ST. JMC JOURNAL OF MEDICINE ISSN 0970-4221 VOL.IIV NO. 1 MARCH 19901.pdf

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ISSN 0970-4221

ST. JOHN'S MEDICAL COLLEGE

JOURNAL OF MEDICINE
VOL IV No 1

March 1991

EDITORIAL

1

SURGERY SYMPOSIUM
Foreword

2

Laproscopic Cholecystectomy

3

Non Surgical Management of Gallstones

5

REVIEWS
New Trends in the

Treatment

of Ascites

8

Management of Bronchial Asthma in Children

11

Chronic Artificial Ventilation

14

CASE REPORT

Disseminated Rhinosporidiosis

3'1 *1

INFORMATION FOR CONTRIBUTORS

EDITOR-IN-CHIEF
Ashley. J. D'Cruz

Submitting the Manuscript

EDITORIAL BOARD

The St. John's Medical College Journal of Medicine accepts scientific contributions from all fields of
modern medicine and from all institutions and health care professionals. The journal is a quarterly
publication which will be published in March, June, September and December. It is owned by the
C.B.C.I. Society for Medical Education and published by the Principal, St. John’s Medical College. The
journal is a part of it's commitment to continuing medical education. Articles and all editorial
communications should be addressed to the Editor, Alumni Office, St. John’s Medical College,
Bangalore-560 034.

Rajini Macaden

Ravi C. Nayar
A.B. Kilpadi

A.S. Arvind
Anil Abraham

Original articles, short case reports and review articles are accepted for publication. Review articles
and editorials are usually on invitation by the Editorial Board. Letters to the Editor will be considered
for publication only if received at least six weeks prior to the next publication.

PREPARING THE MANUSCRIPTS
All manuscripts should be submitted in 3 copies (including the glossy prints). They should be neatly
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A brief abstract of the material of the paper should precede the body of the paper, to run no more than
500 words. INDEX WORDS for the purpose of indexing and computer programming, should appear
on the same page.
The format for articles suggested is as follows: INTRODUCTION, MATERIALS AND METHODS,
RESULTS, DISCUSSION, REFERENCES.
Measurements should be in metric system.

OVERSEAS

R.R. Baliga

A.V. Kurpad

ILLUSTRATIONS AND TABLES
Figures and tables should be cited in order in the text; their position should be marked in the margin
of the manuscripts. Arabic numbering should be used for both figures and tables. All line drawings
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REFERENCES

PUBLISHER
Prof. A.F.A. Mascarenhas
Principal

References should be compiled at the end of the articles according to the order of citation in the text,
not alphabetically. They should be typewritten, double-spaced under the heading REFERENCES.
Abbreviation for titles of medical periodicals should conform to those used in the latest edition of Index
Medicus. Give inclusive page numbers.

EXAMPLES OF REFERENCES
Journal Articles upto six authors, list all names:
Kurpad AV, Shetty PS: Dietary Fibre and the colon. St.John's J Med, 1988;1:5-12.
Journal Articles more than six authors, list three authors followed by et al:

Complete book
Gallagher JR: Medical Care of the Adolescent (ed 2). New York, Appleton, 1966; pp 208-215
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St. John's Medical College Journal of Medicine

EDITORIAL
The journal enters the 4th year and we on the editorial board
are happy on many counts. We are thankful to all you
contributors, for you make the journal. We hope the future
will see more active patronage. A willingness to share expe­
rience and knowledge among fellow readers will ensure its
growth and survival. The last six issues of the journal have
been published on time and of a standard format. We
therefore make ourselves serious contenders for recogni­
tion and indexing. This one achievement,will, inouropinion,
safeguard the future of the journal. We propose to start two
new columns in this volume, ’Letters to the Editor* and
’Collective Reviews’. The letters may be comments or
criticism of articles published in the journal or brief
communications of interesting experiences. The editorial
board will reserve the right to accept these contributions
for publication. The ‘Collective Reviews’ will
cover
interesting publications in the recent past in various
disciplinesand this effort is directed to our readers located
in more peripheral areas.
This journal is yours - help support and develop it.

Editor

SURGERY THE ABUSED WORD
"The word "surgery" designates the medical discipline which
encompasses pre-operative care, intra-operativejudgement
and management, and post-operative care.... Surgeons offer
patients an additional therapeutic modality, namely, the
operation itself. Among medical students, physicians and
some surgical residents, the word "surgery" has become
synonymous with operation. The discipline "surgery" clearly is
more encompassing than mere technical performance of an
operative procedure. In fact, often the operation constitutes
a minor part of our therapeutic armamentariam. Why then do
we permit our discipline to be demeaned by referring to this
fraction of our total care by "doing surgery upon the patient"
or "taking the patient to surgery " or "at the time of surgery,
an appendectomy was done". Clearly, we operate on a
patient, or at the time of operation, pathological conditions
are documented and treated....... "

Calrin B Ernst, M.D.

There is an increasing obfuscation about the term "Surgery”.
Surgery is the art of knowing when and how to operate, and
of the complete care of patients with surgical conditions. I
have been dismayed by some primary physicians whose
patients have a surgical problem that may or may not require
operative management. Gone is the collegiality of a consult
for a surgical opinion. All too often, currently, the surgeon is
called and informed which operation the physician desires.
Occasionally, the desired incision is spelled out as well.
Perhaps we surgeons have abetted this state of affairs by
sloppiness in our terminology. Unwittingly, our own careless
misuse of the word ’’surgery" may have encouraged such an
attitude on the part of our colleagues, who now may think of
us only as technicians or operators.
Just as we do not do Pediatrics or Radiology or Medicine to
a patient, we likewise do not do surgery to a patient. Neither
do we take a patient to surgery, nor do we ever "surgerize" a
patient.

A patient does not have surgery, but an operation in an
operating room. Often, it is good surgery not to operate.

Excerpted from an Editorial
by
Jack White M.D.
J. Pediatr. Surg. 199126:127

March 1991

1

St. John’s Medical College Journal of Medicine

SURGERY SYMPOSIUM
FOREWORD
Surgery of the Liver and Biliary tract has come a long way since the day Sir Walter

Scott, suffering from biliary colic, gave up all hopes of survival, summoned his near and
dear onesto his'death bed'and turned hisfaceto the wall, preparing to meet his maker.
Today, calculous biliary disease, having enthralled surgeons, gastroenterologists and
radiologists alike, is probably the one condition that has unified these three fields of
medical science so much so that there have been tremendous advances in the
management of gall stones by all three specialities.
With the advent of gastrointestinal endoscopy, less invasive procedures evolved for the
treatment of impacted stones and strictures. A better understanding of the etiology and

chemical composition of gall stones led to the development of agents capable of
dissolving gall stones. The excitement of this development has been rather short lived
due to several drawbacks, and we are now in the era of completely non-invasive and
minimally invasive procedures which offer the prospect of a cure.
Technological advances have brought us highly specialised modalities of treatment
such as Laser, and several method of lithotripsy.

This issue of the journal discusses non-surgical management of cholelithiasis and the
pros and cons of laparoscopic cholecystectomy in the form of a surgical symposium.

Dr. Arun B. Kilpadi
Guest Editor

VOL IV No. 1 -----

SURGERY - SYMPOSIUM

St. John's Medical College Journal of Medicine

LAPAROSCOPIC CHOLECYSTECTOMY
ARUN B. KILPADI

INTRODUCTION

ADVANTAGE AND DRAWBACKS

Mouret, a French surgeon in Lyons, first accomplished
laparoscopic cholecystectomy in June 1987 but this pio­
neering achievement went unreported. It was in 1988 that
Francois Dubois of Paris and Jacques Perissat of Bordeaux
each performed the first of their many hundred procedures
to date’.

Whether it is with the use of Laser or Electrocautery,
Laparoscopic Cholecystectomy has certain advantages
over conventional
open cholecystectomy and other
modalities of treatment of gall stones. The procedure is
satisfying to the patient as well as the surgeon when success­
fully accomplished in the indicated case. The cost is lower
and less time is lost from work as the patients can be
discharged within three days. The cosmetic and funtional
results are excellent and the ultimate goal in the treatment
of gall stone disease ie: removal of the gall bladder, is
achieved.1

PROCEDURE

The procedure is better performed under general anaesthesia
which permits immediate transition from the laparoscopic
operation to a minilaparotomy if necessary as in pyocholecystis discovered at laparoscopy.

