Clinical Presentation of Cases with Upper Gastro - Intestinal Bleeding.

Acute upper gastrointestinal bleeding (UGIB) is a common emergency and can be a serious condition that requires hospitalization, rapid evaluation and management. The usual presentation is hematemesis (vomiting of blood or coffee ground-like material) and/or melena (black, tarry stools) 1. UGIB occurs more commonly in men and older subjects. PUD is the most common cause of UGIB in the US accounting for about 50% of the cases, whereas in tropical country like India, esophageal varices attribute to half the cases. Esophago-Gastro-Duodenoscopy [EGD] is a primary diagnostic and therapeutic modality in the setting of UGIB. MATERIAL: Prospective study. Forty patients who have presented with frank blood or coffee ground color vomitus and/or melena were considered for this study. All patients greater than 18 years of age were included. Their clinical presentation, hemogram and endoscopic findings were analyzed. Descriptive statistical analysis has been applied. OBSERVATION: In our study, the age distribution was between 23 and 87 years. There is a male preponderance with 65 % males and 35%females. Among 40 patients,42.5%had varices, 17.5% had Peptic Ulcer Disease and12.5% had Erosive Gastritis. The other causes of UGIB include Pangastritis(10%), Mallory Weiss Tear(7.5%), Polyp(5%), Esophagitis(2.5%), Coagulopathy induced bleed(2.5%) and Carcinoma stomach(2.5%). Of the 40 cases admitted, only 3 patients (7.5%) had massive Upper GI Bleed.10 patients (25%) had moderate bleed and 27 patients (67.5%) had mild bleed. Amongst the patients with massive bleed, an important cause is esophageal varices(66.7%). A total of 21 (52.5%) patients have recovered. There was one death(2.5%) amongst the cases which was not attributed to UGIB. 14 patients(45%) has residual disease of which 42.5% were of variceal bleed. Patients with variceal bleed have undergone banding and have been asked to regularly follow up for check endoscopy and banding till their eradication. There was 1 patient of residual disease with Carcinoma stomach(2.5%) who has been initiated on chemotherapy. CONCLUSION: Hematemesis is much commoner than melena in the presentation of upper GI bleed. EGD has a diagnostic as well as therapeutic role in UGIB .In this study endoscopy provided diagnosis in 97.5% of patients. In this cross sectional study, the most common cause of upper GI bleed was esophageal varices, with alcoholic cirrhosis being the main cause of portal hypertension. Varices remain to be the most common cause of UGIB in both males and females, however, the percentage is more in males as compared to females. Varices are an important cause of massive variceal bleed.

Hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is an immune disorder characterized by uncontrolled inflammation due to defective immune response. It may be familial or acquired, but both share a common feature of threatening the life of a patient and may lead to death unless treated by appropriate treatment. Here in we report a case of adult HLH.

Two-week referrals for suspected head and neck cancer: two cycles of audit, 10 years apart, in a district general hospital.

OBJECTIVE: To analyse trends in two-week rule referrals for head and neck cancer over 10 years. METHOD: Data from two-week referrals received by the Wirral University Hospital NHS Trust between 1 January and 30 June 2012 were compared with similar data from 2002. RESULTS: A total of 357 referrals were received during the 6-month audit period, compared with 149 during the whole of 2002. Cancer pick-up rates were 9 per cent and 5 per cent in the first and second cycles, respectively. CONCLUSION: The annual number of two-week referrals made to our department increased by over 450 per cent in 10 years, but the resulting cancer pick-up rate fell by nearly 50 per cent. Whilst cancer patients need to be seen quickly, the current system is inefficient in parts. Modifications to the treatment pathway should be considered to improve patient care quality and reduce pressure on ENT departments.

Immune reconstitution and inflammatory syndrome due to disseminated tuberculosis in a case of human immunodeficiency virus 2 infection.

