Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer.

BACKGROUND: Therapeutic endoscopy has provided a new means of treating bleeding peptic ulcers. Additional medical therapy may enhance the therapeutic benefit. Hemostasis is highly pH dependent and is severely impaired at low pH. Proton pump inhibitors, by achieving a significantly higher inhibition of gastric acidity, may improve the therapeutic outcomes after endoscopic treatment of ulcers. PATIENT AND METHODS: We enrolled 166 patients with hemorrhage from duodenal, gastric, or stomal ulcers and signs of recent hemorrhage, as confirmed by endoscopy. Twenty-six patients had ulcers with an arterial spurt, 41 patients had active ooze, 37 had a visible vessel, and 62 patients had an adherent clot. All patients received endoscopic injection sclerotherapy using 1:10,000 adrenaline and 1% polidocanol and were randomly assigned to receive omeprazole (40 mg orally) every 12 hours for 5 days or an identical-looking placebo. The outcome measures used were recurrent bleeding, surgery, blood transfusion, and hospital stay. RESULTS: Six (7%) of 82 patients in the omeprazole group had recurrent bleeding, as compared with 18 (21%) in the placebo group (P = 0.02). Two patients in the omeprazole group and 7 patients in the placebo group needed surgery to control their bleeding (P = 0.17). One patient in the omeprazole group and 2 patients in the placebo group died (P = 0.98). Twenty-nine patients (35%) in the omeprazole group and 61 patients (73%) in the placebo group received blood transfusions (P <0.001). The average hospital stay was 4.6 +/- 1.1 days in the omeprazole group and 6.0 +/- 0.7 days in the placebo group (P <0.001). CONCLUSION: The addition of oral omeprazole to combination injection sclerotherapy decreases the rate of recurrent bleeding, reduces the need for surgery and transfusion, and shortens the hospital stay for patients with stigmata of recent hemorrhage.

Gallbladder ascariasis: presentation and management.

BACKGROUND: As many as 1.5 billion people around the world harbour Ascaris lumbricoides in the digestive tract. Gallbladder ascariasis, although less common than bile duct ascariasis, is quite often seen in endemic areas. METHODS: Some 1300 patients with hepatobiliary ascariasis, admitted between October 1992 and June 1998, were analysed prospectively. The clinical features and outcome of 56 cases of gallbladder ascariasis are presented. RESULTS: Forty-seven patients were diagnosed by ultrasonography and nine were diagnosed at laparotomy. Only ten patients diagnosed by ultrasonography expelled the worms spontaneously, with resolution of symptoms and signs. The remaining 37 patients underwent cholecystectomy. CONCLUSION: Gallbladder ascariasis is a significant entity in endemic areas which usually requires cholecystectomy.

Percutaneous sonography-guided fine needle aspiration biopsy of colonoscopic biopsy-negative colonic lesions.

BACKGROUND: Pre-operative tissue diagnosis with colonoscopy is not always possible in patients with colonic lesions. OBJECTIVE: To study the usefulness and efficacy of percutaneous ultrasound-guided aspiration biopsy of colonic lesions. METHODS: Fifty consecutive patients with colonic lesions in whom colonoscopic brush cytology and biopsy were either negative or the lesion was not accessible on colonoscopy on two attempts, underwent percutaneous ultrasound-guided fine-needle aspiration biopsy. The results were compared with surgical findings. RESULTS: Fine-needle aspiration biopsy revealed adenocarcinoma in 40 patients; one had lymphoma, 2 had tuberculosis, 2 had abscess and 5 patients had negative aspiration. Forty-eight patients (excluding 2 with tuberculosis) underwent laparotomy and the diagnoses on aspiration biopsy were confirmed. Of the 5 negative aspirations, 3 had adenocarcinoma, one had tuberculosis and one intussusception. Thus, we had sensitivity of 91.8%, specificity of 100%, predictive value of positive results 100%, predictive value of negative results 20%, and percentage of false negative results 8.1%. Two patients developed complications--hemorrhage into the peritoneum and sepsis due to perforation at the site of aspiration; both survived after surgery. CONCLUSION: Percutaneous ultrasound-guided aspiration biopsy may be attempted for diagnosis of colonic lesions in situations where it may be the only means of obtaining a cytological diagnosis before surgery.

