Background/Objectives: Primary repair of duodenal perforations with the omental patch technique has re-emerged as the mainstay of treatment of this widely-prevalent condition, especially in our country. We have prospectively studied factors affecting outcome (morbidity, mortality) of duodenal ulcer perforations treated by omental patch technique, and have also attempted to study the efficacy of contemporary scoring systems (Haceteppe, APACHE II, Mannheim Peritonitis Index, Jabalpur score) in predicting outcome. Methods: One hundred consecutive patients of non-traumatic duodenal ulcer perforations (NTDUP) over a 2-year period were recruited for this prospective study at a tertiary care hospital in Delhi, India. Clinical and laboratory data, and, outcome, were recorded; all patients were treated with omental patch repair. Results: In 100 patients, there were 97 male (mean age= 40.8 ± 14.2 years) and 3 female (mean age= 38.3 ± 12.6). Fourteen patients recovered completely, 86 had complications; of the latter five died. Age, serum creatinine, and perforation size were associated with unfavourable outcome (p=0.015, 0.000, 0.013 respectively; students t-test). Presence of hypotension, serum creatinine, perforationoperation interval (PO), and perforation size, were associated with mortality alone (p=0.000, 0.001, 0.001, 0.000 respectively; student’s t-test). Age, serum creatinine, PO, and perforation size had correlation with longer hospital stay (p=0.044, 0.005, 0.012, 0.003 respectively; Pearson’s coefficient). Using receiver operating characteristic (ROC) curves, only the APACHE II and the Jabalpur scoring systems accurately predicted poor outcome. Conclusions: Omental patch is a safe and effective method of closure of duodenal perforations. Other procedures may be combined if high-risk factors are identified, e.g., large perforation size. The Jabalpur score is a simple tool in large emergency rooms with limited facilities. Received: March 13, 2018; Accepted: April 06 2018; Published: April 10, 2018 *Corresponding author: Nitin Agarwal, Department of Surgery, Renal Transplant Unit, Postgraduate Institute of Medical Education and Research (PGIMER) and Dr. Ram Manohar Lohia Hospital (RMLH), Delhi 110001, India, Email: drnitinagarwal76@gmail.com Symbiosis www.symbiosisonline.org www.symbiosisonlinepublishing.com Symbiosis Group * Corresponding author email: drnitinagarwal76@gmail.com Introduction The two most common causes of secondary peritonitis are small bowel and gastroduodenal perforation, especially in the developing world. In many studies, duodenal perforation is the most common cause [1-5]. At some point of time, omental patch repair of duodenal ulcer perforations was replaced by definitive acid-reduction procedures because of the high rates of recurrence. But with rapid and vast improvements in proton pump inhibitory agents, and, efficacious anti-Helicobacter pylori regimens, this may no longer be true [6-8]. Omental patch repair of duodenal ulcer perforation is both simpler than and as effective as definitive ulcer surgery in the emergency situation [9]. Perforations larger than 3 cms have also been reported to be successfully repaired with this technique [10]. All these considerations have led to the resurgence of this technique. Mortality due to ulcer perforation treated by simple closure and/or other methods is still around 10% [11-13]. Factors reported to affect mortality in duodenal ulcer perforations in other series are old age, co-morbidity, preoperative hypotension, large size of the perforation, delay in presentation, and, delay in operation [14-18]. This prospective study was designed to study the morbidity and mortality in patients with non-traumatic duodenal ulcer perforation (NTDUP) treated by omental patch repair at a tertiary care centre in north India, and to correlate clinical, laboratory, and, operative factors with outcome. The efficacy of contemporary scoring systems (Haceteppe, APACHE II, Mannheim Peritonitis Index, Jabalpur score) in predicting outcome in our patients was also assessed.
Inflammatory bowel disease (IBD) embraces Crohn’s disease (CD), ulcerative colitis (UC) and the less common indeterminate colitis, all chronic inflammatory processes of the gastrointestinal (GI) tract.