It calls for four abdominal insertion areas namely the
umbilicus (for the endoscope), right subcostal (for the
forceps), epigastric (for the aquapurator also used for liver
retraction) and left subcostal (for the endocoagulation
scissors, clip applicator and gall bladder extractor). The gall
bladder is removed through a 10mm trocar sheath.3

However, the procedure is applicable only in uncomplicated
cases with stones measuring less than 30 mm in diameter.
Examination of the periampullary area and retroperitoneum is
difficult by this route and routine cholangiography is not
possible. This may result in unsuspected bile duct disease
being overlooked. Complications such as haemorrhage
from the cystic artery and choleperitoneum have been
reported.3

CONTROVERSIES

CONCERNS

Controversy exists with regard to the use of Laser as against
Electrocautery.
The former is expensive (cost approximately $120,000),
requires more personnel to maintain the Laser on “Ready"
or “Standby" for safety during surgery and being unfamiliar
to most general surgeons, it takes time to learn to use it.
Also, the operating time is increased by an average of 20
minutes. The expense too is not associated with any
discernible benefit.

At present the concerns regarding this procedure are :- A fear among su rgeons of being shut out and not being
able to be trained or being trained too late to keep up with
the competition.
- A steep learning curve resulting in incorrect patient
selection,
- Too liberal application of the procedure and its
extension to asymptomatic gall stones
- An increase in morbidity, complications and mor­
tality which are now being reported.

The proponents of electrocautery state that the electro­
cautery hook being more familiar and readily available in
most well equipped theatres is easier to use and saves
operating time. It is also less expensive. The cost of one
Laser unit could equip three operating rooms with
laparoscopic and video facilities. It is thus cost effective and
available to a larger section of the population. A skilled
assistant is not mandatory for- the performance of the
procedure using electrocautery.2

ARUN B. KILPADI

ASSOC. PROFESSOR.
DEPARTMENT OF SURGERY
ST.JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE - 560 034

March 1991

An objective analysis may be clouded by entrepreneurial ex­
ploitation of this procedure.

Collection of world wide data would help in evaluating the
efficacy of this procedure, formulating indications,
standardisation of technique and analysis of results in order
to determine the rightful place of laparoscopic cholecystec­
tomy.1

RECOMMENDATIONS
At present, the American College of Surgeons recommends
that this procedure should be performed by surgeons who are
qualified and skilled enough to perform open cholecystec­
tomies and other biliary tract procedures as they would be
able to determine the best method of cholecystectomy and
3

St. John’s Medical College Journal of Medicine

would be competent enough to treat complications conse­
quent to laparoscopic cholecystectomy.
The Society for Surgery of the Alimentary Tract further adds
that the privilege to perform laparoscopic cholecystectomy
should be granted only to trained general surgeons who have
acquired the expertise in laparoscopic procedures through
previous clinical experience or through instruction and have
completed an experience in supervised performance of
laparoscopic cholecystectomy which includes instruction
and practice on animals.1

CONCLUSIONS
Laparoscopic cholecystectomy is here to stay. Experience
and analysis of honestly reported results will determine its
proper place. It is a procedure that must be performed and

4

further developed by general surgeons who have acquired
the necessary skills. The relative efficacy, safety and cost
effectiveness of electrocautery versus laser in dissecting the
gallbladder needs to be objectively evaluated. The recom­
mendations quoted will serve as guidelines in the orderly
evolution of this technique.
REFERENCES
1. Laparoscopic Cholecystectomy, Ronald K. Tompkins, Archives of Surgery,
1990;12:1245.

2. Electrocautery versus Laser in Laparoscopic Cholecystectomy: C.Randle
Voyles, Albert Meena, Antony Petro et al American Journal of Surgery,
1990;160:457.

3. Coelioscopic cyolecystectomy, a preliminary report of 36 cases.
F.Dubois, P.Icard G. Berthelot et al. Annals of Surgery 1990;211:60-62.

VOL IV No. 1 -----

SURGERY - SYMPOSIUM

St. John’s Medical College Journal of Medicine

NON SURGICAL MANAGEMENT OF GALL STONES
ARUN B. KILPADI

The evolution of alternative modalities for the treatment of gall
stone disease has been the outcome of a better understand­
ing of the aetiopathogenesis of cholelithiasis and the
chemical composition of gall stones. Advances in pharmacol­
ogy and medical technology have been applied with revolu­
tionary results to the development of less invasive and noninvasive procedures aimed at curing this ubiquitous disease
with the elimination or significant reduction in morbidity and
mortality.
Non surgical options to treat gall stones can be broadly
classified as follows:
I.

Dissolution

IL Extraction

a) Using Oral agents
b) Using Topical agents
a) Endoscopic (Upper G I Endoscopy)
b) Percutaneous (via a performed tract)

I IL Fragmentation a) Mechanical
b) Electrohydraulic
c) Ultrasound
d) Laser
e) Extracorporeal Shock Waves

(ii) By decreasing the cholesterol saturation of bile by
increasing its phospholipid content, expanding the bile salt
pool or decreasing the cholesterol content of bile by means
of dietary restriction, prevention of intestinal absorption of
cholesterol or limiting its hepatic secretion. The bile acids
used as solvents expand the bile salt pool and to some
extent decrease hepatic synthesis of cholesterol.

The use of bile acids as stone solvents was proposed by
Schiff in 1873 but the first successful report of dissolution of
stones by bile acids came from Rewbridge in 1937.

The bile acids currently in use are Chenodesoxycholic acid
(CDCA) and Ursodesoxycholic acid (UDGA).

CDCA :- This acid is normally synthesised by the liver. The
first clinical trial using this agent was reported in 1970. CDCA
is administered orally.ideally in the dose of 15 mg/kg/day for
a period of two years. It has the disadvantages of requiring
a prolonged course of treatment estimated to cost $ 1000 per
year and is associated with a rise in Serum LDL Cholesterol
and Transaminases. Diarrhoea may pose a problem calling
for reduction of dose or temporary cessation of treatment.
The reported failure rate is as high as 85% and the recurrence
rate of stones is 25-50% at two years.

DISSOLUTION

A) Using Oral Agents

This modality is applicable to cholesterol stones which are
solitary and contained in a functioning gall bladder with a
patent cystic duct. Confirmation of these requirements is
obtained on Oral Cholecystography in which cholesterol
stones would appear to be buoyant in an aqueous medium.
A duodenal aspirate containing over 10% cholesterol would
enhance the accuracy of case selection.

UDCA :- This primary bile acid of the Polar Bear appears
in traces in human bile and has certain advantages over
CDCA in that the dose is smaller (5 to 10 mg/kg/day), the
course of treatment is half as long, there is no marked altera­
tion of liver functions and serum cholesterol and the
incidence of diarrhoea is much lower. However, this agent
is more expensive and trials conducted in Japan, France and
Belgium have not shown any significant differences be­
tween CDCA and UDCA in their dissolving capacities.

COMBINATION THERAPY

There are two ways in which cholesterol stones can be
dissolved :(i) By removing bile from the biliary tree and replacing it with
a lipid solvent. This being an invasive procedure has
obvious limitations.

ARUN B. KILPADI
ASSOC. PROFESSOR
DEPARTMENT OF SURGERY
ST.JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE - 560 034

March 1991

There are proponents of combination therapy using these
two agents whose preliminary data suggest that this may
be more effective.
PARENTERAL THERAPY
The parenteral preparation of CDCA has been used intrave­
nously in Prairie Dogs and this may provide an alternative
route of administration in patients who are unable to take the
oral form or who are on Total Parenteral Nutrition for short
bowel syndrome.

Oral dissolution is not advised in severe symptomatic gall
stone disease, when the stones are over 20 mm in size and
5

St. John's Medical College Journal of Medicine
when the gall bladder is non functioning. These agents are
better avoided in pregnant and nursing women. Diabetics
are better advised cholecystectomy. Dissolution is most
applicable to elderly, high risk patients with mildly sympto­
matic disease whose stones fulfil the criteria required for
dissolution. Asymptomatic patients are best managed expec­
tantly unless they insist on medical treatment.

ing which chemically binds calcium atoms and eliminates
cross linkages of polymers in black pigment stones. It also
solubilises calcium bilirubinate in brown pigment stones. This
agent cannot be used orally or parenterally as it is not con­
centrated in bile. After chelation of calcium with EDTA it may
become necessary to use other solvents to dissolve other
constituents of gall stones.

B) Using Topical Agents

NEWER AGENTS

These agents are infused directly into the biliary tree via a
percutaneous transhepatic catheter, a T Tube, a Chole­
cystostomy tube or an endoscopically placed Nasobiliary
catheter.

The complete medical treatment of gall stones would
require dissolution of existing stones followed by inhibition
of nucleation of cholesterol to
prevent
recurrence.
ROWACHOL, a Terpene mixture, has been shown by Van
Bergmann et al to significantly lower nucleation time in bile
from patients with cholesterol stones.