Ascaris-induced liver abscess.

The prevalence, symptomatology, and outcome of Ascaris-induced liver abscess was studied prospectively in Kashmir, India, which is an endemic area of ascariasis, from December 1987 to December 1997. Of 510 patients with liver abscess admitted during this period, 74 had biliary ascariasis as the cause (14.51%). Of these 74 patients, 11 had intact ascaridae (live or dead) within the abscess. Six patients had a single abscess, and five had multiple abscesses. Seven patients had associated worms in the bile ducts. Ultrasonography was the main diagnostic procedure used. Ten patients were diagnosed based on clinical and ultrasound findings, and one was diagnosed during laparotomy. Most of the patients were young (age range 3-40 years) with a mean age of 17.20 years. Seven were females, and four were males. Ten patients underwent surgery; nine recovered completely, and one died postoperatively due to septicemia. Another patient died as well: a young child who presented late, was in refractory septic shock following suppurative cholangitis and liver abscess, and could not be taken for surgery. The mortality thus was 9.9%. Liver abscess following invasion of intrahepatic biliary radicles by ascaridae through the ampulla is an unusual complication of an otherwise common disease in Kashmir Valley, affecting children and young adults. The outcome depends on early diagnosis and surgical drainage of the abscess with extraction of worms from the ducts.

Role of pulse oximetry during nonsedated upper gastrointestinal endoscopic procedures.

BACKGROUND: Although upper gastrointestinal endoscopy is generally a safe procedure, it is known to be associated with arterial oxygen desaturation, resulting in rare serious cardio-pulmonary events. OBJECTIVE: To determine the severity of oxygen desaturation during nonsedated upper gastrointestinal endoscopy and study the effect of various variables on oxygen saturation. METHODS: 126 patients underwent nonsedated upper gastrointestinal endoscopy (82 diagnostic, 44 therapeutic). Arterial oxygen saturation (SaO2) was monitored using a pulse oximeter. RESULTS: Baseline SaO2 was mean (SD) 97.8 (1.8%). It remained > 95% in 60.2% of patients during the procedure, whereas mild oxygen desaturation (SaO2 90%-94%) occurred in 23.7% and severe oxygen desaturation (SaO2 < 90%) occurred in 15.8% of patients. Six patients (4.7%) required supplemental oxygen administration sometime during the procedure. Desaturation occurred in patients undergoing diagnostic and therapeutic procedures but was severe in the latter group (p < 0.002). Patients aged more than 60 years (p < 0.001), hemoglobin < 10 g/dL (p < 0.001), history of smoking (p < 0.001), and underlying chronic obstructive airway disease (p < 0.001) were significantly related to oxygen desaturation. However, on multivariate analysis, no significant correlation was observed with hemoglobin value. CONCLUSION: Therapeutic intervention during nonsedated upper gastrointestinal endoscopy, old age, smokers and chronic obstructive airways disease are independent risk factors for oxygen desaturation. We recommend continuous monitoring of SaO2 in these high-risk patients undergoing upper gastrointestinal endoscopy.

Short-course ceftriaxone therapy in spontaneous bacterial peritonitis.

Forty patients with spontaneous bacterial peritonitis, three of whom had complicating acute hepatitis syndrome, eight late-onset hepatic failure, and 29 with cirrhosis, were treated with ceftriaxone 2 g intravenously once daily for 5 days. Ascitic fluid culture was positive in 28 patients, with Escherichia coli and Klebsiella as common isolates. All the bacteria isolated were sensitive to ceftriaxone except Enterococcus faecalis, which was isolated in a cirrhotic patient. All culture-positive patients sensitive to ceftriaxone showed bacteriological cure and 26 (65%) patients showed cytological cure after 48 hours of treatment. A total of 95% were cured of their infection after 5 days of treatment. Twelve (30%) patients died during hospitalisation after documented cure of their spontaneous bacterial peritonitis (renal failure, gastrointestinal bleed and cerebral oedema were the primary causes of death). Infection-related mortality due to Pseudomonas septicaemia was seen in one cirrhotic patient.

Percutaneous drainage compared with surgery for hepatic hydatid cysts.