Context:Tumor-induced hypoglycemia is a rare entity and it is mainly due to pancreatic insulinomas.Non-islet cell tumor hypoglycemia is really exceptional and ectopic insulin secretion has been previously suggested. Case description:A 79 year-old type 2 diabetic man, after over 30 years of poorly controlled diabetes, observed an unexplained improving of glycemic control with recurrent hypoglycemia.He progressively reduced insulin doses, till suspension, with persistent frequent hypoglycemia.A fasting test documented symptomatic hypoglycemia with inappropriate elevated insulin and C-peptide.CT scan and endoscopic ultrasound did not reveal any pancreatic lesion.A 68Gallium-DOTANOC showed a focal pathological right pelvic uptake, corresponding to an oval enhancing lesion at the targeted CT images.The patient was submitted to surgical excision of that mass, revealing an appendix neuroendocrine well differentiated tumor with lymph nodes metastasis, showing partial insulin immunohistochemistry staining.After surgery no other hypoglycemic events were documented; to control diabetes insulin therapy needed to be reintroduced. Conclusion:Extra-pancreatic insulin secreting tumors are very rare and their diagnosis in diabetic patients can be challenging.This case addresses the diagnosis and treatment of this rare entity reporting, to our knowledge, the first case of ectopic insulinoma, arising from appendix.
commonly seen in women (two to three times) than in men and its incidence steadily increases with age [1].Thickening of gallbladder wall is a commonly detected finding on different imaging modalities.The finding itself is however non-specific and can result from multiple pathologic conditions including surgical and non-surgical disorders.The least common presentation of gallbladder carcinoma is focal or diffuse thickening of the gallbladder wall, and is difficult to diagnose, particularly in the early stages.Considering the non-specific nature of the clinical manifestations, which are indistinguishable from chronic cholecystitis, it is important to have an imaging tool for early detection of gallbladder cancer, because the management and prognosis of gallbladder carcinoma differs from benign etiologies.It is also well recognized that early detection, although a mere coincidental rarity, improves survival [2][3][4].On the other hand, misinterpretation of diffuse gallbladder wall thickening in patients who do not have primarily gallbladder disease can lead to unnecessary cholecystectomy.This situation calls for an improved imaging strategy to differentiate between benign and malignant causes of thickened gall bladder wall in order to select patients for aggressive therapeutic efforts [4].Computed tomography to differentiate cholecystitis from carcinoma has been evaluated as early as in 1984 [5], however the signs reported to be useful included detecting a focal mass, biliary obstruction at porta hepatis, invasion of liver and nodal metastases.Yun et al [6] evaluated different patterns of enhancement thickened gallbladder wall in arterial and venous phases and found them helpful in differentiating gallbladder carcinoma from chronic cholecystitis when using two-phase helical CT.The authors opined that two-phase spiral CT was more useful than single phase CT for differentiating between these two disease entities.Another retrospective study by Kim et al [7] aimed to differentiate the gallbladder
Objectives:The colorectal cancer is a common and lethal neoplasia.Colonoscopy detects diseases in the initial stages decreasing the mortality.Pain and abdominal discomfort are usual complaints associated mainly with the use of air insufflation.Carbon dioxide (CO2) is increasingly utilized to augment tolerance and disposition to repeat the examination.Compare which insufflation method is related to less unpleasant symptoms, safer examination and best performance are objectives of the study.Methods: Electronic databases were accessed selecting only randomized controlled trials comparing insufflation with CO2 and ambient air in colonoscopy.The evaluated outcomes were pain, abdominal distension and flatulence, cecal intubation rate, cecal intubation and total procedure time, volume of gas, CO2 measurement, and need of sedation or analgesia, and polyp detection rate.Results: Thirty randomized controlled trials were selected (4854 patients).Meta-analysis showed reduction in pain risk in the CO2 group immediately after the colonoscopy (Risk difference-RD 0.11[0.03,0.19]), 1h (RD 0.29 [0.24, 0.34]), 3h (RD 0.22[0.11,0.34]) and 6h (RD 0.21 [0.17, 0.26]) after colonoscopy.The reduction of flatulence risk 1h and 6h after the procedure was greater in CO2 group (RD 0.54 [0.43, 0.66] and RD 0.65[0.38,0.92],respectively).There were no significant differences between the two groups regarding pain during the procedure, pain and flatulence 24h after colonoscopy, abdominal bloating, request for medication, safety, gas volume, polyp detection rate, cecal intubation rate, time to cecum and total procedure time.Conclusions: CO2 insufflation improves tolerance to colonoscopy, reducing pain and flatulence out to 6 hours following the procedure.
