Small Superficial Ulcerations Research Articles

Hand, Foot, and Mouth Disease (HFMD) in India: A Review on Clinical Manifestations, Molecular Epidemiology, Pathogenesis, and Prevention.

HFMD is a childhood viral disease initiated by enteroviruses (EVs). Symptoms are initiated with mild-to-moderate fever of short duration followed by oral and skin lesions. Skin lesions are papulovesicular which appears on palms/soles of feet, hands, knees, and elbows. Oral lesions appear as vesicles producing multiple small superficial ulcers. Disease is usually mild illness but sometimes progresses in severe form as meningitis, encephalitis, and polio-like paralysis. Etiological agents of the disease belong to Picornaviridae family. The causative viral agents are from genus human enterovirus (HEV) such as enterovirus-A 71 (EV-A71), coxsackievirus -A6 (CV-A6), CV-A10, CV-A16. Coxsackievirus A-16 (CV-A16) and enterovirus A-71 (EV-A71) are the major etiological agents of this disease, among children reported globally. In India, studies conducted on HFMD cases revealed CV-A16 as a major EV type and under circulation over a period of time. Molecular studies of different CV-A16 isolates and the viral kinetic studies conducted on organ tissues of experimental mouse model with complete VP1 gene sequencing revealed presence of B1c sub genotype which is currently in circulation. Genetic changes observed at nucleotide and amino acid level in vital organs of experimental infected mice model might predict some targets and can act as markers of virulence. Mice infected with CV-A16 strains revealed progressive pathological changes in mice organs. Major affected organs were to be as brain, heart, intestine, and skeletal muscles. The present review focuses on HFMD caused by CV-A16 with epidemiological, molecular, pathogenesis and need of antivirals against the disease.

Superior Rectal Artery Embolization with Tris-Acryl Gelatin Microspheres: A Randomized Comparison of Particle Size

PurposeTo evaluate the safety and efficacy of superior rectal artery embolization (SRAE) with different-sized tris-acryl gelatin microspheres in symptomatic hemorrhoidal disease (HD). Materials and MethodsForty-two patients (male, 30; female, 12; median age, 45 years) with symptomatic HD (2 grade I, 8 grade II, 17 grade III, and 15 grade IV) were divided into 3 experimental arms (500–700 μm, 700–900 μm, and 900–1,200 μm groups; each had 14 patients) in a prospective randomized style to perform SRAE. Follow-up was performed by rectoscopy, clinical examination, and questionnaires. The primary outcome measure was the clinical success rate at 12 months. Secondary outcome measures were technical success rate, recurrence rate, procedure-related mortality, procedure-related complications, and any outcome changes between particle sizes. ResultsNo procedure-related deaths or major morbidities were observed. There was a 54% minor complication rate (n = 23/42) in the treated zone: 45% sustained small superficial ulcerations (n = 19/42), 7% small rectosigmoid junction ulcerations (n = 3/42), and 2% small fibrotic scar tissue (n = 1/42). The clinical success rate was 93%. Of the groups, the best French bleeding score decrease was obtained in the 900–1,200 μm group. There were improvements in the quality of life score and visual analogue scale score after the SRAE procedure, although not in the Goligher score. No recurrent disease was observed. ConclusionsSRAE with tris-acryl gelatin microspheres for symptomatic HD is a safe and efficient treatment, with results favoring the use of larger microspheres.

3:27 PM Abstract No. 104 ■ FEATURED ABSTRACT Bariatric embolization of arteries for the treatment of obesity (BEAT obesity): 12-month safety and efficacy data

