Association of heterogenicity of Helicobacter pylori cag pathogenicity island with peptic ulcer diseases and gastric cancer.

OBJECTIVE: To investigate the frequency and integrity of certain cag pathogenicity island genes (cagPAI) in Helicobacter pylori strains and their association with peptic ulcer disease (PUD) and gastric cancer. MATERIAL AND METHODS: We enrolled 240 adult patients [120 with functional dyspepsia (FD), 50 with PUD and 70 with gastric cancer] undergoing upper gastrointestinal endoscopy. H. pylori infection was diagnosed when either culture or any two of the three tests (rapid urease test, histopathology and specific ureA PCR) were positive. DNA extracted from H. pylori isolates and positive gastric tissues were tested by PCR for the presence of different genes of cagPAI using specific primers. RESULTS: A total of 122 (51%) patients were H. pylori positive. Frequencies of cagPAI genes cagA, cagE, cagT and cagM in H. pylori strains from different groups of patients were as follows: functional dyspepsia 73, 83, 76 and 60%, PUD 70, 94, 91, 70% and gastric cancer 75, 95, 90 and 70%, respectively. Risk associated for the presence of PUD and gastric cancer with cagPAI genes cagE, cagT and cagM was 5.0-, 4.6- and 4.1- and 3.0-, 2.8- and 2.5-folds, respectively. Prevalence of intact cagPAI was significantly higher in PUD and gastric cancer compared to functional dyspepsia (PUD vs. functional dyspepsia, 71% vs. 38%, P = 0.01; gastric cancer vs. functional dyspepsia, 75% vs. 38%, P < 0.01). Intact cagPAI was associated with increased risk for the presence of PUD (odds ratio 5.2, 95% CI 2.4-11.3) and for the presence of gastric cancer (odds ratio 4.5, 95% CI 2.3-7.1). CONCLUSIONS: cagPAI integrity and its different genes are linked to different forms of gastric disease and so may have a role in pathogenesis, diagnosis and management.

Dynamic article: composite antropyloric valve and gracilis muscle transposition for total anorectal reconstruction: a preliminary report.

BACKGROUND: Technique and functional outcomes of anorectal reconstruction using an antropyloric graft have been reported previously. This technique had reasonable initial outcomes but lacked voluntary function. OBJECTIVE: We hereby report the initial results of patients who underwent gracilis muscle wrapping around the perineally transposed antropyloric valve in an attempt to improve voluntary fecal control. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Eight adult patients (7 men and 1 woman) with a median age of 38 years (range, 19-51 years) underwent this procedure. Seven patients already had anorectal reconstruction with a transposed antropyloric valve, and 1 patient with severely damaged anal sphincter complex underwent single-stage composite antropylorus transposition with a gracilis muscle wrap. MAIN OUTCOME MEASURES: The primary outcome measures were anatomical integrity and functional status of the composite graft in the perineum. RESULTS: No operative mortality or serious procedure-related morbidity occurred in any patient. The median postoperative resting pressure was 29 mmHg (range, 22-38 mmHg) and squeeze pressure was 72.5 mmHg (range, 45-267 mmHg). There was a significant improvement in the squeeze pressure following surgery (p = 0.039). Also, the St. Mark's incontinence scores significantly improved in all patients and varied between 7 and 9 (p = 0.003). The ability to defer defecation and the reduced frequency of leakage accidents were the prime reasons for improved postgraciloplasty outcomes in these patients. On personal interviews, all patients who underwent this procedure were satisfied with the results of their surgery. LIMITATIONS: A longer follow-up with a larger sample size is required. Quality-of-life data have not been evaluated in this study. CONCLUSIONS: Gracilis muscle wrapping around a perineally transposed antropyloric valve is possible and improves the voluntary control and overall functional outcomes in a select group of patients with end-stage fecal incontinence requiring anal replacement (Supplemental Digital Content 1, http://links.lww.com/DCR/A173).

Neurovascular antropylorus perineal transposition using inferior rectal nerve anastomosis for total anorectal reconstruction: preliminary report in humans.

