ERCP in the evaluation of choledochal cyst due to anomalous pancreatobiliary junction

With the application of endoscopic retrograde cholangio pancreatography (ERCP), the association of anomalous pancreatobiliary junction and choledochal cyst is being increasingly recognized. We describe here the ERCP findings in three patients who had this anomaly in association with fusiform (Type I) choledochal cyst. Two of our patients also had evidence of pancreatitis. The importance of ERCP in the preoperative assessment of such patients is highlighted.

Spontaneous rupture of the oesophagus (Boerhaave's syndrome) presenting as pyopneumothorax

Spontaneous rupture of the oesophagus presenting as a pyopneumothorax in an elderly male is described. Delayed presentation of the patient led to serious complications to which he succumbed.

Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate

In a prospective study, 37 consecutive patients with radiation-induced proctosigmoiditis were randomized to receive a four-week course of either 3.0 g oral sulfasalazine plus 20 mg twice daily rectal prednisolone enemas (group I, N = 18) or 2.0 g twice daily rectal sucralfate enemas plus oral placebo (group II, N = 19). The two groups were comparable with respect to demographic features, duration of symptoms, and clinical and endoscopic staging of the disease. Fifteen patients in group I and 17 in group II completed the trial. At four weeks, both groups showed significant clinical improvement (P less than 0.01 for group I and P less than 0.001 for group II) and endoscopic healing (P less than 0.01 for group I and P less than 0.001 for group II). When the two groups were compared, sucralfate enemas showed a significantly better response as assessed clinically (P less than 0.05), although endoscopically the response was not statistically different (P greater than 0.05). We conclude that both treatment regimens are effective in the management of radiation proctitis. Sucralfate enemas give a better clinical response, are tolerated better, and because of the lower cost should be the preferred mode of short-term treatment.

Colonoscopic fine needle aspiration cytology in the diagnosis of ileocecal tuberculosis

Two cases of ileocecal tuberculosis are presented. The diagnosis was achieved by endoscopic fine needle aspiration cytology (FNAC), while endoscopic biopsies and brush cytology were negative. The usefulness of endoscopic FNAC in the diagnosis of gastrointestinal tract tuberculosis is highlighted.

Controlled trial of twice a day versus once a day cimetidine therapy for duodenal ulcer

A randomized controlled trial was carried out to compare the efficacy of conventional 400 mg twice daily dose of cimetidine with single bedtime 800 mg dose, in 40 patients with endoscopically proven duodenal ulcer. At repeat endoscopy after four weeks of therapy, complete ulcer healing was achieved in 78% of patients on twice daily dosage and 79% of patients on single daily dosage. A more convenient single nocturnal dosage of cimetidine is as effective in the treatment of duodenal ulcer as a twice daily dosage in the Indian population.

Modified ultrasound-guided percutaneous transgastric drainage of pancreatic pseudocysts

We describe a modified ultrasound-guided transgastric drainage technique for pancreatic pseudocysts. Using a water-filled stomach to improve visualization, we have successfully drained pseudocysts in ten patients. This report also describes the use of a stiffening cannula to assist transgastric catheter placement. We emphasize the value of constant real-time tracking of the dilator and guidewire to ensure correct positioning of the drainage catheter.

Endoscopic management of chronic organoaxial volvulus of the stomach

Endoscopic correction of the chronic organoaxial volvulus of the stomach was attempted in seven cases of primary and three cases of secondary volvulus. Endoscopic correction was successful in six cases of primary volvulus and one case of volvulus secondary to duodenal carcinoma. This paper describes the details of the technique of endoscopic correction of gastric volvulus, and documentation of correction of the volvulus by barium meal study with a follow-up of 5-26 months.

Gastrointestinal bleeding in malaria

Hematological alterations are frequent in patients with malaria. However, these rarely manifest clinically, except for symptoms due to anemia. Two cases with gastrointestinal hemorrhage as a complication of malaria are reported.

