Effect of Aviptadil, a Novel Therapy, on Clinical Outcomes of Patients with Viral-related Severe ARDS: A Retrospective Observational Study.

Background: Dealing with life-threatening viral acute respiratory distress syndrome (ARDS) has always been challenging and with the recent COVID pandemic experience, there is still the need of newer therapies to alleviate mortality. Aviptadil, has shown significant beneficial results in covid. We share our experience with this molecule by doing a retrospective study to evaluate the effect of this drug on clinical outcomes in viral-related Ards patients. Materials and methods: In this study, all patients with severe viral-related Ards received Aviptadil along with the conventional treatment. The oxygen saturation, SpO2/FiO2 (ratio of pulse oximetric saturation to fractional inspired oxygen) (S/F) ratio and PaO2/FiO2 (ratio of arterial oxygen partial pressure to fractional inspired oxygen) (p/f) ratio, before and after completion of the drug were studied. Radiological clearance and time for complete recovery from respiratory failure was noted. All variables pre- and postadministration of the drug were compared. Results: A total of 68 patients with viral pneumonias were admitted to intensive care unit (Icu) and only 6 patients had severe Ards, who received Aviptadil. The mean oxygen saturation significantly improved from 87.86% before the first Aviptadil dose to 93.43% post 3 days of infusion. Similarly, improvement was seen in PaO2 values from 54.32 to 68.4 posttherapy (p-value < 0.004). SpO2/FiO2 (ratio of pulse oximetric saturation to fractional inspired oxygen) ratio hiked from 149 to 336 at the end of the 3 days infusion (p-value < 0.003). RALE scoring system was used for radiological clearance and the mean change in the score was from 6.42 to 2.5 (p-value 0.00). The average length of stay in the Icu was 12.14 days. No adverse effects were noted. Conclusion: Aviptadil has shown to improve the clinical outcomes in patients with severe viral-related ards without any adverse effects. How to cite this article: Sampley S, Bhasin D, Sekhri K, Singh H, Gupta O. Effect of Aviptadil, a Novel Therapy, on Clinical Outcomes of Patients with Viral-related Severe ARDS: A Retrospective Observational Study. Indian J Crit Care Med 2024;28(1):70-74.

Cerebral Aspergillosis Complicating COVID Recovery.

How to cite this article: Sampley S, Bhasin D, Singh H, Mishra S. Cerebral Aspergillosis Complicating COVID Recovery. Indian J Crit Care Med 2022;26(4):535-536.

Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature.

INTRODUCTION: Snakebites are one of the commonest occupational hazards in tropical countries and viperine bites are potential to cause systemic toxicity. Coagulopathies and acute kidney injury (AKI) have been documented and easily dealt with in past, but pulmonary hemorrhage has been rarely seen and plasmapheresis has shown promising result for the same. This case reports highlight the effective use of plasmapheresis for pulmonary hemorrhage post-snakebite. BACKGROUND: Viperine snakebite has been associated with high morbidity and mortality due to its toxic systemic envenomization. The important systemic manifestations are coagulopathy, neuromuscular paralysis, AKI, myotoxicity, and cardiovascular collapse. Antivenomization, renal replacement therapy, steroids, and other supportive care are considered to be the mainstay of treatment till date. Pulmonary hemorrhage has been an unusual manifestation of viper bite and rarely reported and steroids have been used in such scenario but with mixed results. Role of plasmapheresis has been documented in the management of snakebite but especially for hematological problems and in limb preservation/salvage strategies. The use of same, for pulmonary hemorrhage has not been studied yet. Here, we present a rare case of pulmonary hemorrhage along with renal failure following viper bite which was successfully treated with plasmapheresis. To the best of our knowledge, it is a rare presentation and has not been reported in the literature reviewed till date. CASE DESCRIPTION: A previously healthy, 36-year-old man presented to our hospital 48 hours after a viper bite. He developed local as well systemic manifestations evident as hemolysis and renal failure. Gradually, he started having hemoptysis followed by respiratory failure requiring ventilatory support. CT chest done was s/o bilateral pulmonary hemorrhages correlating clinically with ongoing tracheal bleed. He had no other bleeding manifestations and had normal coagulation profile. He was initially treated with methylprednisolone therapy, but then did not show any improvement and finally plasmapheresis was done as rescue therapy. Following this, he had improvement in respiratory parameters and settling tracheal bleed with resolution of radiological changes. He was successfully weaned off from the ventilation and also his renal failure also improved with near normalization of pulmonary and renal functions. CONCLUSION: This case highlights the unusual presentation of pulmonary hemorrhage in a patient with viperine bite with normal coagulation and was aggressively managed with plasmapheresis. Hence, plasmapheresis can be used as life-saving modality in patients with systemic envenomization post-viperine bit. HOW TO CITE THIS ARTICLE: Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature. Indian J Crit Care Med 2020;24(10):986-990.

