Duodenal varices (DV) although an uncommon cause, are an important cause due to the severe nature of the bleed and associated adverse outcome.
Materials and Methods:
We retrospectively evaluated patients with DV seen at our institution over past 4 years.
A total of 10 patients (nine males; mean age was 35.8 ± 7.68 years) with DV were studied. Five patients had underlying cirrhosis and five had DV because of non-cirrhotic portal hypertension (four patients had extra-hepatic portal venous obstruction and one patient had non-cirrhotic portal fibrosis). Five patients presented with upper gastrointestinal (GI) bleed, whereas in the remaining five patients DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient an initial endoscopic diagnosis of Dieulafoy's lesion was made. However endoscopic ultrasound (EUS) could clearly identify DV in all patients. Of five patients presenting with upper GI bleed, three had the esophageal varices eradicated and two presented 1st time with bleed form DV and did not have esophagogastric varices. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients and there has been no recurrence of bleed in these four patients over a follow-up period of 4-46 months. The five non-bleeding DV were already on beta- blockers and the same were continued. Two of these five patients succumbed to progressive liver failure with none of these five patients having GI bleed on follow-up.
EUS is a useful investigational modality for evaluating patients with DV and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.
Endoscopic ultrasound; duodenum; varices
Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities, and these injuries are often overlooked in cases with extensive multiorgan trauma. The most evident findings of pancreatic injury are post-traumatic pancreatitis with blood, edema, and soft tissue infiltration of the anterior pararenal space. The alterations of post-traumatic pancreatitis may not be visualized within several hours following trauma as they are time dependent. Delayed diagnoses of traumatic pancreatic injuries are associated with high morbidity and mortality. Imaging plays an important role in diagnosis of pancreatic injuries because early recognition of the disruption of the main pancreatic duct is important. We reviewed our experience with the use of various imaging modalities for diagnosis of blunt pancreatic trauma.
Pancreas; Trauma; Pancreatitis; Radiology
Hyperparathyroidism is an uncommon cause of pancreatitis and one should look for its telltale evidence on history (renal stone disease) and investigations (hypercalcemia). Endosonography has an upcoming role in the management of acute pancreatitis, especially in the presence of fluid collection. We report a case of parathyroid adenoma related acute pancreatitis complicated with pseudocyst, which was managed with percutaneous drainage and endosonographic localization of the adenoma to the left parathyroid gland. This patient underwent sestamibi scanning, which confirmed its presence and underwent surgical excision of the adenoma. Endosonography should be included in the work up of patients with unclear etiology and thyroids should be routinely scanned for parathyroid adenomas. One should always look outside the box to get clues for diseases inside the box.
endoscopic ultrasound; hyperparathyroidism; acute pancreatitis
Gastrointestinal duplications usually manifest in children and may involve the esophagus in 20% cases. Esophageal duplication cysts are a rare cause of dysphagia in adults. We report the case of a 35-year-old male who presented to us with progressive dysphagia of 6 months duration. Contrast enhanced computed tomography showed a soft-tissue lesion in right lateral wall of distal thoracic esophagus. On endoscopic ultrasound, a heterogeneously echotextured lesion with anechoic component present at intramural location in the lower esophagus was noted. The patient underwent surgical excision of the lesion and histopathology confirmed the diagnosis of esophageal duplication cyst.
cyst; endoscopic ultrasound; dysphagia; computed tomography
Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years.
We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years.
Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol-ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients.
Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.
endoscopic ultrasound; mediastinum; tuberculosis; computed tomography; dysphagia; fine needle aspiration
A 63-year-old male, chronic alcohol consumer, presented with progressively increasing dysphagia of 6 months duration. Upper gastrointestinal endoscopy revealed dilated esophagus with residue along with esophageal varices. Esophageal manometry revealed findings suggestive of classic achalasia cardia. Endoscopic ultrasound (EUS) examination revealed peri-esophageal collaterals as well as prominent perforators at lower end of esophagus. The co-existence of varices with achalasia is very rare and this case posed a difficult therapeutic dilemma as risk of bleeding from the varices limited the treatment options available. This case was successfully treated with EUS-guided botulinum toxin injection.
