrent variceal bleeding due to NCPF were entered into the sclerotherapy program. Forty-eight patients received intravariceal absolute alcohol and 24 patients received intravariceal sodium tetradecyl sulfate (STD). Variceal obliteration was achieved in 65 (90.3%) patients with a mean of 5.7 +/- 3.0 (range 1-14) sessions. These patients were followed-up for a mean of 21.4 +/- 20.4 (range 1-96) months. Thirteen (17.3%) patients had episodes of upper gastrointestinal bleeding during sclerotherapy. Rebleed after obliteration was seen in 6 (9.2%) patients. Sclerotherapy was associated with a significant reduction in bleeding rate (bleeds per month per patient) during sclerotherapy and after obliteration of varices as compared to presclerotherapy period (P < 0.000001 for both). Recurrence of esophageal varices after obliteration was seen in 9 (13.9%) patients with reobliteration of varices in five patients in whom sclerotherapy was attempted. Complications including esophageal ulcer and stricture formation were seen in 18 (25%) and 4 (5.6%) patients respectively; strictures were restricted to patients who received absolute alcohol. Two (2.77%) patients died of massive upper gastrointestinal bleed during follow-up. We conclude that sclerotherapy is an effective and safe modality in the prevention of variceal bleeds in patients with NCPF.

Primary gastrointestinal lymphoma--disease spectrum and management: a 15-year review from north India

OBJECTIVE

To analyze retrospectively the disease spectrum and outcome of primary gastrointestinal lymphoma (PGIL) in a tertiary referral center in north India.

MATERIAL

Seventy five patients presenting with PGIL between January 1971 and December 1985 were evaluated.

RESULTS

The 49 males and 26 females were aged 3.5-69 years (mean 34) at presentation. Abdominal pain, weight loss and vomiting were cardinal symptoms at presentation; the stomach was the most common site of involvement. Histologically, a majority of patients were classified as having diffuse poorly-differentiated lymphocytic lymphoma (46.7%) and diffuse histiocytic type (30.7%). Twenty seven (36%) patients had stage I disease, 31 (40%) stage II, 11 (14.7%) stage III, and 6 (8%) stage IV. At laparotomy, primary resection and anastomosis was carried out in 66 patients, while only biopsies were taken in nine. Forty eight patients received adjuvant radiation with or without chemotherapy. The mean follow-up was 3.9 years (range 1-14). The 5-year actuarial survival was 34%, 25% and 16% for stages I, II, and higher-stage disease, respectively. The survival was significantly better (p < 0.01) for gastric location (44%) compared to other sites (24%).

CONCLUSION

PGIL was more common in the 3rd and 4th decades of life, with the stomach being the predominant site of involvement. Survival was better among patients with stages I and II disease, and gastric location of lesion.

Infectious mononucleosis hepatitis: report of two patients

Icteric hepatitis and fulminant hepatic failure (FHF) are rare in infectious mononucleosis (IM). We report two patients with icteric IM hepatitis; one died after developing FHF, the other recovered uneventfully. Epstein-Barr virus infection causing hepatitis and FHF should be suspected when tests for other hepatotrophic viral infections are negative.

Primary duodenal tuberculosis diagnosed by endoscopic biopsy

Tuberculosis involves the duodenum very rarely and is usually secondary to lymph node involvement. Endoscopic biopsy usually shows nonspecific changes necessitating laparotomy for confirmation of diagnosis and relief of obstruction. We report a case of duodenal tuberculosis diagnosed by endoscopic biopsy and treated successfully.

