Morphology of the Esophageal Hiatus: Is It Different in 3 Types of Hiatus Hernias?

Background/Aims@#The esophageal hiatus is formed by the right crus of the diaphragm in the majority of subjects. Contraction of the hiatus exerts a sphincter-like action on the lower esophageal sphincter (LES). The aim is to study the hiatal anatomy (using CT scan imaging) and function (using high-resolution manometry [HRM]), and esophageal motor function in patients with sliding and paraesophageal hiatal hernia. @*Methods@#We assessed normal subjects (n = 20), patients with sliding type 1 hernia (n = 18), paraesophageal type 2 hernia (n = 19), and mixed type 3 hernia (n = 19). Hernia diagnosis was confirmed on the upper gastrointestinal series. The hiatal morphology was constructed from the CT scan images. The LES pressure and relaxation, percent peristalsis, bolus pressure, and hiatal squeeze pressure were assessed by HRM. @*Results@#The CT images revealed that the esophageal hiatus is formed by the right crus of the diaphragm in all normal subjects and 86% of hernia patients. The hiatus is elliptical in shape with a surface area of 1037 mm2 in normal subjects. The hiatal dimensions were larger in patients compared to normal subjects. The HRM revealed impaired LES relaxation and higher bolus pressure in patients with paraesophageal compared to the sliding hernia. The hiatal pinch on HRM was recognized in significantly higher number of patients with sliding as compared to paraesophageal hernia. @*Conclusions@#Using a novel approach, we provide details of the esophageal hiatus in patients with various kinds of hiatal hernia. Impaired LES relaxation in paraesophageal hernia may play a role in its pathophysiology and genesis of symptoms.

Estimation of Serum Potassium in Patients Undergoing Laparoscopic Cholecystectomy.

Background: The cardiovascular implications due to CO2 insufflation during laparoscopic surgeries have been a subject of research. Animal studies have reported life threatening increase in serum potassium levels during rise in intra-abdominal pressure. Methods: Induction of 30 patients undergoing laproscopic cholecystectomy was done by giving Thiopentone sodium 5 mg/kg and orotracheal intubation was facilitated by 0.1 mg/kg of vecuronium bromide. Blood samples for potassium were taken at pre-induction, pre insufflation, every 20 minutes during insufflations, immediate post exsufflation and immediately after extubation. Results: Serum potassium increased significantly (p<0.01) after insufflation of carbon dioxide (pre-induction 3.9 ± 0.3 vs. 4.5 ± 0.3 at 40 minutes of insufflation). The haemodynamics i.e blood pressure and pulse rate remained fairly (p>0.05) throughout the study period. Conclusion: Based on the findings of this study, we recommend that monitoring of serum potassium should be done in patients undergoing laparoscopic procedures of prolonged duration.

Esophageal Submucosal Injection of Capsaicin but Not Acid Induces Symptoms in Normal Subjects

BACKGROUND/AIMS: Transient receptor potential vanilloid-1 (TRPV1) is a candidate for mediating acid-induced symptoms in the esophagus. We conducted studies to determine if the presence of acid in the mucosa/submucosa and direct activation of TRPV1 by capsaicin elicited symptoms in normal healthy subjects. We also studied the presence of TRPV1 receptors in the esophagus. METHODS: Unsedated endoscopy was performed on healthy subjects with no symptoms. Using a sclerotherapy needle, normal saline (pH 2.0-7.5) was injected into the mucosa/submucosa, 5 cm above the Z line. In a separate group of healthy subjects, injection of capsaicin and vehicle was also studied. Quality of symptoms was reported using the McGill Pain Questionnaire, and symptom intensity using the visual analogue scale (VAS). Immunohistochemistry was performed on 8 surgical esophagus specimens using TRPV1 antibody. RESULTS: Acid injection either did not elicit or elicited mild symptoms in subjects at all pH solutions. Capsaicin but not the vehicle elicited severe heartburn/chest pain in all subjects. Mean VAS for capsaicin was 91 ± 3 and symptoms lasted for 25 ± 1 minutes. Immunohistochemistry revealed a linear TRPV1 staining pattern between the epithelial layer and the submucosa that extended into the papillae. Eighty-five percent of papillae stained positive for TRPV1 with a mean 1.1 positive papillae per high-powered field. CONCLUSIONS: The mechanism of acid-induced heartburn and chest pain is not the simple interaction of hydrogen ions with afferents located in the esophageal mucosa and submucosa. TRPV1 receptors are present in the lamina propria and their activation induces heartburn and chest pain.

