Yalaka R. Reddy

Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction

BACKGROUND AND AIMS Peptic ulcer disease (PUD)-related gastric outlet obstruction (GOO) is known to respond favorably to endoscopic balloon dilation (EBD). However, data on efficacy of EBD for other etiologies of benign GOO are sparse. We aimed to compare the response of EBD among different etiologies of GOO. METHODS Records of all patients with benign GOO who underwent EBD at our tertiary-care center between January 1998 and December 2017 were analyzed. Dilation was done by using through-the-scope balloons. Procedural and clinical success of EBD was compared among different etiologies. RESULTS A total of 306 patients were evaluated, of whom 264 (mean [± standard deviation] [SD] age 37.89 ± 17.49 years; men 183, women 81) underwent dilation. Etiologically, caustic ingestion was the commonest cause of GOO (53.8%) followed by PUD (26.1%) and medication-induced (8.3%). Overall procedural and clinical success was achieved in 200 (75.7%) and 243 (92.04%) patients, respectively, requiring a mean (± SD) of 2.55 (2.8) and 5.37 (3.9) sessions, respectively. Caustic-induced GOO responded less favorably, requiring a higher number of dilation sessions and having more refractory strictures than other etiologies. Medication-induced GOO performed worse than PUD-related GOO. Of the 264 patients, 9 (3.4%) had perforations during EBD, 3 had contained leaks and were managed conservatively, and 6 underwent successful surgery. CONCLUSION EBD is successful in a majority of patients with benign GOO, with caustic-induced GOO and medication-induced GOO being more difficult than PUD-related GOO.

Relook endoscopy predicts the development of esophageal and antropyloric stenosis better than immediate endoscopy in patients with caustic ingestion

Background and aims Early ( < 24 hours) esophagogastroduodenoscopy (EGD) is used to prognosticate mucosal injury after caustic ingestion. We aimed to compare differences in endoscopic grading on EGDs performed on day 5 and day 1 and to assess the impact of relook endoscopy findings on the development of esophageal and/or antropyloric cicatrization. Patients and methods Consecutive patients admitted within 24 hours of caustic ingestion between 2009 and 2014 underwent EGD and had their mucosal changes graded. Injuries of grade ≤ 2a were classified as mild and ≥ 2b were classified as severe. Patients were followed up for the development of cicatrization and managed per protocol. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LRs) were calculated to compare day 1 and day 5 EGD findings. Results A total of 62 patients (35 men; mean age 33 ± 15) underwent both day 1 and day 5 EGDs. Antropyloric stenosis developed in 16 patients, esophageal strictures in nine, and four had both esophageal and antropyloric strictures. Compared with day 1 EGD, endoscopic grading of severe injury on day 5 had higher specificity (83 % vs. 65 %), higher PPV (60 % vs. 41 %), and higher positive LR (5.65 vs. 2.66) for predicting the development of esophageal stricture. Similarly, day 5 endoscopic grading had higher specificity (95 % vs. 61 %), higher PPV (88 % vs. 54 %), and higher positive LR (16 vs. 2.5) for predicting the development of antropyloric stenosis. Conclusion Endoscopic assessment on day 5 is a better predictor of esophageal and gastric cicatrization than day 1 EGD, which significantly overestimates the grade of injury.

Pin Point Densities on Abdominal X-ray

A 9-y-old boy presented to pediatric emergency with historyof high grade fever and cough for 4 d. During per-oraltemperature recording using mercury (glass) thermome-ter, the child bit the thermometer resulting in the acci-dental ingestion of its tip. There was no pain abdomen orbleeding per rectum. At presentation, the child was afebrile,consciousandresponsive.Abdomenwasnon-tenderandsoft.Chest X-ray was normal (Fig. 1) except for tiny densefoci in the left lower zone. Abdominal radiograph(Fig. 2), however, was striking. It showed multiple tinydiscrete dense foci. Follow up radiograph, 1 day laterrevealed change in the pattern of the densities, both interms of their number and position. Abdominalultrasound was normal. The child was kept under observa-tion for a couple of days.Thermometers contain mercury in elemental form [1]. It ispoorly absorbed from the gastro-intestinal tract (GIT) and ismildly toxic to the GIT mucosa [2]. Accidental ingestion ofelemental mercury is rare and has been reported inchildren in few case reports [3, 4]. Small particles maybe aspirated (as in our case), though innocuous. Injuriesrelated to glass should also be considered; no such injuriesoccurred in present case [5].

Sa1358 Endoscopic Ultrasound Follow up Study of Fluid Collections in Acute Necrotizing Pancreatitis: Are They Pseudocysts, Walled off Pancreatic Necrosis or Need a New Name?

Purpose: The prevalence of obesity is increasing and the number of patients undergoing bariatric surgery is rising. There is no data on the risk factors for AP in this patient population. Methods: Using our historical cohort of post bariatric surgery patients, we performed a nested case-control study to identify risk factors for AP. The medical records of all patients who underwent bariatric surgery at our center from January 2004 to September 2011 were reviewed and patients who developed AP (ACG criteria) during follow-up were identified. The patients with AP had a mean age of 47.3 yrs, 21.7% were males and mean pre-op BMI was 47.4 kg/m2. For each case, two age, gender, and pre operative BMI-matched controls were selected. Univariable Cox regression analysis was performed to assess factors associated with the development of AP after bariatric surgery. Results: 28 patients with AP and 56 controls were included. Table 1 summarizes the results of the Cox regression analysis. The only baseline variable that predicted post-op AP was a prior history of AP. However, three other variables identified after surgery were associated with AP: 1. Rapid weight loss as measured by percent of excess weight loss (EWL) at the first post-op visit ( ,1 month). For every 1% increase in the EWL, the hazard of developing AP increased by 3%. 2. Abnormal findings on post-op ultrasound (US). Of the patients with AP, 13 (46%) had an abnormal finding (stones, sludge or ductal dilation) on right upper quadrant US, and 10 patients needed an intervention in the form of a cholecystectomy or an ERCP. 3. Post-op complications of bowel leak or anastomotic stricture. The type of bariatric surgery was not a risk factor for AP. Conclusions: Other than a past history of AP, no baseline risk factors were found to predict post-op AP. However, extremely rapid excess weight loss and the development of gallstones/sludge on US were predictive. Clinical implication: Screening patients with rapid EWL for stones and sludge using US and offering early intervention may prevent AP in this group. Further study into mechanisms, risk factors and preventive measures for AP in this population is warranted. Results of univariable analysis