BACKGROUND: In recent years percutaneous drainage has been used successfully to treat the hepatic hydatid cysts of echinococcal disease. We performed a controlled trial to compare the safety and efficacy of percutaneous drainage with those of surgical cystectomy, the traditional treatment. METHODS: In a prospective study, we randomly assigned 50 patients with hepatic hydatidosis to treatment with percutaneous drainage (25 patients) or cystectomy (25). Albendazole (10 mg per kilogram of body weight per day for eight weeks) was administered to the patients who underwent percutaneous drainage. Serial assessments included clinical and biochemical examinations, ultrasonography, and serologic tests of echinococcal-antibody titers. RESULTS: The mean (+/-SD) hospital stay was 4.2+/-1.5 days in the drainage group and 12.7+/-6.5 days in the surgery group (P<0.001). Over a mean follow-up period of 17 months, the mean cyst diameter decreased from 8.0+/-3.0 to 1.4+/-3.5 cm (P<0.001) after percutaneous drainage and from 9.1+/-3.0 to 0.9+/-1.8 cm (P<0.001) after surgery. The final cyst diameter did not differ significantly between the two groups (P=0.20). The cysts disappeared in 22 patients (88 percent) in the drainage group and in 18 (72 percent) in the surgery group (P=0.29). After an initial rise, the echinococcal-antibody titers fell progressively and at the last follow-up were negative (<1:160) in 19 patients (76 percent) in the drainage group and 17 (68 percent) in the surgery group (P=0.74). There were procedure-related complications in 8 patients (32 percent) in the drainage group and 21 (84 percent) in the surgery group, 17 of whom had fever postoperatively (P<0.001). CONCLUSIONS: Percutaneous drainage, combined with albendazole therapy, is an effective and safe alternative to surgery for the treatment of uncomplicated hydatid cysts of the liver and requires a shorter hospital stay.

A comparison of omeprazole and placebo for bleeding peptic ulcer.

BACKGROUND: The role of medical treatment for patients with bleeding peptic ulcers is uncertain. METHODS: We conducted a double-blind, placebo-controlled trial in 220 patients with duodenal, gastric, or stomal ulcers and signs of recent bleeding, as confirmed by endoscopy. In 26 patients the ulcers showed arterial spurting, in 34 there was active oozing, in 35 there were nonbleeding, visible vessels, and in 125 there were adherent clots. The patients were randomly assigned to receive omeprazole (40 mg given orally every 12 hours for five days) or placebo. The outcome measures studied were further bleeding, surgery, and death. RESULTS: Twelve of the 110 patients treated with omeprazole (10.9 percent) had continued bleeding or further bleeding, as compared with 40 of the 110 patients who received placebo (36.4 percent) (P<0.001). Eight patients in the omeprazole group and 26 in the placebo group required surgery to control their bleeding (P<0.001). Two patients in the omeprazole group and six in the placebo group died. Thirty-two patients in the omeprazole group (29.1 percent) and 78 in the placebo group (70.9 percent) received transfusions (P<0.001). A subgroup analysis showed that omeprazole was associated with significant reductions in recurrent bleeding and surgery in patients with nonbleeding, visible vessels or adherent clots, but not in those with arterial spurting or oozing. CONCLUSIONS: In patients with bleeding peptic ulcers and signs of recent bleeding, treatment with omeprazole decreases the rate of further bleeding and the need for surgery.

Serial cholangiographic appearances in recurrent pyogenic cholangitis.

From December 1982 to December 1991, cholangiograms were obtained in 227 patients with recurrent pyogenic cholangitis. Cholangiographic abnormalities included biliary dilation, calculi, sludge, excessive branching, and arrowhead formation of intrahepatic ducts and biliary strictures. In 21 patients, previous evidence of biliary ascariasis was seen. Repeat cholangiograms were performed in 55 patients in a follow-up period of 18.0 +/- 1 months. Of these patients, 12 treated conservatively continued to get recurrent cholangitis and revealed worsening abnormalities on repeat cholangiograms. Another 25 patients had successful endoscopic sphincterotomy and extraction of biliary calculi. These patients remained free of symptoms on follow-up, with significant resolution of abnormalities on repeat cholangiograms. The remaining 18 patients with failed surgical or endoscopic interventions continued to get recurrent episodes of cholangitis and worsening of abnormalities on repeat cholangiograms. This retrospective study indicates that the natural course of recurrent pyogenic cholangitis is a progressive, destructive cholangiopathy. Ascaris lumbricoides invasion of the biliary tree is an initiating event in a sub-group of patients.