Co-infection of Central Nervous System by M. Tuberculosis, Cryptococcus and possibly Naegleria fowleri

Co-infection due to Mycobacterium tuberculosis, Cryptococcus and Naegleria fowleri has not been reported till now in literature, to the best of our knowledge. Here we report a curious case of co-infection of the central nervous system due to these three pathogens in an apparently immune-competent, HIV negative boy. The 15 year old boy was a diagnosed case of tubercular meningitis and was on anti-tubercular and anti-epileptic treatment. However, two months later he presented again in the emergency department with sudden loss of consciousness. His CSF showed presence of capsulated budding yeast cells (suggestive of Cryptococcus) and flagellated parasites (resembling the flagellated stage of Naegleria fowleri). CSF was also positive for Cryptococcal antigens by Latex Agglutination test. The boy was HIV negative and apparently immuno-competent. He was subsequently put on amphotericin B therapy for six weeks. Repeat microscopy, done towards the end of amphotericin B course, showed clearing of CSF. However, the patient’s condition improved only slightly, owing to neurological damage caused by the pathogens as suggested by brain CT and MRI scans. Thus infection caused by the members of three different kingdoms in an apparently immunocompetent boy highlights the importance of thinking beyond the ordinary causative pathogens, and actively searching for rarer etiologies to ensure timely intervention; especially in nonresponsive cases.

Neurotuberculosis as a Cause of Obesity.

Childhood obesity, taking the form of pandemic in the present era owing to the food habits, lifestyle etc, is the main cause of adult onset diseases. Obesity is the major risk factor for insulin resistance and diabetes, hypertension, cancer, gall bladder disease, and atherosclerosis in adulthood. Obesity being multi-factorial various genetic, anatomic, environmental factors are implicated to its etiognesis. While evaluating the causes of obesity in a child, in addition to the common causes, diseases involving hypothalamus should not be overlooked. We are discussing here a 9 year male child who reported to us for obesity and neurotuberculosis as the etiology was established.

Length Tension Function of Puborectalis Muscle: Implications for the Treatment of Fecal Incontinence and Pelvic Floor Disorders

BACKGROUND/AIMS: External anal sphincter (EAS) and puborectalis muscle (PRM) play important role in anal continence function. Based on length-tension measurement, we recently reported that the human EAS muscle operates at short sarcomere length under physiological conditions. Goal of our study was to determine if PRM also operates at the short sarcomere length. METHODS: Length-tension relationship of the PRM muscle was studied in vivo in 10 healthy nullipara women. Length was altered by vaginal distension using custom-designed probes of 5, 10, 15, 20, 25 and 30 mm diameters as well as by distending a polyethylene bag with different volumes of water. Probes were equipped with a reverse perfuse sleeve sensor to measure vaginal pressure (surrogate of PRM tension). PRM electromyogram (EMG) was recorded using wire electrodes. Three-dimensional ultra-sound images were obtained to determine effect of vaginal distension on PRM length. RESULTS: Ultrasound images demonstrate distension volume dependent increase in PRM length. Rest and squeeze pressures of vaginal bag increased with the increase in bag volume. Similarly, the change in vaginal pressure, which represents the PRM contraction increased with the increase in the probe size. Increase in probe size was not associated with an increase in EMG activity (a marker of neural drive) of the PRM. CONCLUSIONS: Probe size dependent increase in PRM contraction pressure, in the presence of constant EMG (neural input) proves that the human PRM operates at short sarcomere length. Surgically adjusting the PRM length may represent a novel strategy to improve treat anal continence and possibly other pelvic floor disorders.