BACKGROUND: Technical feasibility of inferior rectal nerve anastomosis to the anterior vagus branch of the perineally transposed antropyloric valve for total anorectal reconstruction has been previously demonstrated in cadavers. To the best of our knowledge, the present study is the first report of using this procedure in humans. METHODS: Eight patients [mean age 35.5 years (range 15-55 years); (male/female = 7:1)] underwent the procedure. The antropyloric valve with its anterior vagus branch was mobilized based on the left gastroepiploic arterial pedicle. The antral end was anastomosed to the distal colon. The anterior vagus nerve was anastomosed by epineural technique to the inferior rectal nerve in the perineum. A diverting proximal colostomy was maintained for 6 months. Anatomical integrity of the graft (on magnetic resonance imaging scans), its arterial pedicle (on computed tomography angiogram) and neural continuity (on ultrasound and pyloric electromyography) were assessed. Functional assessment was performed using barium retention studies, endoscopy, manometry and fecal incontinence scores. RESULTS: Tension-free end-to-end anastomosis of the anterior vagus nerve to the right (n = 7) and left (n = 1) inferior rectal nerve was achieved. An intact left gastroepiploic pedicle, a healthy graft and neural continuity were visualized on perineal ultrasound. Electromyographic activity was noticed on neural stimulation. Endoscopy and barium studies showed voluntary antral contraction and contrast retention, respectively, in all patients. The mean resting and squeeze pressures were 26.25 mmHg (range 16-62 mmHg) and 50.25 mmHg (range 16-113 mmHg), respectively. St. Mark's incontinence scores varied between 7 and 12. There were no major surgical complications. CONCLUSIONS: Pudendal (inferior rectal) innervation of the perineally transposed antropylorus in total anorectal reconstruction is feasible and may improve outcomes in selected patients with end-stage fecal incontinence.

Perineal antropylorus transposition for end-stage fecal incontinence in humans: initial outcomes.

BACKGROUND: Technical feasibility of perineal antropyloric valve transposition to reconstruct a severely damaged incontinent anal sphincter or to replace an excised anorectal sphincter has been reported previously. OBJECTIVE: This study aimed to document the follow-up results of patients who underwent successful perineal antropyloric valve transposition for end-stage fecal incontinence. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Seventeen patients underwent the procedure. Eight patients had replacement (group 1) and 9 patients had augmentation (group 2) of the anal sphincter. Two patients in group 1 with early graft-related complications were excluded from further analysis, because they had the grafts excised. MAIN OUTCOME MEASURES: The primary outcome measures were anatomical integrity and functional status of the graft in the perineum, fecal incontinence scores, and quality-of-life scores (SF-36) over a median follow-up of 18 months. RESULTS: The transposed grafts had a definite tone on digital examination, were well visualized on perineal MRI, showed high-velocity vascular inflow on Doppler ultrasound study, and good vascularity on celiac CT angiography. Anal manometry showed a significant (p = 0.03) rise in the postoperative resting neosphincter pressures with good retention of barium proximal to pyloric valve on distal loopogram. The postoperative St Mark incontinence score improved in both groups and was significantly better in group 2 than in group 1. There was significant improvement in postoperative physical and mental component scores in both groups with higher scores in group 2 than in group 1 on follow-up. LIMITATIONS: A longer follow-up with a larger sample size is required. CONCLUSIONS: Antropyloric valve transposition can be used effectively for a selected group of patients with end-stage fecal incontinence. Patients undergoing anal sphincter augmentation have better outcomes in comparison with those having an excised sensate anorectum.

Expression profile of latent and lytic transcripts of epstein-barr virus in patients with gastroduodenal diseases: a study from northern India.

Epstein-Barr virus (EBV) has been shown to be associated with gastric cancer. However, inconsistent findings have been reported regarding the EBV reactivation in gastric cancer and non-carcinomatous gastric epithelium. Therefore, the aim of the study was to investigate the effect of clinicopathological findings on the expression of different transcripts of EBV in patients with gastric cancer, peptic ulcer, and dyspepsia. A total of 200 adult patients (dyspepsia [120], peptic ulcer [30], gastric cancer [50]) undergoing upper gastrointestinal endoscopy were enrolled. EBV infection was diagnosed with non-polymorphic Epstein-Barr nuclear antigen1 (EBNA1) gene based PCR and confirmed by real-time PCR. The transcripts of EBV were detected by real-time RT-PCR. In patients with gastric cancer and peptic ulcer, EBV DNA was detected more often than in those with dyspepsia (P < 0.05). EBNA1 transcript was detected in all EBV positive cases and its expression was neither associated with disease nor with histopathological findings. The expression of BZLF1 was significantly associated with gastric cancer and peptic ulcer compared to dyspepsia (P < 0.01). BZLF1 expression was also found to be higher in Helicobacter pylori infected patients (P = 0.058). Expression of BARF1 and BcLF1 were significantly higher in gastric epithelium of patients having severe grade chronic inflammation (P = 0.05) and gastric atrophy (P = 0.02), respectively. In conclusion, increased expression of lytic transcripts in patients with gastric cancer, peptic ulcer, gastric atrophy, chronic inflammation and H. pylori infection suggests the association of these factors with EBV reactivation.

