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).

Small intestinal bacterial overgrowth is common both among patients with alcoholic and idiopathic chronic pancreatitis.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is known to occur in patients with chronic pancreatitis, particularly of alcoholic etiology. There are, however, scanty data on frequency of SIBO in patients with chronic idiopathic pancreatitis and factors associated with its occurrence. METHODS: 68 patients with chronic pancreatitis and 74 age and gender-matched healthy subjects (HS) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Persistent rise in breath hydrogen 12 ppm above basal (at least two recordings) was diagnostic of SIBO. RESULT: SIBO was diagnosed more often among patients with chronic pancreatitis than controls (10/68 [14.7%] vs. 1/74 controls [1.3%]; p = 0.003). Of 68 patients, 22 (32.3%) had alcoholic and 46 (67.6%) had idiopathic chronic pancreatitis. SIBO was as commonly detected among patients with alcoholic as idiopathic pancreatitis (3/22 [13.6%] vs. 7/46 [15.2%]; p = 0.86). Age, gender, body mass index (BMI), steatorrhoea, pain, analgesic use, pancreatic calcifications and use of pancreatic enzyme supplements had no relationship with the presence of SIBO. Diabetes mellitus tended to be commoner among patients with chronic pancreatitis with than without SIBO (6/10 [60%] vs. 18/58 [31%]; p = 0.07). CONCLUSION: SIBO was commoner among patients with chronic pancreatitis, both alcoholic and idiopathic, than HS. Though presence of SIBO among patients with chronic pancreatitis tended to be commoner among those with diabetes mellitus, there was no relationship with age, gender, BMI, steatorrhoea, pain, analgesic use, pancreatic calcifications and use of pancreatic enzyme supplements.

Respiratory dysfunction is common in patients with achalasia and improves after pneumatic dilation.

BACKGROUND: Dysphagia, regurgitation, and chest pain are common achalasia, with a variable report of pulmonary symptoms possibly due to micro-aspiration. Pneumatic dilation (PD) may improve pulmonary function. Data on pulmonary dysfunction among achalasia patients are scanty, and the effect of PD is unknown. AIM: To evaluate pulmonary dysfunction in patients with achalasia based on clinical and radiologic evaluation and spirometry and to study the effect of PD at 1-month follow-up. METHODS: Patients with achalasia (diagnosed using high-resolution manometry and the Chicago classification) were evaluated prospectively by spirometry before (n = 38) and 1 month after PD (n = 31). All patients received a chest X-ray, and patients with respiratory abnormality before PD received high-resolution computed tomography of the thorax. RESULTS: Of the 38 patients, 17 and 21 had type I and II achalasia, respectively. The respiratory symptoms, such as pharyngeal symptoms [27/38 (71 %) vs. 8/31 (26 %); P = 0.0001], cough [23/38 (60.5 %) vs. 5/31 (16 %), P = 0.0001], and dyspnea [8/38 (21 %) vs. 0/31 (0 %), P = 0.006], improved after treatment with PD. Spirometry showed abnormalities in 17/38 (45 %) patients before and in 8/15 (53 %) after PD. Median FEV(1), FVC, PEFR, and percentage of predicted MEF(25-75), improved from 78 % (36-85), 74 % (48-100), 62 % (18-72), and 48 % (15-66) before to 83 % (58-94), 86 % (55-99), 69 % (38-81), and 59 % (33-78) after PD, respectively (P < 0.05 for all). CONCLUSION: Respiratory symptoms and spirometry abnormalities are common in patients with achalasia and improved after successful PD.

Capsule endoscopy for obscure gastrointestinal bleed in the tropics: A single-center experience on 350 patients.

