Pancreatico-pleural fistula: successful treatment with octreotide

A patient with chronic pancreatitis who presented with massive pleural effusion due to pancreatico-pleural fistula is reported. Treatment with octreotide for three weeks healed the fistula and resolved the pleural effusion.

Pancreatic ascites and pleural effusion treated by endoscopic pancreatic stent placement

Usefulness of endoscopic pancreatic stents in the management of pancreatic ascites and pleural effusion has been evaluated only recently. We report a patient with alcoholic pancreatitis who presented with ascites and pleural effusion and had a pancreatic duct disruption in the body area on pancreaticography. A 5 F stent was placed across the disruption with rapid subsidence of both ascites and pleural effusion. The stent was removed after 12 weeks and there has been no recurrence during a follow-up period of 9 months.

Gastrointestinal complications after renal transplantation. 10 Year data from a North Indian Transplant Center

Gastrointestinal complications are responsible for substantial morbidity and mortality among renal allograft recipients in developing countries. During a 10 year period, 166 (62.6%) of 265 allograft recipients developed gastrointestinal complications. This figure reflects the high incidence of infectious complications, especially acute diarrheas. Also notable was the incidence of esophageal candidiasis (7.2%), ischemic colitis (2.6%), and gastrointestinal and peritoneal tuberculosis (3.0%). Almost one quarter of the complications developed in the first 6 months after transplantation. Mortality was the highest with acute ischemic colitis (100%), pancreatitis (60%), and upper gastrointestinal hemorrhage (40%). Improvements in standards of living and sanitary conditions, pre transplant evaluation and assessment of risk factors, prophylaxis with anti ulcer drugs, early diagnosis, and appropriate treatment are needed to decrease the frequency and severity of gastrointestinal complications in renal allograft recipients.

A study of hepatitis delta virus infection in patients with acute and chronic liver disease from northern India

To assess the prevalence of hepatitis delta virus (H delta V) in northern India, 204 adult patients with acute and chronic liver disease who were positive for hepatitis B virus (HBV) markers were screened for anti-H delta V antibody by enzyme-linked immunosorbent assay (ELISA). Anti-H delta V antibodies were positive in 29 (14.2%) patients. The incidence of H delta V infection was higher (21.4%) in patients with chronic liver disease when compared with those with acute viral hepatitis (10.7%) (P < 0.05). H delta V antibodies were positive in 16.6% of patients with fulminant hepatic failure (FHF) and in 25% of cases with hepatocellular carcinoma. Co-infections were significantly higher in acute hepatitis (80%), while superinfections predominated (66.7%) in chronic liver disease (P < 0.05). Our data show that H delta V is endemic in northern India and should be considered a major health problem.

Colovesical fistula complicating colonic diverticulosis

Two cases of colovesical fistulae secondary to colonic diverticulosis are reported. Urinary symptoms were the prominent presenting features. Barium enema was helpful in documenting the fistulae, which cystoscopically was not localised. Definitive treatment included resection of the fistula and the diseased segment of the intestine. Both patients are well on follow-up. Diverticulosis coli should be considered in the differential diagnosis of colovesical fistulae even in tropical countries.

Fungal colonization of untreated peptic ulcer

AIM

To evaluate the relationship between Candida and peptic ulcer.

METHODS

One hundred consecutive patients with untreated peptic ulcer (81 with duodenal ulcer and 19 with gastric ulcer) were studied using histopathology, culture and fungal serology. Twenty subjects with non-ulcer dyspepsia were taken as controls.

RESULTS

Forty seven patients (47%) with peptic ulcer were colonized by Candida as compared to 3 patients (15%) with non ulcer dyspepsia (p < 0.05). Confluent growth of Candida on culture of gastric aspirate or biopsy from ulcer edge was a more sensitive method for diagnosis of peptic ulcer-associated candidiasis than histological examination. There was no significant difference in the prevalence of Candida isolation in relation to age or sex of the patients, smoking habit and alcoholism. Large ulcers (> 2 cm) were, however, more often colonized by Candida (75%) than smaller ones (43%) (p < 0.05). Candida albicans was the commonest species isolated (60%). Invasive candidiasis was associated with Candida agglutinin titer of 1:128 in 81% of cases.

