Indian Journal of Gastroenterology 2007 Vol 26 September - October i

Editorials

Measuring hepatic functional reserve using MEGX still a mirage!S K Sarin, Manoj Kumar 203Gastrointestinal stromal tumor - paradigm for successful targeted therapy Susy Kurian 207

Original Articles

Impact of shorter duration of treatment on virological response rate in genotype 2 or 3chronic hepatitis C virus infection Ioannis S Elefsiniotis, Konstantinos D Pantazis, DimitriosDimitroulopoulos, Sotirios Koutsounas, Antonios Moulakakis, Emmanouel Paraskevas 209Gastrointestinal stromal tumors: a demographic, morphologic and immunohistochemicalstudy F Rauf, Y Bhurgri, S Pervez 214Morphological and functional outcome after pancreatic necrosectomy and lesser sac lavagefor necrotizing pancreatitis Mettu Srinivas Reddy, Sumitoj Singh, Rajinder Singh,Kartar Singh, Gurpreet Singh 217Analysis of Helicobacter pylori antimicrobial susceptibility and virulence genesin gastric mucosal biopsies in the United Arab Emirates Mubarak S Alfaresi, Adeel IslamAbdulsalam, Abida A Elkoush 221Gastrointestinal stromal tumors: a single institution experience of 50 cases Senthil Rajappa,Krishna Mohan Muppavarapu, Shantveer Uppin, Raghunadharao Digumarti 225

Review

Celiac disease in India Surender Kumar Yachha, Ujjal Poddar 230Case Series

Hydatidiarrhea Suyash Mohan, Ashish Verma, Sanjay Saran Baijal 238Clinico-pathology conference

A treated case of follicular lymphoma presenting with fever and diarrhea Kim Vaiphei,Pankaj Malhotra, Nidhi Sharma, Anil Kumar Narasiyappah, Subhash Chander Varma 240

Case Snippets

Endovascular management of hepatic hemorrhage and subcapsular hematoma inHELLP syndrome Chandan Jyoti Das, Deep Narayan Srivastava, Jyotindu Debnath, VijayRamchandran, Sujoy Pal, Peush Sahni 244Visceral leishmaniasis: acute liver failure in an immunocompetent Asian-Indian adultG Malatesha, Nishith K Singh, Vinay Gulati 245Endoscopic removal of chicken bone that caused gastric perforation and liver abscessR J Mukkada, A P Chettupuzha, V J Francis, P G Mathew, S P Chirayath,Abraham Koshy, Philip Augustine 246

Letters

Reactogenicity of a combined hepatitis A and hepatitis B vaccine in healthy Indian childrenand adults Rakesh Aggarwal, A Balachandran, Unnikrishnan Menon, Rahul Nagpal, GirishPokharna, Sanjay Rao, Dhananjay Shah, Karthik Srinivasa, Sanjoy Datta, Hans Bock 248Colonoscopic and ileoscopic biopsies increase yield of diagnosis in chronic large bowel diarrheawith normal colonoscopy S Khanna, R Talukdar, N Saikia, S Mazumdar, S Kulkarni,J C Vij, A Kumar 250Delta hepatitis infection in northeast IndiaBiswa Jyoti Borkakoty, Dipankar Biswas, Jagadish Mahanta 251Thrombophilic factors in Egyptian children with portal vein thrombosisKhaled Salama, Nehal El-Koofy, Manal El-Hawary, Mona El-Raziky,Mona Abou-El Ela, Hala Ali, Hanaa El-Karaksy 252

Copyright © 2007 by Indian Society of Gastroenterology

This Journal is indexed by National Informatics Center, New Delhi, and indexed and abstracted by EMBASE/ExcerptaMedica, Amsterdam, the Netherlands, and Index Medicus and Medline, Philadelphia, PA, USA