Virulence attributes of Helicobacter pylori isolates & their association with gastroduodenal disease.

BACKGROUND & OBJECTIVES: Certain genotype(s) of Helicobacter pylori strains may play important role in the development of gastric cancer (GC) and peptic ulcer disease (PUD). This study was undertaken to investigate the association of cagA, cagA3/ region subtypes, babA2 and vacA genotypes of H. pylori with GC, PUD and non-ulcer dyspepsia (NUD) as there are no such studies from India. METHODS: A total of 348 consecutive adult patients (NUD 241, PUD 45, GC 62) undergoing upper gastrointestinal endoscopy between September 2002 and May 2007 in a tertiary referral centre at Lucknow, north India, were enrolled. H. pylori infection was diagnosed by rapid urease test, culture, histopathology and PCR. Genotyping for cagA, cagA3/ subtypes, babA2 and vacA was performed by PCR using sequence specific primers. RESULTS: H. pylori infection was higher in patients with PUD than with GC (80 vs. 56.5%, P < 0.01) and NUD (80 vs. 55.2%, P= 0.002). cagA positive H. pylori isolates were detected in 80 per cent in GC, 83.3 per cent in PUD and 76.7 per cent in NUD with no significant difference among them. Only A subtype of cagA3/ was detected and its distribution in GC, PUD and NUD was 68.8, 69.4 and 52.6 per cent respectively. Presence of babA2 genotype was 31.4 per cent and it had significant association with PUD when compared with NUD (52.8 vs. 26.3%, P<0.003). On univariate regression analysis, s1a allele was associated with GC (P<0.050) and s1a/m2 vacA genotype with both GC (P=0.014) and PUD (P=0.016). INTERPRETATION & CONCLUSIONS: H. pylori infection was strongly associated with PUD with a very high proportion of patients with GC have s1a allele and s1a/m2 vacA genotype. Both s1a/m2 vacA genotype and babA2 are associated with PUD. The study shows that different virulence attributes of H. pylori are involved in different gastroduodenal disorders.

Analysis of Pro12Ala PPAR gamma polymorphism and Helicobacter pylori infection in gastric adenocarcinoma and peptic ulcer disease.

BACKGROUND: Peroxisome proliferator-activated receptor gamma (PPARgamma) is a ligand-dependent transcription factor involved in various disease processes including inflammation and carcinogenesis. We investigated the association of Pro12Ala PPARgamma polymorphism and Helicobacter pylori infection with gastric cancer and peptic ulcer disease (PUD). PATIENTS AND METHODS: In total, 348 adult patients [62 gastric adenocarcinoma, 45 PUD and 241 nonulcer dyspepsia (NUD)] who underwent an upper gastrointestinal endoscopy were enrolled. PPARgamma polymorphism was analyzed by PCR-based restriction fragment length polymorphism. H. pylori infection was diagnosed by rapid urease test, culture, histopathology and PCR. RESULTS: PPARgamma G carrier had significant association with gastric adenocarcinoma [P = 0.023, odds ratio (OR) = 2.136, 95% CI = 1.112-4.104] and PUD (P = 0.028, OR = 2.165, 95% CI = 1.008-4.306) when compared with NUD. Combination of G carrier and H. pylori infection further increased the risk of gastric adenocarcinoma (OR = 3.054, 95% CI = 1.195-7.807) and PUD (OR = 11.161, 95% CI = 3.495-35.644). PPARgamma polymorphism did not increase the risk of gastric adenocarcinoma and PUD in H. pylori-negative subjects. CONCLUSIONS: The study suggests that Pro12Ala PPARgamma polymorphism is associated with gastric adenocarcinoma and PUD, and is a potential marker for genetic susceptibility to these two diseases in the presence of H. pylori infection.

