Broken stent of endoscopic retrograde cholangiopancreatography mimicking a common bile duct stone: a case report

Long standing biliary stent for biliary stricture may have complications like cholangitis, cholecystitis, stent fracture and stent migration. Treatment includes re-do endoscopic retrograde cholangiopancreatography, removal of fractured stent and restenting. Authors report a case of fractured biliary stent mimicking as distal common bile duct stone. Patient presented with features of cholangitis with history of endoscopic stenting 6 years back but lost follow up thereafter. Ultrasound showed 2cm calculus in distal common bile duct and the stent was seen on endoscopy through the papilla in the duodenum. Contrast enhanced computed tomography of abdomen showed radio opaque dense shadow in the distal common bile duct suggesting possibility of broken biliary stent. Redo endoscopic retrograde cholangiopancreatography failed to remove the fractured stent. A new stent was placed without complications. Patient underwent open common bile duct exploration and the fractured stent was removed. Patient recovered completely after the procedure.

A hospital-based epidemiological study of corrosive alimentary injuries with particular reference to the Indian experience.

Corrosive alimentary tract injuries are a source of considerable morbidity all over the world. Despite this, actual data on the epidemiology of this problem are scarce mainly due to the lack of a well-established reporting system for poisoning in most countries. The burden of the disease is naturally more in countries such as India where the condition is common because of poor regulation of sale of corrosive substances. We analyse the available data on epidemiology of corrosive injuries, as well as patterns of involvement of the alimentary tract, with special reference to Indian data, and also provide an overview of the management options and long-term sequelae of this condition.

Palmar cutaneous metastasis from carcinoma cervix.

Carcinoma of the uterine cervix is the most common gynecological malignancy in developing countries. However, its cutaneous metastasis is a rare entity. The reported incidence of cutaneous metastasis ranges from 0.1 to 2%. Frequent sites of cutaneous metastasis in decreasing order are: abdominal wall, vulva and anterior chest wall. To the best of our knowledge, only three cases of cutaneous metastasis to the upper extremity have been reported in the world. We report a case of a 74-year-old postmenopausal lady diagnosed to have carcinoma cervix (stage IIIB) who presented with cutaneous metastasis to palm and thigh, 10 months after radical radiotherapy. At presentation, the primary disease had resolved completely. She had a small nodular growth in the left palm and left thigh. Fine needle aspirate cytology and core needle biopsy from both the nodular lesions were positive for squamous cell carcinoma.

Assessment of vagotomy status with postprandial urinary alkaline tide.

Aim: This study was carried out to assess whether the postprandial urinary alkaline tide, as a marker for the completeness of vagotomy, is dependent on the nature of the test meal, whether it is affected by proton pump inhibitor therapy, and whether it is reliable. Methods: The postprandial urinary alkaline tide (PUAT) pattern was prospectively assessed in three different study groups and one control group of healthy volunteers. The three study groups were as follows; A (n = 20) i.e. the Proton Pump Inhibitor (PPI) Group; B (n = 25) i.e. the Truncal Vagotomy (TV) Group; and C (n = 5) i.e. the Recurrent Ulcer (RU) Group. Urinary pH was measured by a pocket digital pH meter. Results: Postprandial urinary alkaline tide in the control group was significantly higher compared to the fasting levels. Liquid diet did not elicit a significant urinary alkaline tide response. There was a statistically significant fall in both fasting urinary pH (5.34 ± 0.70 vs. 4.80 ± 0.61, p = 0.031) and the postprandial alkaline tide (6.99 ± 0.79 vs. 4.94 ± 0.63, p = 0.0001) after taking proton pump inhibitors. In the truncal vagotomy and gastrojejunostomy group it was found that there was a significant fall in both the mean fasting (5.28 ± 0.58, vs. 4.92 ± 0.66, p = 0.032) and the postprandial urinary pH (6.29 ± 0.92 vs. 5.09 ± 0.73, p = 0.0001) following surgery. Conclusion: This study establishes that simple measurement of the urinary pH before and after a standard test meal can be used as an accurate routine test for the completion of vagotomy. It also showed that proton pump inhibitors abolish the alkaline tide and therefore must be discontinued before measuring the alkaline tide. Liquid test meal was not effective in eliciting an alkaline tide as compared to a solid meal.

