Drug treatment of portal hypertension.

Despite advances in endoscopic management, variceal bleeding is still associated with a significant mortality. In recent years, several therapeutic agents have been shown to lower the portal pressure and reduce variceal bleeding. In patients presenting with acute variceal bleeding, the drug of choice is somatostatin; it is as effective as endoscopic treatment and is virtually free of side-effects. The second-line drug therapy in acute variceal bleeding is a combination of vasopressin and nitroglycerine. Every patient with a history of variceal bleeding is at an increased risk of rebleeding and should receive some form of preventive therapy. In these patients, non-selective beta-blockers and endoscopic treatment are equally effective and either modality can be used. Since each episode of variceal bleeding carries a 30%-50% risk of death, cirrhotics who have never experienced variceal bleeding but are at high risk to develop this complication (high portal pressure, variceal grade III and IV, and presence of red wale markings over the varices) should be identified and treated. Beta-blockers are the treatment of choice and should be continued for the rest of the patient's life. Isosorbide-5-mononitrate is also useful in lowering the portal pressure and may be combined with beta-blockers in those who do not respond to the use of beta-blockers alone. However, isosorbide-5-mononitrate should not be given alone for a long duration because of its adverse haemodynamic effects. Additional measures which are useful in decreasing the risk of variceal bleeding are good control of ascites, especially with spironolactone and a low salt diet, and early recognition and treatment of bacterial infections.

Current status of transjugular intrahepatic portosystemic shunt (TIPS).

TIPS is the creation of an intrahepatic shunt between the portal and hepatic veins. The primary indications for TIPS are unresponsive acute variceal bleeding; bleeding from gastric varices, ectopic varices and portal gastropathy; and variceal bleeding in patients awaiting liver transplantation. Preliminary reports suggest that TIPS may be useful in other conditions such as resistant ascites, cirrhotic hydrothrorax and hepatorenal syndrome. TIPS has also been successfully placed in a proportion of patients with Budd-Chiari syndrome and portal vein thrombosis. The immediate post-procedure complication rate is low, considering the serious underlying illness of patients undergoing TIPS. However, the main concern in the long-term is stent stenosis or occlusion. Within one year, nearly 50% of patients develop stent dysfunction and a significant proportion of these patients suffer from recurrent variceal bleeding. At present, no clear solution has been found to this problem. It is hoped that stents made of material which is less thrombogenic and which provokes a less exuberant host tissue response may become available. Until then, TIPS should be reserved for complications which are unresponsive to standard therapy and in patients where surgery is considered hazardous.

Endoscopic treatment of bile duct stones: is stone extraction necessary after endoscopic sphincterotomy?

BACKGROUND: The current treatment for stones in the biliary tree is endoscopic sphincterotomy (ES) followed by stone extraction with the help of balloon catheters or metal baskets. Stone extraction techniques are often associated with complications. Moreover, the balloon catheters break easily which aids to the cost of the procedure. The present study was designed to examine the effectiveness of endoscopic sphincterotomy (ES) alone in allowing spontaneous expulsion of bile duct stones and to determine the circumstances which warrant stone extraction. METHODS: Endoscopic retrograde cholangio-pancreatography (ERCP) was attempted in 68 patients with stones in the common bile duct. The stone size was determined by ultrasound, cholangiography in post cholecystectomy patients with a T-tube or by ERCP. Patients with stone size of 15 mm or less in diameter were treated with ES alone without stone extraction. Patients were discharged from the hospital within 24 hrs and returned for reassessment every week or earlier, if symptomatic, until complete clearance of stones was demonstrated. RESULTS: Endoscopic sphincterotomy was successfully performed in 63 (93%) patients, the procedure was abandoned in the remaining 5 patients for technical reasons. Spontaneous clearance of stones was observed in 55 (87%) patients, usually without any accompanying pain (47.85%). Persistent stones were seen in 8 (13%) patients; extension of the ES resulted in spontaneous stone expulsion in 6 of these patients. Thus, 61 (97%) of the 63 patients with stones of 10 mm or less in size cleared the stones spontaneously and all 8 patients who failed the initial ES, had stones > 10 mm in size. COMMENT: The present study shows that all small stones (< 10 mm) and most of those < 15 mm are expelled spontaneously after an adequate ES. These finding if substantiated by larger studies will reduce considerably the cost of the procedure as well as the morbidity associated with mechanical stone extraction.

Pathogenesis of peptic ulcer in rheumatoid arthritis.

To assess the pathogenesis of the gastro-duodenal mucosal lesions in rheumatoid arthritis, 36 patients, consisting of 23 (group I) receiving non-steroidal anti-inflammatory drugs (NSAIDs) and 13 (group II) on alternative forms of treatment, were examined by fibreoptic upper gastrointestinal endoscopy. Ten (43%) of 23 patients receiving NSAIDs showed mucosal damage in the form of erosions or a definite ulcer crater, compared to only one (8%) of 13 in group II (p less than 0.05). There was no correlation between the duration of illness and the incidence of mucosal lesions. These findings indicate that the high incidence of gastroduodenal mucosal abnormalities seen in rheumatoid arthritis is related to the use of NSAIDs and not to the underlying disease process.

Pyoderma gangrenosum in ulcerative colitis.

We present a patient with pyoderma gangrenosum, a rare complication of ulcerative colitis. The patient's disease was limited to the distal colon, was clinically mild and responded quickly to treatment, and yet it was associated with pyoderma gangrenosum and arthritis, complications generally associated with more severe and extensive ulcerative colitis.

Separate pancreatic and biliary ductal openings in alcoholic chronic pancreatitis.