Primary hepatic leiomyosarcoma are rare soft tissue sarcomas with about only about 60 cases reported in the English literature [1]. Due to its rare existence and less studied, the diagnostic algorithms and standards of care have not been adequately defined. This has led to a delayed diagnosis and subsequently a poor prognosis and survival of such patients. We herein present a 72 year old lady with primary hepatic leiomyosarcoma treated with chemotherapy and attempt to delineate the line of management after reviewing the medical literature. Primary Hepatic Leiomyosarcoma is a rare primary hepatic malignancy which is usually a diagnosis of exclusion. The standard treatment guidelines are yet to be established; large cohort database is needed for better understanding of disease behaviour and management.
Background: Chronic hepatitis B virus (HBV) related to liver cirrhosis is an advanced liver fibrosis that is usually progressive, irreversible, and the only option for the treatment is liver transplantation in selected patients Objectives: to examine the demographic, clinical, and laboratory characteristics of patients with the chronic HBV related to cirrhosis. Methods: The viral hepatitis clinic in Azadi Teaching Hospital is dealing with all viral hepatitis cases. All patients with liver cirrhosis caused by chronic HBV infection were studied. Demographic, clinical and laboratory information of the patients were retrieved by interviewing and from the case notes of September in 2014 until December in 2016. Child–Turcotte–Pugh (CTP) classification was used to evaluate the prognosis of liver cirrhosis. The results obtained were analyzed by entering the data into a Microsoft Excel spreadsheet. A value of less than 0.05 was considered as statistically significant.
BACKGROUND:Several reports indicate that eosinophils are induced in chronic pancreatitis including patients with pancreatic malignancy. However, significance of eosinophilic pancreatitis (EP) is poorly understood and unexplored.AIM:Accumulation and degranulation of eosinophils promote pancreatic fibrosis and malignancy.METHOD:Human pancreatic tissue biopsy samples including chronic pancreatitis (n=3), malignant (n=4), non-malignant (n=3), and normal (n=3) were used for H&E, anti-MBP staining, anti-tryptase staining, anti-IgE staining and Mason's trichrome staining.RESULTS:We show induced eosinophils and degranulated eosinophils indicated by the presence of anti-MBP stained extracellular granules in the malignant pancreatic (pancreatic cancer) and non-malignant human pancreatic tissues. A comparable number of eosinophils were observed in non-malignant and malignant pancreatic tissue sections, but the sections differed in degranulated eosinophils and the presence of extracellular granules. Additionally, induced mast cells and tissue-specific IgE positive cells were also detected in the tissue sections of malignant pancreatitis patients compared to non-malignant human pancreatic patients. Tissue-specific IgE induction is critical for the degranulation of eosinophils and mast cells that may lead to increased accumulation of collagen in malignant compared to non-malignant human pancreatic tissue samples. We show a large number of anti-tryptase stained extracellular granules in the tissue sections of malignant pancreatic cancer patients. Both IgE and eosinophil major basic proteins (MBP) are reported for the activation and degranulation of mast cells in tissues.CONCLUSION:Taken together, our investigation concludes that eosinophils and mast cells accumulation and degranulation are critical in promoting pancreatitis pathogenesis that may lead to the development of pancreatic fibrosis and malignancy.