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Contents

Indian Journal of Gastroenterology 2007 Vol 26 September - October iii

Hepatitis C virus infection and risk behaviors among injection drug users of NagalandHiranya Kumar Das, Biswa Jyoti Borkakoty, Jagadish Mahanta,Gojendra Kumar Medhi, Pradeep Kumar Chelleng 253Endoscopic removal of giant colonic lipomas Georgia Lazaraki, Dimitrios Tragiannidis,Anestis Tarpagos, Dimitrios Tzilves, Ioannis Pilpilidis, Ioannis Katsos 255Rectal bleeding due to leech bite in a young child Vincent Ho, Peter Boyd 256Cecal web causing neonatal intestinal obstruction Sushil Budhiraja 256

Images

Colonic leiomyoma with huge ulceration Akihiko Takeda, Shinichi Ban, Akihiro Yasumoto,Keiko Ishikawa, Hiroyoshi Iseki, Hideki Takeuchi, Norio Takahashi, Isamu Koyama 213Gastric cancer presenting with cutaneous metastasisGeorge Barreto, Shailesh Shrikhande, Parul Shukla 237Gastroenterology Elsewhere 257India Elsewhere 258AnnouncementsIndian Journal of Gastroenterology J Mitra Memorial Award 206New and Notices 216Index to Advertisers 220Instructions to Contributors 259

Indian Journal of GastroenterologyEditorial Board

2007Editor-in-ChiefShobna J Bhatia

Mumbai

EditorsRakesh Aggarwal B S RamakrishnaHepatology GastroenterologyLucknow Vellore

Editor EmeritusPhilip Abraham

Mumbai

Members

Indian Society of GastroenterologyOffice Bearers

2006-2007

PresidentSubrat K AcharyaPast Presidents

Deepak K Bhasin K R Palaniswamy2005-06 2004-05

President ElectRamesh Roop Rai

Honorary SecretaryGourdas ChoudhuriHonorary Treasurer

Shobna J Bhatia

Governing Council Members Co-opted Members2006-2009 Philip AbrahamMahesh Goenka Yogesh ChawlaV G Mohan Prasad B S Satyaprakash2005-2008 Randhir SudT S ChandrasekarPrabha Sawant2004-2007

Ashok ChackoPramod Garg

Subrat K AcharyaNew Delhi

Anil C AnandNew Delhi

Yogesh K ChawlaChandigarh

Gourdas ChoudhuriLucknow

S Datta GuptaNew Delhi

Uday C GhoshalLucknow

Abraham KoshyKochi

Rakesh KochharChandigarh

S P MisraAllahabad

K M MohandasMumbai

H RameshKochi

Peush SahniNew Delhi

Sudeep R ShahMumbai

Sadiq S SikoraBangalore

Avinash N SupeMumbai

S K YachhaLucknow

Editorial SecretaryMarian D’Souza

Contents (contd.)

Case Snippets

246 Indian Journal of Gastroenterology 2007 Vol 26 September - October

and auto-immune hepatitis were inconclusive. CD4 cellcounts were normal. Initial blood chemistry (Table)showed bi-cytopenia and reflected marked hepatocel-lular injury. Light microscopy of bone marrow aspiraterevealed several amastigotes within marrow macroph-ages. Absent hemophagocytes, and normal serum trig-lycerides (160 mg/dL) and fibrinogen (180 mg/dL) lev-els ruled out hemophagocytic syndrome. After start-ing intravenous amphotericin-B (initiated in a gradu-ally increasing dose from the 3rd day to maximum of 1mg/Kg/day), the patient made a dramatic recovery oversix weeks period. He had clinical and laboratory remis-sion, and a repeat marrow aspirate (at 22 weeks) wasnegative for Leishmania donovani (LD) bodies.

