Corrosive injuries of the upper gastrointestinal tract: A pictorial review of the imaging features.

Corrosive ingestion is a common form of poisoning. Corrosive agents cause severe damage to the gastrointestinal (GI) tract. The most severe forms of injury can lead to mortality; however, the major concern with this type of injury is life-long morbidity. Upper GI endoscopy is the test of choice for assessing severity in the acute phase of the disease. The long-term management is based on the site, length, number, location, and tightness of the stricture. This information is best provided by the barium contrast studies. In this pictorial review, a spectrum of findings in patients with corrosive injuries of the esophagus and stomach is illustrated. The role of various imaging modalities including barium studies, endoscopic ultrasound, computed tomography, and magnetic resonance imaging is discussed.

Role of Multidetector Computed Tomography (MDCT) in Evaluation of Gallbladder Malignancy and its Pathological Correlation in an Indian Rural Center.

OBJECTIVES: Clinically or sonographically suspected gallbladder carcinoma was evaluated on multidetector computed tomography. Based on the spectrum of multidetector computed tomography findings, staging of gallbladder carcinoma was done. Multidetector computed tomography diagnosis was compared with pathological diagnosis. MATERIAL AND METHODS: This is a prospective study carried out in 100 patients at a rural Indian center between May 2012 and June 2015. Multidetector computed tomography was performed in all the cases and the findings were observed. Based on the radiological spectrum, staging of gallbladder carcinoma was done. The diagnosis was confirmed by ultrasound guided fine needle aspiration cytology/histopathological examination of surgical specimens. RESULTS: The most common multidetector computed tomography findings noted by us were mass replacing gallbladder, followed by diffuse/focal gallbladder wall thickening and polypoidal mass. Other findings noted were cholelithiasis, liver infiltration, intra hepatic biliary dilatation, liver metastases, portal vein invasion, antroduodenal and hepatic flexure involvement. Ultrasonography guided fine needle aspiration cytology done in all cases was positive in 92 cases and inconclusive in eight cases. Surgery was performed in only 22 patients, and histopathological findings were correlated with multidetector computed tomography findings. CONCLUSION: Multidetector computed tomography is also reliable in detection of extension of tumor and lymph nodes. multidetector computed tomography plays a major role in evaluating and staging of carcinoma gallbladder. It also guides the surgeons for operatibility and resectability of tumour.

Computerized tomography-based predictive model for differentiation of Crohn's disease from intestinal tuberculosis.

BACKGROUND: Intestinal tuberculosis (ITB) and Crohn's disease (CD) have clinical, radiological, endoscopic, and histological resemblance. There is paucity of literature regarding differentiation of CD and ITB based on radiology using computed tomography (CT). AIMS: The present study was designed to compare CT features of ITB and CD and develop a predictive model to differentiate ITB and CD. METHODS: Patients with ITB and CD, who underwent CT enteroclysis/CT enterography/CT abdomen before starting treatment, were recruited. Specific findings were noted by a radiologist who was blinded to the diagnosis. A predictive model was developed based on the features which were significantly different in these diseases. RESULTS: Fifty-four patients with CD and 50 patients with ITB were compared. On univariate analysis, left colonic involvement, ileocecal involvement, long-segment involvement, comb sign, presence of skip lesions, involvement of ≥3 segments and ≥1-cm sized lymph nodes were significantly different between CD and ITB. On multivariate analysis, ileocecal involvement, long-segment involvement and the presence of lymph node ≥1 cm were statistically significant. Based upon the latter three variables, a risk score (with values ranging from 0 to 3) was generated, with scores 0 and 1 having specificity of 100 % and 87 %, respectively, and positive predictive values (PPV) of 100 % and 76 %, respectively, for ITB and scores 2 and 3 having specificity of 68 % and 90 %, respectively, and PPV of 63 % and 80 %, respectively, for CD. CONCLUSIONS: A predictive model based on the presence of long-segment involvement, ileocecal involvement and lymph nodes sized ≥1 cm on CT could differentiate ITB and CD with good specificity and PPV.

Radiological findings in duodenal tuberculosis: a 15-year experience.

