Gastric outlet obstruction and intussusception following Frey's procedure in a patient with chronic pancreatitis - A case report

Most commonly reported postoperative complications of Frey's procedure include sepsis, delayed gastric emptying, and endocrine insufficiency. Here, we report unusual complications such as gastric outlet obstruction and intussusception following Frey's procedure in the late postoperative period. A 40-year-old patient with chronic pancreatitis with common bile duct stricture who underwent Frey's procedure, presented with recurrent vomiting episodes 3 months postoperatively. Contrast-enhanced computed tomogram (CECT) abdomen showed features of gastric outlet obstruction. A gastrojejunostomy was carried out. The patient was asymptomatic for 2 months following which the patient presented with features of jejunojejunal intussusception confirmed on CECT, which was managed conservatively. The patient remains asymptomatic on follow-up for the past 9 months. Our experience reveals that although reports of such complications following Frey's procedure are rare, gastric outlet obstruction and intussusception can occur following Frey's procedure, and hence, the surgeon should have an index of suspicion in patients with atypical presentation

Helicobacter pylori eradication in complicated peptic ulcer: Beneficial in most?

Helicobacter pylori eradication therapy has a role in minimizing the complications of peptic ulcer disease, namely, bleeding, perforation, and obstruction. However, the precise role of H. pylori eradication therapy in the complicated ulcers remains inconclusive, especially in perforation and gastric outlet obstruction. The prevalence of H. pylori in peptic ulcer bleeding patients has been widely underestimated owing to the differences in diagnostic tests and patient characteristics, and hence, it is recommended that an initial negative test should be followed up by a delayed repeat testing to rule out false negativity. It is well established now that eradication of H. pylori in patients with bleeding ulcers reduces rebleeding and ulcer recurrence. Multiple studies have attributed high recurrence rates of duodenal ulcer following simple closure to a high prevalence of H. pylori infection. Eradication therapy decreases the recurrence rate of perforated ulcers, thus justifying the role of H. pylori eradication therapy following the primary surgical management of perforated ulcers. The role of H. pylori in duodenal ulcer with gastric outlet obstruction is yet to be evaluated clearly. There are some reports of resolution of gastric outlet obstruction following therapy for H. pylori, obviating the need for surgery. Clarithromycin-containing regimens are recommended as first-line in areas of low resistance, whereas bismuth-containing quadruple therapy is the first-line empirical treatment in areas of high clarithromycin resistance. Treatment of H. pylori is beneficial in most of the patients with complicated peptic ulcer disease, especially in reducing recurrence of ulcer with or without complications

Is There an Association between Variceal Bleed and Helicobacter pylori Infection in Cirrhotic Patients with Portal Hypertension? A prospective cohort study

Objectives: The objective of this study was to find the association of H. pylori in patients with variceal bleeding as well as rebleeding in cases of cirrhosis with portal hypertension. Methods: This was a prospective cohort of patients with bleeding esophageal varices. The primary outcome was correlation between prevalence of H. pylori and the incidence of bleeding/ rebleeding from varices and with encephalopathy. The secondary outcome were correlation between the site of bleeding with H. pylori infection and the association of pepsinogen I & II and the ratio of pepsinogen I/II with bleeding. Results: A total of 190 patients were assessed for eligibility, out of which 159 patients were included in this study. 124 out of 159 patients (77.9%) had alcohol-related liver disease. 8 out of 159 patients had HBV-related liver disease. 7 patients with varices had neither bled at presentation nor did bleed in the follow-up period. A total of 78 out of 159 (49.05%) patients were H.pylori-infected. Patients with esophageal varices [Adjusted Risk (AR)=0.7] and H.pylori infection (AR=0.7) had a lower risk of variceal rebleeding. Among the patients negative for H.pylori, pepsinogen I was higher in patients with rebleeding (30.7 vs 14.4; p<0.001). Among H.pylori positive patients, the ratio of pepsinogen I/II was higher in patients with rebleeding (2.9 vs 1.3; p=0.023). Conclusion: H.pylori infection was associated with a lower risk of rebleeding in cases of cirrhosis with portal hypertension. Irrespective of the status of H.pylori infection, rebleeding was associated with more gastric acid output demonstrated by the level of pepsinogen. Keywords: Pepsinogen; hepatic encephalopathy; gastric acid output, Helicobacter pylor

Double splenic artery pseudoaneurysm with pancreatic pseudocyst: A therapeutic stalemate

Pseudoaneurysm is a rare but a potentially fatal complication associated with chronic pancreatitis. The presence of concomitant aneurysms has been reported rarely and poses a therapeutic challenge owing to the technical difficulty in accessing the distal aneurysm by endovascular means and increased chances of rupture and bleeding. Here, we report an unusual presentation of simultaneous occurrence of two pseudoaneurysms on the splenic artery (SA). A 50-year-old male, a known case of chronic pancreatitis, presented with acute abdomen and a pulsating epigastric lump. A diagnosis of double pseudoaneurysm of SA with a concomitant pseudocyst was made based on contrast-enhanced computed tomography and was confirmed by angiography. The endovascular coil embolization by the standard sandwich-technique was expected to increase the risk of expansion and rupture of the distal pseudoaneurysm, and hence was managed by adapting a modified endovascular technique, following which patient made uneventful recovery. Double pseudoaneurysm of SA associated with chronic pancreatitis is an unusual presentation. Conventional endovascular treatment used for single aneurysm may not be feasible in the presence of two aneurysms, and it needs to be tailored according to the physical site, size, and the anatomy of the vasculature associated with the aneurysms

Prospective evaluation of the diagnostic performance of a new Helicobacter pylori stool antigen immunochromatographic test

Introduction: Stool-based immunochromatographic test (ICT) requires validation for use in regional setups. Hence, this study was carried out to evaluate the diagnostic performance of a newly developed ICT kit (Pylori-Strip/Pylori K-Set, Corisbio). Materials and Methods: This was a prospective analytical study on patients who underwent upper gastrointestinal endoscopy. The combination of histology and urease was used as gold standard. Stool specimens were subjected to immunochromatographic stool antigen test using Corisbio stool antigen kit. The diagnostic performance of cassette and dipstick method and combination both was compared to the gold standard. Correlation of test efficacy with endoscopic, histological, and demographic parameters was carried out. Results: A total of 143 patients were included in the study. The diagnostic performance of cassette method and dipstick method was sensitivity, 73.3% (22/30) and 73.3% (22/30); specificity, 97.3% (110/113) and 98.23% (111/113); positive predictive value (PPV), 88% (22/25) and 91.66% (22/24); negative predictive value (NPV), 93.22% (110/118) and 93.27% (111/119); and overall accuracy, 92.3% (132/143) and 93% (133/143), respectively, when compared with the gold standard. The combination of the tests had a sensitivity of 73.3% (22/30), specificity of 97.3% (110/113), PPV of 88% (22/25), NPV of 93.22% (110/118), and accuracy of 92.3% (132/143). The diagnostic performance of the kit was unaffected by various demographic, endoscopic, or histological characteristics. Conclusions: The stool-based ICT is rapid and noninvasive diagnostic test with a high specificity, PPV and NPV, and overall accuracy. However, as the sensitivity is low, it should be primarily used as a rapid office test to determine eradication of Helicobacter pylori