Does elective re-siting of intravenous cannulae decrease peripheral thrombophlebitis? A randomized controlled study.

Background. Peripheral venous thrombophlebitis (PVT) is a common complication of intravenous cannulation, occurring in about 30% of patients. We evaluated the effect of elective re-siting of intravenous cannulae every 48 hours on the incidence and severity of PVT in patients receiving intravenous fluids/drugs. Methods. We randomized 42 patients who were admitted for major abdominal surgery to either the control or study group (n=21 in either group). Informed consent was obtained from all of them. Cannulae in the control group were removed only if the site became painful, the cannula got dislodged or there were signs and symptoms suggestive of PVT, namely pain, erythema, swelling, excessive warmth or a palpable venous cord. Cannulae in the study group were changed and re-sited electively every 48 hours. All the patients were examined every 24 hours for signs and symptoms of PVT at the current and previous sites of infusion. Results. The incidence of PVT was 100% (21/21) in the control group and only 9.5% (2/21) in the study group (p<0.0001). The severity of PVT was also less in the study group compared with that in the control group. Day-wise correlation of the incidence of PVT showed that 82.6% of the episodes of PVT occurred on day 3. Conclusion. Elective re-siting of intravenous cannulae every 48 hours results in a significant reduction in the incidence and severity of PVT. We recommend that this should be adopted as standard practice in managing all patients who require prolonged intravenous therapy.

Is Helicobacter pylori eradication indicated in cirrhotic patients with peptic ulcer disease?

INTRODUCTION: The association between H. pylori infection and peptic ulcer disease (PUD) and the efficacy of eradication of H. pylori in treating ulcer disease in cirrhotic patients remains controversial. This study was carried out to ascertain the prevalence and significance of H. pylori in cirrhotic patients with PUD and to assess the need for anti H. pylori thrapy METHODS: Three groups of patients were studied . These were patients with (A) cirrhosis and PUD, (B) uncomplicated PUD and (C) cirrhosis without PUD. H. pylori status was determined by endoscopic urease test . Eradication therapy was given with a four drug regimen and repeat endoscopy was done three months later to detect ulcer healing as well as H. pylori status with PUD in groups A and B. RESULTS: Cirrhotic patients with PUD had a significantly lesser prevalence of H. pylori compared to uncomplicated ulcer patients (46.9 % vs 80 %; p = 0.04). While H. pylori eradication rates were similar between cirrhotic and non cirrhotic patients, ulcer healing rate was significantly lesser in cirrhotic patients ( 48 % vs 80.9 %) . Majority of residual ulcers in cirrhotic patients were negative for H. pylori. CONCLUSION: Eradication of H. pylori does not reduce the residual ulcer rate indicating that H. pylori infection might not be a significant risk factor for PUD in cirrhotic patients. Hence, routine H. pylori eradication might not be warranted in patients with cirrhosis and peptic ulcer disease.

Improvement in dysphagia and quality of life with self-expanding metallic stents in malignant esophageal strictures.

BACKGROUND: Carcinoma of the esophagus often presents at an advanced stage, with absolute dysphagia or aspiration. Palliative procedures have an important role in improving the quality of life (QOL) of patients who are not candidates for curative therapy. We report on the efficacy and complications of self-expanding metallic stents (SEMS) in such patients. METHODS: Ultraflex nitinol SEMS were placed under endoscopic guidance in patients with malignant esophageal strictures. Dysphagia, pain and QOL were assessed before and after SEMS placement. RESULTS: Thirty patients were treated with SEMS. QOL score improved significantly from 62-94 before stenting to 80-133 after the procedure. There was improvement in dysphagia grades. Pain was the most common complaint noted on follow up. There was no major morbidity or mortality related to the procedure. CONCLUSIONS: SEMS placement is a safe and effective treatment modality for palliation of dysphagia due to malignant esophageal strictures. It provides lasting relief in dysphagia and improvement in QOL, without major complications.