MONOCTANOIN (CAPMUL)

This is an organic solvent of 70% Glyceryl 1 Monoctanoate
and 30% Glyceryl Dioctanoate which was first proved to be
successful in retained Common Bile Duct stones by Mack et
al and Palmer and Hoffmann. The cholesterol content of the
stone is the critical factor affecting the efficacy of
Monoctanoin, therefore analysis of stones removed at
surgery would help in selecting this agent to treat retained
stones. To be effective, Monoctanoin requires adequate and
continuous stone contact, constant circulation and proper
solvent viscosity and temperature. The average rate of
infusion should be 4.8ml/hour for 7 to 15 days under a
constant pressure of 15 cms of water.
The factors limiting the use of this agent are the slow
dissolution time requiring retention of a catheter of some sort
for a prolonged period of time and its inability to dissolve
pigment stones. Reported side effects are nausea,
vomiting, diarrhoea, duodenal ulceration, and jaundice,
cholangitis and pancreatitis due to impaction of stones at
the Ampulla of Vater. These may warrant discontinuation
of treatment in 10% of patients. Monoctanoin is known
to elevate serum Alkaline phosphatase though clinical hepa­
totoxicity has not been observed.

METHYL TERT BUTYL ETHER

(MTBE)

This is an aliphatic ether with a boiling point (55.2° C) above
body temperature which remains liquid when infused. It
dissolves cholesterol stones 5 times more rapidly than Mon­
octanoin (4 to 16 hours in the gallbladder) and elicits a milder
inflammatory response. However, MTBE does not dissolve
pigment stones and may raise serum levels of aminotrans­
ferases 2 to 3 times normal. An increase in total leucocyte
count has been observed. The major drawback with the use
of this agent is the reported recurrence of stones as early as
3 to 4 months following treatment.

ETHYLENE DIAMINE TETRA ACETIC ACID (EDTA)
This is a calcium chelating agent used in heavy metal poison­
—

6

-—---------------------------------------------------------------------------------------------

Cholecystokinetic agents have been used to prevent gall
bladder stasis and sludge formation in animals on parenteral
alimentation by Doty, Pitt et al.
EXTRACTION

This implies removal of stones from the biliary tree and can
be performed either under fluoroscopic guidance, video
monitoring or direct vision.
The methods described are :
i) Insertion of a basket snare under fluoroscopic guidance
via a mature T Tube tract or Cholecystostomy tube tract
to remove stones from the CBD or gall bladder. This
procedure was first described by Burhenne in 1973.
ii) Introduction of a Cholangioscope via a mature T tube tract
to extract stones under direct vision.
iii) Endoscopic papillotomy followed by insertion of a balloon
catheter or basket snare into the CBD. This procedure has
the added advantage of providing a wide papilla to facilitate
spontaneous passage of stones subsequently.
iv) Introduction of a “Baby” scope through a “Mother" endo­
scope into the CBD to extract stones under direct vision or
video monitoring.
v) Akiyama et al describe a 3 stage technique as follows :
a) Percutaneous catheter drainage of the gall bladder
is instituted under ultrasound guidance.
b) A 7 French catheter is then introduced into the gall
bladder and the tract is gradually dilated over a guide wire
until it ultimately accommodates a 5 mm catheter.
c) Finally, a fibre cholangioscope is inserted via this
catheter to extract gall bladder stones under direct vision.

FRAGMENTATION (LITHOTRIPSY)
This
aims at breaking down gall stones into smaller
fragments which then provide a larger surface area for a
dissolving agent to work on more effectively. It also changes
the structure of the gall stone which in turn facilitates the
--------------------------------- —--------------------------------------------- VOL IV No i —

St. John’s Medical College Journal of Medicine

action of solvents. Lithotripsy also facilitates spontaneous
passage of stones. This procedure can by no means be
considered as an end in itself in the treatment of gall stone
disease but forms a useful adjunct to other modalitites of
treatment. Several techniques of lithotripsy have been de­
scribed.

clearance in 86%. Adjuvant non-operative procedures may
be required in upto 76% of patients and surgical intervention
in 6%. Complications include cardiac arythmias, abdominal
wall hematomas, hemobilia, hematuria and biliary pain. A 30
day mortality rate of 0.9% has been quoted.
CONCLUSION

i)
Mechanical
The approach maybe either endo­
scopic or percutaneous. The lithotripter developed by
Riemann and Demling uses a 2 or 4 armed flexible basket
generating large mechanical forces. They report 89%
success in a series of 16 patients. The concept of mechani­
cal lithotripsy has not gained popularity because it is as­
sociated with an unacceptably high rate of recurrence.

ii) Electrohydraulic :- This is based on the principle of
creating shock waves within the stone by passing an
electrical discharge across a coaxial electrode in a liquid
medium. The electrode can be introduced percutaneously
or through an endoscope.
iii) Ultrasound
An ultrasound drill can be placed in
contact with the calculus endoscopically to cause fragmen­
tation.

All these forms of treatment viz : Dissolution, Fragmenta­
tion and Extraction are complimentary to each other and none
of them can claim to offer a complete cure from
cholelithiasis or even freedom from recurrence.
All three require highly specific criteria to be satisfied before •
they can be applied with any degree of satisfaction or applied
at all.

A time may come when a patient with cholelithiasis will have
his/her stones extracted, the cystic duct occluded and the
gall bladder mucosa obliterated - all percutaneously under
sedation or analgesia. But,till then, cholecystectomy by any
means remains the only procedure which offers a lasting cure.
SUGGESTED READING

iv) Laser :- Endoscopic and percutaneous Nd Yag Laser
devices are now being used to fragment gall stones.

1. Alternatives to conventional surgical therapy for calculous biliary tract
disease. Robert J. Fitzgibbon Jr. Gary Anthone, Anthony Tseng etal. Surgery
Annual Vol. 21,1989,237-259.

v) Extracorporeal Shock Wave Lithotripsy (ESWL)
This technology was first developed by Dornier in Germany
and used to fragment renal stones in 1980. It has been used
in the treatment of gall stones since 1985. The procedure
requires the patient under general anaesthesia to be sub­
merged in a waterbath and can endanger nearby structures
likethelung. However these limitations are being overcome
in the newer generation of lithotripters. The older lithotripters employed the Spark gap and the Electromagnetic
principles to produce shock waves and required at least
intravenous analgesia for the procedure. The newer ones
use the Piezoelectric technique and do not require any
analgesia. The procedure is ideally used when there are 3
to 5 stones of 5 to 20 mm in size within a small gall bladder.
Litholytic therapy is commenced 12 days before lithotripsy
and continued for3 months thereafter. Fragmentation can be
achieved in upto 91% of cases and complete stone

2, Modern Management of biliary tract stone disese. Ronals K.Tompkins,
Jeffrey E.Doty. Advances in surgery 1987;20:279-298.

March 1991

3 Chenodesoxycholic acid for dissolution of gall stones. A controlled trial
of efficacy and safety. Schoenfield L.J. Lachin J.M. and the steering commit­
tee, National Co-operative Gall stone study. Annals of Internal Medicine,
1981;95:257-282.
4. A new method of non-surgical cholecystolithotomy. Akiyama H, Yukihuro.
N, Fugita. T. Surgery, Gynaecology and Obstetrics, 1988;161:73-74.

5
Minicholecystectomy and Radiologic Stone extraction in high risk
cholelithiasis patients. Burhenne H.J. Stoller. J.L, American Journal of
Surgery, 1985;149:632-635.
6 Gallstone Dissolution. Mark A. Talamini, Thomas R. Gadacz. Surgical
Clinics of North America, Dec. 1990,70:6,1217-1229

7. Extracorporeal Shock Wave Lithotripsy for Biliary Stones, Jay B Prystowsky, David L. Nahrwold. Surgical Clinics of North America. Dec
1990;70:6,1231-1247.

7

REVIEWS

St. John’s Medical College Journal of Medicine

NEW TRENDS IN THE TREATMENTOF ASCITES
SPYROS DURAKIS

INTRODUCTION
Ascites is a complication of liver disease and in a cirrhotic
patient signifies a diminution of life expectancy. Patients with
massive ascites are uncomfortable and often complain of
difficulty in breathing and indigestion.
Treatment of ascites may not increase life expectancy but
does improve the quality of life. Patients with massive ascites
feel uncomfortable and often are complaining of breathing
problems and indigestion. Treatment of ascites besides im­
proving patient comfort also hinders the development of
spontaneous bacterial peritonitis by increasing the ascitic
concentration of protein and the opsonic activity of the
ascitic fluid2,3. Small collections of ascitic fluid may not
require any treatment4, but larger volumes can compromise
respiratory function and require urgent therapy.

Till I960, repeated paracentesis every 15-20 days was the
treatment of choice for cirrhotic ascites, but because of
complications (encephalopathy, hyponatremia and renal
failure) and the development of potent diuretics paracentesis
fell out of vogue5. Avid sodium and water retention is present
in patients with ascites and for over two decades a combi­
nation of salt restriction (usually less than 50 mmol/d) and
diuretic therapy was the treatment of choice6. This review
addresses newer therapies in the management of ascites.

