Duodenal tuberculosis: radiological features on barium studies and their clinical correlation in 28 cases.

BACKGROUND: A retrospective analysis of 28 cases of duodenal tuberculosis (TB) was done to evaluate radiological findings and their value in the diagnosis of the disease. SUBJECTS AND METHODS: Upper gastrointestinal and small bowel series of 28 patients with duodenal tuberculosis were analysed for radiological findings. The diagnosis of duodenal TB was confirmed by surgery and biopsy in 18, on the basis of radiological findings and response to treatment in 9, and on the basis of findings on upper gastrointestinal scopy and biopsy in 1 patient. RESULTS: The study included 28 patients (14 males, 14 females). The mean age was 32.1 (range 5-65). Twenty-three (82.2%) patients presented with obstructive symptoms while five manifested with dyspeptic symptoms. Of the latter, 4 had ulcerations in the third and fourth parts of the duodenum. In the remaining patient, the mucosa of the duodenum could not be clearly visualised. Two patients had extrinsic impression at the D2-D3 and D3-D4 segments. In 23 patients with obstructive symptoms, 18 demonstrated luminal narrowing of varying degrees and 5 had a sharp band-like cut-off at the third part of the duodenum. Of the 18 patients with luminal narrowing, 13 had extrinsic compression, 12 had proximal dilatation and 14 had ulcerations mainly in the second and third parts of the duodenum. Biliary involvement was seen in 3 patients without any signs or symptoms directly referable to the biliary involvement. CONCLUSION: Though duodenal TB lacks specific radiological features, barium studies help to localise and define the area of narrowing and ulcerations and help to confirm the presence of lymph nodes causing compression of the duodenum.

Tense ascites redefined: renal consequences of tense ascites in decompensated cirrhotics.

Cirrhotics with tense ascites fail to achieve increased diuresis in the supine position. To assess the role of inferior vena cava compression in this phenomenon, we studied cirrhotics with mild to moderate (n = 11) and tense (n = 2) ascites, and patients with membranous inferior vena cava obstruction (n = 2) before and after balloon dilatation, in the sitting, supine and 10 degrees head down tilted positions for 2 hours each. Urinary output (p < 0.005), creatinine clearance (p < 0.025) and sodium excretion (p < 0.025) increased in cirrhotics with mild to moderate ascites in the supine position, and further in the head down position. Similar changes occurred in patients with inferior vena cava membrane. In cirrhotics with tense ascites, these parameters did not change significantly in the supine position, but increased in the head down position. We conclude that failure to augment diuresis in the supine position in cirrhotics with tense ascites is not due to inferior vena cava obstruction alone but is probably also due to compression of the collateral vessels. This clinical observation may serve as a criterion for diagnosing tense ascites.

Clinical implications of acute cerebrospinal fluid changes following iophendylate myelography.

Clinical features and serial cerebrospinal fluid (CSF) samples of 50 patients who underwent myelography with iophendylate were studied. Forty two patients (84%) developed one or more features suggestive of meningism lasting for 2-4 days. There was significant rise in the average (mean) CSF counts from 9.81 in the premyelogram sample to 532.6 at the end of 24 hours (p less than 0.001). Both neutrophil and lymphocyte (p less than 000) count increased. At the end of one week, there was significant decrease of total cells in the CSF to 204 (p less than 0.001). Both, neutrophils and lymphocytes decreased. There was significant rise in total proteins in the 24 hours sample, but the fall at one week was not significant statistically. The sugar and chloride values did not change significantly. All CSF samples were negative for bacterial cultures. In conclusion, a significant proportion of the patients undergoing iophendylate myelography develop clinical features suggestive of meningeal irritation and change in the CSF fractions suggestive of meningitis: however these changes are transient and do not warrant institution of chemotherapy or steroids.

Role of vasculitis in the natural history of abdominal tuberculosis--evaluation by mesenteric angiography.

To investigate the possible role of vascular changes in the pathogenesis of tubercular lesions of the abdomen, findings on barium studies of the bowel and superior mesenteric angiography in 20 patients with abdominal tuberculosis were correlated. Barium studies showed peritoneal lesions in seven patients, isolated intestinal lesions in seven and combined lesions in six. Angiograms were abnormal in all the patients and showed encasement of arteries (13 patients), stretching and crowding of vessels (13), occlusion of vasa recta (5) and hypervascularity (6). All the 13 patients with peritoneal lesions showed arterial stretching, crowding and encasement. Five of six patients with strictures had occlusion of vasa recta. Of seven patients with ulcerations, six had hypervascularity. Our observations suggest that vascular changes occur frequently in abdominal tuberculosis and may explain some pathological and clinical manifestations of this disease. Ulcerated and hypervascular lesions occur in the active and early stages of the disease, and occlusive lesions are associated with healing and 'ischemic' bowel strictures.

