Portal hypertensive enteropathy

Portal hypertensive enteropathy(PHE) is a condition that describes the pathologic changes and mucosal abnormalities observed in the small intestine of patients with portal hypertension. This entity is being increasingly recognized and better understood over the past decade due to increased accessibility of the small intestine made possible by the introduction of video capsule endoscopy and deep enteroscopy. Though challenged by its diverse endoscopic appearance, multiple scoring systems have been proposed to classify the endoscopic presentationand grade its severity. Endoscopic findings can be broadly categorized into vascular and non-vascular lesions with many subtypes of both categories. Clinical manifestations of PHE can range from asymptomatic incidental findings to fatal gastrointestinal hemorrhage. Classic endoscopic findings in the setting of portal hypertension may lead to a prompt diagnosis. Occasionally histopathology and cross sectional imaging like computed tomography or magnetic resonance imaging may be helpful in establishing a diagnosis. Management of overt bleeding requires multidisciplinary approach involving hepatologists, endoscopists, surgeons, and interventional radiologists. Adequate resuscitation, reduction of portal pressure, and endoscopic therapeutic intervention remain the main principles of the initial treatment. This article reviews the existing evidence on PHE with emphasis on its classification, diagnosis, clinical manifestations, endoscopic appearance, pathological findings, and clinical management. A new schematic management of ectopic variceal bleed is also proposed.     

Tessier 30 symphyseal mandibular cleft: Early simultaneous soft and hard tissue correction – A case report

A symphyseal mandibular facial cleft (Tessier 30) is a rare congenital abnormality. Nonunion of bone in the symphysis of the mandible, median cleft of the lower lip and tongue adherence in the midline to the floor of the mouth are the principle features of the anomaly. A satisfactory result can be achieved with early surgical correction of both hard and soft tissue defects in the age of 6 months. More than 3 years follow-up shows total bony fusion of the symphysis and normal lower lip function. There were only left deciduous central incisor and the ipsilateral tooth bud of the permanent central incisor missing.     

Measurement of indocyanine green dye concentration in the extracorporeal circulation

Indocyanine green (ICG) is a dye used to measure plasma volume and cardiac output and to assess hepatic function by monitoring the ICG plasma disappearance rate. A method for continuous and noninvasive measurement of ICG plasma concentration (c) in the extracorporeal circulation is presented using technology originally developed for on-line measurement of hematocrit. As expected from the ICG absorption maximum at 805 nm, the presence of ICG in blood leads to a pronounced increase in hematocrit (Hct) measured by optical means. This apparent change in hematocrit (Hct(rel) = Hct/ Hct(b) - 1) relative to the baseline hematocrit (Hct(b), where c = 0) showed a strong linear relationship (Hct(rel) = k.c) with respect to ICG concentration. The dependence of k on baseline hematocrit was best described by an exponential relationship (k = a*e(b*Hctb)). The constants a and b were determined in in vitro experiments using bovine blood. With the information on a and b, and when baseline hematocrit is known and can be assumed to remain constant throughout the observation phase, plasma ICG concentration can be noninvasively and continuously measured in the extracorporeal circulation by using available optical techniques without taking blood samples. This approach greatly simplifies the diagnostic use of ICG, which may be of importance in patients treated with extracorporeal blood purification techniques.     

A new method for training of ear framework creation by silicon dental impression material

This article presents the novel method of training of creating cartilage framework for total ear reconstruction in microtia. Replica of costal cartilage harvested for real surgery was simulated by silicon dental impression material. Carving of framework was done with wood carving instruments. Silicon dental impression material gives the consistency and texture almost comparable to real costal cartilage. Sequential steps similar to actual surgery were simulated to create the three-dimensional framework.By using this novel technique, novice surgeons can practice creating ear framework and improvise their results in the actual surgery.KEY WORDS: Cartilage framework, microtia, silicon ear model     

