Etiological and Endoscopic Profile of Middle Aged and Elderly Patients with Upper Gastrointestinal Bleeding in a Tertiary Care Hospital in North India: A Retrospective Analysis.

BACKGROUND: Upper gastrointestinal (GI) bleeding is a common medical emergency associated with significant morbidity and mortality. The clinical presentation depends on the amount and location of hemorrhage and the endoscopic profile varies according to different etiology. At present, there are limited epidemiological data on upper GI bleed and associated mortality from India, especially in the middle and elderly age group, which has a higher incidence and mortality from this disease. AIM: This study aims to study the clinical and endoscopic profile of middle aged and elderly patients suffering from upper GI bleed to know the etiology of the disease and outcome of the intervention. MATERIALS AND METHODS: Out of a total of 1790 patients who presented to the hospital from May 2015 to August 2017 with upper GI bleed, and underwent upper GI endoscopy, data of 1270 patients, aged 40 years and above, was compiled and analyzed retrospectively. RESULTS: All the patients included in the study were above 40 years of age. Majority of the patients were males, with a male to female ratio of 1.6:1. The most common causes of upper GI bleed in these patients were portal hypertension-related (esophageal, gastric and duodenal varices, portal hypertensive gastropathy, and gastric antral vascular ectasia GAVE), seen in 53.62% of patients, followed by peptic ulcer disease (gastric and duodenal ulcers) seen in 17.56% of patients. Gastric erosions/gastritis accounted for 15.20%, and duodenal erosions were seen in 5.8% of upper GI bleeds. The in-hospital mortality rate in our study population was 5.83%. CONCLUSION: The present study reported portal hypertension as the most common cause of upper GI bleeding, while the most common endoscopic lesions reported were esophageal varices, followed by gastric erosion/gastritis, and duodenal ulcer.

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.

Endoscopic management of pancreatic pseudocysts at atypical locations.

BACKGROUND AND AIMS: There is paucity of data on endoscopic management of pseudocysts at atypical locations. We evaluated the efficacy of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of pseudocysts of pancreas at atypical locations. PATIENTS AND METHODS: Eleven patients with pseudocysts at atypical locations were treated with attempted endoscopic transpapillary nasopancreatic drainage. On endoscopic retrograde pancreatography (ERP), a 5-F NPD was placed across/near the site of duct disruption. RESULTS: Three patients each had mediastinal, intrahepatic, and intra/perisplenic pseudocysts and one patient each had renal and pelvic pseudocyst. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. The size of the pseudocysts ranged from 2 to 15 cm. On ERP, the site of ductal disruption was in the body of pancreas in five patients (45.4%), and tail of pancreas in six patients (54.6%). All the patients had partial disruption of pancreatic duct. The NPD was successfully placed across the disruption in 10 of the 11 patients (90.9%) and pseudocysts resolved in 4-8 weeks. One of the patients developed fever, 5 days after the procedure, which was successfully treated by intravenous antibiotics. In another patient, NPD became blocked 12 days after the procedure and was successfully opened by aspiration. The NPD slipped out in one of the patient with splenic pseudocyst and was replaced with a stent. There was no recurrence of symptoms or pseudocysts during follow-up of 3-70 months. CONCLUSION: Pancreatic pseudocysts at atypical locations with ductal communication and partial ductal disruption that is bridged by NPD can also be effectively treated with endoscopic transpapillary NPD placement.

An intra-hepatic pancreatic pseudocyst successfully treated endoscopic transpapillary drainage alone.

CONTEXT: An intra-hepatic pseudocyst is a very rare complication of acute and chronic pancreatitis with less than thirty cases described in the literature. Successful resolution of intra-hepatic pseudocysts with endoscopic transpapillary nasopancreatic drain placement has not previously been described. CASE REPORT: We report the case of a 34-year-old male with chronic idiopathic non-calcific pancreatitis, anomalous pancreatobiliary junction and a large intra-hepatic pancreatic pseudocyst along with a large abdominal pseudocyst who was successfully treated by endoscopic transpapillary nasopancreatic drainage alone. CONCLUSION: Pancreatic pseudocysts can present as intra-hepatic cystic lesions and communicating intra-hepatic pseudocysts can be successfully treated by endoscopic transpapillary nasopancreatic drainage alone.

Successful resolution of a mediastinal pseudocyst and pancreatic pleural effusion by endoscopic nasopancreatic drainage.

CONTEXT: A mediastinal pseudocyst is an unusual complication of acute and chronic pancreatitis. The ideal form of management is controversial, and various successful therapeutic interventions including surgical resection, internal or external drainage, and non-operative radiological drainage techniques have been described. Successful resolution of a mediastinal pseudocyst with endoscopic transpapillary stent placement has been described in fewer than five cases. CASE REPORT: We report a case of chronic pancreatitis with complete pancreas divisum together with a mediastinal pseudocyst and pancreatic pleural effusion in which magnetic resonance imaging and endoscopic retrograde pancreatography demonstrated communication of the abdominal pseudocyst with the posterior mediastinum through the diaphragmatic hiatus. This case was successfully treated with endoscopic transpapillary nasopancreatic drain placement alone. CONCLUSION: A communicating mediastinal pseudocyst can be successfully treated by endoscopic transpapillary nasopancreatic drainage alone.