Multi-center prospective survey of hepatocellular carcinoma in Kerala: More than 1,200 cases.

BACKGROUND: Hepatocellular carcinoma (HCC) is considered uncommon in India. The aim of this study was to document the demographic characteristics and clinical aspects of HCC in Kerala, India. METHODS: A survey of HCC in Kerala was performed. All gastroenterologists in the region were invited. From May 2018 to April 2020, data was collected in a standardized questionnaire. RESULTS: Forty-three doctors from 15 centers contributed the data. Total 1217 patients were analyzed. This is the largest state-wide survey of HCC in India. HCC was more common in men (90%) than in women (p < 0.01). The etiology of liver disease was hepatitis B virus (7%), hepatitis C virus (4%) and alcohol (40%). Diabetes mellitus was present in 64%, hypercholesterolemia in 17% and hypertension in 38%. Obesity was present in 33% and 15% were overweight. Non-alcoholic fatty liver disease (NAFLD) with or without metabolic syndrome was present in 44%. Serum alpha-fetoprotein was > 400 ng/mL in 24%, total tumor diameter was > 5 cm in 59%, portal vein invasion was seen in 35% and distant metastasis was seen in 15%. Specific therapy was given to 52%. Treatments given included liver transplantation (n = 24), liver resection (n = 39) and transarterial chemoembolization (TACE, n = 184). Although the study was not designed to compare survival, patients who had liver transplantation had longer survival (median 69 months) compared to matched patients given only TACE (median 18 months) (p = 0.03). CONCLUSION: HCC is common in Kerala, India. NAFLD has a predominant association with HCC in Kerala. Most of the patients report late when curative treatment is not possible.

Correlation between insulin resistance and liver histology in patients with nonalcoholic steatohepatitis with and without obesity.

INTRODUCTION: Insulin resistance (IR) plays a central role in pathogenesis of nonalcoholic steatohepatitis (NASH). The aim of this study was to correlate histopathological grading and IR in overweight/obese patients with NASH as compared with lean NASH. METHODS: Patients with NASH who underwent liver biopsy between January 2012 and December 2012 were included. Anthropometric, clinical, and biochemical features, necro-inflammatory grades, and fibrosis stage on liver biopsies were scored according to Brunt and non-alcoholic fatty liver disease (NAFLD) activity score (NAS). RESULTS: Of 42 patients, 33 (78.6%) had body mass index (BMI) ≥ 23 kg/m2 (overweight/obese) while 9 had BMI < 23 kg/m2 (lean). Mean fasting blood sugar (FBS) and HbA1c levels in overweight/obese patients with NASH were higher than in lean NASH (p < 0.05). The median homeostatic model assessment-estimated insulin resistance (HOMA-IR) among NASH patients with BMI ≥ 23 kg/m2 was higher than among those with BMI < 23 kg/m2 (3.02 [0.34-17.22] vs. 2 [0.52-5.26]; p = 0.045). However, fasting insulin levels were comparable among lean and overweight/obese patients with NASH. Metabolic syndrome could be predicted with 75% sensitivity and 85.3% specificity at a HOMA-IR cutoff value of 3.9. No significant difference was observed with regard to HOMA-IR levels with Brunt grades, Brunt staging, Brunt grades 1 and 2, Brunt scores < 2 and > 2, and NAS scores, and NAS scores < 4 and > 4. CONCLUSIONS: Although IR was significantly higher in overweight/obese patients with NASH as compared with that in lean patients with NASH, there was no difference in the correlation of HOMA-IR with histology between these groups.

Impact of calcifications on diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration for pancreatic ductal adenocarcinoma.

INTRODUCTION: Chronic calcific pancreatitis (CCP) is a major risk factor for pancreatic ductal adenocarcinoma (PDAC) and is common in southern India. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is useful for tissue acquisition in patients with solid pancreatic lesions. Multiple factors may affect the diagnostic yield of FNA samples. The present study was performed to assess the impact of pancreatic calcifications on the diagnostic yield of EUS-FNA in PDAC. METHODS: All patients with confirmed PDAC from January 2013 to December 2017 were included. CCP was diagnosed based on typical imaging characteristics with or without evidence of pancreatic insufficiency along with surgical histopathology reports showing features of chronic pancreatitis. The diagnostic yield and adequacy of cellularity were  assessed by a pathologist who was blinded and were compared between the two groups: group 1: PDAC patients with no evidence of CCP and, group 2: PDAC patients with CCP. RESULTS: A total of 122 patients were included in the study. The diagnostic yield was lower in patients in group 2 (n = 42, 25 [59.52%]) as compared to those in group 1 (n = 80, 63 [78.75%]) (p-value = 0.01). On multivariate analysis, only the presence of calcifications was found to have an independent association with diagnostic yield (odds ratio 3.83 [95% confidence interval 1.22-11.9]). CONCLUSIONS: CCP had a significant impact on the diagnostic yield of EUS-FNA for pancreatic adenocarcinoma. Novel techniques and newer technology that may mitigate the negative effect of calcification on diagnostic yield of EUS-FNA in patients with CCP.

