Successful use of biliary accessories in antegrade dilation of complex upper esophageal stricture due to chemoradiation and surgery

Endoscopic management of complete or near complete upper esophageal strictures is challenging. Current methods such as retrograde esophageal access are high risk and may require additional abdominal surgery. A biliary cannulation technique with a 0.035 inch guidewire was utilized to obtain antegrade esophageal access in a patient with near complete high esophageal stricture due to chemo radiation and surgery for head and neck cancer. Biliary accessories including bougie and balloon dilators were used for the initial dilation of the esophageal stricture, followed by the traditional approach of stricture dilation using over-the-wire dilators. The procedure was successfully performed in a patient with near complete upper esophageal stricture due to chemo radiation and surgery for recurrent laryngeal cancer. The dysphagia of this patient was resolved following serial esophageal dilations and his esophageal stricture was wide open on the last upper endoscopy. Biliary accessories can be safely used for obtaining antegrade esophageal access and dilation of near complete upper esophageal strictures. This approach should be considered in patients with complex esophageal strictures, especially after chemo radiation or surgery for head and neck cancer and prior to seeking other more complex alternatives involving retrograde esophageal access.

Dyspepsia consulters and patterns of management: a population-based study

BACKGROUND

Although dyspepsia is common, management patterns in the United States are unknown.

AIM

To determine the pattern of dyspepsia evaluation and treatment over 20 years in a population-based cohort, and test the hypothesis that the management was influenced by dyspepsia subgroup and gender.

METHODS

The validated Bowel Disease Questionnaire was mailed to a random sample of Olmsted County, Minnesota residents (1988-1990). Of the 835 survey respondents, 213 subjects were identified as having dyspepsia according to Rome I Criteria. The medical chart of each dyspeptic subject who had not denied research authorization (n = 206) was reviewed to identify all episodes of care for dyspepsia symptoms 10 years before and 10 years after the date the Bowel Disease Questionnaire was completed. Of these 206 subjects (mean age 47 years, 48% female), 34% had ulcer-like dyspepsia, 32% had dysmotility-like dyspepsia, and 37% had reflux-like dyspepsia.

RESULTS

Nearly half (n = 98, 48%) had episodes of care for dyspepsia symptoms over 20 years. Of these 98 subjects, 49% had upper gastrointestinal endoscopy, 4% motility studies and 12% were tested for Helicobacter pylori. At the first visit of the episode of care closest to Bowel Disease Questionnaire completion, 72% were seen in primary care, 16% in emergency medicine and 2% in gastroenterology. In addition, 13% were referred to gastroenterology clinic within this episode. During the study period, 70% were given an 'acid' diagnosis, 7% a 'motility' diagnosis and 54% a 'functional' diagnosis; 78% received acid suppression agents (28% proton pump inhibitors), 18% psychotropic agents and 7% prokinetic agents. No significant association was found between gender and test usage, specialty referral or type of treatment, although women were three times less likely to receive proton pump inhibitors (odds ratio 3.3, 95% CI: 1.2-9.1). Symptom severity, frequency and pattern were risk factors for health care seeking in dyspepsia.

CONCLUSIONS

Delivery of care for dyspepsia was similar among dyspepsia subgroups and in men and women.

Pheochromocytoma associated with pregnancy: case report and review of the literature

We report on a young woman with pheochromocytoma associated with pregnancy and review 41 other cases reported in the literature from 1988 to 1997. This review reveals that the overall maternal mortality was 4 percent and the fetal loss 11 percent; antenatal diagnosis of pheochromocytoma reduced maternal mortality to 2 percent; however, fetal loss was 14 percent. Diagnosis of pheochromocytoma was made antepartum in 83 percent of the cases. Although pheochromocytoma associated with pregnancy is rare, a high index of clinical suspicion must be kept and all those at risk must be investigated to achieve an early diagnosis and improved outcome. Once the diagnosis is confirmed, alpha-adrenergic blockade is essential and beta-blockade may be required. Magnetic resonance imaging and computerized tomography scan may be used to localize the tumor during the antenatal period. In early pregnancy, i.e., before 24 weeks, both tumor resection and medical treatment are associated with good fetal outcome; in later pregnancy, elective cesarean delivery followed by tumor resection results in favorable maternal and fetal outcome.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to understand the clinical manifestations of a pheochromocytoma during pregnancy, how to make the diagnosis of a pheochromocytoma during pregnancy, and to know the medical and surgical management of a pheochromocytoma during pregnancy.

Hypokalaemic paralysis

Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogeneous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.

Aluminum phosphide poisoning--a review

Aluminum phosphide poisoning is common in the rural belt of Northern India. The release of cytotoxic phosphine gas primarily affects the heart, lungs, gastrointestinal tract and kidneys, although all organs can be involved. The cellular site of action of phosphine requires further definition. Diagnosis is made by clinical suspicion, silver nitrate test and biochemical examination of the gastric aspirate and viscera. Treatment consists of early gastric lavage, vasopressors and supportive care. Specific therapy with intravenous magnesium sulphate is recommended.

Alcohol and coronary artery disease

Alcohol affects the heart and circulation in several ways. Chronic alcohol consumption can be associated with a variety of cardiovascular disorders, ranging from hypertension and stroke to heart failure and sudden death. At the same time an inverse correlation has been found between moderate drinking and incidence of coronary artery disease, perhaps due to its favourable effects on lipoprotein levels. Reports on acute effects of alcohol on coronary circulation, which may be of great significance in patients with pre-existing heart disease, have been contradictory. However, clinical studies have demonstrated an adverse effect of acute alcohol intake in low to moderate doses on coronary supply-demand relation in patients with angina pectoris. Considering the overall health hazard of alcohol consumption, a recommendation that patients increase their alcohol intake or that they start to drink if they do not already would probably be unjustifiable.

Rare poisoning with cerebra thevetia (yellow oleander): a report of three cases

The common oleanders, Thevetia peruviana (Pila Kaner) and Nerium-oleander contain a mixture of poisons including glycosides and are extremely toxic. They are widely cultivated as an ornamental shrub in the plains of India and have been used for the purpose of suicide, homicide, and as an abortifacient. We have come across three cases of suicidal poisoning with Pila Kaner in the last 9 months, an uncommon occurrence even for a major referral hospital such as ours.