Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship.

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

A Case Series of Amoebic Liver Abscess in Patients With COVID-19 Infection.

Background: Globally, amoebiasis is the second leading cause of death due to parasitic diseases. Amoebic liver abscess (ALA) as an opportunistic infection in recently recovered COVID 19 disease patients has not been reported earlier. Methods: We present here a case series of 13 patients of ALA admitted during the month of May 2021 in BLK hospital, New Delhi, and had recently recovered from COVID 19 disease. Results: Out of 13, eight patients had moderate, and one had severe COVID 19 disease. All these patients had received steroids for the management of COVID 19 disease. The remaining 4 (30%) patients had mild disease. The mean age of our patients was 50 years (37-81 years). Out of 13 patients, nine (70%) were male, 5 were diabetic, 2 were hypertensive, and none were alcoholic. The most common presentation was fever (11/13) followed by upper abdomen pain (10/13). The mean time of symptom (fever or pain abdomen) onset from COVID 19 positivity date was 19 days (range 15-23 days). A complication the in form of localized intraperitoneal rupture was common in these patients and was seen in more than 50% (7/13) of patients. All the patients were managed with IV Metronidazole and abscess aspiration. All the patients were discharged, and the mean hospital stay was 6.6 days. Conclusion: We report here an increase in the incidence of ALA in recently recovered COVID 19 patients and propose that it is most likely due to alteration in the immune state of these patients. It is important for physicians to investigate for liver abscess in patients who present again with fever and/or pain abdomen within 2 weeks of COVID 19 recovery.

Utility of narrow band imaging in predicting histology in celiac disease.

BACKGROUND: Narrow band imaging (NBI) with magnification better visualizes the duodenal microsurface and mucosal vascularity. NBI delineates villous atrophy better than conventional white light endoscopy. AIMS: This study was conducted to evaluate the diagnostic accuracy of narrow band imaging with magnification (NBI-ME) in celiac disease (CD). METHODS: In this prospective study, consecutive patients of suspected CD and controls were subjected to tissue transglutaminase antibody test and endoscopic evaluation initially with white light followed by NBI-ME, and biopsies were taken from duodenum. Duodenal villous patterns on NBI were interpreted as normal, blunted distorted, and absent. Severity of villous atrophy was reported according to the modified Marsh criteria. RESULTS: One hundred and twenty-two patients (mean age of 27.53 ± 13.37 years and a male to female ratio of 1:1.26) and 40 controls were studied. The sensitivity and specificity of NBI-ME in predicting villous atrophy were found to be 95.54% and 90%, respectively. The specificity and negative predictive value of NBI-ME in predicting villous atrophy amongst controls was 100% and 97.5%, respectively. Abnormal findings (blunted and absent villous patterns) combined with elevated transglutaminase antibody (> 5-fold) were found to have high accuracy in predicting villous atrophy. CONCLUSION: NBI with magnification has high sensitivity and specificity in predicting villous atrophy in patients with celiac disease.

Effect of gluten-free diet and compliance on quality of life in pediatric celiac disease patients.

BACKGROUND: Quality of life (QOL) in children with celiac disease (CD) has been sparsely studied. AIMS: We aimed to study QOL in pediatric CD and the effect of a gluten-free diet (GFD) in a North Indian population. METHODS: QOL was assessed at baseline and 6 months after GFD using a pediatric symptom checklist (PSC) score. The effect of GFD was assessed using a CD-specific questionnaire on domains such as dietary compliance, parental behavior and perceptions, children's feeling, and difficulty identifying gluten-free foods. RESULTS: A total of 60 CD children (age 6.03 ± 0. 42 years, range: 2-12 years, M:F 2:1) were prospectively enrolled. The median PSC score at baseline was 11.5 (2-35), which showed a statistically significant improvement after GFD to 2.5 (0-34) (P < 0.001). Significant concerns regarding specific domains emerged: difficulty in maintaining GFD 26.2%, at school 14.3%, at parties 43.2%, poor taste 11.4%, special diet a burden 28.5%, felt left out at school or friend's home 40.9%, felt different from other kids 40.9%, felt embarrassed to bring GFD to parties 54.6%, felt angry about following a special diet 56.8%, felt not invited out for meals because of CD 13.6%, and difficulty determining if food available was gluten free in 75%. CONCLUSION: GFD has a significant impact on emotional, behavioral, and psychosocial domains in children with CD. Proper labeling of commercially available food items, counseling, and patient support groups are the need of the hour.

Multiplex Polymerase Chain Reaction for diagnosis of gastrointestinal tuberculosis.

