S. Sudhindran

Spontaneous rupture of giant gastric stromal tumor into gastric lumen

BackgroundGastrointestinal stromal tumors (GIST) constitute a large majority of mesenchymal tumors of the gastrointestinal (GI) tract, which express the c-kit proto-oncogene protein, a cell membrane receptor with tyrosine kinase activity. GI stromal tumors of the stomach are usually associated with bleeding, abdominal pain or a palpable mass.Case presentationA 75-year-old male presented with upper abdominal pain and palpable mass. Computed tomographic (CT) scan of the abdomen showed a large mass arising in the posterior aspect of fundus, body, and greater curvature of the stomach. Second day after the admission, there was significant reduction in the size of the tumor, clinically as well as radiologically. Endoscopic biopsy showed large bulge in fundus and corpus of the stomach posteriorly with an opening in the posterior part of the corpus, and biopsy from the edge of the opening reveled GIST. Patient underwent curative resection.ConclusionSpontaneous ruptured of giant gastric stromal tumor is very rare presentation of stomach GIST. Thorough clinical examination and timely investigation can diagnose rare complication.

Role of Contrast CT in Acute Lower Gastrointestinal Bleeding

Objective: To evaluate the role of CT abdomen in the localization of acute lower gastrointestinal bleeding. Summary Background Data: The source of bleed in acute lower gastrointestinal bleeding is often difficult to localize. The role of CT in the evaluation of this group of patients has not been clearly addressed. Methods: A retrospective review of all patients with acute lower gastrointestinal bleeding over a 3-year period was carried out. When endoscopy failed to localize the source and bleeding continued, angiography and/or scintigraphy were carried out. In contrast, those who had normal endoscopies and had clinically stopped bleeding, underwent CT abdomen. Results: CT done in 7 patients with no evidence of active bleed identified a lesion in 6 (86%). Conclusions: CT may be useful in acute lower gastrointestinal bleeding where endoscopy fails to localize a lesion and bleeding has stopped temporarily.

Challenges and Outcome of Left-lobe Liver Transplants in Adult Living Donor Liver Transplants.

Adult-to-adult living donor liver transplant (LDLT) frequently depend on using the right-lobes of the donor for obtaining adequate graft-to-recipient weight ratio (GRWR) of over 0.8% in the recipient. However, left-lobes remain an important option in adults, since the morbidity in the donor is considerably less with left donor hepatectomy when compared with right side liver resection. Further benefits of left-lobes in LDLT include more predictable anatomy of the left hepatic duct and left portal vein, which are usually long and single resulting in easier anastomosis in the recipient. Likewise, left-lobe grafts are easier to implant with an excellent venous outflow through the combined orifice of left and middle hepatic vein, as opposed to the complex hepatic vein reconstruction required in right-lobe grafts. However, left hepatic artery is often multiple unlike the right hepatic artery. The holy grail of left-lobe transplants is avoidance of small for size syndrome (SFSS) in the recipients. The strategies for overcoming SFSS currently depend on circumventing portal hyperperfusion in the graft. Measurement of portal pressure and modulating it if high, by splenic artery ligation, splenectomy, or hemiportocaval shunts are proving successful in avoiding SFSS. The future aim in adult LDLT should be to use the left-lobe as much as possible for the benefit of the donor at the same time avoiding SFSS even at very low GRWR for the benefit of the recipient.

Acute liver failure due to zinc phosphide containing rodenticide poisoning: Clinical features and prognostic indicators of need for liver transplantation

Zinc phosphide (ZnP) containing rodenticide poisoning is a recognized cause of acute liver failure (ALF) in India. When standard conservative measures fail, the sole option is liver transplantation. Records of 41 patients admitted to a single centre with ZnP-induced ALF were reviewed to identify prognostic indicators for requirement of liver transplantation. Patients were analyzed in two groups: group I (n = 22) consisted of patients who either underwent a liver transplant (n = 14) or died without a transplant (n = 8); group II (n = 19) comprised those who survived without liver transplantation. International normalized ratio (INR) in group I was 9 compared to 3 in group II (p < 0.001). Encephalopathy occurred only in group I. Model for End-Stage Liver Disease (MELD) score in group I was 41 compared to 24 in group II (p < 0.001). MELD score of 36 (sensitivity of 86.7 %, specificity of 90 %) or a combination of INR of 6 and encephalopathy (sensitivity of 100 %, specificity of 83 %) were the best indicators of mortality. Such patients should undergo urgent liver transplantation.

