Coffee Ground Material Research Articles

Effect of Pretreatment and C/N Ratio in Anaerobic Digestion on Biogas Production from Coffee Grounds and Rice Husk Mixtures

Indonesia has great potential in producing large quantities of renewable energy sources, such as biomass. Biogas is a renewable energy source produced from biomass. It is can be developed in agricultural countries producing rice and coffee, where a large amount of waste is produced in the form of rice husks and coffee grounds. This study examined the effect of physiochemical pretreatment and the C/N ratio on biogas production using coffee grounds and rice husk mixtures. Physical pretreatment was conducted by grinding the mixture up to 50 mesh size, followed by chemical pretreatment by soaking the mixture in 3% KOH; moreover, the variation in the C/N ratio was set at 25 and 30. Anaerobic bacteria were acquired from rumen fluid. The ratio of the coffee ground material, rice husks, and rumen fluid was 1:1:1. This research was conducted in duplicate under batch conditions at ambient temperature (25–35 oC) with a digester volume of 1.5 L. Biogas productivity was measured every 2 d for 60 d. The experimental results indicated that biogas production with a C/N ratio of 30 was 13.3–66.5% higher than that with a C/N ratio of 25. The inclusion of physical pretreatment at a C/N ratio of 30 increased biogas production by up to 31.3%. Moreover, the inclusion of a chemical pretreatment at a C/N ratio of 30 resulted in 30.3% higher biogas production. The kinetics model of biogas production showed that a C/N ratio of 30 with physical and alkaline pretreatment can produce maximum biogas yields of 6,619 mL and 6,570 mL, respectively. Overall, both pretreatments sequentially increased the biogas production significantly.

2754 A Gaping Hole in the Stomach - A Rare PEG Tube Complication

INTRODUCTION: Up to 200,000 gastrostomy tubes (PEG) are placed in the United States each year, with a success rate over of 95%. Here we present a patient with complaints of abdominal pain and discharge from the PEG site, who was found to have an interesting EGD finding. CASE DESCRIPTION/METHODS: A 52 year old cachectic woman with a history of opioid abuse, roux-en-Y gastric bypass for obesity 14 years prior, and PEG placement due to inadequate oral intake almost 3 months prior to her admission, presents to the ED with worsening abdominal pain, nausea, intermittent vomiting and discharge of fecal like material from PEG site for the last few days. On exam patient appeared cachectic, disheveled, and had diffuse erythema of her abdominal wall. Vital signs were significant for hypothermia to 91.3 F, and bradycardia. Labs were significant for sodium of 152. CT abdomen and pelvis showed the PEG tube in satisfactory position. She was started on IV fluids and antibiotics but soon became hypoxic and tachycardic requiring medical ICU care. Subsequently, bleeding around the PEG tube was noted. Hemoglobin dropped from 9.8 to 7.2 within 9 hours. Lavage of the PEG tube revealed coffee ground material. Due to patient’s tenuous respiratory status, it was decided to perform an upper endoscopy by accessing the stomach via the gastrostomy fistula. The PEG tube balloon was deflated and the endoscope was easily inserted without resistance. The peritoneum was immediately visualized, which contained undigested food (Figure 1). The endoscope was withdrawn and was navigated into the body of the stomach, via a large opening. A significant amount of undigested material was seen in the remnant stomach (Figure 2). There was an opening between the remnant stomach and the gastric pouch (Figure 3), which was traversed with the endoscope. The gastric pouch was severely ulcerated and the gastrojejunal anastomosis could not be identified. The patient was then transferred to the hospital where her previous surgery and PEG tube were placed. There, her hospital course was complicated by ARDS requiring intubation. She eventually underwent replacement of PEG tube and after 50 days of hospitalization, she was discharged home. DISCUSSION: Procedure related complications such as perforation can occur anywhere from <0.5-1.8%. In this case, although the PEG tube may have initially been placed in the stomach, the replacement balloon PEG tube may have been inserted into the peritoneum. Complications such as these should always be a consideration.