BACKGROUND AND AIM: To evaluate the role of multiplex polymerase chain reaction (PCR) for diagnosis of gastrointestinal tuberculosis (GITB). METHODS: This was a prospective observational study conducted from July 2015 to November 2016 at a tertiary care teaching institution in north India. Fifty individuals with clinically suspected GITB and older than 18 years of age were recruited. Patients underwent radiological investigations, esophagogastroduodenoscopy, or colonoscopy as clinically indicated. Multiple biopsies for tissue diagnosis and PCR were taken. All specimens were subjected to Ziehl Neelsen staining, histopathology, and multiplex PCR using specific primers for genes IS6110, MPB64, and Protein b. The performance of the assay was assessed using a composite reference standard for diagnosis of tuberculosis. It comprised a combination of clinical characteristics and microbiological methods, including smear, Bactenecin (BACTEC) culture, histopathology, and response to antitubercular therapy. RESULTS: A final diagnosis of tuberculosis was made in 32 cases (Duodenal-4, Ileo-colonic-28). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of histopathology for the diagnosis of tuberculosis was 28.12, 100, 100, and 43.9%, respectively. The sensitivity, specificity, PPV and NPV of BACTEC Mycobacteria Growth Indicator Tube (MGIT) culture for the diagnosis of tuberculosis was 9.3, 100, 100, and 38.29%, respectively. The sensitivity, specificity, PPV, and NPV of multiplex PCR for the diagnosis of tuberculosis was 87.5, 100, 100, and 86.2%, respectively. CONCLUSION: Multiplex PCR using specific primers for genes IS6110, MPB64, and Protein b had a higher sensitivity compared to conventional techniques for the diagnosis of GITB.

Risk of small intestinal bacterial overgrowth in patients receiving proton pump inhibitors versus proton pump inhibitors plus prokinetics.

BACKGROUND AND AIM: Intestinal dysmotility is considered a risk factor for small intestinal bacterial overgrowth (SIBO). Prokinetics improve intestinal motility and are often prescribed with proton pump inhibitors (PPIs) in patients with gastroesophageal reflux disease (GERD) and/or functional dyspepsia. The present study aimed to evaluate the prevalence of SIBO and the orocecal transit time (OCTT) in patients taking PPI compared with those taking PPI plus prokinetics. METHODS: The study is a single-center, cross-sectional study. Enrolled patients (with age > 12 years) were divided into two groups: patients taking PPIs for more than 3 months (Group A) and those taking PPIs with prokinetics for more than 3 months (Group B) for various indications. Lactulose breath test (LBT) for OCTT and glucose breath test (GBT) for SIBO were conducted for all patients. RESULTS: Of the 147 enrolled patients, SIBO was documented in 13.2% patients in Group A versus 1.8% in Group B, P = 0.018. Median OCTT in Group A was 130 (105-160) min compared with 120 (92.5-147.5) min in Group B (P = 0.010). Median OCTT among SIBO-positive patients was 160 (140-172.5) min compared with SIBO-negative patients, where it was 120 (103.75-150) min (P = 0.002). The duration and type of PPI used were not associated with the occurrence of SIBO in our study. CONCLUSION: The use of prokinetics in patients on PPI may reduce the risk of SIBO by enhancing intestinal motility and may reduce SIBO risk associated with long-term PPI use.

Quality of life in celiac disease and the effect of gluten-free diet.

BACKGROUND AND AIM: Patients with celiac disease (CD) have a poor health-related quality of life (HR-QOL). We assessed the QOL in patients with CD using both generic (SF-12) and specific (CD-QOL) questionnaires, and the effect of gluten-free diet (GFD) on HR-QOL. METHODS: We conducted a prospective follow-up study based on consecutive patients of suspected CD between June 2014 and November 2015. After taking a detailed history, all patients were subjected to laboratory investigations (including complete blood count, biochemistry, and the IgA tTG antibody), followed by endoscopy and duodenal biopsies for histopathology. The HR-QOL was assessed using SF-12 and CD-QOL questionnaires. Patients who were strictly adherent to GFD were re-assessed at the end of 6 months for laboratory parameters and QOL. RESULTS: Sixty adult patients of CD, with mean age of 28.85 ± 12.43 years, and a M:F ratio of 1.3:1, were enrolled in the study. The mean PCS (physical health composite scale score) and MCS (mental health composite scale score) at baseline were 37.20 ± 11.09 and 41.88 ± 8.39, which showed a statistically significant improvement after GFD to 50.30 ± 9.88 and 50.22 ± 9.04, respectively. Though there was no significant difference in the total CD-QOL score after GFD, there was a significant improvement in the dysphoria and health-concern subscales. We also found a negative correlation of the pre-GFD symptom score (based on number of positive symptoms) with PCS and MCS and a positive correlation with the CD-QOL score. CONCLUSION: This study has shown a reduced HR-QOL in adult CD patients, which improves significantly on GFD, and is associated with a higher symptom number.