BACKGROUND: Obscure gastrointestinal bleed (OGIB), now called small bowel bleed (SBB), comprises 5% to 10% of all gastrointestinal (GI) bleed episodes and capsule endoscopy (CE) is a tool for its evaluation. Studies on CE in a large sample of SBB patients from the tropics are limited. METHODS: We did a retrospective analysis of a prospectively maintained database of patients with SBB undergoing CE using PillCam or MiroCam CE. RESULTS: Of 350 patients (age 52.4 ± 17.4 years; 248 [70.9%] male) undergoing CE, 243 (69.4%) and 107 (30.6%) had overt and occult SBB, respectively. CE detected lesions in 244 (69.7%) patients (single lesion in 172 [49.1%]; multiple in 72 [20.6%]). The single lesions included vascular malformations (52, 14.9%), ulcer/erosion (47, 13.4%), tumor (24, 6.9%), hookworm (19, 5.4%), stricture (15, 4.3%), hemobilia (1, 0.3%) and blood without identifiable lesion (9, 2.6%). Of 72 with multiple lesions, ulcer with stricture was the commonest finding (n = 43, 12.3%). No abnormality was detected in 106 (30.3%) patients. The frequency of lesion detection was comparable among patients with overt and occult SBB (173/243, 71.2% vs. 71/107, 66.3%, respectively; p = 0.4). Younger patients (0 to 39 years) more often had multiple lesions on CE than the older (≥ 40 years) ones (26/76, 34.2% vs. 46/228, 20.2%, respectively; p = 0.001). CONCLUSION: CE has a high diagnostic yield in SBB in the tropics, regardless of the type of bleed or of CE brand and the duration of recording. Multiple lesions associated with SBB are commoner among younger (< 40 years) patients.

Lactose malabsorption diagnosed by 50-g dose is inferior to assess clinical intolerance and to predict response to milk withdrawal than 25-g dose in an endemic area.

BACKGROUND: Lactose malabsorption (LM), diagnosed currently using lactose hydrogen breath and tolerance tests (LHBT, LTT) with a high, nonphysiological dose (50-g), may mimic irritable bowel syndrome (IBS). In LM-endemic areas, clinically significant malabsorption (lactose intolerance) may be better diagnosed using a lesser dose, and positive results so obtained may predict response to milk withdrawal more effectively. METHODS: Fifty patients each with IBS (Rome III) were evaluated using LHBT and LTT with 50-g, 25-g, and 12-g lactose. Sensitivity and specificity of LHBT and LTT with different dosages (gold standard: lactase gene C/T-13910 polymorphism) and symptom development were evaluated. Effect of milk withdrawal was studied. RESULT: Of 150 patients, 37/50 (74%) and 28/50 (56%) had LM by LHBT and LTT using 50-g lactose; 41/50 (82%) and 31/50 (62%) had LM using 25-g lactose, and 14/50 (28%) and 29/50 (58%) using 12-g lactose, respectively. Sensitivity and specificity of LHBT using 50-g, 25-g, and 12-g lactose were 92.6%, 52.0%, and 94%, 60%, and 36.4%, 88.2%, and those of LTT, 92%, 80.0%, and 84.8%, 82.4%, and 66.7%, 58.8%, respectively. Breath hydrogen correlated with lactose dose. Though patients developing symptoms with 50-g lactose exhaled more hydrogen than those remaining asymptomatic, hydrogen levels did not differ following 25-g and 12-g dosages in relation to symptom development. Patients' milk intake was 335 ± 92 mL/d (≈ 16.7 ± 9.6-g lactose). Positive LHBT using 25-g dose better predicted symptom resolution than by 50-g and 12-g lactose. CONCLUSION: Twenty-five gram is the ideal dose of lactose for LHBT and LTT in LM-endemic areas.

Pathogenesis of tropical sprue: a pilot study of antroduodenal manometry, duodenocaecal transit time & fat-induced ileal brake.