Signet Ring Cell Carcinoma of the Stomach Presenting With Gastric Outlet Obstruction

30 year old male with no significant past history came to the emergency room with 2 week history of abdominal pain,dark brown emesis, early satiety and unable to keep food down.Family history was significant for maternal grandmother who died of colon cancer at age 49.Physical exam was unremarkable except for HR 120 beats per minute. Blood work including a complete blood count and comprehensive metabolic profile were normal.An esophagogastroduodenoscopy showed LA Grade-D esophagitis in the lower thirds of esophagus with contact oozing and massive amount of coffee ground material in stomach. Further suctioning of the gastric contents revealed a cratered necrotic ulcer in the prepyloric region with pyloric distortion precluding duodenal intubation,consistent with gastric outlet obstruction.Gastric biopsies of the ulcer showed poorly differentiated adenocarcinoma with microscopic sections showing >80% signet-ring cells. Further staging with abdominal-pelvic Computed Tomography and laparoscopic staging of the gastric cancer was T3N3aM0. Patient ultimately had a Subtotal gastrectomy with Billroth II with lymphadenectomy. After discharge patient was referred to tertiary center for further enrollment in clinical trials. Gastric cancer is the third most common cause of cancer death worldwide.Signet Ring cell cancer (SRCC) is a poorly differentiated adenocarcinoma characterized by the malignant cells in which the nucleus is pressed to one side by the presence of intracytoplasmic mucus. While the incidence of gastric cancer has been declining with effective treatment of H.pylori,the rising incidence of SRCC indicates that H.pylori infection is not a significant risk factor for SRCC. SRCC has been described in association with hereditary diffuse gastric cancer due to germline mutation in CDH1 resulting in tumor cells proliferation .It has also been a part of Hereditary non-polyposis colorectal cancer and gastrointestinal polyposis syndromes as a result of mutations in APC genes. Our case highlights a rare aggressive histological subtype of gastric cancers.2664_A Figure 1. Endoscopy findings2664_B Figure 2. Black arrow showing normal glandular structure of stomach and red arrow showing cancerous tissue2664_C Figure 3. Black arrow showing Signet ring cell

Gastric Mucormycosis as a Cause of Upper Gastrointestinal Bleeding in an Immunocompetent Patient

Introduction: Mucormycosis is an opportunistic fungal infection primarily diagnosed in immunocompromised individuals. While most cases are either rhinocerebral or pulmonary; gastrointestinal manifestation of the disease is very rare. We report the first case of gastrointestinal mucormycosis (GM) in a male patient with a recent history of intravenous heroin use and binge drinking. Case: A 36-year old Male patient that was brought to our hospital after being found unresponsive and cyanotic. On examination the patient was afebrile but tachycardic (pulse 112beats/min), tachypnic (RR =32/min), and hypotensive (BP 89/56 mmHg). His pupils were pinpoint but reactive and his cutaneous examination revealed numerous track marks along the upper extremities. Patient was stabilized, intubated and admitted to the medical intensive care unit. On hospital day 3, the patient had 3 episodes of melena associated with a 4gm decrease in hemoglobin. Gastric lavage was notable for coffee ground material mixed with clotted blood. An esophagogastroduodenoscopy (EGD) revealed a 5cms necrotic appearing ulcer along the greater curvature of the stomach with surrounding exudate (Figure 1A). The histopathology showed necrotic mucosa with acute on chronic inflammatory infiltrate and many microorganisms. Special periodic-acid schiff and methanine-silver stains showed broad, irregular, nonseptate hyphae with right-angled branching consistent with primary GM (Figure 1B, 1C). Patient was seen by Infectious Disease and prescribed oral Posaconazole. Due to financial restrictions he never started the medication. Repeat EGD at 12 weeks revealed complete resolution of the ulcer (Figure 2).Figure: Necrotic Ulcer with Surrounding Exudate.Figure. 1B: Periodic-Acid Schiff Stains 1C-Methanine-Silver Stains Broad, Irregular, Nonseptate Hyphae with Right-Angled Branching.Figure: Normal Esophagogastroduodenoscopy.Discussion: Gastrointestinal mucormycosis is an exceedingly rare but fatal diagnosis. The pathologic hallmark of mucormycosis is infarction of host tissue resulting from angioinvasion of the hyphae. We hypothesize that contaminated needles and subsequent colonization of presumed gastric erosions due to heavy episodic alcohol use facilitated hyphal invasion and lead to infarction and necrosis of the gastric mucosa. Despite the need for aggressive antifungal treatment with or without surgical debridement our patient fully recovered without therapy. Interestingly, discontinuing alcohol and drug use must have lead to the reconstitution of his immune system causing self-healing of the gastric ulcer in an otherwise immunocompetent patient.