Management of foreign bodies in the upper gastrointestinal tract

Records of 55 consecutive patients who had ingested foreign bodies were reviewed retrospectively. Foreign bodies were located in the esophagus, stomach and duodenum in 25, 27 and 3 patients respectively. Eleven of these passed through the entire gastrointestinal tract spontaneously and uneventfully. Endoscopic extraction was successful in 36 patients while 8 needed surgical removal of the ingested object. Only one death was encountered. We conclude that using simple guidelines, foreign body ingestion can be managed with a low incidence of complications and mortality.

Endoscopic sclerotherapy during pregnancy

Pregnancy in patients with portal hypertension is an uncommon occurrence. Hence, there are no clear guidelines for management of variceal bleed during pregnancy. Moreover, the outcome of variceal sclerotherapy, particularly its effect on conception, as well as its safety and efficacy when used during pregnancy, is not known. We have treated four patients of portal hypertension during pregnancy with sclerotherapy. Two of them presented to us before conception, were put on sclerotherapy for variceal bleed, and conceived while on sclerotherapy schedule. Two other patients were started on sclerotherapy during pregnancy when they presented with variceal bleed. Sclerotherapy with absolute alcohol was effective in control of variceal bleed as well as obliteration of varices in pregnant patients. There was no untoward effect on mother or fetus. The mean number of sessions and volume of alcohol required for variceal obliteration were 6.5 and 42.0 ml, respectively. Variceal sclerotherapy does not interfere with conception and successful pregnancy, and is safe as well as effective during pregnancy.

Acute colitis in renal transplant recipients

Gastrointestinal complications constitute an important cause of morbidity and mortality in renal transplant recipients. The present communication is based on our experience with 10 living related donor kidney transplant recipients who suffered from severe acute colitis in the posttransplant period. A specific etiological factor was detected in only one (atypical mycobacteria). Six patients succumbed to the illness in the acute stage, thus highlighting its seriousness. Various factors involved in etiology have been discussed, and early therapeutic intervention emphasized.

Colonic lipoma presenting with recurrent rectal bleeding

A case of colonic lipoma in a patient who presented with rectal bleeding is presented. The final diagnosis was established at histology. Rarity of the symptomatic colonic lipomas is highlighted.

Solitary ulcer syndrome of the rectum--a histopathologic characterisation of 33 biopsies

Histological analysis of 33 rectal biopsies from 26 patients of solitary ulcer syndrome (SUS) of rectum was undertaken. Fibrous obliteration and smooth muscle extension into the lamina propria were the characteristic and most constant findings. The limitation of the biopsy procedure in procuring deeper tissue made the detection of colitis cystica profunda rare in our study. A combination of fibrosis of the lamina propria, superficial mucosal ulceration, muscularis mucosae hypertrophy and submucosal fibrosis, along with the clinical suspicion should clinch the diagnosis of SUS.

Antipyrine elimination test as a guideline for selecting patients for transhepatic biliary drainage

Antipyrine elimination halflife (AP t1/2) was studied in 18 patients with obstructive jaundice along with routine liver function tests 24-48 h before the expected time of percutaneous transhepatic biliary drainage (PTBD). To see if it is possible to predict the outcome of PTBD, various predrainage parameters were correlated with the postdrainage bilirubin clearance after 1 week of drainage. Predrainage AP t1/2 correlated best with bilirubin clearance (r = 0.775, P less than 0.01) compared with predrainage serum bilirubin, alkaline phosphatase and serum proteins/albumin. Eight patients had AP t1/2 less than 15 h, while 10 had AP t1/2 greater than 15 h. Patients with AP t1/2 less than 15 h had significantly faster recovery after PTBD than patients with AP t1/2 greater than 15 h. If PTBD can be restricted to those with AP t1/2 less than 15 h, the advantages of preliminary PTBD can be achieved with minimum complications. Thus, estimation of AP t1/2 may aid in the selection of patients with obstructive jaundice who are likely to benefit by preliminary biliary decompression.

Ultrasound guided pancreatic ductography

Thirteen patients underwent ultrasound guided percutaneous pancreatic ductography during a one year period. In nine cases the procedure was performed after failure of endoscopic retrograde pancreatography (ERP) and in four patients ERP was not attempted. Under ultrasound guidance a 22 gauge needle was inserted into the pancreatic duct through a vertical transgastric route. After aspiration of 10-15 ml of pancreatic juice, contrast medium was injected into the pancreatic duct. Opacification was successful in 12 (92%) patients. No significant complications were encountered. The usefulness of the procedure in our country is highlighted.