BACKGROUND & OBJECTIVES: Small intestinal bacterial overgrowth (SIBO) due to ileal brake-induced hypomotility may cause tropical sprue (TS). We evaluated effect of infusion of fat or placebo in duodenum randomly in patients with TS and healthy controls on antroduodenal manometry (ADM) and mediators of ileal brake, and duodenocaecal transit time (DCTT). METHODS: ADM and DCTT (lactulose hydrogen breath test, HBT) were evaluated with placebo and fat in eight controls and 13 patients with TS (diagnostic criteria: tests showing malabsorption of two unrelated substances, abnormal duodenal histology, absence of other causes, response to antibiotics and folate). RESULTS: Patients with TS (6 had SIBO by glucose HBT) were similar in age and gender with controls. After fat infusion, proximal gut motility index (MI) was reduced compared to fasting state in TS, and DCTT was longer in TS than controls (200 min, 120-380 vs. 130, 70-160, P=0.001), though comparable after placebo (70 min, 30-140 vs. 60, 40-90). TS patients had higher PYY and neurotensin than controls after fat infusion. DCTT after fat infusion correlated with plasma level of PYY in TS but not in controls. Post-fat PYY and neurotensin levels were higher in TS with lower BMI (<16 kg/m [2] ) than those with higher BMI. Parameters of ileal brake (post-fat DCTT, PYY and neurotensin) were higher in patients with than without SIBO. INTERPRETATION & CONCLUSIONS: Fat infusion reduced proximal gut MI, increased DCTT, PYY, and neurotensin among patients with TS. Malabsorbed fat might cause exaggerated ileal brake reducing gut motility, promoting SIBO and bacterial colonization and malabsorption in TS.

Twenty-four-hour pH metry alone is inferior to additional impedance monitoring in the diagnosis of gastroesophageal reflux disease, particularly in presence of reduced gastric acid secretion.

BACKGROUND: Current gold standard for the diagnosis of gastroesophageal reflux disease (GERD) is 24-hour pH metry though it fails to detect non-acidic reflux. The sensitivity of 24-hour pH metry alone (both catheter-based and Bravo capsule) is questionable, especially if gastric acid secretion is low due to reduced parietal cell mass, Helicobacter pylori-induced gastric atrophy and antisecretory therapy. Accordingly, we analyzed the diagnostic ability of 24-hour pH metry as compared to impedance monitoring in relation to the gastric pH without antisecretory therapy. METHODS: A retrospective analysis of prospectively collected data from 150 patients with suspected GERD undergoing a 24-hour pH impedance study was done. RESULTS: Among 150 patients with symptoms suggestive of GERD, 106 (70.6%) had confirmed GERD diagnosed either by 24-hour pH metry alone (10 [9.4%]), impedance monitoring alone (49 [46.2%]) or both (47 [44.3%]). Abnormal reflux of acidic and non-acidic gastric contents was detected by 24-hour pH metry and 24-hour impedance monitoring in 57/106 (53.7%) and 96/106 (90.5%) of patients, respectively (p < .00001). Patients with GERD diagnosed by 24-hour impedance monitoring had a higher mean gastric pH (2.9 [median 1.3, IQR 5.3]) than those diagnosed by 24-hour pH metry (2.1 [median 1.4, IQR 2.6]) or both (1.6 [median 1.2, IQR 2.1]) (p = 0.001). CONCLUSION: Twenty-four-hour impedance monitoring detects GERD more often than 24-hour pH metry. Patients with higher mean gastric pH leading to non-acidic reflux were more often diagnosed by 24-hour impedance monitoring than 24-hour pH metry. Thus, 24-hour pH metry alone is inferior to additional impedance monitoring in the diagnosis of GERD, particularly in presence of reduced gastric acid secretion.

True peristaltic recovery is uncommon following treatment, particularly endoscopic dilation for achalasia cardia, though pseudo-recovery often occurs.

BACKGROUND: Relieving esophagogastric junction (EGJ) obstruction has been the focus of treatment for achalasia cardia. The recovery of peristalsis has been an elusive goal. Studies analyzing post-intervention peristaltic recovery have several limitations such as the use of conventional manometry or lack of standard definitions of peristalsis. Accordingly, we undertook this study to analyze frequency and pattern of peristaltic recovery following treatment for achalasia cardia on high-resolution manometry (HRM) and standard Chicago definition of peristalsis. METHODS: Pre and post-intervention HRM records of 71 treatment-naive patients diagnosed as achalasia cardia were retrospectively analyzed. Records with pre and post-intervention HRM on different systems (e.g. solid state and water perfusion) and those with inadequate information were excluded. All HRMs were interpreted as per Chicago classification version 3.0. After pneumatic dilation (PD) or laparoscopic Heller's myotomy (LHM), pseudorecovery of peristalsis was defined as any contraction at least 3 cm in length along 20 mmHg isobaric contour with a distal latency of less than 4.5 seconds. True recovery and premature contractions were defined by standard Chicago classification v3.0 criteria. RESULTS: Change in diagnosis was observed in 38 of 71 (53.5%) patients after intervention. While pseudo-peristaltic recovery occurred in 11 of 71 (15.5%) patients, only three (4.2%) had a true recovery. Another nine (12.7%) patients showed new premature contractions. CONCLUSION: True peristaltic recovery is uncommon in achalasia cardia following intervention, particularly PD. Pseudo-peristaltic recovery is more common. Further research is warranted on this issue.