Blocking an N-terminal acetylation-dependent protein interaction inhibits an E3 ligase.

N-terminal acetylation is an abundant modification influencing protein functions. Because ∼80% of mammalian cytosolic proteins are N-terminally acetylated, this modification is potentially an untapped target for chemical control of their functions. Structural studies have revealed that, like lysine acetylation, N-terminal acetylation converts a positively charged amine into a hydrophobic handle that mediates protein interactions; hence, this modification may be a druggable target. We report the development of chemical probes targeting the N-terminal acetylation-dependent interaction between an E2 conjugating enzyme (UBE2M or UBC12) and DCN1 (DCUN1D1), a subunit of a multiprotein E3 ligase for the ubiquitin-like protein NEDD8. The inhibitors are highly selective with respect to other protein acetyl-amide-binding sites, inhibit NEDD8 ligation in vitro and in cells, and suppress anchorage-independent growth of a cell line with DCN1 amplification. Overall, our data demonstrate that N-terminal acetyl-dependent protein interactions are druggable targets and provide insights into targeting multiprotein E2-E3 ligases.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism.

BACKGROUND & OBJECTIVES: The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease. METHODS: In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients. RESULTS: A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P <0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P <0.05) and parathyroid hormone (PTH) (P <0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group. INTERPRETATION & CONCLUSIONS: Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience.

BACKGROUND: Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of "step-up" endoscopic transmural approach for treatment of WON. METHODS: Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided "step up" transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN. RESULTS: Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1). CONCLUSIONS: "Step up" endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.

Timing of surgical intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage.

BACKGROUND: The timing of surgery in patients not responding to percutaneous catheter drainage (PCD) in infected pancreatic necrosis remains challenging. MATERIALS AND METHODS: A randomized controlled trial was designed to establish the optimal timings of surgery following PCD in patients with infected pancreatic necrosis (IPN). Patients who did not improve by day 10 after PCD insertion were included in the present study and were randomized to group A (step-up approach as a bridge to surgery) or group B (step-up approach with intention to avoid surgery). Weekly inflammatory and nutritional markers were monitored in both groups (clinical trials. gov identifier NCT-01527084). RESULTS: From July 2011 to December 2012, 40 patients underwent treatment with PCD. The first 8 patients were randomized into two groups. The trial was stopped prematurely because of difficulty in accrual and poor progress. All subsequent patients were managed with step-up approach with the intention to avoid surgery. Of 35 patients, 24 patients were managed by PCD alone while 11 patients required surgery. In patients who did not require surgery; levels of serum high sensitivity C-reactive protein (hsCRP), interleukin-6(IL6) and prealbumin showed a falling trend. This group also had higher baseline albumin and higher albumin at 4 weeks. CONCLUSION: During the present study, randomization into surgery at a predetermined time in step-up approach was discontinued due to poor progress. Step-up approach with the intention to avoid surgery led to a success rate of 68.5%. The present study failed to predict the optimal timing of surgery after PCD. Patients who needed surgery were sicker at the time of admission, had higher incidence of organ failure, and spent more time in the ICU compared to patients who did not need surgery. In future, inflammatory and nutritional markers may be useful to identify patients who are unlikely to respond to PCD and may help determine the timing of surgery.

Extra-pancreatic necrosis alone: Contours of an emerging entity.

Acute pancreatitis is of two morphologic types: interstitial edematous pancreatitis that is not associated with any tissue necrosis and necrotizing pancreatitis wherein the pancreatic parenchyma with or without varying amount of extra-pancreatic tissue/fat undergoes necrosis. Necrotizing pancreatitis has a worse outcome compared with interstitial pancreatitis because of increased severity related to a heightened systemic response and cytokine storm associated with tissue necrosis. Increasingly, an entity of extra-pancreatic necrosis (EPN) alone, wherein the pancreatic parenchyma is normal on an enhanced computed tomographic scan but the peri-pancreatic tissues undergo necrosis, is being recognized. Available data suggest that the outcomes in patients with EPN alone are between the excellent prognosis of patients with interstitial and adverse prognosis of patients with necrotizing pancreatitis. The extent of EPN also seems to determine the outcome. This review summarizes the currently available literature on this entity and various radiological scores that have been suggested to determine the presence and stage of EPN.

