Efficacy of Ropivacaine for Sub-Arachnoid Block in Patients with Recent History of Scorpion Sting: A case series.

Failure of sub-arachnoid block (SAB), due to resistance to bupivacaine after a recent scorpion sting can lead to multiple block attempts and subsequent conversion to general anaesthesia. We report this case series of 10 patients with successful SAB with newly launched 0.75% hyperbaric ropivacaine, in patients with recent scorpion sting. Thus, intrathecal hyperbaric ropivacaine may be considered as the local anaesthetic agent of choice in patients with scorpion sting to prevent failure of SAB.

Efficacy of intertruncal and corner-pocket approaches of ultrasound-guided supraclavicular block in terms of ulnar nerve blockade: A randomised controlled study.

Background and Aims: The incidence of ulnar nerve sparing has declined with the corner-pocket approach of the supraclavicular block (SCB), however, it continues to persist. A recent technique of SCB, the intertruncal approach, separately blocks each trunk of the brachial plexus. Thus, we hypothesised that the intertruncal approach results in a complete ulnar nerve blockade. Methods: Eighty-eight patients were randomised to undergo SCB using an ultrasound (USG)-guided corner-pocket or intertruncal approach and were compared primarily regarding the complete sensory and motor blockade of the ulnar nerve and all four nerves (ulnar, radial, median and musculocutaneous nerves) at 15 min. Secondary objectives included time required for block performance, patient discomfort score, time to readiness for surgery and duration of sensory blockade of the ulnar nerve. Continous data were compared using an independent t-test, and categorical data were compared using the Chi-square test. Results: The proportion of participants with complete sensory (30/44 vs. 14/44, P < 0.001) and complete motor (22/44 vs. 7/44, P < 0.001) blocks in the ulnar nerve and all four nerves at 15 min was significantly higher in the intertruncal group. Block performance time and patient discomfort score were higher in the intertruncal group (P < 0.001). The total duration of sensory blockade in the ulnar nerve was more in the corner-pocket group (P < 0.001). Conclusion: USG-guided intertruncal approach is superior to the corner-pocket approach of SCB regarding a complete ulnar nerve blockade.

Celiac Disease and Portal Hypertension: A Causal Association or Just a Coincidence?

INTRODUCTION: Celiac disease (CD) has been linked to portal hypertension (PHT) of varied etiology, but the causality association has never been proved. We aim to study the prevalence of CD in patients of PHT of different etiology. METHODS: A prospective observational study was conducted from June 2017 to December 2018 involving all the cases of PHT of varied etiology. Consecutive patients of PHT with chronic liver disease (CLD) of defined etiology like ethanol, viral hepatitis (B or C), Budd-Chiari syndrome (BCS), autoimmune-related cirrhosis, and cryptogenic CLD (cCLD) (group A) and those with noncirrhotic PHT (NCPHT), which included noncirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO) (group B), were screened for CD by IgA anti-tTG antibody followed by duodenal biopsy in serology-positive patients. RESULTS: Out of a total of 464 patients, group A constituted 382 patients, CLD related to ethanol (155), cCLD (147), hepatitis B (42), hepatitis C (21), autoimmune (10), and BCS (7), whereas 82 patients were in group B with NCPF (64) and EHPVO (18). Total 29 patients were diagnosed with CD in both groups, 17 in group A (4.5%) and 12 in group B (14.6%). In group A, 13 patients with cCLD, two with HBV-related CLD, one with BCS, and one with autoimmune-related CLD were concomitantly diagnosed as CD. In group B, CD was diagnosed in 12 patients of NCPF (11) and EHPVO (1). Liver histology showed chronic hepatitis in two patients and was normal in three patients. CONCLUSION: CD is common in PHT of different etiology, especially in cCLD, NCPH and autoimmune hepatitis; however, the etiological basis for this association is still to be defined. The likelihood of CD is higher in liver disease than the general population, and these patients should be screened for CD.

Acute-on-Chronic Liver Failure: Etiology of Chronic and Acute Precipitating Factors and Their Effect on Mortality.

BACKGROUND: The present study is planned to assess etiologies, course, and outcome in patients with acute-on-chronic liver failure (ACLF). METHODS: Two hundred and eight (182 males and 26 females) patients of ACLF fulfilling modified Asia Pacific Association For Study Of Liver Consensus criteria 2009 admitted to the gastroenterology department of SMS Medical College and hospital, Jaipur, between October 2015 and December 2017 were included. We evaluated etiology of underlying chronic disease and the acute event precipitating decompensation in ACLF. RESULTS: Most common etiology of chronic liver disease (CLD) was alcohol with 133 (63.94 %) patients. Viral hepatitis, cryptogenic cirrhosis, autoimmunity, nonalcoholic steatohepatitis, and Wilson disease as causes of CLD were present in 32 (15.4%), 29 (13.94%), 9 (4.3%), 3 (1.4%), and 2 (1%) cases, respectively. Alcohol, sepsis, bleeding, reactivation of hepatitis B, hepatitis E, antitubercular drugs, and autoimmune hepatitis as the causes of acute event were present in 100 (48.08%), 34 (16.35%), 19 (9.1%), 17 (8.2 %), 15 (7.2%), 13 (6.25%), and 2 (0.96%) patients, respectively. In 8 (3.85%) patients, the precipitating event could not be known. Mortality (in-hospital) in this study was 37.5%. Higher model for end-stage liver disease score and high Child-Turcotte-Pugh score score were significantly associated with mortality (P <0.001). Patients with higher ACLF grade were associated with higher mortality. Alcohol as a cause of CLD was significantly associated with mortality (p=0.0146, 95% confidence interval between 3.802 and 30.979). There was no significant difference regarding acute precipitating events between survivors and nonsurvivors. CONCLUSIONS: Alcohol was the most common cause for chronic etiology as well as acute precipitating event. Alcohol as a cause of CLD was significantly associated with mortality.

Pancreato-biliary Endoscopic Ultrasound in Opium Addicts Presenting with Abdominal Pain.

OBJECTIVE: Asymptomatic dilatation of bile duct and symptomatic sphincter of Oddi dysfunction have been reported in opium addicts. Except one case report, there is no report in the literature on endoscopic ultrasound (EUS) study of pancreato-biliary system in opium addicts. The aim of the present study was to report the EUS features of pancreato-biliary system in opium addicts presenting with abdominal pain. PATIENTS AND METHODS: A total of 15 opium addicts presenting with upper abdominal pain and dilated common bile duct (CBD) and or pancreatic duct (PD) on abdominal ultrasound were included in this study. EUS findings of pancreato-biliary system were analyzed in these patients. RESULTS: All the 15 patients were males (mean age 53.3 years) presented with upper abdominal pain. Mean duration of opium addiction was 20.1 years. On EUS CBD was dilated in all the patients while PD was dilated in six patients. Gall bladder, liver and pancreatic parenchyma was normal in all these patients. Surface area of papilla of Vater (SPV) was increased in 12 patients. CONCLUSION: Opium addiction causes obstruction at ampulla and produces dilatation of bile duct and PD. Bile duct dilatation was seen in all the patients while PD dilatation was seen in few patients. Increase in SPV was a peculiar finding and appears to be as a result of direct effect of opium on ampulla.