CT enteroclysis in the diagnosis of obscure gastrointestinal bleeding: initial results

AIM

To evaluate the usefulness of computed tomography (CT) enteroclysis in patients with obscure gastrointestinal (GI) bleeding.

MATERIALS AND METHODS

In a prospective study, CT enteroclysis was performed in 21 patients (median age 50 years; range 13-71 years) with obscure GI bleeding in which the source of the bleeding could not be detected despite the patient having undergone both upper GI endoscopic and colonoscopic examinations. The entire abdomen and pelvis was examined in the arterial and venous phases using multisection CT after distending the small intestine with 2l of 0.5% methylcellulose as a neutral enteral contrast medium and the administration of 150ml intravenous contrast medium.

RESULTS

Adequate distension of the small intestine was achieved in 20 of the 21 (95.2%) patients. Potential causes of GI bleeding were identified in 10 of the 21 (47.6%) patients using CT enteroclysis. The cause of the bleeding could be detected nine of 14 (64.3%) patients with overt, obscure GI bleeding. However, for patients with occult, obscure GI bleeding, the cause of the bleeding was identified in only one of the seven (14.3%) patients. The lesions identified by CT enteroclysis included small bowel tumours (n=2), small bowel intussusceptions (n=2), intestinal tuberculosis (n=2), and vascular lesions (n=3). All vascular lesions were seen equally well in both the arterial and venous phases.

CONCLUSIONS

The success rate in detection of the cause of bleeding using CT enteroclysis was 47.6% in patients with obscure GI bleeding. The diagnostic yield was higher in patients with overt, obscure GI bleeding than in those with occult obscure GI bleeding.

Chronic diarrhea and malabsorption caused by Leishmania donovani

Chronic diarrhea and malabsorption are uncommon in immunocompetent patients with visceral leishmaniasis. We report two immunocompetent patients with visceral leishmaniasis where the predominant presentation was chronic diarrhea. One of them had clinically overt malabsorption and duodenal mucosa was loaded with Leishmania donovani bodies. The other patient had diffuse colonic aphthous and discrete ulcerations and Leishmania donovani bodies were seen in the crush smears of the colonic mucosa. With amphotericin B, there was reversal of malabsorption and healing of colonic ulcers.

Anti-Saccharomyces cerevisiae antibody does not differentiate between Crohn's disease and intestinal tuberculosis

The clinical, morphological, and histological features of intestinal tuberculosis (IT) and Crohn's disease (CD) mimic so much, that it becomes difficult to differentiate between them. The sensitivity of anti-Saccharomyces cerevisiae antibody (ASCA) IgG and ASCA IgA in CD is 60%-80%, whereas the specificity is almost 90%. There are no reports of study of ASCA in patients with IT, nor has it ever been used to differentiate CD from IT. Patients with ulcerative colitis (UC; n=25), CD (n=59), and IT (n=30) and 21 healthy controls were included in this study. The location and behavior of CD were classified according to the Modified Montreal classification. Five milliliters of blood was taken from them and serum was stored at -70 degrees C. ASCA antibodies (both IgG and IgA) were estimated using commercially available ELISA kits (AESKU Diagnostics, Germany). Anti-neutrophilic cytoplasmic antibody was measured by indirect immunofluorescence test. ASCA IgA was positive in 4.7%, 28%, 33.9%, and 43.3% and ASCA IgG was positive in 4.7%, 24%, 50.8%, and 46.6% of healthy controls and patients with UC, CD, and IT, respectively. Either ASCA IgG or ASCA IgA was positive in 9.5%, 40%, 61% and 66.6% of healthy controls, UC, CD, and IT, respectively. ANCA was positive in 0%, 32%, 10.1%, and 6.6% of healthy controls, UC, CD, and IT, respectively. ASCA IgG was positive in a significantly higher number of patients with CD (P<0.0001) and IT (P<0.0001) in comparison to healthy controls. ASCA IgA was positive in a significantly higher number of patients with UC (P<0.04), CD (P<0.013), and IT (P<0.006) in comparison to healthy controls. In comparisons between diseases, ASCA IgG was positive in significantly more patients with CD (P<0.001) and IT (P<0.001) in comparison to UC. There was no significant difference in ASCA IgA (33.9% vs. 43.3%), ASCA IgG (50.86% vs. 46.6%), or ANCA (10.7%, 7.4%) in patients with CD and IT, respectively. There was no correlation between ASCA and duration, location and behavior of CD, and IT. We conclude that ASCA IgG and ASCA IgA do not help to differentiate between IT and CD.