Survival of patients with extensive small-cell lung cancer who have only brain metastases at initial diagnosis

To study the therapeutic outcome of patients with extensive small-cell lung cancer (SCLC) with the brain as the single site of metastases at initial diagnosis, we retrospectively reviewed the outcome of 30 such patients (23 men and seven women; median age, 59 years; range, 36-74 years). Medical histories were taken, and physical examination, complete blood cell count, chemistry profile, chest radiography, radionuclide bone scan, computed tomography (CT) scan of the abdomen or radionuclide liver scan, and CT scan of the head were performed as the staging workup for each patient. Bone marrow biopsies were performed in 19 patients. All patients initially received cisplatin-based chemotherapy and concomitant whole-brain radiation therapy consisting of 3,600-4,800 cGy. Subsequently, 22 patients also received thoracic radiation therapy (17 patients as part of the protocol treatment and five patients at the time of disease progression). Thirteen patients had a complete response, 11 had a partial response, three had regression, and three had stable disease. Median survival of the entire group was 14 months (range, 1.4-70.7 months). Twenty-four patients eventually had progression of disease, with a median time to progression of 10 months (range, 2.3-48.5 months). Only one patient had disease progression in the brain (12.6 months after diagnosis). Twenty-two patients eventually died of the disease. The results of our study suggest that the therapeutic outcome in SCLC with the brain as the single site of metastases at initial diagnosis is similar to that of limited-stage SCLC.

Allelic imbalance and microsatellite instability in resected Duke's D colorectal cancer

Hepatic resection is the treatment of choice for selected patients with liver metastases from colorectal cancer (CRC). Although the 5-year survival rate among patients after liver resection is 25-45%, 55-75% of patients die from progressive disease. The purpose of this study was to characterize molecular genetic alterations, including microsatellite instability and allelic imbalance, in patients with potentially curative resected liver metastases from CRC and to correlate these molecular features with clinical and pathologic characteristics. We examined DNA from formalin-fixed, paraffin-embedded archival tumor specimens from 141 surgically resected hepatic metastases from CRC. We used microsatellite markers localized to chromosome arms 5q, 8p, 10q, 15q, 17p, 18p, and 18q in a polymerase chain reaction-based assay. Allelic imbalance at each locus and the presence of tumor microsatellite instability were correlated with clinicopathologic features of the tumor and clinical course of the patient. Microsatellite instability at multiple loci was seen in only 2.5% of resected liver metastases, a frequency significantly lower than that previously detected for primary CRC. Additionally, these findings had no significant correlation with disease-free survival or overall survival. Allelic imbalance at one or more loci was seen in 87% of informative tumors. Allelic imbalance on chromosome 17p was seen in 84% of informative tumors, and its presence was associated with a significantly poor disease-free survival (p = 0.015) and overall survival (p = 0.05). These data suggest that allelic imbalance on chromosome 17p is an independent prognostic parameter in patients with potentially curative resected liver metastases from CRC. Such alterations could provide a useful stratification criterion for adjuvant therapy for patients who have undergone curative resection of liver metastases from CRC.

Ectopic pregnancy presenting as lower gastro-intestinal hemorrhage

A patient with ruptured tubal pregnancy presenting with lower gastrointestinal bleed is described. Colonoscopy and other investigations were not helpful; laparotomy was diagnosis as well as therapeutic.

Normal pancreatic duct morphology in a north Indian population

Ninety three normal pancreatograms from a North Indian population were studied. The pancreatic duct (PD) was L-shaped in 47%, oblique in 5% and sigmoid in 11%. The mean length (SD) of PD was 18.2 (3.0) cm, being longer in males but not varying with age. The mean maximum diameters of PD in head, body and tail were 3.7 (0.8), 2.7 (0.6) and 1.7 (0.4) mm respectively. These did not vary with sex. The PD diameters showed a statistically significant increase with age but this variation does not appear to be of much practical importance.

Tuberculous esophagocutaneous fistula

Esophagocutaneous fistula due to tuberculosis is a distinctly rare entity, with only two cases reported over the past 25 years. We report this unusual complication in an 85-year-old, human immunodeficiency virus-negative man and review the relevant literature.