Comparisons of the Rome III and Rome IV criteria for diagnosis of irritable bowel syndrome in Indian and Bangladeshi communities and internal shifts in the diagnostic categories of bowel disorders of gut-brain interactions.

BACKGROUND: Although the Rome IV criteria are the most recent criteria to diagnose irritable bowel syndrome (IBS), their sensitivity has been shown to be low in Chinese and Western populations. There are scanty data comparing the Rome III and Rome IV criteria in diagnosis of IBS in the Indian and Bangladeshi populations where abdominal pain, an essential component of diagnosis of IBS by the Rome IV criteria, is less in frequency and of lower severity. METHODS: We analyzed the Indian and Bangladeshi data from the Rome Global Epidemiology Study to compare diagnostic sensitivity of the Rome III and Rome IV criteria for IBS, internal shifts in diagnostic categories of disorders of gut-brain interaction (DGBI), the severity of IBS diagnosed by the Rome III and Rome IV criteria, and consultation patterns in these populations. KEY RESULTS: The Rome IV criteria were less sensitive than the Rome III criteria to diagnose IBS in these populations, and the subjects with Rome III IBS shifted internally to other DGBI when the Rome IV criteria were applied. Moreover, Rome IV IBS subjects had greater symptom severity than the Rome III IBS. A third of people fulfilling diagnostic criteria for IBS consulted doctors, and those diagnosed using Rome IV criteria, those with higher anxiety and depression symptom score, lower global physical health score, and greater IBS symptom severity score had greater correlation coefficients with doctors' consultation. CONCLUSIONS AND INFERENCES: The Rome IV diagnostic criteria for IBS are less sensitive than the Rome III criteria in Indian and Bangladesh communities. Application of the Rome IV criteria to people who meet the Rome III IBS criteria selects a subgroup of people with greater severity of symptoms, and hence, Rome IV IBS is more strongly associated with physician consultation. These findings may have important bearing in future iterations of the Rome criteria for a broader global applicability.

Spectrum of malabsorption syndrome among adults & factors differentiating celiac disease & tropical malabsorption.

BACKGROUND & OBJECTIVES: Aetiology of malabsorption syndrome (MAS) differs in tropical and temperate countries over time; clinical and laboratory parameters may differentiate between various causes. This study was undertaken to investigate the spectrum of MAS among Indian adults and to find out the features that may help to differentiate between TM and celiac disease. METHODS: Causes of MAS, and factors differentiating tropical malabsorption (TM) from celiac disease (CD) were determined in 275 patients. RESULTS: Using standard criteria, causes in 275 patients [age 37.5+13.2 yr, 170, (61.5%) male] were, TM 101 (37%), CD 53 (19%), small intestinal bacterial overgrowth 28 (10%), AIDS 15 (5.4%), giardiasis 13 (5%), hypogammaglobulinemia 12 (4%), intestinal tuberculosis 7 (2.5%), strongyloidiasis 6 (2%), immunoproliferative small intestinal disease 5 (2%), Crohn's disease 6 (2%), amyloidosis 4 (1.5%), intestinal lymphangiectasia 3 (1%) and unknown 22 (8%). On univariate analysis, patients with CD were younger than TM (30.6+12 vs. 39.3+12.6 yr, P<0.001), had lower body weight (41.3+11.8 vs. 49.9+11.2 kg, P<0.001), longer diarrhoea duration (median 36 inter-quartile range 17.8-120 vs. 24-months, 8-48, P<0.01), lower stool frequency (6/day, 5-8 vs. 8, 5-10, P<0.05), lower haemoglobin (9.4+3.2 vs. 10.4+2.7 g/dl, P<0.05), higher platelet count (2,58,000, range 1,35,500-3,23,500 vs. 1,60,000, 1,26,000-2,58,000/mm 3 , P<0.05), and more often had hepatomegaly (9/53, 17% vs. 4/101, 4%, P<0.01), and subtotal or partial villous atrophy (36/50, 72% vs. 28/87, 32%, P<0.001). Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were significant on multivariate analysis. INTERPRETATION & CONCLUSIONS: TM and CD are common causes of MAS among Indian adults. Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were found to be associated with CD.