INTRODUCTION:The role of EUS-guided FNA as a highly sensitive modality in the diagnosis of pancreatic adenocarcinoma is well documented. However, there is little published data on the role of EUS-FNA in diagnosing pancreatic neuroendocrine tumors (NETs).OBJECTIVE:The aim of this study is to compare the sensitivity of EUS-FNA to that of CT-FNA for diagnosing pancreatic NETs.METHODS:This is a single institution retrospective analysis of the operating characteristics of EUS-FNA and CT-FNA in detecting pancreatic NETs. Only patients with a final diagnosis of pancreatic NET were selected for this study. Procedure related data, including tumor size and location, and presence of a cytotechnologist were recorded. The results of each FNA were compared to the final clinico-pathological diagnosis to calculate sensitivity.RESULTS:Twenty-eight patients undergoing FNA (19 by EUS, 9 by CT) were analyzed. NETs diagnosed by EUS-FNA were smaller compared with CT-FNA (2.7 ± 0.9cm vs. 6.5 ± 2.1cm, p = 0.009) and were more often found in the pancreatic head (47.4% vs. 11.1%, p = 0.035). There were no significant differences in sensitivity between EUS-FNA and CT-FNA specimens (73.7% vs. 88.9%, p = 0.33).CONCLUSION:EUS-guided FNA is as sensitive as CT-guided FNA in diagnosing pancreatic NETs, but its main advantage is in the diagnosis of smaller pancreatic NETs in the head of the pancreas. It may also be the preferred approach in the diagnosis of multifocal pancreatic NETs in the setting of MEN I Syndrome.
A high level of cholesterol activates Kupffer cells, which subsequently triggers inflammation and ultimately leads to steatohepatitis.The number of Kupffer cells correlates with the inflammatory grade of Non-Alcoholic Fatty Liver Disease (NAFLD).In this study, we studied the role of 'foamy' Kupffer cells in the nexus between inflammation and steatosis and investigated whether K-604, a selective Acyl-Coenzyme A: Cholesterol Acyltransferase-1 (ACAT-1) inhibitor ameliorates hepatic steatosis and inflammation in rodent models of NAFLD and Non-Alcoholic Steatohepatitis (NASH).Methionine-and Choline-Deficient (MCD) diet-fed KK-Ay mice, High-Fat and High-Cholesterol (HFC) diet-fed Low-Density Lipoprotein Receptor-Deficient (Ldlr(-/-)) mice and Zucker fatty rats were evaluated after 16, 16 and 12 weeks of K-604 treatment.The biochemical parameters, hepatic lipid levels, histopathological changes and gene expression levels were assessed.In the MCD dietfed KK-Ay mice, K-604 significantly improved the NASH symptoms.In the HFC diet-fed Ldlr (-/-) mice, K-604 suppressed the inflammatory gene expression and reduced the number of inflammatory foci.Moreover, K-604 decreased the area and size of foamy Kupffer cells.In the Zucker fatty rats, K-604 could also inhibit hepatic steatosis.These results indicated that K-604 acts directly on Kupffer cells and inhibits hepatic inflammation, suggesting that ACAT-1 is involved in the progression of steatohepatitis.Therefore, ACAT-1 inhibition may be a new therapeutic target for NAFLD and NASH.
Background and aims: Treatment of hepatitis C has become revolutionised with the availability of newer direct acting antiviral (DAA) in last two years. In India, Sofosbuvir was the only available DAA till December 2015.
A 32-year-old obese Caucasian woman presented with acute pancreatitis.Her past medical history includes recurrent pancreatitis, pancreatic divisum, laparoscopic gastric banding and alcohol abuse.The hospital course was complicated by multi-focal hepatic abscesses requiring percutaneous drainage.She eventually underwent pancreatic necrosectomy with J tube placement and was discharged to rehabilitative services.This is a rare case of pancreatitis with concomitant liver abscess from Streptococcus anguinosus.