Determinants and Outcome of Acute Upper Gastrointestinal Bleeding in Yemen

Background: Upper gastrointestinal bleeding is a major medical emergency and one of the most important indications for hospital admissions. The etiology varies in different parts of the world. Objectives: The study aimed to determine the occurrence, the risk factors and outcome of acute upper gastrointestinal tract bleeding in Yemen. Materials and Methods: This is a retrospective study. The medical records of all patients in four Yemeni hospitals within the last 4 years were reviewed, 18 years of age and older, admitted with upper gastrointestinal bleeding as indicated by coffee ground material or bright red blood in gastric aspirates or black, tarry stools in addition to demographic data. Results: There were 350 cases of acute upper gastrointestinal bleeding admitted to the four hospitals within the last 4 years. The commonest causes of upper gastrointestinal bleeding in Yemen were oesophageal varices [90%], erosive gastritis [3.43%] and peptic ulcers 6% [DU: 3.43%, GU: 2.57%] ; Duodenal ulcers, gastric ulcers and malignancy were not so common causes of acute upper GIT bleeding in comparison with oesophageal varices. Patients with variceal bleeding were younger and had a higher mortality rate than non-variceal bleeders. Conclusion: The rate of upper GI bleeding in Yemeni patients is common with many significant causes. The most common causes were esophageal varices, peptic ulcer disease, gastric cancer and erosive gastritis.

Successful Treatment of Duodenal Perforation with Over-The-Scope Clip after Failed Surgical Repair

Purpose: Over-The-Scope Clips (OTSC®) have been reported to be useful in primary repair of iatrogenic endoscopic perforations. We report the successful use of the OTSC® in an elderly patient who failed surgical repair for an iatrogenic duodenal perforation. Methods: A 94-year-old man presented with a history of chronic duodenal strictures due to a duodenal ulcer. He was limited to a liquid diet and had undergone two prior balloon dilations without fluoroscopy. The third dilation, with fluoroscopic guidance, identified the stricture at the apex of the duodenal bulb. As the balloon was dilated to 12 mm, a small amount of blood was seen coming from the stricture. The patient felt well and was discharged. The following day, the patient presented with dyspnea and an episode of coffee-ground emesis. On exam, the patient was tachypneic with a grossly distended, hypertympanic, tender abdomen. Abdominal and pelvic CT revealed a peri-duodenal fluid collection in the anterior perirenal space consistent with a duodenal perforation. The patient was taken to the OR for exploration, where a fist-sized abscess containing coffee ground material as well as a 1.5-cm posterior perforation of the duodenum was found. The duodenum was closed with an omental patch; a gastrojejunostomy was formed and a feeding jejunostomy created. He recovered well until post-operative day six when he experienced bilious emesis and a leukocytosis of 21.1 x 109/L. A CT of the abdomen with oral contrast showed a persistent duodenal perforation. The patient was made NPO and kept on IV antibiotics. Two weeks after the initial repair, endoscopy was performed which identified an abnormal area which had a white non-mucosal base and sutures, representing the area of the failed repair. An OTSC was deployed and the opening could no longer be visualized. Results: The following day, an UGI study revealed no evidence of an extraluminal leak. Five days after clip placement, abdominal CT showed persistent right pararenal fluid collections without evidence of fluid extravasation. The collections were drained by radiology. The patient was discharged on a pureed diet to a skilled nursing facility a week later without further complications. Conclusion: Over-The-ScopeClips may be an intervention to avoid surgery or re-surgery for iatrogenic endoscopic perforations. Given this patient's advanced age, OTSC was attempted and was successful. To our knowledge, this is the first case report of its use after failure of surgical repair. Our unusual case suggests that OTSC should be considered an option in repair of iatrogenic perforation even after failed surgical repair.

Abdominal Pain With Vomiting for 1 Day After Subtotal Gastrectomy More Than 20 Years Ago

Question: A 70-year-old man presented to the emergency department because of abdominal pain with vomiting for 1 day. The patient had a past history of peptic ulcer disease and underwent subtotal gastrectomy 20 years ago; he was afebrile and the blood pressure was 181/110 mmHg. He reported no bloody stool or tarry stool in recent days. However, after nasogastric tube decompression, some coffee-ground material was observed. Physical examination showed a midline scar at the epigastric region. Severe tenderness and distention of the upper abdomen with hyperactive bowel sounds were noted. The laboratory values of liver functions and lipase were within normal limits, but it showed a leukocytosis with a white blood count of 11,440/ L. The hemoglobin was 13 g/dL (normal, 13–17). Computed tomography (CT) was then carried out (Figure A). What is the diagnosis? What is the appropriate management? Look on page 272 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Index of Suspicion * Case 1: Abdominal Pain and Coffee Ground Emesis in a 9-year-old Boy * Case 2: Vomiting, Headache, and Seizures in a 7-year-old Boy * Case 3: Primary Amenorrhea in a 15-year-old Girl