Pancreatic tuberculosis.

Pancreatic tuberculosis is very rare, but recently, there has been a spurt in the number of reports on pancreatic involvement by tuberculosis. It closely mimics pancreatic cancer, and before the advent of better imaging modalities it was often detected as a histological surprise in patients resected for a presumed pancreatic malignancy. The usual presentation involves abdominal pain, loss of appetite and weight, jaundice which can be associated with cholestasis, fever and night sweats, palpable abdominal lump, and peripheral lymphadenopathy. Computed tomography (CT) of the abdomen is an important tool for evaluation of patients with pancreatic tuberculosis. This CT imaging yields valuable information about the size and nature of tubercular lesions along with the presence of ascites and lymphadenopathy. However, there are no distinctive features on CT that distinguish it from pancreatic carcinoma. Endoscopic ultrasound provides high resolution images of the pancreatic lesions as well as an opportunity to sample these lesions for cytological confirmation. The presence of granulomas is the most common finding on histological/cytological examination with the presence of acid fast bacilli being observed only in minority of patients. As there are no randomized or comparative studies on treatment of pancreatic tuberculosis it is usually treated like other forms of tuberculosis. Excellent cure rates are reported with standard anti tubercular therapy given for 6-12 months.

Naso-jejunal fluid resuscitation in predicted severe acute pancreatitis: Randomized comparative study with intravenous Ringer's lactate.

INTRODUCTION: Early management of severe acute pancreatitis (SAP) includes intravenous fluid resuscitation. AIM: To confirm feasibility of naso-jejunal (NJ) fluid resuscitation using oral hydration solution (ORS) and compare its efficacy with intravenous (IV) fluid resuscitation using Ringer Lactate (RL) in predicted SAP. PATIENTS AND METHODS: All patients of predicted SAP (presence of SIRS or BISAP > 2) without significant co morbidities were randomized to NJ group (ORS: 20 ml/kg bolus and then 3 mL/kg/h) or IV group (RL infusion at same rate). The groups were compared vis-à-vis persistent organ failure (POF), pancreatic necrosis, and mortality. RESULTS: Seventy-seven patients were assessed and after exclusion, 49 patients were randomized to either NJ (24 patients) or IV group (25). The demographic and baseline clinical profile of both groups including BISAP score (2.25 ± 0.73 and 2.32 ± 0.56), hematocrit (40.2 ± 6.8 and 38.3 ± 6.6), blood urea nitrogen (16.88 ± 6.69 and 21.44 ± 17.56 mg/dL), and intra-abdominal pressure (14.55 ± 4.8 and 14.76 ± 5.5 cm of water) were similar. NJ resuscitation had to be stopped in two patients because of abdominal discomfort and distension. The change in intra abdominal pressure after 48 h of hydration was comparable in both groups. The occurrence of POF (66.67% and 68%), pancreatic necrosis (69.5% and 76%), intervention (5 each), surgery (1 each), and mortality (16.5% and 8%) were comparable (P > 0.05). CONCLUSION: In select group of patients with SAP, NJ fluid resuscitation with ORS is feasible and is equally efficacious as IV fluid resuscitation with RL.

Prospective comparison of long term outcomes in patients with severe acute pancreatitis managed by operative and non operative measures.

