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   Table of Contents - Current issue
July-September 2018
Volume 9 | Issue 3
Page Nos. 103-143

Online since Thursday, August 30, 2018

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Endoscopy on a human cadaver: A feasibility study as a training tool Highly accessed article p. 103
Avinash Bhat Balekuduru, Amit Kumar Dutta, Satyaprakash Bonthala Subbaraj
Background: Simulation device and porcine models are increasingly being used for training in gastrointestinal endoscopy. However reports on the use of human cadaver for training in diagnostic or therapeutic endoscopy are limited. Method: Human cadavers were preserved at our center in a customized non formalin based solution which retains organoleptic properties (preserves the colour, feel, inflation of gut). We studied the feasibility of using these cadavers for training in endoscopy. Endoscopy was performed using PENTAX/ EP 2940 with a light source processor PENTAX/EPM 3500. Participants performed endoscopy and submucosal injection on cadaver as well as simulator. Before and after simulator and cadaver training, attendees completed a questionnaire on intubation, manoeuvring esophagus, stomach and duodenum for diagnostic endoscopy and scope positioning, needle out, submucosal injection and elevation of mucosa and needle in. The steps of ESD- marking, precut and submucosal dissection were attempted on the stomach of human cadaver. Results: Ten participants with very little prior experience of endoscopy felt the cadaver based training more beneficial in obtaining the sub mucosal plane and positioning the needle for four quadrant injection as compared to the endoscopic simulator (ES). The attendees felt that while ES has the advantage of providing feedback for the procedure, training on cadaver gave more realistic tactile experience and feel of the elasticity of the gut wall. Overall, diagnostic endoscopy was comparable in both cadaver and simulator except for difficulty in intubation in the former due to supine cadaver position. The steps of ESD were done only in the cadaver with limited success. Conclusion: This study shows the feasibility of using human cadaver for simulation-based training programs in gastrointestinal encoscopy.
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Chronic lower gastrointestinal bleeding: Etiological profile and role of colonoscopy among children from sub-Himalayan ranges of North India p. 109
Brij Sharma, Rajesh Sharma, Vishal Bodh, Sudershan Sharma, Ashwani Sood, Rakesh Sharma, Neetu Sharma
Background: Most patients with chronic lower gastrointestinal (GI) bleeding warrant endoscopic examination of the lower GI tract. This study was done to determine the etiological profile of chronic lower GI bleeding and the role of colonoscopy in its diagnosis, as well as the prognosis among children from sub-Himalayan ranges of North India. Methods: In this study, we did a retrospective review of the clinical notes of children between 2 and 15 years of age who presented with chronic lower GI bleeding and underwent diagnostic and therapeutic colonoscopy in the Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, from January 2012 to October 2017. Patient demographics, clinical features, and endoscopic and histopathological findings were recorded. Results: Of the total 57 patients reviewed, 22 (38.59%) were female and 35 (61.40%) were male, with a male-to-female ratio of 1.62:1.0. The highest incidence of lower GI bleeding was between the ages of 6 and 10 years (43.85%). The presenting symptoms were hematochezia in 50 (87.71%), bloody diarrhea in 5 (8.77%), and positive stool occult blood test in 2 (3.50%) patients. The most common accompanying symptom was constipation in 16 (28.07%), abdominal pain in 14 (24.56%), fever in 5 (8.77%), and weight loss in 5 (8.77%) patients. The most common colonoscopy finding was rectosigmoid polyps (36 cases, 63.15%) followed by internal hemorrhoids (9 cases, 15.78%), rectal ulcers (5 cases, 8.77%), findings suggestive of colitis of left colon (5 cases, 8.77%), and findings suggestive of ileocecal tuberculosis (2 cases, 3.50%). The most common histopathological finding was juvenile colorectal polyps (35 cases, 61.40%) followed by solitary rectal ulcer (5 cases, 8.77%), ulcerative colitis (5 cases, 8.77%), tuberculosis (2 cases, 3.50%), and Peutz–Jegher polyp (1 case, 1.75%). Conclusion: Juvenile colorectal polyps constitute the most common cause of chronic lower GI bleeding in children from sub-Himalayan ranges of North India followed by hemorrhoids, solitary rectal ulcer, inflammatory bowel disease, and ileocolonic tuberculosis. Colonoscopy remains a useful and safe procedure in children for evaluation of lower GI bleeding both from the diagnostic and therapeutic points of view.
