Rtika R Abraham

Management of gastric variceal bleeding: Role of endoscopy and endoscopic ultrasound

Gastric varices (GVs) are notorious to bleed massively and often difficult to manage with conventional techniques. This mini-review addresses endoscopic management principles for gastric variceal bleeding, including limitations of ligation and sclerotherapy and merits of endoscopic variceal obliteration. The article also discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis, improved classification, innovative management strategies and confirmatory tool for eradication of GVs.

Palindromic rheumatism: strategies to prevent evolution to rheumatoid arthritis.

may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See ‘‘Information for Authors’’ for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.

Spontaneous pituitary apoplexy during the second trimester of pregnancy, with sensory loss

A 32-year-old Hispanic woman at 23 weeks gestation presented with right-sided headache, associated with photophobia and right-sided numbness. She denied visual problems, menstrual irregularities and galactorrhoea. Examination revealed visual acuity 20/40 bilaterally with some blurriness on the left side, decreased right V1-V2 facial sensation and preserved 5/5 power, but decreased sensation over the entire right upper extremity (RUE) and right lower extremity (RLE) to touch and pinprick. Laboratories suggested normal pituitary function, but MRI of the brain revealed enlargement of the pituitary (1.7 cm), with layering haemorrhage posteriorly and mild compression of the optic nerve. The patient underwent emergent evacuation of a pituitary haematoma, and histology revealed minute fragments of adenohypophysis with haemorrhage and fibrosis.

A 'shock-ing' endoscopic finding on esophagogastroduodenoscopy

Black esophagus is a rare clinical entity, first described in 1990 by Goldenberg et al ,1 the pathogenesis of which is not fully understood,2 but is believed to arise as a result of ischaemic insult seen in haemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophagogastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. We present a case of 55-year-old woman with stage-IV metastatic lung adenocarcinoma on tarceva (erlotinib) who was admitted with coffee-ground emesis, sepsis and multiorgan failure. She was on …

Risk factors for neurocysticercosis: A study from Northwest India

Background: Neurocysticercosis (NCC) is a common cause of epilepsy in the low- and middle-income countries. The risk factors for NCC vary from region to region. Aims: To study the risk factors NCC among patients with NCC and compare with age-and gender-matched controls without NCC. Setting and Design: Hospital-based case-control study. Materials and Methods: A total of 214 subjects were studied (109 NCC patients and 105 age- and gender-matched controls without NCC). The participants were selected from neurology and medical wards of a tertiary referral hospital in Northwest India. They were interviewed by trained medical interns using a questionnaire. Results: Patients with NCC were more likely to dispose garbage close to water source (P = 0.01), eat nonvegetarian food (P < 0.001), and often eat in restaurants (P < 0.001). Pigs were seen more in and around the NCC patient′s houses than the control subjects residential areas (P = 0.001). A total of 15% of the NCC subjects lived close to slaughter houses, while only 2.7% of the control group stayed near a slaughter house (P = 0.002). Conclusions: Unhygienic practices, nonvegetarian food, and eating in restaurants were the risk factors for NCC in this study. There is an opportunity for prevention of NCC using public education.

Clostridium difficile infection: how safe are the household contacts?

Nosocomial transmission of Clostridium difficile infection (CDI) has beenwell studied and strategies to prevent this are standard in all hospitals throughout the United States. It was heartening to read the report by Levin et al1 about the effect of portable pulsed xenon ultraviolet light after terminal cleaning on hospital-associated CDI. However, with the shift of focus of CDI toward long-term care facilities and community-acquired infection, its possible infectivity population is now much larger than merely those confined to hospital settings. Hence it becomes the clinician’s responsibility to educate people who are at risk for infection via household contacts. A recent, interesting report by Pepin et al2 that estimated the risk of secondary cases of CDI among household contacts of index cases may give an impression that the risk is not too large. However, we wish to stress that infection control measures are key to prevent horizontal transmission of CDI. We have encountered at least 2 couples and 1 mothereson duo in our clinical practice during the past year with CDI that was presumably horizontally transmitted. There is high transmissibility and widespread environmental contamination by C difficile via airborne dissemination of spores or fomites that has been underappreciated in clinical practice. A study from the United Kingdom reported that C difficilewas isolated from the air in 70% and from surfaces in 90% of patients, which was confirmed bymolecular characterization.3 These same principles of transmission should theoretically apply in household settings as well. In fact, a report as early as 1981 suggested that C difficile inoculated onto a floor persisted there for 5 months.4 These are the reasons that contact precautions should be advised to household members during treatment of a patient with CDI. When to advise stopping these precautions is still debatable. Sethi et al5 suggested that skin contamination and environmental shedding of C difficile often persists at the time of resolution of diarrhea, and recurrent shedding is common 1-4 weeks after therapy. They hence recommended continuation of contact precautions for a longer period. Efforts are also underway to find ways to minimize environmental contamination; for example, having patients with CDI use toilets with lids.6 There is another concerning situation that strikes us when thinking of ways physicians can play a role in possibly increasing CDI transmission in the community. Fecal microbiota transplant (FMT) has been a recent tool for dealing with refractory cases of CDI with stupendous results. There have been colonoscopic, endoscopic, fecal enema, and nasogastric routes tried for delivery of this

Robotic assisted laparoscopic adrenalectomy: Initial experience from a tertiary care centre in India.

Introduction: Laparoscopic adrenalectomy (LA) is now considered the standard for treatment of surgically correctable adrenal disorders. Robotic adrenalectomy has been performed worldwide and has established itself as safe, feasible and effective approach. We hereby present the first study in robotic transperitoneal LA from Indian subcontinent. Materials and Methods: We conducted a retrospective evaluation of 25 patients who had undergone robotic assisted LA at a tertiary health centre by a single surgeon. Demographic, clinical, histopathological and perioperative outcome data were collected and analysed. Results: Mean age of the patients was 45 years (range: 27-65 years). Eleven male and 14 female patients were operated. Mean operative time was 139 min ± 30 min (range: 110-232 min) and mean blood loss was 85 ml ± 12 ml (range: 34-313 ml). Mean hospital stay was 2.5 ± 1.05 days (range: 2-6 days). Mean visual analogue scale score was 3.2 (range: 1-6) mean analgesic requirement was 50 mg diclofenac daily (range: 0-150 mg). Histopathological evaluation revealed 11 adenomas, eight phaeochromocytomas, two adrenocortical carcinomas, and four myelolipomas. According to Clavien-Dindo classification, three patients developed Grade I post-operative complications namely hypotension and pleural effusion. Conclusion: Robotic adrenalectomy is safe, technically feasible and comfortable to the surgeon. It is easier to perform with a short learning curve.

Is short-term percutaneous endoscopic gastrostomy tube placement beneficial in acutely ill cognitively intact elderly patients? A proposed decision-making algorithm: Short-term PEG tube placement in elderly.

Percutaneous endoscopic gastrostomy (PEG) tube is an important method of enteral feeding for patients who require temporary or long‐term artificial nutritional support to prevent or correct disease‐related malnutrition. However, there is paucity of data on the utility of short‐term PEG tube placements in acute illnesses in cognitively intact older adults.

Is short-term PEG-tube placement beneficial in acutely ill cognitively intact elderly patients? A proposed decision making algorithm

Percutaneous endoscopic gastrostomy (PEG) tube is an important method of enteral feeding for patients who require temporary or long‐term artificial nutritional support to prevent or correct disease‐related malnutrition. However, there is paucity of data on the utility of short‐term PEG tube placements in acute illnesses in cognitively intact older adults.