OBJECTIVE: To evaluate the radiological findings of duodenal tuberculosis with particular emphasis on the barium findings. MATERIAL AND METHODS: A retrospective analysis of 805 cases of gastrointestinal tuberculosis from January 1997 to December 2011 over a period of 15 years was conducted. Thirty two cases (4%) of duodenal tuberculosis were found. The diagnosis of duodenal tuberculosis was based on histopathology following surgery or endoscopic biopsy from the duodenum, ultrasound-guided aspiration cytology/biopsy of lymph nodes or response to anti-tubercular treatment. The patients' clinical presentation was broadly classified into obstructive features and dyspeptic features. Single and/ or double contrast upper gastrointestinal barium studies were reviewed in each case for the segment involved, presence and length of strictures, ulcerations, polypoidal masses, extrinsic impression and complications (viz. perforations and fistulae). RESULTS: The study included 20 males and 12 females with age range of 7-70 years (mean age 26.6 years) Twenty-seven (84.3%) patients presented with obstructive symptoms and five (15.6%) had predominantly dyspeptic symptoms. The radiological findings in patients with obstructive symptoms were duodenal strictures (n = 19), extrinsic compression (n = 10) and polypoidal intraluminal mass with luminal narrowing (n = 3). Among the patients presenting with dyspeptic symptoms, the most common findings was duodenal ulcerations (n = 3). Perforation was seen in 4 cases and fistulisation in 2 cases. A multiplicity of findings was noted in 7 patients. CONCLUSION: Barium studies though not specific for duodenal tuberculosis helped to delineate the mucosal lesions and define the nature, level, and extent of obstruction in these patients.

Duodenoduodenal intussusception: Report of three challenging cases with literature review.

Small bowel intussusception is an uncommon condition with cases of duodenoduodenal intussusception (DDI) being exceptionally rare. Adult intussusception occurs infrequently and differs from childhood intussusception in its presentation, etiology, and treatment. DDI is very unusual due to the fixed position of the duodenum within the retroperitoneum. The lead point usually is hamartomatous polyp, adenoma, or adenocarcinoma. Only few cases of DDI in adults have been reported in the literature. We herein report a series of three cases of DDI encountered in a tertiary level research institute. All cases had underlying abnormality acting as lead point with different etiologies. DDI is a challenging condition due to its rarity and nonspecific presentation and should be considered in the differential diagnosis of gastric outlet obstruction, pancreatitis, and obstructive jaundice. We elaborate this condition with a detailed review of the literature to gain a better understanding of its clinical features and enable early diagnosis.

Clinical presentation and outcome of endoscopic therapy in patients with symptomatic chronic pancreatitis associated with pancreas divisum.

CONTEXT: The results of endoscopic drainage in pancreas divisum with chronic pancreatitis have been debatable. OBJECTIVE: To evaluate clinical presentation and long term results of endoscopic therapy in patients of calcific and non-calcific chronic pancreatitis with pancreas divisum. PATIENTS AND METHODS: Between 1996 and 2011, 48 patients (32 males and 16 females) with chronic pancreatitis and pancreas divisum were treated endoscopically. Patients were considered to have clinical success if they had resolution of symptoms and did not require surgery. RESULTS: All patients presented with abdominal pain and symptoms were present for 36.6 ± 40.5 months. Pseudocyst, diabetes, pancreatic ascites, pancreatic pleural effusion, segmental portal hypertension and steatorrhea were seen in 13 (27.1%), 6 (12.5%), 3 (6.3%), 2 (4.2%), 2 (4.2%) and 1 (2.1%) patients, respectively. Ductal calculi and strictures were noted in 3 (6.3%) and 2 (4.2%) patients, respectively. In 47 patients, an endoprosthesis (5 or 7 Fr) was successfully placed in the dorsal duct. Following pancreatic endotherapy, 45/47 (95.7%) patients had successful outcome. The mean number of stenting sessions required to have clinical success was 2.6 ± 0.9. One patient each had mild post ERCP pancreatitis, inward migration of stent and precipitation of diabetic ketoacidosis. Over a follow up of 2-174 months (median: 67 months), 12 out of 31 patients with pain only and no local complications (38.7%) required restenting for recurrence of pain and none of these patients required surgery. CONCLUSION: Intensive pancreatic endotherapy is safe and effective both in patients with chronic calcific, as well as non-calcific, pancreatitis associated with pancreas divisum. It gives good long term response in patients having abdominal pain and/or dorsal ductal disruptions.