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Soft coagulation using hemostatic forceps for prevention of postendoscopic papillectomy hemorrhage p. 114
Nobuhiko Fukuba, Hiroki Sonoyama, Ichiro Moriyama, Shunji Ishihara, Yoshikazu Kinoshita
Aim: Few reports of the prophylactic use of soft coagulation with hemostatic forceps for postendoscopic papillectomy hemorrhage (PEPH) have been presented. The aim of this study was to clarify the utility of that procedure for prophylaxis. Materials and Methods: From April 2009 to March 2012, PEPH was treated in four patients after the development of the condition with a conventional procedure at our institution. Thereafter, from April 2012 to March 2016, soft coagulation using hemostatic forceps was performed as prophylactic hemostasis following an EP in five patients. For the latter procedure, the hemostatic forceps device (FD411-QR, Olympus, Tokyo, Japan) was used in a closed position, with the coagulation wave set at 60 W (VIO 300D; ERBE, Tubingen, Germany). The primary outcome was the onset of PEPH, which was defined as a decrease in hemoglobin ≥2 g/dL after EP. Secondary endpoints were the success rate and the incidence of adverse events of soft coagulation using hemostatic forceps for emergency bleeding cases after EP. Results: The incidence of PEPH was 20% (1 of 5 cases) in the prophylactic procedure group, which was lower than that in the conventional procedures group (75%, 3 of 4 cases), though the difference was not statistically significant (P = 0.206, Fisher's exact test). All cases of PEPH were successfully treated by soft coagulation using hemostatic forceps. Conclusion: Soft coagulation with hemostatic forceps may be suitable for use as a routine technique following EP to prevent PEPH.
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Palliation of obstructive jaundice: endoscopic ultrasound-guided choledochoduodenostomy in the presence of bleeding duodenal infiltration due to metastatic urinary bladder cancer p. 118
Surinder Singh Rana, Ravi Sharma, Rajesh Gupta, Sobur Uddin Ahmed
Obstructive jaundice is a common manifestation of malignancies involving pancreaticobiliary area of the gastrointestinal tract. The palliation of obstructive jaundice involves bypassing the obstruction by an endoprosthesis using either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage route. Endoscopic ultrasound-guided choledochoduodenostomy (ECD) is a challenging alternative for obstructive jaundice due to distal bile duct obstruction in patients who have failed ERCP. In this report, we describe a challenging case of disseminated urinary bladder cancer that presented with extensive duodenal as well as periduodenal infiltration leading on to gastrointestinal bleed and severe pruritus along with obstructive jaundice and was successfully managed with initial argon plasma coagulation of bleeding duodenal lesions followed by ECD.
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Interposed bowel loop during percutaneous endoscopic gastrostomy placement; rare and nightmare p. 122
Irfan Ali Shera, Ram Chandra Soni
Percutaneous endoscopic gastrostomy (PEG) is one of common means of enteral nutrition in day-to-day gastroenterology practice. However, PEG is associated with complications such as infection, buried bumper, interposed bowel loops, and colocutaneous fistula. Herein, we present a case of PEG tube placement with interposed bowel loop in the gastric and parietal wall that was managed conservatively.