Worm extraction and biliary drainage in hepatobiliary and pancreatic ascariasis.

From December 1989 to March 1992, 50 (32%) of 156 patients with hepatobiliary and pancreatic ascariasis underwent various endoscopic interventional procedures. Endoscopic intervention was performed when patients did not respond to energetic symptomatic treatment within the first few days of hospitalization (n = 45) or when worms had not moved out of the ducts into the duodenum at 3 weeks (n = 5). Worm extraction was successful in all 18 patients from the ampullary orifice and in 34 (89.5%) of 38 patients from the bile or pancreatic duct. In five patients with pyogenic cholangitis, endoscopic nasobiliary drainage was performed to decompress the bile ducts. After worm extraction/nasobiliary drainage, 41 (91%) of the 45 patients with biliary disease (n = 42) or acute pancreatitis (n = 3) had rapid relief of symptoms. Three patients developed complications related to endoscopy, including cholangitis (n = 2) and hypotension (n = 1).

Biliary abnormalities associated with extrahepatic portal venous obstruction.

We prospectively studied 21 consecutive patients with extrahepatic portal venous obstruction for evidence of biliary tract disease. Two patients were first seen with extrahepatic cholestasis; another had recurrent cholangitis. All three patients with clinically manifest biliary disease were adults. Another five patients had icterus on clinical examination. Liver function tests revealed elevated bilirubin levels in 14 patients (66.6%), elevated alkaline phosphatase levels in 17 (80.9%) and elevated serum ALT levels in 8 (38.0%). Endoscopic retrograde cholangiography revealed abnormal findings in 17 patients (80.9%). The changes involved the common bile duct (66.6%) more often than they did the hepatic bile ducts (38.1%). Cholangiographic abnormalities included strictures (52.4%), caliber irregularity (23.8%), segmental upstream dilatation (42.8%), ectasia (9.5%), collateral veins causing extraluminal bile duct impressions (14.3%), displacement of ducts (9.5%), angulation of ducts (4.7%) and pruning of intrahepatic ducts (9.5%). The pathogenesis of such cholangiographic abnormalities is unknown. However, possible factors in such changes include collateral veins bridging the blocked portal vein, causing bile duct impressions; fibrous scarring of porta hepatis, causing angulation of bile duct; and ischemic injury to bile duct, leading to stricture formation and caliber irregularity. Biliary disease is important in the clinical outcome of patients with extrahepatic portal venous obstruction because variceal sclerotherapy has prolonged the life expectancies of such patients.

Oddi's sphincter motor activity in patients with recurrent pyogenic cholangitis.

Oddi's sphincter motor activity was studied in 15 healthy subjects and 15 patients with recurrent pyogenic cholangitis. No significant difference was found in the common bile duct pressures, the Oddi's sphincter basal pressures or the amplitude, frequency and duration of phasic contractions between the controls and patients. However, a significant difference was found in the percentage of antegrade and retrograde phasic wave sequences between the two groups. In control patients 64.0% +/- 5.3% of phasic wave sequences were antegrade, and 20% +/- 3.6% were retrograde. In patients with recurrent pyogenic cholangitis, 37% +/- 3.6% of phasic wave sequences were antegrade, and 42% +/- 5.5% were retrograde. No significant difference was found in the percentage of simultaneous phasic wave sequences (16% +/- 1.5% vs. 18.5% +/- 2.8%, respectively) between the two groups. In all, five (33%) patients with recurrent pyogenic cholangitis had abnormal propagation of phasic contractions of Oddi's sphincter (retrograde phasic wave sequences greater than 50%), two (13%) patients had elevated Oddi's sphincter basal pressures (greater than 40 mm Hg) and one (7%) patient had increased frequency of Oddi's sphincter phasic contractions (more than 9/min). Six of the 15 patients had evidence of papillitis on duodenoscopy. We believe papillitis could induce motor abnormalities in these patients, thus resulting in delayed biliary drainage and recurrent attacks of cholangitis.