CONCLUSION

Candida colonization rate in peptic ulcer is significantly higher than in non-ulcer dyspepsia.

Esophageal candidiasis after renal transplantation: comparative study in patients on different immunosuppressive protocols

OBJECTIVES

The incidence of esophageal candidiasis (EC) in renal allograft recipients has not been well documented. The present study was done to determine the incidence of EC in renal allograft recipients receiving different forms of immunosuppressive therapy and to identify patients at a high risk of developing Candida esophagitis.

METHODS

We conducted a retrospective study of 265 live related renal allograft recipients and compared three groups: patients given azathioprine and prednisolone (group I), those given cyclosporine, azathioprine, and prednisolone (group II), and those given cyclosporine and prednisolone (group III). EC was diagnosed by esophagogastroduodenoscopy.

RESULTS

The overall incidence of EC was 10.5%. Group II patients had a significantly higher incidence (28.6%) than those in group I (10.4%) and group III (3.8%). EC was noted earlier in patients in groups II and III, who were on higher doses of steroids than group I patients. Dysphagia (57.1%) was the most common presenting symptom of EC, but 21.4% of patients were asymptomatic. Oral thrush was present in 42.9%. The entire esophageal mucosa was affected in six (46.1%) patients in group II and one (20%) in group III. No correlation was found between fungal serology or daily dose of steroids and extent of esophageal involvement. Treatment included nystatin in seven, nystatin and ketoconazole in 10, ketoconazole alone in eight, amphotericin B in one, and ketoconazole and amphotericin B in two episodes. Treatment failure occurred in seven (25%). Three patients died of disseminated candidiasis. Serology and biopsy were poor predictors of dissemination.

CONCLUSIONS

In this retrospective study of renal allograft recipients, patients on triple drug immunosuppression, diabetics, and those with myelosuppression had an increased risk of developing EC. This high incidence calls for prophylactic use of antifungal agents in selected renal transplant recipients.

Colonic diverticulosis in India: the changing scene

BACKGROUND

The prevalence of colonic diverticulosis has a wide geographic and ethnic variation and has been considered to be quite low in India. This study was aimed at determining the prevalence of colonic diverticulosis in northern India based on barium enema examination in symptomatic patients.

METHODS

All barium enema examinations performed between January 1985 and December 1991 were reviewed for the presence of colonic diverticulosis. Clinical data of such patients were retrieved.

RESULTS

51 (3.2%) of 1610 barium enema studies showed colonic diverticulosis. The frequency of diverticulosis in barium studies increased from 0.3% among subjects in the third decade to 32.4% in patients above 60 years. Most patients were city dwellers, vegetarians and belonged to the upper socio-economic stratum. Twenty patients (39.2%) presented with a complication; the spectrum of such patients was no different from that reported from the West. While the sigmoid colon was the commonest site of diverticuli, there was a relative preponderance of right sided diverticuli as compared to the Western experience. Seven patients with complications required surgical treatment, while the rest were managed conservatively.

CONCLUSION

Colonic diverticulosis and its complications are not rare in India and should be considered in the differential diagnosis of abdominal disorders.

An audit of pneumatic dilatation and oesophagomyotomy in patients with achalasia cardia

The role of pneumatic dilatation and oesophagomyotomy in the management of achalasia cardia was evaluated. Twenty patients with achalasia cardia managed either by pneumatic dilatation (n = 10) and oesophagomyotomy (n = 10) were studied. Patients undergoing dilatation were followed up for a mean of 20 months (12-30 months) and those undergoing myotomy for 17 months (6-48 months). The patients were evaluated clinically, radiologically and endoscopically. Relief of dysphagia was excellent in 20%, good in 50% and fair in 30% of those who underwent dilatation. In the myotomy group, 60% had an excellent result, 30% had a good result and fair results was observed in 10%. Oesophagitis on endoscopic evaluation, was found in two patients in myotomy group. The diameter of the gastro-oesophageal junction increased from a mean of 2 mm (range 1 to 4 mm) to a mean of 11 mm (range 4 to 15 mm) in dilatation group while in myotomy group it changed from a mean of 2 mm (range 0.5 to 8 mm) to a mean of 9 mm (range 5 to 15 mm). Symptomatic improvement was better after myotomy than after pneumatic dilatation and correlated poorly with radiological features.