Endoscopic management of pancreatic injury due to abdominal trauma.

CONTEXT: There is limited experience with pancreatic endotherapy in patients with pancreatic injury due to trauma. OBJECTIVE: To retrospectively evaluate our experience of endoscopic management of pancreatic trauma. PATIENTS: Eleven patients (10 males and 1 female; mean age: 21.8±11.9 years) with pancreatic trauma. INTERVENTION: Endoscopic therapy. Patients with pseudocyst and a gastroduodenal bulge were treated with endoscopic transmural drainage. Pseudocysts without bulge or patients with external pancreatic fistula were treated with transpapillary drainage. RESULTS: Seven patients (6 males, 1 female) were treated for symptomatic pseudocyst and 4 patients (all males) were treated for persistent external pancreatic fistula. Three patients with external pancreatic fistula had partial disruption of pancreatic duct (head: 2 cases; tail: 1 case) and were successfully treated with bridging pancreatic stent (2 cases) or bridging nasopancreatic drain (1 case) with resolution of external pancreatic fistula in 4 to 6 weeks. Of seven patients presenting with symptomatic pseudocyst (size range: 4-14 cm), two patients were successfully treated with cystogastrostomy and there has been no recurrence over a follow up of 20 and 16 months, respectively. Five patients underwent transpapillary drainage. Three patients had partial disruption and two had complete disruption. In the former, a bridging nasopancreatic drain was placed in one patient and stent in two patients. All three patients had resolution of pseudocyst within 8 weeks and there has been no recurrence over a follow-up of 11 to 70 months. In two patients with complete disruption, non-bridging stent did not resolve the pseudocysts and required surgery. CONCLUSION: Pancreatic injury due to trauma can be effectively treated endoscopically.

Comparative evaluation of barium meal follow-through and barium enteroclysis before capsule endoscopy in obscure gastrointestinal bleeding.

BACKGROUND/AIMS: Small bowel radiological investigations have lower diagnostic yield in comparison to capsule endoscopy (CE) and are inaccurate in predicting capsule impaction. Most studies have used barium meal follow-through (BAMFT) and more sensitive barium enteroclysis (BE) is infrequently used. This study was done to retrospectively compare results of performing BAMFT or BE before CE in patients with obscure gastrointestinal bleeding. METHODOLOGY: Sixtyfive patients with obscure gastrointestinal bleeding underwent barium examination (BE or BAMFT depending upon patient's preference) and CE was performed if barium examination was normal. The demographic data, barium examination results and CE findings were retrospectively collected. RESULTS: Sixteen patients underwent BAMFT and 49 patients underwent BE prior to CE. BAMFT was normal in all 16 patients whereas CE was normal in only 1/16 patient. Seven of 49 (14.2%) patients had stricture or mass on BE. In these 7 patients CE was not performed. In contrast to BAMFT, 22/41 (53.6%) patients with normal BE had normal CE findings also. The capsule got stuck in one patient with NSAID induced diaphragm disease who had normal BE and required surgical removal. CONCLUSIONS: BE should be preferred over BAMFT as the radiological imaging technique for evaluation of small bowel before CE in patients with obscure gastrointestinal bleeding as it may detect unexpected strictures and intraluminal masses. However, radiological findings either on BAMFT or BE cannot predict passage of capsule endoscope through small bowel.

Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.