Familial pachydermoperiostosis in association with protein-losing enteropathy

In this report we describe a rare association of pachydermoperiostosis with protein-losing enteropathy (PLE) in a family of three brothers. The first brother had the complete form of pachydermoperiostosis along with PLE. The second brother had the 'forme fruste' of pachydermoperiostosis, with minimal skin changes, bony abnormalities and PLE, which was due to intestinal lymphangiectasia. The third brother had an incomplete form of pachydermoperiostosis without evidence of PLE. To our knowledge, the association of pachydermoperiostosis with PLE due to intestinal lymphangiectasia has not been reported previously.

Acute pancreatitis associated with acute hepatitis E infection

A 45-year-old male presented with severe abdominal pain, hyperamylasaemia and a bulky pancreas. In addition, he had deep jaundice and markedly raised serum transaminases, and his serum was positive for IgM anti-hepatitis E virus (HEV) antibodies. The common aetiologies of acute pancreatitis were excluded. The patient ran a benign course for both acute viral hepatitis and acute pancreatitis, and recovered completely. Acute pancreatitis caused by HEV infection has been reported only occasionally.

Intussusception due to gastrointestinal stromal tumour of the colon: diagnosis by colonoscopy

Intussusception of the intestine is rare in adults. We report a case of a 45-year-old male who presented with long-standing pyrexia of unknown origin, abdominal pain, gastrointestinal bleeding and constitutional symptoms. Colonoscopic examination revealed a large invaginated mass suggestive of colonic intussusception due to gastrointestinal stromal tumour of the colon. His symptoms disappeared after surgical removal of the tumour.

Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures

INTRODUCTION

The cornerstone treatment for benign esophageal strictures is endoscopic dilation. There are reports suggesting that intralesional corticosteroid injection decreases the frequency of endoscopic dilation.

METHODS

Seventy-one patients (mean age 42.39 [17.52] years; range, 13-78 years) with benign esophageal strictures (corrosive 29, peptic 14, anastomotic 19, radiation-induced 9) were recruited for this study. All were being managed with a program of intermittent endoscopic dilation by using over-the-wire polyvinyl dilators. All patients were treated by intralesional injections of triamcinolone acetonide (40 mg/mL diluted 1:1 with saline solution) by using a 23-gauge, 5-mm long sclerotherapy needle in aliquots of 0.5 mL. At each session, 4 injections (4 quadrants) were made at the proximal margin of the stricture with another 4 injections into the strictured segment itself whenever possible. The intervals between dilations and frequency of dilations were calculated before and after triamcinolone injections. A periodic dilation index (defined as number of dilations required per month) before and after the triamcinolone injections was calculated.

RESULTS

The overall mean (SD) duration of treatment before intralesional injection was 10.9 (19.8) months (range, 1-120 months) and the mean number (SD) of esophageal dilations required was 9.67 (13.06) (range, 1-70). The mean number of sessions of intralesional injection was 1.4 (0.62). After initiation of intralesional injections mean follow-up was 8.1 (5.6) months (range 3-30 months) and the mean number of esophageal dilations was 3.8 (3.0) (range 0-16). The periodic dilation index decreased significantly from 1.24 (0.05) (range 0.13-3.16) before injection to 0.5 (0.33) (range, 0-2) after injection (p < 0.001). For each category of stricture, the periodic dilation index decreased significantly: corrosive, 1.24 (0.5) to 0.53 (0.34) (p < 0.001); peptic, 0.92 (0.44) to 0.42 (0.2) (p < 0.001); anastomotic, 1.24 (0.49) to 0.51 (0.4) (p < 0.001); and radiation-induced, 1.32 (0.6) to 0.6 (0.3) (p < 0.02).