THERAPY

Sodium Restriction : Ascites per se is not an indication
to initiate diuretic treatment. Approximately 20% of patients
develop a spontaneous diuresis with bed rest and sodium
restriction7. The assumption of an upright posture is
associated with a marked activation of the renin-angiotensin
and sympathetic systems, a reduction of glomerular filtration
rate and sodium excretion and a decrease in response to
diuretics.
Diuretics : Cirrhotic patients excrete little sodium in the
urine. Usually the urinary sodium is less than 50mmol per day
and can be less than 10mmol in resistant ascites. A 40 mmol

DR. SPYROS DURAKIS M.D.
CONSUL TANT PHYSICIAN
HIPPOKRATIC HOSPITAL
ACADEMIC DEPT OF MEDICINE
AMPELDKIPI 11523
ATHENS, GREECE
8

sodium diet is typical for a cirrhotic patient treated in
hospital but is unpalatable. A “no-added salt” diet contains
2 grams of salt (80mol) and can be easily followed. The
addition of a diuretic allows the sodium content of a diet
to be increased. Spironolactone is the diuretic of choice.
It is particularly helpful in correcting secondary hyperal­
dosteronism which characterizes
cirrhosis. As an
aldosterone
inhibitor spironolactone blocks the sodium
absorption in the distal renal tubule. The dose of spironolac­
tone is 100-200mg, but it can be increased to 600mg. If
gynecomastia induced by spironolactone is a problem
amiloride may be substituted for spironolactone in doses of
10-40mg per day.

In resistant cases frusemide, a very potent diuretic, can be
added in doses of 40-80mg/d. Frusemide acts on the ascend­
ing limb of Henle’s loop and increases the sodium delivery to
the distal tubule. Absorption of Na+ in the distal tubule is
blocked by spironolactone. Other loop diuretics such
bumetanide and ethacrinic acid have been used success­
fully. The pretreatment urinary Na can be used as a guide
for planning diuretic treatment. Patients with very low daily
urinary sodium output (less than 10 mol/d) need a combina­
tion of diuretics, acting in different sites of the nephron9.
The reported frequency of complications after the use of
diuretics is 11-71%10. The long term complications of
diuretics-are encephalopathy, renal impairment, hypoka­
lemia, hyponatremia, metabolic acidosis, hyperuricaemia,
haematological toxicity, sexual disturbances, intense
muscle cramps and hyperglycemia. Spironolactone treat­
ment is associated with sexual disturbances and gynecomas­
tia in men and menstrual irregularities in women because of
its antiandrogenic activity.

The existence of peripheral oedema makes diuretic
treatment safer because fluid can be mobilised easily from the
subcutaneous space11. From the abdominal cavity the fluid
can be mobilised only at a limited rate of about 900ml per day.
A larger diuresis than this decreases the intravascular
volume and precipitates renal impairment and encephalopa­
thy. Patients not responding to treatment with 160mg frusem­
ide and 400mg spironolactone should be considered as
having diuretic-resistant ascites. Truly refractory ascites
however is an infrequent condition.

Prostaglandins play a very important role in the maintenance
of renal haemodynamics and in the renal response to
diuretic treatment Non-steroidal, anti-inflammatory drugs
should be avoided.
Paracentesis - Some patients with severe liver disease do
VOL IV Bi 1 —

St. John's Medical College Journal of Medicine

not respond to diuretics and in them abdominal paracentesis
is the next step. A daily 5-6 litre paracentesis is safe, pro­
vided paracentesis is followed by albumin infusion, 4-6g per
litre of ascitic fluid removed13. Dextrans have been proposed
as safe alternatives of albumin14. Large volume paracentesis
combined with albumin infusion seems to be safer than high
dosage diuretic treatment15116. Systemic haemodynamics,
renal function and serum electrolytes remain unchanged
after this form of treatment17-18
Ascitic fluid can be safely removed within a single two hour
paracentesis session provided the intravascular volume
is expanded with human serum albumin19-20. Large volume
paracentesis without the administration of albumin is asso­
ciated with an increase in plasma renin activity suggesting
an impairment of effective blood volume and with the
development of hyponatremia or renal failure in 20% of
patients21,22. Therapeutic paracentesis with albumin infu­
sion even in the absence of peripheral oedema, is safe and
is useful in the treatment of diuretic-resistant ascites23. The
subsequent administration of diuretics avoids reaccumula­
tion of ascites. Repeated large-volume paracentesis (4-5
litres) are preferred to total paracentesis.
In our experience, most cirrhotic patients admitted to the
hospital for the treatment of ascites are those who develop
tense ascites despite a standard diuretic treatment. Once
ascites has been eliminated, patients should be treated with
diuretics to delay the reaccumulation of the fluid.

Peritoneovenous Shunting : The peritoneovenous shunt
(PVS) has been used for the treatment resistant ascites. It
appears to expand effective arterial blood volume as evi­
denced by increases in cardiac output, renal blood flow, right
atrial pressure atrial natriouretic peptide concentration and
decreases in renin and aldosterone concentrations20-29. The
shunt has not been widely accepted due to complications, in­
cluding sepsis, coagulopathies and pulmonary oedema30131.
Besides, comparison of diuretic treatment with the peritoneo­
venous shunt has showed no difference in short-term and
long-term survival32. Intermittent total volume paracentesis
with albumin replacement has been proved to be a suitable
substitute for peritoneovenous shunt. There is, however, still
a place for the PVS to relieve ascites in a small group of ap­
propriately selected patients37.

Portocaval Shunt : Portocaval shunts, previously de­
scribed as potential treatment of ascites, have now been
abandoned. Patients fit enough to be operated on, must be
offered the possibility of liver transplantation. This treatment
will cure ascites and the underlying liver disease at the same
time.
Whatever the treatment, reaccumulation of ascites and long
term prognosis remains the same, influenced by the severity
of the liver disease and the resultant liver failure. Liver
transplantation offers new hopes to these patients.
REFERENCES

The long term prognosis as determined by the readmission
rate, the survival and the cause of death are not affected
significantly by any form of ascites treatment.

1. Lalch J, Gines P, Arroyo V et al. Prognostic value of arterial pressure,
endogenous vasoactive systems and renal function in cirrhotic patients
admitted to the hospital for the treatment of ascites. Gastroenterology
1987;94:341-343.

OTHER FORMS OF THERAPY

2. Runyon B. A, Van Epps D. E. Diuresis of cirrhotic ascites increases its
opsonic activity and may help prevent Spontaneous Bacterial Peritonitis.
Hepatology 1986;6:396-399.

Water immersion by increasing plasma volume has been
used as experimental therapy in patients with cirrhotic
ascites. Combination of frusemide with water immersion
has been used successfully for the treatment of refractory
ascites24. Obviously, this form of treatment is impractical
for widespread application.
Ascitic fluid reinfusions : Paracentesis with reinfusion
of ascitic fluid into the general circulation has been used for
the treatment of ascites. In the 1970’s a machine was
designed in which the ascitic fluid was concentrated by
pressure ultrafilteration and then reinfused into the central
venous system after the low molecular weight substances
contained in the ultrafiltrate were discarded25. This method
was very popular in Europe during the last decade. It allowed
removal of large quantities of ascitic fluid in a short time.
Complications (pulmonary oedema, peritonitis, intravas­
cular coagulation, gastrointestinal bleeding) have restricted
the wide application of the method26. A recent report has
renewed interest in the technique27.

March 1991

3. Runyon BA, Antilion MR, Montano AA. Effect of diuresis versus therapeutic
paracentesis on ascitic fluid opsonic activity and serum complement. Gastro­
enterology 1988;97:158-162.

4, Boyer TD: Removal of ascites: what’s the rush? Gastroenterology
1986;90:2022-2026.
5. Uebowitz HR. Hazards of abdominal paracentesis in the cirrhotic pa­
tients. (part III) NY State J Med. 1962;62:2223-2229.
6. Wilkinson SP and William R. Ascites, electrolyte disorders and renal failure.
In Wright R(ed) Liver and Biliary Disease 1979,pp 1060-1086. London: WB
Saunders Company.
7. Stassen WN, McCullough AJ Management of ascites. Sem. Uv Dis
1985;3:291-307.

8. Arroyo V, Rodes J.A rational approach to the treatment of ascites.
Postgrad Med J. 1975; 51:558-562.

9. Perez-Ayuso RM, Arroyo V, Planas R et al: Randomized comparitive
study of efficacy of frusemide versus spironolactone in nonazotemic cirrho­
sis with ascites. Gastroenterology 1984;84:961-968.

