Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Per-oral Endoscopic Myotomy (Z-POEM): An Effective Treatment for Zenker's Diverticulum with Long-Term Results
Full text linkZenker's diverticulum (ZD) arises from impaired cricopharyngeal (CP) muscle distensibility during deglutition (swallowing), leading to a clinical presentation characterised by dysphagia, regurgitation, aspiration, cough, and potential weight loss. The definitive treatment for ZD is a CP myotomy. Traditionally, open surgical approaches (transcervical diverticulectomy, diverticulopexy, or diverticular inversion) with or without concomitant CP myotomy and rigid endoscopic techniques utilizing stapling or CO2 laser therapy have been employed. However, these interventions are often associated with significant morbidity and mortality, particularly in the elderly and comorbid ZD patient population.
The advent of flexible endoscopic ZD treatment has revolutionized the therapeutic landscape, rapidly becoming the preferred first-line modality for the management of small to moderate-sized diverticula. The past decade has witnessed the emergence of a multitude of novel techniques within the realm of flexible endoscopic ZD treatment.
In this medical illustration, we report a woman, 64-years-old with Zenker’s diverticulum treated with Z-POEM. She came to our clinic with dysphagia and regurgitation for 6 months prior. Diagnostic gastroscopy showed ZD of 3 cm, located 18 cm from incisors with a thick septal muscle. A triangle-shaped knife created a 2-cm mucosal incision, and submucosal tunneling was made by spray coagulation. The gastroscope was advanced through the submucosal space of the esophageal lumen and the diverticulum site until the bottom of the diverticulum. The septal muscle was completely cut, immediately allowing the gastroscope to pass through easily, and the mucosal defect was closed with hemoclips. Six months after the treatment, the patient no longer experiences dysphagia and regurgitation.
Z-POEM offers a precise approach to treating Zenker's diverticulum by providing a complete visualization of the entire septal muscle. This comprehensive view minimizes the risk of incomplete myotomy, ensuring a more effective treatment
Wernicke Encephalopathy Associated with Crohn’s Disease
Full text linkPoorly controlled Crohn’s disease is associated with several complications, including malabsorption of vitamins and minerals such as vitamin D, vitamin B12, and vitamin B1 (thiamine). Thiamine, among other vitamins, plays a crucial role in Adenosine Triphosphate formation as well as nerve propagation. Thiamine deficiency initially manifests as wet or dry beriberi but may lead to the devastating Wernicke–Korsakoff syndrome. In this report, we present a case of full-blown Wernicke encephalopathy associated with uncontrolled Crohn’s disease.An 18-year-old young man was admitted with a chief complaint of hematemesis for 2 weeks before admission. He was previously diagnosed with Crohn’s disease in the past year, with constipation as the predominant symptom, and has been taking mesalazine 500 mg twice daily. Esophagogastroduodenoscopy and colonoscopy re-evaluation showed a worsening picture of Crohn’s disease pangastritis. The patient experienced swelling in both legs, the scrotum, and the upper extremities during hospital admission. On day 14 of hospitalization, the patient fell into a state of confusion with visual and auditory hallucinations, ophthalmoplegia, and ataxia. A Brain MRI showed a typical picture of Wernicke encephalopathy. Intravenous thiamine was administered, and the patient regained consciousness. His clinical symptoms improved every day until he was discharged. Uncontrolled Crohn’s disease may have several complications that clinicians need to be aware of, including thiamine deficiency. Wernicke encephalopathy shows a devastating clinical picture, but with thiamine therapy, it may resolve before further deterioration leads to irreversible Korsakoff syndrome
Buried in Trapped Air: Tension Pneumothorax, Massive Subcutaneous Emphysema and the Battle for Airway Control
Full text linkABSTRACT: Background: Tension pneumothorax (TP) is defined as a pneumothorax in which the pressure of intrapleural air exceeds atmospheric pressure, producing adverse effects, including contralateral mediastinal shift associated with cardiovascular collapse, due to reduced venous return (because of compression of the SVC and IVC ) and hypoxia. Usually, patients with TP present to the Emergency Department with vague pleuritic chest pain and shortness of breath, but being considered a red flag it should be diagnosed during the primary assessment and managed promptly with large bore needle decompression followed by chest tube insertion. Presence of extensive subcutaneous emphysema (SCE) can further aggravate the respiratory distress and make the airway management even more challenging in the ER. Situation can become even worse when such a patient needs cardiopulmonary resuscitation on arrival.Case report: We report an unusual case of a 55 years old man, who presented in the ER with history of sudden onset respiratory distress while taking bath. Patient was brought to the ER in a state of gasping, hypoxia and shock . Needle decompression of the pneumothoraces was not sufficient as he also had extensive subcutaneous emphysema which resulted in cardiac arrest. The CPR and the airway management extremely were practically difficult. He was finally tracheostomised in the ER and accompanied by bilateral chest-tube thoracotomy. He was discharged for home after pleurodesis without any neurological deficit.Conclusion: Primary spontaneous pneumothorax is an uncommon condition but can rarely end up in tension pneumothorax and accompanying subcutaneous emphysema can make the management further challenging. Airway skills of the ER team are important in saving such patients’ lives.