Bariatric Embolization is a new endovascular procedure, developed for obesity treatment. BEAT Obesity is an investigator-initiated IDE, designed to assess the safety and efficacy of BAE to treat morbidly obese patients using 300-500μm Embospheres. We present our 12-month safety and efficacy data. Morbidly obese (BMI of 40-60) adult patients without comorbid conditions (n = 20, 4 male) were enrolled. Primary endpoints were weight loss and 30-day adverse events (AEs). Secondary endpoints (12-month follow-up) are: blood pressure, lipid profile, serum obesity hormones (Ghrelin, Leptin, GLP-1, PYY), hunger/satiety assessments, quality of life (QOL) (SF-36 and IWQOL) surveys, endoscopy and gastric emptying results. Complete 12-month data are presented. Mean age and BMI were 44.5 ± 10.7 years and 45.1 ± 4.1 kg/m2, respectively. The left gastric artery alone (LGA) was embolized in 5 patients and the LGA and gastroepiploic arteries were embolized in 15 patients. No major AEs occurred. Small superficial ulcers were seen in 8 of the 20 patients at 2-week endoscopy, all of which had resolved at 3-month endoscopy. There was 1 case of transient sub-clinical pancreatitis. Six patients were discharged the evening of their procedure, and the remainder stayed for the indicated <48 hr hospital stay for control of nausea, vomiting and pain. There was 8.3 ± 3.9% (n = 20), 11.5 ± 5.5% (n = 18), 12.8 ± 7.7% (n = 14), and 11.7 ± 10.8% (n = 12) Excess Weight Loss at 1, 3, 6, and 12 months, respectively. There was a trend towards improvement in QOL parameters and decreased appetite scores. Full updated hormonal profiles for all patients will be presented. Complete twelve-month data from the BEAT Obesity trial demonstrates that bariatric artery embolization is well-tolerated in severely obese patients. BAE appears to have sustained weight loss up to 12 months post procedure. Future clinical trials will focus on improving efficacy while maintaining the tolerated safety profile.

Endoscopic Management of Choledochoduodenal Fistula Presenting as Pneumobilia

Biliary-enteric fistulas are uncommon and often arise spontaneously due to gallstones, peptic ulcer disease, malignancy, or trauma. Diagnosis is typically made on endoscopic retrograde cholangiography (ERCP). Radiographic findings typically demonstrate pneumobilia, or air within the biliary tree. Only 8.6% of biliary-enteric fistulas are of the choledochoduodenal type. These fistulas present a formidable diagnostic and management challenge for physicians due to the infrequency with which they are encountered and their non-specific presentation. Here, we present a case of a choledochoduodenal fistula discovered in a young male. A 28-year-old male with a history of recurrent hepatic abscesses presented with intermittent and sharp epigastric abdominal pain that started the prior night. His abdominal pain was associated with non-bloody, non-bilious emesis. The patient had a history of recurrent hepatic abscesses that were treated with IR drainage and antibiotics. His labs on presentation were notable for a WBC count of 11.5 with 89% neutrophils. His liver function panel was abnormal with a total bilirubin of 5.5, direct bilirubin 2.9, AST 154, and ALT 252. Alkaline phosphatase, INR, and albumin were normal. Hepatitis panel, tuberculosis, and HIV testing were negative. An abdominal CT scan and MRCP demonstrated high attenuation in the right lobe of the liver suspicious for neoplasm, enlargement of the biliary ducts with extensive pneumobilia, and no definite evidence of choledocholithiasis. A triple phase CT showed evidence of liver cirrhosis and intrahepatic biliary ductal dilatation with no apparent focal hepatic masses. The patient subsequently underwent endoscopic intervention (Figure 1). EUS demonstrated abnormal echogenicity in the left and right lobes of the liver. ERCP confirmed the presence of a choledochoduodenal fistula containing a gallstone within the fistula tract. The patient was treated with antibiotics and successful placement of a stent across the fistula site. Biopsy of the common bile duct stricture showed no malignancy. Biopsies of the right and left lobes of the liver was negative for malignancy and showed acute and chronic inflammation with evidence of fibrosis. Recent case reports have described the use of the over-the-scope-clip system to endoscopically close choledochoduodenal fistulae. The purpose of this case is to increase awareness of this unusual clinical scenario and discuss the current treatment modalities available.Figure: Upper endoscopy identifying diffuse mild inflammation in the gastric fundus, gastric body, and gastric antrum. A large fistula was found between the common bile duct and duodenal bulb (choledochoduodenal fistula). There is a gallstone sitting within the fistula tract. Many small superficial ulcers are seen in the duodenum.

Imaging of Drug-induced Complications in the Gastrointestinal System.