9

St. John’s Medical College Journal of Medicine

10. Sherlock S. Senewiratne B, Scott A, Walker JG Complications of diuretic
therapy in hepatic cirrhosis. Lancet 1966;i:1049-1053

22. Panos M, Moore K, Vlavianous P et al: Single, total paracentesis for
tense ascites: sequential hemodynamic changes and right artrial size.
Hepatology 1990;11:662-667.

11. Pockros PJ, Reynolds TB. Rapid diuresis in patients with ascites from
chronic liver disease: the importance of peripheral oedema. Gastoenterology
1986;90:1827-1833..

23. Runyon BA. Paracentesis of ascitic fluid: A safe procedure Arch Inter
Med. 1986;146:2259-2261.

12. Perez-Ayuso RM, Arroyo V, Camps J et al: Evidence that renal
prostaglandins are involved in renal water metabolism in cirrhosis. Kidney
Int. 1984;26:72-80.

24. Fawthrop F,O’Hare JP, Miller N et al: Combined use of water immersion
and frusemide in treatment of resisteant ascites in liver cirrhosis. J R Soc Med
1987;80:776.

13. Salerno F, Badalamenti S, Incerti P et al. Repeated paracentesis and
i.v. albumin infusion to treat “tense” ascites in cirrhotic patients. A safe
alternative therapy. J Hepatol. 1987;5:102-108.

25. Levy VG, Opolon P, Pauleau N, Caroli Ji Treatment of ascites by
reinfusion of concentrated peritoneal fluid-a review of 318 procedures in 210
patients. Postgrad Med J 1975,51:564-566.

14. Salerno F, Lorenzano E, Moser P et al. Haemacel infusion is a safe and
inexpensive method to prevent hypovolemia and hyponataemia after
paracentesis. J Hepatol. 1988;7:S74.

26. Wilde JT.Cooper P, Kennedy HJ et al.Coagulation disturbances following
ascites recirculation.J Hepatol.1990;10:217-222.

15. Quintero E, GinesP, Arroyo Vetal: Paracentesis versus diuretics in the
treatment of cirrhotic with tense ascites. Lancet 1985;i:611-612.

16. Gines P, Arroyo V, Quintero Eetal: Comparison between paracentesis
and diuretics in the treatment of cirrhotics with tense ascites. Results of a
randomised study. Gastroenterology 1987;93:234-241.
17. Simon DM, McCain JR, Bonkovsky HL et al: Effects of therapeutic
paracentesis on systemic and hepatic homodynamics and on renal and
hormonal function. Hepatology 1987;7:423-429.
18. Pinto PC, American J, Reynolds TB. Large-volume paracentesis in
nonedematous patient with tense ascites: its effect on intravascular volume.
Hepatology 1988;8:207-210.
19.

27. Smart HL, Triger Dr. A randomized prospective trial comparing daily
paracentesis and intravenos albumin with recirculation in diuretic refractory
ascites. J Hepatol. 1990; 10:191-197.

28. LeVeen HH, Christoudias G, Moon JP et al. Peritoneo-venous shunting
for ascites. Ann. Surg. 1974;180:580-591.
29. Epstein MPeritoneo-venous shunt in the management of ascites and the
hepatorenal syndrome. Gastroenterology 1982;82:790-799.

30. Greig PD, Langer B.BIendis LM et al: Complications after peritoneovenous shunting for ascites. Amer.J.Surg.1980;139:125-131.
31. Scholz DG, Nagorney DM, Linder KD. Poor outcome from
peritoneovenous shunts for refractory ascites. Am J Gastroenterol.
1989;84:540-543.

Tito L Gines P, Arroyo V et al. Total paracentesis associated with

intravenous albumin in the management of patients with cirrhosis and ascites.
Gastroenterology 1990;98:146-151.
20. Dourakis S: Total paracentesis for the treatment of tense ascites, latriki
(Gr) 1989;6:234-236.

21. Gines P, Tito L, Arroyo V et al. Randomized comparative study of thera­
peutic paracentesis with and without intravenous albumin in cirrhosis. Gastro­
enterology 1988;93:234-241.

10

32. Stanley MM, Ochi S, Lee KK et al: Peritoneovenous shunting as compared
with medical treatment in patients with alcoholic cirrhosis and massive
ascites. N Engl J Med 1989;321:1632-1638.
33. Ring-Larsen J, Siemssen O, Krinel JJ etal. Denver shunt in the treatment
of refractory ascites in cirrhosis:a randomized controlled trial. Gastroenterol­
ogy 1989;96:A649.
34. Smajda C and Franco D: The LeVeen shunt in the elective treatment of
intractable ascites in cirrhosis. A prospective study on 140 patients.
Ann.Surg.1985;201:488-493.

- VOL IV No. 1

REVIEWS

St. John's Medical College Journal of Medicine

MANAGEMENT OF BRONCHIAL ASTHMA IN CHILDREN
EDWIN DIAS, CHANDRA SEKHARA M.K.
Bronchial asthma is one of the leading causes of acute and
chronic illnesses in children. Asthma has a prevalence rate
in childhood of 5%-12% in most developing nations. The
American Thoracic Society defines Asthma as "A disease
characterised by increased responsiveness of the trachea
and bronchi to various stimuli and manifested by the wide
spread narrowing of the airways which changes in severity
either spontaneously or as a result of therapy”. Any child
regardless of age should be considered as having asthma
until proven otherwise if the child had 3 or more recurrent
episodes of wheezing or dyspnea. A detailed history is of
paramount importance when evaluating a child for asthma.

Exclude less common causes of recurrent wheezing in
infants and young children by clinical evaluation.

TABLE 1 : CAUSES OF RECURRENT WHEEZING IN
INFANTS AND CHILDREN

Investigations to confirm non asthmatic condition
No reversibility of airflow obstruction with bronchodilators
Focal or persistant chest radiographic findings.
-Once the diagnosis is established, treatment can be
initiated for asthma.
Common management strategies in children of all ages :

The management goals are
1. To reduce symptoms
2. Reduce limitations on activity at home, school, work and
leisure.
3. Reduce side effects of medication
4. Prevent asthma related emotional disorders
5. Avoid hospitalisation
6. Reduce morbidity and mortality.
7. Restoration of normal lung function
8. The prevention of irreversible airway obstruction
9. Maintaining normal growth pattern

Common

Uncommon

Rare

Assessment of Baseline severity

Asthma
Recurrent
aspiration

Cystic fibrosis
Foreign body
Bronchopulmonary
dysplasia

Left Ventricular failure
Vascular anomalies
Mediastinal masses
Tracheomalacia
Bronchomalacia

Before treating, it is preferable to assess lung function at
baseline and after full doses of £2 agonists (stimulants) to
determine what improvements in airflow are possible.
Symptoms severity should be continually reassessed during
treatment Are the ^symptoms truly intermittent or do they
regularly interfere with sleep, sport, or other activities.
Progress can be monitored by a diary card (event card).
Measurements of peak flow rate should be implemented
regularly above 6 years of age. Frequency of use of acute
treatments such as J32 - agonists should be assessed.

Clinical features suggestive of one of these alternative
conditions are summarised in Table 2 suggesting an alterna­
tive diagnosis.
TABLE 2

Self Management

HISTORY
Neonatal onset of symptoms and Ventilatory support
Intractable wheeze, unresponsive to bronchodilators
Wheeze associated with feeding or vomiting
Sudden onset of 'coughing/choking’

Physical examination
Failure to thrive, clubbing/cardiac murmur, stridor, Focal lung
signs.

DR. EDWIN DIAS, DCH
PROF. M.K.CHANDRASEKHARA MBBS, DABP,FAAP

DEPARTMENT OF PAEDIATRICS
ST.JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE - 560 034

March 1991

Train the child and/or the parents to manage with first line
drugs in the attacks that they can cope without a doctor, but
also to have clear guidelines on when to seek medical help.
They should have ready access to medical advice, if long term
control is poor and for acute severe attacks. This needs
instructions to the patients and parents in the use of drugs
and apparatus required for asthma control. The manage­
ment of asthma should be an example of shared caring in
which the child, the parent, ano ihe medical advisors act as
a team in managing the asthma.1
Information including instructions about medication, is given
in written form so that it can be referred to from time to time.
An event card should be maintained by parent/child. Children
should carry with them a card which provides an action
plan for emergency treatment at home and in the hospital.

11

St. John’s Medical College Journal of Medicine
Environmental manipulation
Precipitating trigger factors should be identified and parents
and children counselled on avoidance if possible. If allergy to
the family pet is present, it should be removed. It will take
alleast three months for the danger to be totally eliminated
from the house dust. Exposure to seasonal pollens can be
reduced by keeping windows closed during the day and by
installing airconditioners and\or air filters. Inchildren, asthma
is rarely precipitated by food or drink, when avoidance is
needed. Asthma may be exacerbated by emotional distur­
bance and asthma control can be compromised by adverse
psychosocial factors. Various psychotherapeutic ap­
proaches have been helpful as an adjunct to standard drug
treament.

hours more till the child is stable clinically. Base deficit is given
in 30-60 minutes, sodium bicarbonate is only indicated when
pH <7.25. The patient can then be managed with oral,
or aerosol p2stimulants/and or xanthines and steroids for
7 days. After the child’s clinical condition is stable for 1-2
days the child is discharged. Sedatives are contraindicated
in status asthmaticus. The treatment is continued till a
response is achieved which is relief of respiratory distress
and peak expiratory flow >60% predicted value.