Achalasia cardia; endoscopic ultrasound; cirrhosis; varices
Dilated common bile duct (CBD) without obvious cause is a not uncommon finding on magnetic resonance cholangiopancreatography (MRCP). The aim of this study was to evaluate the diagnostic performance of endoscopic ultrasound (EUS) in patients with unexplained dilated CBD on MRCP.
Patients referred for EUS evaluation of a dilated CBD were retrospectively analyzed with respect to serum alkaline phosphatase prior to EUS and subsequent outcome after EUS.
Over a 3-year period, 40 patients (24 males; mean age 38.9±9.9 years) with dilated CBD were retrospectively identified. Ten patients had elevated serum alkaline phosphatase. The diagnosis reached after EUS examination was: CBD stones in 15 (37.5%) with largest size of CBD stone being 9 mm, mass in CBD in 2 (5%), benign biliary stricture in 2 (5%), biliary stricture with underlying chronic pancreatitis in 1 (2.5%) patient respectively. EUS examination revealed normal CBD in 20 (50%) patients and two of these patients had periampullary diverticulum. All the patients with abnormal liver function tests had a detectable CBD pathology whereas 20/30 (66.6%) patients with normal liver biochemistry had normal EUS findings. There was no significant difference in the mean CBD diameter between the groups with demonstrable pathology compared with those without (P=0.64).
EUS is a useful investigational modality for patients with unexplained dilated CBD on MRCP. The mean CBD diameter and the presence of normal liver function tests are not predictive of underlying pathology.
Endoscopic ultrasound; common bile duct stones; magnetic resonance cholangiopancreatography; endoscopic retrograde cholangiopancreatography; ampulla
Benign ileal strictures can cause considerable morbidity and they have been conventionally treated with surgery. The aim of this study was to report our experience of endoscopic balloon dilatation (EBD) in patients with terminal ileal strictures because of Crohn’s disease and tuberculosis.
Over the last 8 years, 9 patients (6 males; mean age 39.7±13.2 years) with benign terminal ileal strictures were treated by EBD using a colonoscope and through-the-scope controlled radial expansion balloon dilators.
The etiology of benign ileal stricture was Crohn’s disease in 5 and tuberculosis in 4 patients. All the patients with Crohn’s disease had no or partial response to 4 weeks of steroid therapy and there were no mucosal ulcerations on ileoscopy. Three patients with ileal strictures due to tuberculosis underwent dilatation after completion of the antitubercular therapy (ATT) while one patient required dilatation 3 months after starting ATT. All patients had single ileal stricture with length of stricture ranging from 0.6-1.8 cm. EBD was successful in all 9 patients with a median number of dilating sessions required of 2 (range: 1-5 sessions). Patients with Crohn’s disease required more endoscopic sessions as compared to patients with tuberculosis but this difference was not statistically significant (mean number of session being 3.0±1.58 vs. 1.75±0.5 sessions respectively; P=0.1). One patient with ileal tuberculosis had enterolith proximal to the stricture that could be removed with dormia. There were no complications of the endoscopic procedure.
EBD is an effective, safe, and minimally invasive treatment modality for benign ileal strictures.
Tuberculosis; Crohn’s disease; balloon dilatation; steroids; enteroclysis
The published data on the accuracy of the detection of pancreas divisum by endoscopic ultrasound (EUS) is limited. In this study, we evaluate the accuracy of detection of pancreas divisum by radial EUS in patients with chronic pancreatitis.
We retrospectively evaluated patients with chronic pancreatitis who underwent EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) in the last four years to identify patients with complete pancreas divisum.
One hundred and forty six patients with chronic pancreatitis underwent EUS examination and 20 patients (13.6%) had pancreas divisum. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of absence of stack sign on EUS for the diagnosis of pancreas divisum were 50%, 97%, 73%, 93% and 91%, respectively and for the inability to trace pancreatic duct from the head to the body were 100%, 96%, 80%, 100% and 96%, respectively.
EUS can diagnose pancreas divisum in a majority of patients. Pancreas divisum can be reliably excluded if pancreatic duct could be tracked backwards from the head to the body around the genu.
chronic pancreatitis; pancreas divisum; endosonography; computed tomography
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.
celiac disease; capsule endoscopy; gastrointestinal bleeding
Idiopathic acute pancreatitis (IAP) is a diagnostic challenge. Finding a treatable cause after appropriate investigation may help to prevent recurrent pancreatitis and further management. The aim of our study was to retrospectively report our experience with endoscopic ultrasound (EUS) in investigating patients with IAP.
