Colorectal tuberculosis

Our objective was to evaluate the incidence of colorectal tuberculosis in our series and to study its radiological spectrum. A total of 684 cases of proven gastrointestinal tuberculosis with positive barium contrast findings seen over a period of more than one decade were evaluated. The study did not include cases where colon was involved in direct contiguity with ileo-caecal tuberculosis. Seventy-four patients (10.8%) had colorectal tuberculosis. Commonest site involved was transverse colon, closely followed by rectum and ascending colon. Radiological findings observed were in the form of strictures (54%), colitis (39%) and polypoid lesions (7%). Complications noted were in the form of perforations and fistulae in 18.9% of cases. Colorectal tuberculosis is a very common site for gastrointestinal tuberculosis. Typical findings of colorectal tuberculosis are strictures, signs of colitis and polypoid lesions. Common complications are perforation and fistulae.

Imaging of esophageal tuberculosis: a review of 23 cases

PURPOSE

To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

MATERIAL AND METHODS

The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

RESULTS

Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Perforations and fistulae in gastrointestinal tuberculosis

BACKGROUND

Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies.

MATERIAL AND METHODS

A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae.

RESULTS

Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression.

CONCLUSION

Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.

Celiac disease presenting as iron-deficiency anemia in northern India

BACKGROUND

Adult celiac disease is infrequent in India. Iron-deficiency anemia as its presenting manifestation is still rarer.

METHODS

We investigated patients with refractory iron-deficiency anemia attending the hematology clinic of a tertiary-care hospital for celiac disease. The diagnosis of celiac disease was based on histology, serology and response to treatment.

RESULTS

Of 19 patients with refractory iron-deficiency anemia seen from April 1998 to March 2000, 11 were diagnosed to have celiac disease. Four of these had abnormal D-xylose test and 3 had fat malabsorption. All 11 patients responded to gluten-free diet with improvement in hematological parameters.

CONCLUSION

Patients with refractory iron-deficiency anemia of unknown cause should be investigated for subclinical celiac disease.

Lactose intolerance in different types of irritable bowel syndrome in north Indians

BACKGROUND

Twenty-five patients of irritable bowel syndrome (IBS) and 25 normal healthy individuals serving as controls, were studied for lactose intolerance.

METHODS

Hydrogen breath test was used as an investigation after giving 50 g of oral lactose. Clinically, the patients were classified into 3 types of IBS.

RESULTS

Eleven (44%) out of 25 patients belonged to diarrhoeal type of IBS, 7 (28%) of 25 patients to spastic and rest 7 (28%) of 25 patients had features of both types of symptoms. Lactose hydrogen breath test was abnormal in 9 cases (82%) of 11 diarrhoeal type of IBS which was significantly higher (p < 0.02) than controls. However, the difference of abnormal hydrogen breath test between spastic type of IBS and patients with features of both types was not significant as compared to controls.

CONCLUSIONS

These results suggest that patients with diarrhoeal type of IBS have a higher incidence of lactose intolerance as compared to spastic type as well as patients with features of both types.

Primary small bowel tumors: a radiologic-pathologic correlation

BACKGROUND

Primary small bowel tumors are rare and their preoperative diagnosis is unsatisfactory. The cornerstone of diagnosis remains contrast radiography. The present study was done to evaluate the radiologic findings of primary small bowel tumors as shown on enteroclysis and to correlate these observations with surgical and histopathologic findings.

METHODS

Seventy two patients with primary small bowel tumors identified by enteroclysis were evaluated. All the patients were subjected to jejunal biopsy or surgery. The diagnosis was established by histopathologic examination in all cases.

RESULTS

Radiologic findings were suggestive of benign tumors in 19 patients and malignant tumors in 31 patients. Nonspecific findings in the form of diffuse involvement of the small bowel were noted in 22 patients. There was 100% radiologic-surgical correlation. Leiomyomas and lymphomas were the most common benign and malignant tumors, respectively. Tumor specificities were 89.5% for benign tumors and 41.5% for malignant tumors.

CONCLUSION

Distinctive morphologic patterns as shown on enteroclysis are highly suggestive of specific tumor types in the majority of cases.