Longitudinal Muscle Dysfunction in Achalasia Esophagus and Its Relevance

Muscularis propria of the esophagus is organized into circular and longitudinal muscle layers. Goal of this review is to summarize the role of longitudinal muscle in physiology and pathophysiology of esophageal sensory and motor function. Simultaneous manometry and ultrasound imaging that measure circular and longitudinal muscle contraction respectively reveal that during peristalsis 2 layers of the esophagus contract in perfect synchrony. On the other hand, during transient relaxation of the lower esophageal sphincter (LES), longitudinal muscle contracts independently of circular muscle. Recent studies provide novel insights, i.e., longitudinal muscle contraction of the esophagus induces LES relaxation and possibly descending relaxation of the esophagus. In achalasia esophagus and other motility disorders there is discoordination between the 2 muscle layers. Longitudinal muscle contraction patterns are different in the recently described three types of achalasia identified by high-resolution manometry. Robust contraction of the longitudinal muscle in type II achalasia causes pan-esophageal pressurization and is the mechanism of whatever little esophageal emptying that take place in the absence of peristalsis and impaired LES relaxation. It may be that preserved longitudinal muscle contraction is also the reason for superior outcome to medical/surgical therapy in type II achalasia esophagus. Prolonged contractions of longitudinal muscles of the esophagus is a possible mechanism of heartburn and "angina like" pain seen in esophageal motility disorders and possibly achalasia esophagus. Novel techniques to record longitudinal muscle contraction are on the horizon. Neuro-pharmacologic control of circular and longitudinal muscles is different, which provides an important opportunity for the development of novel pharmacological therapies to treat sensory and motor disorders of the esophagus.

evaluation of efficacy and safety of paravertebral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy

Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery. Fifty patients were included in this prospective randomized study and allocated to two groups: Group A [25 patients] receiving general anesthesia alone and Group B [25 patients] receiving nerve-stimulator-guided bilateral thoracic Paravertebral Block [PVB] at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl [0.5 micro g/kg] based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia [PCA] morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups. Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A [17.6 micro g and 38.6 micro g, respectively, P=0.001]. PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A [4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P < 0.0001 at all intervals]. Pre-induction PVB resulted in improved analgesia for 24 hours following laparoscopic cholecystectomy in this study, along with a significant reduction in perioperative opioid consumption and opioid-related side effects

Colloidion Baby.

A two day old male baby, third issue of a second degree consanguineously married couple with clinical features of colloidion baby is being presented. Early recognition of this clinical entity and early institution of appropriate therapy can definitely reduce morbidity and mortality in neonates.

Pattern of Congenital Anomalies in Newborn : A Hospital Based Prospective Study.

This hospital based prospective descriptive study highlights the point prevlance of congenital anomalies in one year. The number of congenital anomalies were more in males (M: F = 1.6:1.4), in neonates of young (= 20 years) and elderly mothers (= 35 years). The pattern of congenital anomalies included musculoskeletal (30.6%), CNS (20.5%), GIT (18.5%), skin (7.6%), genitourinary (4.7%), CVS (4%) etc. In musculoskeletal group, telipes was most common malformation followed by spinabifida and polydactyly. In CNS, group meningomyeleceole was the most common malformation followed by anencephaly and hydrocephalus. Frequency of congenital anomalies were more common in muslims as compared to hindus (1.77% vs. 1.4%), in cesarean born babies as compared to vaginally delivered (1.96% vs. 1.48%), in LBW babies (4.95%) and still born as compared to live born babies (4.46% vs. 1.39%). Present study stress upon the importance to carrying out a thorough clinical examination of neonate at birth.

Bilateral Pulmonary Cyst in a Child.

A four year old male child presented with history of cough for last six months. Chest skiagram and CT scan of mediastinum revealed bilateral pulmonary hydatid cyst. Serology did authenticate diagnosis. The child was prescribed albendazole for 6 months and was advised to come for follow up. The case of bilateral pulmonary hydatid cyst is being presentated because of rarity.

Turner Syndrome

Turner Syndrome is one of the important chromosomal disorders characterised by loss (total or part) of sex chromosome. The manifestations being peripheral edema, short stature, extra skin fold, webbing of neck, renal and cardiovascular anomalies, sexual infantilism, learning disability etc. We present here a one month female baby who had classical features of Turner Syndrome. The karyotape analysis was consistent with the diagnosis.

Sturge Weber Disease in a Child

Sturge Weber Disease is one of the important neurocutaneous syndrome characterized by abnormities of both the integument and central nervous system. We present here a classical case of Sturge Weber Disease. This 16 month male child had facial angioma and seizures. CT Scan head was consistent with the diagnosis.

Clinical Profile of Pica in Childhood

The various aspects of clinical profile in 200 children (18 months to 10 years) with pica have been highlighted. There was a definite male predominance and majority of children belonged to 2– 4 year age group. Direct history of pica was given by 32% mothers. Cough, pain abdomen, poor appetite, increasing pallor, abdominal fullness etc were other presenting features. Clay, sand, mud, plaster, uncooked rice, paper, clothes etc were material used for pica. Intestinal parasites were quite common