AIM: Present study reports the long term functional and morphological changes following severe acute pancreatitis and compares patients managed by operative and non-operative methods. Association between morphological changes and functional parameters were studied. MATERIALS AND METHODS: 35 patients with one year of follow up after recovery from attack of acute pancreatitis were evaluated. RESULTS: Etiology was alcohol in 19, gallstones in 11 and idiopathic in 5. Fourteen patients were managed non-operatively and 21 operatively. Patients in non-operative group had a mean follow-up of 18.4 ± 8.2 months while patients in necrosectomy group had 31.4 ± 20.6 months. 40% patients had exocrine insufficiency (abnormal fecal fat) while 48.5% patients (17/35) had new onset diabetes. 90% patients had morphological changes in pancreas. Exocrine abnormality was significantly higher in necrosectomy group compared to non-operative group (57.2% vs 14.1%, p = 0.01). Patients undergoing necrosectomy had higher incidence of endocrine dysfunction {61.9% in surgery and 28.5% in non-operative group (p = 0.053)}. Operative group had more number of patients with completely non-visualized main pancreatic duct (MPD) (p = 0.028) and non-operative group had significantly higher irregular MPD (p = 0.021). Exocrine dysfunction was more in patients with complete non-visualization of MPD and/or incompletely visualized MPD (p = 0.013). CONCLUSION: Patients managed non-operatively had significantly less exocrine and endocrine dysfunction compared to operated patients. Exocrine dysfunction was significantly associated with complete non-visualization of MPD and/or incompletely visualized MPD.

Clinical significance of presence and extent of extrapancreatic necrosis in acute pancreatitis.

BACKGROUND AND AIM: Extrapancreatic necrosis (EPN) alone represents a subgroup of pancreatitis with better outcome than patients with pancreatic parenchymal necrosis (PN). However, data on clinical significance of EPN is limited, and significance of the extent of EPN is not known. METHODS: Two hundred thirteen patients (136 [63.8%] males; mean age: 39.8 ± 13.2 years) with acute pancreatitis were prospectively enrolled and followed up till recovery or death. Contrast-enhanced computed tomography of each patient was retrospectively evaluated for presence of PN and EPN, pleural effusion and ascites. EPN was termed extensive if it extended to paracolic gutters or pelvis. RESULTS: Twenty-one (9.9%) patients had interstitial pancreatitis, seven (3.3%) patients had PN alone, 48 (22.5%) patients had EPN alone, and 137 (64.3%) patients had combined PN and EPN. Patients with EPN alone had significantly higher frequency of organ failure than patients with interstitial pancreatitis. Compared with patients with EPN alone, the patients with combined necrosis had significantly higher frequency of pleural effusion (88.2% vs. 75%), ascites (41% vs. 20.8%), and need for intervention (32.6% vs. 14.6%). Patients with extensive EPN (n = 57) had significantly higher frequency of pleural effusion, ascites, and multi-organ failure than those with limited EPN. CONCLUSION: EPN alone should be considered as a separate category of acute pancreatitis as it has less severe course than PN but has more severe course than interstitial pancreatitis. Patients with extensive EPN in spite of having increased frequency of ascites, pleural effusion, and multi-organ failure had similar outcome as compared to patients with limited EPN.

Metabolic signatures of malignant and non-malignant mass-forming lesions in the periampulla and pancreas in FDG PET/CT scan: an atlas with pathologic correlation.

Positron emission tomography (PET) has been used for the characterization of pancreatic and periampullary lesions. Pancreatitis-associated inflammation affecting only a portion of the pancreas gives the appearance of a mass lesion on imaging. Consequently, the differential diagnosis between cancer and pancreatitis becomes a commonly encountered problem. Traditionally, PET was interpreted as positive (to denote malignancy) if fluorodeoxyglucose (FDG) activity in the pancreas exceeded background activity and as negative (to denote benign) if activity was less than or equal to background activity. However, the specificity was limited with this method of interpretation. A relatively wide overlap has been reported between semiquantitative uptake values obtained in cancers and those in inflammatory lesions. Also, the qualitative (metabolic patterns) and quantitative variables (standardized uptake values) have been complementary and at sometimes controversial to each other in various clinical situations. There is paucity of data in the literature highlighting the role of FDG PET/CT in characterization of such mass lesions. The primary aim of this pictorial review is to list the various pathologic processes of pancreas and periampulla that could be studied with FDG PET/CT and recognize the different FDG uptake patterns and apply this information to characterize the different lesions affecting the pancreas and periampulla. We have also discussed the limitations of conventional imaging and advantages of FDG PET/CT for the evaluation mass-forming lesions of the pancreas and periampulla.

Diagnostic accuracy of F-18 FDG PET/CECT vs. CECT for detecting recurrence of periampullary carcinoma and its prognostic significance.

