Rakesh Kochhar

The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns

We prospectively evaluated the role of fiberoptic esophagogastroduodenoscopy in the management of 81 patients with corrosive ingestion. A total of 381 endoscopic examinations were performed: 88 within 96 hours following corrosive ingestion, 108 between the third and ninth week, and 185 during the period of follow-up after bougie dilation of esophageal strictures. The customary endoscopic classification of burns (grades 0 to 3) was modified by subdividing grade 2 burns into 2a and 2b, and grade 3 burns into 3a and 3b for prognostic and therapeutic implications. There was no significant correlation between oropharyngeal and upper gastrointestinal tract injury. Early major complications and deaths were confined to patients with grade 3 burns. All patients with grade 0, 1, and 2a burns recovered without sequelae. The majority of patients (71.4%) with grade 2b injury and all survivors with grade 3 injury developed esophageal or gastric cicatrization, or both, which needed endoscopic or surgical treatment. There were no complications related to endoscopy. We conclude that early endoscopy is not only a safe, reliable, and accurate diagnostic tool in such patients, but also is of crucial importance in management and prognosis.

Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate

In a prospective study, 37 consecutive patients with radiation-induced proctosigmoiditis were randomized to receive a four-week course of either 3.0 g oral sulfasalazine plus 20 mg twice daily rectal prednisolone enemas (group I,N=18) or 2.0 g twice daily rectal sucralfate enemas plus oral placebo (group II,N=19). The two groups were comparable with respect to demographic features, duration of symptoms, and clinical and endoscopic staging of the disease. Fifteen patients in group I and 17 in group II completed the trial. At four weeks, both groups showed significant clinical improvement (P<0.01 for group I andP<0.001 for group II) and endoscopic healing (P<0.01 for group I andP<0.001 for group II). When the two groups were compared, sucralfate enemas showed a significantly better response as assessed clinically (P<0.05), although endoscopically the response was not statistically different (P>0.05). We conclude that both treatment regimens are effective in the management of radiation proctitis. Sucralfate enemas give a better clinical response, are tolerated better, and because of the lower cost should be the preferred mode of short-term treatment.

Ingestion of corrosive acids: Spectrum of injury to upper gastrointestinal tract and natural history

We have prospectively evaluated 41 patients who ingested acid for location, extent, severity, and outcome of the injury to the upper gastrointestinal tract. The injury was assessed within 36 h of acid intake by endoscopy or surgery, or at autopsy. Symptoms and signs were unreliable in predicting the extent and severity of injury. The degree of burns was classified as follows: grade 0 in 2 patients, grade 1 in 3, grade 2 in 16, and grade 3 in 20. Esophageal injury was seen in 87.8% of the patients, gastric injury in 85.4%, and duodenal injury in 34.1%. All patients with grade 0, 1, and 2a injury recovered without sequelae. Acute complications occurred in 39.1% of the cases, and death in 12.2%. It is significant that all such patients had grade 3 burns. Five of the 8 patients with grade 2b injury and all survivors of grade 3 injury developed esophageal or gastric cicatrization, or both, which subsequently needed endoscopic or surgical treatment. We find that endoscopy is not only the tool of choice for diagnosis in such cases but also aids in deciding upon treatment and prognosis. We conclude that acid injury of the upper gastrointestinal tract is a very serious condition that affects the esophagus and stomach equally and results in high morbidity and mortality.

Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures

INTRODUCTION The cornerstone treatment for benign esophageal strictures is endoscopic dilation. There are reports suggesting that intralesional corticosteroid injection decreases the frequency of endoscopic dilation. METHODS Seventy-one patients (mean age 42.39 [17.52] years; range, 13-78 years) with benign esophageal strictures (corrosive 29, peptic 14, anastomotic 19, radiation-induced 9) were recruited for this study. All were being managed with a program of intermittent endoscopic dilation by using over-the-wire polyvinyl dilators. All patients were treated by intralesional injections of triamcinolone acetonide (40 mg/mL diluted 1:1 with saline solution) by using a 23-gauge, 5-mm long sclerotherapy needle in aliquots of 0.5 mL. At each session, 4 injections (4 quadrants) were made at the proximal margin of the stricture with another 4 injections into the strictured segment itself whenever possible. The intervals between dilations and frequency of dilations were calculated before and after triamcinolone injections. A periodic dilation index (defined as number of dilations required per month) before and after the triamcinolone injections was calculated. RESULTS The overall mean (SD) duration of treatment before intralesional injection was 10.9 (19.8) months (range, 1-120 months) and the mean number (SD) of esophageal dilations required was 9.67 (13.06) (range, 1-70). The mean number of sessions of intralesional injection was 1.4 (0.62). After initiation of intralesional injections mean follow-up was 8.1 (5.6) months (range 3-30 months) and the mean number of esophageal dilations was 3.8 (3.0) (range 0-16). The periodic dilation index decreased significantly from 1.24 (0.05) (range 0.13-3.16) before injection to 0.5 (0.33) (range, 0-2) after injection (p < 0.001). For each category of stricture, the periodic dilation index decreased significantly: corrosive, 1.24 (0.5) to 0.53 (0.34) (p < 0.001); peptic, 0.92 (0.44) to 0.42 (0.2) (p < 0.001); anastomotic, 1.24 (0.49) to 0.51 (0.4) (p < 0.001); and radiation-induced, 1.32 (0.6) to 0.6 (0.3) (p < 0.02). CONCLUSION Intralesional injections of triamcinolone augment the effects of dilation in patients with benign esophageal strictures.

Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures

BACKGROUND Intralesional corticosteroid injection has been shown to be effective in refractory esophageal strictures of various etiologies. The present study was conducted to determine the efficacy of intralesional triamcinolone in augmenting results of endoscopic dilation in corrosive esophageal strictures. METHODS Seventeen patients with corrosive esophageal strictures were treated with endoscopic dilation together with injection of triamcinolone acetonide into the stricture. Fourteen patients were already undergoing dilation; 3 patients were newly recruited. The interval between dilations and frequency of dilation were calculated before and after corticosteroid injections, and periodic dilation index was calculated as number of dilations/number of months. RESULTS The mean age of the 17 patients (8 men and 9 women) was 30+/-9.21 (range 13 to 52). Thirteen had strictures due to acid ingestion, four to alkali ingestion. There were 18 strictures in total, involving the upper (n = 2), middle (n = 10), and lower (n = 6) thirds of esophagus. Fourteen patients already on a dilation program had undergone 27.92+/-28.63 (range 6 to 92) dilations over a period of 22.92+/-30.73 months (range 2 to 96) before corticosteroid injections. Nine patients received a single injection of triamcinolone, whereas four each had two and three sessions. The dilation requirement after injections in these 14 patients was reduced to 3.57+/-2.90 (range 0 to 10) dilations over a period of 10.5+/-5.58 (range 4 to 21) months. The median total periodic dilation index irrespective of corticosteroid therapy was 0.33 (range 0.55 to 1.8). In 12 of the 14 patients, periodic dilation index before injections (range 0.91 to 3.0, median 1.67) was higher than the median total periodic dilation index and in all the 14 patients periodic dilation index after corticosteroid therapy (range 0 to 0.83, median 0.32) was less than the median of total periodic dilation index (p < 0.01). In addition three patients received intralesional corticosteroid injections at the time of first dilation. These three patients could be effectively dilated with 5, 3, and 3 dilations. CONCLUSIONS Intralesional triamcinolone injections augment the effects of endoscopic dilation in patients with corrosive esophageal strictures.

Natural History of Late Radiation Proctosigmoiditis Treated with Topical Sucralfate Suspension

Rectal bleeding due to radiationproctosigmoiditis is often difficult to manage. We hadearlier shown the efficacy of short-term therapy withtopical sucralfate in controlling bleeding in theradiation proctosigmoiditis. We now report our long-termresults with this form of therapy. The study comprised26 patients with radiation proctosigmoiditis.Sigmoidoscopically, 9 (34.6% patients had severechanges, 15 (57.69%) had moderate, and 2 (7.69%) hadmild changes. Severity of bleeding was graded as severe(>15 episodes per week), moderate (8-14 episodes perweek), mild (2-7 episodes per week), negligible (1 episode per week), or nil (no bleeding). Tenpatients had moderate rectal bleeding, while 16 hadsevere bleeding. All patients were treated with 20 ml of10% rectal sucralfate suspension enemas twice a day until bleeding per rectum ceased orfailure of therapy was acknowledged. Response to therapywas considered good whenever the severity of bleedingshowed improvement by a change of two grades. Rectally administered sucralfate achieved good responsein 20 (76.9%) patients at 4 weeks, 22 (84.6%) patientsat 8 weeks, and 24 (92.3%) patients at 16 weeks. Thischange was significant by Wilcoxon matched-pairs signed-ranks test. Two patients requiredsurgery due to poor response. Over a median follow-up of45.5 months (range 5-73 months) after cessation ofbleeding, 17 (70.8%) patients had no further bleeding while 7 (22.2%) had recurrence of bleeding. Allrecurrences responded to short-term reinstitution oftherapy. No treatmentrelated complications wereobserved. Ten patients had other associated latetoxicity due to pelvic irradiation in the form ofasymptomatic rectal stricture (N = 3), rectovaginalfistula (N = 1), intestinal stricture (N = 1), vaginalstenosis (N = 1), and hematuria (N = 6). Three patients had progression of the primary disease in theform of pelvic recurrence (N = 2) and hepatic metastases(N = 1). We conclude that topical sucralfate induces alasting remission in a majority of patients with moderate to severe rectal bleeding due toradiation proctosigmoiditis.