CHRONIC ASTHMA

Pharmacotherapy

Assessment of severity of asthma is based on response
to treatment. Mild asthma may be classified as discrete
attacks occuring less than once a month, or as more
frequent minor wheezes. Moderate asthma can be recog­
nised as discrete attack occuring no more frequently than
once a week and in which more than 1-3 doses (per week)
of bronchodilators are required. Severe asthma attacks
tend to have poor response to bronchodilators and sodium
cromoglycate, attacks occur more than once a week and
need steroid treament. Continuous therapy is used in
severe asthmatics, asthmatic attacks requiring frequent
admission and associated with a significant change from
normal daily life.

This is the sheet anchor of therapy in asthma1.

MILD ASTHMA

ACUTE ASTHMA

These children usually require no drug therapy especially in
the 1st year of life. In early and late childhood, oral
intermittent JB2 stimulants or oral xanthines may be used. If
wheezing persists inhaled p2 stimulants or sodium cromo­
glycate7, or ketotifen8 is used.

Immunotherapy
This roleof immunotherapy remainscontroversial. It should
be used only when a clear unavoidable antigen allergen
is identified. It is less effective when used in the more severe
cases and may exacerbate uncontrolled asthma. It is most
beneficial in patients with seasonal rhinocon junctivitis with
mild asthma.

OUT PATIENT MANAGEMENT
Once acute asthma is diagnosed in the outpatient, treatment
is warranted immediately. £2 stimulant (aerosol or in­
jectable) is given and the response is noted2. If there is an
inadequate response subcutaneous adrenaline is given and
the patient is observed. The child is hospitalized if
respiratory distress persists even after an intravenous theo­
phylline dose, 8mg/kg (if no previous theophylline has been
used)3. If adequate response4 has been noticed the patient
is sent home on £2-stimulants and theophylline and prednisolone(3-5 day course) 2mg/kg/day in 3 divided dose with an
outpatient follow up after 7 days.
IN PATIENT MANAGEMENT

MODERATE ASTHMA
These children require more care and put on oral intermittent
£2 stimulants with addition of oral xanthines in later child­
hood, patients need sodium cromoglycate or ipatropium
bromide9. If they still do not respond, they need inhaled
steroids (Beclomethasone) kept at the lowest dose.
SEVERE ASTHMA

If the child still is in respiratory distress, treatment is
instituted for status asthmaticus and assessment by arterial
blood gases and pulmonary function tests is preferable.
Administration of intravenous fluids, oxygen, hydrocorti­
sone, continous aminophylline infusions5 and £2 stimulant
injectables are used. If there is no response, infusion of
isoprenaline is recommended till any of these occur; the
paco2 falls below 55 or heart rate exceeds 200/min or an
arrythmia develops or progressive deterioration in clinical
state or blood gas status.

Inspite of this medication these children still have significant
change from their daily routine and need a combination of B2
stimulants and oral xanthines with sodium cromoglycate;
inhaled oral steroids, either daily or on alternate days. Older
children can be put on slow release p2 stimulants to slow
release oral xanthinese with ipatropium bromide9 and oral
steroids either daily or alternate day courses. Patients
should be ideally managed free of symptoms for atleast one
year before instituting a trial of dosage reduction which must
be assessed, using lung function. Review of progress must
be done at all stages during therapy.

If this occurs the child is endotracheally intubated and
mechanical ventilation is started. The child is then weaned
off slowly and the intravenous medication continued for 24

Exercise induced asthma : In children exercise induced
asthma can be controlled with an adrenergic aerosol 10-20
minutes before the exercise. Oral theophylline and cromolyn

12

VOL IV No. 1

St. John’s Medical College Journal of Medicine
TABLE - 3 : Therapeutic Approaches to chronic Asthma

Suggested approach to the management of asthmatic children
Primary therapy

Second therapy

Tertiary therapy

Al Beta-adrenergic
agonists
A2 Theophylline
A3 Ketotifen
A4 Cromolyn

Bl Inhaled steroids

Cl oral steroid
alternate day
C2 oral steroid daily

Mild Asthma
Mod. Asthma

Severe

B2 Anti cholinergics

Regime to Begin
with

For persistent
wheezing

For more persistent
wheezing

A1 or A2
or A3 or A4
A1 + A2 + A3
or A1 + A2 + A4
A1 + A2 + C1

A1 + A2 or A1 + A3
or A1 + A4
A1 + A2 + B1

Consider it as
moderate
A1 + A2 + B2

A1 + A2 + C2

A1 + A2 + C2
A4 + B2

Intractable Asthma Add. Methyl Prednisolone + Troleandomycin

TABLE - 4 : Drugs commonly used in Bronchial asthma in children
Oral

Xanthine
derivatives

Theophylline
4-6 mg/kg

—

Isoethaline HCL
5ml/10min Q4-Q6H
Salbutamol (0.5%) or Ter­
butaline (0.5%) 5 ml/10 min
or 1-2 puffs Q8H-Q12H
Ipatropium Bromide
40 pg qid
20mg qid.
(1-2 puffs qid)
Beclomethasone 2-4 puffs
qid (84 mg qid)

Adrenergics

Anticholinergics

Salbutamol 0.1 mg/kg, upto
4mgtid/day. Terbutaline
0.75mg/kg/day. Q6H
Ketotifen 1mgQ12H.

Cromolyn
Sodium
Steroids

Prednisolone 2mg/kg/day

Parenteral

Aerosol

Bolus Aminophylline
5-7 mg/kg IV over 20 minutes
Inufsion Aminophylline
1 mg/kg/hr.
Epinephrine 0.0 1mI/kg.S/c
max. 0.4ml/dose Q2-Q4H.(3 doses)
Terbutaline 0.01 mg/kg/Sc Max.
0.3mg/dose Q4-Q6H

Hydrocortisone IV 10mg/kg/day
Q4-Q6H.

1983;72:539.

sodium can also be used.

Intractable Asthma : This may need methyl prednisolone
and troleandomycin10 (ruling out intercurrent problems is
most important) for adequate asthma control.

5. Rossing TH, Fanta CH, Goldstein DH.etal Emergency therapy of asthma;
comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophyline An Rev. Respir Dis. 1980;122:365.

6. AMA Drug Evaluations. Drugs used in bronchial diseases, American
Medical Association, Chicago, 1984;p577.

REFERENCES
1. Rachelefsky GS, Siegel SC. Asthma in infants and children * treatment
of childhood asthma J. Allergy Clin Immunol 1985*,76:409.

2. Nelson HS. Stepwise therapy of brochila asthma; The role
adrenergic agonists Ann. Allergy 1985;54:289

of

beta

3. Weinberger M. The pharmacology and therapeutic use of theophyline. J.
Allergy Clin. Immunol 1984;73:525
4.

Levison H. Isler A. Response; Asthma in childhood J. Allergy Clin. Immunol.
March 1991

7. Bernstein IL. Cromolyn sodium in the treatment of asthma, coming of age in
the United States. J. Allergy Clin. Immunol 1984;73:525

8.

Mac Donald GF. An overview of ketotifen Chest 1982;82:30.

9. Gross
NJ,
Skorodin
MS.
Anticholinergic,
Anti muscarinic
bronchodilators. State of the art Am. Rev. Respir Dis. 1984,129:856*870.

10. Zeiger RS, et al Efficacy of troleandomycin in outpatients with severe
corticosteroid dependent asthma. J. Allergy Clin. Immunol 1980;66:438-446.

13 —

REVIEWS

St. John’s Medical College Journal of Medicine

CHRONIC ARTIFICIAL VENTILATION
ANDRE J. A. BREMERS

A review of three decades of experience in chronic artificial
ventilation in the Netherlands

INTRODUCTION

In 1952 Lassen and Ibsen started chronic artificial ventilation
in patients suffering from respiratory insufficiency due to
poliomyelitis, when their country Denmark was hit by an
exceptionally bad epidemic of the disease. When the epi­
demic hit the Netherlands in 1956, Sluiter and collegues
used the same technique. As time went by the number of
indications for the technique gradually increased, as did the
number of patients involved. This resulted amongst oth­
ers in a search for possibilities to ventilate patients in a less
high-tech setting then was the case previously.
This article is a review on more than three decades of expe­
rience in chronic artificial ventilation, and discusses the
various points of view which have evolved in this course of
time.