Aggressive angiomyxoma of the jejunum: a rare cause of obscure gastrointestinal bleeding.

Obscure gastrointestinal bleeding accounts for nearly 5% of all gastrointestinal haemorrhage and is frequently due to a lesion in the small bowel. We report the case of a male patient with obscure overt gastrointestinal bleed in whom repeated upper gastrointestinal endoscopy, colonoscopy, computed tomography scanning and exploratory laparotomy showed no specific pathology. However, on capsule endoscopy done subsequently, a small polyp in the jejunum was located and resected. Histology revealed an aggressive angiomyxoma. This type of small bowel lesion has not been reported in the literature before.

Gastroduodenal dysmotility in patients with gallbladder carcinoma: frequency of occurrence and clinical importance.

BACKGROUND: Gastric stasis, common in patients with gall-bladder carcinoma (GBC), results from anatomical obstruction or motor abnormalities. We studied patients with GBC for antroduodenal motor dysfunction using manometry. METHODS: Forty-one patients with GBC without endoscopic gastric outlet obstruction and 10 healthy controls were evaluated using a symptom scoring system for gastric stasis, saline load test and water perfusion antroduodenal manometry. Fasting, post-prandial and post-octreotide motility were recorded and analysed on a computer using GiPC manometry software. RESULTS: Sixteen of 41 patients (39%) with GBC reported recurrent vomiting; patients with vomiting had a higher symptom score (13 [11-17] v. 6 [4-10], p<0.0001] and higher volume of aspirate on the saline load test (460 ml [210-650] v. 160 ml [70-260], p<0.0001) as compared with those without vomiting. Healthy subjects more often had spontaneous fasting migratory motor complex than patients with GBC (9/10 v. 13/41, p=0.002). The amplitudes of contractions in the antrum and duodenum were significantly lower in patients with GBC than in healthy subjects. Patients with GBC had lower fasting (157 [68-284] v. 190.5 [150-284], p=0.01) and post-prandial (200 [96-395] v. 284 [178-395], p<0.0001) antral motor indices than healthy subjects. Patients with GBC and vomiting had significantly lower contraction amplitude and motility indices than those without vomiting. Motility indices correlated inversely with the symptom score and volume of aspirate on the saline load test (Spearman correlation, p = 0.01 for all). CONCLUSION: Antroduodenal motor abnormalities are common in patients with GBC. These may explain the symptoms of gastric stasis and abnormal results of the saline load test in the absence of anatomical obstruction in such patients.

Identification of opportunistic enteric parasites among immunocompetent patients with diarrhoea from Northern India and genetic characterisation of Cryptosporidium and Microsporidia.

PURPOSE: Enteric parasitic infestation is a major public health problem in developing countries. Parasites such as Cryptosporidium spp., Cyclospora spp., Cystoisospora spp. and Microsporidia may cause severe diarrhoea among immunocompromised patients. There is scanty data on their frequency among immunocompetent patients. Accordingly, we studied the frequency of enteric opportunistic parasites among immunocompetent patients with diarrhoea from northern India; we also performed genetic characterisation of Cryptosporidia and Microsporidia among them. PATIENTS AND METHODS: Stool samples from 80 immunocompetent patients with diarrhoea, and 110 healthy controls were examined. Parasites were detected by direct microscopy, modified acid-fast (Kinyoun's) and modified trichrome stain. Polymerase chain reaction--restriction fragment length polymorphism was used for genetic characterisation of selected species such as Cryptosporidia and Microsporidia. RESULTS: Enteric parasites were detected in 16/80 (20%) patients (mean age 28.8±20 years, 45, 56% males) and in 2/110 (1.8%) healthy controls (P=0.00007). Parasites detected were Cryptosporidium spp. (8/16, 50.0%), Cystoisospora spp. (4/16, 25%), Microsporidia (1/16, 6.25%), Cyclospora spp. (1/16, 6.25%) and Giardia spp. (1/16, 6.25%). One patient had mixed infection with Cystoisospora spp. and Giardia spp. The species of Cryptosporidia and Microsporidia detected were Cryptosporidium hominis and Enterocytozoon bieneusi, respectively. Parasites were more often detected in younger patients (≤20 years of age) than in older. Most of the parasite infected patients presented with chronic diarrhoea. CONCLUSION: Opportunistic enteric parasitic infestation was more common among immunocompetent patients with diarrhoea than healthy subjects. Special staining as well as molecular methods are essential for appropriate diagnosis of these parasites.

