Spontaneous Ascitic Fluid Infection: Are we Experiencing an Epidemiological shift in Causative Organisms?

BACKGROUND: Spontaneous ascitic fluid infection (SAI) is common in cirrhotic patients leading to significant morbidity and mortality. Third-generation cephalosporins are currently recommended as first-line therapy. This is a retrospective observational study that aims to determine bacterial etiology, susceptibility patterns of SAI, and its correlation with model for end-stage liver disease-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) score. MATERIALS AND METHODS: The present study was conducted on 274 consecutive cases admitted in Bombay Hospital and Medical Research Centre, Mumbai, India. Cases of cirrhosis (irrespective of etiology) with ascites between the ages of 18-85 years were included in this study. Ascitic fluid of every patient was aspirated under all aseptic measures and was sent for biochemical, culture, and cytological analysis. RESULTS: Of the 274 patients studied, 34 (12.4%) patients were diagnosed to have SAI. Culture-negative neutrocytic ascites (CNNA) was present in 27 patients, spontaneous bacterial peritonitis (SBP) was present in six patients, and monomicrobial bacteriascites was seen in one patient. Mean age of patients enrolled was 56.05 ± 2.47 years. Eighty-two percent were males and 18% were females. Alcohol (45.45%) was the leading cause of cirrhosis followed by nonalcoholic steatohepatitis (NASH) related cirrhosis (26.47.7%) and hepatitis C virus (HCV) related cirrhosis (11.46%) and cryptogenic cirrhosis (8.82%). Average MELD-Na score was 25 and the CTP class C was most common. Klebsiella pneumoniae was the most commonly isolated organism followed by Escherichia coli. The various factors that predispose to development of SBP include low ascitic fluid protein concentration, a high level of serum bilirubin, deranged serum creatinine, high Child-Pugh score, and high MELD-Na score. CONCLUSION: Ascitic fluid analysis remains the single most important test for identifying and assessing a course of SBP. Early diagnosis and treatment will reduce the mortality rate in these patients.

Early removal of biflanged metal stents in the management of pancreatic walled-off necrosis: a prospective study.

BACKGROUND AND STUDY AIMS: Dedicated stents placed under endoscopic ultrasound (EUS) guidance have shown promise for the management of pancreatic walled-off necrosis (WON). A long duration of stent placement may increase the risk of adverse events. We prospectively evaluated the effects of (i) early removal of biflanged metal stents (BFMSs) and (ii) additional stenting of the pancreatic duct with plastic stents in patients with ductal leaks, on the risk of WON recurrence. PATIENTS AND METHODS: Symptomatic patients with pancreatic WON underwent EUS-guided BFMS placement, followed by necrosectomy, when required, from Day 3. A 5 Fr plastic stent was placed in patients with ductal leak. BFMS was removed when the WON cavity had collapsed completely. Patients were followed up at 3-month intervals. RESULTS: BFMS placement was successful in all 88 patients. A total of 64 patients (72.7 %) underwent necrosectomy (median 3 sessions). All BFMSs were removed at a median of 3.5 weeks (range 3 - 17 weeks). Ductal disconnection and leak occurred in 53/87 (60.9 %) and 61/87 (70.1 %) patients, respectively. A 5 Fr stent was placed in 56/61 patients (91.8 %) with ductal leak. Overall, 22 patients (25.0 %) had adverse events (17 mild, 1 moderate, 3 severe, 1 fatal). Recurrence was noted in 8/88 (9.1 %) at a median follow-up of 22 months. The recurrence rate was higher in patients with ductal disconnection than in those without (13.2 % vs. 2.9 %; P = 0.08), and was similar in patients with vs. without pancreatic duct stenting (7.1 % vs. 12.9 %; P = 0.44). Seven recurrences (87.5 %) partially regressed on follow-up and did not require therapy; in one case, drainage with a plastic stent was performed. CONCLUSIONS: Short-term BFMS placement is an effective therapy for pancreatic WON. The majority of recurrences developed in patients with ductal disconnection and did not require therapy. Additional pancreatic duct stents probably do not influence the recurrence rate.

Persistent Hiccups-An Unusual Presentation of Bilateral Pheochromocytoma without Syndromic Association: A Case Report.

Pheochromocytoma is a rare catecholamine-producing tumor arising from chromaffin tissue in the adrenal medulla, occurring in less than 0.2 percent of patients with hypertension. The mean age at diagnosis is about 40 years. Pheochromocytomas are commonly inherited as features of multiple endocrine neoplasia type 2 or several other pheochromocytoma-associated syndromes and have variable clinical presentation. Among the presenting symptoms, episodes of palpitations, headaches, and profuse sweating are typical and constitute a classic triad. We report a case of a 17-year-old male patient with rare bilateral pheochromocytoma presenting with persistent hiccups for 4 months and blurring of vision for 1 week, later followed by hypertensive crisis. There was neither family history of pheochromocytoma nor any classic symptoms. Patient was diagnosed with bilateral pheochromocytoma without any syndromic association. But still this patient needs to be followed for future development of medullary carcinoma of thyroid because it could be an initial presentation of MEN 2A/2B/VHL syndromes. Our paper highlights the importance of maintaining a high level of suspicion for persistent hiccups and careful clinical screening for hypertension even in absence of associated syndromes of pheochromocytoma and classical symptoms to achieve prompt diagnosis and to avoid improper management.

Detection of anaerobic infection in diabetic foot ulcer using PCR technique and the status of metronidazole therapy on treatment outcome.

UNLABELLED: Metronidazole is the drug of choice for anaerobic infection in diabetic foot ulcers (DFU) for a majority of clinicians. The present study was conducted to determine if Metronidazole is really making a difference in the healing of DFU. METHODS: Deep tissue samples from the wound area of 61 diabetic foot patients were tested for anaerobic bacterial infection (Peptostreptococcus productus, Bacteroides, and Clostridium) by polymerase chain reaction (PCR). PCR-positive patients were randomized into 2 groups: Metronidazole and non-Metronidazole. Antibiotics for the control of infection were given in both groups as per clinical condition of patients. Treatment outcome was assessed by complete healing of the wound. RESULTS: Out of 61 patients, PCR detected evidence of anaerobic infection in 32 (52%), while culture methods detected only 5 (8%) (Clostridium spp.), hence emphasizing the significance of the PCR technique over culture methods in detection of microbes. In this study, Clostridium was found with maximum prevalence of n (75%), followed by Bacteroides with n (53.1%), and Peptostreptococcus productus with n (40.6 %). Across all Wagner Ulcer Classification grades, Clostridium was the most prevalent anaerobe, and significantly associated with wound age and total leukocyte count. No difference was noted in wound healing in both groups at the end of 16 weeks. CONCLUSIONS: The authors propose that it is not mandatory to supplement Metronidazole in antibiotic regime for treatment of DFU.