ARTIFICIAL VENTILATION
Artificial Ventilation means taking over of absent, or assisting
impaired mechanical functions involved in respiration.

This can be done in an acute stage, as in acute diseases
resulting in acute respiratory failure, with prospect of recovery
of ventilation, or death, orchronic respiratory failure within, for
example, six weeks time. A protracted situation of acute
artificial ventilation does not fade away, but the patient ends
up in a more stablised situation in which the hope for recov­
ery of the ventilation has to be given up.
Chronic artificial ventilation means that the patient is ex­
pected to be dependant on artificial ventilation for the rest of
his life. This can mean the need for continuous ventilation
(24 hours per day) or chronic intermittent artificial ventilation,
in which case the patient is ventilated periodically, e.g. during
the night, occasionally supplemented by a period during the
day, or in other cases, two or three times a week.

Two basic principles of artificial ventilation are operated. Both
are in use for chronic artificial ventilation.

DR. ANDRE J.A. BREMERS
KASTANJELAAN 2
5268 CA HELVOIRT
THE NETHERLANDS
14

1. In positive pressure ventilation inspiration is forced by
inflating air into the airways.
2. In negative pressure ventilation the pressure in a compart­
ment of air surrounding the thorax and abdomen is lowered
in order to obtain inspiration. In the Netherlands two
versions of both systems are at present in use for chronic
ventilation. The most common method is positive pressure
ventilation using a tracheostoma. The advantages of this
procedure for chronic ventilation are the relative freedom
in movements for the patient, a higher possible efficiency
compared to negative pressure systems, and the possibil­
ity of suction through the tracheostoma.

On the otherhand, the need for suction can make the patient
dependant on better trained staff, and inevitably speech
is interfered with during ventilation. The tracheostomy itself
results in cosmetic problems, and carries with it the risk of
bleeding and infection.
Less widespread is the use of positive pressure ventilation
using a mouthpiece or mask, as advocated and successfully
used by Alba in New York, thus taking advantage of
positive pressure ventilation whilst avoding the tracheo­
stomy.
The classic way to apply negative pressure ventilation is by
use of the old iron lung. Resulting in an almost complete
immobilisation of the patient it is obvious that this machine
is very unfavourable for, especially, continuous ventilation.
At present it’s use for chronic ventilation in the Netherlands
is restricted to a few patients ventilated a few times a week,
even though the modern version of the’ device is less
restricting and only rarely results in pressure sores, provided
that the patient is strong enough to move himself. The
cuirass finally, is a kind of shell covering the thorax and
abdomen, usually made to an individual fit, and within which
the pressure is varied. Though tracheostomy and speech
problems are avoided, it results in restricted mobility during
ventilation and in progressive disease it’s efficiency can
become inadequate in the long run.

Indications for chronic artificial ventilation

There is only a limited number of conditions resulting in long
term or definitive ventilatory insuffieciency, which can
therefore be considered for chronic artificial ventilation.

As stated above, chronic artificial ventilation was introduced
in patients of poliomyelitis, and they remain the largest
group needing it.
With the introduction of successful vaccination program­
mes the incidence of polio has been drastically reduced, so
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St. John's Medical College Journal of Medicine

that the prevalence is almost static, and can be expected to
remain so, for quite a long time; recently cases have been
reported from the United States, in which ventilation had to
be resumed in patients who had been weaned off completely
decades ago.

Amyotrophic Lateral Sclerosis is a rapidly progressive dis­
ease (a course of at the most a few years), in which, when
ventilation is applied, a stage may be reached wherein the
patient is unable to communicate, even though mentally
sound.

A second relatively large group are the patients with respira­
tory insufficiency due to scoliosis, partly caused by poliomye­
litis, partly due to idiopathic scoliosis. The latter, which will
remain to be an important cause in the future.

Duchenne’s dystrophy is less rapidly progressive. Usually
patients are wheel chain bound from approximately 12
years of age, and with a life expectancy of about 20 years.
With the help of artificial ventilation an age of well into the
thirties can be reached, but by then the patient has become
fully dependant on help, and existance is reduced to passive
activities such as watching TV, swallowing food presented
on a spoon right in front of the mouth, etc.

A third group involves patients with chronic airways disease.
A number of other reasons also result in small numbers of
patients being ventilated chronically, e.g. high spinal trans­
sections. At present however, the largest group in The
Netherlands is formed by patients suffering from some
neuromuscular condition other than polio. Not long ago
ventilation of these patients was not considered; however,
opinions here have changed quite markedly over the past
years. Of course, one should bear in mind that this group
of conditions is very pluriform, varying from slowly progres­
sive and mildly invalidating diseases, e.g. Pompe’s disease
(acid maltase deficiency) to more severe and quickly
progressive diseases like Duchenne’s or even Amyotrophic
Lateral Sclerosis.

No one will be surprised that what the discussion is really
about is the latter ones. Since it is strongly affecting the
number of patients on chronic ventilation it is important to pay
a bit more attention to this subject.

Chronic artificial ventilation of these patients increases the
lifespan. In progressive conditions like these it automatically
means that the degree of disability which is finally reached is
much higher. It is beyond doubt that initially, the quality of life
is improved considerably (that is, if ventilatory problems are
not anticipated and ventilation is not started early, guided by
blood gases), but the progression of the disease is not sig­
nificantly affected. For example, in Amyotrophic Lateral
Sclerosis it has been demonstrated that progression is not
at all influenced by ventilation. For other conditions it has
been suggested that positive influence can be detected, but
to my knowledge this has never been proved.
Of course, as in any case of medical treatment, one has to
ask the question whether or not the benefit (including the
quality of life) merits the technical intervention “inflicted” on
the patient. In the past the answer to this question,
regarding patients with this kind of neuromuscular conditions
was based on experiences with isolated cases treated with
the more primitive and less user-friendly equipment of that
time. With the considerable advances in technical facilities
quality of life has substantially improved, compelling a change
in point of view of many experts in this field.
However, discussion is still going on about conditions like
Amyotrophic Lateral Sclerosis and Duchenne’s dystrophy.
March 1991

Of course, the question of the quality of life has to be
answered by the patient, as well as the decision whether or
not ventilation, when medically indicated, is started and
continued. It is a well known phenomenon that, invalidity
progressing, the disability acceptable to patient and his
environment charges. Positive reactions heard from pa­
tients treated accordingly make it unacceptable to decline
ventilation of these cases without further consideration.

In the Netherlands this has resulted in a rapid increase
in numbers of patients with neuromuscular conditions ven­
tilated in a population of approximately 15 million people, in
1979 no cases were ventilated on this indication, by the end
of 1985 there were 54 (of which 12 with Duchennes dystro­
phy and 7 with Amyotrophic Lateral Sclerosis), whereas a
number between 150 and 200 is expected for the mid
nineteennineties.
The setting of the patient on chronic ventilation
So far almost all patients on chronic ventilation started as an
acute emergency in an ITU, since the need or possibility
of chronic artifical ventilation was not recognised or known,
and symptoms of hypoxia and hypercapnia (malaise,
nausea, fever, headache, vomiting, tiredness, concentration
disturbances, sleep disorders, euphoria or depression, per­
spiration, dry skin, and eventually cyanosis) are missed
quite frequently. Indeed, these signs and symptoms are non
specific and easily missed if the diagnosis is not borne in
mind, but it is this very fact which causes the period of sheer
misery most of these patients undergo before ventilation is
eventually started, and the fact that the decision whether or
not to ventilate is made in an acute emergency situation,
whereas that could have been anticipated; and the decision
is then taken by doctors who rarely know the individual
patient, and whose impression of chronic ventilation is often
very much out of date.
It is favourable to anticipate the future need for ventilation in
these patients, and have a realistic view on the possibilities
available on the market nowadays, so that a wise decision
can be made quitely by doctors and patient. Preferably the
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St. John’s Medical College Journal of Medicine
patient’s ventilation is then started in a center specialised
in ventilation (ITU), with experience in long lasting ventila­
tion procedures.
Continuation of chronic ventilation
Many colleagues are surprised to hear that there is indeed a
range of possibilities here!

When the polio epidemic hit the Netherlands in 1956 the
only alternative available at the time was to put these patients
in long stay wards specialised in this treatment, and all the
patients had in common that they were ventilated. The main
aims therefore, were an acceptable environment combined
with the care for the ventilation.
With the development of more advanced ways of
ventilation gradually the number of patients cared for in
home care situations has largely grown. In fact, the majority.
of these cases is now cared for in their own homes (often with
hardly any professional help at all); many are now living in a
setting aimed at the other disabilities (revalidation centres,
housing for disabled etc.), whereas those still living in the
three centres for chronic ventilation often do so as they
already lived there for decades.

CONCLUSION
In the above it has been stressed that life prospect has
become more humane for people in need of chronic ventila­
tion, so that the opinion on indications should be reviewed.

