Abstract: We describe diffuse colonic calcification detected on CT scan of the abdomen in a young female patient who presented to our clinic with vague intermittent abdominal pain of four weeks duration. Her investigative profile was normal and her colonoscopy did not reveal any mucosal changes. Colonic calcification has been known to occur mostly as a result of ischemic phenomenon but the index case had no such features or any other predisposing factor. The patient is currently symptom-free and is following our clinic for the last 8 months. After the review of literature and thorough investigations her colonic calcification remains unexplained.
Abstract: Inflammatory bowel diseases (IBD) are among the leading cause of financial burden, morbidity and employee absenteeism in developed countries because of their chronic remitting and relapsing courses. IBD is estimated to affect the Canadian economy to the tune of 100 million dollars per year. The data regarding exact prevalence in Asian countries, including Saudi Arabia, is still incomplete as there is underreporting and lack of proper registry of the diagnosed cases. The prevalence of inflammatory bowel disease (Ulcerative colitis, Crohn's disease) has increased over the last decade in Saudi Arabia due to increased IBD awareness among population, as more patients seek medical help and also due to unknown reasons. There is a need of proper registration of IBD patients and establishment of Crohn's & colitis foundation of Saudi Arabia (CCFSA) as in other parts of the world. The Crohn's & colitis foundation of Saudi Arabia will be a forum which will co ordinate IBD treatment and research in the country in addition to health education among IBD population.
Abstract: We report progressive painless jaundice in a 39 year old female with a suspicion of metastatic liver disease on ultrasound and computed tomography scan of the abdomen. Although the most frequent liver lesions are liver metastasis because of dual blood supply of the liver and the impact of hormones, the index case proved to have acute autoimmune hepatitis (AIH) after liver biopsy was undertaken. AIH, an unresolving inflammation of liver, occurs predominantly among females worldwide. It may present acutely and even fulminant hepatitis has been described. The index case had a dramatic response to steroid treatment with total recovery and complete resolution of liver lesions. She is clinically fine and has been regularly attending our clinic for the last year. To our knowledge from a Medline search, this is the first report where AIH was seen to mimic metastatic liver disease.
Abstract: Treating a pyogenic liver abscess is a therapeutic challenge when a patient presents with atypical symptoms. One of the rare causes of treatment failure of these abscesses is the unrecognised migration of a foreign body from the gastrointestinal tract. The authors describe a pyogenic liver abscess in a 45-year-old male who presented with a 10 day history of fever, and abdominal pain. A CT scan of the abdomen revealed a needle-like foreign body in the liver. At operation a 2.5 cm fish bone was extracted from the liver. Subsequently, his feverish symptoms disappeared, and he has remained well in the ensuing 3 month postoperative period. Fish bone-induced liver abscess is discussed in this brief report.
Abstract: Polycystic ovarian syndrome (PCOS) is a clinically heterogeneous endocrine disorder affecting up to 4-8% of women of reproductive age. The aim of this study was to evaluate the presence of microalbuminuria in women with PCOS and study its correlation with the various metabolic, clinical, and hormonal parameters.
Abstract: Biliary parasitosis is one of the important causes of biliary obstruction in endemic areas, however due to migration and travel the disease is known to occur in non endemic zones as well. The spectrum of biliary fascioliasis ranges from recurrent biliary colics to acute cholangitis. The long term complications are gall stones, sclerosing cholangitis and biliary cirrhosis. We describe fascioliasis as a cause of recurrent biliary colics in a young male necessitating multiple hospitalizations over a period of four years. Investigative profile had been non-contributory every time he was hospitalized for his abdominal pain prior to the current presentation. He never had cholangitis due to the worm in the common bile duct. It was only at endoscopic retrograde cholangiopancreatography (ERCP) biliary fascioliasis was discovered to be the cause of his recurrent biliary colics. After removal of the live Fasciola hepatica from the common bile duct he became symptom free and is attending our clinic for last 11 months now. Clinical spectrum of biliary fascioliasis is discussed in this report.
Abstract: Bezoar is the accumulation of exogenous undigested materials in the gastrointestinal tract. Various names have been used to describe bezoars based on the accumulated material. Commonly seen types are phytobezoar (composed of vegetable matter and seeds of fruits), tricobezoar (hair) lactobezoar (milk cuds). Lithobezoar (composed of stones and rocks) is uncommon and only limited reports are available in the English literature. The authors report a case of gastrointestinal lithobezoar presenting with ulcer-like abdominal pain. Some of the stones were removed endoscopically and some got expelled out after the use of promotility drugs. Invariably, there are predisposing factors for such behaviour. This case emphasises a meticulous psychiatric evaluation in a given patient, in order to prevent recurrence of symptoms.