Fine needle aspiration cytology of rectal masses

This paper describes the results of transproctoscopic fine needle aspiration cytology in the diagnosis of rectal lesions. Fifty one consecutive patients referred with a presumptive diagnosis of rectal mass were subjected to proctoscopic examination when fine needle aspiration cytology, brush cytology and biopsy samples were taken. Of the 30 patients of malignancy of rectum in whom all the three sampling techniques were applied, the biopsy was positive in 27 (90%), brush cytology in 25 (83.3%) and fine needle aspiration cytology in 29 (96.6%). A combination of fine needle aspiration cytology with brush cytology gave a positive yield in 96.6% while that fine needle aspiration cytology with brush cytology gave a yield of 100%. Fine needle aspiration cytology was most helpful in infiltrative tumours. All 10 patients with secondaries in the pouch of Douglas or rectovesical pouch, and the single patient with submucosal rectal carcinoma were correctly diagnosed at fine needle aspiration cytology. There were no false positive results with fine needle aspiration cytology and no complications were encountered with the procedure.

Crush preparations of gastroesophageal biopsy specimens in the diagnosis of malignancy

The diagnostic value of crush preparations of endoscopic biopsy samples from gastroesophageal malignancies was studied. Forty-two patients with esophageal or gastric carcinomas were subjected to endoscopic biopsy and brushing. Half of each of two biopsy pieces from each case was crushed between two glass slides for cytologic evaluation. A positive yield (a diagnosis of malignancy) was achieved by histologic study of biopsy samples in 38 cases and by cytologic study of brushing smears in 37 cases and crush preparations in 40 cases. The advantages of the cytologic study of crush preparations were: (1) it expedited the workup of the patients and (2) it gave a positive yield in cases whose biopsy specimens were otherwise inadequate for making a definitive histologic diagnosis. Crush preparations thus combined the usefulness of biopsy and brushing techniques for the diagnosis of gastroesophageal malignancies.

A comparative evaluation of sclerosants for esophageal varices: a prospective randomized controlled study

The aim of this prospective randomized controlled study was to find a safe and effective sclerosing solution for endoscopic injection sclerotherapy in the treatment of esophageal variceal bleeding. Ninety consecutive patients with portal hypertension and variceal bleeding were randomized to receive sclerotherapy with 5% ethanolamine oleate, 3% sodium tetradecyl sulfate, or absolute alcohol at an interval of 3 weeks. Sixty-four patients who received more than three sessions were analyzed. All three agents were found to have similar success and complication rates (p greater than 0.05). However, absolute alcohol required fewer sessions (p less than 0.01) and lesser amounts (p less than 0.01) to produce successful variceal sclerosis and had the added advantage of low cost and easy availability.

Evaluation of different methods for detection of Helicobacter pylori in patients with gastric disease

Endoscopic gastric antral biopsy specimens (133) from 92 dyspeptic patients with endoscopically evident gastritis (34; including one patient with dual pathology) gastric ulcer (13), duodenitis (17; including one patient with dual pathology) duodenal ulcer (29) and 41 subjects of non ulcer dyspepsia (NUD) with endoscopically normal upper gastrointestinal tract were examined for H. pylori by stained smear, various urease tests, culture and histopathology. Crushed tissue smear stained by Gram's method using carbol fuchsin counterstain proved to be the simplest and a reliable technique. Up to 4 h urease broth + ve test correlated well with smear and culture. Positive association of H. pylori with disease was considered when at least two of the above methods were suggestive. Significantly higher positivities were observed in gastritis (61.7%), gastric ulcer (84.6%), duodenitis (58.8%) and duodenal ulcer (82.8%) patients, as compared to NUD subjects (46.3%). Severe histopathological lesions were frequently associated with multiple bacteriological test positives.