Anemia in celiac disease is multifactorial in etiology: A prospective study from India.

BACKGROUND AND AIMS: Anemia is one of the most common extraintestinal manifestations of celiac disease (CD), with iron deficiency anemia (IDA) being the predominant cause. However, anemia in CD can have varied etiologies, including mixed nutritional deficiency. We aimed to study the prevalence and etiology of anemia in CD in a north Indian population. METHODS: In this prospective observational study, consecutive patients with documented CD between January 2012 and December 2013 were included, and all patients underwent detailed clinical assessment; hematological investigations including iron profile, serum folate, and vitamin B12 levels; and esophageoduodenoscopy with duodenal biopsies for histopathological examination. Prevalence of anemia and different deficiencies were calculated, and a correlation between hematological parameters and histological findings was found. RESULTS: Of the 103 patients studied, anemia was detected in 96 patients, giving a prevalence of 93.2% with a baseline hemoglobin of 8.94 ± 2.54 g/dL. Overall, iron deficiency was seen in 84 (81.5%) patients, followed by vitamin B12 deficiency in 14 (13.6%) and folate deficiency in 11 (10.7%) patients; 17 (16.5%) patients had anemia due to mixed nutritional deficiencies, and 4 (3.9%) patients had anemia of chronic disease. The mean hemoglobin and median ferritin levels were significantly lower in patients with severe villous atrophy compared to those with mild atrophy. CONCLUSION: Anemia in patients with CD is multifactorial. Even though iron deficiency is the most common cause, other nutrient deficiencies should always be explored.

Role of Positron Emission Tomography in Assessing Disease Activity in Ulcerative Colitis: Comparison with Biomarkers.

BACKGROUND: Disease activity in ulcerative colitis (UC) is best assessed clinically by Mayo score. 18-Fluorodeoxyglucose positron emission tomography-computerized tomography (FDG PET-CT) is a noninvasive imaging technique to assess extent, disease activity and response to treatment of UC, especially in high risk population or patients unwilling for endoscopy. AIMS: We conducted a prospective observational study with the aim of assessing and correlating UC disease activity by clinical criteria, endoscopy, histology, serum and fecal biomarkers, and FDG PET-CT. METHODS: Sixty eligible patients of UC were enrolled into three groups (26 remission, 24 moderate and 10 severe activity) as per Mayo score and FDG PET-CT was performed within 72 h of colonoscopy. ESR, CRP, and fecal calprotectin (FC) levels were determined for all patients. RESULTS: Of 60 enrolled patients, 10% patients had proctitis, 43.3% left-sided colitis, and 46.7% extensive colitis. ESR, CRP, FC levels, and rectal PET activity were significantly higher in groups with moderate and severe disease activity. Rectal PET activity showed a significant correlation with the Mayo score (k = 0.465, p < 0.001), endoscopic subscore (k = 0.526, p < 0.001), histological score (k = 0.496, p < 0.001), and FC (k = 0.279, p = 0.031). Extent evaluation by FDG PET-CT and colonoscopy showed a significant correlation (k = 0.582, p < 0.001). Besides, FDG PET-CT identified sacroiliitis in one patient and adenocarcinoma in one patient. CONCLUSION: FDG PET-CT is a reliable noninvasive tool for detection of disease activity, extent in UC with good correlation with Mayo score, histology and fecal biomarkers and accurate predictor of disease remission.

Symptomatic relapse of HIV-associated cryptococcal meningitis: recurrent cryptococcal meningitis or Cryptococcus-related immune reconstitution inflammatory syndrome?

Cryptococcosis, a significant opportunistic infection, has become a global concern since the advent of immunosuppressive chemotherapy or in immunodeficient patients. Host responses range from a harmless colonization to disseminated disease. An accurate or definitive diagnosis in patients with cryptococcal meningitis is often delayed because of the similar clinical presentation and biochemical or cerebrospinal fluid findings to those of a variety of infectious and non-infectious aetiologies, most of which are also especially prevalent in developing countries. Rarely, patients with cryptococcal meningitis can develop immune reconstitution inflammatory syndrome (IRIS) when initiated on combination antiretroviral therapy (cART) the diagnosis which is often missed and can be fatal. Due to the similar presentation of infection and IRIS, it is often confused with the relapse of cryptococcal meningitis. We report a case of paradoxical recurrent meningitis in response to the initiation of cART in a patient diagnosed with cryptococcal meningitis and propose that the recurrent symptoms resulted from a therapy-induced reconstitution of the immune response against residual Cryptococcus neoformans.