Milder forms of liver involvement occur in17% of cases with kala-azar, and are structurallyand functionally reversible after treatment.1,2 Se-vere symptomatic forms like acute hepatocellularfailure are rare and reported only in children. Wedid not find any previous case of acute liver fail-ure due to leishmaniasis in an immunocompetentadult.1,3,4 Pathophysiologically, liver involvementin VL is typically self-limited and involves amononuclear cell-dominated granulomatous inflam-mation mediated by cytokines, chemokines andreactive oxygen and nitrogen species.5 In our pa-tient exposure to an endemic zone, cytopenia, sple-nomegaly, and altered albumin/globulin ratio werethe vital clues which helped us diagnose the dis-ease.

References1. Singh UK, Sinha RK, Sharma VK. Fulminant hepatitis in

kala-azar. Indian J Pediatr 1995;62:571-4.2. el Hag IA, Hashim FA, el Toum IA, Homeida M, el Kalifa

M, el Hassan AM. Liver morphology and function invisceral leishmaniasis (Kala-azar). J Clin Pathol1994;47:547-51.

3. di Martino L, Vajro P, Nocerino A, Scotti S, NapolitanoG, Vegnente A. Fulminant hepatitis in an Italian infantwith visceral leishmaniasis. Trans R Soc Trop Med Hyg1992;86:34.

4. Pahwa R, Gupta SK, Singh T, Nigam S. Acute fulminantvisceral leishmaniasis in children - a report of two cases.Indian J Pathol Microbiol 2004;47:428-30.

5. Malla N, Mahajan RC. Pathophysiology of visceral leish-maniasis - some recent concepts. Indian J Med Res2006;123:267-74.

Correspondence to: Dr Gulati, Assistant Professor, Depart-ment of Medicine, All India Institute of Medical Sciences, NewDelhi 110 029. E-mail: drvinaygulati@gmail.com

Received April 24, 2007. Received in final revised form June 19,2007. Accepted July 30, 2007

Endoscopic removal of chicken bone thatcaused gastric perforation and liver

abscess

R J Mukkada, A P Chettupuzha, V J Francis,P G Mathew, S P Chirayath,

Abraham Koshy, Philip Augustine

Department of Gastroenterology, Lakeshore Hospital,Kochi 682304, India

A 40-yr-old gentleman presented with abdominal pain,nausea and vomiting since 3 weeks. CT scan of theabdomen showed a liver abscess but also a bonepenetrating the left lobe of the liver. A 5-cm-longchicken bone was removed endoscopically. He wasdischarged on day 8 and was asymptomatic 12months later. Endoscopic retrieval of an extraluminalforeign body causing liver abscess has not beenreported previously. [ Indian J Gastroenterol2007;26:246-247]

Most ingested foreign bodies (FB) pass throughthe gastrointestinal tract uneventfully but

about 1% cause perforation.1 We report an ingestedFB perforation of the stomach that caused a liverabscess and was treated successfully by endoscopicretrieval.

A 40-year-old gentleman working in Bahrain pre-sented with analgesic-responsive recurrent abdominal painof 1-year duration, with exacerbation of pain, nausea andvomiting since 3 weeks. He gave no history of ingestionof a FB or use of dentures and had no other predisposingcircumstances. Physical examination showed no abnor-mality. Abdominal ultrasound showed a 5 cm liver ab-scess in right lobe and another 3 cm abscess in left lobe.

Investigations: Hemoglobin 11 g/dL, WBC 6700/µL,Platelets 795000/µL, ESR 85 mm/h, GGT x1.7 upper limitof normal. Other liver function tests, blood sugar, renalfunction, alpha-fetoprotein and amebic serology werenormal. CT scan of the abdomen showed the 4 cm x 5cm liver abscess. It also showed a bony structure pen-etrating the left lobe of the liver (Fig 1). Endoscopyshowed oozing and then spurting of pus from a pinholein the antrum (Fig 2A). The hole, extended by cuttingwith a needle-knife-sphicterotome, revealed a foreignbody: it was pulled out with a foreign-body-forcepsand the 5-cm-long intact chicken bone (Fig 2B) wasremoved along with the endoscope. The patient wasgiven naso-jejunal tube feeding for 4 days, metronida-zole and cefoperazone+sulbactam. He was discharged,asymptomatic, on day 8. Repeat US abdomen 1½ monthslater, showed a 1.7x1.5 cm abscess and absence of for-eign body. He was asymptomatic 12 months later.

