Intrapericardial teratoma masquerading as pyopericardium.

A 10-year-old boy was admitted with cardiac tamponade. Initial pericardiocentasis yielded pus. A subxiphoid tube-pericardiostomy was done and thick, purulent material was drained out. Subsequently, pericardiectomy was undertaken as features of pericardial constriction persisted. At surgery, however, an intrapericardial mass was discovered. Successful excision was performed and the patient made an uneventful recovery. Histopathology of the mass revealed features of an intrapericardial teratoma. Rarity of the lesion, and a hitherto unreported mode of presentation make this case worthy of documentation.

Palliation of malignant colonic obstruction by self-expandable metal stent.

Advanced obstructive colorectal cancer is routinely treated by surgical colostomy. Self-expandable metal stents are a promising alternative. We report the use of an expandable metal stent to relieve colonic obstruction in an elderly lady with advanced colorectal malignancy.

Epidemiology of digestive tract cancers in India IV. Gall bladder and pancreas.

Pancreatic cancer is a leading cause of cancer-related deaths in developed countries. Gall bladder cancer is very common in South American countries, around the Mediterranean and in Japan. A majority of patients with these cancers receive only palliative therapy in spite of recent advances in investigation and surgery. Their poor prognosis and increasing incidence in India necessitate a better epidemiologic approach towards their control. This review is based on epidemiological data, publications and abstracts from India. Population-based data reveal that the incidence of gall bladder cancer is very high in northern Indian cities (5-7 per 100,000 women) and low (0-0.7 per 100,000 women) in southern India. The distribution suggests a high-incidence region comprising Uttar Pradesh, Bihar, Orissa, West Bengal and Assam. The cancer is twice more common in women and is the leading cancer among digestive cancers in women in the northern Indian cities of Delhi and Bhopal. There are few analytical data to hypothesize why this geographical predisposition. The high incidence is also observed in north Indian immigrants to the United Kingdom. The incidence of pancreatic cancer is low (0.5-2.4 per 100,000 men and 0.2-1.8 per 100,000 women) in most parts of India. Somewhat higher rates are seen in the male urban populations of western and northern India. Studies from Kerala support an association between tropical pancreatitis and pancreatic cancer. Time trends reveal an increase in the incidence of gall bladder and pancreas cancers; the increase in the former is alarming. We estimate that the approximate annual cancer burden of India in 2001 would include 17,730 cases of gallbladder cancer and 14,230 of pancreatic cancer. Multi-center studies are needed to identify potentially preventable risk factors associated with gall bladder and pancreatic cancer in India.

Epidemiology of digestive tract cancers in India. III. Liver.

Liver cancer or hepatocellular carcinoma (HCC) is the fourth commonest cause of cancer deaths in the world. The condition is extremely common in Southeast Asia and Africa. In this report the available data on the epidemiology of HCC from India are summarized. We estimate that 12,750 new patients will be diagnosed to have HCC in India in the year 2001; this will comprise 1.6% of all incident cancers. Published studies from India and those involving Indian immigrants to other countries suggest that the prevalence of HCC is relatively lower in Indians than in most parts of the world. This contrasts with the widespread contamination of foods with aflatoxin and the moderately high prevalence of hepatitis B (HBV) and hepatitis C (HCV) virus-related chronic liver disease in India. There are no studies available to explain this observation. There are several articles on HBV and HCC in India but there is a paucity of analytical epidemiological data on HCV and HCC from India. Published studies indicate HBV to be the single most important etiologic association, with HCV playing a lesser but important role. About 80% of Indian patients with HCC have hepatitis virus-associated liver disease. Multicenter epidemiological studies are needed to solve some of the enigmas and observations peculiar to India.

Gastric carcinoids--a clinicopathologic study.