A prospective cross sectional study of detection of Clostridium difficile toxin in patients with antibiotic associated diarrhoea.

BACKGROUND AND OBJECTIVES: Clostridium difficile infections (CDI) include self-limiting antibiotic associated diarrhoea (AAD), antibiotic-associated colitis, and pseudomembranous colitis. The present study aimed at detecting C. difficile toxin in stool samples of patients with AAD and analyzing the antibiotic use and presence of other risk factors in these patients. MATERIALS AND METHODS: In this study, which was conducted on 660 samples, a 2- step strategy was used. In the first step, glutamate dehydrogenase (GDH) was detected in stool samples by enzyme-linked immunofluorescent assay (ELFA). In the second step, GDH positive samples were tested for C. difficile toxin A and B by ELFA. Nucleic acid amplification test (NAAT) was also performed on few samples that were found to be GDH positive and toxin negative or equivocal by ELFA. RESULTS: Of the 660 samples screened, toxin was detected in 8.8% (58/660) by ELFA and 9.7% (64/660) by NAAT. GDH was detected in 23.8% (157/660) and toxin in 36.9% (58/157) of the GDH positives. Most of the toxin positive patients were on one or more antibiotics prior to developing diarrhoea. The implicated antibiotics were meropenem, amikacin, colistin and cephalosporins. Diabetes, hypertension, use of proton pump inhibitors, previous hospitalization, malignancy and chemotherapy were found to be the risk factors in our study. CONCLUSION: Prevalence of GDH was 23.8% (157/660) by ELFA. Toxin prevalence was 9.7% (64/660). Detection rates of C. difficile associated diarrhoea (CDAD) increased with inclusion of NAAT testing by ELFA.

Multi-center prospective survey of inflammatory bowel diseases in Kerala: More than 2000 cases.

BACKGROUND: Inflammatory bowel disease (IBD) is considered uncommon in Asia. The aim of this study was to document the demographic characteristics and clinical aspects of ulcerative colitis (UC) and Crohn's disease (CD) in Kerala, India. METHODS: A survey of IBD in Kerala was performed. All gastroenterologists in the region were invited. From May 2013 to October 2015, data were collected in a standardized pro-forma. RESULTS: Forty-seven doctors in 34 centers contributed data. A total of 2142 patients were analyzed. This is the largest state-wide survey of IBD in India. Ulcerative colitis was diagnosed in 1112 (38 new), Crohn's disease in 980 (53 new), and 50 were unclassified (5 new). The district-wise distribution of IBD cases correlated with the District-wise Gross State Domestic Product (r = 0.69, p < 0.01). Three percent was below the age of 18. Patients with UC had more diarrhea (73% vs. 51%), bleeding PR (79% vs. 34%), and intermittent flares (35% vs. 13%) (all p < 0.01). Patients with CD had more abdominal pain (62% vs. 46%), weight loss (53% vs. 40%), fever (28% vs. 18%), and history of antituberculosis treatment (21% vs. 5%) (all p < 0.01). Compared to adults, children (below 18 years) were more likely to have extensive UC (58% vs. 34%, p < 0.01) and unclassified IBD (15% vs. 2%, p < 0.01). CONCLUSION: Inflammatory bowel disease is common in Kerala, India. The disease characteristics of patients with IBD are almost similar to those from other parts of the country. Both UC and CD were seen in equal proportion in Kerala.