Forty patients (26 males; age range: 17-72 years) of IAP with no underlying cause identified on transabdominal ultrasound, computed tomography and magnetic resonance cholangiopancreatography were studied. In 23 patients (57.5%), it was the first attack of acute pancreatitis whereas in 17 patients (42.5%) there was at least one previous attack of documented acute pancreatitis. EUS examination was done using a radial echoendoscope.
Twenty (50%) of the patients had biliary tract disease (cholelithiasis in 3, gallbladder sludge in 13, choledocholithiasis in 1 and common bile duct sludge in 3 patients). One each had an 8 mm tumor in the head of pancreas and pancreas divisum. No underlying cause could be found in 18 (45%) patients. Nine patients had features of chronic pancreatitis (CP) and the remaining had a normal pancreas.
Occult biliary pathology is the predominant cause of IAP. Half of the cases without identified etiology already had an underlying CP. EUS is a very important tool in evaluating IAP especially after an initial negative diagnostic workup.
endoscopic ultrasound; pancreas divisum; cholelithiasis; chronic pancreatitis; endoscopic retrograde cholangiopancreatography
Malignancies can metastasize through hematogenous or lymphatic routes. Enlarged lymph nodes in a known case of malignancy do not always imply metastasis. A middle-aged female patient presented to us with abdominal pain and jaundice. Investigation revealed ampullary growth due to adenocarcinoma. Positron emission tomography-computerized tomography scan revealed uptake of the tracer in the ampullary region as well as in enlarged mediastinal lymph nodes. Endoscopic ultrasound-guided fine needle aspiration cytology of the mediastinal lymphadenopathy revealed it to be tuberculous. Mere radiologic evidence of a distant nodal spread must not be regarded as final evidence and obtaining a tissue diagnosis should be strongly considered, as potentially curative therapy may be offered.
endoscopic ultrasound; tuberculosis; adenocarcinoma; pancreas; lymph node
AIM: To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.
METHODS: In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory.
RESULTS: Between January 2008 and December 2010, 38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients. Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy. There were 8 (61.5%) males and 5 (38.5%) females. The most common presenting symptom was jaundice (100%), followed by fever (46.2%), melena (38.5%), abdominal pain (30.8%) and weight loss (30.8%). All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of (11.2 ± 1.9) mg/dL (normal value < 1 mg%) and the mean ± SD serum alkaline phosphatase was (288.0 ± 94.3) IU/L (normal value < 129 IU/L). Serum CA 19.9 level estimation was done in 11 patients; it was elevated (cut off value > 70.5 IU/L) in all of them with a median of 1200 IU/L (inter quartile range 274-3500). Side viewing endoscopy showed a bulky papilla in all of them. Adequate tissue was obtained in all of the 13 patients for histological evaluation; 12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma. There were no complications from the needle knife papillotomy in any of the patients.
CONCLUSION: Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.
Carcinoma; Periampullary; Papillotomy; Needle knife; Endoscopic ultrasound; Endoscopy
Aluminum phosphide (AlP) is a lethal solid fumigant pesticide which has been recently linked to esophageal stricture formation. This paper aims to study the clinical profile and response to treatment of AlP-induced esophageal strictures. Data on all patients of AlP-induced strictures seen between January 2004 and June 2008 were retrieved and analyzed for clinical parameters and response to endoscopic dilation. Each patient underwent barium swallow to define the site and length of stricture and then was dilated endoscopically. Twelve patients of AlP-induced esophageal stricture (seven males) with a mean age of 26.83 ± 8.43 years were evaluated. They had consumed one to three AlP tablets, 4–156 weeks before reporting to us. They had onset of dysphagia within 2 to 8 weeks of ingestion of AlP. Of 14 strictures in 12 patients, seven were in upper third, two in middle third, and five in lower third of esophagus with a mean length of 1.96 ± 0.75 cm. Nine patients responded to dilation requiring 5.56 ± 2.65 dilations. Four patients were given intralesional steroids to augment the effect of dilation. Three patients failed and were operated upon. All patients remained symptom free over a follow-up of 3–30 (15.67 ± 9.41) months. AlP-induced esophageal strictures can be dilated endoscopically in a majority of patients; however, 25% of them require surgical intervention. AlP-induced esophageal strictures, thus, behave like caustic-induced strictures.