Drug-induced injury commonly affects the gastrointestinal and hepatobiliary systems because of the mechanisms of absorption and metabolism. In pill esophagitis, injury is frequently related to direct contact with the esophageal mucosa, resulting in small superficial ulcers in the mid esophagus. Nonsteroidal anti-inflammatory drugs can lead to gastrointestinal tract ulcers and small bowel mucosal diaphragms (thin weblike strictures). Injury to the pancreatic and hepatobiliary systems can manifest as pancreatitis, acute or chronic hepatitis, cholestasis, or steatosis and steatohepatitis (which may progress to cirrhosis). Various drugs may also insult the hepatic vasculature, resulting in Budd-Chiari and sinusoidal obstructive syndromes. Focal lesions such as hepatic adenomas may develop after use of oral contraceptives or anabolic steroids. Ultrasonography, computed tomography, and magnetic resonance imaging can aid in diagnosis of drug-induced injuries and often are necessary to exclude other causes.

Asymptomatic De Novo Inflammatory Bowel Disease Late After Liver Transplantation for Primary Sclerosing Cholangitis: A Case Report

Guidelines recommend colonoscopy screening for possible asymptomatic inflammatory bowel disease (IBD) in all patients diagnosed with primary sclerosing cholangitis (PSC). PSC-IBD warrants regular dysplasia-surveillance colonoscopy. However, no consensus exists regarding follow-up colonoscopy in PSC patients without IBD who remain asymptomatic. We describe a 43-year-old female who had undergone liver transplantation (LT) due to advanced PSC. Previous colonoscopies had been normal. The post-transplantation course was uneventful, with no rejections and signs of PSC recurrence. Immunosuppression was by tacrolimus monotherapy. She was asymptomatic with normal inflammation markers. A protocol colonoscopy, performed as general dysplasia surveillance 8 years post-transplantation, revealed mucopurulent-covered small superficial ulcerations and erythema diffusely distributed from the cecal to sigmoid colon with intervening normal mucosa and rectal sparing. Histologic examination showed patchy chronic colitis with crypt architectural distortion and mild-moderate inflammation activity. Infection samples were negative. Findings complied with de novo IBD, type unclassified. In conclusion, the link between PSC and clinically silent IBD may manifest after the PSC diagnosis and even several years after LT. Given the increased colorectal cancer risk associated with PSC, IBD, and LT, repeat colonoscopy might be warranted in PSC patients without IBD at initial assessment, and also after LT.

Evaluation of the role of distal revascularization with interval ligation (DRIL) and revision using distal inflow (RUDI) in treatment of dialysis associated steal syndrome

Objective: Dialysis-associated steal syndrome (DASS) is a complication that may occur in >4% of patients with arteriovenous fistula. The best treatment method for this condition is up till now controversial. Aim of the work: The purpose of this study was to evaluate two common procedures to treat this condition; Distal Revascularization with Interval Ligation (DRIL) or Revision Using Distal Inflow (RUDI) aiming at preservation of both the function of the fistula and the limb. Patients and methods: Fourteen patients having native brachiocephalic or brachiobasilic hemodialysis AV fistula complicated by dialysis associated steal syndrome (DASS), were randomly divided according to treatment method into DRIL and RUDI groups with 7 patients in each group. Patients with proximal or distal arterial disease and those with low-flow steal were excluded Short term access patency and limb salvage were set as primary endpoints. In all patients great saphenous vein was harvested from the thigh. Early post-procedural follow up and mid-term follow up were after one and three months. Results: From November 2011 to March 2013, 14 patients presented with (DASS). In DRIL group (7 patients), the mean age was 49.2 years, 4 females and 4 diabetics while in RUDI group (7 patients), the mean age was 52.3 years, 5 females and 7 diabetics. All fistulas were brachiocephalic and only one was brachiobasilic AVF in DRIL group. All patients in both groups presented with pain, pallor, coldness and cyanosis of the hand Stage III DASS {rest pain) was present in 2 cases of each group, whereas Stage IV small superficial ulcers were present in 3 vs 4 and digital gangrene in 2 vs. 1 in DRIL vs. RUDI respectively In group 1 (DRIL) technique; 5 patients (71.4%) had marked improvement of pain, cyanosis, capillary refill and coldness. Pallor improved in all cases. Distal pulses returned in 4 patients, remained weak in one patient and failed to return in 2 (28.6%). Closure of the access was necessary in 2 patients due to infection in one and due to risk of limb loss in the other; access patency was (71.4%) and limb salvage was (100%). In RUDI cases, pain, hand coldness, pallor and cyanosis greatly improved in all cases post-operatively. Distal pulses and capillary refill returned and became comparable to the healthy side in 6 patients (85 7%). Limb salvage and access patency were achieved in all cases (100%). Conclusion: RUDI procedure incorporates most of the advantages of other access and hand-preserving procedures. In contrast to DRIL procedure, it is the fistula that is placed at risk by ligation and revascularization, not the native arterial supply to the ischemic hand RUDI may become the procedure of choice for patients with dialysis-associated steal syndrome after a brachial artery-based arteriovenous fistula.