Characteristics and Care Quality of Patients with Type 2 Diabetes in Indonesia: A Study of DISCOVER CaReMe Registry Program
Full text linkBackground: Type 2 diabetes mellitus (T2DM) is considered one of the top 3 causes of death in Indonesia. However, the current scenario regarding the management of T2DM in Indonesia remains unclear. Thus, the present study aimed to describe the baseline characteristics, treatment types, and quality of care indicators in T2DM patients under the DISCOVER CaReMe Registry program. Methods: DISCOVER CaReMe Registry program is a multi-centre, prospective, and observational study conducted over 3 years from 2018 to 2021. The data were collected from five different sites across Indonesia. Results: A total of 539 patients with a mean age of 58.98 ± 9.76 were enrolled in the study. Among them, 62% (334/539) of patients were females. Further, the mean glycated haemoglobin (HbA1c) levels were 8.54 ± 2.88%, which was much higher than the American Diabetes Association (ADA) recommended target of 7%. Overall, 69% of the patients had HbA1c levels of >7%. First-line treatment in patients was mostly metformin (26%). As per the quality-of-care indicators, 72.2% of patients use glucose monitoring equipment and receive education about diabetes treatment and management. Furthermore, the knowledge of T2DM among patients was assessed in over 85% of cases, and misconceptions about the condition were clarified by healthcare professionals (HCPs). HCP advised a “diabetic diet” to 69.4% of patients. Conclusion: Despite a good knowledge and quality of care indices in patients with T2DM, the proportion of patients with HbA1c levels of >7% is still higher. There is an urgent need for diabetic management programs to prevent such complications in the Indonesian population
The Role of Psychotherapy in the Management of Inflammatory Bowel Disease
Full text linkInflammatory bowel disease (IBD), consisting of ulcerative colitis (UC) and Crohn’s disease (CD), represents one of the debilitating chronic gastrointestinal diseases that affects the physical and psychological aspects of patients, leading to increased morbidity and mortality and affecting patients' quality of life. There is an increased prevalence of depressive disorders and anxiety among IBD patients, with the gut-brain axis as the proposed underlying mechanism. Treatment of psychological issues among patients with IBD enhances long-term management outcomes. Therefore, we provide a comprehensive review of epidemiology, pathomechanism, diagnosis, and treatment modality of psychological issues frequently found among IBD patients
Potential Use and Limitation of Artificial Intelligence to Screen Diabetes Mellitus in Clinical Practice: A Literature Review
Full text linkThe burden of undiagnosed diabetes mellitus (DM) is substantial, with approximately 240 million individuals globally unaware of their condition, disproportionately affecting low- and middle-income countries (LMICs), including Indonesia. Without screening, DM and its complications will impose significant pressure on healthcare systems. Current clinical practices for screening and diagnosing DM primarily involve blood or laboratory-based testing which possess limitations on access and cost. To address these challenges, researchers have developed risk-scoring tools to identify high-risk populations. However, considering generalizability, artificial intelligence (AI) technologies offer a promising approach, leveraging diverse data sources for improved accuracy. AI models (i.e., machine learning and deep learning) have yielded prediction performances of up to 98% in various diseases. This article underscores the potential of AI-driven approaches in reducing the burden of DM through accurate prediction of undiagnosed diabetes while highlighting the need for continued innovation and collaboration in healthcare delivery
Urological Complications of Hirschsprung-Related Crohn’s Disease: A Case Report
Full text linkHirschsprung disease (HSCR) is a rare congenital intestinal disease characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the intestine. Individuals with HSCR demonstrate a higher risk for inflammatory bowel disease (IBD), with Chron’s disease (CD) commonly observed. Renal and urinary involvement is reported by between 4 and 23% of IBD patients, which manifests as urinary calculi, fistulas, and ureteral obstruction, which causes hydronephrosis. Those conditions can lead to a predisposition to recurrent urinary tract infections (UTIs) and should be suspected in male patients with IBD. A 26-year-old male with a history of HSCR and multiple surgeries presented with recurrent UTIs over 3 months. Upon further evaluation, he was found to have hydronephrosis in both kidneys. An MRI of the abdomen with contrast showed thickening and fibrosis in contact with the posterior wall of the rectum, causing a narrowing of the bilateral ureter. This clinical case has been reported to raise awareness of urological complications in CD patients with a history of HSCR, with recurrent UTIs as the presenting symptom
Coronary Artery Calcium Score as a Potential Non-Invasive Marker for Pulmonary Artery Hypertension