Aluminum phosphide; Esophageal; Strictures
Endoscopic balloon dilatation (EBD) has important role in the management of benign gastric outlet obstruction. Although there are many reports on the role of EBD in the management of corrosive-induced and peptic benign GOO, there is scanty data on its role in the management of NSAID-induced GOO. We report 10 cases of NSAID-induced pyloroduodenal obstruction and their endoscopic management. The most common site of involvement was duodenum (5/10) followed by both pylorus and duodenum (4/10) and pylorus (1/10). Most of the strictures were short web-like, and the mean (SD) number of stricture was 2.0 (0.94). Endoscopic balloon dilatation was successful in 90% (9/10) cases requiring mean (SD) of 2.0 (1.6) sessions of dilatation to achieve target diameter of 15 mm and mean (SD) of 5.3 (2.7) sessions to maintain it over a treatment period of 4.5 months (IQR 2–15 months). There was no procedure-related complication or mortality.
Viral Hepatitis; Celiac Disease; Autoimmune Diseases; Hepatitis B Virus
EUS, as it images the full thickness of the gastrointestinal tract wall, could provide more detailed information on benign esophageal strictures. Aim of this study was to evaluate the role of EUS in predicting the response to endoscopic dilatation in benign esophageal strictures.
27 patients with benign strictures (corrosive 14, peptic 10 & post-radiation 3) were prospectively studied with radial EUS.
The maximum esophageal wall thickness was significantly greater in patients with corrosive and post-radiation strictures in comparison to patients with peptic strictures. In patients with peptic stricture, the mucosal thickness involved either the mucosa (n=2) or submucosa (n=8) and in none of the patients was the muscularis propria involved. However, muscularis propria was involved in all 3 patients with post-radiation strictures and in 11/14 (78.5%) patients with corrosive strictures. Two peptic stricture patients with only mucosal thickening required a single session of dilatation whereas patients with involvement of submucosa required 2-4 sessions of dilatation. Patients with corrosive stricture having only involvement of submucosa required significantly fewer sessions in comparison to patients having muscularis propria involvement (2.67±0.58 vs. 6.30±1.16 sessions, respectively; p=0.0003).
EUS by delineating the extent of wall involvement in benign esophageal strictures predicts the response to endoscopic dilatation.
Corrosive; endoscopic ultrasound; endoscope; computed tomography
Background and aims
Acute-on-chronic liver failure (ACLF) is associated with a high mortality rate in the absence of liver transplantation. There is limited data on predictors of survival in ACLF in children. Therefore, we prospectively studied the predictors of outcome of ACLF in children.
A prospective evaluation of 31 children in the age group of 1–16 years who fulfilled the criteria for ACLF according to Asian Pacific Association for the Study of the Liver (APASL) 2008 consensus was done. All consecutive children were evaluated for etiology, diagnosis and severity of ACLF. For grading of organ dysfunction, the sequential organ failure assessment (SOFA) score was calculated. SOFA constitutes the parameters of respiration, coagulation, cardiovascular system, central nervous system, and renal and liver functions. We evaluated possible correlation between outcomes and different variables.
Of the 31 children who fulfilled the criteria for ACLF, the common underlying chronic liver diseases (CLD) were autoimmune hepatitis (AIH) in 41.9% and Wilson disease in 41.9% of the patients. Superinfection with hepatitis A virus (HAV) (41.9%) was the most common etiology of acute deterioration. To find the best predictor for outcome, linear regression analysis was performed. Multivariate analysis revealed that the SOFA score and the International Normalized Ratio (INR) were predictors of survival. Six (19.4%) patients died. Causes of death were multiorgan failure in four and liver failure in two patients.
The mortality in ACLF is 19.4% and the causes of death were multiorgan failure and liver failure. The SOFA score and INR were predictors of outcome of ACLF in children.
