Combined transcatheter embolisation and medical treatment as a replacement therapy for surgery, in low-operative risk patients with endoscopically unmanageable massive bleeding from gastric-duodenal ulcers

There is a concept that embolization does not change the underlying pathophysiology of peptic ulcer disease, so endovascular therapy is still used as an alternative treatment to surgery, only in high-risk patients. In this study, we assess the usefulness of endovascular therapy as an alternative to operation in low risk patients with massive bleeding from a peptic ulcer. A retrospective study of 22 consecutive embolization procedures in endoscopically unmanageable, hemodynamically unstable patients, referred from 2004 to 2010. Different techniques and embolization materials were used. Mean follow-up was 7 months. Endoscopy was performed for 12 patients 5 to 9 months after embolization to assess healing of the ulcer. Gastric ulcer was noted in 7 patients, bulbar duodenal ulcer in 13 patients and postbulbar duodenal ulcer in 2 patient. The technical success rate was 100%. The rebleeding rate was 9%, and 30-days mortality rate was 4%. No major complications were reported. Follow up endoscopy revealed healing of the ulcer in 10 of the 12 patients [83%]. Angio-embolization is safe and effective for controlling life-threatening endoscopically unmanageable, bleeding from gastroduodenal ulcers especially in low risk patients. Whenever combined with proper medical therapy it allows ulcer healing without the need for higher risk laparotomy

Prophylactic embolisation of the left gastric artery in cases with massive upper gastrointestinal haemorrhage with normal angiographic findings

The management of massive upper gastrointestinal haemorrhage [UGIH] is problem ridden, especially if the arteriorgraphy shows no pathological findings. Percutaneous embolotherapy of the apparently normal gastric artery could provide a safe haemostatic effect. Our study is a descriptive one aimed to highlight the efficacy and safety of trans-arterial embolisation of the left gastric artery in six cases with massive UGIH and normal angiographic findings. From January 2004 to December 2008, we performed 24 embolisation procedures for treatment of patients with massive UGIH. All patients had significant bleeding and were referred for arteriography. The outcomes for nine patients having massive UGIH with normal angiographic findings were studied retrospectively. Six of these patients had undergone embolisation of the left gastric artery, whereas the remaining three exsanguinated before embolisation. Nine patients with massive UGIH, who had normal findings on arteriography, were selected to represent the study group. Three patients who did not undergo embolisation exsanguinated after arteriography and two of them died from massive haematemesis. All the six embolised cases showed cessation or marked decrease of bleeding. No major complications were reported during or after embolisation. Left gastric artery embolisation may be a safe and effective method in controlling UGIH with normal angiographic findings, for which both, a large number of patients and a multi-centre study, are recommended

Immunohistochemical study of inducible nitric oxide synthase [iNOS] in peritoneal Tuberculous granuloma

Nitric Oxide [NO] is important in host defense against Mycobacterium tuberculosis in rodents, but the presence of high-output NO production in human tuberculosis has been controversial. This study aimed to investigate iNOS expression by peritoneal macrophages in TB peritonitis and to gain insights into the structural properties of peritoneal TB granuloma. Peritoneal biopsies were obtained from 28 undiagnosed cases of ascites and examined histopathologically by H and E stain. Accordingly, specimens proved to be TB peritonitis were then immunohistochemically stained for iNOS, the macrophage marker CD68 and CD3 and CD20 as markers of T and B lymphocytes respectively. Eight control cases of normal peritoneum were included. TB peritonitis was diagnosed in 16 cases. TB granulomas were found in 9/16 cases [56%] and a diffuse granulomatous reaction was found in the remaining7/16 cases [44%]. Immunoreactivity to iNOS and CD68 were intensely expressed in macrophage rich TB granuloma and in the diffuse granulomatous TB reaction. Most Langhans cells [multinucleated giant cells] showed strong reactivity to both CD68 and iNOS. In TB granuloma, CD3[+] cells were found at the periphery with few CD20[4] cells in its center. Control cases showed complete negativity for iNOS, CDS, very small number of CD68 and/or CD20 cells. In TB peritonitis, an increased local expression of iNOS in granuloma associated macrophages of untreated patients indicating excess NO production in the active stage of this form of Tuberculosis. Further studies are needed to test the therapeutic implications of NO in different forms of TB

Alterations in thyroid gland size and functions in cirrhotic patients: relationships with splanchnic haemodynamics