CONCLUSION

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

Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures

INTRODUCTION

The cornerstone treatment for benign esophageal strictures is endoscopic dilation. There are reports suggesting that intralesional corticosteroid injection decreases the frequency of endoscopic dilation.

METHODS

Seventy-one patients (mean age 42.39 [17.52] years; range, 13-78 years) with benign esophageal strictures (corrosive 29, peptic 14, anastomotic 19, radiation-induced 9) were recruited for this study. All were being managed with a program of intermittent endoscopic dilation by using over-the-wire polyvinyl dilators. All patients were treated by intralesional injections of triamcinolone acetonide (40 mg/mL diluted 1:1 with saline solution) by using a 23-gauge, 5-mm long sclerotherapy needle in aliquots of 0.5 mL. At each session, 4 injections (4 quadrants) were made at the proximal margin of the stricture with another 4 injections into the strictured segment itself whenever possible. The intervals between dilations and frequency of dilations were calculated before and after triamcinolone injections. A periodic dilation index (defined as number of dilations required per month) before and after the triamcinolone injections was calculated.

RESULTS

The overall mean (SD) duration of treatment before intralesional injection was 10.9 (19.8) months (range, 1-120 months) and the mean number (SD) of esophageal dilations required was 9.67 (13.06) (range, 1-70). The mean number of sessions of intralesional injection was 1.4 (0.62). After initiation of intralesional injections mean follow-up was 8.1 (5.6) months (range 3-30 months) and the mean number of esophageal dilations was 3.8 (3.0) (range 0-16). The periodic dilation index decreased significantly from 1.24 (0.05) (range 0.13-3.16) before injection to 0.5 (0.33) (range, 0-2) after injection (p < 0.001). For each category of stricture, the periodic dilation index decreased significantly: corrosive, 1.24 (0.5) to 0.53 (0.34) (p < 0.001); peptic, 0.92 (0.44) to 0.42 (0.2) (p < 0.001); anastomotic, 1.24 (0.49) to 0.51 (0.4) (p < 0.001); and radiation-induced, 1.32 (0.6) to 0.6 (0.3) (p < 0.02).

CONCLUSION

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

Colonoscopic barotrauma treated by conservative management: role of high-flow oxygen inhalation

Most patients with colonoscopy-induced colonic perforation require urgent surgical intervention. Certain patients may, however, recover with conservative management. If the colonic perforation has been induced by barotrauma, there may be an extravasation of air which may lead to collection and tracking of air along the tissue planes, involving the retroperitoneum, peritoneal cavity, mediastinum, pleura, pericardium, or even the scrotum. The conservative treatment of colonic perforation includes bowel rest and antibiotics. Absorption of air collected in different body cavities may take some time, and inhalation of high-concentration oxygen may enhance the rate of gaseous absorption. We describe here a patient with colonic perforation induced by barotrauma, who recovered fully on conservative management with inhalation of high-concentration oxygen. We recommend that this approach should be used more frequently in such a situation.

Association of Dubin-Johnson syndrome and portal vein thrombosis

Dubin-Johnson syndrome is neither complicated by liver cell necrosis nor associated with portal hypertension. We report a 22-year-old man who had recurrent episodes of jaundice (conjugated hyperbilirubinemia) because of Dubin-Johnson syndrome and portal hypertension secondary to portal vein thrombosis. The relationship between Dubin-Johnson syndrome and portal vein thrombosis in this case is most likely a chance occurrence.

Plummer Vinson syndrome: unusual features

Plummer Vinson syndrome is a constellation of postcricoid esophageal webs, iron deficiency anemia, dysphagia and koilonychia. We describe some unusual manifestations in three patients with this syndrome; these were clubbing instead of koilonychia, tortuous esophagus in addition to presence of esophageal webs, and celiac disease.