Isolated gastric tuberculosis presenting as massive hematemesis: report of a case

Tuberculous involvement of the stomach is rare. We report herein the unusual case of a 25-year-old man in whom a benign gastric ulcer was found along the lesser curvature after he presented with massive upper gastrointestinal bleeding. Histopathological examination helped to confirm a diagnosis of tuberculosis. The granulomas typical of tuberculosis were caseation with epithelioid and giant cells. The patient was successfully treated by a combination of appropriate surgical therapy and prompt institution of antituberculosis medication.

Cholangiopathy in extrahepatic portal venous obstruction. Radiological appearances

PURPOSE

To evaluate cholangiographic abnormalities resulting from extrahepatic portal venous obstruction (EHPVO) by sonography and endoscopic retrograde cholangiopancreaticography (ERCP).

MATERIAL AND METHODS

Forty-three patients with an established diagnosis of EHPVO were subjected to duplex Doppler sonography and ERCP. Of these, 8 patients had obstructive jaundice.

RESULTS

Dilated common bile duct with pericholedochal varices showing a continuous type of flow pattern was seen in 5 EHPVO patients with obstructive jaundice. ERCP revealed cholangiographic abnormalities in 40 patients (93%). Extrahepatic bile ducts were involved in 100% of cases compared to intrahepatic bile ducts (57%). Abnormalities noted were contour irregularity with indentations, displacement and angulation, strictures and filling defects in the extrahepatic ductal system. Intrahepatic bile ducts showed dilatation with areas of narrowing and filling defects.

CONCLUSION

Cholangiographic abnormalities are very common in patients with EHPVO, even without clinical manifestations of biliary disease. Extrahepatic bile ducts are far more often involved compared to intrahepatic bile ducts. Extrinsic compression with contour irregularity is the most common cholangiographic finding. Sonographic findings are not diagnostic. Dilated common bile duct with pericholedochal varices was seen in only 5 patients.

Clostridium difficile toxin and faecal lactoferrin assays in adult patients

Clostridium difficile is the primary aetiological agent of antibiotic-associated diarrhoea. The faecal lactoferrin (FL) assay is a simple in vitro test which is highly sensitive to the presence of a marker of polymorphonuclear cells. We evaluated the use of the FL assay in conjunction with the C. difficile toxin assay in faecal samples obtained from 231 adult patients. The relationship between C. difficile toxin and FL in both negative and positive status was highly significant statistically (P < 0.001). Therefore, the FL assay performed simultaneously with the C. difficile toxin assay can help rule out asymptomatic carriage of C. difficile.

Cholangiopathy in extrahepatic portal venous obstruction. Radiological appearances

PURPOSE

To evaluate cholangiographic abnormalities resulting from extrahepatic portal venous obstruction (EHPVO) by sonography and endoscopic retrograde cholangiopancreaticography (ERCP).

MATERIAL AND METHODS

Forty-three patients with an established diagnosis of EHPVO were subjected to duplex Doppler sonography and ERCP. Of these, 8 patients had obstructive jaundice.

RESULTS

Dilated common bile duct with pericholedochal varices showing a continuous type of flow pattern was seen in 5 EHPVO patients with obstructive jaundice. ERCP revealed cholangiographic abnormalities in 40 patients (93%). Extrahepatic bile ducts were involved in 100% of cases compared to intrahepatic bile ducts (57%). Abnormalities noted were contour irregularity with indentations, displacement and angulation, strictures and filling defects in the extrahepatic ductal system. Intrahepatic bile ducts showed dilatation with areas of narrowing and filling defects.

CONCLUSION

Cholangiographic abnormalities are very common in patients with EHPVO, even without clinical manifestations of biliary disease. Extrahepatic bile ducts are far more often involved compared to intrahepatic bile ducts. Extrinsic compression with contour irregularity is the most common cholangiographic finding. Sonographic findings are not diagnostic. Dilated common bile duct with pericholedochal varices was seen in only 5 patients.

Paterson-Kelly syndrome and celiac disease--a rare combination

Paterson-Kelly syndrome is characterized by an association of iron deficiency with dysphagia. We describe a patient with this syndrome who was later diagnosed to have celiac disease.

Intestinal pseudo-obstruction due to neurofibromatosis responding to cisapride

Gastrointestinal involvement in neurofibromatosis presenting with mechanical obstruction, hemorrhage or intussusception is known. Small bowel dysmotility and intestinal pseudo-obstruction due to neurofibromatosis is rare. A 23-year-old man with classical neurofibromatosis presented with intermittent episodes of intestinal pseudo-obstruction, small bowel bacterial overgrowth and steatorrhea. The patient had good symptomatic improvement with cisapride.