A cross-cultural investigation of attachment style, catastrophizing, negative pain beliefs, and symptom severity in irritable bowel syndrome.

BACKGROUND: Little information exists regarding whether psychosocial variables in irritable bowel syndrome (IBS) vary by geographic location. Adult attachment is an important psychological concept rooted in childhood relationship experience that has not been previously studied in IBS. Catastrophizing and negative pain beliefs have been described in IBS and may be affected by attachment. AIMS: In this cross-cultural study, we determined: (i) whether attachment differs between IBS patients and controls, (ii) whether geographic location has a significant effect on attachment style, catastrophizing and negative pain beliefs, and (iii) how all three variables correlate with IBS symptom severity. METHODS: 463 IBS patients, with moderate to severe symptom scores, and 192 healthy controls completed validated questionnaires about attachment, catastrophizing, negative pain beliefs and IBS-SSS in nine locations, USA (New York, Los Angeles), Mexico, Italy (Rome, Bari), Romania, Iran, India, and China. KEY RESULTS: Attachment anxiety and avoidance scores were significantly higher in IBS patients than in controls (p < 0.001). This was particularly true for the fearful-avoidant attachment category, especially in China and Romania. Path analysis showed that attachment anxiety and avoidance had indirect effects on IBS-SSS through catastrophizing (p < 0.0001) and negative pain beliefs (p = 0.005). All three psychosocial measures varied significantly depending on location. CONCLUSIONS & INFERENCES: In the IBS population studied, attachment style was significantly different in IBS compared to a control population. Geographic differences in attachment, catastrophizing and negative pain beliefs were documented and their correlation with symptom severity and thus, research of psychosocial variables in IBS should take into account the location of the population studied.

Intestinal microsporidiosis in renal transplant recipients: Prevalence, predictors of occurrence and genetic characterization.

PURPOSE: Intestinal microsporidiosis, which occurs in immunocompromised states such as acquired immunodeficiency syndrome, has rarely been studied in patients with renal transplantation (RT) on immunosuppressive therapy. MATERIALS AND METHODS: Three hundred and twenty-four consecutive RT recipients on immunosuppressive treatment and 170 healthy subjects were evaluated for intestinal microsporidiosis and other parasites by modified trichrome staining, wet mount using normal saline, iodine and polymerase chain reaction (PCR). Clinical, demographic and laboratory parameters associated with occurrence of intestinal microsporidiosis were studied using univariate and multivariate analysis. The species of microsporidia were studied using PCR-restriction fragment length polymorphism (RFLP). Patients were treated with albendazole (400 mg twice daily for 2 weeks). RESULTS: Of 324 RT recipients initially screened, 52 were excluded from final analysis due to incomplete data. Patients with RT [n=272, age 42±12.54 years, 222 (81.6%) male] more often had microsporidiosis than healthy subjects by modified trichrome stain and PCR [n=170, age 33.8±6.7 years, 123 (72.3%) male] [16/272 (5.8%) vs. 0/170 (0%), P<0.001]. Patients with intestinal microsporidiosis were younger (33.9±8.3 years vs. 42.3±12.6 years; P=0.009), had diarrhoea more often (13/16, 81% vs. 123/256, 48%; P=0.02), which was longer in duration (60, 32.5-105 days vs. 12, 6.2-18 days; P<0.001) and had associated giardiasis (2/16, 12.5% vs. 2/256, 0.8%; P=0.018). Younger age, presence of diarrhoea and associated giardiasis were significant on multivariate analysis. Enterocytozoon bieneusi was detected in 15/16 (93%) patients with intestinal microsporidiosis. CONCLUSION: Intestinal microsporidiosis occurs frequently in patients with RT on immunosuppressive treatment, particularly among younger patients with longer diarrhoea duration and associated giardiasis. E. bieneusi is the major species identified among these patients.

Coeliac disease in Indian children: assessment of clinical, nutritional and pathologic characteristics.

