Dieulafoy's lesion: a rare cause of massive upper gastrointestinal haemorrhage

Out of 900 cases of Upper Gastrointestinal haemorrhage seen during 1985-1989, 6 (0.67%) cases had Dieulafoy's lesion as the causative factor. All patients presented with massive upper gastrointestinal haemorrhage. The mean age of the patients was 46.3 year (32-60 yrs) and 4 were males and 2 females. No consistent associated medical factors could be identified. The diagnosis was established by emergency endoscopy which showed an active arterial spurter in 4 patients and located the bleeding site to be close to the fundus in other 2 patients. Injection sclerotherapy tried in 3 patients was not successful. Four patients had bleeding lesion along the greater curvature close to the fundus and two had on posterior wall but all within 6 cm. of gastroesophageal junction. All patients underwent curative emergency surgery with wedge resection of the lesion. We conclude that Dieulafoy lesion should be suspected in a patient with massive, recurrent and obscure upper gastrointestinal bleeding. Emergency endoscopy for diagnosis and prompt surgical intervention can cure the lesion which is potentially fatal if untreated.

Pneumatic dilatation is a satisfactory first-line treatment for achalasia

The results of 124 pneumatic dilatations done in 92 patients with achalasia cardia were assessed. Relief of dysphagia and other symptoms was obtained in 90 (97.8%) patients--in 68 (73.9%) after one dilatation, in 16 (17.8%) after two dilatations and in six (6.5%) after three dilatations. Two patients who did not obtain relief after three sittings of dilatation underwent surgery and both became totally asymptomatic thereafter. Most of the patients successfully treated with pneumatic dilatation remained asymptomatic during a follow up of 6 months--5 years. The few who did become symptomatic (8.01%) within a year after pneumatic dilatation responded well to the same procedure when repeated. Immediate and late complications of pneumatic dilatation occurred in 3.3% and 4.35% of patients respectively and were all medically manageable. In our assessment, pneumatic dilatation is a simple, quick, safe and effective method for treating achalasia. It should be used as the primary mode of treatment and surgery should be offered only to those patients who fail to respond to at least three attempts at pneumatic dilatation.

Management of retained common bile duct stones in patients with T-tube in situ: role of endoscopic sphincterotomy

Retained common bile duct stones in postcholecystectomy patients who have a T-tube in situ should be treated, preferably, by nonoperative means. Thus, we treated seven such patients with common bile duct perfusion (through T-tube) of methyl tertiary butyl ether, and 10 patients with perfusion of monooctanoin. However, successful dissolution was achieved in only one and three patients, respectively. Hence, endoscopic sphincterotomy (ES) was performed in the patients in whom solvent perfusion had failed, and in other subsequent patients with T-tube in situ. Of 28 patients thus treated, bile duct clearance could be achieved in 27 (96.5%) patients; minor bleeding occurred in only three patients. After sphincterotomy, the stones passed out spontaneously in 20 patients while the T-tube was still in situ, but in two patients, only after the T-tube was removed. Similarly, basketing of the stones could be done in four patients with the T-tube in position, but in one patient whose ductal stones were above the T-tube, the tube had to be removed to make basketing successful. Endoscopic sphincterotomy is an efficient method of treating retained common bile duct stones in patients with T-tube in situ. However, in those patients whose ductal stones are above or astride the T-tube, the T-tube may have to be removed to attain bile duct clearance.

Zollinger Ellison syndrome

ZES is an uncommon disease with clinical manifestations akin to patients with peptic ulcer. Marked gastric acid hypersecretion can be checked but cause of death in the patients is usually metastasis. An early diagnosis and hence a possible surgical cure is very important and one must have high index of suspicion for diagnosis. As many as 50% of patients may have non diagnostic serum gastrin levels and hence need provocative tests to establish the diagnosis. Hypersecretion of acid should be controlled by antisecreting drugs followed by tumor localization with contrast CT, selective angiography and portal venous sampling for gastrin levels in doubtful cases. In MEN-I and metastatic patient, major surgery should be avoided. All pancreatic and extra pancreatic tumors should be resected if there is no metastasis.

Endoscopic polypectomies in upper gastrointestinal tract

Nine polyps retrieved from the upper gastrointestinal tract by endoscopic polypectomy in nine patients are reported. Polyps were removed from the distal esophagus (1), stomach (7) and duodenum (1). Dysphagia, obstructive jaundice and upper gastrointestinal bleeding were the presenting features in four patients. In five patients gastric polyps were detected incidentally at endoscopy. Of the nine polyps, six were adenomas, two were hyperplastic polyps and one in the esophagus was inflammatory. All the polyps could be retrieved completely and there were no complications. Thus polyps do occur in the upper gastrointestinal tract in India; their electrosurgical removal is easy and safe and allows histopathological examination of the entire polyp.

Paroxysmal nocturnal hemoglobinuria with hepatic vein thrombosis presenting as hepatic encephalopathy

We present a patient with paroxysmal nocturnal hemoglobinuria with diffuse hepatic central vein thrombosis who presented with encephalopathy and recovered from the hepatic manifestations with antihepatic coma measures alone.

