Obscure gastrointestinal bleeding persisting for a decade: a rare manifestation of a common disease

Celiac disease commonly presents with diarrhea but variable presentation with anemia, osteoporosis, incidental recognition, and liver function abnormalities is also known. Overt blood loss is uncommon in celiac disease. We present the case of a 60-year-old female who presented with obscure gastrointestinal blood loss for more than a decade necessitating multiple transfusions and was eventually diagnosed to have celiac disease. After introduction of gluten-free diet, her symptoms improved and there has been no recurrence of gastrointestinal bleeding.

Endoscopic ultrasound-guided treatment of bleeding duodenal varix

A 35-year-old man presented with recurrence of upper gastrointestinal bleed after eradication of esophageal varices. Upper gastrointestinal endoscopy revealed submucosal lesion in the duodenum and endoscopic ultrasound (EUS) demonstrated it to be a duodenal varix. Cyanoacrylate glue was injected into the duodenal varix and successful obliteration of the duodenal varix was demonstrated on a follow up EUS.

Endoscopic ultrasound-guided fine needle aspiration of peritoneal nodules in patients with ascites of unknown cause

Ascites can pose a difficult diagnostic problem and in some patients, despite extensive work-up, diagnostic laparoscopy or laparotomy is required. We evaluated the usefulness of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of peritoneal nodules in 12  patients with undiagnosed ascites (9  men, 3 women; mean [SD] age 47.5 [11.8] years). On EUS, peritoneal deposits, noted as hyperechoic rounded lesions compared with surrounding anechoic ascitic fluid, were observed in 10/12  patients (83.3%). Cytological examination of EUS-FNA samples from these deposits revealed metastatic adenocarcinoma in four patients, poorly differentiated carcinoma in one patient and pseudomyxoma peritonei in one patient. It also revealed inflammatory cells without granulomas in four patients, and polymerase chain reaction (PCR) for Mycobacterium tuberculosis was positive in 2/4 patients (50%). Deposits were larger and clearly defined in malignant ascites in comparison with tubercular ascites. No complications of EUS-FNA were observed.

Colonic lesions in patients undergoing small bowel capsule endoscopy

PURPOSE

Capsule endoscopy by enabling direct visualization of small bowel mucosa has conquered the last frontier of diagnostic endoscopy. However, its ability to simultaneously detect colonic lesions has not been evaluated. This study was done to evaluate frequency of detection of colonic abnormalities in patients undergoing small bowel capsule endoscopy and its impact on the clinical management.

PATIENTS AND METHODS

Eighty-seven patients (60 males; mean age: 51.2 ± 18.6 years) who had obscure gastrointestinal bleeding or unexplained abdominal pain or unexplained diarrhea underwent capsule endoscopy. The demographic data and capsule endoscopy findings were retrospectively evaluated.

RESULTS

Capsule endoscopy was normal in 26 (29.8%) patients and small bowel abnormalities were noted in 49 (56.3%) patients. Capsule endoscope did not reach the cecum during the battery life period of the capsule in five (5.7%) patients. Colonic abnormalities were noted in eight (9.1%) patients. These included cecal angiodysplasia (four), cecal carcinoma (one), transverse colon polyp (one), sigmoid colon ulcerations with histological diagnosis of Crohn's colitis (one), and cecal ulcers with final diagnosis of amebic colitis (one).

CONCLUSION

The colon should also be carefully evaluated in patients undergoing small bowel capsule endoscopy as significant lesions can be detected that helps in appropriate management.

Endoscopic ultrasound (EUS) features of mediastinal tubercular lymphadenopathy

BACKGROUND/AIMS

Endoscopic ultrasound (EUS) findings in mediastinal tubercular lymphadenopathy have not been well characterized. This study aims to assess the accuracy of EUS findings of patchy anechoic or hypoechoic areas and hyperechoic foci in mediastinal lymph nodes for the diagnosis of mediastinal tuberculosis.

METHODOLOGY

Forty-two patients with enlarged mediastinal lymph nodes who underwent EUS guided FNA were included. EUS findings were retrospectively reviewed for size, patchy anechoic or hypoechoic areas and hyper echoic foci. The final diagnosis was based on cytological examination of aspirate as well as clinical follow-up.

RESULTS

Final diagnosis was tuberculosis in 22 patients and non-tubercular diagnosis in the rest. Hyperechoic foci in the lymph nodes was seen in 77.2% of patients with tubercular mediastinal lymphadenopathy and in 5% of patients with non-tubercular mediastinal lymphadenopathy (p=0.00). Patchy anechoic or hypoechoic areas were seen in 40.9% patients with tubercular mediastinal lymphadenopathy whereas none of the patients with non-tubercular mediastinal lymphadenopathy presented these (p=0.01). The patchy anechoic or hypoechoic areas or hyperechoic foci in the mediastinal lymph nodes had accuracies of 69.0% and 85.7%, respectively, for the diagnosis of tuberculosis.

