Prevalence of short segments of specialized columnar epithelium in distal esophagus: association with gastroesophageal reflux.

BACKGROUND AND AIMS: Recent studies have reported high prevalence rates of short segments of specialized columnar epithelium (SCE) in the distal esophagus. The association of SCE with gastroesophageal reflux disease is not well established. We studied the prevalence and associations of short segments of SCE in the distal esophagus amongst Indians. METHODS: 271 patients (mean age 36 [14] y; 160 men) undergoing diagnostic upper gastrointestinal endoscopy were interviewed regarding symptoms of gastroesophageal reflux, and history of medications, smoking or chewing tobacco and alcohol ingestion. At endoscopy, presence and grade of esophagitis and hiatus hernia were recorded. One biopsy each was taken from the squamocolumnar junction and 2 cm proximal to it. Biopsies were stained with hematoxylin/eosin and alcian blue/periodic acid-Schiff. The pathologist was blinded to the clinical and endoscopic data. RESULTS: Short segments of SCE in the distal esophagus were present in 16/271 (6%; CI 5.03-6.97) patients. Increasing age (p<0.01), and endoscopic (p<0.01) and histologic (p<0.001) esophagitis were associated with its presence, whereas symptoms of gastroesophageal reflux, smoking, tobacco chewing, use of alcohol or non-steroidal anti-inflammatory drugs, and hiatus hernia were not. One patient with SCE had dysplasia. CONCLUSION: Prevalence of short segments of SCE in the distal esophagus amongst Indians is low and is usually associated with inflammation in the esophagus.

High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis.

OBJECTIVES: The fregency of bacteremia after endoscopic variceal band ligation (EVL) is reported to be lower when compared to that after endoscopic variceal sclerotherapy (EVS). However, there are conflicting reports on the infectious sequelae after EVL. AIM: To compare the frequency on bacteremia and infectious sequelae after EVL and EVS in patients with cirrhosis of liver. METHODS: Bacteremia and infectious sequelae were studied in 32 sessions of EVL in 18 cirrhotic patients (Child-Pugh class A-6, B-5, C-7), 30 sessions of EVS in 22 cirrhotic patients (Child-Pugh class A-2, B-5, C-15) and 14 diagnostic upper gastrointestinal endoscopies. Blood cultures were collected before, during and 30 minutes after the procedure. Patients were observed for infectious sequelae during subsequent hospitalization. RESULTS: Before the procedure, bacteremia was present in 7/62 (11%) sessions. Significant bacteremia during and 30 min post-procedure developed in 8/32 (25%) and 12/30 (40%) of EVL and EVS sessions, respectively (p = ns), and in 1/14 (7%) upper gastrointestinal endoscopy sessions. There was more frequent bacteremia with severe liver disease (Child-Pugh class A-0/6, B-1/5. C-7/21; p = 0.09) in the EVL but not in the EVS group (Child-Pugh class A-1/3, B-2/5, C-9/22; p = ns). The incidence was higher with emergency sclerotherapy compared to elective sclerotherapy (6/8 [75%] vs 6/22 [27%]; p <0.01). One patient in the EVS group developed spontaneous bacterial peritonitis. CONCLUSIONS: Bacteremia occurs frequently following EVL and EVS in patients with advanced liver diseases. In the EVS group it is more common after emergency sclerotherapy. This bacteremia is rarely associated with significant infectious sequelae.

Prospective evaluation of medication-induced esophageal injury and its relation to esophageal function.

BACKGROUND: Few prospective studies are available on the incidence of medication-induced esophageal injury (MIEI). AIMS: To prospectively study the occurrence of MIEI with indomethacin and doxycycline and the predictive factors for its development. METHODS: In an operator-blinded study, 51 patients (age 16-65 y) requiring indomethacin (n = 24) or doxycycline (27) underwent symptom evaluation, endoscopy and scintigraphy before and after 7 days of therapy. MIEI was defined as de novo occurrence or worsening of pre-existing esophagitis or development of esophageal ulcer. RESULTS: Pre-therapy endoscopy was normal in 32 patients and revealed esophagitis in 19 (grade I--11, grade II--8). Post-therapy, 16 patients developed esophageal symptoms, which appeared earlier with doxycycline (2.0 [0.8] vs 4.1 [1.7] days, p = 0.016). MIEI developed in 23 patients--de novo esophagitis in 16, worsening of esophagitis in 6; 5 patients developed ulcer. Seven of 12 patients with hiatus hernia developed MIEI. Presence of pre-therapy gastroesophageal reflux disease did not predict MIEI. There was no difference in pre- or post-therapy transit values between patients with and without MIEI; patients who developed ulcers had significantly slower esophageal transit (p < 0.05). There was no difference in esophageal transit or occurrence of MIEI between patients who received indomethacin or doxycycline; however, 5 of 8 patients with hiatus hernia who received doxycycline developed MIEI (p = 0.02; relative risk 3.96 [CI 1.2-12.7]). CONCLUSIONS: 40% of patients receiving doxycycline or indomethacin developed MIEI; 10% developed ulcers. Hiatus hernia increased the risk for MIEI.

