Gastric schwannoma

Gastric Schwannomas are rare benign slow-growing tumors and warrant treatment/resection only when symptomatic. Watchful waiting is recommended for incidental or asymptomatic schwannomas.

Efficacy and tolerability of sofosbuvir and daclatasvir for treatment of hepatitis C genotype 1 & 3 in patients undergoing hemodialysis- a prospective interventional clinical trial

Background

There is paucity of data using direct anti-viral agents (DAA) in patients on maintenance hemodialysis (MHD) infected with HCV-genotype 1 & 3. Aim of the study was to evaluate DAA therapy in patients infected with HCV-genotype 1 & 3 on MHD.

Methods

A prospective open label, parallel, non-randomized interventional trial was conducted in patients with Hepatitis-C on maintenance hemodialysis. Total of Sixty two (62) patients with hepatitis-C on maintenance hemodialysis were screened and 36 patients were enrolled and then equally allocated in 1:1 ratio to group 1 who received 400 mg daily sofosbuvir/ 60 mg daily daclatasvir and group 2 who received thrice a week 400 mg Sofosbuvir and daily 60 mg daclatasvir for 12 weeks. Patients with compensated cirrhosis received therapy for 24 weeks. Relevant data was obtained before, during and after therapy. HCV viral load was assessed at week 4, 8, at end of therapy and 12 weeks after treatment.

Results

Eighteen (18) patients were allocated in each group. Three patients in group 1 withdrawn from the study after 2 weeks due to refusal to participate, while one withdrawn in group 2 due to development of adverse effect. Mean age of patients was 47.22 + 14.17 in group 1 and 53.89 + 14.11 in group 2. Genotype 3 was most common in group 1 patients, n = 12 (66.6%), and n = 11 (61.1%) in group 2. All patients in both groups achieved undetectable viral load at 12th week. As per intention to treat analysis overall 29/36 (80.55%) patients achieved SVR (group 1 = 15/18; group 2 = 14/18) and as per-protocol analysis overall 29/32 (90.62%) patients achieved SVR (group 1 = 15/15; group 2 = 14/17).

Conclusion

Direct acting antiviral therapy using sofosbuvir and declatsavir is highly effective and tolerable in patients with HCV genotype 1 & 3 undergoing maintenance hemodialysis, especially when given daily.

Trial registration

This trial is registered in WHO, International Clinical Trial Registry Platform, through Iranian Registry of Clinical Trials (IRCT) having IRCT ID: IRCT20170614034526N3, registered retrospectively on 2019-03-08.

Effectiveness of multidisciplinary approach in patients undergoing therapy for chronic hepatitis C

OBJECTIVE

To assess the effect of a multidisciplinary approach on the outcome of treatment for hepatitis C virus infection.

METHODS

This retrospective study was conducted at the gastroenterology division by primary care providers at Phoenix VA Healthcare system in Phoenix, Arizona, United States, and comprised clinical and laboratory data of all hepatitis C patients treated between November 2002 and December 2006. The patients were clinically evaluated to determine whether they were candidates for treatment with pegylated interferon a-2a or a-2b plus ribavirin. Patients were given detailed orientation prior to the therapy, and were closely monitored during the treatment.

RESULTS

Of the 295 patients, 179(60.7%) received pegylated interferon a-2b and ribavirin and 116(39.3%) received pegylated interferon a-2a and ribavirin. Overall, 202(68.47%) had genotype 1 and 93 (31.52%) had non-genotype 1. Age range was 35 to 66 years (mean 51±8.51 and Mean BMI was 28.2±4.22), and the majority was Caucasian males who served in the Vietnam era. The overall sustained virological response was 120(40.7%).

CONCLUSIONS

High sustained virological response was achieved among the participants.

A rare case of Mirizzi syndrome due to pure calcium carbonate stones (Limy Bile)

We report the first case of Mirizzi syndrome in a patient who presented with biliary obstruction caused by pure calcium carbonate stones. A 61 years old male with history of portal vein thrombosis presented with rash, nausea and jaundice. An ultrasound of biliary tree showed gallstones with dilatation of hepatic duct and intrahepatic biliary tree. There was suspicion of a stone in proximal CBD. CT scan showed an opaque gallbladder with dense radio-opaque material in its lumen. An ERCP was then performed revealing external common hepatic duct obstruction at the neck of the gallbladder. A plastic biliary stent was placed across the obstruction, followed by a cholecystectomy. Resected gallbladder specimen revealed thick whitish paste like material, and formed stones filling the gallbladder lumen. Laboratory testing showed this material to be composed of 100% calcium carbonate crystals.

Cortical venous infarcts and acute limb ischaemia in acute carbon monoxide poisoning: A rare case report

A case of carbon monoxide poisoning is presented with unusual complications; some of which have not been reported previously. A 48-years-old Asian male presented to the emergency department with dyspnoea, altered state of consciousness and pale discolouration of skin after being locked inside a factory room with burning coal. Patient was in acute respiratory distress. Arterial blood gas analysis showed respiratory acidosis with hypoxaemia. On 3rd day, patient developed dark coloured urine and right upper limb ischaemia. Acute renal failure was diagnosed. A doppler ultrasound showed stenosis of radial and ulnar arteries. 0n 8th day, patient regained consciousness and complained of loss of vision. An MRI of the brain revealed bilateral occipital venous infarcts. Cortical venous infarcts and arterial stenosis are rare complications of acute carbon monoxide poisoning.