Sonographic findings in gallbladder ascariasis.

Invasion of the adult roundworm, Ascaris lumbricoides, into the gallbladder is rare and was seen in 14(2.1%) of the 665 cases with hepatobiliary ascariasis. The diagnosis was suggested in all 13 cases in which sonography was performed and in 5 of the 11 cases at endoscopic retrograde cholangiography. Sonographic findings included a nonshadowing, long, echogenic structure in the form of a coil, an echogenic strip with central anechoic tube, an echogenic structure extending across the gallbladder giving it a septate appearance, and characteristic erratic, nondirectional, zig-zag movements of these echogenic structures in the gallbladder. Serial sonograms accurately predicted spontaneous exit of the worm. Pregnancy and anomalous origin of the cystic duct directly from the papilla of Vater facilitated worm invasion into the gallbladder. We conclude that real-time sonography offers a simple, rapid approach for the diagnosis and follow-up of patients, whereas endoscopic retrograde cholangiography has limited diagnostic value in this disorder.

The colon in shigellosis: serial colonoscopic appearances in Shigella dysenteriae I.

Twenty-five patients (16 males and 9 females; mean age 24.7 +/- 8.4 years) with acute colitis caused by Shigella dysenteriae I were studied, a total of 115 colonoscopic examinations being performed. Twenty-two patients had weekly colonoscopic examinations until the last procedure revealed normal colonic mucosa. Six abnormal colonoscopic appearances were documented, namely mucosal edema, ulcers, friability, punctate spots, erythematous areas and luminal exudate. Mucosal edema was the dominant finding in the first week of the disease. Star-shaped mucosal ulcers and friability were observed in the 2nd and 3rd weeks of the disease. Punctate hemorrhagic spots with normal intervening mucosa in patients with minimal constitutional and colonic symptoms were the hallmark of the disease from the 4th week onwards. None of the patients revealed granularity, cobblestoning, linear fissures, pseudopolyps, pseudomembrane or anal lesions. The colonic involvement was subtotal in 20 patients and total in 5 patients. The mucosal disease was continuous in the initial stage and became patchy during the later stage of recovery. The mucosal disease lasted for 38.8 +/- 12.1 (10-65 days). All the patients followed-up by serial colonoscopy examinations eventually had normal colonic mucosa.

Prevalence of peptic ulcer in India: an endoscopic and epidemiological study in urban Kashmir.

The prevalence of peptic ulcer disease in the general population of Kashmir, India, was determined by endoscopy in a randomly selected sample population of 2763 adults aged 15 years and above who were interviewed using a questionnaire. Of 239 persons with ulcer symptoms, 193 (80.7%) had an oesophagogastroduodenoscopy. A randomly selected 177 individuals from among the remaining population without ulcer symptoms, were also endoscoped. The point prevalence of peptic ulcer was 4.72% and the lifetime prevalence was 11.22%. The duodenal to gastric ulcer ratio was 17.1:1. Duodenal and gastric ulcer were common in men. The prevalence of peptic ulcer increased with age, with a peak prevalence of 28.8% in the 5th decade of life. Peptic ulcer was not related to socio-economic status. The prevalence of complications, such as bleeding, stenosis, or perforation were similar to those reported in the West.

Prevalence of biliary tract disease in India: a sonographic study in adult population in Kashmir.

Sonography was used to investigate the prevalence of symptomatic and silent biliary tract disease, in free living urban population in Kashmir. A randomly drawn sample of 1695 subjects aged 15 years or above was interviewed by a questionnaire. Twenty six had previous cholecystectomies, all for gall stones. Ultrasonography was carried out on 1104 (65.1%). The responder rates for ultrasonography in men (64.3%) and in women (66.0%) were similar (p greater than 0.2). Gall stones were detected in 49 adults. Three of these had previous biliary symptoms. The prevalence of gall stones in adult population was 6.12% (men 3.07% and women 9.6%). The prevalence of gall stones rose with age in both sexes to a peak in the sixth decade prevalence of gall stones was significantly higher in age adjusted parous women than in nullipara. There was no correlation with obesity, diet, or socioeconomic status. Five subjects had sonographic appearances of the worm Ascaris lumbricodis in the bile ducts: and had previous biliary symptoms.