Abstract: A 45-year-old male farmer had noticed a swelling of the left side of his hypochondrium that persisted for six months. He had no history of severe abdominal pain, jaundice, fever, or weight loss. On evaluation, the patient was found to have hydatid cyst of the pancreas. He was managed surgically. In this case report, we emphasize the preoperative diagnosis in hydatid cyst of the pancreas.
Abstract: The authors report a sudden painless blindness in a 42-year-old male with membranous nephropathy of idiopathic origin. He was admitted with a history of decreased urine output and painful abdomen of a 3-day duration in the Department of Nephrology, Sheri Kashmir Institute of Medical Sciences, Srinagar, Kashmir - a tertiary care centre in the state of Jammu and Kashmir, India. On evaluation, he was found to have renal vein thrombosis. On day 3 of admission, he suddenly developed progressive painless blindness. Indirect ophthalmoscopic examination showed retinal vein thrombosis. Patient's clinical condition deteriorated due to his underlying condition and he succumbed to his illness. Renal vein thrombosis as a complication of nephrotic syndrome is well known. To the best of our knowledge, this is the first case of retinal vein thrombosis in the course of nephrotic syndrome.
Abstract: We present the clinical scenario of acute abdominal pain in a 27-year-old man with recent-onset type 1 diabetes mellitus. Evaluation of the patient revealed elevated levels of serum amylase, lipase, and transaminase without any biliary obstruction. He had elevated serum IgG4 levels, and his computed tomography scan showed features consistent with autoimmune pancreatitis. Further evaluation revealed celiac disease. He was treated as a patient with autoimmune pancreatitis and was started on steroids in addition to a gluten-free diet. His liver function improved in 6 weeks. He gained weight and his glycemic control also improved. Magnetic resonance cholangiopancreatography after 3 months revealed complete resolution of pancreatic enlargement. The patient is being followed up in our clinic since the past 3 years. To the best of our knowledge and according to the Medline search, this is the first case report of celiac disease as an association of autoimmune pancreatitis.
Abstract: The use of bee venom as a therapeutic agent for the relief of joint pains dates back to Hippocrates, and references to the treatment can be found in ancient Egyptian and Greek medical writings as well. Also known as apitherapy, the technique is widely used in Eastern Europe, Asia, and South America. The beneficial effects of bee stings can be attributed to mellitinin, an anti-inflammatory agent, known to be hundred times stronger than cortisone. Unfortunately, certain substances in the bee venom trigger allergic reactions which can be life threatening in a sensitized individual. Multiple stings are known to cause hemolysis, kidney injury, hepatotoxicity and myocardial infarction. The toxicity can be immediate or can manifest itself only weeks after the exposure. We describe hepatotoxicity in a 35-year-old female, following bee sting therapy for multiple sclerosis. She presented to our clinic 3 wk after therapy with a history of progressive jaundice. The patient subsequently improved, and has been attending our clinic now for the last 9 mo.
Abstract: We describe colonoscopic features in a 77-year-old female with relapse of mantle cell lymphoma, who presented with a history of rectal bleeding of 2 months' duration. Her initial colonoscopy 3 years prior to the current presentation had revealed no gross lesions of mantle cell lymphoma; however, there was evidence of microscopic disease at that time as well. The patient had now developed classical lesions following relapse of the disease. The present case report gives the natural history of this rare tumour. The comparative colonoscopic features with a brief review of mantle cell lymphoma are presented.
Abstract: Gastrocolonic fistula after percutaneous endoscopic gastrostomy (PEG tube) placement is an uncommon but a serious complication of the procedure. These fistulous tracts are often fibrotic and require surgical intervention if the spontaneous closure fails. We describe development of gastroclonic fistula in an old man who presented with history of post feeding diarrhea of 2 weeks duration three months after placement of PEG tube. Successful closure of fistulous tract was documented after local glue injection and hemostatic clips without any complication obviating need of surgery. The patient is on our follow-up for last 8 months now.
Abstract: Megaloblastic anemia is not uncommon in developing countries. Its presentation as thrombocytopenia and hemorrhagic manifestation are, however, rare. We describe the clinical scenario in two young patients who presented to the emergency room of Sir Ganga Ram Hospital, a tertiary care center in New Delhi, India, with pancytopenia and bleeding diathesis. Both patients improved after B12 supplementation. Reports of two cases and a brief review is presented.