Sucralfate enema in ulcerative rectosigmoid lesions

To assess the efficacy of sucralfate enemas in distal colonic ulcerative lesions, 22 patients with radiation proctitis (n = 8), idiopathic ulcerative proctitis (n = 5), and solitary rectal ulcer (n = 5) unresponsive to conventional medical therapy, and those with ulcerated and bleeding rectal polyps awaiting polypectomy (n = 4) were studied. Enemas of sucralfate suspension (2 gm in 20 ml water) were administered twice daily for a period of three weeks. Clinical and sigmoidoscopic improvements were observed in 19 and 18 of the 22 patients, respectively (86 and 82 percent, respectively). No side effects were seen. The authors conclude that sucralfate enemas are useful in the treatment of ulcerative lesions of the rectosigmoid.

Severe duodenal candidiasis in a patient with IgA deficiency and T cell defects

Candida albicans was found to repeatedly colonise and invade the duodenal ulcer base in a 45 years old otherwise healthy patient receiving H2 receptor antagonists for a prolonged period. He had no delayed hypersensitivity to Candida skin test, and had T cell deficiency, abnormality in T cell blast transformation, defective macrophage migration inhibition factor (MIF) and IgA hypogammaglobulinemia. When treated with ketoconazole alone his ulcer healed completely. Ulcer scar biopsy and aspirates revealed no Candida and anti candidal antibodies disappeared from his serum. His T cell blastoid transformation, MIF and skin DTH to Candida were restored to normal levels, but IgA levels remained unchanged. Thus H2 receptor antagonists probably caused abnormalities in T helper cells leading to lymphokine unresponsiveness and subsequently loss of cellular immunity to candidal antigen. This combined with prior IgA immunodeficiency resulted into severe invasive candidiasis.

Hematemesis: a rare presentation of gastric volvulus

Gastric volvulus is a rare condition. Upper gastrointestinal bleeding in gastric volvulus is extremely rare. We describe two patients with gastric volvulus who presented with upper gastrointestinal bleeding.

A modified technique of ultrasonically guided percutaneous transhepatic biliary drainage

Ultrasonically guided percutaneous transhepatic biliary drainage was performed for palliative treatment in 31 patients and for pre-operative drainage in 21. The drainage was performed through a right intercostal approach with the ultrasound transducer placed in the midclavicular line without use of any specialized adaptor. No major complications were encountered. The main advantages of ultrasound guided drainage were (1) the rapidness of the procedure, (2) the negligible risk of puncturing blood vessels, and (3) the minimal exposure to radiation.

Pseudomyxoma peritonei. A report of three cases

Pseudomyxoma peritonei is an infrequently encountered clinical entity which presents mainly with abdominal distension. We present here our experience with three such cases and emphasize on the aggressive combined operative and chemotherapeutic approach in this disease.

Ultrasonography in non-cirrhotic portal hypertension: correlation with splenoportography

Real time sonography followed by splenoportography was performed in 38 cases with non-cirrhotic portal hypertension. Eleven of these cases, in whom porto-systemic shunt surgery was done, were also evaluated by real time sonography post-operatively. The ultrasound findings correlated well in 37 cases (98%) with splenoportography. All the post-operative cases also revealed a patent portosystemic shunt on sonography. Ultrasonography, a valuable, non-invasive, initial investigation of portal hypertension, may thus be used as the only investigation to distinguish intra- from extra-hepatic obstruction and to evaluate patency of surgically created porto-systemic shunts. Invasive portography may be performed only if surgical treatment is anticipated.

Ingestion of corrosive acids. Spectrum of injury to upper gastrointestinal tract and natural history

We have prospectively evaluated 41 patients who ingested acid for location, extent, severity, and outcome of the injury to the upper gastrointestinal tract. The injury was assessed within 36 h of acid intake by endoscopy or surgery, or at autopsy. Symptoms and signs were unreliable in predicting the extent and severity of injury. The degree of burns was classified as follows: grade 0 in 2 patients, grade 1 in 3, grade 2 in 16, and grade 3 in 20. Esophageal injury was seen in 87.8% of the patients, gastric injury in 85.4%, and duodenal injury in 34.1%. All patients with grade 0, 1, and 2a injury recovered without sequelae. Acute complications occurred in 39.1% of the cases, and death in 12.2%. It is significant that all such patients had grade 3 burns. Five of the 8 patients with grade 2b injury and all survivors of grade 3 injury developed esophageal or gastric cicatrization, or both, which subsequently needed endoscopic or surgical treatment. We find that endoscopy is not only the tool of choice for diagnosis in such cases but also aids in deciding upon treatment and prognosis. We conclude that acid injury of the upper gastrointestinal tract is a very serious condition that affects the esophagus and stomach equally and results in high morbidity and mortality.