Candida overgrowth after treatment of duodenal ulcer. A comparison of cimetidine, famotidine, and omeprazole

Acid-reducing drugs can cause increased growth of microbes, including fungus, because of high gastric pH. Our purpose was to evaluate the occurrence of mycotic infection in patients with duodenal ulcer on anti-ulcer therapy and to compare the effects of cimetidine, famotidine, and omeprazole. Eighty patients with duodenal ulcer (62 males and 18 female patients, 16-65 years old) were evaluated for mycotic infection before and after 6 weeks of therapy (cimetidine, 20 patients; famotidine, 40 patients; omeprazole, 20 patients). Mycotic infection was diagnosed by endoscopic biopsy from the ulcer edge subjected to smear, culture, and histopathology and by endoscopic brush samples and gastric aspirate. On the basis of these studies, patients were categorized as having no fungal growth, saprophytic growth, or significant fungal growth. Thirty-five (43.8%) patients had evidence of fungus before ulcer therapy, and 16 of the 35 (20%) had significant fungal growth. The fungal isolation rate was higher in older patients (> and = 45 years of age) and in those with an ulcer size > and = 2 cm. While there was no significant increase in the total number of patients with evidence of fungus after therapy (n = 36), there was a significant increase in those with significant growth (n = 27, p < 0.05) compared with pretreatment status. We found that posttreatment gastric pH of > and = 4 was associated with a higher fungal positivity rate (59.4%) than pH values < 4 (32.4%, p < 0.05). However, neither the type of drug used nor the response in terms of ulcer healing correlated with the presence of fungus. Regardless of the type of drug used, acid-reducing therapy is associated with increased significant fungal growth.

Angioimmunoblastic lymphadenopathy: an etiology for gastrointestinal lymphomatous polyposis

We describe a case of angioimmunoblastic lymphadenopathy with multiple polyps of the gastrointestinal tract. The patient presented with fever, abdominal mass, ascites, diarrhea, generalized lymphadenopathy, anemia, and marked peripheral eosinophilia. She had multiple polyps in the colon, as well as in the stomach and duodenum. Histology of a colonic polyp showed involvement by angioimmunoblastic lymphadenopathy. The patient responded initially to combination chemotherapy, with total disappearance of polyps. However, she succumbed later to infections. Angioimmunoblastic lymphadenopathy, although rare, should be included as a cause of lymphomatous polyposis of the gastrointestinal tract.

Primary sclerosing cholangitis: an experience from India

Primary sclerosing cholangitis (PSC) is considered to be rare in India. The aim of the present study was to investigate the incidence, clinical profile and outcome of PSC seen in a tertiary care centre. Over a period of 10 years (July, 1984-June, 1994) 18 patients of PSC were diagnosed at cholangiography (14 patients by endoscopic retrograde cholangiopancreatography, two patients by percutaneous transhepatic cholangiography and two patients by both methods). The presence of secondary causes, such as choledocholithiasis, biliary tract surgery, congenital biliary tract anomalies, cholangiocarcinoma and pancreatic diseases, were excluded. These patients were evaluated retrospectively with respect to their clinical presentation, radiological findings, presence of associated idiopathic ulcerative colitis (IUC), treatment instituted and outcome. The mean (+/- s.d.) age at diagnosis of PSC was 39.0 (+/- 16.1) years with a male:female ratio of 1.57:1. Nine (50%) patients had associated IUC. The diagnosis of the IUC preceded that of PSC in all but one case. Fifteen (83.3%) patients had cholestatic jaundice at presentation, while three (16.7%) patients had asymptomatic rise of alkaline phosphatase. Three (16.7%) patients had recurrent cholangitis and five (27.8%) patients developed portal hypertension during the course of the disease. At cholangiography, intrahepatic radicles were involved in all and extrahepatic radicles in 12 (66.6%) cases. Patients were managed with steroids (n = 7), colchicine (n = 3), ursodeoxycholic acid (UDCA; n = 2) and methotrexate (n = 1), along with symptomatic measures. Mean duration of follow up available in 11 (61%) patients was 20.1 months (range: 1 month-8 years). Four (36.4%) patients died. Steroids and colchicine did not have any effect while the one patient on UDCA and one on methotrexate showed improvement. In conclusion, in India PSC does not seem to be a rare entity. Its clinical profile and outcome are somewhat similar to those seen in Western countries.

