Shiran Shetty

Hereditary hemorrhagic telangiectasia

Background: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder, which affects various internal organs and has a tendency for bleeding. It has a classic triad of mucocutaneous telangiectasias, recurrent hemorrhages and positive familial history of first-degree relative. Epistaxis or gastrointestinal telangiectasia can be fatal in a small number of cases. Case Report: A 44-year-old woman came with complaints of recurrent episodes of hematemesis and epistaxis. Patient had a family history of similar complaints. Patient underwent esophagogastroduodenoscopy (EGD), which revealed telangiectasia in the stomach. Imaging of the abdomen showed features suggestive of arteriovenous shunting. Conclusion: HHT can remain undiagnosed for a long time, and is rarely being reported in the literature with management needing a multidisciplinary approach with early inputs from a gastroenterologist.

Pancreatico-Pleural and Bronchial Fistulae and Associated Pseudocysts: Case Series

CONTEXT Pancreatico-pleural fistula is rare complication of chronic or acute pancreatitis. Previous studies have reported imaging features and various management options of this condition including conservative/medical management, endoscopic treatments and surgery.This article reviews the myriad of imaging appearances of this condition in multimodality imaging and different strategies for the successful management in a short case series. METHODS After obtaining the institutional ethics committee approval, retrospective review of the medical records of five patients of pancreatico-pleural fistulae who were diagnosed and successfully managed in our hospital in 2012 and 2013 was done. Follow up with out patient records of these patients was also included.Findings were compared with the current available literature on this entity. RESULTS AND DISCUSSION Pancreatico-pleural fistulae presents with massive pleural effusion.A high index of suspicion is essential for accurate diagnosis. Demonstration of the fistulous tracts requires cross sectional imaging with contrast enhanced CT being most commonly used and affords accurate diagnosis. MRI demonstrates the tracts and ductal disruptions with greater detail and are helpful in confirming the CT findings. Endoscopic ultrasound and ERCP also offer potential of diagnosis, although being technically demanding and invasive is reserved for interventions. Management of these conditions should be initially conservative with endoscopic stenting being offered in selected cases with favourable anatomy and not responding to conservative management. Surgery is reserved for cases not responding to conservative and endoscopic management. CONCLUSION In conclusion this case series highlights the clinical and imaging spectrum of pancreatico-pleural fistulae and provides insight into the different management strategies that can be adopted for this condition.

Grave's Disease and Primary Biliary Cirrhosis—An Unusual and Challenging Association

Jaundice in Graves diseases is uncommon, but when it does occur, complication of thyrotoxicosis (heart failure/infection) or intrinsic liver disease should be considered. Graves disease can cause asymptomatic elevation of liver enzymes, jaundice and rarely acute liver failure. It is associated with other autoimmune diseases like autoimmune hepatitis, or primary biliary cirrhosis. The cause of jaundice in Graves disease is multifactorial.

Quality of life in dyspepsia and its subgroups using EQ-5D (EuroQol) questionnaire

Background/Aim: Dyspepsia has a significant impact on the quality of life. Health-related quality of life (HRQoL) can be assessed by disease-specific and generic HRQoL instruments. The present study evaluated HRQoL and compared it among dyspepsia subgroups by using EQ (Euro QoL)-5D questionnaire. Patients and Methods: Patients with abnormal findings on upper gastrointestinal endoscopy were classified to have organic dyspepsia, whereas those with normal endoscopy were classified as functional dyspepsia if they met the ROME III criteria or as endoscopy negative recent dyspepsia if symptom duration was <6 months. HRQoL was assessed using the EQ-5D questionnaire, and the overall health status on a visual analogue scale (VAS); and the frequency of impairment in each dimension were compared between the dyspepsia subgroups. Results: The overall health status was affected equally in all three dyspepsia subgroups. Impairment in HRQoL was commonly seen in the dimensions of pain (98.4%), usual activities (66.20%), and anxiety/depression (70.60%), however, much less so in mobility (22.70%) and self-care (10.9%). Any impairment in HRQoL was not significantly different between the three subgroups in the dimensions of mobility and usual activities. Self-care was more commonly affected in organic dyspepsia, anxiety/depression was more common with functional dyspepsia, while pain, though significantly different among various subgroups, was very common in all three subgroups. Conclusion: HRQoL was equally affected in all three subgroups of dyspepsia but variably so in the different domains of EQ-5D. These differences need to be studied further to improve the management of different etiological subgroups of dyspepsia.

Role of noninvasive markers to predict the presence of esophageal varices in cirrhosis: Pilot study