Radiation therapy of esophageal cancer: Role of high dose rate brachytherapy

Fifty untreated cases of squamous cell carcinoma arising from the middle one-third of the esophagus, with no apparent extraesophageal spread on a computed tomography (CT) scan and with a Karnofsky performance status of over 70, were treated by external beam irradiation to a dose of 3500 cGy/15 fractions/3 weeks. Twenty-five patients (Group A) received treatment with further external beam irradiation to a dose of 2000 cGy/10 fractions/2 weeks. Another group of 25 patients (Group B) received treatment with high dose rate intracavitary irradiation to a dose of 1200 cGy delivered in two sessions of 600 cGy each a week apart. All patients were assessed symptomatically, endoscopically, and radiologically every 3 months. There was marked difference at the end of 1 year in relief of dysphagia (37.5% in Group A vs. 70.6% in Group B), local control (25% in group A vs. 70.6% in group B) although the results were statistically insignificant (p greater than 0.05) and actuarial survival (44% in group A vs. 78% in group B) which was, however, significant statistically (z = 2.83). The cumulative radiation effect (CRE) by external beam irradiation was 1729 reu and by external beam and intracavitary irradiation 1741 reu, but the biological dose effect was better with external beam and intracavitary irradiation. Eight percent of patients treated by external beam and intracavitary irradiation had strictures in contrast to 4% treated by external beam irradiation alone. Moderate doses of external beam and intracavitary irradiation can give a better local response than external beam irradiation alone for the same biological dose in the treatment of esophageal carcinoma.

Visceral leishmaniasis associated hemophagocytic lymphohistiocytosis – Case report and systematic review

BACKGROUND The clinical features of leishmaniasis overlap with that of hemophagocytic lymphohistiocytosis (HLH) and the diagnosis of visceral leishmaniasis (VL) related HLH can be challenging. OBJECTIVES To review information available on disease course, treatment, adjunctive therapy used and the outcomes of VL related HLH. METHODS We describe an illustrative case and review all reported cases of VL associated HLH in the English literature till March 2007. RESULTS VL associated HLH is rare, with 56 cases reported in the English literature. Clinical features lack discriminating value to recognize VL as the inciting etiology. Bone marrow aspiration (BMA) establishes the diagnosis in 78% of cases but is often negative at onset of the syndrome due to the pauci-microbial nature of the disease and patchy involvement. Repeated marrow aspiration, liver biopsy, blood cultures and serology may be required to establish the diagnosis. Liposomal amphotericin is the drug of choice. IVIG may be considered when there is an inadequate response to anti-leishmanial therapy in severe and refractory disease. CONCLUSIONS VL related HLH is often under-recognized because of overlapping clinical features and negative marrow evaluation at onset, leading to high mortality rates.

Sucralfate enema in ulcerative rectosigmoid lesions.

To assess the efficacy of sucralfate enemas in distal colonic ulcerative lesions, 22 patients with radiation proctitis (n=8), idiopathic ulcerative proctitis (n=5), and solitary rectal ulcer (n=5) unresponsive to conventional medical therapy, and those with ulcerated and bleeding rectal polyps awaiting polypectomy (n=4) were studied. Enemas of sucralfate suspension (2 gm in 20 ml water) were administered twice daily for a period of three weeks. Clinical and sigmoidoscopic improvements were observed in 19 and 18 of the 22 patients, respectively (86 and 82 percent, respectively). No side effects were seen. The authors conclude that sucralfate enemas are useful in the treatment of ulcerative lesions of the rectosigmoid.

Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia

OBJECTIVE To assess the role of multidetector CT angiography (MDCTA) in the diagnosis of acute mesenteric ischemia (AMI) and to compare the diagnostic utility of axial images with reconstructed images. MATERIALS AND METHODS In this Institute Review Board approved prospective study, MDCTA was performed on 31 patients who presented with the clinical suspicion of AMI (25M; 6F, age range: 16-73 years). Axial and reconstructed images of each patient were evaluated independently by two radiologists for evidence of bowel wall thickening, abnormal mucosal enhancement, bowel dilatation or obstruction, mesenteric stranding, ascites, solid organ infarcts, pneumatosis intestinalis or porto-mesenteric gas, and mesenteric arterial or venous occlusion. MDCT findings were correlated with the surgical findings and clinical outcome. Patients were later divided into two groups: a study group of patients with proven AMI and a control group of patients with an alternate diagnosis, for the purpose of statistical analysis. RESULTS AMI was correctly diagnosed in all 16 patients on MDCTA (100% sensitivity and specificity) of whom nine patients underwent surgical exploration. Three patients expired before surgery and the remaining 5 patients were proven based on positive clinical and laboratory findings. Mesenteric arterial occlusion was seen in 7 patients while 5 patients had portomesenteric venous thrombosis. Reconstructed images using minimum intensity projection, volume rendering and multiplanar volume reconstruction were found to perform better for the detection of vascular abnormalities and improved the diagnostic confidence of both radiologists in the evaluation of bowel and mesenteric abnormalities. CONCLUSION MDCTA is an effective non-invasive modality for the diagnosis of mesenteric ischemia.