D. K. Bhargava

Diagnosis of ileocecal and colonic tuberculosis by colonoscopy

The colonoscopic findings in 11 proven cases of ileocecal tuberculosis consisted of deformed ileocecal valve in all 11 and contracted cecal lumen in 10. This was associated with mucosal nodules predominantly around the ileocecal valve, pseudopolypoid folds, and mucosal protuberance. Two patients had an isolated cecal ulcer. In three of the 11 patients the examination enabled a histologic diagnosis to be made on the basis of typical granuloma. In the other four patients Mycobacterium tuberculosis was isolated from the tissue obtained through biopsies.

Endoscopic diagnosis of segmental colonic tuberculosis

We report colonoscopic findings in 29 proven cases of segmental colonic tuberculosis. The colonoscopic appearances of tuberculosis included: mucosal nodules and ulcers, stricture with nodules and ulcerations, and mucosal nodules with or without pseudopolypoid folds. In 12 (41%) of 29 patients colonoscopy biopsies enabled a histologic diagnosis to be made on the basis of typical granulomas. Culture of biopsy tissue on Lowenstein Jensen media isolated Mycobacterium tuberculosis in six (40%) of 15 patients. Combined histologic and bacteriologic evaluation established the diagnosis in 60% of patients. We conclude that even though target biopsy is an effective method of diagnosis, anti-tuberculous chemotherapy may be started on the basis of the endoscopic appearance if there is a high clinical suspicion of tuberculosis.

Adenosine deaminase (ADA) in peritoneal tuberculosis: Diagnostic value in ascitic fluid and serum

Simultaneous determination of ascitic fluid and serum adenosine deaminase (ADA) activity was evaluated as a diagnostic aid in peritoneal tuberculosis. The ascites was due to peritoneal tuberculosis (group 1), cirrhosis of the liver (group 2), cirrhosis of the liver with spontaneous bacterial peritonitis (group 3), peritoneal malignancy (group 4), Budd-Chiari Syndrome (group 5) and miscellaneous conditions (group 6). Serum from patients of pulmonary tuberculosis and healthy volunteers was analysed for enzyme activity. In patients with peritoneal tuberculosis the ascitic fluid and serum ADA activity was significantly higher than for the other groups (P less than 0.001). Levels above 36 u/l in ascitic fluid and above 54 u/l in the serum suggest tuberculosis. The ascitic fluid/serum ADA ratio was also higher in patients with peritoneal tuberculosis than with other causes of ascites (P less than 0.01). A ratio of more than 0.984 was suggestive of tuberculosis.

Role of omeprazole in prevention and treatment of postendoscopic variceal sclerotherapy esophageal complications. Double-blind randomized study.

Endoscopic variceal sclerotherapy-related esophageal complications are quite common. The potential efficacy of omeprazole in the prevention and treatment of postsclerotherapy esophageal complications was evaluated in 47 patients with portal hypertension in a randomized, placebo-controlled study. Twenty-one patients in the omeprazole group and 23 patients in the placebo group completed the study. The two treatment groups were similar in regards to the etiology of portal hypertension, Childs class, and clinical characteristics. Esophageal ulcers developed in 16 patients in the omeprazole group (2.43 ulcers/patient) and 18 patients in the placebo group (2.39 ulcers/patient). Most of the ulcers (>90%) healed within 14 days in each group. Esophageal strictures requiring dilatation developed in two and one patient in the omeprazole and placebo groups, respectively. There was no statistically significant difference in regards to the complication rate between the two groups. We conclude that omeprazole is not effective for the prevention or treatment of postsclerotherapy esophageal complications.Endoscopic variceal sclerotherapy-related esophageal complications are quite common. The potential efficacy of omeprazole in the prevention and treatment of postsclerotherapy esophageal complications was evaluated in 47 patients with portal hypertension in a randomized, placebo-controlled study. Twenty-one patients in the omeprazole group and 23 patients in the placebo group completed the study. The two treatment groups were similar in regards to the etiology of portal hypertension, Childs class, and clinical characteristics. Esophageal ulcers developed in 16 patients in the omeprazole group (2.43 ulcers/patient) and 18 patients in the placebo group (2.39 ulcers/patient). Most of the ulcers (>90%) healed within 14 days in each group. Esophageal strictures requiring dilatation developed in two and one patient in the omeprazole and placebo groups, respectively. There was no statistically significant difference in regards to the complication rate between the two groups. We conclude that omeprazole is not effective for the prevention or treatment of postsclerotherapy esophageal complications.

Hepatic granulomas due to visceral larva migrans in adults: appearance on US and MRI

Visceral larva migrans is a syndrome characteristically involving children with a history of pica, and usually presents with fever, abdominal pain, tender hepatomegaly, and hypereosinophilia. Hepatic granulomas of visceral larva migrans are rare in adults. We describe three adult patients with hepatic lesions which on histopathology demonstrated characteristic granulomas of visceral larva migrans. All patients had abdominal sonograms and two had additional MR scans of the liver. Both ultrasound and magnetic resonance imaging demonstrated characteristic appearances which have not been described previously (viz., ill-defined central necrotic areas surrounded by concentric thick walls and perifocal edema in the liver parenchyma).