We present a case of human immunodeficiency virus 2 (HIV- 2) infection with acquired immune deficiency syndrome with immune reconstitution and inflammatory syndrome due to disseminated tuberculosis. We address here the drug interactions between antiretroviral therapy and antituberculous treatment (ATT), choice of ATT, and duration of ATT when rifampicin is omitted as in our case. Though this problem is encountered rarely, we felt that it is important to report the issue to counter drug resistance in tuberculosis and HIV.

Methyl ethyl ketone peroxide ingestion: a rare cause of corrosive chemical poisoning.

Methyl ethyl ketone peroxide, commonly used in the lamination industry, is a highly inflammable substance. Ingestion of methyl ethyl ketone peroxide is associated with a high morbidity and mortality. It can cause injury to the gastrointestinal tract on ingestion, leading to gangrene or perforation. Gastric lavage is contraindicated as it is a highly corrosive substance. We report a patient with poisoning due to methyl ethyl ketone peroxide who presented with upper gastrointestinal bleeding, and developed gangrene of the bowel and died of septicaemia and multiorgan failure.

Renal cortical necrosis at presentation in a patient with systemic lupus erythematosus: an autopsy case report.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder. Renal involvement has the worst prognosis. However, renal cortical necrosis is extremely unusual in SLE. In this case report, we describe the autopsy findings in a young female patient with SLE presenting with renal failure. At autopsy, there was Libmann-Sacks endocarditis with multiorgan infarcts and renal cortical necrosis. Secondary antiphospholipid antibodies contribute to the cardiac and renal manifestations in SLE. We discuss the incidence and pathogenesis of endocarditis with differential diagnosis for cortical necrosis in a patient of SLE.

Transtympanic gentamicin treatment using Silverstein MicroWick in Ménière's disease patients: long term outcome.

OBJECTIVE: To assess the long term outcome of gentamicin inner-ear perfusion using the Silverstein MicroWick in the treatment of Ménière's disease. STUDY DESIGN: Retrospective questionnaire survey of patients and review of medical records. SETTING: A district general hospital. PARTICIPANTS: All 15 patients who completed a minimum follow up of at least 24 months were included. MAIN OUTCOME MEASURES: Subjective symptoms, change in hearing thresholds and Glasgow benefit inventory scores. RESULTS: Based on the American Association of Otolaryngology-Head and Neck Surgery (1995) guidelines for reporting, 80 per cent of respondents obtained class A vertigo control and 20 per cent obtained class B control. Respondents' functional level improved from pre-operative levels of between three and six to post-operative levels of between one and three. Three respondents had pre-operative 'dead ears' and one developed the condition post-operatively. Hearing deteriorated further in three respondents, improved in two and remained unchanged in the rest. Respondents with class A control demonstrated improved quality of life, with a mean Glasgow benefit inventory total score of +34. CONCLUSION: Transtympanic gentamicin therapy via the Silverstein MicroWick results in good vertigo control. Patients should however be made fully aware of the risk of hearing deterioration.

Day-case endoscopic sinus surgery using dissolvable haemostatic nasal packs: a pilot study.

In a prospective pilot study, we assessed the efficacy and safety of dissolvable nasal packs (Sinu-knit) for control of post-operative bleeding in patients undergoing endoscopic sinus surgery (ESS), as well as potential complications of this novel packing material and patients' satisfaction with the dissolvable nasal packs. The patients included were considered suitable for a day-case procedure. We excluded subjects under 16-year-old, as well as patients on warfarin or with any coexisting medical or social reasons rendering them unsuitable for a day-case procedure. The main outcome measures were: readmission rate, postoperative bleeding rate, any other postoperative complications and patient satisfaction survey (including management as a day case and views about the packs). Fifteen patients fulfilled our criteria and were enrolled in this study (between March and August 2005). Fourteen patients were able to go home on the same day. One patient stayed overnight because of vomiting. All operations were performed by the same surgeon and the same anaesthetist. There were no readmissions due to postoperative bleeding. All patients were followed up with rigid video-nasendoscopy weekly for three weeks with further reviews at 6 weeks, 3 months and a final follow-up 6 months postoperatively. No postoperative adhesions were seen on nasendoscopy up to 6 months postoperatively. Dissolvable packs appear to be safe and effective and can be used for day case sinus surgery. There is no need for packing removal, thus greater patients' satisfaction.

