Arunanshu Behera

Portal hypertensive biliopathy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertension in the developing countries, and constitutes up to 40% of all patients with portal hypertension.1,2 EHPVO is a common cause of major upper-gastrointestinal bleeding among children.2–4 The most common presentation in children is well-tolerated variceal bleeding and splenomegaly. In adults, EHPVO is often recognised when evaluating for other disorders or with uncommon presentations such as jaundice, pruritus, acute cholecystitis-like syndrome, ascites and so on, resulting from prolonged portal hypertension.5–7 The portal vein in EHPVO is transformed into a cavernoma, which is a bunch of multiple collateral veins around the obstructed portion of portal vein (fig 1). Marked improvements in the management of variceal bleeding in patients with EHPVO have resulted in an improved survival, thus presenting with unusual symptoms in adulthood. Figure 1  Splenoportovenogram showing multiple collaterals (portal cavernoma) replacing the portal vein (arrows) in a patient with extrahepatic portal venous obstruction. The splenic vein is normal (arrowheads). The reasons for EHPVO are obscure in approximately half of the patients. Omphalitis and intra-abdominal sepsis are the common causes in neonates and children. Adults develop EHPVO due to increased blood coagulability, local inflammation, intra-abdominal sepsis, myeloproliferative disorders, underlying cirrhosis, or tumours in the liver, bile ducts or pancreas.7,8,9,10 Gibson et al 11 first reported the relationship between EHPVO and jaundice in 1965. Since then, several cases of obstructive jaundice due to common bile duct (CBD) obstruction caused by cavernomatous transformation of portal vein (portal cavernoma) have been described. Williams et al 12 were the first to report cholangiographic changes caused by choledochal varices. We, for the first time, describe abnormalities on endoscopic retrograde cholangiography (ERC) in a prospective study.13 These abnormalities were similar to those of primary sclerosing cholangitis and …

Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: Recognition and management

Background: Internal pancreatic fistulas are well recognized complications of chronic pancreatitis.

Current management of gall bladder perforations

Background:  Gall bladder perforation is a serious complication of acute cholecystitis. The purpose of the present study is to evaluate the presenting symptoms, diagnosis and management of patients with gall bladder perforations.

Pseudoaneurysm of the cystic artery: a rare cause of hemobilia

Aneurysms are a rare cause of hemobilia, and usually involved are branches of the hepatic and gastro-duodenal arteries. A case of a patient with hemobilia secondary to a pseudoaneurysm of the cystic artery is presented. Fewer than 10 cases have been reported in the literature, and in all of them the condition was associated with inflammation of the gall bladder, as in our case. Selective hepatic angiography is the procedure of choice for diagnosis. Upper gastrointestinal endoscopy with side-viewing scopy can demonstrate bleeding from papilla. Color-Doppler ultrasonography also may prove to be useful in equivocal cases. Cholecystectomy and ligation of cystic artery with proximal control of the hepatic artery was done at laparotomy after diagnosis was made.

Vascular complications of drug abuse: an Indian experience

Background:  Vascular complications resulting from i.v. drug abuse constitute a range of clinical problems from simple to serious. In addition, patients who present with these complications frequently have viral infections, which are a hazard to health care workers.

Isolated roux loop pancreaticojejunostomy vs single loop pancreaticojejunostomy after pancreaticoduodenectomy