Background: Celiac disease pathogenesis involves increased permeability of intestinal epithelial tight junctions due to immunogenic mechanisms.Larazotide acetate is a tight junction regulator peptide that was recently described. Aims:To assess the efficacy and safety of larazotide acetate in celiac disease Methods: Study Selection Criteria: Studies evaluating the efficacy and safety of larazotide acetate (LA group) in patients with celiac disease who were simultaneously challenged with gluten. Data collection & extraction:Articles were searched in Medline, Pubmed, and Ovid journals.Statistical Method: Pooled proportions were calculated using fixed and random effects model.Results: Initial search identified 89 reference articles, of which 19 were selected.Three studies (N=136) met the inclusion criteria.In the pooled proportion of patients, the change in urinary lactulose to mannitol fractional excretion ratio (LAMA) scores from baseline after the intervention in LA group and placebo group was 1.34(95%CI=0.96to 1.71) and 1.91(95%CI=1.50to 2.32) respectively.Change in Gastrointestinal Symptom Rating scale (GSRS) scores after intervention was 0.04(95%CI=-0.32to 0.40) and 0.46(95%CI=0.09to 0.83) in LA and placebo group respectively.Change in Celiac disease GSRS (CeD-GSRS) scores after intervention was -0.11(95%CI=-0.48to 0.26) and 0.35(95%CI=-0.29 to 0.99 in LA and placebo groups respectively.Odds ratio for overall adverse events (gastrointestinal symptoms, headache, urinary tract infection, fatigue) in LA group versus placebo group was 0.60(95%CI=0.28to 1.28).Conclusions: Lower doses of Larazotide acetate seemed to control gastrointestinal symptom severity induced by the gluten challenge in celiac patients.It has a relatively safe side effect profile compared to placebo.
Three groups of conventional therapies include salicylates, immunosuppressants and antibiotics. Yet relief is often shortlived and comes with significant side effects. 80% and 45% of CD and UC patients (Respectively) will still require surgery [16]. Biological response modifiers or ‘biologics’, macromolecules that target inflammatory lymphocytes or the cytokines they produce [7], have more recently emerged as another highly effective therapeutic class. In 1998, the FDA approved infliximab, with a high response rate, significant mucosal and fistula healing and long-term remissions in Crohn’s disease. Other biologics targeting p40, p19, IL-12, IL-17 and anti-alpha 4 integrin [7, 8] are either marketed or in various development stages. However as many as 30% of patients will not respond to biologics and half of those who initially respond, will relapse within a year. None have significant impact on surgical intervention rates [9].
Background and Aims: Definitive diagnosis of IBD requires endoscopic and pathologic confirmation.These tools are also used to classify disease activity.Our aim was to determine if the fractional exhaled nitric oxide (FeNO) could be utilized to screen for IBD and assess for disease activity. Methods:We matched weighted IBD cases and controls from the 2009-2010 NHANES dataset.All subjects underwent measurement of FeNO using standardized techniques.We assessed for potential confounders for FeNO measurement including age, height, and asthma.For IBD subjects, we used the presence of diarrhea, fatigue, and weight loss as a proxy for IBD activity.Laboratory parameters examined to estimate disease activity included anemia (≤ 10 g/dl), iron deficiency (ferritin ≤ 20 ng/ml), hypoalbuminemia (≤ 3.2 g/dl), and CRP (≥ 1.1 mg/dl). Results:The weighted sample represented 199,414,901 subjects.The weighted prevalence of IBD was 2,084,895 (1.0%).IBD subjects had nearly the same FeNO level as those without IBD (17.0 ± 16.2 vs. 16.7 ± 14.5 ppb).The odds of a FeNO > 25 ppb was half (OR=0.501;95% CI 0.497-0.504)for subjects with IBD compared to those without IBD after controlling for confounders.The AUROC curve for FeNO was 0.47 (0.35-0.59).FeNO levels were not higher in patients with laboratory values suggestive of active disease.FeNO levels were higher in IBD patients with diarrhea, rectal urgency, and fatigue but were lower in those with unintentional weight loss. Conclusion:Measurement of FeNO does not appear to be useful to screen for IBD or assess disease activity.