Trends in laryngopharyngeal reflux: a British ENT survey.

There is a lot of scepticism surrounding laryngopharyngeal reflux (LPR). Symptoms such as globus pharyngeus, constant throat clearing, chronic cough, idiopathic hoarseness, catarrh and choking episodes may be reflux-related. The aim of this survey was to highlight current treatment trends in LPR. Questionnaires were emailed to 260 members of the British Academy of Otolaryngology-Head and Neck surgery (BAO-HNS). Survey recipients were asked about type, duration and dose of antireflux treatment and length of follow-up appointments, if any. Finally, they were asked about awareness of any reflux symptom and reflux sign questionnaires. Survey response rate was 60%. The vast majority of the otolaryngologists surveyed believe in laryngopharyngeal reflux (90%) and more than 50% prescribe proton pump inhibitors (PPIs). The preferred duration of treatment is 2 months (37%). Only a minority will prescribe PPIs for 6 months or more. Most otolaryngologists will give the standard GORD dose (70%) (once daily) and only a few (20%) will prescribe more aggressive and prolonged doses. The commonest symptoms for which proton pump inhibitors are prescribed are globus (73%), followed by choking episodes (66%) and chronic cough (62%). If LPR is suspected, most of the otolaryngologists will follow-up the patients (61%) and approximately one third (31%) will discharge them back to the general practitioners. Only eight-percent 8% will refer to gastroenterologists. The three commonest laryngoscopic signs that makes them suspect LPR are erythema of the arytenoids (86%) or the vocal cords (57%) and granulomas (42%). The majority of the otolaryngologists (94%) do not use popular questionnaires such as the RFS or RSI. Despite the controversy surrounding laryngopharyngeal reflux, our results suggest that the majority of the otolaryngologists surveyed believe in LPR and attempt to treat it. Interesting findings are: the duration of treatment, the doses used, the length of follow-ups or the lack of, and the fact that the majority does not request any specific diagnostic tests. "symptoms and signs" questionnaires are rarely used.

Lymph node infarction--a rare complication associated with disseminated intra vascular coagulation in a case of dengue fever.

BACKGROUND: Lymph node infarction is known to occur in association with many non-neoplastic and neoplastic conditions however its occurrence in association with DIC is not reported hitherto in the literature. CASE PRESENTATION: We describe an unusual case of lymph node infarction in a twenty seven year old male following disseminated intravascular coagulation (DIC) in a case of dengue fever. Multiple sections of the infarcted and the surrounding non-infarcted lymph nodes failed to reveal any predisposing condition. How ever the parahilar vessels showed thrombotic occlusion, which must have been responsible for the infarction. CONCLUSION: Global infarction of the lymph node may mask the underlying pathology. Any malignancy especially lymphoma may coexist or follow lymph node infarction, therefore the patient needs constant surveillance.

Myringoplasty using a subcutaneous soft tissue graft.

A retrospective study was performed on patients who underwent myringoplasty using an autologous subcutaneous soft tissue graft over a 5-year period. Details including age, site and size of perforation, grade of surgeon, surgical approach, postoperative dressings, overnight stay, complications and outcome were recorded and analysed. Fifty-two patients underwent myringoplasty using a subcutaneous soft tissue graft. Their ages ranged from 4 to 78 years (median = 36 years). The mean follow-up period was 19 months. Successful closure to give an intact tympanic membrane was obtained in 82.7% of patients. Thresholds improved on pure tone audiometry in 57.1% and deteriorated in only one patient. There was no case of dead ear as a result of surgery. Subcutaneous tissue graft has comparable outcomes with temporalis fascia graft with additional advantages of a smaller incision, minimum dissection and a lower risk of bleeding.