Acute-on-chronic liver failure; Predictors of mortality; Sequential organ failure assessment
Celiac disease is an important cause of chronic diarrhea, failure to thrive, and anemia in children. Mode of presentation of celiac disease has changed in last few years. Study was conducted to determine the mode of clinical presentation of a large group of patients with celiac disease and whether there has been a change in the presentation with the time.
A prospective study was conducted on 134 children diagnosed to be having celiac disease in the Pediatric Gastroenterology, PGIMER, Chandigarh, from July 1st 2006 to December 31st 2007. Their detailed clinical profile was recorded on a pretested proforma and all patients underwent hemogram, liver function tests, IgA anti-tissue transglutaminase (anti tTG), and upper gastro-intestinal endoscopy.
Major symptoms at presentation were diarrhea (54.5%), failure to thrive (52.2%), abdominal distension (41%), anemia (40%), pain abdomen (19.4%), vomiting (15.7%) and constipation (2.2% of cases). 60.4% of patients had short stature. Anemia was microcytic hypochromic in 79.1% of patients, and dimorphic in 20.9%. Serum transaminases were raised in 38.8% of cases. The mean serum anti tTG level was 164.24U/ml (Range 0-749 U/ml) and levels correlated with the severity of small intestinal damage on biopsy. 15 patients were negative for the serology but 8 out of them had IgA deficiency and all had histopathology suggestive of celiac disease.
Classical presentation of celiac disease is less commonly encountered these days probably related to the more widespread use of serologic testing and early recognition of atypical manifestations of celiac disease.
Celiac disease; Gluten enteropathy; Sprue, celiac; Tissue-type transglutaminase; IgA
This communication reviews recent literature and summarizes hepatobiliary abnormalities that may complicate the clinical course of celiac disease. A wide spectrum of hepatobiliary diseases has been described, including asymptomatic elevations of liver enzyme levels, nonspecific hepatitis, nonalcoholic fatty liver disease, and autoimmune and cholestatic liver disease. Moreover, in the majority of patients, liver enzyme levels will normalize on a gluten-free diet. In addition, celiac disease may be associated with rare hepatic complications, such as hepatic T-cell lymphoma. Because many celiac patients do not have overt gastrointestinal symptoms, a high index of suspicion is required. Simple methods of detecting celiac disease such as serum antibody tests help in the early identification of the disease, thus preventing serious complications of the disorder. The IgG DGP antibody test and IgA tTG antibody test used in combination are an excellent screening test for suspected cases of celiac disease.
Background and objective
Portal hypertension may affect intestinal functions, brush border enzymes and absorption parameters. Information about these in extrahepatic portal venous obstruction (EHPVO) in children is limited and poorly reported. We therefore studied the brush border enzymes and absorptive capacity in EHPVO in children.
The study was conducted on 52 children of EHPVO. The diagnosis of EHPVO was made on the basis of clinical presentation and ultrasound examination. All patients underwent upper gastrointestinal endoscopy. Endoscopic tissue biopsies from duodenum were taken on aluminum foils and kept immediately at −20°C for estimation of brush border enzymes. Tissue biopsies were homogenized in sodium maleate buffer, 0.1 M pH 6.0, by a homogenizer and processed for the enzymes: lactase, maltase, and sucrase. Enzyme levels were compared to normal healthy controls (n = 20). d-Xylose test, stool acid steatocrit for fat excretion in stools and stool alpha-1 antitrypsin were done to know about the absorptive parameters.
Enzyme levels of lactase (6.21 ± 5.67 IU/mg) and sucrase (37.07 ± 21.06 IU/mg) in EHPVO group were significantly lower as compared to lactase (23.32 ± 10.48 IU/mg) and sucrase (95.96 ± 46.55 IU/mg) in normal healthy controls. Maltase levels were lower, but difference was not statistically significant in EHPVO group (56.90 ± 28.65 IU/mg) as compared to normal controls (63.28 ± 22.88 IU/mg). There was no significant difference of urinary d-xylose and stool fat in patients with normal or short stature EHPVO patients.
EHPVO leads to decrease in levels of brush border enzymes in small bowel but their absorption capacity remains normal.
EHPVO; Brush border enzymes; Absorption capacity