Full text linkBackground: Early prediction of cardiac dysfunction is crucial in preventing the progression to heart failure and associated complications. To achieve this, the utilization of clinical indicators, molecular and pathological markers, and non-invasive evaluation methods has gained significant interest. One potential predictive tool that can be measured through non-invasive imaging modalities is the coronary artery calcium (CAC) score. Recent studies have extensively examined the correlation between coronary atherosclerotic plaque calcium score and cardiac dysfunction. However, data are scarce regarding the usefulness of the calcium score in predicting pulmonary artery hypertension, which is a known consequence of ventricular dysfunction. Methods: A total of 167 patients with suspected coronary artery involvement were included in the study. Before performing CT angiography, the score of CAC was measured in all patients based on their CT results. The CAC value was calculated using Vitrea software. The CAC score of each coronary artery, as well as the total CAC score (by summing the scores of each artery), was determined based on the Agatston method. Then the patients were subjected to CT angiography, and the value of pulmonary artery pressure or PAP, as well as the pulmonary artery dilatation, was measured based on the results of CT angiography. Results: The average CAC score in the two groups with and without PAH was 107.57 ± 268.60 and 35.47 ± 93.98, respectively, which indicated a significant difference between the two groups (P value 0.011). Accordingly, the number of cases with a positive CAC score in the two groups with and without PAH was 24 (49.0%) and 47 (39.8%), respectively, which showed a significant difference between the two groups (P = 0.046). There was a significant correlation between CAC score and PAH. Based on the analysis of the area under the ROC curve, CAC score evaluation had a high ability to predict PAH in women and in patients over 50 years old. Conclusion: The measurement of CAC score could be incorporated as a predictive index for the increase of pulmonary artery pressure and the occurrence of PAH. However, this predictive value is more evident in women and in older patients
The Role of Mesenchymal Stem Cells for Hemorrhagic Stroke Management
Full text linkStroke is ranked as the second-leading cause of death worldwide. As a result, the long-term sequelae of motor and cognitive abnormalities, such as hemiparesis, paralysis, psychomotor, chronic pain, and behavioral symptoms, can delay the patient's full recovery and function in society. In this context, stem cell-based treatment for stroke has been proven effective due to the potential to provide neurorestorative benefits. This study presented a case of a 50-year-old patient admitted to Cipto Mangunkusumo National General Hospital, Jakarta, in 2022 with intracerebral hemorrhage in the left thalamus, surrounding perifocal edema, and left lateral intraventricular hemorrhage. The patient was given mesenchymal stem cells (MSCs) treatment three times through Digital Subtraction Angiography (DSA). The patient achieved good outcomes in terms of body mobility, balance, and voluntary movement of the upper and lower right limbs
The Role of Changes in the Proportion of Fecal Short-Chain Fatty Acids on the Severity of Hepatic Encephalopathy in Cirrhosis Patients
Full text linkBackground: Short-chain fatty acids (SCFA) are the main metabolites of the intestinal microbiota, which play a role as colonocyte trophic factors and maintain the integrity of the gastrointestinal tract and blood-brain barrier. Microbiota dysbiosis that occurs in cirrhosis reduces SCFA production and plays a role in the pathogenesis of hepatic encephalopathy (HE). This study aims to compare the amount and composition of fecal SCFA in patients with cirrhosis, with and without HE. Methods: This research is a cross-sectional study at the Hepatobiliary Clinic and Integrated Procedure Room, Dr. Cipto Mangunkusumo Hospital, Jakarta, in 2023. Patients with cirrhosis underwent a flicker or Stroop test, fecal SCFA examination (acetate, butyrate, and propionate), and a questionnaire with a food recall technique to assess dietary patterns. Results: A total of 86 patients with cirrhosis participated in this study, with a mean age of 53 ± 8.10 years, and the majority were male (68.6%). Hepatic encephalopathy (HE) was identified in 20 patients (23.25%). Multivariable analysis of SCFA profiles showed no statistically significant associations with HE. The absolute SCFA proportion had an adjusted prevalence ratio (PR) of 1.98 [95% CI: 0.75–5.24; p = 0.171], the absolute acetate proportion had an adjusted PR of 2.06 [95% CI: 0.40–10.62; p = 0.388], and the butyrate proportion had an adjusted PR of 2.02 [95% CI: 0.76–5.39; p = 0.158]. Conclusion: Changes in SCFA composition may be associated with the presence of HE in patients with cirrhosis. Although no statistically significant relationships were found, these findings suggest that SCFA profiles warrant further investigation concerning dysbiosis and HE in cirrhosis