Cirrhosis of liver leads to portal hypertension and development of esophageal varices (EV), rupture of which results in spontaneous hematemesis. Upper gastrointestinal (UGI) bleeding is a catastrophic presentation of EV. Endoscopy remains the standard procedure for diagnosis [1] and esophageal variceal ligation as treatment of varices for decades; but with each passing day, the demand to develop noninvasive methods to diagnose varices is increasing. This pilot study aimed to find the association between esophageal varices, liver stiffness, spleen stiffness, and platelet counts and also to assess whether these indicators can be used to establish benchmarks in the future as noninvasive predictors of portal hypertension. A cross-sectional observational study was done at a tertiary health center from February 2014, to January 2015. Adult patients of ages ≥ 18 years of either sex with newly diagnosed chronic liver disease (CLD) and portal hypertension were included. The patients underwent routine biochemical and radiological investigations. Patients underwent an UGI and esophageal varices were graded as per Baveno V consensus. Liver stiffness (LS) and spleen stiffness (SS) values were assessed in patients with Acoustic Radiation Force Impulse (ARFI) (Siemens Acuson S2000TM). Individual readings were taken for the liver and spleen, the mean of which was taken as a final value expressed in meters per second. For LS, the METAVIR scoring system was used. Toshiba SSA-70 was used to carry out ultrasound examination. Fifty patients (with mean age of 50.44 ± 13.11 years were taken. OnUGI endoscopy, the presence of EVwas noted in 39 (78%) patients. Thirty-two (94.12%) patients had platelet count < 150,000/mm and 7 (5.88%) patients had platelet count ≥ 150,000/mm (p < 0.001). Sixteen patients (41.03%) had liver size ≥ 14.6 cm and 23 patients (58.97%) had liver size < 14.60 cm. However, this difference was statistically not significant. The diagnostic accuracy of liver size in predicting EV was 38% with 41.03% sensitivity, 27.27% specificity, and 0.56 positive likelihood ratio. Twenty-six had LS ≥ 2.09 while 11 patients (had LS < 2.09 [p = 0.104]. LS had an accuracy of 68% in predicting EV with 71.79% sensitivity and 54.55% specificity and positive likelihood ratio was 1.58. SS was ≥ 2.87 in a significantly higher number of patients (26 patients; 89.66%) compared to those who had < 2.87 (13 patients; 61.9%) (p = 0.023). SS had an accuracy of 68% for EV, with sensitivity of 66.67%. Among the 39 patients with EVs, a majority of the patients had LS of ≥ 2.09, that is 28 (71.8%) patients and 11 patients (28.2%) who did not have EV, but the difference was statistically not significant (p = 0.104). However, the sensitivity of LS in predicting EV was slightly high, that is 71.79% but less specific 54.55% resulting in diagnostic accuracy of 68% and positive likelihood ratio of 1.58. There is a wide variation of LS values in the literature that ranges from 2.5 to 75 kPa. These values are altered by gender, BMI, etiology, and necroinflammatory change [2, 3]. Normal TE values are 3.8 to 8 kPa in men and 3.3 to 7.8 kPa in women while in fibrosis (METAVIR fibrosis stage ≥ 2) the values are 7 to 8 kPa and in cases with cirrhosis, the values are 13 to 17 kPa [4]. Platelet count has been reported as the most sensitive and specific noninvasive parameter for predicting * Shiran Shetty drshiran@gmail.com

Subclinical anal sphincter injuries following instrumental delivery-a physiological analysis: A pilot study

Introduction: Obstetric Anal Sphincter Injuries (OASIS) has been reported in up to 25% patients and occult OASIS has been reported in up to 1.2%. Instrumental delivery has been considered a risk factor for OASIS. Aim: To compare the anal sphincter functions as assessed by Anorectal Manometry (ARM) in asymptomatic patients following instrument delivery with those of patients who underwent Lower Segment Caesarian Section (LSCS) after six months of delivery. Materials and Methods: Seventeen women who had instrumental delivery and thirteen who underwent elective cesarean section were recruited. Evaluation included a detailed history and physical examination, administration of the Cleveland Clinic Questionnaire and ARM to record the basal pressure, squeeze pressure, anorectal sensation and balloon expulsion time. Categorical variables were compared using the Chi-square test. All calculations were done using the software SPSS 21.0. Results: We found statistically significant lower basal (34 ± 3.4 vs 60±2.3 mm hg, p<0.05) and squeeze pressures (56±4.1 vs 76±5.2 mm hg, p<0.05), and higher balloon expulsion time (58±2.9 s vs 19±1.8 seconds, p<0.05) in women with instrument delivery compared to LSCS. The rectal sensation was comparable in both the groups. Conclusion: Persistent subtle anal sphincter dysfunctions are common following instrument delivery compared to LSCS. The role of identifying these and preventing future incontinence in such women needs to be assessed in future studies.

Jejunal Diverticulosis - Rare Cause of Gastrointestinal Bleed

Jejunal diverticulosis was first described by Somerling in 1794 and by Sir Astley Cooper in 1807. Jejunal diverticula are rare. Hemorrhage from jejunal diverticula usually presents as gastrointestinal bleeding. Here, we present a case of severe gastrointestinal bleeding presenting as malena due to jejunal diverticulosis.

Abdominal catastrophe in infective endocarditis

A 49-year-old male with Type II diabetes mellitus presented with fever for 3 months and on evaluation was found to have infective endocarditis involving the aortic valve. Blood culture grew Streptococcus viridans. He was treated with intravenous antibiotics and improved clinically. He developed severe abdominal pain with vomiting and minimal clinical signs on the tenth day of hospitalization. CT abdomen showed a 3.3 cm × 1.6 cm lobulated aneurysm of the distal superior mesenteric artery (SMA) along with early ischemic changes of the small bowel (Figs. 1 and 2).

Esophageal lipoma presenting as a long tongue

A 42-year-old man presented with history of non progressive dysphagia both for solids and liquids for the past 2 years. He used to bring out a fleshy mass from mouth during retching, followed by choking. Upper gastrointestinal endoscopy revealed a soft, long, smooth, bulging lesion in the upper esophagus, extending for a length of 20 cm. Pillow-sign was positive. Patient coughed immediately after the procedure, and brought out a fleshy pink tubular mass with a blind end from the mouth (Fig. 1), which caused sudden choking. The mass was maneuvered back by the patient himself. Endoscopic ultrasound showed hyperchoic lesion arising from the third layer of esophageal wall suggestive of lipoma. His CT thorax showed submucosal elongated polypoidal lesion with feeding blood vessels, and luminal narrowing in the upper part of the esophagus (Fig. 2). Surgical excision of the