The vascular armamentarium explored-the ultimate goal achieved

Peripheral arterial disease is one of the commonest causes for a limb being amputated most often, we present this case of medium vessel vasculitis with chronic threatening limb ischemia to make a note of our attempt to save her limb by multiple modalities which included medical management with steroids, immunosuppressants, pulsed cyclophosphamide, interventional radiological procedure of catheter directed thrombolysis with urokinase, surgical procedures like bypass, split skin grafting and minor amputations, implemented novel modalities like hyperbaric oxygen therapy. By exploring the armamentarium available, involving a multidisciplinary team which included vascular surgeon, rheumatologist, intervention radiologist, plastic surgeon, physiotherapist and aptly using the right modality at the right time we were able to ultimately achieve our goal of limb salvage.

A184 NON-CIRRHOTIC HYPERAMMONEMIA SECONDARY TO EXTRAHEPATIC PORTOSYSTEMIC VENOUS SHUNT PRESENTING AS A CONGNITIVE DYSFUNCTION: A CASE REPORT AND LITERATURE REVIEW

Background Hyperammonemia secondary to liver disease is a very common cause of hepatic encephalopathy (HE) and it is easily recognized in patients with advanced liver disease. Non-cirrhotic causes of hyperammonemia are rare, particularly extrahepatic portosystemic venous shunts (EPS). The majority of these shunts are between a mesenteric vein and the inferior vena cava. We report a case of a non-cirrhotic hyperammonemia secondary to a shunt between the superior mesenteric vein (SMV) and the right renal vein (RRV) that presented with encephalopathy. Diagnosis was delayed due to lack of awareness of non-cirrhotic hyperammonemia underscoring the importance of measuring ammonia in all patients presenting with encephalopathic symptoms irrespective of their liver function. Aims To report our experience with a patient with unexplained cognitive dysfunction that was eventually attributed to hyperammonemia secondary to a rare non-cirrhotic portosystemic shunt. Also, we discuss the differential diagnoses of non-cirrhotic hyperammonemia and the pathophysiology, classification and diagnosis of spontaneous portosystemic shunts. Methods A retrospective chart review Results A 57-year-old woman with longstanding essential tremors on topiramate presented with a 30-month history of recurrent disabling episodes of unexplained “zoning out”. Her neurologists undertook extensive investigations which excluded primary neurological conditions. These episodes persisted despite discontinuation of topiramate, treatment of urinary tract infection (UTI) and continuing daily prophylactic antibiotics for recurrent UTIs as presumed etiologies. Due to her unexplained and disabling symptoms she was referred to an internist. During further evaluation, ammonia level was measured for first time, in the absence of any obvious features of chronic liver disease, and the level was strikingly elevated 152uml/l. Hence, an abdominal CT was obtained and revealed a prominent shunt between SMV and RRV. The patient was diagnosed with non-cirrhotic hyperammonemia secondary to EPS. She is currently stable on lactulose and rifaximin with a drop in her ammonia level to 63uml/l, and an interventional radiological procedure is being considered. Conclusions While hyperammonemia is most commonly related to liver failure, our case highlights the importance of awareness of non-cirrhotic hyperammonemia. Any unexplained change in level of consciousness, cognition and/or behavior merits measurement of serum ammonia irrespective of clinical liver status. Funding Agencies None

Gastrointestinal bleeding

Gastrointestinal bleeding (GIB) is a common emergency, which can be subdivided into upper and lower, and acute or chronic, with acute upper GIB further subdivided into variceal (11%) and nonvariceal (89%) bleeding. Risk stratification in acute upper GIB can be performed using simple clinical and endoscopic criteria that can be used to estimate the risk of mortality, but there are no validated systems for use in acute lower GIB. The immediate management of the hypovolaemic patient is first directed towards resuscitation and then to identification of the site and cause of bleeding. Most patients will stop bleeding spontaneously and should then be investigated with either upper gastrointestinal endoscopy or colonoscopy as appropriate. Patients with acute ongoing upper GIB require urgent investigation by oesophagogastroduodenoscopy with a view to applying endoscopic haemostatic therapy, which is efficacious in up to 95% of patients. High-dose proton pump inhibitor treatment should be given following successful endoscopic therapy to patients with major ulcer bleeding. If these techniques fail to arrest bleeding, then either selective mesenteric angiography with embolization or surgery is indicated. Patients who are unstable with acute lower GIB require early oesophagogastroduodenoscopy (to exclude an upper gastrointestinal cause) and then an interventional radiological procedure to embolize the bleeding vessel(s); surgery is generally a last resort.