Polyp detection rates using magnification with narrow band imaging and white light

AIM: To compare the yield of adenomas between narrow band imaging and white light when using high definition/magnification.

METHODS: This prospective, non-randomized comparative study was performed at the endoscopy unit of veteran affairs medical center in Phoenix, Arizona. Consecutive patients undergoing first average risk colorectal cancer screening colonoscopy were selected. Two experienced gastroenterologists performed all the procedures that were blinded to each other’s findings. Demographic details were recorded. Data are presented as mean ± SEM. Proportional data were compared using the χ² test and means were compared using the Student’s t test. Tandem colonoscopy was performed in a sequential and segmental fashion using one of 3 strategies: white light followed by narrow band imaging [Group A: white light (WL) → narrow band imaging (NBI)]; narrow band imaging followed by white light (Group B: NBI → WL) and, white light followed by white light (Group C: WL → WL). Detection rate of missed polyps and adenomas were evaluated in all three groups.

RESULTS: Three hundred patients were studied (100 in each Group). Although the total time for the colonoscopy was similar in the 3 groups (23.8 ± 0.7, 22.2 ± 0.5 and 24.1 ± 0.7 min for Groups A, B and C, respectively), it reached statistical significance between Groups B and C (P < 0.05). The cecal intubation time in Groups B and C was longer than for Group A (6.5 ± 0.4 min and 6.5 ± 0.4 min vs 4.9 ± 0.3 min; P < 0.05). The withdrawal time for Groups A and C was longer than Group B (18.9 ± 0.7 min and 17.6 ± 0.6 min vs 15.7 ± 0.4 min; P < 0.05). Overall miss rate for polyps and adenomas detected in three groups during the second look was 18% and 17%, respectively (P = NS). Detection rate for polyps and adenomas after first look with white light was similar irrespective of the light used during the second look (WL → WL: 13.7% for polyps, 12.6% for adenomas; WL → NBI: 14.2% for polyps, 11.3% for adenomas). Miss rate of polyps and adenomas however was significantly higher when NBI was used first (29.3% and 30.3%, respectively; P < 0.05). Most missed adenomas were ≤ 5 mm in size. There was only one advanced neoplasia (defined by size only) missed during the first look.

CONCLUSION: Our data suggest that the tandem nature of the procedure rather than the optical techniques was associated with the detection of additional polyps’ and adenomas.

Interferon-induced retinopathy and its risk in patients with diabetes and hypertension undergoing treatment for chronic hepatitis C virus infection

BACKGROUND

Ocular complications are amongst many side-effects of interferon based therapy for hepatitis C virus (HCV) infection. Some suggest that diabetic and hypertensive patients are at increased risk of these complications.

AIM

To determine the frequency of ophthalmological complications related to interferon use.

METHODS

Retrospective analysis of patients undergoing HCV treatment with pegylated interferon alpha-2a, alpha-2b or consensus interferon plus ribavirin between 2005 and 2007. All patients underwent a baseline eye examination and any visual complaints during treatment prompted a repeat examination. Data recorded included HCV genotype, treatment duration, interferon type, pre-treatment and on treatment visual complaints, known ocular pathology, and retinal findings at baseline and at follow-up.

RESULTS

Of 183 patients, 29 (16%) had diabetes and 85 (46%) had hypertension. Seventy-one (38%) received interferon alpha-2a, 100 (55%) alpha-2b, and 12 (7%) consensus interferon. Seven (3.8%) had retinal changes on follow-up and treatment was discontinued in 3 (1.6%). Of seven with ocular changes two had hypertension and one had both hypertension and diabetes.

CONCLUSION

The incidence of symptomatic retinopathy in HCV patients undergoing interferon therapy appears low and treatment cessation is rarely needed. Furthermore, patients with hypertension and diabetes may not be at higher risk for interferon-induced retinopathy.

Hepatic hydrothorax: current concepts of pathophysiology and treatment options

Pleural effusions develop in 6-10% of patients with end-stage liver disease. Although, commonly seen in conjunction with ascites, isolated hepatic hydrothorax can occur in a small number of patients with cirrhosis. Refractory hepatic hydrothorax particularly poses a challenging therapeutic dilemma as treatment options are limited at best in these patients. Current patho-physiologic understanding of this disorder, as a cause, points towards the presence of diaphragmatic defects responsible for the shift of fluid from the peritoneal to the pleural cavity. When sodium restriction and diuretic treatment fail, liver transplantation remains the most definitive therapy in these refractory cases. However, transjugular intrahepatic porto-systemic shunt (TIPS), or video-assisted thoracoscopic (VATS) repair of the diaphragmatic defects (with or without pleurodesis) are effective strategies in those who are not transplant candidates or those awaiting organ availability. Hepatic hydrothorax, especially when refractory to medical treatment, poses a challenging management dilemma. An early recognition and familiarity with available treatment modalities is crucial to effectively manage this exigent complication of cirrhosis.