Percutaneous endoscopic gastrostomy (PEG) site infections: a clinical and microbiological study from university teaching hospital, India.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is used to provide enteral access in patients who are unable to swallow. Infection of the stoma is an important complication and there is little data from India on this problem, which can be used to inform infection prevention and prophylactic strategies. AIM: The objective was to assess the prevalence and the role of contributory factors in PEG site infections. METHODS: A total of 173 patients underwent PEG insertion from January 2011 to May 2012. Clinical and microbiological data were collected for culture-positive cases. Insertion was performed using a standard sterile pull-through technique. Infections were defined as two of: peristomal erythema, induration, and purulent discharge. RESULTS: A total of 54 PEG infections occurred in 43 patients (28.85%). Seventy-seven organisms were isolated. Pseudomonas aeruginosa was the most common (n=29) followed by coliforms (n=21) and meticillin resistant Staphylococcus aureus (MRSA) (n=6). Thirty-one (72%) received amoxicillin-clavulanic acid as prophylaxis and 12 (28%) were receiving concomitant antibiotics for their underlying conditions. The occurrence of PEG site infections was statistically independent of the administered prophylactic antibiotics (p=0.3). CONCLUSIONS: This study has demonstrated the importance of PEG sites as a cause of healthcare associated infections. Educating patients on wound care practices would play a significant role in prevention of PEG site infections.

Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions.

BACKGROUND AND AIMS: External pancreatic fistulas (EPFs) are a therapeutic challenge. The present study was conducted to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage (NPD) in patients with EPF. METHODS: Over 12 years, 23 patients (19 males) with EPF underwent attempted endoscopic transpapillary NPD. The end points were fistula closure with healing of pancreatic duct disruption on nasopancreatogram, or need for surgery. RESULTS: All 23 patients had persistent drain output (>50 mL/day) for >6 weeks. The mean output volume of the fistula was 223 mL (range: 60 mL to 750 mL). Sixteen patients had partial and seven patients had complete pancreatic duct disruption. The NPD could be successfully placed in 21/23 (91.3%) patients. Disruption was bridged in 15 of 16 patients with partial duct disruption. EPF healed in 2-8 weeks of placement of NPD in all of the patients with partial duct disruption that was bridged and there was no recurrence at a mean follow-up of 38 months. The EPF resolved in only 2/6 (33%) patients with complete duct disruption. CONCLUSIONS: External pancreatic fistulas developing following percutaneous drainage of pancreatic fluid collections or surgical necrosectomy can be effectively treated by transpapillary nasopancreatic drain placement especially when there is partial ductal disruption and the disruption can be bridged.

Agenesis of the dorsal pancreas with chronic calcific pancreatitis. case report, review of the literature and genetic basis.

CONTEXT: Agenesis of the dorsal pancreas is a rare developmental anomaly. This anomaly may be complicated by recurrent acute and chronic pancreatitis. CASE REPORT: We report the case of a 28-year-old female with agenesis of the dorsal pancreas and chronic calcific pancreatitis. The diagnosis of agenesis of the dorsal pancreas is discussed and the genetic changes leading to it are reviewed. The possibility of the patient having tropical pancreatitis is mentioned. CONCLUSIONS: This is probably the first report of chronic calcific pancreatitis complicating agenesis of the dorsal pancreas.

Endoscopic transpapillary nasopancreatic drainage alone to treat pancreatic ascites and pleural effusion.

BACKGROUND: Pancreatic ascites and pleural effusion are uncommon sequelae of pancreatitis and are associated with significant morbidity and mortality. Endoscopic decompression of the pancreatic duct through transpapillary stent or nasopancreatic drain (NPD) has shown encouraging results but the experience is limited. The aim of the present study was to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage in patients with pancreatic ascites and pleural effusion. METHODS: Over a period of 9 years, 10 patients (eight male) with pancreatic ascites and/or pleural effusion with pancreatic duct disruption documented on pancreatogram were studied. After informed consent, endoscopic transpapillary NPD was placed. The end-points were resolution of ascites and/or pleural effusion or need for surgery. RESULTS: Of 10 patients (age range: 13 months-46 years), four patients had only ascites, four had only pleural effusion and two had both ascites and pleural effusion. Ascites and/or pleural effusion resolved in all the patients within 4 weeks of placement of NPD. The healing of ductal disruption was demonstrated by nasopancreatogram as early as 2 weeks and NPD could be removed without necessitating another endoscopy. No major complications related to NPD placement were noted. There was no recurrence of pancreatic ascites and/or pleural effusion at a mean follow up of 39 months. CONCLUSIONS: Pancreatic ascites and pleural effusion can be effectively treated by endoscopic retrograde pancreatography and transpapillary NPD placement.