BACKGROUND Pancreatic anastomotic leaks are a major cause of morbidity and mortality following pancreaticoduodenectomy, and no single technique of reconstruction has shown to be superior. The aim of this study was to review the experience of single loop versus isolated Roux loop pancreaticojejunostomy in a series of patients undergoing pancreatic head resection. METHODS A retrospective review involving 111 patients who underwent pancreatic head resections over 13year period (1994-2006) for malignant (n=106) and benign (n=5) disease was performed. Reconstruction of the pancreatic remnant was done using a single loop in 51 patients and by an isolated Roux loop in 60 patients. All pancreatic anastomosis were performed as a duct to mucosa anastomosis, in two layers, with pancreatic stent and closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50ml of amylase rich fluid for more than 7days postoperatively. RESULTS The two groups were comparable as regards to their demographic profiles, preoperative laboratory values and disease status in terms of pathology, pancreatic texture and pancreatic duct diameters. The overall incidence of pancreatic anastomotic leak was 11% (12) and was similar in both the groups; single loop 12% (6) and isolated Roux loop 10% (6). Isolated Roux loop pancreaticojejunostomy was associated with a significant prolongation of operative time (7.25+/-1.14h vs 6.07+/-1.12h) (p<0.05) and the need for more blood transfusion (2.25+/-0.84units vs 2.62+/-0.69units) (p<0.05). There was no significant difference in the morbidity or mortality between the two groups. Forty five percent (23) patients had complications in the single loop group and 48% (29) patients had complications in the isolated group. There were 8% (4) death in the single loop group and 8% (5) in the isolated group (p>0.05). CONCLUSION There does not appear to be a significant difference in the rates of pancreatic fistula following either method of reconstruction. However, performance of an isolated Roux loop pancreaticojejunostomy entails a prolongation of operative time and more intraoperative requirement of blood transfusions.

Pheochromocytoma associated with pregnancy

Pheochromocytoma associated with pregnancy is rare with potentially lethal consequences. Antepartum diagnosis improves the maternal and perinatal outcome. The issue of mode of delivery is unresolved. Its definitive treatment is surgical resection preceded by medical management. Surgical resection may be done during caesarean section as is reported in the present case.

Necrotizing fascitis after injection sclerotherapy for hemorrhoids

A case report of a patient who underwent submucosal injection sclerotherapy for hemorrhoids is presented. Subsequently developed necrotizing fascitis of the anorectum, perianal region, and scrotum necessitated emergency debridement and defunctioning colostomy. Postoperatively, the patient developed septicemia and renal failure requiring an extended hospital stay. Restoration of bowel continuity was done after three months. A brief review of known complications of this technique was made. It would appear that necrotizing fascitis can be added to this list.

Influence of age and gender on presentation of symptomatic primary hyperparathyroidism.

BACKGROUND The geographical difference in presentation of primary hyperparathyroidism (PHPT) is known. However, there is sparse literature on the influence of age and gender on presentation of PHPT. AIM To analyze the effect of age and gender on presentation of symptomatic primary hyperparathyroidism. SETTING AND DESIGN This is a retrospective analysis of data from the primary hyperparathyroidism registry of a north Indian tertiary care teaching institute. MATERIALS AND METHODS Analysis of 184 histopathologically proven PHPT patients registered between March 1990 and March 2010 from a single centre of north India. PHPT patients were divided into three different age groups i.e. children and adolescents less than 25 years, adults 25-49 years, and ≥ 50 years. Clinical presentations, biochemical parameters and parathyroid weight were compared between different age groups and gender using appropriate statistical methods. RESULTS Mean age of patients was 38.5±13.8 years with female: male ratio of 7:3. Rickets as presenting manifestations were seen in one child and adolescent each. Prevalence of renal stones (P=0.03) and gall stones (P=0.02) was higher in the adult groups compared to the younger and older. There was no difference in bone pain (P=0.7), fracture (P=0.3), osteitis fibrosa cystica (P=0.2), fatigue (P=0.6) and other symptoms among different age groups. There was no difference in serum calcium, phosphate, parathyroid hormone (PTH) and 25 (OH) D levels among different age groups, however, as expected alkaline phosphatase was higher in adolescents compared to adults (P=0.03). Bone pain and muscle aches (P<0.001), fracture (P=0.04), osteitis fibrosa cystica (P=0.01), and gall stones (P=0.03) were more common among women while renal stones (P=0.05) and pancreatitis (P=0.02) were common in men. Serum calcium and phosphate levels were similar in either sex but parathyroid hormone (iPTH) level was higher among women (P=0.02). Parathyroid adenoma weight was higher in older compared to young but did not reach to a level of statistical significance. CONCLUSION Age and gender have substantial influence on presentation of PHPT. Bone pain and rickets were common in children and adolescents while renal stones in adults. Women have more severe disease as musculoskeletal manifestations are common and iPTH levels are also higher compared to men.

Portal Cavernoma Cholangiopathy: Consensus Statement of a Working Party of the Indian National Association for Study of the Liver

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.