Polycythemia: a mystery solved by history

Testosterone is responsible for increased muscle mass. Leaner body mass helps control weight and increases energy. High levels of testosterone help build muscles and also stimulate growth in strength. Androgenic-anabolic steroids (AAS) are drugs that are structurally related to the cyclic steroid rings system and have similar effects to testosterone in the body. Athletes who abuse steroids do so for muscle growth and quick recovery. Testosterone - whether it's injected, applied via a patch or cream, or taken orally - allows athletes to rapidly increase muscle mass beyond their usual capacity, and also reduces their recovery time which allows them to train continuously with little need to rest their bodies in between workouts. Physiologically, erythrocytosis is defined by an erythrocyte mass that exceeds 125% of that predicted for sex and body mass. Much of the concern with the use of testosterone involves increase in blood viscosity, resulting from increased red blood cell mass causing a potential increased risk for venous thromboembolism (VTE), myocardial infarction (MI), and cerebrovascular accidents (CVA). We report a case of secondary polycythemia related to testosterone therapy

A rare case of cranial metastasis from an initial presentation of hepatocellular carcinoma

Cranial metastases from hepatocellular carcinoma (HCC) has been seldom reported. Reported herein is the case of a painless parietal bone mass as an initial presentation of HCC in a 63-year-old female patient who was subsequently diagnosed to have HCV related cirrhosis. The biopsy from cranial lesion was confirmatory of HCC on immunohistochemistry. The patient had no known history of chronic liver disease. The presented diagnosis was made through detailed history, laboratory parameters and cross sectional imaging

Symptomatic improvement with gluten restriction in irritable bowel syndrome: a prospective, randomized, double blinded placebo controlled trial

Background/AimsThe existence of non-celiac gluten sensitivity has been debated. Indeed, the intestinal and extra-intestinal symptoms of many patients with irritable bowel syndrome (IBS) but without celiac disease or wheat allergy have been shown to improve on a gluten-free diet. Therefore, this study set out to evaluate the effects of gluten on IBS symptoms.MethodsWe performed a double-blind randomized placebo-controlled rechallenge trial in a tertiary care hospital with IBS patients who fulfilled the Rome III criteria. Patients with celiac disease and wheat allergy were appropriately excluded. The participants were administered a gluten-free diet for 4 weeks and were asked to complete a symptom-based questionnaire to assess their overall symptoms, abdominal pain, bloating, wind, and tiredness on the visual analog scale (0-100) at the baseline and every week thereafter. The participants who showed improvement were randomly assigned to one of two groups to receive either a placebo (gluten-free breads) or gluten (whole cereal breads) as a rechallenge for the next 4 weeks.ResultsIn line with the protocol analysis, 60 patients completed the study. The overall symptom score on the visual analog scale was significantly different between the two groups (P<0.05). Moreover, the patients in the gluten intervention group scored significantly higher in terms of abdominal pain, bloating, and tiredness (P<0.05), and their symptoms worsened within 1 week of the rechallenge.ConclusionsA gluten diet may worsen the symptoms of IBS patients. Therefore, some form of gluten sensitivity other than celiac disease exists in some of them, and patients with IBS may benefit from gluten restrictions

A family of congenital hepatic fibrosis and atypical retinitis pigmentosa

Congenital hepatic fibrosis is a rare cause of portal hypertension and esophageal varices in children. We report cases of siblings with biopsy proven congenital hepatic fibrosis and with atypical retinitis pigmentosa. They presented with repeated episodes of jaundice along with progressive decrease of vision in night. They had hepatosplenomegaly and portal hypertension with esophageal varices. One of the siblings had a large regenerating nodule replacing the entire right lobe of the liver and other one developed repeated hematemesis. This constellation of diagnosis belongs to the ciliopathy group of disorders. The spectrum of ciliopathy disorders has been evolving, and it varies from mild to severe manifestations

Gastroduodenal Tuberculosis: A Case Series and Review of Literature

Gastroduodenal tuberculosis is infrequently seen in day-to-day clinical practice with few cases reported in the literature. It is usually associated with features of gastric outlet obstruction. This is a case series of 4 patients with 2 of them having associated lower gastrointestinal involvement. One of them resembled a growth in the cardia of the stomach which responded to antitubercular drugs. Another had duodenal erosions with portal lymph node enlargement which responded to antitubercular drug treatment. None of the patients required surgical management. Gastroduodenal tuberculosis should be considered with a high degree of suspicion when patients present with gastric outlet obstruction or with endoscopic evidence of ulceronodular disease in areas endemic for tuberculosis