Upper gastro-intestinal mucosal changes in patients with chronic renal failure

A prospective study was undertaken to determine the radiological, endoscopic and histological changes of upper gastro-intestinal mucosa in patients with end-stage renal failure and the effect of haemodialysis. Of the 30 patients studied, 28 (93%) had presented with upper gastrointestinal symptoms. Abnormal findings on upper gastrointestinal endoscopy were observed in 66.7% patients. These comprised oesophagitis (23.3%) gastritis (30%), duodenitis (33.3%) and peptic ulcer (6.7%). Histological study of the mucosal tissue biopsy in 24 patients showed oesophagitis, gastritis and duodenitis in 12.5%, 45.8% and 37.5% respectively. Ten patients were re-evaluated after institution of haemodialysis therapy for a minimum of one month. Though there was a significant improvement in gastrointestinal symptoms (p less than 0.05), there was no effect on endoscopic changes. The study documents a high incidence of mucosal inflammatory changes rather than that of ulcer disease in chronic renal failure.

Endoscopic management of impacted Sengstaken-Blakemore tube

Impaction of the Sengstaken-Blakemore tube may occur due to incorrect placement of clamps, biting of the outlet channel(s) or inadvertent injection of particulate matter at the time of inflation of the balloon(s). Endoscopic deflation of the impacted balloon using a pointed object is an easy remedy. This report highlights the pathogenesis of this avoidable complication in one patient.

Contamination of an endoscope due to Trichosporon beigelli

Trichosporon beigelli was isolated from the gastric aspirates of ten patients who had undergone endoscopy. Suspecting fungal contamination of the endoscopic equipment, samples from the biopsy channel, the water bottle, aspiration catheter and the tip of the endoscope were examined. Only the sample from the biopsy channel showed fungal elements on direct examination and grew Trichosporon beigelli. The original source for the fungus was an immunocompromised patient who had undergone endoscopy earlier. This episode occurred despite adherence to apparently adequate disinfection procedures for endoscopes. Because of the risk of cross-infection, especially in immunocompromised patients, it is imperative to take special steps to prevent fungal contamination of endoscopes.

Association of Candida with carcinoma of esophagus

Twenty-five patients with carcinoma of the esophagus (group I) and 25 patients suffering from non-ulcer dyspepsia with normal endoscopy (group II) were studied to know the incidence of isolation of Candida from their esophagus. Endoscopic brushings were taken from the esophagus in both groups and studied by smear examination and culture. Fungal organisms could be detected in 75% of cases of group I and 32% of cases of group II by culture techniques, and 45.8% and 12% respectively by smear examination. The difference was statistically significant (p less than 0.05) for both the techniques. Candida albicans was the commonest species isolated. No correlation was found between Candida agglutination titres and density of Candida growth on culture. We conclude that an association exists between carcinoma esophagus and the occurrence of Candida in the esophagus.

Effect of smoking on gastric acid secretion in patients with duodenal ulcer

The effect of smoking on gastric secretion was studied in 15 consecutive patients with duodenal ulcer--six normosecretors (basal acid output less than or equal to 3 mEq/h), and nine hypersecretors (basal acid output greater than 3 mEq/h). The volume, acid output, acid concentration, and pH of the gastric juice measured before, during and after 1 h of smoking did not show any significant difference in these patients taken as a single group, or when the normosecretors and hypersecretors were analysed as separate groups (P greater than 0.05 for each parameter in each group). The higher acid output before and during smoking in hypersecretors than in normosecretors was due to the higher acid concentration in the gastric juice (P less than 0.01). Study of the pH curves of the gastric juice after acute smoking showed that hypersecretors had a lower pH for a longer duration compared with normosecretors. This could make the hypersecretors with a history of chronic smoking more prone to developing duodenal ulcer.

