Case Snippets 8. Chen YY, Soon MS. Endoscopic diagnosis of hookworm infection that caused intestinal bleeding. Gastrointest Endosc 2005;62:142. 4. Khoshoo V, Schantz P, Craver R, Stern GM, Loukas A, Prociv P. Dog hookworm: a cause of eosinophilic enterocolitis in humans. J Pediatr Gastroenterol Nutr 1994;19:44852. 3.
Correspondence to: Dr. Thomas, Associate Professor. E-mail:
[email protected] Received October 21, 2005. Accepted December 27, 2005
Laparoscopic control of spontaneous external hemorrhage from umbilical varix
Fig: Colonoscopy showing multiple punctate erosions and hookworms (Inset: worm with one end buried in mucosa, with blood in its gut)
colonoscopy was normal.
Hookworms develop into adults in the small intestine and anchor themselves to the mucosa. Very rarely they have been recovered from the gastric antrum 1 and cecum. 2 The ectopic localization in the antrum has been attributed to jejuno-duodeno-gastric reflux. The recovery of hookworms from the cecum has been attributed to bowel preparation that may have washed the worms downstream. In our patient the duodenum and ileum were normal and worms were seen on initial sigmoidoscopy itself. Moreover the hookworms were seen anchored to the mucosa with evidence of oozing of blood from punctate erosions in the colon. To the best of our knowledge this is the first report of symptomatic hookworm infestation of the colon. Unusual cases of hookworm infection of proximal jejunum causing intestinal bleeding diagnosed by enteroscopy have been reported. 3 Recently the dog hookworm Ancylostoma caninum has been found in adult form in the human small intestine and has been implicated in cases of eosinophilic enteritis.4 Diagnosis of hookworm infection relies on the identification of ova in the feces but differentiation between species based on morphology of ova is extremely difficult. In some instances of infestation by male hookworms only, stool examination will be negative for ova. As colonoscopy is indicated in most patients with iron-deficiency anemia and positive stool occult blood test, the physician who performs endoscopies on patients from endemic regions should recognize these helminths. References 1.
2.
Dumont A, Seferian V, Barbier P. Endoscopic discovery and capture of Necator americanus in the stomach. Endoscopy 1983;15:65-6. Dunzendorfer T, Nunes DP, Kasznica J. More intestinal worms on colonoscopy. Am J Gastroenterol 1996;91:1677-
Adhish Basu, Sarath Chandra Sistla, S Jagdish Department of Surgery, Jawaharlal Institute of
Postgraduate Medical Education and Research,
Pondicherry
Spontaneous external hemorrhage from an umbilical varix is rare. We describe a 40-year-old man with cir rhosis and portal hypertension, who presented with recurrent external bleeding from an umbilical varix. The first episode was controlled by transfixation of the vein under local anesthesia. Contrast-enhanced CT scan demonstrated a hugely distended recanalized umbilical vein arising from the left branch of the por tal vein and ending in the umbilical cicatrix. Recur rent bleeding necessitated laparoscopy and in-situ clipping of the bleeding vein in the falciform ligament. At six months' follow up the patient has no further bleeding. [Indian J Gastroenterol 2006;25:211-212]
S
ymptomatic ectopic varices in portal hypertension are unusual. The detection of a recanalized umbilical vein has been an incidental ultrasound finding in these patients. 1 External hemorrhage from rupture of an umbilical varix is rare.2,3 The two cases reported in literature were managed by exomphalectomy. 2,3 A 40-year-old man presented to the emergency medi cal services with massive hemorrhage from his umbilicus following trivial blunt trauma to the abdomen when he slipped and fell. He was a chronic alcoholic, receiving treatment for diabetes mellitus and essential hyperten sion for the past 3 years. On examination, he was pale, anicteric, with blood pressure 90/60 mmHg and pulse rate 110/min. There was active bleeding from an umbilical varix. There was no visible caput medusae or periumbilical venous hum. The spleen was enlarged and there was no ascites. The patient was resuscitated and the umbilicus was ex plored under local anesthesia and a dilated umbilical vein was isolated and transfixed with silk sutures. Investigations: Hemoglobin 7.5 g/dL, total leukocyte count 3,200/mm 3, platelet count 59,000/mm 3, blood sugar
Indian Journal of Gastroenterology 2006 Vol 25 July - August 211
