Sanjay Nayyar

Acute pancreatitis in children

OBJECTIVES:Currently, there is no scoring system for predicting severity in acute pancreatitis in children. Our intent was to evaluate the performance of existing scoring systems in children, to develop a system for children, and to examine the etiology of acute pancreatitis in children.METHODS:A chart review of children with acute pancreatitis was conducted at six centers, three serving as criterion centers and three as validation centers. Ranson and Glasgow scores were calculated for each admission. Additional clinical data were collected, and parameters correlating with severity were incorporated into a new scoring system. Performance characteristics were calculated for each system.RESULTS:A total of 301 admissions were reviewed, 202 in the criterion group and 99 in the validation group. Eight parameters were included in a new scoring system for children. The parameters were as follows: age (<7 yr), weight (<23 kg), admission WBC (>18,500), admission LDH (>2,000), 48-h trough Ca2+ (<8.3 mg/dl), 48-h trough albumin (<2.6 g/dl), 48-h fluid sequestration (>75 ml/kg/48 h), and 48-h rise in BUN (>5 mg/dl). When the cut-off for predicting a severe outcome was set at 3 criteria, the new system had better sensitivity versus Ranson and Glasgow scores (70% vs 30% and 35%, respectively) and a better negative predictive value (91% vs 85% and 85%). The specificity (79% vs 94% and 94%) and positive predictive value (45% vs 57% and 61%) fell slightly.CONCLUSION:The new scoring system performs better in this group than do existing systems.

An audit of the utility of in-patient fecal occult blood testing

Abstract OBJECTIVES: Recent surveys of physician practice have suggested the existence of excessive, inappropriate use of the fecal occult blood test (FOBT). We studied the implementation of this test in hospitalized patients. METHODS: We performed a retrospective chart review of 1000 randomly selected patients who had been discharged from the Medicine service at four teaching hospitals. Patient demographics, clinical presentation, presence or absence of overt GI bleeding, and use of medications that might affect the FOBT were recorded. Reviewers assessed whether patients who had FOBT would have been candidates for colon resection if asymptomatic colon cancer had been found. RESULTS: Digital rectal examination was documented in 44.8% of patients; the findings were recorded in only 9%. A total of 421 patients had FOBT on admission, usually on stool obtained at digital rectal examination. Of the patients with a positive FOBT, 17% had active GI bleeding. Only 41.1% of patients with a positive FOBT were referred to the gastroenterology service. In 70.5% of patients, FOBT could be considered inappropriate because of factors such as age, active GI bleeding, or use of aspirin or other nonsteroidal anti-inflammatory drugs. CONCLUSIONS: The FOBT, which is validated only for colorectal cancer screening, is often performed inappropriately in patients admitted to the hospital. This test should be restricted in hospital practice. It would be preferable to identify patients who are appropriate candidates for colorectal cancer screening at the time of hospital discharge and to advise them about the appropriate performance of the FOBT at home.

Is renal failure a contraindication for steroid use in acute alcoholic hepatitis

The cricopharyngeal (CP) bar is a common radiographic finding that can cause oropharyngeal dysphagia (OPD). Treatment options include CP myotomy, which is problematic given that CP bars primarily affect elderly patients with comorbidities who are at higher risk for peri-operative complications. The aim of this study was to examine the effectiveness of endoscopic dilation in the management of dysphagia attributed to a CP bar. Review of upper endoscopic (EGD) and videofluoroscopic swallowing studies from 1999-2002 identified 32 patients with CP bars. CP bar was defined by radiology as a distinct posterior impression in the cervical esophagus inferior to the vocal cords. Six of these patients had dysphagia without any other identifiable cause aside from the CP bar. Each of these six patients underwent EGD with Savary (5) or balloon dilation (1) of the upper esophageal sphincter to a diameter of 51–60 Fr. Shortand long-term follow-up was conducted post-dilation at 1–4 weeks and 10–27 months, respectively. The median age of the 32 patients with CP bars was 63 yrs. The 6 symptomatic patients who underwent endoscopic therapy were women with median age of 62 yrs. Each of the 6 patients experienced immediate improvement in dysphagia. None of the patients developed complications of post-dilation pain, bleeding or perforation. Five patients had continued improvement of their OPD at short-term follow-up. One patient who was dilated to 51 Fr using a Savary dilator experienced return of globus sensation after 48 hours, although dysphagia and regurgitation had resolved. A second Savary dilation, one month after the initial procedure, resulted in complete elimination of symptoms at subsequent shortterm follow-up. Four patients had continued complete resolution of OPD at long-term follow-up. The remaining two patients reported the recurrence of significant dysphagia after 6 and 8 months, which they stated was less severe than at initial presentation. None of the patients required surgical or endoscopic myotomy for residual or refractory dysphagia. Every patient was satisfied with the results and stated they would recommend endoscopic dilation to others with the same problem.(1) CP bar is an important cause of dysphagia that affects elderly patients. (2) Endoscopic dilation of symptomatic CP bars can produce long-term relief of dysphagia. (3) Further controlled studies are warranted to better define the efficacy and safety of endoscopic CP bar dilation as an alternative to surgical myotomy in symptomatic patients.