Delta hepatitis infection in north India. A preliminary report

There is a paucity of data on occurrence of delta hepatitis in India. We here present our preliminary data showing that delta coinfection and superinfection occur quite frequently in our set up. The coinfection rate was found to be 15% and superinfection rate 26.6% in the initial screening of 69 patients of acute and chronic liver disease.

Cholangiographically guided aspiration cytology in the management of malignant biliary obstruction

Fifteen patients with malignant biliary obstruction were subjected to fine needle aspiration cytology (FNAC) under fluoroscopic guidance. Fourteen (93%) of them were correctly diagnosed to have a malignancy at FNAC. Simultaneous with FNAC or at a later date, all the patients underwent percutaneous biliary drainage with a drop in serum bilirubin from a mean of 23.2 mg/dl to 8.5 mg/dl. Ten patients were subjected to exploratory laparotomy and biopsy at which the diagnosis of FNAC was confirmed in nine of them. The tenth patient with a negative yield at FNAC had a 1.0 cm cholangiocarcinoma. The usefulness of FNAC combined with biliary drainage as an alternative to surgery is highlighted.

Gastric metastasis and ectopic amylase production in bronchogenic carcinoma

A case of small cell anaplastic carcinoma of bronchus is described. Primary tumour had metastasized in the stomach and there was production of amylase by the tumour evidenced by raised serum amylase and pleural fluid amylase.

Pneumatic dilatation in achalasia

Pneumatic dilatation of achalasia cardia was performed on 22 patients using Rider-Moeller bag under fluoroscopic control-during a three year period. The diagnosis was established at barium study and endoscopy. A total of 28 dilatations were performed on 22 patients. Sixteen patients required a single dilatation, five required another sitting while one patient had to be dilated thrice. Surgery was not required in any patient. There was a single complication in the form of an intramural leak which could be successfully managed conservatively. Our short term follow up results reiterate the consensus that pneumatic dilatation should be the initial form of management in these cases.

Upper gastrointestinal endoscopy in infants and children

Fibreoptic endoscopy is a highly efficient diagnostic tool which is now being increasingly used in pediatric age group also. However, certain special considerations like the use of special instruments, use of general anesthesia in younger children and various indications of diagnostic and therapeutic endoscopy need to be clearly emphasized. Over a period of 24 months, 132 children underwent upper gastrointestinal endoscopic examination in our section. Diagnostic endoscopy was carried out on 102 occasions and therapeutic on 162 occasions. Most of the children below 3 years of age required general anesthesia for the procedure. Children above 3 years of age could be managed by intravenous diazepam and pentazocine. The commonest cause of upper gastrointestinal bleed in children was variceal (60.6%) followed by erosive gastritis (27.2%). In children with recurrent abdominal pain no underlying cause was detected at endoscopy. Injection sclerotherapy was found to be a safe and effective mean for control of variceal bleed and most of the foreign bodies ingested by children and still lying proximal to 2nd part of duodenum could be successfully retrieved endoscopically.

Tube esophagogram: a better radiological technique for evaluation of esophageal diseases

Forty-six patients with suspected esophageal disease were studied by tube esophagography. This was performed by positioning a rubber tube in the proximal esophagus, followed by swallowing of high density barium suspension and insufflation of air through the tube. Comparison in 20 cases showed superiority of tube study over conventional double contrast barium, with alteration in diagnosis in six cases and additional information in 14 cases. Tube esophagogram is a safe, simple and valuable adjunctive technique leading to accurate and definitive radiological diagnosis of esophageal disease.

The clinical spectrum of anomalous pancreatobiliary junction

Anomalous junction of pancreatobiliary ducts (AJPB) is known to be associated with choledochal cyst and gallbladder cancer. This report describes our experience with eight patients with AJPB, six of whom were diagnosed at endoscopic retrograde cholangiography and two at transhepatic cholangiography. Four of the patients with AJPB had an associated congenital choledochal cyst, two had a normal biliary tree and one each had inspissated bile syndrome and cholangiocarcinoma. The last two associations have not been previously described. It is felt that the clinical spectrum of AJPB may unfold further with the widespread use of the cholangiographic techniques.