Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Conventional and advanced brain MR imaging in patients with sickle cell anemia.

BACKGROUND: Sickle cell disease (SCD) is an autosomal recessive hemolytic disorder; its cerebrovascular complications include silent cerebral ischemia, infarct, and brain atrophy. Conventional magnetic resonance imaging (MRI) often underestimates the extent of injury. Diffusion tensor imaging (DTI) can demonstrate and quantify microstructural brain changes in SCD cases having normal routine MRI. OBJECTIVE: To identify various neurological abnormalities in asymptomatic sickle cell patients using routine MRI and to evaluate the microstructure of various regions of the brain using DTI. MATERIALS AND METHODS: A prospective, randomized case-control study was conducted over a period of 2 years. A total of 58 cases of SCD and 56 age- and sex-matched controls were included. Routine MRI and DTI were performed in both the groups following a standard protocol. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were calculated in certain pre-defined regions. Primary data were analyzed using MS excel version 17. Analysis of variance test was performed and statistical significance was set at P < 0.05. RESULTS: Thirty regions of interest with 60 variables were included in the final analysis. Patients with SCD showed statistically significant reduced FA values, increased ADC values, or both, clustered in several brain areas, including pons, cerebral peduncle, corpus callosum, frontal, temporal, parietal white matter, centrum semiovale, periventricular areas, basal ganglia, and left thalamus (P < 0.05). CONCLUSION: DTI is a promising method for characterizing microstructural changes, when conventional MRI is normal.

Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

von Hippel Lindau syndrome presenting as obstructive jaundice with involvement of pancreas in two siblings.

Von Hippel Lindau disease is rare autosomal dominant disorder. In our patient's family, 4 out of 7 siblings had manifestations of the disease; 3 of those affected had pancreatic lesions with obstructive jaundice in 2 siblings caused by pancreatic cysts is reported for the first time.

A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver.

BACKGROUND AND AIMS: Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients. METHODS: In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated. RESULTS: One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p = 0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI = 1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI = 2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001). CONCLUSIONS: Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.

The natural history of portal hypertensive gastropathy: influence of variceal eradication.

OBJECTIVE: The natural history and likelihood of bleeding from portal hypertensive gastropathy (PHG) present in patients with portal hypertension before endoscopic variceal obliteration may differ from that in patients who develop PHG during or after variceal eradication. METHODS: A total of 967 variceal bleeders who had achieved variceal eradication by endoscopic sclerotherapy in the recent past were prospectively studied. In all, 88 (9.1%) patients (cirrhosis in 54, noncirrhotic portal fibrosis in 18, and extrahepatic portal vein obstruction in 16) had distinct mucosal lesions. PHG alone was present in 78, PHG with gastric antral vascular ectasia (GAVE) in eight, and GAVE alone in two patients. PHG was graded as mild or severe and according to whether present before (group A) or after endoscopic intervention (group B). Patients underwent regular endoscopy at follow-up to see if the PHG was transitory (disappearing within 3 months), persistent (no change), or progressive. Bleeding from PHG lesions was defined as acute or chronic. RESULTS: Twenty-two (26%) patients had PHG before (group A) and 64 (74%) developed PHG after variceal eradication (group B). During a mean follow-up of 25.1 +/- 14.2 months, PHG lesions disappeared in group A in only two patients (9%), but in group B in 28 (44%) patients (p < 0.05). PHG lesions more often progressed in the former as compared to the latter (18% vs 9.4%, p = NS). The incidence of bleeding was higher in group A than group B (32% vs 4.7%, p < 0.02). Bleeding from PHG occurred in 10 patients (11.6%); seven of them were from group A, and all had either progressive (n = 3) or persistent (n = 4) lesions. CONCLUSIONS: PHG developing after variceal eradication is often transitory and less severe. If PHG is pre-existing, endoscopic therapy for varices could worsen the PHG, with a likelihood of bleeding. Such patients may be benefited by concomitant beta-blocker therapy.

Prevalence and presentation of hepatitis C related chronic liver disease in southern India.

To determine the importance of hepatitis C virus (HCV) infection in the aetiology of chronic liver disease in southern India, the prevalence of HCV antibodies and HBV markers was estimated in 100 patients with chronic liver disease and in 56 patients with a variety of other gastrointestinal and liver diseases who served as controls. HCV antibody was measured by a second-generation ELISA. HBsAg, anti-HBc, anti-HBs and anti-D were also estimated. HCV antibodies were detected in 26/100 patients with chronic liver disease compared to 0/56 controls. HBV markers were present in 72 of 100 patients with chronic liver disease compared to 21/56 (37.5%) controls. Anti-D was noted in 4/100 patients with chronic liver disease and in none of the controls. Many patients had serological evidence of both B and C infection; 73% of those with anti-HCV also tested positive for HBV markers. HCV related disease presented at a median age of 60 years compared to HBV related disease which presented at a median age of 40. There was no significant difference between HCV and HBV positive patients in symptomatology, but encephalopathy was uncommon and cirrhosis the usual finding at histology in HCV positive individuals, while chronic active hepatitis was found in 30% of biopsied HBV related disease. HCV is a significant cause of chronic liver disease in this geographic region, although HBV infection continues to account for the largest proportion of cases.

Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence.

BACKGROUND/AIMS: Endoscopic variceal ligation and endoscopic sclerotherapy are both recommended for the prevention of variceal rebleeding. To compare their efficacy, their influence on gastric varices and the development of portal gastropathy, 95 patients with variceal bleeding were studied. METHODS: The patients were randomized to receive weekly endoscopic sclerotherapy using alcohol (n=48) or endoscopic variceal ligation (n=47). The endoscopic sclerotherapy and endoscopic variceal ligation groups were comparable in etiology, severity of liver disease and grade of varices. RESULTS: In the arrest of acute bleed, endoscopic sclerotherapy and endoscopic variceal ligation were comparable (86% vs. 80%, p=ns). Endoscopic variceal ligation as compared to endoscopic sclerotherapy, obliterated esophageal varices in fewer sessions (4.1+/-1.2 vs. 5.2+/-1.8, p<0.01) and a shorter time (4.4+/-1.3 vs. 6.9+/-3.4 wk, p<0.01). Three (6.4%) patients bled after endoscopic variceal ligation and 10 (20.8%) after endoscopic sclerotherapy (p<0.05). The actuarial percentage of variceal recurrence during a follow-up of 8.5+/-4.4 months, was higher after endoscopic variceal ligation than endoscopic sclerotherapy (28.7% vs 7.5%, p<0.05). Esophageal stricture formation after endoscopic sclerotherapy occurred in five (10.4%) patients, but in none after endoscopic variceal ligation. Significantly more patients developed gastropathy after endoscopic sclerotherapy than ligation (20.5% vs. 2.3%; p=0.02). Endoscopic sclerotherapy (52%) and endoscopic variceal ligation (59%) were equally effective in obliterating the lesser curve gastric varices. Six patients died: three in each group. CONCLUSIONS: (i) Endoscopic sclerotherapy and endoscopic variceal ligation were equally effective in controlling acute bleed; (ii) endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions; (iii) endoscopic variceal ligation had a significantly lower rate of development of portal gastropathy and rebleeding, (iv) while both techniques influenced gastric varices equally, there was significantly higher esophageal variceal recurrence after endoscopic variceal ligation than sclerotherapy.