Barrett's esophagus.

Contrary to earlier definition of Barrett's oesophagus which referred to the presence of metaplastic columnar epithelium of either gastric or intestinal type, the new definition lays stress on presence of specialised columnar epithelium (SEC) with goblet cells. Hence this study was carried out to determine the frequency of specialised columnar epithelium in Indian population. 150 cases of dyspepsia underwent esophagogatro duodenoscopy with esophageal biopsy. Slides were stained with routine H and E stain and alcian blue-PAS stain. Histologically, esophagitis was found in 75 (50%) and columnar epithelium-gastric type in 63 (42%) cases only 4 (2.6%) cases showed presence of specialised columnar epithelium which were labelled as Barrett's esophagus, giving an incidence of 2.6% in this study.

Seroprevalence of hepatitis A virus in Mumbai, and immunogenicity and safety of hepatitis A vaccine.

OBJECTIVES: Since epidemiologic trends of hepatitis A are changing worldwide, we studied its seroprevalence in Mumbai, which is thought to be a high-endemicity area. The immunogenicity and safety of a hepatitis A vaccine were also studied. METHODS: Six hundred and seventy subjects (456 men; age range 6 mo-60 y) answered a questionnaire on social and medical history. Qualitative analysis of total anti-HAV was performed in all subjects by ELISA. One hundred and seven of 147 anti-HAV negative subjects received hepatitis A vaccine at months 0, 1 and 6. Subjects were followed up (months 1, 2, 6, 7) to look for side-effects and seroconversion. RESULTS: The seroprevalence of HAV was 523/670 (78%); 38% of children < 5 years were anti-HAV negative. Seroprevalence rates of 80% were reached by 15 years. Prevalence was lower in the higher socio-economic group (151/234; 64.5%) compared with the lower socio-economic group (372/436; 85%) (p < 0.001). One month after doses 1, 2 and 3 of the hepatitis A vaccine, seropositivity was 92%, 99% and 100%, respectively. Minor self-limited side-effects occurred in 19.5% of subjects; there were no major side-effects. CONCLUSIONS: The seroprevalence of anti-HAV is high in Mumbai. Seroprevalence is lower in the higher socio-economic groups. The hepatitis A vaccine is safe and immunogenic.

Prevention of gastrointestinal diseases.

The prevalence of gastrointestinal diseases markedly differs between developed and developing countries because of the poor sanitation, hygiene, impure water and food ingestion, widespread illiteracy and poverty in the developing world. The incidence of gastrointestinal diseases such as diarrhoea, cholera, typhoid, dysentery, viral hepatitis (A and E virus) can be substantially reduced by providing clean water and food to the population. Restricting consumption of tobacco and nonsteroidal anti-inflammatory drugs will reduce diseases and/or complications of the upper gastrointestinal tract. Diminishing alcohol intake and overuse of blood transfusion and improving blood banks would prevent many acute and chronic liver diseases. Costly passive and active immunoprophylaxis will become unnecessary if these measures are undertaken.

Stomach in portal hypertension.

365 consecutive patient of portal hypertension [Cirrhosis 285, Non-cirrhotic portal fibrosis (NCPF) 50, Extrahepatic portal vein obstruction (EHPVO)-30] were evaluated prospectively over a period of 2 years. Of these, 33 patients underwent successful sclerotherapy with evaluation before and after the same. Portal hypertensive gastropathy (PHG) was found in 56.4% (mild 28.2%, Severe 28.2%) of total patients; while its incidence was 60.6% in cirrhosis, 54% in NCPF and 20% in EHPVO. Incidence of PHG was significantly higher in cirrhotics when compared with non-cirrhotics (60.7% vs 41.25%: p < 0.05). PHG is more common in patients with large esophageal varices as compared to those with small varices (64.1% vs 50.8%: p < 0.05). Overall incidence of gastric varices was 29.3% while its incidence in cirrhosis, NCPF and EHPVO was 22.1%, 44% and 73.3% respectively. Incidence of gastric varices was significantly higher in non-cirrhotics (NCPF + EHPVO) when compared with cirrhotic (p < 0.05) and in patients with large esophageal varices when compared with patients having small esophageal varices (p < 0.05). Peptic ulcer was found in 10.9% patients with portal hypertension. (More than 90% were cirrhotics, mainly alcoholics). 33 patients underwent successful sclerotherapy of which 11 had PHG (mild--6, severe--5) at the beginning of sclerotherapy. After successful sclerotherapy 26 patients had PHG (mild--14, severe--12) p < 0.001). There was no significant difference in incidence of gastric varices before and after sclerotherapy. Incidence of PHG was significantly higher in cirrhotics while gastric varices were seen more commonly in patients with non-cirrhotic portal hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)