Paraneoplastic cholestasis and hypercoagulability associated with medullary thyroid carcinoma. Resolution with tumor debulking

The authors report a 69-year-old woman with a hypercoagulable state manifesting as superior sagittal sinus thrombosis, thrombocytosis, right lower extremity deep venous thrombosis, and subsequent pulmonary embolus. The liver enzyme values were elevated in a cholestatic pattern. Carcinoembryonic antigen level was markedly elevated. Evaluation revealed that her longstanding "goiter" had slowly enlarged during the past 6 years. The serum calcitonin level was markedly elevated. Subsequent biopsy revealed medullary thyroid carcinoma. Surgical debulking of the tumor and lymph nodes resulted in substantial reduction of the calcitonin and carcinoembryonic antigen levels in a matter of days. Long-term follow-up revealed normalization of cholestasis and resolution of the hypercoagulable state. Review of the literature revealed no previously reported cholestasis or hypercoagulable state associated with medullary thyroid carcinoma. The literature on paraneoplastic cholestasis, carcinoembryonic antigen production, and hypercoagulable states is reviewed.

Oral sucralfate in acute radiation oesophagitis

Eighty patients with carcinoma in the middle third of oesophagus and with acute radiation oesophagitis following external beam and intracavitary radiotherapy were managed by two different schedules. Group 1 (n = 40) received an antacid containing sodium alginate whereas Group 2 (n = 40) were given a 10% sucralfate suspension during 4 weeks. In Group 2, 32 patients had significant relief of symptoms within 7 days of treatment and most ulcers had healed by 12 days of treatment as seen on endoscopy. Patients in Group 1, on the other hand, showed little improvement of symptoms and had persistent ulcers even after 4 weeks of therapy. We conclude that sucralfate is useful in the management of acute radiation oesophagitis.

Spectrum of lower gastrointestinal hemorrhage: an endoscopic study of 166 patients

BACKGROUND

The spectrum of lesions causing lower gastrointestinal hemorrhage shows marked geographic variation. The study was aimed to determine this spectrum in our region using endoscopic examination.

METHODS

166 patients presenting with lower gastrointestinal hemorrhage were investigated using colonoscopy as the first investigation.

RESULTS

Lesions responsible for bleeding could be identified in 141 patients (84.9%). In 25 patients (15.1%), the etiology of bleed could not be determined either because of failure to identify a lesion (10 patients) or because of an incomplete examination (15 patients). Major causes of lower gastrointestinal bleeding included idiopathic ulcerative colitis (19.3%), acute colitis (12.0%), colonic polyps (10.2%), radiation colitis (9.0%), solitary rectal ulcer (7.8%), colonic carcinoma (7.2%), colonic tuberculosis (4.2%) and enteric fever (3.0%).

CONCLUSION

Endoscopic examination is very useful in evaluating patients with lower gastrointestinal hemorrhage. The predominant causes of lower gastrointestinal bleeding in our experience are different from those reported from western countries.

Abdominal tuberculosis. Diagnosis by fine needle aspiration cytology

One hundred five cases of tuberculosis of the abdomen (excluding genitourinary involvement) diagnosed initially by fine needle aspiration cytology between 1988 and 1991 were analyzed retrospectively. The diagnosis of tuberculosis was suspected clinically in 60% of the cases prior to aspiration. The anatomic locations of the lesions were ileocecal in 69 cases, lymph node in 18, colon in 10, jejunoileal in 2, duodenojejunal in 1, peritoneal in 1 and liver in 4. Cytomorphologic analysis of the aspirates from these 105 cases showed only necrotic material in 19 cases, necrotic material with epithelioid granuloma in 36 cases and epithelioid granuloma without necrosis in 50 cases. Ziehl-Neelsen staining for acid-fast bacilli was positive in 47 of 105 cases (45%). Cultures for mycobacteria were positive in 5 of 24 cases. Histologic confirmation was available in five cases only. The cytodiagnosis correlated well with the radiologic findings and response to antituberculosis chemotherapy.

