Biju Pottakkat

Hepatogastric fistula: a rare complication of pyogenic liver abscess

Hepatogastric fistula is very rare. We report a case of hepatogastric fistula as a complication of pyogenic liver abscess. A 40-year-old man presented with upper abdominal pain and high-grade fever of 2 weeks. Evaluation revealed multiple liver abscesses. On an empirical diagnosis of pyogenic liver abscess, he was treated with antibiotics. During hospital stay he developed intermittent large quantity bilious vomiting. Gastroduodenoscopy and contrast-enhanced CT of the abdomen showed rupture of left lobe liver abscess into the stomach. As expectant management failed to resolve the abscess, endoscopic retrograde papillotomy and stenting of common bile duct was performed. After endoscopic stenting, symptoms subsided. Imaging repeated after 2 weeks of endoscopic stenting showed resolving abscess. He was discharged and is doing well on regular follow-ups. We conclude that hepatogastricfistula can be managed by endoscopic stenting as bile flow through the stent hastens resolution and healing of the fistula.

Pathogenesis and Management of Hepatolithiasis: A Report of Two Cases

Hepatolithiasis or primary intrahepatic stones are prevalent in the Far-East countries such as Korea, Japan and Taiwan. It has been associated with helminthiasis, bacterial infections, environmental and dietary factors. Despite high prevalence of helminthiasis like ascariasis, poor environmental condition and low protein diet, India and Middle-East countries have a low incidence of hepatolithiasis. We report two cases of hepatolithiasis associated with bacterial infections and were surgically managed. The first case is a 45-year-old female presenting with upper abdominal pain and fever. She had multiple calculi in intrahepatic biliary radicles, common bile duct, common hepatic duct and gall bladder. She was managed by cholecystectomy, left lateral liver sectionectomy, choledochoscopy assisted stone clearance of the residual liver and Roux-en-Y hepatico-jejunostomy. The second case is a 60-year-old female presenting with epigastric pain and fever and past history of cholecystectomy for cholelithiasis. She had multiple right and left intrahepatic calculi and managed by left lateral liver sectionectomy with excision of CBD and Roux-en-Y hepatico-jejunostomy. Both the cases showed growth of bacteria in the culture of the intraoperatively collected bile.

Solitary fibrous tumor of the liver: a rare tumor in a rarer location

Solitary fibrous tumor is an uncommon mesenchymal neoplasm. Liver is a rare location of this tumor. We report a case of hepatic solitary fibrous tumor in a 56-year-old female, who presented with right upper abdominal pain. An extended right hepatectomy was performed. Histopathological and immunohistochemical examination revealed solitary fibrous tumor of the liver.

Biliary ascariasis: Mimicker of retained bile duct stone

We report a 22-year-old woman, a known case of systemic lupus erythematosus (SLE) with systemic hypertension on prednisolone, azathioprine, and antihypertensive medications, who was found to have gallbladder stones and choledocholithiasis. Elsewhere, she had undergone endoscopic sphincterotomy for symptomatic common bile duct stone followed by placement of a 7-Fr diameter ¥ 7 cm long, straight stent in the bile duct. While awaiting laparoscopic cholecystectomy, she developed recurrence of biliary colic 1 week prior to presenting to us. Evaluation revealed normal hemogram with elevated gamma glutamyl transferase (126 IU/L [normal 8–61 IU/L]) and alkaline phosphatase (327 IU/L [normal 30–125 IU/L]). Abdominal ultrasonography showed biliary dilatation with biliary sludge and stent in situ. Retained bile duct stone was suspected and repeat endoscopic retrograde cholangioscopy (ERC) was planned. Duodenoscopy showed the biliary stent and one Ascaris lumbricoides (Fig. 1a,b) projecting out of the papilla. The worm was alive and moving in and out (Video S1) of the papilla. Stent and worm were removed. Balloon occlusion cholangiogram did not reveal any retained stone. On follow up, the patient had no recurrence of symptoms. Mature parasites live in the small intestine and mostly remain asymptomatic. Biliary tract is an uncommon, but welldescribed, site for Ascaris infestation, probably attributed to the exploratory nature of the worm. To enter the bile duct, the worm has to move against the peristalsis; hence, it is supposed that biliary ascariasis occurs in a background of either heavy parasitic load pressing worms to look for unexplored areas, or reduced peristaltic movements. Biliary ascariasis is known to cause a wide spectrum of complications, such as biliary colic, cholangitis, acute pancreatitis, biliary obstruction, gallstones, cholecystitis, and liver abscess. Progesterone-induced sphincter of Oddi relaxation and endoscopic sphincterotomy are considered to be contributors to inducing biliary ascariasis. In our case, both of these risk factors were present. ACKNOWLEDGMENT

Double Trouble: Synchronous Adenocarcinoma of Gallbladder and Pancreas

Multiple primary malignant neoplasms in a single patient have been documented in the literature. It can be either synchronous or metachronous. Metachronous primary malignancies are becoming increasingly frequent because of an increase in the number of elderly patients and improvements in diagnostic techniques. However, synchronous primary malignancies are still unusual. Synchronous or metachronous cancers in the biliary system are often attributed to abnormal pancreaticobiliary junction (APBJ). Synchronous gallbladder and bile duct cancer are the most common association reported in patients with APBJ. An extremely rare association of gallbladder and pancreatic cancer in a middle-aged female is described in this report.