Efficacy of endoscopic sclerotherapy on long‐term management of oesophageal varices: A comparative study of results in patients with cirrhosis of the liver, non‐cirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHO)*

A prospective study was conducted to compare the results of long‐term endoscopic variceal sclerotherapy in patients with different aetiologies of portal hypertension. A total of 404 consecutive patients were included. There were 234 patients with hepatic cirrhosis, 83 with non‐cirrhotic portal fibrosis (NCPF) and 87 with extrahepatic portal venous obstruction (EHO). The mean follow‐up for patients with cirrhosis, NCPF and EHO was 25, 37 and 28 months. A total of 73 (31%) patients with cirrhosis, 19 (23%) with NCPF and 10 (11.5%) with EHO rebled (P < 0.05) on follow‐up, prior to eradication of varices. Irrespective of the aetiology, 40 (17%) patients of Childs A class, 42 (33%) of Childs B and 20 (50%) of Childs C class rebled (P<0.01). The median bleeding free period (BFP) was longer (P<0.05) in patients with EHO than in cirrhotics. Patients in Childs A class had significantly longer BFP than those in Childs B, and the latter had a longer BFP than those in Childs C class (P<0.01). The probability of 7‐year survival was also better with EHO (97.5%) and NCPF (73.6%) than cirrhotics (41%). Survivals in patients with EHO and NCPF were comparable (P<0.1). Similarly 7‐year survival irrespective of aetiology in Childs A patients (90.7%) was longer than in Childs B (28.8%), and longer in Childs B than Childs C patients (0%). Success of eradication was greater (P<0.05) in EHO (92%) and NCPF (87%) than cirrhotic patients (75%). This was also related to the Childs status of patients. Recurrence of varices, and complications related to the procedure, were not influenced by Childs status or by the aetiology of portal hypertension. For a given Childs class, the results of scierotherapy in the different aetiological groups were similar.

Endoscopic sclerotherapy for portal hypertension due to extrahepatic obstruction: long-term follow-up

Between 1982 and 1987, 43 patients with variceal bleeding due to extrahepatic portal obstruction were treated by repeated endoscopic injection sclerotherapy using 1% polidocanol intravariceally. This decreased rebleeding, as evidenced by a decrease in bleeding risk factor (BRF), mean transfusion requirement, and mean number of transfusions per patient per month of follow-up. Differences between pre- and postsclerotherapy parameters were significant (p less than 0.001). The varices were eradicated in 86% of patients. The mean sclerotherapy sessions required were 7.68 +/- 2.39 (SD). Complications were infrequent. Forty-three patients were followed from 5 to 68 months: cumulative survival was 97.7% and varices recurred in 16%. Sclerotherapy avoided a second operation in 21 postsurgical patients. Sclerotherapy for managing variceal bleeding due to extrahepatic portal obstruction is a reasonable alternative to surgery.

Comparative efficacy of emergency endoscopic sclerotherapy for active variceal bleeding due to cirrhosis of the liver, non-cirrhotic portal fibrosis and extrahepatic portal venous obstruction

Patients with continued variceal bleeding due to portal hypertension (n= 202) were treated by endoscopic injection sclerotherapy after resuscitation. Portal hypertension was due to hepatic cirrhosis in 123, non‐cirrhotic portal fibrosis (NCPF) in 49 and extrahepatic portal venous obstruction (EHO) in 30 patients. Polidocanol 1% was injected intravariceally. An adequate sclerotherapy was carried out in 97% of patients.

Laparoscopy in carcinoma of the gallbladder

Twenty-three patients with gallbladder carcinoma were critically evaluated by laparoscopy. The diagnosis was confirmed in each case by either histology, cytology, or laparotomy. Direct evidence of carcinoma was present in 15 (65%) and indirect in eight (35%) patients. Cytology alone was positive in 80%, biopsy alone was positive in 60%, and the two techniques in combination yielded tissue diagnosis in 86% of patients having direct evidence. The yield of positive biopsy or cytology was low in cases with indirect evidence. Laparoscopy also circumvented laparotomy in 39% of patients because of the finding of multiple metastatic lesions over the liver surface.

Results of endoscopic variceal sclerotherapy: Influence of etiology of portal hypertension and hepatic functional status

SummaryIn India 50% of patients with gastrointestinal bleeding bleed from esophageal varices. Causes of portal hypertension includes hepatic cirrhosis, non-cirrhotic portal fibrosis and extrahepatic portal obstruction. Endoscopic sclerotherapy is the treatment of choice to control continued active bleeding. Immediate hemostasis was not influenced by the etiology of portal hypertension. However, rebleeding episodes were lower, in extrahepatic portal vein obstruction than non-cirrhotic portal fihrosis and cirrhotic patients. Child’s status significantly influenced recurrence of bleeding and mortality which was lower in child’s A than B and lower in B than C irrespective of etiology. Results of long term sclerotherapy were also influenced by the etiology of portal hypertension and hepatic functional status. Sclerotherapy was most effective in patients of (EHO), than (NCPF) followed by cirrhosis of the liver.