Can anti-Helicobacter pylori and anti-CagA antibodies be used to select patients with dyspepsia for gastroscopy?

BACKGROUND: agA IgG antibody in sera may indicate presence of peptic ulcer disease among dyspeptic patients and therefore may be used as a serological marker to identify high risk patients for peptic ulcer who can be subjected to endoscopy. Present study was performed to identify association of CagA IgG antibody in patients with peptic ulcer. METHODS: Consecutive patients with dyspepsia were subjected to endoscopy and sera was collected from each. Rapid urease test in antral tissue collected from each patient by endoscopic biopsy was performed. Antral tissue was also examined histologically. IgG Antibody against H. Pylori and CagA IgG antibody was tested in each patients sera. RESULTS: Out of 82 patients with dyspepsia included in the study 28 had peptic ulcer. Of whom 26 were positive for anti IgG H. Pylori antibody. More than 80% patients with peptic ulcer patients had detectable anti Cag A antibody in contrast to 33% patients with non ulcer dyspepsia (P < 0.001). CONCLUSION: Anti-Cag A antibody may be used as a screening test in patients with dyspepsia to select high risk patients for peptic ulcer for upper gastrointestinal endoscopy.

Celiac disease in osteoporotic Indians.

OBJECTIVE: 1) The aim of the study was to identify the atypical celiac disease (CD) in a cohort of symptomatic osteoporotic patients, younger than 55 years of age and 2) To study associated clinical and laboratory features and outcome with gluten-free diet. MATERIAL AND METHODS: We studied 33 patients (F:M = 28:5), mean age 29 years (range 15-52 years) with osteoporosis (WHO diagnostic criteria, T-score less than -2.5 on DEXA scan) from January 2000 - June 2002. Serological screening for CD was done by detecting circulating IgA antibodies to tissue transglutaminase by ELISA. Patients with presence of antibodies to transglutaminase were subjected to biopsy from the 2nd part of the duodenum by upper GI endoscopy. The biopsies were reported independently by two pathologists who were blinded for the serology report. Measurement of mucosal thickness, crypts and villi were done with an ocular micrometer. Other parameters like complete hemogram, serum iron, total iron binding capacity (TIBC), calcium profile, 25-OH-D, parathyroid hormone (PTH) were evaluated. Assessment of clinical and laboratory parameters was performed within 4-12 weeks of starting gluten-free diet (GFD). RESULTS: Thirteen patients had circulating IgA antibodies to transglutaminase. Intestinal biopsies were performed on 11 patients and were consistent with the diagnosis of CD (total villous atrophy--two, subtotal villous atrophy with crypt hyperplasia--nine). Patients with CD had significant anaemia when compared with non-CD osteoporotic patients. Other important observations in these 11 patients were low serum calcium and phosphorus, low 25-OH-D, high PTH. Significant improvement in clinical and laboratory parameters was noted in all patients within 6-12 weeks of starting GFD. CONCLUSION: Symptomatic osteoporotic patients (younger than 55 years of age) especially with associated anaemia should be investigated for CD. Simple measures like omission of wheat from diet (GFD) lead to significant improvement in symptoms within weeks.

Endoscopic sclerotherapy in children with extrahepatic portal venous obstruction.

BACKGROUND: Extrahepatic portal vein obstruction (EHPVO) is a common cause of variceal bleeding in children in India. There is paucity of data regarding the results of treatment with endoscopic sclerotherapy. METHODS: Fifty-nine children (mean age 11 +/- 3.8 years; range 7 months to 12 years; 36 males and 23 females) were studied from February 1990 to September 1999. EHPVO was diagnosed on the basis of portal cavernoma on ultrasonography in 55 patients and on splenoportovenogram in 4 patients. Endoscopic sclerotherapy was caried out at weekly intervals for the first three weeks and at 3 weekly intervals thereafter till complete or near complete thrombosis was achieved. All patients were followed up with check endoscopy every 3-6 months after thrombosis of oesophageal varices. RESULTS: Over a mean follow up of 25.4 months (range 3 to 87 months) total thrombosis was achieved in 53 (89.8%) of 59 children. The mean number of sclerotherapy sessions required were 7.5 +/- 2.2. The mean number of blood transfusions required per bleeding episode was 3.8 +/- 3.2. Of the 59 children 21 (35.6%) rebled, of which 17 (28.8%) bled during and 4(6.8) after thrombosis of varices. Seven (11.9%) children had more than one episode of bleeding. Once thrombosis of the varices was achieved 15 (26%) of 59 children developed fresh varices on follow up. Gastric varices were detected in 47 (60%) children. In 39 (66%) children it was present at the onset and in 8 (13.5%) children it developed after thrombosis of oesophageal varices. Bleeding from gastric varix occurred in 7(9%) children. Ascites developed in 6(10.6%) children. One child developed oesophageal stricture. There were 3 (5%) deaths. Two died due to upper gastrointestinal bleed while on sclerotherapy schedule and one died due to cerebral abscess. CONCLUSION: EHPVO is an important and common cause of upper gastrointestinal bleeding in children in Western India. EST is safe and useful in controlling oesophageal variceal bleeding in children.

