Endoscopic esophageal variceal sclerotherapy using 3% aqueous phenol.

Endoscopic esophageal variceal sclerotherapy was performed in 301 patients with portal hypertension (emergency, 72 and elective, 229) using 3% aqueous phenol as sclerosant. The cause of portal hypertension was cirrhosis of the liver in 189 patients (Child's class A-48, B-66, and C-75), extrahepatic portal venous obstruction (EHPVO) in 90, and non-cirrhotic portal fibrosis in 22 patients. In the emergency group, active bleeding was controlled in 87% of cases. Re-bleeding occurred in 101 of 290 (35%) surviving patients. Obliteration of varices was achieved in 228 (84%) patients, with a mean of 5.14 +/- 2.27 sclerotherapy sessions. Of 301 patients, 29 (9.6%) had an early in-hospital mortality (30.5% in emergency and 3% in elective group), with 16 deaths due to variceal bleeding. Of the remaining 272 patients, 40 (15%) died during follow-up, of which only 11 died of variceal bleeding. Complications, such as superficial ulcers, dysphagia, and strictures, were observed in 14%, 7% of emergency, and 3% of elective patients. None of the patients developed systemic toxicity. In conclusion, 3% aqueous phenol is an effective, safe, and economical sclerosant for esophageal variceal sclerotherapy.

Immune response to hepatitis B viral antigens in chronic infection & its relationship with liver necrosis.

Markers of hepatitis B virus (HBV) and immune response against them were studied in 18 chronic asymptomatic carriers, 8 patients of the virus induced chronic liver disease (CLD), and 7 patients of chronic alcoholic liver cirrhosis, who were also chronic HBV carriers (CALC). The LMI responses to HBeAg were elevated in HBeAg and/or HBV-DNA positive chronic asymptomatic carriers, (median response 31.5%), along with elevation of serum alanine aminotransferase (sALT) levels (59-150 IU/l). On the other hand the LMI responses to this antigen, in HBeAg and HBV-DNA negative chronic carriers were in the normal range (median response 12%) and their sALT levels were also normal (7-50 IU/l). The CLD and CALC patients did not show any relation between their LMI to HBeAg and sALT levels. In contrast no relation between LMI to HBsAg and sALT levels was observed in any group. The LMI responses to HBsAg in CLD patients were elevated (median response 38%) and the responses of chronic asymptomatic carriers and CALC patients were either in the normal range or poor (median responses, 18 and 7% respectively), irrespective of their sALT levels. These results suggest that T cell responses to both the antigens may be involved in liver cell damage.

Comparative trial of three different schedules for endoscopic esophageal variceal sclerotherapy.

We analyzed our experience in 125 patients with variceal bleeding to compare the efficacy and complications of various schedules of endoscopic variceal sclerotherapy. The schedules for the first three injections were as follows: (A) 3-5 ml of aqueous phenol injected at intervals of three weeks (Group I, n = 28), one week (Group II, n = 30) and three days (Group IIIa, n = 33), and (B) 2-3 ml of phenol at each site at intervals of 3 days (Group IIIb, n = 34). Subsequent injections were given at four week intervals for all groups. Varices could be obliterated significantly earlier (p less than 0.001) in patients injected at 3-day intervals (mean +/- SD 9.12 +/- 5.95 weeks) as compared with those injected at 1-week (13.50 +/- 10.28 weeks) and 3-week (20.55 +/- 7.77 weeks) intervals. The rebleeding rate was not significantly less in the 3-day interval group (Group IIIa--16.66% and Group IIIb--17.64%) as compared with the 1-week (23.3%) and 3-week (28.5%) groups. However the mortality due to rebleed was significantly less (p less than 0.05) in patients injected at 3-day interval (nil), as compared with those injected at 1-week (13.3%) and 3-week (10.7%) intervals. Mucosal ulcerations and stricture formation were observed significantly (p less than 0.001) more frequently in patients undergoing sclerotherapy at 3-day intervals (Group IIIa--51.5% and 18.18%) with 3-5 ml of phenol as compared with those injected similar volume at 1-week (16.66% and 3.3%) and 3-week (7.1% and 3.5%) intervals respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphological changes in esophagus following endoscopic sclerotherapy with 3% aqueous phenol.

Autopsy studies have shown that a majority of sclerosants presently used for endoscopic variceal sclerotherapy achieve their end result by a process of necrotizing inflammation of the esophageal wall followed by fibrosis and thrombosis, rather than bland thrombosis of varices. We have been using 3% phenol in water for variceal sclerotherapy and found it to be an effective sclerosant. To study the effect of this sclerosant on varices and the esophageal wall, autopsies were performed in 15 patients who died following sclerotherapy. Histopathological examination of sections from the esophagus showed (a) fresh thrombus in the varices immediately following injection, (b) intimal damage with medial sclerosis and superficial mucosal ulceration after one week, (c) organisation and recanalization with marked medial sclerosis at 3-4 weeks, and (d) complete obliteration of varices after 6-12 weeks. None of the patients was found to have esophageal necrosis, perforation or mediastinitis. Thus, 3% aqueous phenol appears to be an effective and safe sclerosant for variceal sclerotherapy.

Adaptative changes in terminal ileum after total colectomy, mucosal proctectomy and straight ileo-anal anastomosis in chronic ulcerative colitis.

Total colectomy, mucosal proctectomy and straight ileo-anal anastomosis was performed in four adult patients with chronic ulcerative colitis (three males, one female; mean age 27.4 years). During a follow-up period of one to five years, all patients were continent, had spontaneous bowel evacuation (average 4-5 per day), and had normal bladder and sexual function. Sequential per rectal ileoscopies revealed loss of ileal folds and gradual transformation to a colonic type of mucosa. On barium studies, the anastomosed terminal ileum showed progressive ballooning and assumed a rectosigmoid appearance with complete disappearance of ileal characteristics. The histology showed a progressive transformation from ileal to colonic type of mucosa, with blunting and ultimate disappearance of villi, increasing goblet cell population, and increase in mononuclear cells in the lamina propria. Histochemical studies (high iron diamine and alcian blue stains) revealed a change from small intestinal to colonic mucin, progressing proximally from just above the anastomotic site. Two patients had a single recurrence with ileal histology resembling that of active ulcerative colitis; both responded to short term steroid therapy. The results of straight ileo-anal anastomosis compare well with Western reports of ileal reservoirs. Adaptative changes of 'colonisation' can be consistently demonstrated in the anastomosed ileum on follow-up; these start just above the anastomotic site and ascend proximally. The colonised ileum appears to be susceptible to the ulcerative disease.

Prognostic value of rectal biopsies in idiopathic ulcerative colitis.

Eighty seven biopsies and five total colectomy specimens following surgery were studied in 40 cases with idiopathic ulcerative colitis. They were categorised as acute ulcerative colitis with evidence of chronic activity in the first or subsequent biopsies (10 cases), chronic active ulcerative colitis (25 cases), and chronic quiescent ulcerative colitis (5 cases). The histological criteria were predefined with special reference to chronic crypt changes. Repeat biopsies were available in 28 cases and were found to be valuable in diagnosis and follow up of the disease.

Diarrhea associated with metastasis from medullary carcinoma of thyroid.

Watery diarrhea is a prominent symptom in medullary carcinoma of the thyroid (MCT) and may occur as the initial symptom and/or during the course of metastatic malignant disease. Death is generally the result of widespread dissemination of the tumour. We report a case with MCT and metastatic disease manifesting with diarrhea and dying due to widespread metastatic disease.