* ALT: : alanine aminotransferase AST: : aspartate aminotransferase BUN: : blood urea nitrogen CBC: : complete blood count CNS: : central nervous system CSF: : cerebrospinal fluid CT: : computed tomography ECG: : electrocardiography ED: : emergency department EEG: : electroencephalography ESR: : erythrocyte sedimentation rate GI: : gastrointestinal GU: : genitourinary Hct: : hematocrit Hgb: : hemoglobin MRI: : magnetic resonance imaging WBC: : white blood cell A 9-year-old boy presents to the ED with severe abdominal pain and vomiting. He has no history of diarrhea, fever, chills, rash, trauma, arthralgia, or headache. He has no prior history of gastrointestinal complaints or other chronic illnesses. He cannot tolerate clear liquids and is admitted for observation. He vomits coffee ground material and then blood. On physical examination, his temperature is 38.5°C, heart rate is 140 beats/min, blood pressure is 123/83 mm Hg, and respiratory rate is 24 breaths/min. He is uncomfortable and diaphoretic. He has tachycardia, but his cardiopulmonary examination results are normal otherwise. He has generalized abdominal tenderness, with guarding and rebound tenderness most pronounced in the periumbilical region and extending to the right lower quadrant. Hip abduction elicits pain. CBC documents a normal Hgb value and platelet and leukocyte counts, with a left shift and 78% neutrophils. Urinalysis shows moderate blood and trace proteinuria, with 2 RBCs per high-power field. The chest radiograph appears normal. The abdominal radiograph shows a few mildly distended small bowel loops but no radiographic evidence of obstruction. CT scan of the abdomen leads to exploratory laparoscopy and the correct diagnosis. A 7-year-old developmentally appropriate boy presents to the ED with a 3-day history of forceful vomiting, headache, and reduced oral intake. Several times after vomiting, he had complained of numbness in his hands and feet that lasted several seconds. Two hours after receiving a dose of promethazine prescribed by his pediatrician, he could not be aroused by his parents. On arrival at the ED by ambulance, he is initially sleepy and confused. He is afebrile. His blood pressure is 99/74 mm Hg, heart rate is 89 beats/min, and oxygen saturation is 98% in room air. He has no dysmorphic features and no skin findings. His funduscopic findings and extraocular movements are …

Falciform Ligament Sign After Shock Episode in an Elderly Man

An 86-year-old man presented with abdominal distension and septic shock after he had received 8 days of aspirin and dexamethasone treatment that was prescribed for acute paraplegia and suspected spinal cord compression. Coffee ground material was drained from a nasogastric tube, and a change in level of consciousness was also noted. On examination, a distended and tense abdomen became soft and flat about 6 h after presentation. A laboratory test revealed leukocytosis (white blood cell count 30,500/uL) without anemia (hemoglobin 14.6 g/dL).

Risk of Bleeding Following Percutaneous Endoscopic Gastrostomy (PEG): A Five Year Retrospective Study

Percutaneous Endoscopic Gastrostomy (PEG), the primary procedure for the long term nutrition of patients with swallowing disorders, is considered a high risk endoscopic procedure for bleeding complications. This retrospective review aims to determine predictive factors of bleeding complications associated with PEG, including the risk of anticoagulation and anti-platelet therapy. Methods: During a 5 year period (Jan 1, 2002 to Dec 31, 2006), 956 PEG were performed using a standard pull-through technique. Complete electronic medical records were available in 883 cases, and were reviewed for predictive factors of bleeding, bleeding complications, and interventions for hemostasis. Bleeding was defined as blood per PEG (bright blood, coffee ground material, heme-positive aspirate), hematemesis, melena, hematochezia, peri-stomal bleeding, drop in hemoglobin or occult blood in stool. Results: Of the 883 cases, 54.9% (n=495) were male, 45.1% (n=398) were female, with a mean age of 67.8 ± 16.6 years. Gastrointestinal bleeding following PEG occurred in 28 cases (3.2%), of which only 5 cases (0.57%) were found at endoscopy to be a result of PEG placement; 3 developed immediate peri-stomal bleeding, one of which required intra-dermal injection of epinephrine. Endoscopy on the other 2 patients revealed PEG related bleeding gastric ulcers treated with injection therapy. Blood transfusion was required in 1 patient. Cases were reviewed for the use of anti-platelet (aspirin, clopidogrel) or anticoagulants (heparin, enoxaparin, warfarin). Among cases where PEG related bleeding was identified, 100% (n=5) were on at least 1 anti-platelet or anticoagulant drug, with none having received clopidogrel. In the non-bleeding group, 62.53% (n=549) were on at least one anti-platelet or anticoagulant drug administered in proximity to PEG insertion, and 9.7% (n=85) were treated with clopidogrel. The mean cessation period for clopidogrel prior to PEG was 2.3 ± 2.14 days. A multiple logistic regression analysis of variables including gender, indication, or the use of anti-platelet or anticoagulant medications showed that none of these variables were statistically significant predictors of bleeding (p≥ 0.127). Conclusions: Bleeding complications associated with PEG placement are rare, even in the face of recent use of anticoagulants and anti-platelet medications. Specifically, clopidogrel did not contribute to an increase in bleeding outcomes, despite cessation of the drug a mean of 2.3 days prior to PEG. Prospective studies are needed to establish evidence-based guidelines for optimal cessation of anti-platelet or anticoagulant medications prior to PEG.