AIM: Our objective was to document the clinical and pathological findings in eight patients with gastric carcinoids seen in our institution over a 16-year period (1980-96). METHODS: All cases reported during this period as microcarcinoids, atypical carcinoids and mixed carcinoid-carcinoma of the stomach were retrieved from pathology records. Eight cases with typical histologic features of carcinoid were studied. RESULTS: Seven cases were men (median age 53 years, range 35-55). Four patients presented with upper abdominal pain. Serum gastrin level was elevated in two cases. The endoscopic appearances and the endoscopic biopsy histology were not diagnostic. Surgical treatment ranged from simple nodule excision to partial, subtotal or extended gastrectomy and Whipple's pancreatico-duodenectomy. Lymph node and liver metastasis were seen in four patients each. The median duration of follow-up was one year. CONCLUSION: Gastric carcinoids have varied etiopathogenesis. These may arise in a background of hypergastrinemic conditions or may be sporadic. Most appear to be slow growing but aggressive neoplasms are capable of distant metastasis.

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost.

OBJECTIVE: To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy. METHODS: Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused. RESULTS: Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents. CONCLUSIONS: Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.

Precut papillotomy using a needle knife: experience in 100 patients with malignant obstructive jaundice.

BACKGROUND: Precut papillotomy enhances the success of selective bile duct cannulation. Doubts have been raised about the relative safety of the procedure. This study was undertaken to assess the success rate and complications of precut papillotomy using a needle knife. METHODS: 100 consecutive patients undergoing precut papillotomy for biliary endoprosthesis placement were studied. A needle knife was used in these patients after bile duct cannulation was not successful using other techniques. The success rate, complications and mortality were determined. RESULTS: Selective bile duct cannulation was achieved in 65 patients. There were six complications: bleeding (3), pancreatitis (2), and perforation (1). One patient died following duodenal perforation. The success rate for endoprosthesis placement was increased by 14.2% following precut papillotomy. CONCLUSIONS: Precut papillotomy enhances the success of selective bile duct cannulation, with complication rates similar to standard papillotomy.

Synchronous adenocarcinoma and lymphoma of the colon.

Synchronous lymphoma and adenocarcinoma of the colon are extremely rare. A 32-year-old woman was referred to us for colon cancer. Investigations revealed two primary tumors, one in the cecum and the other in the sigmoid colon. Subtotal colectomy with ileorectal anastomosis was performed. Histology revealed the cecal tumor to be non-Hodgkin's lymphoma, diffuse small cell type with plasmacytoid features. The sigmoid colon tumor was moderately differentiated adenocarcinoma. The patient received 6 cycles of chemotherapy postoperatively for lymphoma but died of recurrent disease after 17 months.

Topical pharyngeal anesthesia without intravenous sedation during upper gastrointestinal endoscopy.

BACKGROUND: There have been conflicting reports about the usefulness of topical pharyngeal anesthesia as a pre-endoscopic medication. AIMS: To assess the effect of topical pharyngeal anesthesia without intravenous sedatives on easing upper gastrointestinal endoscopy. METHODS: 153 consecutive consenting patients were randomized to receive either placebo (normal saline) spray (78 patients) or 80 mg of 4% lidocaine spray (75 patients). Difficulty of intubation was judged both by the patient and the physician on a linear analogue scale. RESULTS: There was no significant difference in the scores in the two groups (p > 0.05). The patient and physician assessments correlated well. CONCLUSIONS: Topical lignocaine spray does not facilitate upper gastrointestinal endoscopy in the absence of intravenous sedation.

Multiple mucosal bridges of esophagus: an unusual cause of dysphagia.

We describe the clinical, radiographic and endoscopic features of a young man presenting with dysphagia who was detected to have multiple esophageal mucosal bridges. This patients had no predisposing condition responsible for the bridge formation.

Removal of impacted basket during endoscopic papillotomy: a novel method using precut papillotome.

Basket impaction is a rare problem during endoscopic papillotomy and stone extraction for the bile duct. Mechanical lithotriptor is usually employed to break the stone, but a few patients may require surgery. We describe a patient in whom a precut papillotome was used to break the stone and remove the impacted basket.