Chloroquine for mild to moderately active ulcerative colitis: comparison with sulfasalazine

Chloroquine and hydroxychloroquine have been used successfully in a number of immunological diseases because of their immunomodulatory effect. Preliminary studies have shown them to be effective in the treatment of idiopathic ulcerative colitis. We assessed the efficacy or oral chloroquine in the treatment of idiopathic ulcerative colitis of mild to moderate severity in a randomized, controlled, blinded trial. Forty patients were assigned to receive chloroquine phosphate (500 mg/day) or sulfasalazine (3 g/day). The outcome of therapy was monitored at the end of 2 wk and 4 wk by symptom assessment and sigmoidoscopic examination. An objective scoring system was used for the evaluation, and patients were categorized into those showing complete remission, partially responding, and nonresponders. There was a sequential improvement in the individual scores as well as total activity score in both groups at 2 wk and 4 wk. With chloroquine, 12 patients (60%) showed complete remission at 4 wk, whereas six (30%) had a partial response. With sulfasalazine, 11 patients (55%) had complete remission at 4 wk, and eight (40%) showed partial response. There was no significant difference in the response to the two drugs (p > 0.05). Five (25%) patients in the chloroquine group had side effects, compared with eight (40%) in the sulfasalazine group (p > 0.05). All side effects were minor and transient, not requiring withdrawal of the drug. We conclude that short-duration chloroquine therapy is a safe and effective alternative to sulfasalazine in the treatment of mild to moderately active ulcerative colitis.

Endoscopic retrograde cholangiopancreatography in postcholecystectomy syndrome

The study was aimed to determine the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with postcholecystectomy symptoms in respect to interval of presentation following cholecystectomy. 170 patients with postcholecystectomy symptoms and negative upper gastrointestinal endoscopy were evaluated using ERCP. One hundred and seventeen (75%) out of 156 patients with successful ERCP had one or more abnormalities seen at ERCP. Bile duct stones (55 patients), benign strictures of bile duct (27 patients) were the common lesions detected. A significantly higher (p < 0.001) positive diagnosis was possible at ERCP in patients presenting with jaundice (100%) as compared to those without jaundice (61.8%). Spectrum of causes among patients presenting in early post-operative period (< 1 month) was somewhat different from those presenting later. Bile duct ligature and biliary fistula were the predominant causes in the former group, while stones and benign strictures were commoner in the patients presenting late. Endoscopic sphincterotomy and stone removal was performed successfully in 25 out of 30 patients in whom it was attempted. ERCP was found to be a very useful procedure in the management of postcholecystectomy symptoms. Spectrum of underlying disease was different in patients presenting before 1 month following cholecystectomy as compared to those presenting later.

Pancrease divisum: five years' experience in a teaching hospital

AIM

To study the frequency and significance of pancreas divisum.

METHODS

Retrospective analysis of all pancreatograms carried out between July 1989 and June 1994.

RESULTS

The 809 pancreatograms performed included 207 in patients with pancreatitis (acute 74, chronic 133), 330 with biliary disease, 238 with obscure abdominal pain and 34 with pancreatic malignancy. Of these, 30 patients (3.7%) were diagnosed to have pancreas divisum - 26 had type I variant, one had type II variant and three had type III variant. Accessory papillary cannulation was attempted in 10 patients; 8 were successful, with dorsal ductography confirming pancreas divisum in all of them. Two of these 8 patients had changes of chronic pancreatitis in the dorsal duct. The frequency of pancreas divisum in patients with pancreatitis (19 of 207, 9.2%) was significantly higher than in patients with biliary diseases and those with obscure abdominal pain (11 of 568, 1.9%; p < 0.001).

CONCLUSIONS

Pancreas divisum is not an uncommon condition in India and its frequency in patients with idiopathic pancreatitis is higher than that in patients with other abdominal conditions. It should be looked for in any case of idiopathic pancreatitis.