The potential of methylene blue in treating septic shock: Is it worth a shot?

Shock is a circulatory failure that results in insufficient oxygen supply to cells. Septic shock is the most common variety in patients admitted to the Intensive Care Unit (ICU) and is a fatal condition that accounts for a considerable number of deaths in the ICU. [1, 2]. Treatment of septic shock consists of a triad that comprises hemodynamic resuscitation via crystalloid, vasopressor infusion and antibiotic delivery within the first hour of recognition [2]. Despite the evidence that these measures help reduce mortality, the percentage of death remains greater than 40%, necessitating the requirement for alternative treatment strategies [2]. Research shows that methylene blue significantly increases mean arterial pressure (MAP) and systemic vascular resistance (SVR).Furthermore, treatment with methylene blue aids in the tapering of vasopressors [3]. In a recent single-centre randomised control trial including patients suffering from septic shock, Ibarra-Estrada et al. Investigated the effect of early adjuvant methylene blue on time to vasopressor discontinuation. They discovered that in comparison to the control group, patients who were administered methylene blue had decreased time to vasopressor discontinuation with no adverse but rather had a shorter length of ICU and hospital stay [4]. Another trial by R. Ismail et al. involving preterm neonates with refractory septic shock reported similar findings where methylene blue led to a significant rise in arterial blood pressure, reducing the need for norepinephrine [5]. In addition, pooled data from a systematic review and meta-analysis shows that the use of MB in conjunction with vasopressors dramatically reduced mortality in patients with vasodilatory shock. These findings suggest that methylene blue has favourable outcomes in treating septic shock. Due to limited data, more research is required to compare the efficacy of methylene blue in different types of shock states and in different subgroups such as neonates, adolescents, adults and the elderly population. At this stage, more evidence regarding the short-term and long-term benefits and possible side effects of using methylene blue is also required, to allow physicians to be able to incorporate it in regular treatment protocols when practicing evidence-based medicine. Newer studies could help shed some light on appropriate dosing regimens and discover populations that would reap the most benefits from its use. Accurate conclusions, drawn via systematic reviews and meta-analyses including newer large-scale multi-centred clinical trials might be just what is needed to enhance the already existing treatment regimens for shock.

Exploring the uncommon: A case report on localized peritonitis caused by ingested toothpick

INTRODUCTION

Bowel perforation is a serious emergency. Occasionally, sharp objects like toothpicks can get stuck in narrow parts of the small intestine, potentially resulting in impaction, obstruction, or perforation.

PRESENTATION OF CASE

A 20-year-old male arrived at our hospital's emergency department with sudden, severe abdominal pain persisting for 24 h. On examination, his abdomen showed tenderness, and bowel sounds were reduced. Contrast-enhanced computed tomography (CECT) indicated possible small intestine inflammation due to a foreign object and a diagnostic laparoscopy revealed a hyperemic terminal ileum.

DISCUSSION

This case involves ileal perforation from an unnoticed toothpick ingestion. Detecting foreign object perforations is challenging, often leading to misdiagnoses and CT scans are the most effective for toothpick detection. Definitive diagnosis is through laparoscopy, and treatment varies between laparoscopic suturing to intestinal resection.

CONCLUSION

Healthcare providers must consider toothpick ingestion in cases of acute abdominal symptoms to avert treatment delays and potential life-threatening outcomes.

Longterm outcome of endoscopic sclerotherapy of variceal bleeding: comparative study between schistosomiasis and others

BACKGROUND/AIMS

This comparative study was conducted on 111 patients to evaluate the long term outcome of endoscopic variceal therapy in patients with portal hypertension, and particularly with schistosomiasis.

PATIENTS AND METHODS

There were 45 patients with chronic liver disease due to schistosomiasis, 31 with chronic hepatitis B and 21 with chronic NNb hepatitis. The remaining 14 had chronic liver disease of other etiologies. The mean follow up period was 40 months.

RESULTS

Esophageal varices were completely sclerosed in 32 out of 111 patients in 5 sessions (average) over a mean duration of 8 months. A comparison of patients with schistosomal and non-schistosomal liver diseases revealed that 68% of the schistosomal group patients were in child's A classification, compared to 30% of the patients in the non-schistosomal group. There was no significant difference with respect to early rebleeding and recurrence of oesophageal varices. The outcome of sclerotherapy in schistosomal group was better with respect to survival span over a 5 year period of 78% while for the nonschistosomal group it was less than 59%.

CONCLUSIONS

This study has shown that injection sclerotherapy for bleeding oesophageal varices gives best results when liver function is usually well preserved and for chronic schistosomal liver disease.