Obstructive jaundice--an unusual complication of duodenal tuberculosis: treatment with transhepatic balloon dilatation.

This is a report of a patient on treatment for duodenal tuberculosis, who developed obstructive jaundice due to a benign stricture of the terminal common bile duct. This complication of duodenal tuberculosis, to our knowledge, has not been reported before. Percutaneous, transhepatic balloon dilatation of the stricture alleviated the jaundice.

Pneumatic dilatation in achalasia cardia results and follow-up.

Pneumatic dilatation is one of the more recent methods in the management of achalasia cardia. Fifty dilatations were done in 42 patients with achalasia cardia over 5 years. There was a significant decrease in the maximum diameter of the oesophagus and a significant increase in diameter in the narrowed lower oesophageal segment in all the patients. Of the patients studied, 95.23% were relieved of their symptoms after only one to two sessions. There were no immediate complications. Out of the 38 patients on long term follow up, 8 (21.05%) had recurrence of symptoms. On repeat dilatations, 4 (50%) of them had good response. Late complication like reflux oesophagitis was observed in only 1 patient over a median follow up period of 22 months. It was thus concluded that pneumatic dilatation is a safe, simple and effective procedure in managing patients with achalasia cardia.

Choledochoduodenal fistula complicating duodenal ulcer disease (a report of 3 cases).

Choledochoduodenal fistula complicating duodenal ulcer disease is a rare occurrence. The present paper describes 3 such cases which were incidentally picked up on upper gastro-intestinal (GI) radiographic study and endoscopy done for ulcer like symptoms. The relevant literature is reviewed.

Continuous intra arterial vasopressin infusion for control of typhoid hemorrhage.

A 35 year old man presented with massive lower gastrointestinal hemorrhage due to typhoid enteritis. After confirming the site of bleeding on a selective superior mesenteric angiogram, a vasopressin infusion was given at the rate of 0.2-0.4 units/min initially, followed by tapering doses over 36 hours. Cessation of bleeding was achieved immediately. The patients did not have any complications due to the procedure. Continuous vasopressin infusion is an effective method for the treatment of uncontrolled bleeding from typhoid enteritis.

Ileal endometriosis (a case report).

A case of endometriosis involving small bowel is reported here. It is the first case reported at our institution in the last 10 years period.

Tortuous aorta--a new cause for esophageal chest pain?

Three patients (average age 61 years) presenting with retrosternal pain were evaluated with barium studies of the upper gastrointestinal tract. In each case, the esophagus was significantly displaced by a tortuous aorta. All patients had sliding hiatal hernias; these hiatal hernias, and the esophagitis and disordered motility seen in our patients, could be a consequence of esophageal displacement by the tortuous aorta. Two patients were relieved symptomatically with antacids and metoclopramide. Thus, tortuosity of the thoracic aorta can cause esophageal chest pain.

Endoscopic removal of retained bile duct calculi via T-tube tract.

A simple and safe technique for removal of retained bile duct calculi using a flexible fibreoptic choledochoscope and rigid nephroscope via the T-tube tract has been described. The technique allowed removal of large impacted calculi under direct vision without damage to the bile duct.

Control of life-threatening hemorrhage in cecal tuberculosis by transcatheter embolisation.

Torrential hemorrhage is rare in tuberculous affection of the bowel. The traditional method of treatment has been immediate surgical intervention aimed at bowel resection. To our knowledge, this is the first report of successful control of such life-threatening hemorrhage by transcatheter embolisation.

Late post-traumatic spinal stenotic progressive myelo-radiculopathy.

A case of late progressive myelo-radiculopathy associated with severe canal stenosis secondary to post-traumatic hypertrophy of thoracic laminae and ossification of spinal ligaments viz. ligamentum flavum and posterior longitudinal ligament in the absence of developmental spinal stenosis or post-traumatic deformity, is presented with a brief critical review of the relevant literature.

Pneumoperitoneum and pneumomediastinum: unusual complications of laparoscopy.

Pneumoretroperitoneum and pneumomediastinum are rare complications of laparoscopy. We report one such case. The mechanism of development of these complications is explained. No specific treatment needs to be instituted in most of these patients.

Ischemic bowel disease.

Twenty-five cases with ischemic bowel disease seen over a period of 4 years are presented. Of these, 20 cases presented with acute symptoms and five with chronic symptoms. In the majority of patients, the diagnosis was established at operation and on histopathology. Occlusive disease of the superior mesenteric artery was the commonest cause of acute ischemia. Non-occlusive ischemia was not observed in any case. All the patients were treated by resection and anastomosis of the involved bowel. Vascular procedures were not carried out in any. No planned second-look procedures were carried out. Of the 20 acute cases, eight patients died and three developed complications. One chronic case died and there were no other complications in this group. We suggest that ischemic bowel disease should be considered while dealing with cases presenting as acute abdomen or with chronic abdominal pain.