Day-case myringoplasty: five years' experience.

A retrospective study of patients who underwent myringoplasty as a day-case procedure in two freestanding day-surgery units during a five-year period was carried out. Their case notes were identified and details including age, site and size of perforation, grade of surgeon, surgical approach, graft material, post-operative dressings, overnight stay, complications, and outcome were noted and analysed. The total number of patients including both children and adults who had myringoplasty as a day case was 144. Of these, 125 patients with 143 procedures were included in this study. Their ages ranged from four to 74 years (mean = 31 years). The perforation size was small in 40 cases, medium in 61 cases, and large/subtotal in 42 cases. The overnight stay rate was 2.7 per cent and this was for immediate post-operative problems such as nausea and bleeding from the wound. The readmission rate for post-operative complications was 2.1 per cent. The follow-up ranged from six months to five years (mean = 19 months). The success rate was 83.3 per cent and thresholds on pure tone audiometry improved in 69.2 per cent of cases. The age of the patient, grade of the surgeon, and graft material did not influence the surgical outcome. There was no case of dead ear as a result of surgery. Myringoplasty can be safely performed in both adults and children as a day-case procedure with low overnight stay and readmission rates. Success rates are comparable to when the procedure is performed on an in-patient basis.

Myelopathy during treatment of autoimmune hemolytic anaemia.

A specific neurological syndrome resembling, subacute combined degeneration of spinal cord, has been observed to occur during treatment of autoimmune hemolytic anaemia (AHA). We propose that folate administration can precipitate this neurological syndrome in patients with subclinical deficiency of vitamin B12, a phenomenon more likely to occur in tropical countries. Such cases have not been previously reported.

Isolated splenic tuberculosis.

The authors report two cases of isolated splenic tuberculosis treated since 1989 in Nizam's Institute of Medical Sciences. One case presented as pyrexia of unknown origin (PUO) and another with idiopathic thrombocytopenic purpura (ITP). Both were found to have splenic tuberculosis after splenectomy. Pre operative diagnosis could not be made in these cases. Splenectomy followed by antituberculous chemotherapy cured the condition in both the cases. The authors underline the diagnostic difficulties, essentially related to the rarity of this condition inspite of the progress in modern imaging.

Clinical profile of falciparum malaria in a tertiary care hospital.

Falciparum malaria presents with protean manifestations and is associated with a variety of complications and has a high mortality. One hundred and fifty-eight consecutive cases of falciparum malaria were studied with respect to the clinical presentation, complications, and response to treatment. The mean age of patients was 38.60 +/- 15.45 years and majority of them were males i.e., males being 110 (69.62%) and females being 48 (30.37%). The commonest presenting manifestations were fever with chill and rigor (98.10%), altered sensorium (48.10%), algid malaria (18.35%), and jaundice (27.21%). The other presenting features being oliguria (6.96%) and bleeding manifestations due to disseminated intravascular coagulation (DIC) (4.43%). The frequently encountered complications were anaemia (74.68%), jaundice (40.50%), cerebral malaria (45.56%), thrombocytopenia (40.50%) and renal failure (24.68%). Most of the patients i.e., 126 (79.74%) recovered with treatment and 32 (20.25%) succumbed. Higher mortality was associated with higher parasite count, presence of complications like anaemia, jaundice, renal failure, DIC, adult respiratory distress syndrome (ARDS), and septicaemia. Most of the deaths were encountered in patients where there was delay in clinical diagnosis, in the pre-hospital phase, and consequent presentation in multiorgan failure. Early diagnosis and institution of specific therapy were rewarding in the remaining patients in this series.

Snake bite presenting as acute myocardial infarction, ischaemic cerebrovascular accident, acute renal failure and disseminated intravascular coagulopathy.

An unusual presentation of a viperine snake bite presenting with ischaemic damage to the major organs like brain and heart leading to cerebrovascular accident and acute myocardial infarction along with acute renal failure and disseminated intravascular coagulopathy (DIC) is described in this report.