Coeliac disease is an important cause of chronic diarrhoea, failure to thrive, and anaemia in children. Little information on the disease is available in India. This study was undertaken to determine the prevalence, clinical, anthropometric and histological profiles of coeliac disease in patients attending a tertiary referral centre in India. Coeliac disease was diagnosed in 42 (16.6%) of 246 children with chronic diarrhoea, failure to thrive, and anaemia. The mean ages at onset of symptoms and at diagnosis were 2.4 (range 0.5-10) years and 8.3 (range 3-14) years respectively, and a mean period of delay in diagnosis was 5.9 (range 1-13.5) years. Of the 42 cases, history of failure to thrive was observed in 38 (90%), chronic diarrhoea in 37 (88%), and anaemia in 6 cases. Short stature, under-nutrition, anaemia, oedema of feet, rickets, clubbing of fingers, features of vitamin A deficiency, and B-vitamin deficiency were found in 42, 26, 38, 9, 8, 6, 3, and 2 cases respectively. Onset of symptoms, such as, chronic diarrhoea and failure to thrive, was earlier in children with subtotal villous atrophy than in those with partial villous atrophy (mean +/- SD; 2.00 +/- 1.46 years vs 3.30 +/- 2.72 years; p < 0.05). Results of the study suggest that coeliac disease is not uncommon in Indian children. Coeliac disease should be considered in the differential diagnosis, particularly in children without any symptoms of diarrhoea.

Treatment of chronic hepatitis B with interferon-alpha: cost-effectiveness in developing countries.

BACKGROUND: Treatment with interferon-alpha (IFN) has been shown to be cost-effective in developed countries. However, cost-effectiveness In developing countries such as India has not been studied. METHODS: Using the Markov transitional probability model, we studied two cohorts of young patients (30 years of age) with chronic hepatitis B, one untreated and the other treated with interferon (IFN), 5 million units daily for 16 weeks, with evidence of viral replication and chronic hepatitis, but not cirrhosis, and were followed up over a 30-year period. Rates of disease progression, efficacy of IFN and quality of life associated with various disease states were estimated from the available literature. Direct costs were estimated using Indian prices of IFN and from the usual costs of medical treatment in India based on expert opinion. Unrelated mortality rates were modelled on age-specific death rates of the general population. The efficacy of IFN was judged In terms of extra life-years and quality-adjusted life-years (QALY) gained, and marginal cost-effectiveness and cost-utility. Several sensitivity analyses, both undiscounted and with discounted analyses, were done. RESULTS: At the end of the 30-year period, fewer patients in the IFN-treated group developed cirrhosis or decompensated cirrhosis, or were dead. The average life span of the treated cohort was 25.14 years, a gain of 0.6 years over the untreated cohort (24.54years). The QALY lived bythetwocohortswere 23.69 and 22.75 years, respectively, representing a gain of 0.94 years for the IFN-treated group. The cost Incurred by the IFN-treated group was Rs 300,000, and that for the untreated cohort was Rs 40 700, a substantial difference. Using the baseline estimates, undiscounted costs per year of life gained and per QALY gained were Rs 432,500 and Rs 276,900, respectively; these estimates are 20.5 and 13.1 times the per capita gross national income of the Indian population. Sensitivity analyses showed that changes in various parameters led to only minor changes in these estimates. Use of discounting led to an increase in marginal cost per life-year or QALY gained. CONCLUSION: In developing countries with a low per capita Income, IFN therapy for chronic hepatitis B may not be cost-effective. A careful consideration of cost-effectiveness is therefore essential before Instituting IFN therapy in patients with chronic hepatitis B In such populations.

Association of digital clubbing with corrosive stricture of esophagus.

We report a young woman who developed digital clubbing following corrosive esophageal injury. The clubbing regressed with effective dilatation of the esophageal stricture.

Pneumatic dilation versus intrasphincteric botulinum toxin injection in the treatment of achalasia cardia in India: an economic analysis.