Role of eradication of Cag A Helicobacter pylori in non ulcer dyspepsia.

The role of Helicobacter pylori (H.pylori) in patients with non ulcer dyspepsia (NUD), the relationship of the virulence of the organism to the occurrence and severity of NUD and the need for eradication of H. pylori in alleviating symptoms of NUD remain controversial. This study was carried out for the purpose of determining the interaction between virulent H.pylori and symptoms of NUD and to clarify whether H. pylori eradication is beneficial in-patients with NUD. Sixty consecutive patients who fulfilled standard criteria for the diagnosis of NUD and who were positive H. pylori status by the urease test were studied. NUD was classified into ulcer-like and dysmotility-like as per standard criteria. All patients were treated with a triple drug regimen for H. pylori for 10 days, which consisted of Clarithromycin, Amoxicillin and Omeprazole. Blood was drawn for IgG antibodies against Cag A strains and H. pylori by ELISA. All patients were evaluated at 6 months for symptomatic improvement, which was, correlated with Cag A H. pylori positive status. No significant difference was seen in the H. pylori Cag A prevalence between ulcer-like and dysmotility-like dyspepsia. While there was a trend towards a better symptomatic improvement with H.pylori eradication in patients with ulcer-like NUD as opposed to dysmotility-like NUD, this did not reach significance (73% vs. 57%, p= 0.18). However "there was a statistically significant benefit of eradication of H. pylori in-patients with ulcer-like NUD who were positive for Cag A H.pylori status (p=0.02). No such benefit was seen in-patients with dysmotility-like NUD. H. pylori eradication seems to confer significant benefit as regards symptomatic relief inpatients with ulcer like NUD who are positive for Cag A strain for H. pylori.

Helicobacter pylori and recurrent pain abdomen.

OBJECTIVE: Pain abdomen is a common problem in childhood. Many factors i.e., organic changes in the gut, psychological and environment contribute to recurrent pain abdomen (RAP) in children. Helicobacter pylori infects children very early in childhood and stays indefinitely in the gut without its eradication. It may be responsible for pain abdomen and peptic ulcers in children. This study was done to assess the HP status in children with RAP diagnosed and evaluate the effects of eradication of HP infection in them. METHODS: 76 children were included in the study. RESULT: Out of 76 children studied 14.8% had evidence of a secondary cause for pain abdomen and responded to appropriate therapy. 65.45% of children who had undergone UGIE, had evidence of HP infection in the upper gastrointestinal tract. Most of these children responded to HP eradication therapy by becoming free of abdominal pain after the eradication therapy with OCA or OMA regimen. We could not do repeated endoscopies in all of them to prove the eradication due to parents' refusal and this is the main drawback of this study. CONCLUSION: However, in view of clinical response to HP eradication therapy in almost all the cases, we strongly advocate this therapy for those children with RAP, in whom HP infection of the upper gastrointestinal tract can be established beyond doubt.

Spontaneous antegrade enteral migration of feeding jejunostomy tube.

Spontaneous migration of enteral feeding tubes is unusual. We report an 18-year-old man with corrosive stricture of the upper esophagus in whom feeding jejunostomy was performed using an 18F Levine's tube. Thirteen months later, he presented with absence of the tube. The patient was tolerating liquid diet and was managed conservatively. Serial radiographs and colonoscopy showed a steady progress of the tube through the gut. The tube was passed out spontaneously after 20 days.

Effect on gallbladder function subsequent to truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer.