Successful Endoscopic Management of Bile Leak: A Single-Center Experience

Background and Aims: Bile leak is a rarely encountered complication most commonly occurring in the setting of biliary tract surgery. Site of leak may be from the gallbladder bed, the cystic duct, or rarely from injury to a major bile duct. Management has evolved with from radical surgery prevalent in earlier days to recent increased expertise in biliary endoscopy. This study aims to determine the impact of endoscopic management in treating symptomatic bile leak and discusses the role of surgery. Patients and Methods: In this retrospective study, patients with symptomatic bile leak admitted between 2012 and 2015 to the Department of Gastroenterology of a tertiary care center in Western India were analyzed. Site and extent of bile leak was evaluated using contrast enhanced computed tomography or magnetic resonance cholangiopancreatography. Endoscopic retrograde cholangiopancreatography (ERCP) was mainly used as a therapeutic tool rather than a diagnostic tool. ERCP was used as a primary mode of treatment wherever feasible. Percutaneous biliary drainage was used in technically difficult cases. Results: Twenty-seven patients with symptomatic bile leak were identified in aforesaid period. Bile leak in 21 (77.88%) patients was due to postlaparoscopic cholecystectomy injury, while in 6 (22.22%) patients, it was associated with liver abscess. Major bile duct injury was seen in 10 patients with postcholecystectomy status and in 5 patients with liver abscess. Out of 27 cases, 25 (92.59%) were treated with ERCP and 2 (7.40%) with percutaneous drainage. Surgery was not required in any of the patients. Sphincterotomy with stent placement for 6 weeks was effective in 23 (92%) patients, and only sphincterotomy was effective in 2 (8%) patients undergoing ERCP. There was no mortality due to bile leak. Conclusion: Most patients presenting with bile leak including major bile duct injury without complete bile duct transection can be successfully treated by endoscopic therapy without the need for surgery

Haemoseal Spray for Nonvariceal Gastrointestinal Bleeding: An Initial Experience from India

Background and Aims: The aim was to reflect the use and effectiveness of Haemoseal spray as a treatment option in gastrointestinal (GI) bleed in everyday gastroenterology practice. Materials and Methods: This was a single‑center, retrospective observational study conducted over a period of 12 months from January 2016 to December 2016. Consecutive patients of upper or lower GI bleed where haemoseal powder was used either as salvage therapy after a failed hemostasis or as an add‑on to the standard methods or as monotherapy were identified and analyzed. Results: Of 284 patients with GI bleed, haemoseal spray was used in 20 (7.04%) patients. Bleeding was due to duodenal ulcer in 7 (35%), gastric ulcer 3 (15%), esophageal ulcer 2 (10%), colonic postpolypectomy bleed 2 (10%), gastric carcinoma 2 (10%), Mallory‑Weiss tear 1 (5%), postsphincterotomy bleed 1 (5%), gastric antral vascular ectasia 1 (5%), and portal hypertensive gastropathy 1 (5%). The nature of bleed was oozing in 17 (85%) and spurting in 3 (15%). Initial hemostasis when used as monotherapy was seen in 3/3, as add‑on therapy in 6/6, and as salvage therapy in 9/11 patients. Rebleed was seen in 4 (20%) and 30‑day mortality was seen in 2 (10%) patients. Rebleed rate at day 7 was more in monotherapy cases; however, the difference was not statistically significant (33.33% vs. 16.66% vs. 18.18%, P = 0.819). Conclusion: Haemoseal spray is an effective hemostatic agent in various clinical situations with GI bleeding, especially when used as salvage therapy or as add‑on therapy

Primary Esophageal Intramural Squamous Cell Carcinoma Masquerading as a Submucosal Tumor: A Rare Presentation of a Common Disease

Esophageal squamous cell carcinoma (ESCC) is the commonest primary malignant esophageal tumor, which typically presents as endoscopically visible surface mucosal ulcerations, irregularities, or polyploidal masses. We here report a rare case of primary ESCC with completely intramural growth under a normal looking intact nondysplastic surface squamous epithelium disguising as a submucosal tumor. Upper gastrointestinal endoscopy-guided mucosal biopsy was negative for malignancy. Endoscopic ultrasound (EUS) revealed a heteroechoic solid mass originating from the muscularis propria of the distal esophagus. Cytological study of EUS-guided fine needle aspiration from the mass was suggestive of squamous cell carcinoma, which was confirmed on immunohistochemistry. There was no evidence of metastatic origin of this tumor or continuous cancer involvement from the surrounding structures, including the head, neck, and lungs on bronchoscopy, computed tomography scan, and positron emission tomography scan. Exclusive intramural squamous cell carcinoma with normal overlying mucosa is an exceedingly rare presentation of primary ESCC with only four cases reported in the literature so far. A high index of suspicion is required by the gastroenterologists and pathologists in diagnosing these cases as these tumors closely mimic the mesenchymal submucosal tumors such as lipoma, leiomyoma, and gastrointestinal stromal tumors. EUS is an indispensable tool in making a preoperative diagnosis and therapeutic decision making

A child with debilitating pruritus

We describe a case of two-year-old boy presenting with debilitating pruritus, patchy alopecia and jaundice since the age of 6 months. On evaluation he had intrahepatic cholestasis with persistently raised serum alkaline phosphatase, normal Gamma glutamyl transferase and raised serum bile acid levels. His liver biopsy showed bland cholestasis and electron microscopy showed granular bile suggestive of progressive familial intrahepatic cholestasis type I. Medical therapy with ursodeoxycholic acid, cholestyramine, rifampicin with nutritional modification was successful in alleviating the symptoms and correcting the nutritional status. To our knowledge this is only the sixth case of progressive familial intrahepatic cholestasis type I reported from India. Herein we discuss the diagnostic and therapeutic hurdles that one encounters in managing progressive familial intrahepatic cholestasis and also review the literature regarding this rare disorder