AIM: To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma. METHODS: In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory. RESULTS: Between January 2008 and December 2010, 38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients. Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy. There were 8 (61.5%) males and 5 (38.5%) females. The most common presenting symptom was jaundice (100%), followed by fever (46.2%), melena (38.5%), abdominal pain (30.8%) and weight loss (30.8%). All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of (11.2 ± 1.9) mg/dL (normal value < 1 mg%) and the mean ± SD serum alkaline phosphatase was (288.0 ± 94.3) IU/L (normal value < 129 IU/L). Serum CA 19.9 level estimation was done in 11 patients; it was elevated (cut off value > 70.5 IU/L) in all of them with a median of 1200 IU/L (inter quartile range 274-3500). Side viewing endoscopy showed a bulky papilla in all of them. Adequate tissue was obtained in all of the 13 patients for histological evaluation; 12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma. There were no complications from the needle knife papillotomy in any of the patients. CONCLUSION: Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.

NSAIDs-Related Pyloroduodenal Obstruction and Its Endoscopic Management.

Endoscopic balloon dilatation (EBD) has important role in the management of benign gastric outlet obstruction. Although there are many reports on the role of EBD in the management of corrosive-induced and peptic benign GOO, there is scanty data on its role in the management of NSAID-induced GOO. We report 10 cases of NSAID-induced pyloroduodenal obstruction and their endoscopic management. The most common site of involvement was duodenum (5/10) followed by both pylorus and duodenum (4/10) and pylorus (1/10). Most of the strictures were short web-like, and the mean (SD) number of stricture was 2.0 (0.94). Endoscopic balloon dilatation was successful in 90% (9/10) cases requiring mean (SD) of 2.0 (1.6) sessions of dilatation to achieve target diameter of 15 mm and mean (SD) of 5.3 (2.7) sessions to maintain it over a treatment period of 4.5 months (IQR 2-15 months). There was no procedure-related complication or mortality.

Comparative evaluation of transpapillary drainage with nasopancreatic drain and stent in patients with large pseudocysts located near tail of pancreas.

BACKGROUND: Endoscopic transpapillary drainage is usually not advocated for large pseudocysts for fear of infection. We compared efficacy of transpapillary drainage with nasopancreatic drain (NPD) or stent alone in large pseudocysts (>6 cm) located near tail of pancreas. METHODS: In a prospective study, a 5-Fr stent/NPD was placed across/near pancreatic duct disruption in 11 patients (nine chronic and two acute pancreatitis) with large pseudocysts located near tail of pancreas. The patients were followed up for resolution of pseudocyst, need for surgery, and complications. RESULTS: Pseudocysts diameter ranged from 7 to 15 cm. An attempt to place NPD was made in five patients and a stent in six patients. In NPD group, deep cannulation could not be achieved in one patient; it was treated successfully with percutaneous drainage. In four patients with partial duct disruption, NPD was successfully placed bridging disruption and all had resolution within 6 weeks. In stent group, five had partial and one had complete duct disruption, who later recovered by placement of a stent. Of five patients with partial disruption, one recovered uneventfully at 6 weeks with stent bridging disruption. Other four patients (bridging stent in three) developed febrile illness and infection of pseudocyst. They required additional percutaneous drainage and antibiotics. There was no recurrence of pseudocysts over follow-up of 16.4 months. CONCLUSION: Endoscopic transpapillary drainage with NPD bridging disruption is associated with good outcome in patients with large pseudocysts at tail end of pancreas. However, there was increased frequency of infection when stent was used for drainage.

Endoscopic balloon dilatation without fluoroscopy for treating gastric outlet obstruction because of benign etiologies.