New approach in the management of proximally migrated stent with an obstructing anti-reflux valve

New approach in the management of proximally migrated stent with an obstructing anti-reflux valve

Enteroscopy as a diagnostic modality in the diagnosis of chylous ascites

Chylous ascites is an uncommon cause of ascites and its etiology could be a diagnostic challenge. We present one such case of chylous ascites that was diagnosed in a 44 year-old African-American woman who presented with new onset of ascites and abdominal pain. Physical examination was remarkable for generalized lymphadenopathy and a 8 cm periumblical mass lesion. There was no hepatosplenomegaly. Laboratory data was significant for a normocytic anemia (Hb=8.5) and leucocytosis with a left shift and thrombocytosisD Abnormalities on liver function test were a total protein 4.1, albumin 1.9, cholesterol 128, Alk Phos 371 and GGT 185. Ascitic fluid analysis showed a low SAAG ascites (0.9), TG 341 with WBC count of 610 (L: 73%, N: 5%). Cytology of the fluid was non conclusive. CT abdomen showed large ascites and bulky retroperitoneal lymphadenopathy. With a clinical suspicion of malignancy/lymphoma, an axillary lymph node biopsy was planned for tissue diagnosis, which was inconclusive even after flow cytometry. Hence an open laparotomy was performed. It showed a large 8 cm 10 cm mesenteric mass in the jejunal area, with extension to the mesenteric vessels and periaortic area. Frozen section and biopsy were negative for malignancy. At this point an enteroscopy was performed, which showed diffuse erythematous mucosa with multiple small nodules in the third portion of the duodenum and jejunum. Histopathology of biopsy specimens revealed an atypical large cell malignant lymphoma. Chylous ascites is most commonly caused by cirrhosis and malignancy/ lymphoma. GI tract is the most frequent location for primary extranodal lymphomas. Various modalities can be used in making the diagnosis of the underlying cause. Our case is an example where enteroscopy as an adjunctive test was able to identify the cause of chylous ascites despite inconclusive findings on more invasive interventions.

Unusual presentation of Churg-Straus syndrome as multiple non-perforating gastrointestinal ulcers

Achalasia is a primary esophageal motor disorder of unknown cause characterized by incomplete lower esophageal sphincter relaxation and esophageal aperistalsis. We present a case with a previously unreported complication of botox injection for achalasia. A 77 year-old male with history of achalasia presented with regurgitation of both liquids and solids. He had been treated three previous times for relief of achalasia symptoms. His last botox treatment was seven months ago and patient had been symptom free till now. Patient was not deemed a surgical candidate due to multiple medical problems. An EGD was performed and 1cc of botox was injected in all four quadrants at the gastroesophageal junction with a standard sclerotherapy needle. Upon awakening post procedure the patient started to complain of abdominal pain. Abdominal exam revealed distended abdomen and tympanic bowel sounds, along with mild diffuse abdominal tenderness. Stat abdominal x-ray revealed free air under the diaphragm and some mediastinal air. Cardiothoracic surgical consultation recommended surgical repair. Instead, we ordered a CT scan of the chest and abdomen, which showed no contrast extravasation into mediastinum, or abdomen but there was presence of large amount of intraand retroperitoneal air with pneumomediastinum. A gastrograffin and then barium swallow showed no extraluminal extravasation of contrast. The patient was started on IV antibiotics and was transferred to ICU for observation. Three days later a follow up esophagram still did not show any leakage of contrast, the patient was allowed to eat and was subsequently discharged. The patient did well 1 year on follow up with resolution of his air collections and achalasia symptoms. To our knowledge, this is the first case to report of microperforation of the esophagus secondary to botox injection leading to pneumoperitoneum. Conservative management should be considered in a patient with suspected microperforation of the esophagus prior to considering surgical repair.