Edematous striae distensae

A 14-year-old girl presented with complaints of total body swelling for the previous 3 months. There were no complaints of fever, joint pain or swelling, rash, excessive hair loss or oral ulcers. The physical examination revealed anasarca and very large, swollen striae over the abdominal wall with occasional, small superficial ulcerations (Fig. 1). These striae were especially prominent in dependent areas in the flanks (Fig. 2). Laboratory analyses revealed 4? dipstick proteinuria, numerous RBCs on urine microscopy, 24 h urinary protein excretion of 3.5 g, serum albumin of 1.3 g/dl and serum creatinine of 0.7 mg/dl. She had undetectable anti-nuclear antibody titres in the blood, and there was no evidence to suggest present or past hepatitis B or hepatitis C virus infections. Serum complement levels were normal. She had not responded to 2 months of therapy with prednisolone at a dose of 80 mg/day, which was prescribed by her primary care physician. A diagnosis of nephrotic syndrome was made, the steroid dose was tapered, and the patient was symptomatically improved with fluid restriction and diuretics. Subsequently, a renal biopsy was performed, which was consistent with a diagnosis of mesangiocapillary glomerulonephritis. Striae distensae is a commonly described complication of steroid use. However, high dose steroid use complicated by mechanical stress due to rapid increase in body size because of accumulation of edema fluid led to formation of unusually large edematous striae distensae in our patient. It

Shave therapy is a simple, effective treatment of persistent venous leg ulcers

Background: Leg ulcers in deep venous insufficiency, especially the postthrombotic type, are often resistant to therapy. Objective: The purpose of this study was to evaluate short-term and long-term effects of shave therapy in persistent or recurrent venous ulcers. Methods: From January 1994 to October 1997, 80 patients with 105 chronic leg ulcers were treated by shave therapy. This method involved removing ulcers together with the surrounding lipodermatosclerosis and covering the wounds with meshed split-skin graft. Fifty-nine patients with 76 ulcers were examined after 3 months for assessment of short-term results. The first 18 patients with 26 ulcers from the years 1994 and 1995 were evaluated for long-term results. Results: The short-term healing rate after 3 months in 59 patients was 79%. Of 8 patients from 1995 (follow-up period, 1 year and 8 months), 7 patients had complete healing and 1 patient had a small ulcer. Of 10 patients from 1994 (average follow-up period, 2 years and 8 months), 8 patients had complete healing and 2 patients showed small superficial ulcerations within the transplanted areas. From these results, a long-term healing rate of 88% was calculated in 18 patients. Two of the 3 patients with recurrences had stopped compression therapy after good short-term results. Conclusion: For patients with recalcitrant leg ulcers in deep venous insufficiency and/or postthrombosis, shave therapy is a simple, quick, and effective surgical method with favorable short-term and long-term results. (J Am Acad Dermatol 1998;39:232-8.)

Chronic Colitis After Aeromonas Hydrophilia Infection

Chronic Colitis After <i>Aeromonas Hydrophilia</i> Infection

Low dose, short duration therapy for the eradication of Helicobacter pylori in patients with duodenal ulcer