Abstract: Several attempts have been made in the last two decades to investigate ulcerative colitis (UC) patients during the natural course of the disease so as to identify appropriate surrogate markers of disease activity. Most patients with quiescent inflammatory bowel disease have low grade inflammation and it is possible that relapse occurs only once the inflammatory process crosses a critical intensity. Since inflammation is a continuous process, its direct assessment may provide us a quantitative pre-symptomatic measure of imminent relapse. If substantial, it may allow targeted treatment early, to avert relapse or formulate newer therapeutic strategies to maintain symptomatic remission. It is clinically very important to identify these patients at a subclinical stage, noninvasively, by various biomarkers. Biomarkers help to gain an objective measurement of disease activity as symptoms are often subjective. Biomarkers also help to avoid invasive procedures which are often a burden to the patient and the health care system. If an ideal biomarker existed for UC, it would greatly facilitate the work of the gastroenterologist treating these patients. Both "classical" and "emerging" biomarkers of relevance for UC have been studied, but the quest for an ideal biomarker still continues. In this brief review we describe various biomarkers of clinical importance.
Abstract: We describe the clinical scenario of a young male with history of non ulcer dyspepsia who had endoscopic evidence of gastric polyposis in antral area. The polyps disappeared four months after proton pump inhibitors were stopped. Proton pump inhibitors have been linked to gastric fundal polyposis and not antral gland polyposis. This is the first report originating from an Asian country describing antral gland polyposis (AGPs) in a patient on long-term PPI therapy with no evidence of Helicobacter pylori. A case report with brief review is presented.
Abstract: Acute disseminated encephalomyelitis (ADEM) also known as post infectious encephalomyelitis is a demyelinating disease of the central nervous system (CNS) that typically presents as a monophasic disorder associated with multifocal neurological symptoms and disability. It may follow vaccination in children or infection. Viral infection like measles, rubella, influenza, Epstein bar, HIV, herpes, cytomegalusvirus (CMV) and West Nile virus have been implicated in the causation. Among bacteria, group A hemolytic streptococcus, mycoplasma pneumonia, Chlamydia, Rickettesia and leptospira have been shown to cause ADEM. There are few reports of ADEM due to tuberculosis (TB). We describe acute disseminated encephalomyelitis due to tuberculosis in a 35 year old female who initially started with neuropsychiatric manifestations and later developed florid neurological deficit and classical magnetic resonance imaging (MRI) lesions suggestive of the disease. The patient recovered completely after antitubercular therapy and is following our clinic for the last 12 months now.
Abstract: There is paucity of data on endoscopic management of pseudocysts at atypical locations. We evaluated the efficacy of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of pseudocysts of pancreas at atypical locations.
Abstract: Ellis-Van Creveld syndrome or chondroectodermal dysplasia is a form of short-limbed dwarfism that affects the skeleton and skin appendages. Disproportionate dwarfism, postaxial polydactyly, ectodermal dysplasia, a small chest, and a high frequency of congenital heart defects characterize this autosomal recessive syndrome. Metabolic consequences of chondroectodermal dysplasia have not been reported previously from India. We report a case of chondroectodermal dysplasia associated with metabolic disturbances qualifying a diagnosis of syndrome X. To our knowledge, this association has not been previously reported in the medical literature, and helps to unravel the metabolic association of this disorder.
Abstract: We describe the clinical scenario in an 80 year old female who presented with history of epigastric discomfort and postprandial fullness of three weeks duration without any alarming symptoms. On upper GI endoscopy she was found to have gastric polyp with a long stalk which was partially obstructing her pyloric ring giving rise to features of intermittent gastric outlet obstruction. Polypectomy was done with complete relief of symptoms. She is following our clinic for last 6 months now. Although possibility of malignant etiology in gastric outlet obstruction ranks high in the elderly some patients are lucky to have a benign cause as the index case. Report of the case and brief review is presented.
Abstract: We describe a dead ascaris-induced extrahepatic bilary obstruction in a young female who presented with acute cholangitis. The dead ascaris was removed by laparoscopic exploration of common bile duct after endoscopic retrograde cholangiopancreatography failure. Patient had an uneventful hospital course after the procedure and was discharged afebrile after 3 days of hospital stay.
Abstract: Disease activity and severity of ulcerative colitis (UC) is assessed using colonoscopy, which is invasive, costly and has poor patient acceptability. The role of non-invasive biomarkers of intestinal inflammation in the evaluation of patients with UC is not known. The aim of the study was to examine the role of serum C-reactive protein (SCRP), fecal myeloperoxidase (FMPO) and fecal lactoferrin (FLF) in assessing disease severity, activity and response to therapy.