The effect of various anaesthetics on the spatial tuning of two major wave peaks in the transient pattern electroretinogram of the cat: evidence for pattern and luminance components

The main PERG component of the transient contrast reversal pattern electroretinogram (PERG) in cats was a negative wave (3.5 microV average, SD 1.7 microV) peaking at about 130 msec (N130) with a spatial resolution above 5.5 c/deg, close to behavioural estimates. The early positivity (P35) was more variable, smaller and had lower spatial resolution. Different anaesthetic protocols affected both the waveform and the amplitude by spatial frequency functions. Responses of urethane anaesthetised cats were like those reported previously for decerebrate cats or cats paralysed and ventilated with N2O/O2/CO2 (75%/24%/1%). P35 was evoked only by coarse stimuli and N130 amplitude decreased linearly as spatial frequency increased. When the luminance response amplitude, predicted from the optical transfer function of the eye, was subtracted, spatial tuning appeared. An anaesthetic mixture of ketamine hydrochloride and xylazine depressed both P35 and N130 at low spatial frequencies while enhancing them at high frequencies. In paralysed animals ventilated with N2O/O2 (67%/33%) P35 was larger and recordable to 1.6 c/deg. Peak times were reduced and the inter-peak time halved. Other anaesthetics depressed the ERGs. These effects suggest that cats are a good model for studying N130 in isolation or its interaction with P35 and that both PERG peaks include luminance and pattern components.

Urethane as a sole general anaesthetic in cats used for electroretinogram studies

Cats are very sensitive to induction of anaesthesia by urethane. To anaesthetize cats with urethane, 1.0-1.3 g/kg, of freshly prepared urethane is administered intravenously at a rate of 1.92 g/h, while anaesthesia is maintained with 0.5% halothane in a 66%/33% nitrous oxide/carbogen gas mixture. Cats can then be maintained for up to 3 days by intravenous infusion at a rate of 4 ml/h of a 100 ml solution containing 50 IU heparin, 2.4 mg atropine, 4.7 g anhydrous D-glucose, and 240 mg urethane/kg. Using this anaesthetic, excellent electroretinograms can be recorded with no interfering eye movements.

Endoscopic sclerotherapy for portal hypertension due to extrahepatic obstruction: long-term follow-up

Between 1982 and 1987, 43 patients with variceal bleeding due to extrahepatic portal obstruction were treated by repeated endoscopic injection sclerotherapy using 1% polidocanol intravariceally. This decreased rebleeding, as evidenced by a decrease in bleeding risk factor (BRF), mean transfusion requirement, and mean number of transfusions per patient per month of follow-up. Differences between pre- and postsclerotherapy parameters were significant (p less than 0.001). The varices were eradicated in 86% of patients. The mean sclerotherapy sessions required were 7.68 +/- 2.39 (SD). Complications were infrequent. Forty-three patients were followed from 5 to 68 months: cumulative survival was 97.7% and varices recurred in 16%. Sclerotherapy avoided a second operation in 21 postsurgical patients. Sclerotherapy for managing variceal bleeding due to extrahepatic portal obstruction is a reasonable alternative to surgery.

Effect of incorporation of isabgol husk in a low fibre diet on faecal excretion and serum levels of lipids in adolescent girls

The effect of consumption of isabgol husk for 3 weeks on faecal excretion and serum levels of lipids was investigated in 11 adolescent girls. The consumption of isabgol husk lowered serum lipids and increased faecal fat.

Gastrointestinal tract infection in immunocompromised hosts

The recent regognition of AIDS has stimulated the development of newer cytotoxic therapies and hematological support system which have prolonged the life of these immunocompromised subjects. Moreover, greater number of patients are being recognised who are susceptible to various opportunistic infections involving the GI tract. In view of the poor anti-inflammatory response and minimal signs and symptoms of infection, the diagnosis of these organisms is often difficult. Hence a proper knowledge of the predisposing conditions and meticulous attention to minor symptoms and thorough physical examination alone can lead to an early diagnosis of infection. The common infectious agents include cryptosporiodium, herps virus cytomegalovirus and Giardia. Since, a satisfactory treatment is not available for many of these pathogens, attention should be paid to preventive measures while injudicious use of broadspectrum antibiotics must be checked to prevent superinfections.

Massive lower gastrointestinal bleeding as a presenting feature of Behcet's disease

This reports a 27 yr old female Patient with seronegative polyarthritis who presented with lower GI bleeding and subsequently developed evidence of cutaneous vasculitis (palpable purpura) and orogenital ulcers. The cause of the GI bleeding was multiple ulcerations in the terminal ileum, cecum ascending colon and transverse colon. Continued and massive bleeding necessitated surgical resection of the involved segment of gut which on histopathological examination confirmed the presence of vasculities. This patient was thus diagnosed as having Behcet's disease. Although major GI bleeding is a rare manifestation of Behcet's disease with vasculitis of the gut, one must consider this possibility if the patient has multi-system involvement with evidence of vasculitis involving the skin in the form of palpable purpura.