Showkat Ali Zargar

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.

Hepatobiliary and pancreatic ascariasis in India

500 patients with hepatobiliary and pancreatic disease due to Ascaris lumbricoides infection were studied. 274 patients had duodenal ascariasis, 171 biliary ascariasis, 40 hepatic ascariasis, 8 gall bladder ascariasis, and 7 pancreatic ascariasis. Five clinical presentations were recognised: acute cholecystitis (64 patients), acute cholangitis (121), biliary colic (280), acute pancreatitis (31), and hepatic abscess (4). Ascarides in the duodenum (which were seen to invade only the ampullary orifice) induced either severe biliary colic or episodes of acute pancreatitis. 27 patients had pyogenic cholangitis and were managed by surgical (2) or endoscopic (25) biliary decompression and drainage. Removal of worms from the ampullary orifice and their extraction by mouth led to rapid relief of biliary colic (214 patients) and acute pancreatitis (16). 4 patients died (acute pancreatitis 2, pyogenic cholangitis 1, hepatic abscess 1). In 12 patients worms persisted in the biliary tree at 3 weeks; dead worms were removed from the biliary tree by surgery (5 patients) or with an endoscopic basket (7). Worms moved out of the ductal system in 211 patients. During a mean follow-up of 48 months (SD 14), 76 patients had worm re-invasion of the biliary tree due to ascaris re-infection. Intrahepatic duct and bile duct calculi developed in 7 patients in whom dead worms formed the nidus of stones.

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.

Percutaneous drainage versus albendazole therapy in hepatic hydatidosis: A prospective, randomized study

BACKGROUND Recently, drug treatment and percutaneous drainage have been used successfully when treating hepatic hydatid cysts. Until now, there is no published study comparing the relative safety and efficacy of these two forms of treatment. METHODS In a prospective study, 33 hepatic hydatid cysts were randomly distributed to receive percutaneous drainage (10), albendazole (10 mg.kg-1.day-1 for 8 weeks) plus percutaneous drainage (12), and albendazole alone (11). Patients were serially assessed by clinical and biochemical examinations, ultrasonography, and hydatid serology. RESULTS On serial ultrasonography, cysts attained heterogeneous echopattern in 18, uniform echogenicity in 11, and disappearance in 3. All 22 cysts treated with percutaneous drainage and only 2 (18.2%) cysts treated with albendazole alone reduced in size and change in echopattern (P < 0.01). Maximum size reduction was observed in cysts treated with a combination of percutaneous drainage and albendazole (P < 0.05). Complications observed with drainage were cyst infection in 2 patients, fever in 3, cyst biliary rupture in 1, and urticaria in 2. These were managed successfully without any mortality. Three patients who received albendazole developed reversible elevation of liver cell enzymes. CONCLUSIONS It was concluded that percutaneous drainage with albendazole therapy is an effective form of management for hepatic hydatid cysts.

Biliary ascariasis: A common cause of biliary and pancreatic disease in an endemic area

We prospectively evaluated the incidence, clinical features, radiographic findings, and course of biliary and pancreatic disease caused by ascariasis in an endemic area in India. Ascariasis was an etiologic factor in 40 (36.7%) of the 109 patients studied who had biliary and pancreatic diseases. Disease was prevalent in adult women and was associated with recurrent biliary colic in 38 patients (95%), recurrent pyogenic cholangitis in 27 patients (68%), acalculous cholecystitis in 9 patients (23%), and pancreatic disease in 6 patients (15%). Vomiting of roundworms during biliary colic occurred in 19 patients (48%) and often led to confirmation of biliary ascariasis by direct visualization of the biliary tree. Endoscopic retrograde cholangiopancreatography was an excellent diagnostic tool and often demonstrated worms in the dilated common bile duct and intrahepatic ducts. The worms moved actively into and out of the biliary tree from the duodenum. Thirty-six (90%) patients recovered on symptomatic treatment followed by anthelmintic therapy once acute symptoms subsided. Surgery was needed in 4 patients, as the worms were trapped in the ducts and had led to the formation of common bile duct and intrahepatic duct stones with the worm fragment as the nidus.

Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer

BACKGROUND Therapeutic endoscopy has provided a new means of treating bleeding peptic ulcers. Additional medical therapy may enhance the therapeutic benefit. Hemostasis is highly pH dependent and is severely impaired at low pH. Proton pump inhibitors, by achieving a significantly higher inhibition of gastric acidity, may improve the therapeutic outcomes after endoscopic treatment of ulcers. PATIENT AND METHODS We enrolled 166 patients with hemorrhage from duodenal, gastric, or stomal ulcers and signs of recent hemorrhage, as confirmed by endoscopy. Twenty-six patients had ulcers with an arterial spurt, 41 patients had active ooze, 37 had a visible vessel, and 62 patients had an adherent clot. All patients received endoscopic injection sclerotherapy using 1:10,000 adrenaline and 1% polidocanol and were randomly assigned to receive omeprazole (40 mg orally) every 12 hours for 5 days or an identical-looking placebo. The outcome measures used were recurrent bleeding, surgery, blood transfusion, and hospital stay. RESULTS Six (7%) of 82 patients in the omeprazole group had recurrent bleeding, as compared with 18 (21%) in the placebo group (P = 0.02). Two patients in the omeprazole group and 7 patients in the placebo group needed surgery to control their bleeding (P = 0.17). One patient in the omeprazole group and 2 patients in the placebo group died (P = 0.98). Twenty-nine patients (35%) in the omeprazole group and 61 patients (73%) in the placebo group received blood transfusions (P <0.001). The average hospital stay was 4.6 +/- 1.1 days in the omeprazole group and 6.0 +/- 0.7 days in the placebo group (P <0.001). CONCLUSION The addition of oral omeprazole to combination injection sclerotherapy decreases the rate of recurrent bleeding, reduces the need for surgery and transfusion, and shortens the hospital stay for patients with stigmata of recent hemorrhage.

p53 mutation profile of squamous cell carcinomas of the esophagus in Kashmir (India): a high-incidence area.

Esophageal squamous cell carcinoma (ESCC) has been reported to show geographical variation in its incidence, even within areas of ethnic homogeneity. Kashmir valley, in north of India, has been described as a high‐risk area for ESCC. Here, we make a preliminary attempt to study mutations in exons 5–8 (the DNA binding domain) of the tumor suppressor gene, p53, in 55 ESCC patients from Kashmir. Polymerase chain reaction followed by direct sequencing analysis revealed the presence of mutations in 36.36% (20/55) tumors, assessed for the extent of allelic instability. The 20 mutations, found in 20 patients, comprised of 17 single‐base substitutions (11 transitions + 6 transversions) and 3 deletions. The 17 single‐base variations represented 12 missense mutations, 2 nonsense mutations and 3 variations located in intron 6, 1 of which resulted in a splicing variant. The patients when compared for the incidence of p53 mutation with various demographic features revealed females to be at increased risk (p = 0.016; OR = 4.13; 95% CI = 1.26–13.46). Comparison of mutation profile with other high‐risk areas reflected both differences and similarities indicating coexposure to a unique set of risk factors. This might be due to the special dietary and cultural practices of Kashmir that needs validation, as does the gender‐based difference in the incidence of p53 mutation observed in this study.

Biliary Ascariasis: A Review

Ascariasis, a helminthic infection of humans, is the most common parasitic infestation of the gastrointestinal tract. It infects about 25% of the world’s population; around 20 thousand deaths occur per year from an adverse clinical course of the disease. This review is focused on biliary ascariasis, examining in some detail the pathogenesis of the disease with special reference to postcholecystectomy ascariasis and related issues. Although an endemic disease of tropical and subtropical countries, increasing population migration facilitated by fast improving communication facilities demands that clinicians everywhere be familiar with the clinical profile and management of biliary ascariasis.

Sucralfate retention enemas in solitary rectal ulcer

The conservative treatment of solitary rectal ulcer is generally unsatisfactory. Six patients, aged 27–54 years, with recurrent solitary rectal ulcer were treated with topical administration of sucralfate in a daily dose of 2 g twice a day for 6 weeks. Four patients experienced complete relief of symptoms and the remaining two patients had marked improvement. Although macroscopic healing of the ulcer was apparent in all, histologic improvement was not appreciable. Five of the six patients remain in remission during a follow-up period of 4–14 months (mean, 8±1.5 months). Recurrence was observed in one patient at 5 months, which satisfactorily resolved with sucralfate enemas. From these preliminary observations we infer that solitary rectal ulcer can be effectively treated with topical application of sucralfate.

Worm extraction and biliary drainage in hepatobiliary and pancreatic ascariasis

From December 1989 to March 1992, 50 (32%) of 156 patients with hepatobiliary and pancreatic ascariasis underwent various endoscopic interventional procedures. Endoscopic intervention was performed when patients did not respond to energetic symptomatic treatment within the first few days of hospitalization (n = 45) or when worms had not moved out of the ducts into the duodenum at 3 weeks (n = 5). Worm extraction was successful in all 18 patients from the ampullary orifice and in 34 (89.5%) of 38 patients from the bile or pancreatic duct. In five patients with pyogenic cholangitis, endoscopic nasobiliary drainage was performed to decompress the bile ducts. After worm extraction/nasobiliary drainage, 41 (91%) of the 45 patients with biliary disease (n = 42) or acute pancreatitis (n = 3) had rapid relief of symptoms. Three patients developed complications related to endoscopy, including cholangitis (n = 2) and hypotension (n = 1).