Protean manifestation of gastrointestinal tuberculosis: report on 130 patients

Over the past 8 years, 820 patients with tuberculosis were seen at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. A total of 292 of these patients (35.6%) had pulmonary tuberculosis, and 130 patients (15.8%) had alimentary tract tuberculosis, making this the second commonest site of involvement. In these 130 patients, the disease was located in the upper gastrointestinal tract in 11 patients (8.5%), small bowel 44 patients (33.8%), large bowel 29 patients (22.3%), peritoneum 40 patients (30.7%), and liver 19 patients (14.6%). The diagnosis in most patients was made by specimens from endoscopy or laparoscopy, or liver or surgical specimens. Gastrointestinal tuberculosis is not uncommon in developing countries, and its incidence is increasing in developed countries due to immigration and in patients with AIDS or those receiving immunosuppressive therapy. It can mimic any diseases affecting the gastrointestinal tract and may present with very different symptoms, so a high index of suspicion is required.

Alpha interferon in treatment of chronic hepatitis C viral infection (CHCV): Pilot study of 18 patients

Eighteen patients with chronic hepatitis C virus infection (CHCV) were treated with three million units of interferon (IFN) three times a week for a minimum of six months. Four (22.2%) had completely responded, two (11.1%) had partial response and the rest (eight or 44.4%) did not show any evidence of response. After stopping treatment, patients who had a complete or partial response developed a relapse during the follow-up period. Few reversible adverse effects of treatment were reported in more than half of the patients. So, we conclude that three million units of IFN three times weekly is not recommended for treating patients with CHCV. Perhaps a larger dose of five to six million units should be tried and for a longer duration.

Helicobacter pylori: Prevalence in 352 consecutive patients with dyspepsia

At the Riyadh Armed Forces Hospital (RAFH), 352 patients had gastroscopy and from each, antral gastric biopsies were taken for identification of Helicobacter pylori, by urease test and histopathology. In 217 (61.64%) of these 352 patients, the histology specimens showed Helicobacter pylori in 73.68% of patients with duodenal ulcer, 70% of patients with gastric ulcers and gastric erosions, 61% of patients with duodenitis and 52% of patients with gastritis. The urease test was positive at six hours in 164 (49.59%) of these 352 patients. The urease test was positive in 60% of each group of patients with endoscopic findings of gastric erosions, gastric ulcers and duodenal erosions.

Frequency of gastroesophageal reflux in patients with liver cirrhosis

Twenty-five adult patients with liver cirrhosis, and another 30 patients with no liver disease but referred with symptoms suggestive of gastroesophageal reflux disease were selected at random. Twenty-four hour ambulatory intra-esophageal pH measurement and upper gastrointestinal endoscopy were carried out on all patients recruited. Applying the former test, 16 (64%) of the patients with liver cirrhosis have gastroesophageal reflux disease. This figure is comparable with the 70% (21/30) rate recorded in the group of dyspeptic patients clinically thought to have the disorder. A positive endoscopic diagnosis was much lower at 12% and 23%, respectively. No significant differences were observed among liver disease patients when they were subdivided in accordance with the etiology of liver cirrhosis and the grade of esophageal varices. We conclude that gastroesophageal reflux disease occurs at a high frequency (64%) in patients with liver cirrhosis and portal hypertension, irrespective of the etiology of cirrhosis and the grade of esophageal varices. It is therefore considered to be the main cause of esophagitis in these patients, and that it might play a role in initiating a variceal bleeding episode. The latter hypothesis needs further evaluation.

Hepatitis C virus infection in chronic liver disease and hepatocellular carcinoma in Saudi Arabia

The prevalence of antibody to hepatitis C virus (HCV) was determined in 139 patients with chronic liver disease (CLD) and 42 patients with hepatocellular carcinoma (HCC) during one year at the Riyadh Military Hospital, Saudi Arabia. The anti-HCV was detected in 36 of 96 (37.5%) HBsAg-negative patients with chronic liver disease and six of 43 (13.9%) HBsAg-positive patients with chronic liver disease. In addition, 11 (42.3%) HBsAg-negative hepatocellular carcinoma patients and two of 16 (12.5%) HBsAg-positive hepatocellular patients had antibody to HCV. The anti-HCV prevalence was 1.5% in 4818 healthy blood donors and 1% in 385 antenatal patients. The overall HCV seropositivity of 30.4% in 181 liver disease patients (CLD and HCC) in Saudi Arabia is lower than that reported from European countries.