Gastric Metastasis of Merkel Cell Carcinoma

An 80-year-old man with a history of Merkel cell carcinoma of the right upper extremity with involvement of 2 local lymph nodes treated with excision and radiation 2 years ago presented with 4 days of progressive fatigue, pre-syncope, and melena. Physical examination revealed diffuse pallor, orthostatic hypotension, and black, guaiac-positive stool. Coffee-ground material was appreciated on gastric lavage. Initial laboratory work showed a hemoglobin level of 7.7 g/dL and a hematocrit of 22.6%. Subsequent esophagogastroduodenoscopy revealed a bulky anterior gastric antral mass with a large, penetrating ulcer (Figure A). Histopathologic analysis showed an infiltrate of malignant cells in the lamina propria with increased nuclear to cytoplasmic ratios, scant eosinophilic cytoplasm, finely granular chromatin, multiple nucleoli, and frequent mitoses. Cytokeratin 20 expression on immunohistochemical staining confirmed a diagnosis of metastatic Merkel cell carcinoma (Figure B). Computerized tomography scan revealed diffuse concentric thickening of the stomach (Figure C, small arrows) most prominently in the posterior aspect (Figure C, large arrows) with multiple enlarged perigastric lymph nodes. A positron emission tomography scan showed no other foci of metastatic disease. The patient underwent combined chemoradiation with 4 cycles of carboplatin and etoposide. Positron emission tomography after therapy noted a near-complete gastric response to therapy, however, abdominal wall metastases were noted. He died soon thereafter.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Merkel cell carcinoma is a rare, aggressive neuroendocrine malignancy of the skin that generally carries a poor prognosis. Sun exposure is thought to be the major risk factor because lesions are found primarily in sun-exposed areas of elderly Caucasians. Reports also have suggested that altered host immune status may play an important etiologic role.1Goessling W. McKee P.H. Mayer R.J. Merkel cell carcinoma.J Clin Oncol. 2002; 20: 588-598Crossref PubMed Scopus (254) Google Scholar Patients typically present with a painless, firm, raised nodule with a flesh or bluish-red appearance on the head, neck, or extremities. Typical sites of metastasis include liver, bone, brain, and skin.2Voog E. Biron P. Martin J.P. et al.Chemotherapy for patients with locally advanced or metastatic Merkel cell carcinoma.Cancer. 1999; 85: 2589-2595Crossref PubMed Scopus (265) Google Scholar This case represents only the fourth documented case in the literature of gastrointestinal metastasis.3Li M. Liu C. Cytokeratin 20 confirms Merkel cell metastasis to stomach.Appl Immunohistochem Mol Morphol. 2004; 12: 346-349Crossref PubMed Scopus (13) Google Scholar, 4Idowu M.O. Contos M. Gill S. et al.Merkel cell carcinoma: a report of gastrointestinal metastasis and review of the literature.Arch Pathol Lab Med. 2003; 127: 367-369PubMed Google Scholar, 5Canales L.I. Parker A. Kadakia S. Upper gastrointestinal bleeding from Merkel cell carcinoma.Am J Gastroenterol. 1992; 87: 1464-1466PubMed Google Scholar Immunohistochemical staining confirms the diagnosis because Merkel cell carcinoma often resembles small-cell carcinoma, melanoma, and lymphoma histologically.1Goessling W. McKee P.H. Mayer R.J. Merkel cell carcinoma.J Clin Oncol. 2002; 20: 588-598Crossref PubMed Scopus (254) Google Scholar Treatment generally includes wide surgical excision of the primary tumor in conjunction with adjuvant radiation therapy and chemotherapy.1Goessling W. McKee P.H. Mayer R.J. Merkel cell carcinoma.J Clin Oncol. 2002; 20: 588-598Crossref PubMed Scopus (254) Google Scholar Formal staging and management guidelines do not exist because of low disease prevalence. The authors give special thanks to Dr. Kimberly Heightchew, MD, Department of Pathology, Mainline Health System.