SUGGESTED READING
Mechanical Ventilation, Physiology, equipment design, and management,
J. Popovich, Postgrad. Med. 1986:79(1)217-20,223-4,226-7.
Home Care for Life-Supported Persons in England, the Responaut program.
Allen I.Goldberg M.D..F.C.C.P., Eveline A.M. Faure M.D. Chest1986;6:910-4.

Chronic Ventilation in 1987in the Netherlands (DUTCH) Dr. A.J.A.Bremers,
Medisch Contact 1987;34:1065-1067
To Ventilate and to Contemplate (Dutch) Dr. B.S.Hylkema, Medisch Contact
1985;40:1185-1190.
Experience with a prolonged respiratory care unit-revisited. F J. Indihar et al.
Chest 1984;84(4):616-20.

Concept beleidsprotocal betreffende dreigende respiratoire problemtiek bij
patienten met een progressieve neuromusculaire aandoening (concept
management protocol for patients
with progressive neuromuscular
disorders with impending respiratory problems), Mw.Drs. A.C. DullemontWestland, edited by VSN-Vereniging Spierziekten Nederland (Muscular
Disease Association The Netherlands), in Baarn, The Netherlands,
December 1985. (DUTCH)
Beademingscentrum Groningen 1955-1985 (Partially in Dutch, partially in
English), presentations of a symposium on 23/24 August 1985, Prof.
Dr.H.J Sluiter et al., Van Gorcum, Assen/Maastricht (The Netherlands),
1986.

16

VOL IV No. 1

CASE REPORT

St. John's Medical College Journal of Medicine

DESSEMINATED RHINOSPORIDIOSIS
KEVIN PEREIRA, J.J. ALAPATT, S. DUTT, A.S. ARVIND

ABSTRACT
Rhinosporidiosis is a chronic granulomatous infection
predominantly affecting the nose, nasopharynx and
contigous mucosal surfaces caused by the fungus Rhino­
sporidium seeberi. Systemic involvement is very occasion­
ally reported. A case report of a 58 year old male with
decompensated liver disease, who presented with dissemi­
nated Rhinosporidiosis is being presented along with a review
of relevant literature.

KEY WORDS : Rhinosporidiosis, Disseminated.

feet and hoarseness of voice of 8 months' duration. He was
a known chronic alcoholic with alcoholic liver disease and a
known hypertensive on treatment. He also complained of
multiple swellings and bleeding warts all over the body of 6
months* duration. A biopsy of the skin lesion done elsewhere
was reported as cutaneous Rhinosporidiosis. He gave
history of excision of a mass from the nose once before.

Clinical examination showed multiple swellings in both upper
and lower limbs-firm in consistency, nontender and mobile.
Warty sessile lesions were also noted on the back, face and
nape of the neck. BP - 150/100. Pedal edema was present
No. - lymphadenopathy, jaundice or anaemia.

INTRODUCTION

Rhinosporidiosis is due to an infection by the fungus
rhinosporidiosis seeberi which predominantly affects the
mucous membranes of the nose and nasopharynx but occasionlly the eyes, the oropharynx, hypopharynx, lower respi­
ratory tract and genitalia may also be involved. It is a
granulomatous infection usually limited to surface epithe­
lium, but rarely wide dissemination may occur. The first pub­
lished report of the disease was by Seeber in 1890 at Buenos
Aires after whom the organism has been named. At first
thought to be a protozoon the organism’s life cycle was stud­
ied in detail by Ashworth in 1923 who relegated its place to
a low order of fungi among the phycomycetes. The disease
is endemic in many parts of India and Sri Lanka.

CASE REPORT
K.T. a 58 year old male presented to the Gastroenterology OPD with a history of Abdominal distention, swelling of the

DR. KEVIN PEREIRA
DR; J.J. ALAPATT
DR. S. DUTT
DR. A.S. ARVIND
DEPT OF E.N.T. AND GASTROENTEROLOGY
ST.JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE - 560 034.

ADDRESS FOR CORRESPONDENCE:

DR. KEVIN PEREIRA
DEPARTMENT OF E.N. T.
ST.JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE - 560 034

March 1991

Systemic examination revealed free fluid in the abdomen.
No organomegaly could be detected due to the ascites. An
ENT consultation was sought to evaluate his hoarseness
of voice. Fibreoptic laryngoscopy showed a large globular
growth with an ulcerated surface in the left hemilarynx
crossing the midline and restricting the movement of both
vocal cords. A biopsy was taken of the growth which bled
profusely.

The Pathology report - fragments of respiratory epithelium
with granulation tissue consisting of polymorphs and lympho­
cytes. New vessel formation and hemorrhage seen in parts.
Many sporangia in various stages of development were seen
in the granulation tissue consistent with Rhinosporidiosis.
Radiographs of his hands and lower limbs showed soft
issue swellings over the metacarpals without bone involve­
ment. X Ray chest was normal. Liver function tests were
consistent with decompensated liver disease. Routine blood
and urine examination were within normal limits. Ultrasound
of the liver showed a homogenous hypodense globular
shadow in the liver. The patient refused a liver biopsy.

The patient was discharged with a diagnosis of Decompen­
sated alcoholic liver disease, hypertension and dissemi­
nated Rhinosporidiosis He was put on Dapson 50 mg OD
on discharge in addition to the treatment for his allied
problems.
Follow up 10 days later showed almost no response of the
mycotic infection. The patient returned 2 months later in
hepatic coma and succumbed to hepatic failure. VimSilverman needle biopsies of the subcutaneous nodules
were reported, histopathologically as consistent with
subcutaneous Rhinosporidiosis.

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St. John’s Medical College Journal of Medicine
COMMENTS
Rhinosporidiosis is common in many parts of India and the
chronicity of infection is well documented.’ An identical case
of desseminated Rhinosporidiosis was first reported in litera­
ture by Chatterjee et al in 1977 and since then only two more
cases have been reported. In the largest series of Rhinospo­
ridiosis reported in literature by Satyanarayana in 1970 i.e.
255 cases, not a single case of dissemination was found.1
In our patient we were not able to demonstrate the charac­
teristic osteolytic lesions of skeletal Rhinosporidiiosis as in
the patient reported by Chatterjee2. Also in the case report
of Chatterjee et al the patient was suffering from decompen­
sated liver disease. It is well known that chronic debilitating
illness predisposes to mycotic infections. But to-date
rhinpoiridal dissemination in such patients has not been
documented. The nose is by far the most common site of
involvement in this disease and within the nose, the septum,
the inferior turbinate and floor are the usual sites. The usual
presentation is with nasal obstruction or with epistaxis with
a mucopurulent nasal discharge. Pain is present only when
secondary infection
supervenes.3 The
mode
of
transmission ofthisfungusisthoughttobe by water and dust.
The organism is present in large numbers in bathing pools
shared by both cattle and human beings.4 The prediliction
of the organism for exposed mucosal surface suggests that
minor trauma may play a role in its acquirement.1 Laryngeal
involvement is usually secondary to nasal lesions. If there
is a saprophytic form of the organism, it has not yet been

recognised.3 The treatment is by surgical excision with a
recommendation to cauterize the base.5 Snaring alone is
associated with considerable bleeding and a high risk of
recurrence, probably due to implantation of the wound with
spores.6 Medical treatment using Antimonials, Gresiofulvin
and Amphotericin B has to date been unsuccessful. Since
the past decade Dapsone has been used extensively in
reducing the rate and severity of recurrence. This drug is
chemically related to the sulphonamides and owes its
bacteriostatic action to a similar mechanism7. The exact
mechanism of action against Rhinosporidiosis is unknown.

REFERENCES
1. Sathyanarayana C : Rhinosporidiosis - 225 cases Acta Otolaryngologica
(Stockholm) 1960;51:348-356
2. Chatterjee P K. & Dastidar N. Recurrent Rhinosporidiosis with ostiolytic
lesions SLO 1977;91(8):103-107.
3. Van Haake P.N. & Mugliston TA : Rhinosporidiosis. J. Laryngology and
Otology 1982;96:743-749.

4. Darbari B.S. Gupta RL & Arora MM : Rhinosporidiosis in Raipur, in J Patho
Bact 1972;15(4):103-107.

5. Kameshwaran S : Surgery in Rhinosporidiosis, experience in 293 cases.
Internal Surg. 1966;46:602-612.
6. Khan AA and Huda MN : Rhinosporidiosis of the nose, J Laryngol Otol
1969;83:461-473.
7. Goodman LS & Gilman A : the Parmacological basis of Therapacutis,
Macmillan 1970

Fig 2. Showing subcutaneous swellings on both hands - caused by
Rhinosporidious.

Fig 1. Showing Rhinosporidial lesions on the forehead and medical
canthus of Right Eye.

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