PURPOSE: To evaluate the additive value of whole-body F-18 fluoro-deoxyglucose positron emission tomography (FDG PET) as an adjunct to contrast-enhanced computed tomography (CECT) for detecting recurrence following Whipple's resection for periampullary carcinoma and to analyze the prognostic significance of FDG PET-/CECT-based detection of recurrence. METHODS: Fifty patients (34 males, 16 females; mean age: 55 ± 11 years) who underwent PET/CECT following resection of periampullary carcinoma were included. The study was duly approved by the institutional ethical committee for retrospective analysis of the data. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of FDG PET/CECT and CECT alone for detection of recurrence were calculated, and the accuracy was compared with ROC analysis. The prognostic factors for survival following recurrence were analyzed by univariate and multivariate methods. RESULTS: PET/CECT indicated recurrence of disease in 26 (52%) patients. The overall mean survival time was 46 months with an overall survival rate of 42%. The sensitivity, specificity, PPV, NPV and accuracy of PET/CECT and CECT for detection of recurrence were 96.1%, 91.6%, 92.6%, 95.6%, 94% and 76.9%, 75%, 76.9%, 75%, 76%, respectively (p = 0.037). Also change in management could have been achieved in 18% of patients based on the PET/CECT results. In univariate analyses, SUVmax >7.3 was the only predictor of poor survival (p < 0.05). CONCLUSION: PET/CECT could be used as a one-stop imaging tool for staging and prognostication of recurrent periampullary carcinoma that could result in better patient management.

Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome.

BACKGROUND: There is paucity of data on the effect of interventions on risk of gastrointestinal bleeding (GIB) in acute pancreatitis (AP). METHODS: Retrospective study of records of patients with AP and GIB. RESULTS: 16 (3.7%) patients (14 males; mean age 39.3 ± 12.8 years) had gastrointestinal bleeding. Two patients had peptic ulcer disease related GIB. The cause of GIB in remaining patients was: pseudoaneurysms in 5, gastrointestinal fistulization in 4, and no identifiable lesion in 5. Two patients with pseudoaneurysms were treated with angioembolisation whereas 3 needed surgery. The patients with gastrointestinal fistula had complicated course and 3 of these 4 patients died due to sepsis and multi organ failure. Rest 5 patients with no identifiable lesion were managed conservatively and there was no recurrence of GIB. Of the 14 patients with AP related GIB, a previous intervention had been done in 11(79%) patients. Fifty-three patients (12.7%) without GIB died whereas 5 (31.2%) patients with GIB succumbed to the illness (p = 0.04). CONCLUSIONS: The majority of our patients of AP with GIB had antecedent history of interventions. The mortality was higher in patients with GIB, which was not due to hemorrhage but to sepsis and related complications.

Streptokinase may play role in expanding non-operative management of infected walled off pancreatic necrosis: preliminary results.

GOALS AND BACKGROUND: We evaluated ex and in vivo effect of streptokinase on pancreatic necrosum to improve the success rate of pigtail catheter drainage and irrigation in infected walled off pancreatic necrosis using step up approach and also looked at potential risk of bleeding. EXPERIMENT AND CLINICAL CASES: 1000 IU/ml of streptokinase was added to 10 g. of intra-operatively obtained fresh tissue of peripancreatic necrosis and results compared to treatment with saline. Mixture was incubated for 12 h in thermostat at 37.5 °C and subjected to histopathology. Subsequently streptokinase (50,000 units thrice a day for 5 days through PCD) was used in two patients with walled off pancreatic necrosis (WOPN) not responding to step up approach and who were being considered for surgery. Grossly there was fragmentation of necrosum in streptokinase treated tissue. Microscopically complete loss of supportive collagenous framework was noted in streptokinase treated necrosum with clumping of necrotic tissue into structure-less mass. No such changes were discernible in saline treated tissue. In two patients with WOPN there was clearance of debris after streptokinase instillation. None of the patients was on thromboprophylaxis and bleeding was not noticed in any of the patients. CONCLUSION: Based on ex vivo effect of streptokinase in dissolution of necrosum at periphery, we believe that in patients with walled off pancreatic necrosis (WOPN) not responding to pigtail catheter drainage and saline irrigation; streptokinase may prove to be useful adjunct.

Comparison of encapsulated versus nonencapsulated (14) C-urea breath test for the detection of Helicobacter pylori infection: a scintigraphy study.