Acute widening of mediastinum in a patient with oesophageal cancer after surgery

A 59-year-old man vomited coffee ground material for 2 days. He had had oesophageal cancer surgically removed 7 months previously followed by gastric tube reconstruction. An initial chest radiograph showed...

Variceal Hemorrhage 13 Years After Nephrectomy For Wilms Tumor

Variceal Hemorrhage 13 Years After Nephrectomy For Wilms Tumor

A sixty-two year-old female with an unusual complication of a PEG tube —a case report

A 62 year-old female with a history of laryngectomy, secondary to laryngeal carcinoma, and percutaneous endoscopic gastrostomy (PEG) tube placement eight months prior to hospitalization presented with two days of coffee ground emesis. The patient had one epidsode of melena on the day of admission. She denied having any abdominal pain, use of nonsteroidal anti-inflammatory drugs, history of peptic ulcer disease or alcohol use. On admission, the patient's blood pressure was 140/80 mm Hg and her pulse was 110 beats/min. Physical exam revealed an intact PEG tube without evidence of infection around the site and a benign abdomen. Initial laboratory values revealed HGB 14.8 mg/dl, HCT of 44 mg/dl, and platelet of 108,000 with normal PT and PTT. Lavage through the PEG tube was positive for coffee ground material. The patient underwent an upper endoscopy which revealed an intact PEG tube with a buldging mass, believed to be duodenal intussusception into the stomach, obtructing the pylorus. Under the supervision of a surgeon, the intact PEG tube was removed. Several hours later, the patient had another episode of coffee ground emesis. As a result, upper endoscopy was repeated. The endoscopy revealed persistence of the duodenal intussusception into the stomach. The patient underwent surgical exploration which confirmed gangrenous small bowel with intussusception of the duodenum into the stomach. At that time, gastrojejunostomy and choledochoduodenostomy was performed. A few days after the operation, the patient became febrile and hypotensive. A swan ganz cathether was placed and was consistent with septic shock. Chest x-ray was suggestive of acute respiratory distress syndrome. The patient did not improve with antibiotics, aggressive ventillatory support and vasopressors. After much deliberation, her family decided to withdraw care and she subsequently expired a few hours after extubation. Percutaneous endoscopic gastrostomy (PEG) tubes have several indications. However, they are also associated with numerous complications. It is believed that migration of a PEG tube provides a focal point for the formation of intussusception. This case demonstrates an unusual complication, intussusception of the duodenum into the stomach, of PEG tube placement.

Acquired antral diaphragm

A 23-year-old woman was hospitalized because of vomiting of coffee-ground material and epigastric discomfort of 3 days' duration followed by melena. She was treated with antacids at another hospital, but her symptoms persisted and she was transferred for further evaluation. Upper endoscopy showed an annular ulcer in the gastric antrum (A). Biopsy specimens showed inflammatory changes and infection with Helicobacter pylori. The patient was treated with a proton pump inhibitor, amoxicillin (500 mg twice daily), and clarithromycin (250 mg twice daily) for 2 weeks.