Unusual bone metastasis as the initial symptom of gastric cancer--a report of four cases.

Four cases of gastric cancer presenting with bone pain due to metastasis as the initial symptom are reported. Investigations revealed solitary osteolytic metastasis in the mandible in one, and left scapula in one patient. Third patient had multiple osteosclerotic metastasis with elevation of acid phosphatase and another had multiple discrete osteolytic metastasis simulating multiple myeloma. All the primary gastric cancers were poorly differentiated adenocarcinoma and three were of Borrman type III on gross appearance. One patient had sparing of the liver inspite of extensive metastasis. Chemotherapy was in effective in two patients and the prognosis was uniformly poor.

Multiple lymphomatous polyposis of the gastrointestinal tract.

We report two rare cases of multiple lymphomatous polyposis of the gastrointestinal tract. Both patients had multiple polypoidal defects involving large segments of gastrointestinal tract. The histopathology in both cases was diffuse poorly differentiated lymphoma. One case had multiple relapses despite treatment and died after 58 months. The second patient died following induction chemotherapy.

Role of endoscopic ambulatory laser therapy in palliation of malignant colorectal diseases.

BACKGROUND: Endoscopic laser therapy is widely used in the palliation of advanced malignant colorectal diseases. The role of this therapy in improving the quality of life of these patients needs adequate assessment. METHODS: Nine patients with advanced colorectal cancers and three patients with secondary colorectal involvement by pelvic cancers underwent endoscopic Nd:YAG laser therapy for palliation using non-contact laser guides for tumor bleeding alone (n = 12) or associated with obstruction (n = 7). The therapy was performed on an outpatient basis in 9 of the 12 patients. One patient was lost to follow up. RESULTS: Symptom control was achieved in all the 11 bleeding tumors and in 5 of the 7 obstructive tumors. There were no major complications. Three patients had no improvement in the quality of life in spite of control of symptoms. CONCLUSION: Ambulatory endoscopic laser therapy is a minimally invasive, safe and effective method of palliation for selected patients with non-resectable malignant colorectal tumors.

A prospective study of radiation induced damage of pancreatic ducts.

To study radiation-induced pancreatic duct damage, endoscopic retrograde pancreatograms of 11 patients with primary gastric lymphoma who had completed chemotherapy and moderate dose external radiation therapy were compared with those of 22 normal subjects. No significant alteration was seen in the length and caliber of the main pancreatic duct and number of side branches. Clubbing of one or two side branches was observed in four patients who had received radiation (p = ns). We conclude that significant structural changes do not develop in the pancreas following moderate dose upper abdominal radiation.

Out-patient esophageal dilation: an experience in 130 patients using Savary-Gilliard dilators.

Experience of outpatient esophageal dilation using Savary-Gilliard dilators in 130 patients during a 17 month period is reported. The strictures were radiation induced (48), tumoral stenoses (40), anastomotic (16) and due to other causes (26). Both fluoroscopy and endoscopy were used in 58%, endoscopy alone in 23% and fluoroscopy alone in 19% of patients for placement of the guide wire. One hundred and twenty six stricture dilations (97%) were technically successful. Eighty one (62%) patients could be dilated to 14 mm or more. One hundred and nineteen (94%) patients were dilated in one or two sessions. Among the 109 patients who followed up, dilation was successful in providing adequate dysphagia relief in 97 patients and facilitated the performance of other therapies in 9 patients. Major complications included severe continuous chest pain (1 case), hematemesis (2), fever (4) and transient stridor (2). The patient with persistent pain and 9 patients undergoing other therapies required hospitalization. There were no perforations or death. We conclude that esophageal dilation with Savary-Gilliard dilators is safe and effective even in tumors and post-radiation strictures. It can be performed on an outpatient basis in a majority of patients.