An Unusual Case of Isolated Duodenal Varices With Superior Mesenteric Vein Thrombosis.

Duodenal varices usually occur due to portal hypertension and are rare causes of gastrointestinal tract bleeding. We report a unique case of a previously fit patient who presented with melena and was found to have isolated duodenal varices (DV) in the third part on esophagogastroduodenoscopy. No esophageal or gastric varices were noticed. The duodenal varices were successfully managed by endoscopic banding. A computerized tomography scan of the abdomen to further investigate the cause confirmed duodenal varices and revealed superior mesenteric vein thrombosis. The liver was normal with patent hepatic and portal veins. No evidence of thrombophilia was found. Apixaban was prescribed for superior mesenteric vein thrombosis and on follow-up. no further bleeding was reported.

Retrospective Analysis of Characteristics, Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Tertiary Referral Center in Saudi Arabia.

BACKGROUND:  Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is an essential tool in the management of pancreaticobiliary diseases. There is limited data available on the indications and outcomes of ERCP from this region. Therefore, we aim to report the characteristics of patients, indications and outcomes of ERCP in Saudi Arabia.  Methods: We retrospectively looked at ERCP procedures done at a tertiary referral center covering the western region of Saudi Arabia from August 2018 until July 2020. Data were collected from the hospital's electronic patient record and endoscopy database. RESULTS:  Of 1001 ERCPs performed, full data was available on 712 procedures on 581 patients that were included in the final analysis. Mean age was 53.1 years. Four hundred four (56.7%) were female. Board-certified consultants performed all ERCPs. The most common intervention was sphincterotomy, which was performed in 563 (96.9%) patients who underwent first-ever ERCP, followed by dilatation and stenting. The commonest indication of ERCP was confirmed or suspected choledocholithiasis (52.6%), followed by replacement or removal of a biliary stent (15.7%), 55 (7.7%) for suspected ascending cholangitis, 54 (7.5%) for acute biliary pancreatitis and 15 (2%) for suspected sphincter of Oddi dysfunction. The commonest finding among all patients was choledocholithiasis in 57.9%, debris in 15.2% and biliary stricture in 14.8%. The commonest complication was pancreatitis in 22 (3.1%) followed by post-sphincterotomy bleeding in 16 (2.2%) and perforation in nine (1.2%). Bleeding was controlled by endoscopic intervention in four (25%) and one (6.2%) patient underwent surgery. One (0.14%) patient had procedure-related mortality secondary to post-procedure pulmonary embolism and one had significant morbidity and prolonged hospitalization because of complicated perforation. The deeper common bile duct (CBD) cannulation rate was 97.3%. CONCLUSION: Our study results revealed that ERCP performed in the western region of Saudi Arabia has similar indications and findings as reported in the international literature. ERCP is successful in achieving the therapeutic objectives with complication rates consistent with published data.

Cadmium-induced ultramorphological and physiological changes in leaves of two transgenic cotton cultivars and their wild relative.

The present study describes cadmium-induced alterations in the leaves as well as at the whole plant level in two transgenic cotton cultivars (BR001 and GK30) and their wild relative (Coker 312) using both ultramorphological and physiological indices. With elevated levels of Cd (i.e. 10, 100, 1000 microM), the mean lengths of root, stem and leaf and leaf width as well as their fresh and dry biomasses linearly decreased over their respective controls. Moreover, root, stem and leaf water absorption capacities progressively stimulated, which were high in leaves followed by roots and stems. BR001 accumulated more cadmium followed by GK30 and Coker 312. Root and shoot cadmium uptakes were significantly and directly correlated with each other as well as with leaf, stem and root water absorption capacities. The ultrastructural modifications in leaf mesophyll cells were triggered with increase in Cd stress regime. They were more obvious in BR001 followed by GK30 and Coker 312. Changes in morphology of chloroplast, increase in number and size of starch grains as well as increase in number of plastoglobuli were the noticed qualitative effects of Cd on photosynthetic organ. Cd in the form of electron dense granules could be seen inside the vacuoles and attached to the cell walls in all these cultivars. From the present experiment, it can be well established that both apoplastic and symplastic bindings are involved in Cd detoxification in these cultivars. Absence of tonoplast invagination reveals that Cd toxic levels did not cause water stress in any cultivars. Additionally, these cultivars possess differential capabilities towards Cd accumulation and its sequestration.

Vaginal melanoma: a current review.

Vaginal melanoma is rare, accounting for less than 3% of primary vaginal tumours. It principally affects postmenopausal women, however no risk factors have been identified. Patients frequently present with vaginal bleeding, but the tumour is locally advanced at presentation. Surgery is only the potential cure. The relative merits of radical surgery-vaginectomy and iliac or inguinal lymphadenectomy-versus wide local excision with prompt treatment of recurrences remains uncertain. High dose external radiotherapy and regional chemotherapy trials have been encouraging, although there is no definite survival advantage. Patients should be offered excisional therapy with the opportunity to participate in trials of adjuvant therapy. Prognosis is poor with a five-year survival of 5-21%. Effective screening measures are required enabling earlier diagnosis.

Teratomas in pediatric age group: experience with 75 cases.

The clinicopathological features of 75 children under the age of 12 years with teratomas are reviewed. Tumors arose in the following anatomic sites: sacrococcygeum (n = 49), ovary (n = 10), Testis (n = 5), oral cavity (n = 3), retroperitoneum (n = 2) and others (n = 6). Fifty five (74%) presented within the first year of life. Excluding the gonadal tumors, male-female ratio was 2:5. Majority of the tumors had only mature tissues. Such patients and those 9 patients in whom the histology was not specified, underwent excision alone and had 95% early survival rates. Five patients had admixture of mature and immature tumors. Nine patients had malignant tissues. Germ cell tumors containing only malignant component, but no mature or immature teratomatous tissues were excluded from the series. The patients with immature and malignant tissues underwent multimodal therapy including surgical excision, multiagent chemotherapy (VAC regimen) and at times radiotherapy. Mortality in patients with immature and malignant teratomas was 20 and 66.7%, respectively. Besides histology, the only factor which affected prognosis, especially in case of sacrococcygeal teratomas was the age at the time of presentation. Our experience highlights the importance of early recognition and complete surgical excision of teratomas in the pediatric age group.

Pattern of childhood trauma. Indian perspective.

Although infectious diseases are still the chief cause of death in children in a developing country like ours, but a definite increase in incident and related mortality due to trauma has been noted in the last decade. The problems relating to pediatric trauma are peculiar to our setup and differ considerably to the severe multiple organ trauma met with in the high velocity vehicular accidents, seen in developed Western countries. The present study identifies patterns of childhood trauma from our region. It comprises 2100 patients admitted over a 3 years period to Pediatric Surgical Unit. Cranial injuries were the most commonly encountered injuries followed by the abdominal and skeletal injuries. Fall from the house roofs is the commonest mode of injury, although road traffic accidents are also recognized to be on the increase. The overall mortality was 7.7%; its chief determinant being the presence of severe head injury. A few important epidemiological factors involved were identified.

Spontaneous gastrointestinal perforation in the neonate.

Twenty seven cases of spontaneous gastro-intestinal perforation were treated from 1981 to 1990. Four perforations were in the stomach, 17 in the small bowel and seven in the large bowel. One of them had dual perforation, one in the stomach and another in the duodenum. The exact etiology remained obscure. Various factors observed were maternal obstetric complications, prematurity and perinatal asphyxia. Stress should be laid on early diagnosis by following up 'at risk neonates' thus, giving a better overall survival rate.