Duodenal leiomyoma--a rare cause of haematemesis.

Leiomyoma of the duodenum is a rare tumour. Small intestinal tumours contributing to upper gastrointestinal bleed is still rare. They usually present with malena and anaemia, rarely hematemesis. We report a case of leiomyoma of duodenum diagnosed on endoscopic ultrasound that presented with massive haematemesis.

Foreign bodies in gut.

BACKGROUND: Foreign body ingestion is common and a frightening experience to the patients and relatives. We report our experience with 102 patients, (78 children and 24 adults), with foreign body ingestion. METHODS: After locating foreign bodies radiologically, 34 (43.6%) foreign bodies in children and 13 (54.2%) foreign bodies in adults were removed endoscopically. General anesthesia was used in 32 children and overtube was used for all sharp foreign bodies. RESULTS: In our study, 78 (76%) patients were below 12 years of age. Coins (79.5%) were commonest foreign bodies in children while dentures (25%) were commonest in adults. Foreign bodies were most commonly sited in stomach (25.6%) in children and esophagus (58.3%) in adults. In 41 (52.6%) children and in three (12.5%) adults, i.e. total 44 out of 102 (43.1%) patients passed foreign bodies spontaneously. The largest foreign body that passed spontaneously was 4-cm long nail in a child. In 34 (43.6%) children and in 13 (54.2%) adults foreign bodies were removed endoscopically. Only 3.8% children and 33.3% adults required surgery. CONCLUSIONS: There was no mortality in our series. Majority of foreign bodies do not require any intervention. Sharp foreign bodies are commonest indication for surgery. However, endoscopic removal is safe, effective and is the method of choice for most patients.

Colonic tuberculosis: colonoscopic appearance and clinico-pathologic analysis.

BACKGROUND: There has been a resurgence of interest in intestinal tuberculosis because of acquired immunodeficiency syndrome (AIDS) epidemic sweeping our country. Role of colonoscopy and colonoscopy directed histology for diagnosing the disease have been emphasised since last few years. AIMS AND OBJECTIVES: To know the colonoscopic features in patients with intestinal tuberculosis and to study the clinicopathological findings in the same. METHODS: We studied twenty-one patients with intestinal tuberculosis referred to us between 1993-1997. Colonoscopy was done in all patients and biopsy specimens were collected from the site of lesion during the procedure. RESULTS: Ileocaecal disease was found in 9 patients, ileocaecal with contiguous ascending colon involvement in eight and segmental colonic tuberculosis in four cases. The colonoscopic findings included nodules in seven patients, nodules with ulcerations in three, ulcerations alone in seven, nodules with strictures in three and polypoidal mass in one patient. Eight cases revealed granuloma on histopathology. CONCLUSIONS: Though bacteriological and histological assessment of tissue is essential to differentiate tuberculosis from other disorders, we stress the importance of colonoscopic appearances in diagnosing tuberculosis. We also recommend antituberculous chemotherapy in patients with high clinical suspicion of tuberculosis on the basis of colonoscopic appearance alone after ruling other causes on histopathological examination.

Hepatitis B subtypes and hepatitis C genotypes in cirrhosis in western India: results of a pilot study.

BACKGROUND: Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the major causes of viral chronic liver diseases in India. HBV subtypes and HCV genotypes have not been reported from Western India. The aims of the study were (i) To study the prevalence of viral markers to HBV and HCV in adult cirrhotics, (ii) To determine HBV subtypes and HCV genotypes using serological and molecular biological methods. METHODS: A total of 99 adult cirrhotic patients, proven by liver biopsy, laparoscopy, or a combined score of clinical features, biochemical tests, ultrasonography of abdomen, and radioisotope 99m Technetium scan in presence of oesophageal varices were studied. Sera collected from these patients were stored at -8 degrees C and subjected to various tests. HBsAg was determined by ELISA, anti-HBc by ELISA and anti HCV Ab was determined by the third generation ELISA. HBsAg subtypes were determined by enzyme immunoassay. HCV RNA was determined by PCR in those who tested positive for anti HCV antibody. Genotyping of HCV was done with a second generation PCR. RESULTS: HBsAg was detected in 16, out of which subtyping was possible in 14, adw was found in 6 and ayw in 8. Anti HCV Ab was found in 5. Genotyping was possible in three samples which revealed one to be of genotypes 3, one of genetic group 4, and one of genetic group 5. CONCLUSIONS: Subtypes and genotypes of HBV and HCV have not been reported from Western India. Their determination can have implications in understanding the spectrum of disease, characteristics and response to treatment.