Endoscopic retrograde cholangiopancreatograms of 49 patients with chronic pancreatitis (alcohol related 18; idiopathic 31) were assessed retrospectively. Thirteen (72%) of 18 patients with alcohol-related chronic pancreatitis had separate openings of the common bile duct and the main pancreatic duct into the duodenum. This was significantly more frequent (p less than 0.01) than in previously studied controls (37%). Although this finding was seen more frequently in patients with alcohol related chronic pancreatitis than in those with idiopathic chronic pancreatitis (14 of 31, 45%), the difference was not statistically significant. It is concluded that alcohol-related chronic pancreatitis, but not idiopathic chronic pancreatitis, is associated with the presence of separate openings of the common bile duct and main pancreatic duct into the duodenum.

Post-cholecystectomy syndrome due to a broken T-tube.

Breaking of a biliary T-tube during removal is unusual. One such case who presented with features of post-cholecystectomy syndrome is presented.

Long term behaviour of healed duodenal ulcer with and without maintenance therapy.

Seventy six patients who showed complete ulcer healing at endoscopy were treated within 48 hr with either placebo (41 patients) or cimetidine 400 mg nocte (35 patients) as a maintenance therapy for a period of one year in a double blind controlled study. Patients were reviewed every month and an endoscopy was performed every 3 months after starting the treatment or earlier if there was recurrence of symptoms. During the first three months of treatment the relapse rate in the two treatment groups were similar. The difference between the two first became obvious at 4 mo, but statistically significant difference appeared only at 6 mo: 70.7% in the placebo group suffered a relapse compared to 42.9% in the cimetidine group (x2 = 6.01; p less than 0.02). The difference remained significant until the 10th mo (78.1% vs 48.6%; x2 = 7.16; p less than 0.01). At 12 mo, the difference was not significant (80.5% vs 62.9%; x2 = 2.93). The age, sex, duration of illness, previous treatment and blood group status did not influence ulcer relapse. However, two factors had an influence on the relapse rate: a) in patients receiving placebo the relapse rate was significantly greater in smokers compared to non smokers; no such difference was observed in the cimetidine group. Moreover, smokers on cimetidine had a significantly lower relapse rate at 6.9 and 12 mo compared to smokers on placebo (50% vs 88.9%, 50% vs 94.4% and 53.3% vs 94.4%; p less than 0.01 for each).(ABSTRACT TRUNCATED AT 250 WORDS)

Colonoscopic polypectomy. North Indian experience.

Colonoscopic snare polypectomy was carried out in 70 patients (40 children, 30 adults). There was a male preponderance in both the groups with a combined male: female ratio of 4.4:1. The majority of patients (85%) were aged 20 years or below. All patients presented with intermittent bleeding per rectum, ranging from 2 months - 6 years (mean 1.2 +/- 1.1 years) in children and 1-14 years (1.9 +/- 2.3) in adults. The majority of patients polyps were located in the rectum (73%) or in the rectosigmoid region (21%). Polyps were significantly more common in the rectum (80% vs 63%; P less than 0.01) and less frequent in the rectosigmoid (15% vs 30%; p less than 0.01) in children as compared to adults. A single polyp was present in 49 (70%) patients; 17 (24%) had 2-10 polyps, while 4 patients (2 children, 2 adults) had more than ten polyps. Most patients (94%) had polyps of less than 2 cm size. Histologically, the most polyps (91.5%) were of the juvenile variety; 39 (97.5%) children and 25 (83%) adults had this variety of polyp. The remaining 5 (17%) adults and one (2.5%) child had adenomatous polyps. The difference in the polyp histology between the two age groups was statistically significant (p less than 0.05). Only one patient (1.4%) had excessive bleeding following polypectomy. The present study suggests two important differences in the nature of polyps as compared to the West: 1) our patients were much younger, and polyps were rare after 40 years; and (2) histologically, the commonest polyps were of the juvenile variety (91.5%) while adenomatous polyps were rare (8.5%).

Endoscopic sphincterotomy--experience with 110 patients.

During the last two years, 116 endoscopic sphincterotomies (ES) were attempted in 110 patients. The indication for ES was choledocholithiasis in 102 (93%) patients, including 37 (36.2%) with gallbladder in situ and 65 (64%) post-cholecystectomy patients; the other 8 (7%) were performed for stricture of the lower end of the common bile duct (CBD) with cholangitis (2), insertion of nasobiliary drain (2), restenosis after previous sphincterotomy (1), stone in the cystic duct stump causing cholangitis (1), papillary stenosis (1) and post-cholecystectomy cholangitis with no obvious cause (1). ES was achieved in 113 (97.4%) attempts in 107 (97%) patients and was overall successful in 81% of patients. Of the 95 patients with choledocholithiasis in whom ES could be performed and a follow-up was available, 79 (83%) cleared their CBD. Of 98 patients with choledocholithiasis, 79 (80.6%) finally cleared their CBD of stones. Three patients developed complications, one needing emergency operation. There were no deaths. ES was found to be effective in patients with retained stones and also in patients with choledocholithiasis with gallbladder in situ, especially those who were poor surgical risk.

Detection of hepatitis Β virus in blood samples negative for surface antigen, by DNA probe hybridization assay.

A DNA hybridization assay was developed using a cloned hepatitis Β viral genome to detect the presence of infectious virions in human serum. The merit of this assay was to put in evidence virus particles in 7 out of 133 sera that were negative for surface antigen (HBsAg) using routine serological methods. The usefulness of this assay was confirmed by actual visualization of the virus under electron microscope. Some serum samples although positive for surface antigen, did not give a hybridization signal by dot blot assay and might indicate cases of acute hepatitis.