Randomized trial on extended versus modified right lobe grafts in living donor liver transplantation

Despite advances in the practice of living donor liver transplantation (LDLT), the optimum surgical approach with respect to the middle hepatic vein (MHV) in right lobe LDLT remains undefined. We designed a randomized trial to compare the early postoperative outcomes in recipients and donors between extended right lobe grafts (ERGs; transection plane was maintained to the left of MHV and division of MHV performed beyond the segment VIII vein) and modified right lobe grafts (MRGs; transection plane was maintained to the right of MHV; the segment V and VIII drainage was reconstructed using a conduit of recipient portal vein). Eligible patients (n = 86) were prospectively randomized into the ERG arm (n = 43) and the MRG arm (n = 43) at the beginning of donor hepatectomy. The primary endpoint considered in this equivalence trial was patency of the MHV or the reconstructed “neo‐MHV” in the recipient. The secondary endpoints included biochemical parameters, postoperative complications, mortality in recipients as well as donors and volume regeneration of remnant liver in donors, measured at 2 months. The patency of the MHV was comparable in the ERG and MRG arms (90.7% versus 81.4%; difference, 9.3%; 95% confidence interval [CI], –5.8 to 24.4; z score, 1.245; P = 0.21). Volume regeneration of the remnant liver in donors was significantly better in the MRG arm (111.3% versus 87.3%; mean difference, 24%; 95% CI, 14.6‐33.3; P < 0.001). The remaining secondary endpoints in donors and recipients were similar between the 2 arms. To conclude, MRG with reconstructed neo‐MHV has comparable patency to native MHV in ERG and confers equivalent graft outflow in the recipient. Furthermore, it allows better remnant liver regeneration in the donor at 2 months. Liver Transplantation 24 888–896 2018 AASLD.

Gastrointestinal intramural hematoma-Analysis of clinical and radiological features for early differentiation from mesenteric ischemia

IntroductionLong-term anticoagulation is associated with hemorrhage at various sites. Gastrointestinal intramural bleeds and hematomas (IMH) often mimic mesenteric ischemia (MI) due to similar clinical settings and imaging features, making early differentiation difficult.AimTo compare the demography, clinical features and imaging characteristics of patients presenting with IMH with those of MI, so as to help in evolving clinical and imaging guidelines to differentiate both early in the course of the disease.MethodsAll radiologically (contrast-enhanced computed tomogram [CT]) diagnosed cases of gastrointestinal IMH from the hospital database during the period between 2006 and 2012 were retrospectively analyzed. This data was compared with the clinical and imaging features of a group of surgically confirmed MI during the same period. Patients not on anticoagulation therapy at the time of presentation and those with incomplete clinical or radiological data were excluded from the study.ResultsThere were 16 patients in IMH group and 54 patients in MI group. Clinical features like overt rectal bleeding or melena, and prolonged prothrombin time-international normalized ratio (PT-INR) more than three, and CT features like proximal location in the bowel, increased bowel wall thickness, hyperdensity on plain scan (>40 Hounsfield units (HU)), and short segment bowel involvement were significantly associated with IMH. Visualization of embolus and absent mesenteric vasculature to a segment of intestine in CT was significantly associated with MI.ConclusionAttention to clinical features and early CT scan can aid in early differentiation of IMH from MI, facilitating appropriate intervention early in the course of disease.

26 BILIRUBIN AS A PREDICTOR OF EARLY MORTALITY AFTER LIVER TRANSPLANTATION

Case Report: A 42-year-old male was admitted to our hospital with the diagnosis of alcohol-induced decompensated liver disease. He underwent deceased donor liver transplantation on 09.03.2011. Caval anastomosis was done by a piggy-back technique to the common cloaca of the recipient hepatic veins. After the reperfusion, the liver got congested and compressed the inferior vena cava (IVC) causing persistent hypotension. To relieve the hepatic outflow obstruction, side-to-side anastomosis between recipient IVC and donor IVC was done. Even after cavo-caval anastomosis, the hepatic outflow obstruction persisted. Lifting the liver anteriorly and slightly downward relieved the hepatic outflow obstruction which in turn relieved the IVC compression. Liver was then fixed to the anterior abdominal wall to maintain the position. Patient is on regular follow-up and doing well.

44 hepatic steatosis-quantification by non-enhanced ct scan.

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19 cost of immunosuppression using generic products after liver transplantation.

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