Ascites and spontaneous bacterial peritonitis in fulminant hepatic failure

OBJECTIVE

Although presence of ascites has been reported in patients with fulminant hepatic failure (FHF), spontaneous bacterial peritonitis (SBP) has not been studied in a large group of such patients. Hence, the present study was conducted to evaluate the prevalence and prognostic significance of ascites and SBP in FHF patients.

METHODS

Two hundred ninety-eight consecutive patients (mean age 32.9+/-14.8 yr) with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. Acute viral hepatitis accounted for 91.6% of the patients and were analyzed in the present study.

RESULTS

Ascites was clinically detected in 79 (28.9%) patients. The patients with ascites were older (p = 0.005), had longer jaundice-encephalopathy interval (p<0.0000001), lesser grade of encephalopathy on admission (p = 0.0000043), and a lower incidence of raised intracranial pressure on admission (p = 0.0007). Patients with ascites had significantly lower serum albumin (p = 0.021), ALT (p = 0.0005), AST (p = 0.00017), and PT (p = 0.002) on admission than in patients without ascites. Multivariate logistic regression analysis showed that jaundice-encephalopathy interval (> or =14 days) and serum albumin (< or =2.5 g/dl) were the only independent predictors of ascites. SBP was detected in 14 (17.7%) patients (neutrocytic culture positive, 4; neutrocytic culture negative, 9; and monomicrobial bacterascites, 1). Escherichia coli was identified in three patients. Survival was no different between patients with and those without ascites and also between patients with and those without SBP.

CONCLUSIONS

Ascites is a frequent accompaniment of FHF and is complicated by SBP. Jaundice-encephalopathy interval of 14 days or more and serum albumin (< or =2.5 g/dl) on admission predicts the development of ascites in these patients.

Ascites and spontaneous bacterial peritonitis in fulminant hepatic failure

OBJECTIVE

Although presence of ascites has been reported in patients with fulminant hepatic failure (FHF), spontaneous bacterial peritonitis (SBP) has not been studied in a large group of such patients. Hence, the present study was conducted to evaluate the prevalence and prognostic significance of ascites and SBP in FHF patients.

METHODS

Two hundred ninety-eight consecutive patients (mean age 32.9+/-14.8 yr) with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. Acute viral hepatitis accounted for 91.6% of the patients and were analyzed in the present study.

RESULTS

Ascites was clinically detected in 79 (28.9%) patients. The patients with ascites were older (p = 0.005), had longer jaundice-encephalopathy interval (p<0.0000001), lesser grade of encephalopathy on admission (p = 0.0000043), and a lower incidence of raised intracranial pressure on admission (p = 0.0007). Patients with ascites had significantly lower serum albumin (p = 0.021), ALT (p = 0.0005), AST (p = 0.00017), and PT (p = 0.002) on admission than in patients without ascites. Multivariate logistic regression analysis showed that jaundice-encephalopathy interval (> or =14 days) and serum albumin (< or =2.5 g/dl) were the only independent predictors of ascites. SBP was detected in 14 (17.7%) patients (neutrocytic culture positive, 4; neutrocytic culture negative, 9; and monomicrobial bacterascites, 1). Escherichia coli was identified in three patients. Survival was no different between patients with and those without ascites and also between patients with and those without SBP.

CONCLUSIONS

Ascites is a frequent accompaniment of FHF and is complicated by SBP. Jaundice-encephalopathy interval of 14 days or more and serum albumin (< or =2.5 g/dl) on admission predicts the development of ascites in these patients.

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.

Spontaneous bacterial peritonitis in a patient with gastric carcinoma

Spontaneous bacterial peritonitis (SBP) is classically described in patients with cirrhosis and nephrotic syndrome. However, SBP rarely occurs in patients with malignant ascites. We report a patient with gastric cancer with ascites, who developed SBP. Clinicians need to be aware of this complication in patients with malignant ascites.