Biliary sphincteroplasty facilitates retrieval of proximally migrated plastic biliary stent.

BACKGROUND AND AIM: Proximal migration of biliary stents presents a technical challenge for the therapeutic endoscopist. It may require multiple, complicated corrective procedures resulting in significant morbidity to the patients. In this study we evaluated the utility of balloon biliary sphincteroplasty with CRE (Controlled Radial Expansion) Balloon Dilator on retrieval of proximally migrated biliary stents. METHODS: We identified patients from our ERCP database who presented with proximal migration of biliary stent, between August 2011 and October 2013. Patients in whom the stent could not be retrieved with conventional methods, balloon sphincteroplasty was performed with a 12 mm CRETM Balloon Dilator (Boston Scientific). Stent removal was attempted with extraction balloon or basket thereafter. RESULTS: We identified 28 patients with proximal migration of biliary stents, placed for benign diseases of the common bile duct. Stent removal was successful in 18 patients (64.28%) with help of an extraction balloon or basket. Of the remaining 10 patients, balloon sphincteroplasty was successfully followed by stent removal in eight patients. CONCLUSIONS: Balloon biliary sphincteroplasty increases the success rate of retrieving proximally migrated biliary stents. The procedure is safe, technically easy and yields a good success rate in our experience.

Diastolic dysfunction characterizes cirrhotic cardiomyopathy.

AIM: Present study aims to study the occurrence of cirrhotic cardiomyopathy and its correlation to hepatorenal syndrome by assessing the cardiac status in patients with cirrhosis of liver and healthy controls. METHODS: Thirty alcoholic cirrhotic, thirty non-alcoholic cirrhotic and thirty controls were enrolled for the study. Cardiac parameters were assessed by color doppler echocardiography. Patients were followed up for twelve months period for development of hepatorenal syndrome. RESULTS: Mild diastolic dysfunction was present in 18 cirrhotic patients (30%): grade I in fifteen patients and grade II in three. Diastolic dysfunction was unrelated to age; sex and etiology of cirrhosis. Among all the echocardiographic parameters, only deceleration time was found to be statistically significant. Echocardiographic parameters in systolic and diastolic function were not different in compensated vs decompensated patients in different Child-Pugh classes or cirrhosis aetiologies. At one year follow-up, no significant differences were found in survival between patients with or without diastolic dysfunction. Hepatorenal syndrome developed in only two patients and its correlation with diastolic dysfunction was not statistically significant. CONCLUSIONS: Present study shows that although diastolic dysfunction is a frequent event in cirrhosis, it is usually of mild degree and does not correlate with severity of liver dysfunction. There are no significant differences in echocardiographic parameters between alcoholic and non-alcoholic cirrhosis. HRS is not correlated to diastolic dysfunction in cirrhotic patients. There is no difference in survival at one year between patients with or without diastolic dysfunction. Diastolic dysfunction in cirrhosis is unrelated to circulatory dysfunction, ascites and HRS.

Esophageal tuberculosis presenting with hematemesis.

Esophageal tuberculosis is rare, constituting about 0.3% of gastrointestinal tuberculosis. It presents commonly with dysphagia, cough, chest pain in addition to fever and weight loss. Complications may include hemorrhage from the lesion, development of arterioesophageal fistula, esophagocutaneous fistula or tracheoesophageal fistula. There are very few reports of esophageal tuberculosis presenting with hematemesis due to ulceration. We report a patient with hematemesis that was due to the erosion of tuberculous subcarinal lymph nodes into the esophagus. A 15-year-old boy presented with hemetemesis as his only complaint. Esophagogastroduodenoscopy (EGD) revealed an eccentric ulcerative lesion involving 50% of circumference of the esophagus. Biopsy showed caseating epitheloid granulomas with lymphocytic infiltrates suggestive of tuberculosis. Computerised tomography of the thorax revealed thickening of the mid-esophagus with enlarged mediastinal lymph nodes in the subcarinal region compressing the esophagus along with moderate right sided pleural effusion. Patient was treated with anti-tuberculosis therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for 6 mo. Repeat EGD showed scarring and mucosal tags with complete resolution of the esophageal ulcer.

Uncomplicated spontaneous rupture of pancreatic pseudocyst into stomach: A case report.

Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography (CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.