BACKGROUND: Benign gastric outlet obstruction (GOO) causes considerable morbidity and conventional treatment has been surgery. Endoscopic balloon dilatation is a minimally invasive treatment modality for GOO but experience with its use is mainly in patients with GOO due to peptic ulcer disease. We report our experience of endoscopic balloon dilatation in benign GOO of various etiologies. METHODS: Over 4 years, 25 patients with benign GOO were treated by endoscopic balloon dilatation done with through-the-scope controlled radial expansion (CRE) balloon dilators. Dilatation was repeated every 2 weeks with the end point being dilation of 15 mm or the need for surgery. Helicobacter pylori, when present, was eradicated. RESULTS: Etiology of benign GOO was peptic ulcer (11), corrosive ingestion (7), chronic pancreatitis (4, groove pancreatitis in 1), tuberculosis (2), and Crohn's disease (1). Endoscopic balloon dilatation was successful in 21/25 (84%) patients. Patients required one to six sessions of endoscopic dilatation (mean=2.2±1.2). Corrosive-induced GOO required more dilatation sessions (3.83±0.75) compared to peptic GOO (2.1±0.56; p<0.05). Balloon dilatation was also effective in patients with GOO due to gastroduodenal tuberculosis and Crohn's disease. Patients with chronic pancreatitis-related GOO had poor response to dilatation, with two patients (50%) requiring surgery and the remaining two with recurrence of symptoms requiring repeat dilatation. None of the other patients with successful treatment had recurrence of symptoms. Complication in the form of perforation was noted in two patients (8%). CONCLUSIONS: Endoscopic balloon dilatation is an effective, safe, and minimally invasive treatment modality for benign gastric outlet obstruction.

Clinical, biochemical, and radiologic parameters at admission predicting formation of a pseudocyst in acute pancreatitis.

GOALS: To evaluate clinical, biochemical, and radiologic parameters at admission, which predict the development of acute pseudocyst (AP) after acute pancreatitis. BACKGROUND: There is limited data on factors that predict the development of AP. STUDY: Seventy-five consecutive patients with AP were prospectively enrolled and subjected to clinical, laboratory, and radiologic investigation. The patients were followed up for a period of 4 weeks and then investigated radiologically for the development of AP. RESULTS: After exclusion, 65 patients (44 males) were studied. The median age was 37 years (40.9±15.5 y). Etiology of acute pancreatitis was alcohol in 24 patients, gallstones in 18, both in 4, drugs in 4, pancreas divisum in 2, postendoscopic retrograde cholangiopancreatography in 1, trauma in 1, and idiopathic in 11 patients. On admission, acute fluid collections were observed in 34 (52.31%) patients. Necrosis was noted in 38 (58.46%) patients (<30% necrosis, 30% to 50% necrosis, and >50% necrosis was observed in 36.8%, 26.3%, and 36.8% patients, respectively). On follow-up, 34 (52.3%) patients developed a pseudocyst. On univariate analysis, the factors significantly associated with pseudocyst formation were male sex, palpable mass, blood sugar greater than 150 mg/dL, necrosis, sepsis, acute fluid collections, presence of ascites, pleural effusion, a high grade of pancreatitis, and a high computed tomography severity index (CTSI) score. Multivariate regression analysis showed that male sex, presence of a palpable abdominal mass, ascites, and a high CTSI score were associated with the development of AP. CONCLUSIONS: Male sex, palpable mass, ascites, and a high CTSI score at admission can predict the development of a pseudocyst after an attack of acute pancreatitis. Acute pancreatitis patients with these parameters at admission should be closely followed for the development of a pseudocyst.

Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions.

BACKGROUND AND AIMS: External pancreatic fistulas (EPFs) are a therapeutic challenge. The present study was conducted to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage (NPD) in patients with EPF. METHODS: Over 12 years, 23 patients (19 males) with EPF underwent attempted endoscopic transpapillary NPD. The end points were fistula closure with healing of pancreatic duct disruption on nasopancreatogram, or need for surgery. RESULTS: All 23 patients had persistent drain output (>50 mL/day) for >6 weeks. The mean output volume of the fistula was 223 mL (range: 60 mL to 750 mL). Sixteen patients had partial and seven patients had complete pancreatic duct disruption. The NPD could be successfully placed in 21/23 (91.3%) patients. Disruption was bridged in 15 of 16 patients with partial duct disruption. EPF healed in 2-8 weeks of placement of NPD in all of the patients with partial duct disruption that was bridged and there was no recurrence at a mean follow-up of 38 months. The EPF resolved in only 2/6 (33%) patients with complete duct disruption. CONCLUSIONS: External pancreatic fistulas developing following percutaneous drainage of pancreatic fluid collections or surgical necrosectomy can be effectively treated by transpapillary nasopancreatic drain placement especially when there is partial ductal disruption and the disruption can be bridged.