USG-Guided Percutaneous Aspiration: an Effective Way for Managing Appendicular Abscess

Background: During last 2−3 decades image-guided drainage procedures have been developed complementing modern surgical drainage techniques. The development of interventional radiological procedure has made percutaneous puncture and drainage of abdominal fluid collection possible. Image-guided percutaneous drainage of appendicular abscess has become well-established because of its proven safety and efficacy. Objectives: To evaluate the safety and feasibility of USG-guided percutaneous aspiration for draining appendicular abscess with special attention to the need for conversion and to see the nature of complications after draining of abscess. Materials and Methods: Between May 2013 to May 2014, 25 cases of appendicular abscess were selected from the admitted patients (surgery department) in Enam Medical College & Hospital who underwent USG-guided percutaneous aspiration. Procedure was performed mostly under local anaesthesia. Patients were followed up for 6 months. Interval appendicectomy was not performed routinely. Results: USG-guided aspiration was successful in 23 (92%) patients and in 2 (8%) patients procedure failed. Single attempt was successful in 21 (84%) cases and 4 (16%) patients needed double attempt for draining appendicular abscess. In 23 (92%) patients, PCA was done under local anaesthesia and two (8%) patients needed general anaesthesia. Complications developed in 4 (16%) patients. Four (16%) patients needed follow-up USG. Average hospital stay was 5 days (2−8 days) and average duration of using I/V antibiotic was 3.5 days (2−5 days). Conclusion: USG-guided percutaneous aspiration is an easy and safe method for draining appendicular abscess with minimum procedural complications. J Enam Med Col 2019; 9(1): 41-45

Fallopian Tube Recanalization (F.T.R): application of Interventional Radiology (I.R) post hysterosalpingography in management of female infertility at rural hospital

Background: Infertility is defined as inability to conceive even after 1 year of unprotected intercourse. Tubal blockage is one of the common causes of primary as well as secondary infertility in females. Fallopian tube recanalization (FTR) an interventional radiological procedure is one of the most promising, effective, minimally invasive and cost-effective technique in patients having infertility owing to tubal blockage. The aim is to study the cause, hysterosalpingography findings, and outcome of fallopian tube recanalization by interventional radiological procedure in patients with tubal-blockage presenting with infertility.Methods: This was a prospective observational study of women with primary or secondary infertility presenting to interventional radiology department. The patients either had already undergone hysterosalpingography (HSG) or came for HSG. Fallopian tube recanalization was done as per institutional protocol. Hysterosalpingography abnormalities, outcome and complications of fallopian tube recanalization procedure were studied.Results: In this study of 87 patients unilateral or bilateral tubal blockages were seen in 16 and 24 patients respectively. Majority of the patients had Segment I proximal block. Bilateral recanalization could be successfully done in 12 patients (24 tubes) with bilateral Proximal Tubal Blockage (PTO). Unilateral recanalization was possible in 12 patients (tubes) with unilateral proximal block and 8 tubes with bilateral proximal tubal block. 10 tubes with PTO could not be recanalized. 5 cases diagnosed with bilateral Distal Tubal Block (DTO), recanalization was not attempted and were referred for appropriate gynecological management. Minor complications were noted in 8 patients while no major procedure related complications were observed.Conclusions: Fallopian tube recanalization (by interventional radiology procedure) in patients with fallopian tube blockage diagnosed on HSG is found to be cost effective, minimally invasive and have low complication rate. It is associated with excellent outcome in terms of technical success and improved conception rate.