Risk factors of upper gasterointestinal tract bleeding caused by stress ulcer

During the period of December 1 st 1997 until April 30 th 1998, an observational study with cross sectional design was conducted at the Pediatric Intensive Care Unit (PICU). Risk factors of the occurrence of upper gastrointestinal tract bleeding (VGTB) on patients admitted to the PICU Medical School University of Indonesia/ Cipto Mangunkusumo Hospital were described analysed. Upper gastrointestinal tract bleeding was confirmed if there was evidence of brown or coffee ground material of the gastric fluid in the nasogastric or gastrotomy tube, hematemesis or melena, which was subsequently proved by benzidin test. The risk factors in this study was defined based on the risk factors found from previous studies i.e. shock, sepsis. severe head injury, multiple complication, liver insufficiency, pneumonia, respiratory failure, intervention during treatment (operation >3 hours, ventilator, corticosteroid >3 days). From 26 patients with UGTB risk factors in this study, 19 persons (73%) developed UGTB. The proportion of UGTS was not different on the patient's characteristic (age, sex, nutritional status). UGTB found were bleeding through nasogastric tube (58%) and occult bleeding 37%, hematemesis only one person (II %).The majority of VGTB occurred on the 3 rd day of hospitalization (84%) and after ventilator usage of >48 hours (58%). Patient who underwent >3 hours operations were craniotomies. All the patients who received >3 days of corticosteroid (4 persons) developed VGTS.

A prospective study of simplified omeprazole suspension for the prophylaxis of stress-related mucosal damage.

To determine the efficacy, safety, and cost of simplified omeprazole suspension in mechanically ventilated critically ill patients who have at least one additional risk factor for stress-related mucosal damage. Prospective, open-label study. Surgical intensive care and burn unit at a university tertiary care center. Seventy-five adult, mechanically ventilated patients with at least one additional risk factor for stress-related mucosal damage. Patients received 20 mL of simplified omeprazole suspension (containing 40 mg of omeprazole) initially, followed by a second 20-mL dose 6 to 8 hrs later, then 10 mL (20 mg) daily. Simplified omeprazole suspension was administered through a nasogastric tube, followed by 5 to 10 mL of tap water. The nasogastric tube was clamped for 1 to 2 hrs after each administration. The primary outcome measure was clinically significant gastrointestinal bleeding determined by endoscopic evaluation, nasogastric aspirate examination, or heme-positive coffee ground material that did not clear with lavage, which was associated with at least a 5% decrease in hematocrit. Secondary efficacy measures were gastric pH measured 4 hrs after omeprazole was first administered, mean gastric pH after omeprazole was started, and the lowest gastric pH during omeprazole therapy. Safety-related outcomes included the occurrence rate of adverse events and pneumonia. No patient experienced clinically significant upper gastrointestinal bleeding after receiving omeprazole suspension. The 4-hr postomeprazole mean gastric pH was 7.1, the mean gastric pH after starting omeprazole was 6.8, and the mean lowest pH after starting omeprazole was 5.6. The occurrence rate of pneumonia was 12%. No patient in this high-risk population experienced an adverse event or a drug interaction that was attributable to omeprazole. Simplified omeprazole suspension prevented clinically significant upper gastrointestinal bleeding and maintained gastric pH of > 5.5 in mechanically ventilated critical care patients without producing toxicity.

Traumatic transection of the intrapancreatic common bile duct due to blunt injury: a case report and literature review

An N-year-old previously healthy man was brought by the Emergency Medical Team to our hospital, an hour after being beaten up by a gang of young men. He had been beaten all over his body including several blows to his abdomen. He was conscious (Glasgow Coma Scale 13), although agitated. Vital signs were, heart rate 116 beats/ min and BP 110/‘70 mmHg. His only complaint was of diffuse abdominal pain. On physical examination, ecchymoses and contusions were absent, no penetrating wounds were present and a small laceration of 3 cm on the lower lip was noted. Lung examination was normal. The abdomen was flat with diffuse tenderness in all four quadrants. There were no other abnormalities. Because of his intoxicated and agitated state the patient was sedated and anaesthetized and an elective intubation was performed. At this point a nasogastric tube was inserted and brought up 300 cm3 of coffee-ground material. A urinary catheter was inserted with good urine output and no signs of haematuria. X-Rays of the chest, pelvis and cervical spine were normal. Computed tomography (CT) of the head revealed findings of a small frontal intracerebral bleed. There were no signs of increased intracranial pressure (Figure 2). CT of the abdomen showed free fluid in the abdominal cavity extending from the subhepatic region to the pelvis. The spleen and liver were intact (Figure 2). Because of the intact spleen and liver and the presence of free fluid in the abdomen, the abdomen was explored. A large subcutaneous haematoma was observed in the epigastric regtion, and 500 cm3 of fresh blood was aspirated from the peritoneal cavity. A large haematoma was detected in the retroperitoneum extending from the duodenum down to the sacral region. A blotch of bile was found staining the upper portion of the first part of the duodenum. A Cattell procedure was performed and the duodenum was mobilized using the Kocher manoeuvre, at which time a blowhole of 2 mm by 3 mm was observed in the duodenum, approximately in the middle of the 1st to 2nd division of the organ. Exploration of the common bile duct showed an intact duct. During the procedure bile was noticed to exude from