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Ciliated foregut cyst of the pancreas presenting as a mucinous cystic neoplasm p. 125
Nadia Huq, Wesley Papenfuss, Nalini M Guda
A 53-year-old underwent an abdominal computed tomography for hematuria that incidentally discovered a cystic lesion of the pancreas. Endoscopic ultrasound revealed a structure with debris and septations; fine-needle aspiration with negative cytology but elevated tumor marker suggested a mucinous cystic neoplasm or an intraductal papillary mucinous neoplasm. Laparoscopic excision confirmed a walled-off cyst detachable from the posterior aspect of the pancreas consistent with a ciliated foregut cyst. There are limited data on ciliated foregut cysts of the pancreas, and the current report highlights the diagnostic dilemma and a review of the current literature.
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Migration of pigtail biliary stent through surface of the left lobe of liver p. 128
Bhavik Bharat Shah, Usha Goenka, Debashish Banerjee, Vijay Rai, Mahesh Kumar Goenka
We report a rare case of a patient of choledocholithiasis who underwent CBD stone removal with pigtail biliary stenting four year back, presenting with proximal migration of stent piercing the left lobe of liver. The stent was removed at laparotomy, by doing hepatotomy. We discuss this unreported case of proximal migration of pigtail biliary stent through surface of left lobe of liver.
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Giant gastroduodenal trichobezoar: An endoscopic surprise p. 131
Ashish Kumar Jha, Manish Kumar Mishra, Rakesh Kumar, Madhur Chaudhary, Shubham Purkayastha, Praveen Jha, Nazis Raza
A trichobezoar is a rare condition, mostly seen in teenage girls with abnormal psychiatric behavior of eating hairs and nails (trichophagia). Trichobezoar may rarely present with nonspecific abdominal symptoms without obvious trichotillomania and trichophagia. Trichobezoar can be complicated with potentially serious conditions such as gastric outlet obstruction, gastric bleeding, intussusceptions, and perforation peritonitis. Conventional laparotomy is method of choice for the removal of trichobezoar. We describe a rare case of giant trichobezoar treated by laparoscopic-assisted gastrostomy and removal of bezoar. We also reviewed the literature on the current status of endoscopic treatment of trichobezoar.
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Upper gastrointestinal bleed: Do not forget a look at ampulla p. 134
Avinash Bhat Balekuduru, Abhinav Kumar, Athish Shetty, Satyaprakash Bonthala Subbaraj
Hemosuccus pancreaticus (HP) and hemobilia (HB) are uncommon causes of upper gastrointestinal bleed. In this report, 4 cases of HP and 1 case of HB with intermittent bleeding are described. The causes of HP are rupture of splenic artery pseudoaneurysm in 3 and gastroduodenal artery aneurysm in one. The cause of HB is due to cystic artery bleed. HP can be secondary to chronic or acute pancreatitis with bleeding from pseudoaneurysm arising from peripancreatic arteries. Iatrogenic transhepatic techniques, trauma, operative injuries, malignancy, and inflammation in hepatobiliary system are the common causes of HB. All the cases are missed on first endoscopy and diagnosed on second-look endoscopy. A strong clinical suspicion is required at first endoscopy for early diagnosis and management. This case report compares presentation of HP with HB, diagnosis, and their management.
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Endoscopic ultrasound-guided fine needle aspiration from pericardial lesion: A case of metastatic pericardial involvement from breast malignancy p. 138
Narendra S Choudhary, Mukesh Nasa, Rinkesh K Bansal, Hemanti Sarin, Rajesh Puri
Tissue acquisition from mediastinum is difficult due to anatomic location and presence of vessels. Endoscopic ultrasound provides access to difficult mediastinal locations that are near esophagus. We describe a case of pericardial lesion, endoscopic ultrasound guided guided fine needle aspiration cytology was done and the lesion proved to be metastatic in nature.
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Cytomegalovirus colitis presenting as a rectal mass p. 140
Vipul D Yagnik
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Endoscopic ultrasound elastography for solid pancreatic lesions: Ready to replace fine-needle biopsy? p. 141
Roshan Agarwala, Surinder Singh Rana
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