Measuring prices of Medicare physician services

This study develops two sets of price indices for Medicare physician services. The first measures price changes, and the second measures geographic price differentials. The indices can be used to adjust Medicare physician spending data to examine growth or variations in the volume and intensity of services. In both instances, it is necessary to apply an index form that reflects both the rapid changes and variability in the mix of physician services received by Medicare beneficiaries and their relative importance. This suggests that an index based on a fixed basket of services (e.g., a Laspeyres index) can produce a biased measure of price. An alternative methodology based on the Fisher's Ideal Index form was used. This index allows service weights to vary over time and across areas. In the case of price change, the index is "chained" to acknowledge the introduction of new services over several years. It is concluded that the Fisher's Ideal approach is essential for cross-sectional price comparisons, in light of the high variability in service mix across areas. In measuring price changes, it was found that "chaining" was more important empirically than allowing the relative importance of services to change between years. During the 1985-1989 study period, Medicare payment rates grew, on average, by 3.5% annually. This rate varied across both time and types of services as a result of differential fee updates and explicit pricing policies implemented by Medicare (e.g., reductions in payments for "overvalued" procedures). Cross-sectionally, our results show that 1988 fees in the highest-priced areas were more than 1.5 times those in the lowest-priced areas.

Lactose intolerance in idiopathic ulcerative colitis in north Indians

The incidence of lactose intolerance in 60 patients with idiopathic ulcerative colitis (IUC) from northern India and the effect of disease activity and extent of colonic involvement on the occurrence of lactose intolerance, was studied. Twenty controls matched for age and sex were also studied using 50 g lactose hydrogen breath test. The incidence of lactose intolerance in patients with IUC (41.7%) was no different from that in the control group (40%). There was however, a significant difference (P < 0.05) in the incidence of lactose intolerance in patients with active colitis (59.1%) as compared to those with quiescent disease (31.5%).

Identification of Helicobacter pylori by endoscopic crush cytology

BACKGROUND

Gastric crush cytology is employed in a variety of situations including diagnosis of malignant disease and the detection of Helicobacter pylori infection.

OBJECTIVE

To evaluate the usefulness of gastric crush cytology in the detection of H pylori infection.

METHODS

Gastric biopsy specimens from 50 patients of gastric or duodenal peptic ulceration were studied by gastric crush cytology, histopathology, bacteriologic culture and rapid urease test and results of various methods compared.

RESULTS

Thirty seven patients had H pylori demonstrable in crush smears and 28 in histopathological sections. In 15 patients, the organism was detected by cytology alone and in 6 samples by histopathology alone. There was concordance of 76% between these two morphological techniques. The organism could be cultured from 22 biopsy specimens and urease test was positive in 37 specimens.

CONCLUSION

Gastric crush cytology is a useful method for detection of H pylori infection.

Role of infectious agents in exacerbations of ulcerative colitis in India. A study of Clostridium difficile

Fifty patients with idiopathic ulcerative colitis--25 with acute exacerbation of the disease (Group I) and 25 in quiescent phase (Group II)--were studied. None of the patients had a history of recent exposure to antimicrobial drugs or hospitalization. Evidence of infection with protozoal and bacterial agents and/or presence of Clostridium difficile toxin was demonstrated in eight (32%) patients in group I and one (4%) patient in group II (group I vs. group II, p < 0.05; chi 2 test with Yate's correction). In five of the six patients with demonstrable Clostridium difficile toxin in the stool, one patient with Entamoeba trophozoites, and another with Salmonella infection, the exacerbation responded clinically and endoscopically to specific antimicrobial therapy. Another two patients who had Entamoeba histolytica cysts in the stool had no change in their clinical status with metronidazole. We conclude that infectious agents are responsible for some of the exacerbations in patients of ulcerative colitis in a tropical country like India, where careful microbiologic examination is in order in every acute exacerbation of this disease. This contrasts with the findings in developed countries.

Fatal pulmonary arterial hypertension complicating noncirrhotic portal fibrosis

A 25-yr-old female with noncirrhotic portal fibrosis underwent a lienorenal shunt for variceal bleed. Ten years after shunt surgery, she presented with progressive breathlessness, and severe pulmonary arterial hypertension was detected, to which she subsequently succumbed. Autopsy revealed classical plexogenic pulmonary arteriopathy.