The effect of truncal vagotomy on gallbladder function and on the incidence of lithogenesis has remained controversial. A prospective and retrospective investigational study was undertaken to evaluate the effect of truncal vagotomy and gastrojejunostomy on gallbladder function. The study included a total of 76 patients and 77 controls. In Group I (Prospective group), 32 consecutive patients with chronic duodenal ulcer and gastric outlet obstruction undergoing truncal vagotomy and gastrojejunostomy were included. Group II included 25 age and gender matched controls (prospective group). Group III included 44 patients who had undergone truncal vagotomy and gastrojejunostomy 3 years or more prior to presentation (Retrospective group) and Group IV included 52 age and gender matched controls for the retrospective group. The patients in the prospective groups were followed up for a period of 1 year. An alkaline tide test was done in the prospective and retrospective group to assess for the completeness of vagotomy. Gallbladder contractile response to fatty meal and the presence of stones and sludge were noted in all the four groups by ultrasonography. There were 30 patients in the prospective group and 40 in the retrospective group after excluding patients with incomplete vagotomy. On ultrasound examination, there was no significant difference in the gallbladder volume and contractility of the study group when compared with the controls. Gallbladder sludge was found in 16 to 25% of patients in the prospective group (group I) during follow up, where as similar finding was documented in 8% of the matched control (group II (P>0.1). However, in the retrospective (group III) 10% (4 out of 40) had calculi and 20% of patients demonstrated sludge which was significantly higher when compared with the controls (p = 0.001). Truncal vagotomy and gastrojejunostomy did not affect gallbladder contractility, but it might predispose to the formation of sludge and subsequent calculi in a proportion of patients in long term.

Anterior or posterior gastro-jejunostomy with truncal vagotomy for duodenal ulcer--are they functionally different?

Truncal vagotomy with gastrojejunostomy (GJ) is the standard treatment for chronic cicatrizing duodenal ulcer with gastric outlet obstruction. We tried to determine if a significant functional difference exists in the early and late outcomes following anterior and posterior types of GJ to treat this condition. The case records of 106 patients who underwent truncal vagotomy and GJ at our institute from 1 January 1995 to 31 December 1999 were studied retrospectively. Patients were followed up with a personal interview. Perioperative and long-term parameters were compared in the anterior and posterior G.I. groups. Sixty-five patients (61.32%) were followed up; 31 in the anterior group and 34 in the posterior group. The median follow-up was 5 years (range 2.5-7.5 years). Except for a significant difference in length of afferent loop (p < 0.0001), there were no significant differences in the duration of hospital stay, nasogastric aspirates on postoperative days 1, 2, 3 and 4 and the day the nasogastric tube was removed. Early postoperative complications were uncommon and not different in the two groups and long-term outcomes were similar. The Anterior GJ, being technically easier and needing less operative time, may be advocated in all cases of chronic duodenal ulcer, with gastric outlet obstruction requiring truncal vagotomy and drainage.

Evaluation of long-term results of choledochoduodenostomy for benign biliary obstruction.

The role of choledochoduodenostomy (CDD) in the management of lower common bile duct (CBD) obstruction is controversial because of the long-term complications such as ascending cholangitis, sump syndrome and alkaline reflux gastritis. In spite of the good long-term results observed in some studies, CDD is considered a last trial for lower CBD obstruction. This study was done to analyze the efficacy and long-term results observed in patients who underwent CDD. A total of 21 patients who underwent side-to-side CDD for various causes of lower CBD obstruction from 1992 to 2002 in our institute were analyzed retrospectively. Symptoms, indications and complications were noted from the hospital records. Long-term follow-up evaluation was done through personal communication, examination, and subsequent ultrasonography and endoscopy in symptomatic patients. The most common presenting symptom was abdominal pain (95.2%) and the most frequent indication for CDD was multiple CBD stones (61.9%). Eighteen of the 21 patients (85.7%) had a normal postoperative recovery without any complications. One patient (4.8%) had an anastomotic leak and peritonitis, and 2 (9.5%) had wound infection. Long-term follow-up was possible in only 15 patients as the others were lost to follow-up. Nine patients (60%) were asymptomatic and 6 (40%) were occasionally symptomatic (abdominal pain and bilious vomiting), to an extent which did not affect their day-to-day life. Recurrent or retained stones were not noted, in any patient. All 6 symptomatic patients showed duodenogastric reflux but alkaline reflux gastritis was seen in only 1 patient (6.66%). Anastomotic stoma was patent in all the patients subjected to endoscopy. Features of cholangitis or sump syndrome were not noted in any patient. Side-to-side CDD is a safe and definitive procedure for the decompression of lower CBD obstruction. It has good long term results with infrequent complications.