OBJECTIVE:Over the last decade, a strong association has been found between smoking and chronic pancreatitis. Some studies suggest that smoking may be a more important cause of chronic pancreatitis than alcohol and the two are additive. The primary purpose of our study was to test the use of a questionnaire to assess patient's knowledge regarding the association of smoking with pancreatic disease.METHODS:The questionnaire was administered prospectively during a 9 month period in 2013 to patients referred to a pancreas clinic at the University of Alabama Birmingham. The primary purpose of the questionnaire was to investigate patient awareness regarding the association of smoking with pancreatic disease; however, it was also designed for assessing doctor-patient communication regarding smoking in general and pancreatic disease specifically and the patient's stage of change for quitting smoking.RESULTS:Eighteen patients (mean age 52 years; 85% male) were used for the analysis. The data analysis showed that 56% of patients were aware of the relationship between smoking and chronic pancreatitis and 72% were aware about alcohol and pancreatitis. Patients related that physicians were an important reference source for their knowledge regarding the causes of chronic pancreatitis, but only 39% stated that their physician had specifically mention the effect of smoking on the pancreas.CONCLUSION:Elaborate studies involving greater number of study population, are necessary to better define measuring tools and to further assess patient's knowledge regarding the relationship between smoking and chronic pancreatitis. Additionally, efforts should be directed towards enhancing physician's knowledge on this established relationship and the importance of patient education as well.
factors that induce the movement of the appendix have been unknown except for pregnancy [9,10].We hypothesized that the position change of the vermiform appendix relates the development process of appendicitis.In this study, we investigated to determine whether the position of the appendix changes during the development of inflammation and whether the final position of the appendix at diagnosis is related to the pathological inflammatory grade. MethodsWe reviewed the medical records of 396 consecutive Japanese patients who received an appendectomy at our facility from 2009 to 2013.Among this group, 221 patients presented with acute abdominal pain, underwent an intravenous contrast-enhanced CT scan upon initial presentation, underwent an appendectomy within 24 h of the initial diagnosis, and were pathologically diagnosed with acute appendicitis.In 16 patients, we were able to detect that part of the appendix was inflamed but were unable to interpret the position of the appendix; these patients were excluded from the study.A total of 205 patients met the study criteria.The position of the appendix for each case was classified into the following 6 groups: preileal, postileal, pelvic, subcecal, postcecal, and prececal.The retrocolic position was included in the postcecal group, and the precolic position was included in the prececal group.The age and gender of the patients were also recorded.The cases were divided into two groups depending on the time from the onset of symptoms to the CT scan as follows: group S underwent a CT scan within 10 h of the onset of symptoms, and group L was scanned after a symptom duration of more than 10 h.The distributions of appendix positions in groups S and L were compared.We also divided the cases into two groups according to the pathological inflammatory grade, namely, non-gangrenous appendicitis (group non-G) and gangrenous appendicitis (group G).To determine whether the final position of the appendix at diagnosis is related to the pathological inflammatory grade, the distributions of appendix positions in group's non-G and G were also compared.For statistical analyses of distributions of appendix positions,
Objective:To analyze the SVR rates and medication experience in patients treated with boceprevir or telaprevir, in combination with ribavirin and peginterferon alfa for HCV infection. Materials and methods:This study was a retrospective observational study in a United States specialty pharmacy, from July 2011 through June 2012.The primary outcome for this study was sustained virologic response (SVR) obtained through prescriber confirmation.2,004 patients receiving treatment for hepatitis C infection that were eighteen years of age and older, with prescription claims for ribavirin, pegylated interferon and a protease inhibitor (boceprevir or telaprevir) between July 1, 2011 and June 30, 2012 were initially included in the study.Results: SVR was achieved in 67% of patients analyzed which was significantly different from previous study rates seen in dual therapy.The most commonly reported adverse effect leading to discontinuation of therapy in the 138 patients that discontinued was hematologic adverse effects.Patients were more than 90% adherent to each medication in the regimen overall.SVR based on therapeutic regimen and medication possession ratio were also evaluated. Conclusion:Patients on protease inhibitor-based triple therapy for the treatment of genotype 1 hepatitis C infection had significantly improved SVR rates compared to previous published dual therapy rates.These findings support the American Association for the Study of Liver Diseases (AASLD) guideline recommendation for use of protease inhibitors.