Abstract: Gastrointestinal stromal tumors are the commonest mesenchymal tumors of the gastrointestinal tract, the stomach and small intestine are the favored sites of occurrence. They rarely occur in the colon, rectum and esophagus. GIST is neoplasm of mesenchymal origin originating from precursors of the interstitial cells of cajal. The symptoms of gastrointestinal stromal tumor depend on the site and size of the tumor, and may include abdominal pain, gastrointestinal bleeding or signs of obstruction; small tumors may, however, be asymptomatic. Majority of the patients with gastrointestinal stromal tumor have bloody stools and abdominal pain as the commonest manifestation. We describe a young female with extra luminal colonic gastrointestinal stromal tumor presenting as mass abdomen.
Abstract: Progressive Multifocal Leucoencephalopathy (PML) is a rare neurological disorder. The clinical suspicion about this disease in the setting of an immunosuppressive patient even in presence of vague neurological symptoms has to be very high. We describe here two cases of PML a post renal transplant patient and second elderly patient with no underlying immunosuppression.
Abstract: We here report a case of celiac disease and Budd Chiari syndrome. This 19-year-old boy was diagnosed to have portal hypertension in another hospital when he had developed variceal bleeding. In our hospital, he was found to have occlusion of all three hepatic veins as the cause of portal hypertension. On a routine endoscopy, he was found to have scalloping of duodenal folds. Suspecting celiac disease, he was investigated further. He did have positive serology for celiac disease as well as suggestive histology. He was found to be deficient for protein C and protein S. He was managed conservatively and put on gluten-free diet, with which he showed clinical improvement. A review of literature showed that only 14 previous cases of this combination were recorded and except for one all were from North Africa or southern Europe.
Abstract: A 25 year old male had presented with history of abdominal distension of 20 days duration and on examination he had prominent abdominal vein and a venous hum with Ascites. He had no history of altered sensorium, melena. The clinical scenario was suggestive of Cruveilhier Baumgarten syndrome.
Abstract: Non alcoholic fatty liver disease occurs in those who don't consume alcohol in amounts considered harmful to the liver. It represents a spectrum of conditions characterized histologically by mainly macrovesicular hepatic steatosis. There are two histological patterns of NAFLD: fatty liver alone and steatohepatitis. In this brief review, clinical and histologic spectrum, natural history, diagnosis, and management of this condition are discussed.
Abstract: Upper gastrointestinal (UGI) endoscopy is an important diagnostic modality in evaluation of patients with upper gastrointestinal (GI) disorders. However, lesions located in the cricopharyngeal area and upper esophagus can be missed, as this area may not be well visualized during endoscopy. This study was conducted to study the utility of a new technique of endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire in diagnosing esophageal disorders. Patients with suspected upper esophageal disorders on history and radiological investigations were assessed using guide wire assisted endoscopic examination during withdrawal of the endoscope. In this technique, endoscope is inserted into the esophagus under vision and thereafter the whole of esophagus, stomach and proximal duodenum is examined. The endoscope is then withdrawn into the mid-esophagus, a guide wire is fed into the biopsy channel, and thereafter inserted into the esophagus. Once guide wire has been advanced into the esophagus, the endoscope is withdrawn gently over the guide wire into esophagus carefully examining for lesions in upper esophagus and cricopharyngeal area. Twenty cases of various abnormalities localized to the upper esophagus were studied. The final diagnosis in these patients was cervical esophageal web (10), post transhiatal esophagectomy leak (4), heterotopic gastric mucosa (3), posttraumatic esophageal perforation (2), and Zenker's diverticulum (1). Intact web was detected in 2 patients and in 8 patients fractured web was seen. Guide wire assisted examination of upper esophagus improved the ability to visualize and characterize these lesions and no complications were encountered as a result of this procedure. Endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire is safe and effective in diagnosing anatomical abnormalities of the upper esophagus that may be missed or poorly characterized during standard endoscopy.
Abstract: This syndrome is characterized by the presence of hypothyroidism with myxoedema, muscle stiffness and pseudo hypertrophy. We describe the disorder in a 21 year old male, who got admitted with complaints of generalized weakness, cold intolerance, constipation, and hoarse voice, difficulty in walking and progressive enlargement of muscles of thighs and back with crampy pains for two years. Examination revealed mild mental retardation, enlarged tongue, dry and rough skin, enlargement of thighs and back muscles, motor weakness in flexors of hips and knees with delayed relaxation of deep tendon reflexes. Investigations revealed evidence of hypothyroidism with marked elevation of muscle enzymes. Following institution of replacement therapy with thyroxine, the patient showed marked clinical and biochemical improvements after six months, but insignificant decrease in muscle mass. In this report we review relevant literature.
Abstract: 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.