Thyroid dysfunction has long been reported in liver diseases. But limited informations are available on thyroid size and the involvement of thyroid hormones in the haemodynamic alterations of cirrhosis. To 1] study changes in thyroid gland volume and functions in different grades of liver cirrhosis. 2] Investigate the relationship of thyroid hormone levels to changes in the hepatic and splenic haemodynamics in cirrhotic patients. Thirty-six cirrhotic patients with different disease severity were chosen according to Child- Pugh classification [12 Child class A, 12 Child Band 12 Child C]. Twelve healthy controls were included in the study. For all subjects, serum levels of FT3, FT4 and TSH levels were measured. An ultrasound scan of the thyroid was done for measuring thyroid volume. A colour Doppler ultrasound scan of the abdomen was performed for measuring portal vein diameter [PVD], cross sectional area, maximal velocity [PV V max], mean velocity [PV V mean], blood flow rate [PV BFR] and congestion index [CI]. Hepatic and splenic arteries resistive indices [HA RI, SA RI] were also studied. Total thyroid volume was increased in patients compared to healthy controls and it significantly increased with progression of the disease from Child A to C. Mean serum levels of free T3 [FT3], free FT4 [FT4] and TSH were significantly decreased in patients compared to healthy controls. However, they were not correlated to thyroid volume. FT4 had a significant negative correlation with PVD, PV BFR and CI, while FT3 had a significant positive correlation with PV V max. Total thyroid volume showed a significant negative correlation with PV V max and positive correlations with both CI and HA RI. Thyroid volume is increased in cirrhotic patients independently from thyroid hormones status. Low FT4 values of cirrhotic patients may participate in arterial vasoconstriction present in hepatic and splenic arteries. FT4 levels are directly correlated with Doppler parameters of portal hypertension

Immunohistochemical study of INOS in peritoneal tuberculous granuloma

The human tuberculous granuloma provides the morphological basis for local immune processes central to the outcome of tuberculosis. Nitric Oxide [NO], produced by the inducible nitric oxide synthase [INOS], is important in host defense against Mycobacterium tuberculosis in rodents, but the presence of high-output NO production in human tuberculosis has been controversial. Because of the scarcity of information in human patients especially in peritoneal tuberculosis, the present study aimed to: 1-investigate iNOS expression by peritoneal macrophages in TB peritonitis. 2- gain insights into the structural properties of peritoneal TB gronuloma. Laparoscoy was done for 28 patients with undiagnosed ascites and peritoneal biopsies were obtained and examined histopathologically by H and E stain. Accordingly, specimens proved to be TB peritonitis were then iminunohistochemically stained for iNOS, the macrophage marker CD 68 and CD 3 and CD 20 as markers of T and B lymphocytes respectively. Eight Control cases of peritoneum removed with surgically excised organ specimens [e.g. with excised tumors] were included. TB peritonitis was diagnosed in 16 cases. TB granulomas were found in 9/16 cases [56%] and a diffuse granulomatous reaction was found in the remaining 7/16 cases [44%]. Immunoreactivity to iNOS and the macrophage marker CD 68 were intensely expressed in macrophage rich TB granuloma and in the diffuse granulomatous TB reaction. Most Langhans cells [multinucleated giant cells] showed strong reactivity to both CD 68 and iNOS. The expression intensity of iNOS and/or CD 68 was stronger in diffuse and premature-stage granulomas than in late-stage granulomas [caseating granuloma]. In TB granuloma, CD 3 cells were found at the periphery with few CD 20[+] cells in its center. While in diffuse granulomatous TB reaction, CD 3[+] lymphocytes were diffusely dispersed in the lesion with few CD 20[+] lymphocytes. Control cases showed complete negativity for iNOS, CD 3, very small number of CD 68 and/or CD 20 cells. In TB peritonitis, the distribution of different immune cells in the granuloma is similar to that described in pulmonary TB granulomas. An increased local expression of iNOS in granulomas associated macrophages of untreated patients indicating excess NO production in the active stage of this form of Tuberculosis. Further studies are needed to test the therapeutic implications of NO in different forms of TB

Predictors of presence of oesophageal varices in cirrhotic patients without a previous history of variceal bleeding

Current medical management dictates that all cirrhotic patients without a history of variceal bleeding undergo endoscopic screening for the presence of oesophageal varices [OV]. However, referral for endoscopic screening of only patients at high risk for varices may be cost-effective. To identify clinical, laboratory, and ultra-sonographic parameters that predict the presence of OV in patients with liver cirrhosis. The study included 100 patients with liver cirrhosis without a history of variceal bleeding. A complete blood count, complete liver function tests, abdominal ultrasonography, and upper gastrointestinal endoscopy were done for all patients. Also platelet count/spleen diameter ratio [P/S ratio] was calculated for all patients. Cases defined as the presence of any oesophageal varices [OV] and controls defined as no oesophageal varices [NOV]. Logistic regression analysis was performed to evaluate association between the presence of O/ and patient characteristics. The prevalence rate of OV was 76% of cirrhotic patients. We found that platelet count, spleen diameter, P/S ratio, portal vein diameter, ascitis, serum albumin, serum bilirubin, prothrombin time and concentration, and Child-Pugh's classes were significantly different among patients with and without OV. In a multivariate analysis, the P/S ratio was the only parameter which was independently associated with the presence of OV. The prevalence adjusted positive and negative predictive values of P/S ratio cut-off value