To study the efficacy and acceptability of low dose, short duration triple therapy in eradicating Helicobacter pylori from patients with duodenal ulcer. A prospective study of 105 patients with H. pylori associated duodenal ulcer presenting consecutively to a regional Melbourne general hospital and a local private endoscopy clinic. Patients were treated with H2-antagonists (if required), followed by two weeks of triple therapy consisting of colloidal bismuth subcitrate (Denol) one tablet four times daily between meals, tetracycline hydrochloride 250 mg four times daily and metronidazole 400 mg twice daily. Four weeks, and again 12 months after treatment, patients were assessed by gastroscopy and antral biopsy for ulceration and H. pylori as measured by rapid urease test. Side effects of treatment were documented. Four patients withdrew because of drug side effects. Of 101 patients completing treatment, H. pylori was eradicated in 91 (90%, or 87% of total). Eight of the 10 patients in whom initial treatment failed received one or more further courses of triple therapy, with H. pylori being eradicated in five. Mild nausea occurred in 6% and possible candida infection in 3%. Of 68 patients who were reassessed after 12 months, 66 were still clear of H. pylori but, in four, small superficial ulcers were present. Two patients were positive for H. pylori, one with and one without ulceration, giving an H. pylori recurrence rate of 3% and an ulcer recurrence rate of 7%. This particular regimen of triple therapy was highly effective, safe and acceptable and could be offered to all patients with H. pylori associated duodenal ulcer.

Interstitial radiation in the treatment of carcinoma of the tonsillar region

From 1964 to 1972, 69 patients were treated for carcinoma of the tonsillar region; all have been followed for at least 4 years. Sixteen patients (23%) had second primaries, and in 11 they were clearly the cause of death. No irradiated patient has died from primary recurrence after 2 years. The overall 3 year determinate survival rate (NED) for patients treated curatively was 63% (32/51). Twenty-four patients had interstitial implants after preliminary external radiation (usually 4,000 rad in 4 weeks). Local control (2+ years) was obtained in at least 82% (18/22); two clearly had recurrence. Of 12 stage I or II patients, 11 survived at least 2 years without evidence of disease; of 12 stage III or IV patients, seven did. Survival could have been improved by more aggressive management of neck nodes, as shown by results for the patients treated since 1969. While small superficial ulcers frequently occurred in the group with implants, all healed spontaneously in 1--6 months; there were no serious complications. The main advantages of implantation are reduction in serious complications and xerostomia.

The formation of gastric ulcer in pregnant and nonpregnant rats in the light of data on the gestation dominant

Caffeine and arsenous acid were administered per os to pregnant and nonpregnant rats for a period of 15 to 19 days to induce gastric ulcer. The ulcerative process developed in 100% of the control, nonpregnant female rats; severe lesions with coalescence of small superficial ulcers into large, and involvement of all the gastric layers in the process, were observed in 60% of the animals. In some cases, adhesions to the adjacent organs, or perforation of the stomach wall were noted. An insignificant superficial affection of the gastric mucosa, with no lesions of the serous membrane, was noted only in 16.6% of the pregnant rats.

Perianal dermatitis of the newborn.

PERIANAL dermatitis of the newborn is a common eruption which is not described in leading American dermatologic and pediatric textbooks.1This may be because of confusion with the well-recognized napkin dermatitis. The two differ, however, in location, age incidence, and cause. Napkin dermatitis is also called diaper eruption, erythema gluteale, and erythema of Jacquet. This, in the words of Cooke,2is a dermatitis limited to the convex surfaces of the thighs and buttocks since the approximated flexures and the sulci between them are protected from constant contact with the diaper and ammonia. The perianal dermatitis, on the other hand, is an irritation of the skin about the anus. It is erythematous, red, and frequently exudative. Patients with severer disease show multiple small superficial ulcerations. The involved area varies from 3 to 4 cm. in diameter and centers at the anus. The inflammatory reaction fades gradually at the periphery.