A Modified Framework for Multislice Image Fusion for High Contrast Liver Cancer Detection

ABSTRACT The exact boundary extraction of liver using abdominal computed tomography (CT) images continues to be the greatest challenge in the computer-assisted diagnosis of liver tumour, as the organ boundary is very weak. In this paper, an efficient algorithm is proposed to enhance the edge information of the CT images prior to segmentation, by means of multislice image fusion and anisotropic diffusion filtering in non-subsampled contourlet (NSCT) domain. The two adjacent slices of CT images are decomposed using NSCT, and the fusion of low- and high-frequency coefficients is obtained by means of phase congruency and sum-modified Laplacian operators, respectively. The major highlight of this work is that, prior to high-frequency fusion; the high-frequency coefficients of both images are processed using anisotropic diffusion to strengthen the edge information. Finally, the edge-enhanced image is obtained by NSCT reconstruction. The performance metrics show that the information pertaining to the edges is found to be precise in the fused image. The proposed logic, when applied to the real-time contrast-enhanced triple-phase CT image, has proven to be highly effective. All the image samples used in this work for test purpose were obtained from Jawaharlal Institute of Postgraduate Medical Education Research (JIPMER), a Medical Research Institute and Hospital at Puducherry, India.

A multimodal intervention to improve hand hygiene compliance in a tertiary care center

Background: Healthcare‐associated infections (HAIs) are a major threat to patient safety worldwide. HAIs are mainly transmitted via the hands of healthcare workers (HCWs), and HCW compliance with hand hygiene (HH) practices is reportedly low. Therefore, multimodal interventions are needed to develop effective HH improvement strategies. In this study, we assessed the effect of multimodal interventions on improvement of HH compliance. Methods: This study was conducted in 2 intensive care units from August 2016 to October 2016. It encompassed 3 phases: pre‐intervention (20 days), intervention (1 month), and post‐intervention (20 days). A total of 53 HCWs, including physicians, nurses, and housekeeping staff, were included in the HH audit. The audit was analyzed by direct observation and by a completed knowledge, attitude, and practice (KAP) questionnaire. Results: A total of 6350 HH opportunities were recorded; the results were 34.7%, 35%, and 69.7% for hand hygiene complete adherence rate (HHCAR), hand hygiene partial adherence rate (HHPAR), and hand hygiene adherence rate (HHAR), respectively. The HHCAR in the pre‐intervention and post‐intervention phases were 3% and 70.1%, respectively. HHCAR was highest among nurses (3.6% in the pre‐intervention phase and 80.7% in the post‐intervention phase). Other findings were that senior physicians had better HH compliance than junior physicians; in the pre‐intervention phase, the HHCAR was better in the evening (4.8%); in the post‐intervention phase, the HHCAR was better in the morning (72.1%); women had a higher HHCAR than men; and in the pre‐intervention phase, good compliance was seen with Moments 2 and 3 of the World Health Organizations (WHO) Five Moments for Hand Hygiene, whereas in the post‐intervention phase, good compliance was seen with Moments 3, 4, and 5. Questionnaire‐based data were also analyzed to assess KAP of HH. We found that only 55%‐82% of HCWs were aware of the WHOs Five Moments for Hand Hygiene. In the post‐intervention phase, we observed a significant improvement in KAP of the study group. Conclusion: Significant improvement in HH compliance can be achieved through a systematic, multidimensional intervention involving all types of HCWs.

Bacteriological Profile of Pancreatic Juice in Patients with Chronic Pancreatitis

CONTEXT Information regarding the association of bacteria in the pancreatic fluid in patients with chronic pancreatitis is limited. OBJECTIVE This study was designed to analyze the prevalence of bacteria in pancreatic juice in patients with chronic pancreatitis and the association of positive pancreatic fluid culture with pre-operative and post-operative parameters. METHODS All patients with chronic pancreatitis who underwent operation from November 2011 to October 2013 were prospectively included in the study. Intra-operatively pancreatic duct fluid was collected and sent for culture sensitivity in all patients. The bacteriology of the fluid was analyzed and was correlated with preoperative, intraoperative and postoperative parameters. RESULTS A total of 26 patients were analyzed. Two patients underwent endoscopic retrograde cholangio-pancreatography (ERCP) preoperatively. Bacteria was present in pancreatic duct fluid in 11 (42%) patients. Both patients who underwent ERCP had positive cultures. Most common organism observed was Escherichia coli (6/11, 55%) followed by Klebsiella pneumonia (3/11, 27%). Five patients with positive culture developed wound infection. Bacteria isolated from the wound were similar to pancreatic fluid. CONCLUSION Bacteria is commonly present in the pancreatic juice in patients with chronic pancreatitis and its presence may have an effect on the post-operative infections following operations. Based on the pancreatic fluid culture results appropriate antibiotic can be given to the patients who will develop septic complications following surgery. Role of bacteria in the pathogenesis of the chronic calcific pancreatitis needs to be investigated in future studies.

Tuberculous bronchoesophageal fistula: A case report

Tracheoesophageal fistula and bronchoesophageal fistula (BEF) usually result from malignancy. BEF caused due to benign conditions is rare. Here, we report a case of BEF due to tuberculosis. A 65-year-old lady presented with 15 days history of dysphagia, cough, and fever. Esophagoscopy revealed an ulcerated lesion at 22 cm. Further evaluation with contrast-enhanced computed tomography revealed mid-esophageal wall thickening, mediastinal and supraclavicular lymphadenopathy, along with BEF. Endoscopic tissue biopsy from ulcer revealed tuberculosis. The patient was put on antituberculous drugs and showed good response to therapy.