CONCLUSIONS

Patchy anechoic or hypoechoic areas or hyperechoic foci in the mediastinal lymph nodes on EUS are important signs of mediastinal tubercular lymphadenopathy and EUS guided FNA is a useful modality for diagnosis of mediastinal tuberculosis.

Safety and efficacy of vitamin-based antioxidant therapy in patients with severe acute pancreatitis: a randomized controlled trial

BACKGROUND/AIM

Oxidative stress plays a major role in the pathogenesis of pancreatitis. Antioxidant therapy in the form of high-dose vitamin has been used for the treatment of severe acute pancreatitis with equivocal results. We wished to evaluate the efficacy and safety of antioxidant (vitamin A, vitamin C, vitamin E) therapy in patients with severe acute pancreatitis.

SETTING AND DESIGN

This was a single-center, prospective, randomized, open-label with blinded endpoint assessment study of antioxidant therapy, conducted in the emergency department attached to our hospital.

MATERIALS AND METHODS

Thirty-nine patients with severe acute pancreatitis were randomly assigned to antioxidant treatment group (n=19) or a control group (n=20) within 96 hours of developing symptoms. Patients in the antioxidant group received antioxidants (vitamin A, vitamin E, vitamin C) in addition to the standard treatment provided to both the groups for a period of 14 days. The primary outcome variable was presence of organ dysfunction at day 7. The secondary outcome variables were length of hospital stay, multiorgan dysfunction (MODS) at day 7, recovery at the end of 4 weeks, complications, and mortality. The change in markers of oxidative stress from baseline was also measured.

RESULTS

We demonstrated no significant difference in organ dysfunction (P=1.0), MODS (P=0.8), and length of hospital stay (P=0.29) between the two groups. All the patients survived in the antioxidant-treated group, whereas two patients died in the control group. The change in the levels of malondialdehyde, superoxide dismutase, and reduced glutathione were not significantly different in the two groups at day 7. Univariate analysis showed marginal benefit with antioxidant treatment (P=0.034) in patients with severe acute pancreatitis.

CONCLUSIONS

This randomized study demonstrates that there is no significant benefit from antioxidant therapy in patients with established severe acute pancreatitis.

Small bowel hemangiomas: Diagnostic role of capsule endoscopy

Vascular anomalies involving the small bowel are an uncommon cause of gastrointestinal bleeding in childhood. We present here an 11-year-old boy who presented with severe anemia and malena. The routine investigations did not reveal any pathology. A capsule endoscopy study was performed, which clinched the diagnosis and identified two intestinal hemangiomas. The hemangiomas were resected and the child recovered.

Isolated pancreatic tuberculosis mimicking focal pancreatitis and causing segmental portal hypertension

CONTEXT

Isolated pancreatic tuberculosis is a common mimicker of pancreatic malignancy and a common presentation is abdominal pain. However, segmental portal hypertension is very uncommon.

CASE REPORT

A case of isolated pancreatic tuberculosis mimicking focal pancreatitis and causing segmental portal hypertension is presented.

CONCLUSION

A histological or microbiological diagnosis of the presence of pancreatic masses is necessary to detect potentially treatable diseases, such as tuberculosis, in endemic countries like India.

Periampullary Dieulafoy's lesion: an unusual cause of gastrointestinal bleeding

CONTEXT

Dieulafoy's lesion is an unusual cause of gastrointestinal bleeding with the most common location being the stomach. A periampullary location is rare for a bleeding Dieulafoy's lesion.

CASE REPORT

We present the case of a 52-year-old female who presented with intermittent painless melena. Her upper gastrointestinal endoscopy and colonoscopy were normal. She was a diagnostic challenge as no definite lesion could be identified on capsule endoscopy. However, as there was presence of fresh blood in the proximal jejunum, a push enteroscopy was performed which revealed the presence of fresh blood in the duodenum and proximal jejunum. But no bleeding lesion could be identified. A side view endoscopy was performed which revealed a bleeding periampullary Dieulafoy's lesion. Immediate hemostasis was achieved with an injection of adrenalin. Other episodes of bleeding occurred and the patient was finally treated surgically.

CONCLUSION

A periampullary Dieulafoy's lesion presenting with obscure gastrointestinal bleed is a diagnostic challenge and can be missed on capsule endoscopy.

Successful resolution of bronchobiliary and biliocutaneous fistula by prolonged endoscopic transpapillary biliary drainage

Bronchobiliary fistula is a rare condition that has been usually treated surgically. We report successful resolution of a rare case of combined bronchobiliary and biliocutaneous fistula by prolonged endoscopic transpapillary biliary drainage. The patient developed these fistulae following right hepatectomy for blunt trauma to the abdomen. Although endoscopic biliary drainage has been reported to be effective in healing of post-traumatic and post-surgical bile leaks, there are limited reports describing the efficacy of endoscopic drainage in complex biliary fistulas. This case report describes the successful closure of complex biliary fistula by prolonged endoscopic drainage.