Case Snippets 17 mmol/L, bilirubin 51 μmol/L (direct 15), AST 90 IU/L, ALT 45 IU/L, alkaline phosphatase 369 IU/L, GGT 1549 U/ L, prothrombin time within 1 second of control. Serologi cal tests were negative for HBsAg and anti-HBs. Ultrasonography revealed coarse echopattern of a normal-sized liver, enlarged spleen of 16.5 cm in the lon gitudinal axis, portal vein diameter of 14 mm with left branch more dilated than the right, and no ascites. Duplex ultra sound revealed a 0.9-cm umbilical vein with flow away from the liver and arising from the left branch of the por tal vein, with multiple collateral vessels in the splenic hilum, spleno-renal ligament and retroperitoneum. Gastro duodenoscopy revealed two columns of esophageal va rices and mild portal congestive gastropathy. The varices were prophylactically injected with six mL polidocanol. Contrast-enhanced CT scan revealed a nodular shrunken liver with mild hypertrophy of left lobe. Portal vein mea sured 18 mm and had a patent lumen. The spleen was enlarged, with splenic vein 14 mm. Multiple splenic hilar, spleno-renal, mesenteric and anterior abdominal wall collaterals with a 1-cm umbilical vein were seen. Five days following the first bleed he had recurrence of bleeding (about 100 mL) from the umbilical varix, fol lowing a bout of cough in the night, which was controlled with external pressure alone. In view of recurrent bleed ing, laparoscopic proximal clipping of the umbilical vein was suggested. At laparoscopy under general anesthe sia, a Veress needle was inserted in the left lumbar area away from the anterior abdominal wall collaterals and a closed pneumoperitoneum was established. A left lumbar port was introduced, followed by introduction of a left hypochondrial port under direct vision of the laparoscope, avoiding the other abdominal wall collaterals. Laparoscopy revealed a macronodular cirrhotic liver with a 1-cm di lated umbilical vein in the falciform ligament. In-situ clip ping of the umbilical vein was done using a 10-mm clip applicator with large titanium clips (LT 400 Ligaclip® Extra; Ethicon Endo-Surgery, Cincinnati, OH, USA) (Fig). The operating time was less than half an hour and the patient did not receive blood transfusion.
Postoperative duplex ultrasound revealed no flow in the umbilical vein distal to the site of clip application. The patient was discharged with propranolol and his oral hypoglycemic and antihypertensive medications. There was no further episode of bleed attributable to portal hy pertension at six months of follow up. Gastro-duodenos copy revealed obliterated esophageal varices.
Rupture of a recanalized umbilical vein leading to hemodynamic instability is exceedingly rare. Rup ture usually results in hemoperitoneum. 4 Treatment involves urgent laparotomy and ligation of the bleed ing varices. 4,5 One patient died of esophageal va riceal bleed following ligation of all the anterior abdominal wall collaterals.4 We clipped only the bleed ing recanalized umbilical vein in our patient and did not obliterate the other abdominal wall varices. The success of minimal-access clipping of the umbilical varix is due to the precise mapping of the abdominal wall collaterals on pre-operative imaging. As a result, safe placement of the Veress needle with minimal blood loss could be achieved during the procedure. Laparoscopy is considered safe in Child’s class A and B patients. 6 Only two cases of spontaneous umbilical hem orrhage from umbilical varices have been reported, to the best of our knowledge. 2,3 Both had favorable outcome following variceal ligation and exomphalectomy. Our patient had re-bleeding following umbilical explo ration and variceal ligation, necessitating proximal clip ping of the vein laparoscopically. References 1. Saddekni S, Hutchinson DE, Cooperberg PL. The sonographically patent umbilical vein in portal hyperten sion. Radiology 1982;145:441-3. 2. Douglas JG. Umbilical hemorrhage – an unusual complica tion of cirrhosis. Postgrad Med J 1981;57:461-2. 3. Lewis CP, Murthy S, Webber SM, Chokhavatia S. Hemor rhage from recanalized umbilical vein in a patient with cirrhosis. Am J Gastroenterol 1999;94:280. 4. Hunt JB, Appleyard M, Thursz M, Carey PD, Guillou PJ, Thomas HC. Intraperitoneal hemorrhage from anterior ab dominal wall varices. Postgrad Med J 1993;69:490-3. 5. Goldstein AM, Gorlick N, Gibbs D, Fernandez-del Castillo C. Hemoperitoneum due to spontaneous rupture of the umbilical vein. Am J Gastroenterol 1995;90:315-7. 6. Poggio JL, Rowland CM, Gores GJ, Nagorney DM, Donohue JH. A comparison of laparoscopic and open cholecystec tomy in patients with compensated cirrhosis and symp tomatic gallstone disease. Surgery 2000;127:405-11. Correspondence to: Dr Basu, 90 Ballygunge Place, Kolkata 700019. E-mail:
[email protected] Received October 24, 2005. Received in final revised form November 12, 2005. Accepted November 27, 2005
Fig: Laparoscopic image of the umbilical vein (a) before and (b) following application of clips
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