Possible Role of Pancreatic Enzymes in the Etiology of Ulcerative Colitis

It is a common observation that patients with ulcerative colitis frequently exhibit remarkable clinical improvement following ileostomy. Weight gains of fifty pounds or more have been recorded. Since ileostomy diverts the fecal stream from the colon, perhaps some substance in the upper gastrointestinal tract initiates or aggravates the symptoms of this disease. Portis, Block and Necheles1 succeeded, by perfusing the colons of dogs with 1 to 2% trypsin solutions, in both acute and chronic experiments, in damaging the colonic mucosa. This was manifested by hyperemia, capillary hemorrhages, extensive hemorrhages of the mucosa, and surface necrosis of the mucosa. Ivy and Clarke2, however, did not succeed in producing any mucosal changes in six dogs by diverting the upper jejunal contents to the appendix. They state that their experiments did not rule out the possibility that the quantity or activity of the proteolytic enzymes of the upper intestine may be greater than normal in ulcerative colitis, or that the colon may be more susceptible in this disease. To investigate the first possibility, we studied the external secretion of the pancreas in a group of patients with this disease, using intravenous secretin as the stimulus. As a preliminary study, we undertook a series of experiments with dogs. Ten mongrel dogs were used. Under pentothal anesthesia a loop of colon with its intact blood supply was transposed into the duodenum distal to the ampulla of Vater with end to end anastomosis (Figure 1). This colonic segment had of necessity to be from the right side of the colon, inasmuch as the left side of the colon does not lend itself well to transposition because the blood supply to the left side in the dog cannot be interrupted without producing gangrene of the distal segment. These animals died or were sacrificed at intervals of two weeks to ten months (Table 1). In every case except one the colonic segments were intact. In one dog which lived for fourteen weeks there was moderate inflammation with small superficial ulcerations. These experiments confirm the findings of Ivy and Clarke2 that the dog's colonic mucosa can tolerate the bile and pancreatic juice normally present in the duodenum. Meyer and his collaborators3 have shown that the lysozyme content of ileostomy drainage is not abnormally high in this disease. We verified this in two patients.

Two Cases of Melioidosis

Two cases of fatal melioidosis are described. The first a robust Indian labourer; the second a well-nourished, muscular European.Case 1. Gradual onset. Irregular fever. Pain in the epigastrium. No physical signs of disease at first, except enlarged spleen; later, there were signs of consolidation at the bases of both lungs. Constipated at first; diarrhoea came on towards the end and the patient collapsed and died at the end of the third week.At the autopsy; there were small patches of consolidation in the lungs, composed of minute suppurating tubercles. In the liver there were similar aggregations of small suppurating tubercles and two circumscribed abscesses. The gall-bladder was thickened. The spleen was enlarged and contained septic infarcts and abscesses. In the caecum there were small superficial ulcers. B. whitmori was cultivated from the lungs, spleen, liver and gall-bladder.Animals were inoculated as follows: A guinea-pig, inoculated in the anterior nares with pus from the liver, died nine days later with caseous inflammation of the nasal passages and a caseous inguinal gland from which B. whitmori was recovered. A guinea-pig, inoculated subcutaneously with pus from the liver, died on the twenty-fifth day with abscesses in the lymphatic glands from which B. whitmori was cultivated. A guinea-pig, inoculated subcutaneously with a culture of the organism, died within sixteen hours from septicaemia. B. whitmori was recovered from the heart and spleen. A guinea-pig, inoculated subcutaneously with an attenuated culture, died on the twenty-fifth day with suppurating buboes and with abscesses in the liver and lungs from which B. whitmori was cultivated. Two horses were inoculated subcutaneously with cultures of the strain of B. whitmori cultivated from the patient. An abscess developed at the site of inoculation, in each case, but the local lesion healed and the animals have, so far, remained healthy.Case 2. The illness commenced gradually with pain after food, occasional vomiting and looseness of the bowels. The temperature became high and of the swinging type, accompanied by rigors and sweats. The liver was enlarged. The patient died on the twenty-fifth day.At the autopsy, two large abscesses were found in the liver, the gall-bladder was thickened and there were a few small superficial ulcers in the caecum. B. whitmori was cultivated from the liver abscess. No amoebae were found.The following animals were inoculated. Two wild rats were inoculated subcutaneously with a culture from this case and both died from septicaemia in less than twenty-four hours. B. whitmori was recovered from the heart's blood. The result of the subcutaneous inoculation of a guinea-pig was the same. A guinea-pig, inoculated in the nostril, died on the fifth day with a cheesy deposit in the nose and septicaemia. Another guinea-pig, inoculated in the same way, but after the organism had been subcultivated repeatedly, died on the twelfth day, with caseous tracheal glands containing B. whitmori. A rabbit, inoculated subcutaneously, died in twenty-six hours from septicaemia with tubereles in the peritoneum. B. whitmori was cultivated from the peritoneum and from the heart's blood. A monkey fed on a culture remained healthy. A pony inoculated intravenously recovered after a week's fever.