FB perforations of the stomach, duodenum,and large intestine tend to have longer, subtlerclinical features than perforations of the jejunum

Case Snippets

Indian Journal of Gastroenterology 2007 Vol 26 September - October 247

or ileum.2 Bilimoria reviewed 30 cases of liverabscess as a consequence of FB penetration of thegut.2 The lack of history of ingestion of a foreignbody, the relatively non-specific symptoms andsigns, and the insensitivity of conventional radi-ography often resulted in delayed recognition and10% mortality.2

Helical and multidetector-row CT are very ef-fective imaging modalities for the diagnosis of in-testinal perforations caused by calcified alimen-tary foreign bodies.3,4 Ultrasound is useful to de-tect non-metallic FBs.5

Approximately 5% of ingested FB require sur-gery.1 Of these, 31% had long gastric FBs with notendency for distal passage and were removed viagastrostomy, 15% had thin, sharp FBs, causingperforation. Most FB perforations with liver ab-scess were dealt with by surgery. A single reportof percutaneous removal has been documented.6

Although perforating FBs have been removed en-doscopically from the colon5 and duodenum,7 thepresent case is the first report of an ingested FBperforation of the stomach causing liver abscess,treated successfully with endotherapy. 8-10

References1. Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT.

Ingested foreign bodies of the gastrointestinal tract: ret-rospective analysis of 542 cases. World J Surg1996;20:1001-5.

2. Bilimoria KY, Eagan RK, Rex DK. Colonoscopic identi-fication of a foreign body causing an hepatic abscess. JClin Gastroenterol 2003;37:82-85.

3. Goh BK, Tan YM, Lin SE, Chow PK, Cheah FK, OoiLL, Wong WK. CT in the preoperative diagnosis of fishbone perforation of the gastrointestinal tract. AJR Am JRoentgenol 2006;187:710-714.

4. Coulier B, Tancredi MH, Ramboux A. Spiral CT andmultidetector-row CT diagnosis of perforation of the smallintestine caused by ingested foreign bodies. Eur Radiol2004;14:1918-1925.

5. Mohr HH, erkes-Globisch A. Endoscopic removal of aperforating toothpick. Endoscopy 2001;33:295.

6. Horii K, Yamazaki O, Matsuyama M, Higaki I, Kawai S,Sakaue Y. Successful treatment of a hepatic abscess thatformed secondary to fish bone penetration by percutane-ous transhepatic removal of the foreign body: report of acase. Surg Today 1999;29:922-926.

7. Honaas TO, Shaffer EA. Endoscopic removal of a for-eign body perforating the duodenum. Can Med Assoc J1977;116:164, 169.

8. Chintamani, Singhal V, Lubhana P, Durkhere R, BhandariS. Liver abscess secondary to a broken needle migra-tion—a case report. BMC Surg 2003;3:8.

9. Yang CY, Kao JH, Liu KL, Chen SJ. Medical treatmentof fish bone-related liver abscess. Clin Infect Dis2005;41:1689-1690.

10. Chiang TH, Liu KL, Lee YC, Chiu HM, Lin JT, WangHP. Sonographic diagnosis of a toothpick traversing theduodenum and penetrating into the liver. J Clin Ultra-sound 2006;34:237-240.

Correspondence to: Professor Koshy. Fax: 91 (484) 701 996. E-mail: koshyabe@yahoo.com

Received May 29, 2007. Accepted August 27, 2007

Fig 2: Spurting of pus from a pinhole in the antrum (above).The 4 cm long intact chicken bone removed with the endo-scope (below).

Fig. 1: Liver abscesses in right and left lobes (arrows) and(below) a hyper dense bony structure penetrating left lobe ofliver

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