Primary gastric lymphoma in a boy.

Primary gastric lymphoma is an extremely uncommon entity in children, and diffuse large-cell-type lymphoma in this age group is still rarer. An 11-year-old boy with primary gastric lymphoma who responded to CHOP regime is reported.

Helicobacter pylori and intestinal metaplasia of gastric mucosa.

BACKGROUND: The role of Helicobacter pylori in stomach carcinogenesis is currently under study. H pylori-related chronic gastritis leading to dysplasia or intestinal metaplasia (IM) especially of the colonic type is postulated as one of the mechanisms. METHODS: We studied 120 patients with or without H pylori infection to determine the frequency of occurrence of IM in the stomach. RESULTS: IM was found in 16.6% of patients; most cases had the small intestinal type, which is not known to have a malignant potential. There was no relation between H pylori infection and development of IM. CONCLUSION: H pylori infection leading to IM does not appear to be a factor in the genesis of carcinoma stomach in our population.

Gallbladder varices: diagnosis in children with portal hypertension on duplex sonography.

We established the prevalence of gallbladder varices (GBVs) as seen on duplex sonogram of children with portal hypertension. Fifty-five consecutive children with portal hypertension underwent duplex sonographic examination by an experienced sonologist who was blinded to clinical presentation. Forty children had extrahepatic portovenous obstruction (EHPVO), 12 had cirrhosis, and three had noncirrhotic portal hypertension. GBVs were seen on sonography in 10 of 40 children with EHPVO (25%), two of 12 children with cirrhosis (16.6%), and no children with noncirrhotic portal hypertension. Sonographic findings of GBVs were confirmed on duplex sonographic imaging. Among patients with EHPVO, GBVs did not correlate with size of esophageal varices, number of sessions of sclerotherapy, presence or absence of gastric varices, portal gastropathy, or splenorenal shunt placement. In cirrhotic patients, GBVs did not correlate with Child Pugh grade. Children with EHPVO have a higher incidence of developing GBVs. The clinical significance of GBVs is their propensity to bleed during biliary surgery; thus, the operating surgeon should be made aware of them.

Achalasia cardia dilatation using polyethylene balloon (Rigiflex) dilators.

OBJECTIVE: Results of 20 dilatation sessions in 15 patients with achalasia cardia were assessed to determine the safety and efficacy of polyethylene balloon achalasia dilators (Rigiflex). METHODS: All patients underwent an initial dilatation by inflating a 30 mm balloon to 9 psi for one minute. Need for subsequent dilatations was assessed on symptom assessment; 35 mm balloon was used for repeat procedure. RESULTS: Overall success rate was 93.3%. The 30 mm balloon achieved a satisfactory result in 73.3% and the 35 mm balloon in 75% of the remainder. Only one patient needed surgery. No short-term complications were observed. The only late complication encountered over an average follow-up period of 16.2 months was gastroesophageal reflux in two patients. CONCLUSIONS: Dilatation using Rigiflex dilators is a safe, effective and simple procedure for treating patients with achalasia.

Asymptomatic spinal tuberculosis presenting as esophageal stricture.

Esophageal tuberculosis is rare and is usually due to secondary extension from contiguous structures. We report a patient who presented with dysphagia and was found to have esophageal stricture. Endoscopic biopsy was not suggestive of malignancy or tuberculosis. CT scan of the thorax revealed involvement of the fourth thoracic vertebra with paratracheal lymphadenopathy. The patient responded to anti-tubercular therapy.

Esophageal tuberculosis with intramural pseudodiverticulosis.

Esophageal tuberculosis is rare, and its association with intramural pseudodiverticulosis is not widely appreciated. We report a patient with dysphagia who proved to have esophageal narrowing, mediastinal lymphadenopathy, and intramural pseudodiverticulosis. Results of endoscopy and biopsy were nonspecific, but biopsy of the supraclavicular node showed histology consistent with tuberculosis. The patient experienced a dramatic response to antitubercular therapy, with resolution of the esophageal narrowing, mediastinal lymphadenopathy, and esophageal intramural pseudodiverticulosis.

Esophageal dilation in pediatric patients using balloon along the side of the endoscope.

Balloon dilation is an effective modality of treatment for esophageal strictures. As standard through-the-scope balloons do not pass through the biopsy channel of pediatric endoscopes, we have developed a technique by which these balloons can be used in pediatric patients by passing them alongside the endoscope. We report our experience of dilation in four patients using this technique.