Repeat colonoscopy’s value in gastrointestinal bleeding

AIM:To assess the diagnostic yield and clinical value of early repeat colonoscopies for indications other than colorectal cancer(CRC) screening/surveillance.METHODS:A retrospective review of patients who had more than one colonoscopy performed for the same indication within a three year time frame at our tertiary care referral hospital between January 1,2000 and January 1,2010 was conducted.Exclusion criteria included repeat colonoscopies performed for CRC screening/surveillance,poor bowel preparation,suspected complications from the index procedure,and incomplete initial procedure.Primary outcome was new endoscopic finding that led to an endoscopic therapeutic intervention or any change in clinical management.Clinical parameters including age,sex,race,interval between procedures,indication of the procedure,presenting symptoms,severity of symptoms,hemodynamic instability,duration between onset of symptoms and when the procedure was performed,change in endoscopist,withdrawal time,location of colonic lesions and improvement of quality of bowel preparation were analyzed using bivariate analysis and logistic regression analysis to examine correlation with this primary outcome.RESULTS:Among 19 772 colonoscopies performed during the above mentioned period,947 colonoscopies(4.79%) were repeat colonoscopies performed within 3 years from the index procedure.Out of these repeat colonoscopies,139 patient pairs met the inclusion criteria.The majority of repeat colonoscopies were for lower gastrointestinal bleeding(88.4%),change in bowel habits(6.4%) and abdominal pain(5%).Among 139 eligible patient pairs of colonoscopies,only repeat colonoscopies that were done for lower gastrointestinal bleeding and abdominal pain produced endoscopic findings that led to a change in management [25 out of 123(20.33%) and 2 out of 7(28.57%),respectively].When looking at only recurrent lower gastrointestinal bleeding cases,new endoscopic findings included 8 previously undetected hemorrhoid lesions(6.5%),7 actively bleeding lesions requiring endoscopic intervention,which included 3 bleeding arterio-venous malformations(2.43%),2 bleeding radiation colitis(1.6%),and 2 bleeding internal hemorrhoids(1.6%),5 previously undetected tubular adenomas [4 were smaller than 1 cm(4.9%) and 1 was larger than 1 cm(0.8%)],3 radiation colitis(2.43%),1 rectal ulcer(0.8%),and 1 previously undetected right sided colon cancer(0.8%).Of the 25 new endoscopic findings,18(72%) were found when repeat colonoscopy was done within the first year after the index procedure.These findings were 1 rectal ulcer,3 radiation colitis,4 new hemorrhoid lesions,3 previously undetected tubular adenomas,and 7 actively bleeding lesions requiring endoscopic intervention.Of all parameters analyzed,only the interval between procedures less than one year was associated with higher likelihood of finding a clinically significant change in repeat colonoscopy(odds ratios of interval between procedures of 1-2 year and 2-3 year compared to 0-1 year were 0.09;95%CI 0.01-0.74,P = 0.025 and 0.26;95%CI 0.09-0.72,P = 0.010 respectively).No complications were observed among all 139 colonoscopy pairs.CONCLUSION:There is clinical value of repeating a colonoscopy for recurrent lower gastrointestinal bleeding,especially within the first year after the index procedure.     

Same site submucosal tunneling for a repeat per oral endoscopic myotomy: A safe and feasible option

Per oral endoscopic myotomy (POEM) is a novel endoscopic procedure for achalasia treatment. Due to its novelty and high success rates, a repeat procedure is usually not warranted, making the feasibility and safety of such approach unknown. We report the first case of a successful repeat POEM done at the same site of a previously uncompleted POEM. An 84-year-old female with type 2 achalasia presented for a POEM procedure. The procedure was aborted at the end of tunneling and before myotomy due to hypotension, which later resolved spontaneously. POEM was re-attempted at the same site of the original tunnel 1 year afterward, and surprisingly we didn’t encounter any submucosal fibrosis. The procedure felt similar to a native POEM and a myotomy was performed uneventfully. Our case is the first to suggest that submucosal tunneling during a repeat POEM can be done at the same site. Hypotension during POEM is a rare complication that should be recognized as a potential result of tension capnothorax, it can however, be managed with close supportive care.