BACKGROUND AND AIMS: (14) C-urea breath test ((14) C-UBT) is considered as "gold standard" for detection of active gastric H. pylori infection. However, till date no comparative study using encapsulated and non-encapsulated (14) C-UBT protocols has been conducted in same subjects in identical conditions. We monitored gastric fate of capsule containing (14) C-urea with real time display and compared sensitivities of these protocols at different time points of breath collection. METHODS: Non-encapsulated (14) C-UBT was performed using 74 kBq of (14) C-urea in 100 dyspeptic patients by collecting breath samples at 10, 15 and 20 minutes. Thereafter, within 2 days a gelatin capsule containing (14) C-urea along with 6.0 MBq of (99m) Tc-diethylene triamine penta-acetic acid was administered to each patient for real time display of capsule movement and its fate in gastrointestinal tract by gamma camera. Simultaneously, breath samples were collected for (14) CO2 measurement during image acquisition. RESULTS: Employing non-encapsulated (14) C-UBT, 74 out of 100 dyspeptic patients were found to be H. pylori positive. Discordant (14) C-UBT results were obtained in 4/74 (5.4%) cases using these two protocols. By employing encapsulated and nonencapsulated (14) C-UBT protocols, sensitivities of (14) C-UBT were found to be 90.5 versus 98.6% at 10 and 91.8 versus 97.2% at 15 minutes respectively; while these were 94.6 versus 100, 90.7 versus 98.6 and 83.7 versus 93.2% considering any one, two or all three positive values respectively. CONCLUSIONS: Incomplete/non-resolution of (14) C-urea capsule in stomach during the phase of breath collections appears to decrease sensitivity of encapsulated (14) C-UBT as compared to nonencapsulated protocol for detection of H. pylori infection.

Effect of gender, biochemical parameters & parathyroid surgery on gastrointestinal manifestations of symptomatic primary hyperparathyroidism.

BACKGROUND & OBJECTIVES: Information on gastrointestinal manifestations and then response after curative parathyroid surgery is scarce in symptomatic primary hyperparathyroidism (PHPT). This study was carried out to analyse gastrointestinal manifestations in patients with PHPT and their associations with biochemical parameters. METHODS: This retrospective study included 153 patients with symptomatic primary hyperparathyroidism (PHPT). The signs and symptoms pertaining to gastrointestinal system were analyzed. The difference of symptoms between men and women and difference in biochemical parameters in presence of different symptoms were evaluated. The relationship between serum calcium, phosphate and parathyroid hormone (PTH) levels with presence of gallstone and pancreatitis was also studied. RESULT: Of the 153 patients, 46 (30%) were men. The mean age was 39.2 ± 13.9 yr. Nearly 80 per cent of PHPT patients had at least one symptom/ sign related to gastrointestinal system. The most common gastrointestinal manifestations were abdominal pain 66 (43%), constipation 55 (36%), and nausea/or vomiting 46 (30%). Nearly one-fourth 34 (22%) of patients had a history of either gallstone disease or cholecystectomy or both. The prevalence of gallstone disease was higher in women (P<0.05). Imaging and biochemical evidence of pancreatitis was found in 27 (18%) patients. Pancreatitis was more common in men compared to women (P<0.05) despite the higher prevalence of gallstones in women. Serum calcium, phosphate or PTH levels were not associated with high risk for gallstone disease, however, serum calcium (P<0.05) was associated with 1.3 times higher risk of developing pancreatitis. In majority of patients, gastrointestinal manifestations resolved within three months of curative parathyroidectomy. Except two patients, none had recurrence of pancreatitis. INTERPRETATION & CONCLUSIONS: The study revealed that the gastrointestinal symptoms were common in patients with symptomatic PHPT. There was not much gender difference in gastrointestinal symptoms except higher occurrence of gallstones in women and pancreatitis in men. There was no difference in biochemical profile between those who had and did not have gastrointestinal symptoms.

Pancreatic encephalopathy: an unusual cause of asterixis.

CONTEXT: Pancreatic encephalopathy is the occurrence of neuropsychiatric abnormalities in setting of acute pancreatitis which is not otherwise explained by presence of electrolyte abnormities, or organic lesions. The pathogenesis of pancreatic encephalopathy is incompletely understood. The clinical presentation is variable. CASE REPORT: A 60 year old male, a diabetic for 5 years, was admitted with three days of abdominal pain associated with vomiting and complicated by altered sensorium for one day. He developed asterixis during the course of his hospital stay. Other workup was non-contributory and patient improved with supportive management. CONCLUSION: Asterixis has not hitherto been reported in pancreatic encephalopathy.