Prevalence of Barrett’s esophagus in patients with moderate to severe erosive esophagitis

AIM: To investigate the proportion of patients with moderate-severe erosive esophagitis (EE) who will have Barrett’s esophagus (BE) after healing of inflammation.

METHODS: Patients with EE of Los Angeles (LA) class B, C and D who underwent follow-up endoscopy documenting complete mucosal healing.

RESULTS: A total of 86/169 patients were suspected of having BE (38 before healing and 48 after healing of EE) and, 46/86 eventually had the histological confirmation. At index esophago-gastro-duodenoscopy (EGD), BE was suspected in 38/169 (22%), and ultimately, histologically confirmed in 20 of these. In 11 patients where biopsies were performed in the presence of inflammation, BE was detected in 2 and missed in 5 (including 2 dysplasias). In 131/169 patients (77.5%), BE was not suspected at index EGD. After healing of EE though, 48 patients had suspicion of BE who underwent biopsies, and in 26 of these histology was positive for BE. The length of inflammation had a linear correlation with the length of BE (P = 0.01). Out of multiple variables to predict BE, only the suspicion at index endoscopy was statistically significant (P = 0.01).

CONCLUSION: BE was seen in 46/169 (27%) patients with EE of LA class B, C and D. The length of EE can predict the length of underlying BE segment. Even when suspected, BE and associated dysplasia can be missed in the presence of inflammation; therefore, repeat evaluation should be considered after complete healing of esophagitis.

Review article: gastrointestinal amyloidosis - clinical features, diagnosis and therapy

BACKGROUND

Amyloidosis is one of the unusual diseases about which a physician may not think when it is affecting the patient. During the last three decades, there has been an enormous progress in the understanding of the chemical nature, classification, pathogenesis, clinical features, diagnostic measures and therapy of this disorder.

AIM

To provide an updated review of amyloidosis affecting the gastrointestinal tract.

METHODS

Review of current medical literature.

RESULTS

Amyloid proteins (irrespective of the type) can deposit in various parts of the gastrointestinal tract and liver resulting in symptoms of abdominal pain, dysmotility, diarrhoea, gastrointestinal bleeding, hepatomegaly and even portal hypertension with its associated complications. Definitive diagnosis can only be made by histological examination of the affected organ. Disease modifying treatment with high-dose chemotherapy followed by autologous stem-cell transplantation has shown promise. Liver transplantation is an option for a select group of patients.

CONCLUSIONS

Suspicion of gastrointestinal amyloidosis in patients without known history of amyloidosis is difficult, but should be considered in those older than 30 years with unexplained diarrhoea, weight loss, autonomic dysfunction, malabsorption or proteinuria. While most gastrointestinal complications are managed symptomatically, causal therapy is reserved for a select few from various subtypes of this disorder.

The yield and safety of string capsule endoscopy in patients with dysphagia

BACKGROUND

Dysphagia is a contraindication for the use of conventional capsule endoscopy (CE). Because string CE (SCE) allows for the immediate retrieval of the device, it eliminates the risk of capsule retention.

OBJECTIVE

To assess the yield and safety of SCE in patients with dysphagia.

DESIGN

Comparative study of SCE and EGD.

SETTING

Phoenix Veteran Affairs Medical Center.

PATIENTS AND INTERVENTIONS

Patients with dysphagia underwent SCE and EGD.

RESULTS

In 40 patients with dysphagia, the EGD findings were normal in 13 (32.5%); Schatzki's ring in 10 (25%); esophageal tumors in 9 (22.5%), with 1 of these having 2 separate and distinct malignancies; erosive esophagitis in 4 (10%); strictures in 2 (5%); and a web and large esophageal varices in 1 patient each (2.5%). The sensitivity of SCE for diagnosing anatomic pathology as the likely cause of dysphagia was 92.9%, with a specificity of 92.3%, a positive predictive value of 96.3%, and negative predictive value of 85.7%. The overall agreement between SCE and EGD was 92.7% and the kappa index was 0.83. There were no complications with either procedure. There was no case of capsule retention. The SCE recording time was 385.8 seconds; 77.5% patients preferred SCE to EGD.

CONCLUSIONS

(1) SCE was safe, well tolerated, and accurate for the diagnosis of pathology responsible for dysphagia; (2) SCE was preferred to EGD by more than three fourths of patients; (3) SCE can be safely performed in patients with dysphagia.

Endoscopic resection of an ampullary carcinoid presenting with upper gastrointestinal bleeding: A case report and review of the literature

Ampullary carcinoid is a rare tumor that can present with gastrointestinal bleeding, obstructive jaundice or pancreatitis. Some of these tumors are associated with Von Recklinghausen disease. The usual surgical options are a biliary-enteric anastomosis, Whipple procedure or rarely a local resection. The mean survival does not appear to be much different after a pancreaticoduodenectomy versus local surgical excision. We report a very rare case of a non-metastatic ampullary carcinoid causing upper gastrointestinal bleeding, which was managed by endoscopic ampullectomy.