Vidhyachandra Gandhi

Stent angioplasty of narrowed portocaval shunt in Budd Chiari syndrome: a case report

BackgroundHepatic vein thrombosis (Budd-Chiari Syndrome) is a rare disorder resulting from an obstruction to the outflow of blood from the liver. Early decompression is needed to prevent liver dysfunction and death. Radiological intervention includes angioplasty of stenosis and webs and the placement of transjugular intrahepatic portosystemic shunts (TIPPS). Side-to-side portacaval shunt (SSPCS) remains the gold standard for achieving good long-term results.Case presentationA 37-year old lady underwent side-to-side portacaval shunt for Budd Chiari syndrome. She had early shunt blockage and this was successfully treated with the placement of a metallic stent across the shunt.ConclusionAt five years, she remains asymptomatic, with normal liver functions, no ascites, and normal flow through the stent on Colour Doppler examination.

Analysis of the delayed approach to the management of infected pancreatic necrosis

AIM To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP). METHODS Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed. RESULTS Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d. CONCLUSION This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

Management of Severe Acute Pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Endoscopic ultrasound in biliary fasciolosis

A 16-year-old woman presented with recurrent episodes of severe upper abdominal pain and vomiting of 3 years duration. Multiple upper gastrointestinal scopies and ultrasonographies (USG) were normal. CT scan of abdomen had revealed mild intrahepatic biliary radical dilatation up to the lower end of common bile duct (CBD), but no stones or mass lesion. Her amylase and lipase levels during attacks of pain were normal. She was labeled as suffering from depression and was on antidepressants. Her liver function tests were normal except deranged alkaline phosphatase (178 IU/L). Clinical examination was unremarkable. Endoscopic ultrasound (EUS) revealed dilated CBD with a 3–4 cm floating and moving structure in the mid CBD coming down into the lower CBD with appearance like fluke (Fig. 1a). A biliary sphincterotomy was performed and a leaf like live worm was extracted with balloon catheter (Fig. 1b). Microbiological examination revealed diagnosis of Fasciola gigantica. She received a course of antihelminths and is asymptomatic on follow up of 9 months. Conventional USG in biliary fasciolosis usually reveals biliary dilatation, irregular thickened walls and worms are seen as vermiform structures without acoustic shadowing. USG is believed to be helpful in diagnosis of biliary fasciolosis, it may miss distal CBD lesions. EUS is an accurate investigation for imaging the lower biliary tree. Its role in the diagnosis of biliary fasciolosis has been documented earlier [1].

Pseudomyxoma Peritonea: Uncommon Presentation

Pseudomyxoma peritonei is rare being characterized by intraperitoneal accumulation of mucinous ascites produced by neoplastic cells, mostly originating from a perforated appendiceal adenoma. The clinical presentatation of the disease is variable, and preoperative diagnosis is often difficult. We describe the clinical case of a 60-year-old patient who presentated predominantly with urological symptoms. CECT revealed an appendiceal lesion infiltrating and projecting into the urinary bladder. Surgical cytoreduction was performed and patient remains symptomatically better on follow up.

An unusual cause of vomiting in a child

The authors report the case of a 13-month-old male child who presented with sudden onset vomiting and refusal to take solid food. Barium swallow and CT scan of the chest were inconclusive. The cause of symptoms was only evident more than a month later on endoscopy, which revealed an unusual flower-shaped foreign body impacted in the cervical oesophagus. This was successfully removed, and review of imaging made the diagnosis obvious in retrospect. This report is to emphasise the importance of considering the possibility of foreign body ingestion with unusual sudden onset symptoms and vigilant interpretation of findings on imaging studies, especially in the paediatric population.

Recurrent cholangitis in the tropics: worm or cast?

The development of biliary casts is very rare, especially in non-liver transplant patients. The etiology of these casts is uncertain but several factors have been proposed which lead to bile stasis and/or gallbladder hypo-contractility and promote cast formation. Here, we report a 54-year-old male, with diabetes and ischemic heart disease, who presented with recurrent attacks of cholangitis. Magnetic resonance cholangiopancreatography revealed linear T1 hyperintense and T2 hypointense filling defects in the right and left hepatic ducts extending into the common hepatic duct, and a calculus in the lower common bile duct, raising a suspicion of worm in the biliary tree. In view of failed attempts at extraction on endoscopy, patient underwent surgery. At exploration, biliary casts and stones were extracted from the proximal and the second order bile ducts, with the help of intraoperative choledochoscopy and a bilio-enteric anastomosis was accomplished. Although endoscopic retrieval of the biliary cast can be employed as first-line management, surgery should be considered in case it fails.

An unusual surgical site infection in a liver transplant recipient

Mycobacterium abscessus is a rare cause of human infection and is difficult to diagnose unless it is suspected. A 45-year-old woman underwent deceased donor liver transplantation following which she developed non-healing surgical site infection, which did not resolve with routine antibiotics for 2 months. The scraping of the wound revealed M abscessus infection. Definitive identification of this species of mycobacterium was possible by its growth characteristics on culture and reverse line blot hybridisation assay. She was treated with clarithromycin and cotrimaxazole as per sensitivity and showed complete recovery from the infection within 6 weeks of starting the drugs, which were continued for 6 months. We believe that this is the first documented case of surgical site infection by M abscessus in a liver transplant recipient.

Management of a large retroperitoneal primitive neuroectodermal tumour: ‘a multimodal approach’

Retroperitoneal primitive neuroectodermal tumour (PNET) is a rare disease having poor prognosis. Treatment mainly consists of en block resection of the tumour to achieve RO resection, however multimodal approach has also been used with improved survival. The authors report a 40-year-old male with large retroperitoneal PNET adherent to aorta and compressing the inferior vena cava. He was subjected to P6 protocol chemotherapy (cyclophosphamide, adriamycin, vincristine, ifosfamide and etoposide) in view of borderline operability. Postchemotherapy contrast enhanced CT revealed significant reduction in size of the lesion. He underwent complete resection of the tumour followed by concurrent chemoradiation. He remains asymptomatic on follow-up over a period of 2 years.

Secondary omental torsion.

A middle-aged-woman presented with symptoms and signs of acute abdomen. Clinically a suspicion of acute appendicitis was raised, although the abdominal x-ray and ultrasound were normal. She was managed conservatively, which she failed to respond. In the view of persisting pain, a contrast enhanced CT (CECT) was done. CECT showed a whirling mass of fatty and fibrous tissue adherent to the anterior abdominal wall suggestive of omental torsion and the diagnosis was confirmed on laparotomy and she underwent excision of the ischaemic omentum. Omental torsion though rare, should be included in the differential diagnosis of acute abdomen. High index of suspicion is required to diagnose this entity. CECT abdomen shows the classical finding of fatty mass with whirling pattern. It is seldom considered in the differential diagnosis preoperatively based on clinical findings and the diagnosis is only established during the surgical procedure.