Concurrent renal transitional cell carcinoma and right colon cancer

A 45-year-old man who had undergone right radical nephrectomy for transitional cell carcinoma 3 months earlier was admitted with right colonic tumor. Review of CT done for right kidney tumor was suggestive of right colon pathology. Right hemicolectomy was performed, followed by a course of chemotherapy for mucinous adenocarcinoma, and he is well a year later.

Teratocarcinoma presenting with duodenal metastases diagnosed on endoscopic fine needle aspiration

Upper gastrointestinal bleed as the first symptom of metastatic testicular tumors is rare. We describe a 17-year-old man who presented with upper gastrointestinal bleed; endoscopic fine needle aspiration cytology from a duodenal mass suggested germ cell tumor, which was later confirmed on histology of the testis.

Pregnancy and its outcome in patients with noncirrhotic portal hypertension

There is paucity of data in the literature on the occurrence of pregnancy and its outcome in patients with noncirrhotic portal hypertension. The present study was undertaken to assess the fertility pattern, fetal loss, and consequences of variceal bleeding during pregnancy in these patients. Fifty-five women of child-bearing age with a diagnosis of noncirrhotic portal hypertension (including 32 with noncirrhotic portal fibrosis and 23 with extrahepatic portal venous obstruction) and 44 age-matched controls were studied. A detailed history of obstetric events and bleeding episodes was recorded in all patients. Any complication of portal hypertension was managed accordingly. Patients were classified into three groups for analysis: group 1-obstetric events after the diagnosis of portal hypertension in patients; group II-obstetric events before the diagnosis of portal hypertension in patients; and group III-obstetric events in controls. A total of 116 pregnancies took place in 44 patients. Of these, 36 occurred after and 80 before the diagnosis of portal hypertension was made. In the 44 controls, 118 pregnancies took place. The mean fertility rates of groups I, II and III were 0.20+/-0.24, 0.18+/-0.21, and 0.22+/-0.12 pregnancies per year, respectively, which were not statistically different (P>0.05). The numbers of fetal losses in groups I, II and III were 3/36 (8.3%), 6/80 (7.5%), and 12/118 (10.17%) pregnancies, respectively. Menstrual irregularities were found in 7/55 (12.72%) patients and 6/44 (13.6%) controls (P>0.05). Five episodes of variceal bleeding occurred in 36 pregnancies after the diagnosis of portal hypertension (13.88%). All five were successfully managed with endoscopic sclerotherapy. In conclusion, noncirrhotic portal hypertensive patients have normal fertility and outcome of pregnancy. Variceal bleeding episodes are not common and endoscopic sclerotherapy is safe and effective in pregnancy.

Fine needle aspiration biopsy of the spleen in pyrexia of unknown origin

To evaluate the diagnostic utility, value and potential risk of fine needle aspiration biopsy of spleen (sFNAB) in patients with splenomegaly in pyrexia of unknown origin (PUO), a retrospective analysis of medical records and cytological material of 31 patients on whom FNAB was performed between April 1994 and October 1997 was done. The patients were HIV- and presented with PUO. All other relevant investigations were negative. The spleen was either palpable or detected to have space-occupying lesions on ultrasonography (USG). The splenic aspirates showed tuberculosis in 11 patients (35.4%) and inconclusive or reactive changes in nine patients (25.8%). One case out of this group proved to be Kaposi's sarcoma on autopsy. The other diseases encountered were leishmaniasis (n = 3), non-Hodgkin's lymphoma (n = 4), fungal infections (n = 2), Hodgkin's lymphoma (n = 1). The patients who were diagnosed as having tuberculosis had epithelioid cells, giant cells, necrosis and inflammatory cells in various combinations. AFB positivity was 63.6%. The other cases which showed granulomas but no AFB were diagnosed on empirical grounds and all responded to the anti-tuberculosis therapy. No complications were encountered with the procedure. Therefore the authors conclude that sFNAB is rewarding in patients where all other non-invasive modalities of diagnosis have failed.

Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension

Rectal bleeding due to radiation proctosigmoiditis is often difficult to manage. We had earlier shown the efficacy of short-term therapy with topical sucralfate in controlling bleeding in the radiation proctosigmoiditis. We now report our long-term results with this form of therapy. The study comprised 26 patients with radiation proctosigmoiditis. Sigmoidoscopically, 9 (34.6%) patients had severe changes, 15 (57.69%) had moderate, and 2 (7.69%) had mild changes. Severity of bleeding was graded as severe (> 15 episodes per week), moderate (8-14 episodes per week), mild (2-7 episodes per week), negligible (< or = 1 episode per week), or nil (no bleeding). Ten patients had moderate rectal bleeding, while 16 had severe bleeding. All patients were treated with 20 ml of 10% rectal sucralfate suspension enemas twice a day until bleeding per rectum ceased or failure of therapy was acknowledged. Response to therapy was considered good whenever the severity of bleeding showed improvement by a change of two grades. Rectally administered sucralfate achieved good response in 20 (76.9%) patients at 4 weeks, 22 (84.6%) patients at 8 weeks, and 24 (92.3%) patients at 16 weeks. This change was significant by Wilcoxon matched-pairs signed-ranks test. Two patients required surgery due to poor response. Over a median follow-up of 45.5 months (range 5-73 months) after cessation of bleeding, 17 (70.8%) patients had no further bleeding while 7 (22.2%) had recurrence of bleeding. All recurrences responded to short-term reinstitution of therapy. No treatment-related complications were observed. Ten patients had other associated late toxicity due to pelvic irradiation in the form of asymptomatic rectal stricture (N = 3), rectovaginal fistula (N = 1), intestinal stricture (N = 1), vaginal stenosis (N = 1), and hematuria (N = 6). Three patients had progression of the primary disease in the form of pelvic recurrence (N = 2) and hepatic metastases (N = 1). We conclude that topical sucralfate induces a lasting remission in a majority of patients with moderate to severe rectal bleeding due to radiation proctosigmoiditis.

Watermelon stomach: a rare cause of upper gastrointestinal bleeding

Watermelon stomach is a rare cause of upper gastrointestinal bleeding. We report a middle-aged woman who had been having recurrent bleeding from watermelon stomach. She was treated surgically by gastrectomy and Billroth II anastomosis.

Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures

BACKGROUND

Intralesional corticosteroid injection has been shown to be effective in refractory esophageal strictures of various etiologies. The present study was conducted to determine the efficacy of intralesional triamcinolone in augmenting results of endoscopic dilation in corrosive esophageal strictures.

METHODS

Seventeen patients with corrosive esophageal strictures were treated with endoscopic dilation together with injection of triamcinolone acetonide into the stricture. Fourteen patients were already undergoing dilation; 3 patients were newly recruited. The interval between dilations and frequency of dilation were calculated before and after corticosteroid injections, and periodic dilation index was calculated as number of dilations/number of months.

RESULTS

The mean age of the 17 patients (8 men and 9 women) was 30+/-9.21 (range 13 to 52). Thirteen had strictures due to acid ingestion, four to alkali ingestion. There were 18 strictures in total, involving the upper (n = 2), middle (n = 10), and lower (n = 6) thirds of esophagus. Fourteen patients already on a dilation program had undergone 27.92+/-28.63 (range 6 to 92) dilations over a period of 22.92+/-30.73 months (range 2 to 96) before corticosteroid injections. Nine patients received a single injection of triamcinolone, whereas four each had two and three sessions. The dilation requirement after injections in these 14 patients was reduced to 3.57+/-2.90 (range 0 to 10) dilations over a period of 10.5+/-5.58 (range 4 to 21) months. The median total periodic dilation index irrespective of corticosteroid therapy was 0.33 (range 0.55 to 1.8). In 12 of the 14 patients, periodic dilation index before injections (range 0.91 to 3.0, median 1.67) was higher than the median total periodic dilation index and in all the 14 patients periodic dilation index after corticosteroid therapy (range 0 to 0.83, median 0.32) was less than the median of total periodic dilation index (p < 0.01). In addition three patients received intralesional corticosteroid injections at the time of first dilation. These three patients could be effectively dilated with 5, 3, and 3 dilations.

CONCLUSIONS

Intralesional triamcinolone injections augment the effects of endoscopic dilation in patients with corrosive esophageal strictures.