Continuous intravenous cimetidine decreases stress-related upper gastrointestinal hemorrhage without promoting pneumonia

To determine whether a continuous i.v. infusion of cimetidine, a histamine-2 (H2) receptor antagonist, is needed to prevent upper gastrointestinal (GI) hemorrhage when compared with placebo and if that usage is associated with an increased risk of nosocomial pneumonia. Due to the importance of this latter issue, data were collected to examine the occurrence rate of nosocomial pneumonia under the conditions of this study. A multicenter, double-blind, placebo-controlled study. Patients were randomized to receive cimetidine (n = 65) as an iv infusion of 50 to 100 mg/hr or placebo (n = 66). Intensive care units in 20 institutions. Critically ill patients (n = 131), all of whom had at least one acute stress condition that previously had been associated with the development of upper GI hemorrhage. Samples of gastric fluid from nasogastric aspirates were collected every 2 hrs for measurement of pH and were examined for the presence of blood. Upper GI hemorrhage was defined as bright red blood or persistent (continuing for > 8 hrs) "coffee ground material" in the nasogastric aspirate. Baseline chest radiographs were performed and sputum specimens were collected from all patients, and those patients without clear signs of pneumonia (positive chest radiograph, positive cough, fever) at baseline were followed prospectively for the development of pneumonia while receiving the study medication. Cimetidine-infused patients experienced significantly (p = .009) less upper GI hemorrhage than placebo-infused patients: nine (14%) of 65 cimetidine vs. 22 (33%) of 66 placebo patients. Cimetidine patients demonstrated significantly (p = .0001) higher mean intragastric pH (5.7 vs. 3.9), and had intragastric pH values at > 4.0 for a significantly (p = .0001) higher mean percentage of time (82% vs. 41%) than placebo patients. Differences in pH variables were not found between patients who had upper GI hemorrhage and those patients who did not, although there was no patient in the cimetidine group who bled with a pH < 3.5 compared with 11 such patients in the placebo group. Also, the upper GI hemorrhage rate in patients with one risk factor (23%) was similar to that rate in patients with two or more risk factors (25%). Of the 56 cimetidine-infused patients and 61 placebo-infused patients who did not have pneumonia at baseline, no cimetidine-infused patient developed pneumonia while four (7%) placebo-infused patients developed pneumonia. The continuous i.v. infusion of cimetidine was highly effective in controlling intragastric pH and in preventing stress-related upper GI hemorrhage in critically ill patients without increasing their risk of developing nosocomial pneumonia. While the number of risk factors and intragastric pH may have pathogenic importance in the development of upper GI hemorrhage, neither the risk factors nor the intragastric pH was predictive. Therefore, short-term administration of continuously infused cimetidine offers benefits in patients who have sustained major surgery, trauma, burns, hypotension, sepsis, or single organ failure.

Prevalence of, and risk factors for, upper gastrointestinal tract bleeding in critically ill pediatric patients

To determine the occurrence of, and risk factors for, the development of upper gastrointestinal (GI) tract bleeding in critically ill pediatric patients. Prospective, descriptive, comparative study. ICU in a tertiary care pediatric hospital affiliated with a university. All patients < 19 yrs of age who were admitted to the ICU for a 4-month period (n = 429) were eligible for inclusion. A total of 221 patients were excluded for reasons listed below. Thus, 208 patients were studied. None. Patients were evaluated for overt upper GI bleeding as indicated by coffee ground material or bright red blood in gastric aspirates or black, tarry stools. Excluded were patients who were transferred out of the ICU within 24 hrs of admission, were receiving medications that would alter their risk for upper GI bleeding, or had a GI tract surgical procedure. Patients were categorized by diagnoses and analyzed for relative risk for upper GI bleeding. Of the 208 patients included, 25% had evidence of upper GI bleeding. There was no association between upper GI bleeding and age, weight, race, or sex. Diagnoses independently associated with an increased risk for upper GI bleeding were: circulatory shock, an operative procedure > or = 3 hrs in duration, and trauma. No clinically important sequelae were directly attributable to upper GI bleeding in this group of patients; however, intervention with antacids and histamine-2 receptor (H-2) antagonists likely decreased the progression of GI bleeding. Overt evidence of upper GI bleeding is not uncommon in critically ill pediatric patients. Certain diagnoses or risk factors may predispose these patients to develop upper GI bleeding.