BACKGROUND: Pneumatic dilation (PD) is an established therapeutic option for achalasia cardia. Recently, intrasphincteric botulinum toxin (BT) has been used to treat achalasia cardia in view of its simplicity and safety. However, it is likely to be a costly treatment as repeated injections are often needed due to its short-lasting effect. No economic analysis of PD and BT strategies has been done in India. METHODS: A decision tree was constructed using decision analysis software (DATA 4.0; TreeAge Software, Williamstown, MA, USA). Probability estimates for BT injection and PD (and, in case of failure, surgery) were obtained from published literature, preferably from India. Direct "out-of-pocket" costs (in Indian rupees; currently US$ 1 = 49 rupees approximately) for baseline analysis were obtained from our hospital and from some private hospitals. Sensitivity analysis was done using a wide range of probability and cost estimates. RESULTS: Intrasphincteric BT injection strategy was more costly at 18,520 rupees per patient than PD strategy (4,568 rupees), yielding an incremental cost of 13,952 rupees per patient successfully treated. Sensitivity analysis supported the conclusions of the baseline analysis. CONCLUSION: Primary intrasphincteric BT injection strategy was costlier than primary PD strategy in the treatment of achalasia cardia in India, and therefore cannot be justified despite its efficacy, relative ease of administration and safety.

Fungal colonization of untreated peptic ulcer.

AIM: To evaluate the relationship between Candida and peptic ulcer. METHODS: One hundred consecutive patients with untreated peptic ulcer (81 with duodenal ulcer and 19 with gastric ulcer) were studied using histopathology, culture and fungal serology. Twenty subjects with non-ulcer dyspepsia were taken as controls. RESULTS: Forty seven patients (47%) with peptic ulcer were colonized by Candida as compared to 3 patients (15%) with non ulcer dyspepsia (p < 0.05). Confluent growth of Candida on culture of gastric aspirate or biopsy from ulcer edge was a more sensitive method for diagnosis of peptic ulcer-associated candidiasis than histological examination. There was no significant difference in the prevalence of Candida isolation in relation to age or sex of the patients, smoking habit and alcoholism. Large ulcers (> 2 cm) were, however, more often colonized by Candida (75%) than smaller ones (43%) (p < 0.05). Candida albicans was the commonest species isolated (60%). Invasive candidiasis was associated with Candida agglutinin titer of 1:128 in 81% of cases. CONCLUSION: Candida colonization rate in peptic ulcer is significantly higher than in non-ulcer dyspepsia.

Subacute hepatic failure in hepatitis A.

Hepatitis A is usually thought to be innocuous. We report a woman who developed subacute hepatic failure due to hepatitis A and died of the disease.

Infectious mononucleosis hepatitis: report of two patients.

Icteric hepatitis and fulminant hepatic failure (FHF) are rare in infectious mononucleosis (IM). We report two patients with icteric IM hepatitis; one died after developing FHF, the other recovered uneventfully. Epstein-Barr virus infection causing hepatitis and FHF should be suspected when tests for other hepatotrophic viral infections are negative.

Does Entamoeba histolytica cause irritable bowel syndrome?

BACKGROUND: Symptoms of patients with irritable bowel syndrome (IBS) closely mimic those of patients with non-dysenteric amebic colitis. AIM: To examine the clinical relevance of presence and types of Entamoeba histolytica in stools of patients with IBS. METHODS: IBS was diagnosed by Manning's criteria. Stool examination was done 4-weekly for 48 weeks to detect E. histolytica cysts or trophozoites. Patients underwent initial sigmoidoscopy. Sera of 22 IBS patients, 23 asymptomatic cyst passers and 36 healthy volunteers whose stools were also examined were tested for presence of antiamebic antibodies. Stools were cultured for amebae; positive cultures were subjected to polyacrylamide-gel electrophoresis (PAGE) using hexokinase (HK) isoenzyme to distinguish between pathogenic (fast-moving band) E. histolytica infection and nonpathogenic (slow band) species of Entamoeba dispar. RESULTS: E. histolytica cultured from stool samples of four IBS patients had slow-moving band of HK on PAGE. All patients spontaneously eradicated the infection during the next eight to 24 weeks; all had negative serology for antiamebic antibodies, and normal rectal mucosa on sigmoidoscopy. No change in symptom score occurred on follow up in IBS patients, although all of them cleared the infection. Three additional E. histolytica isolates from IBS patients obtained from another laboratory also showed nonpathogenic isoenzyme pattern. CONCLUSION: Bowel symptoms in IBS patients were not related to E. histolytica infection. The term non-dysenteric amebic colitis thus appears to be inappropriate, since it may be used erroneously for patients with IBS with nonpathogenic ameba, leading to injudicious treatment with antiamebic drugs.