Pneumatic dilation for achalasia cardia: reduction in lower esophageal sphincter pressure in assessing response and factors associated with recurrence during long-term follow up.

BACKGROUND: Data on utility of post-pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long-term efficacy of dilation, which tears the non-relaxing LES in achalasia, are scanty. METHODS: Post-PD LES pressure was measured in 72/98 patients with achalasia. The best cut-off pressure classifying responders and non-responders was determined by receiver operating characteristic (ROC) curve. Factors associated with non-response and recurrence were evaluated. RESULTS: Of 98 patients (41.1 ± 13.3 years, 58 male), 75 improved, three had perforation requiring surgery, and 20 did not respond to the first PD session. Of 18/20 patients undergoing a second PD, 11 improved and six non-responders needed myotomy. 37/58 (71%) male and 17/40 (42.5%) female patients had a first PD with a 35-mm balloon (P = 0.03). Age and gender of patients did not influence outcome. LES pressure was lower in responders or in those having recurrence than in non-responders (17 mmHg [6.4-75], 11 mmHg [4.6-31]vs 25 mmHg [13-55]). On the ROC curve, 22.5 mmHg was the best cut-off value differentiating responders and non-responders (area under curve [AUC] 0.73). Of the 86 patients responding to PD, 20 had recurrence. Patients who responded to one session of PD or had LES pressure <10 mmHg after the procedure recurred less often, although there was no relationship with age and gender. CONCLUSION: Post-PD LES pressure measurement is useful to assess treatment response. Patients responding to the first session and those with post-PD LES pressure <10 mmHg tended to recur less. Age and gender did not influence outcome, which might be related to preferential use of a 35-mm balloon, particularly for male patients, during the first session.

Nocturnal acid breakthrough and esophageal acidification during treatment with dexlansoprazole as compared to omeprazole in patients with gastroesophageal reflux disease.

BACKGROUND: Nocturnal acid breakthrough (NAB) may differ based on duration of proton pump inhibitor (PPI) action and Helicobacter pylori (H. pylori) infection; NAB may influence esophageal acidification (EA) and mucosal damage. Dexlansoprazole, a long-acting PPI, was not compared with omeprazole for NAB, gastric acid suppression, and EA in relation to H. pylori infection. METHODS: In this prospective open-label comparative observational study, gastroesophageal reflux disease (GERD) patients were evaluated using 24-h dual-channel pH-impedance monitoring while on dexlansoprazole (60 mg, n = 39) and omeprazole (20 mg, n = 41) to study the degree of gastric acid suppression, esophageal acid exposure, and NAB (primary outcome measures). H. pylori was detected by rapid urease test and histology. RESULTS: NAB tended to be frequent with omeprazole than dexlansoprazole (33/41 [80.5%] vs. 23/39 [59%]; p = 0.06). Though nocturnal mean esophageal pH was comparable between the dexlansoprazole and omeprazole groups, its duration was less with the former (181.5 [15.2-334.2] vs. 283 [158-366] min, p = 0.03). NAB was as frequent in the H. pylori-infected than the non-infected group (11/19 [57.9%] vs. 45/61 [73.8%]; p = 0.1). The nocturnal gastric and esophageal pH in the H. pylori-infected group was higher than in the non-infected group (4.6 ± 1.7 vs. 4 ± 1.6, p = 0.157; 6.1 ± 0.6 vs. 5.8 ± 0.6, p = 0.128). Dexlansoprazole tended to increase 24-h and nocturnal mean gastric pH among H. pylori-infected more than omeprazole (5.9 ± 1.1 vs. 4.2 ± 1.7, p = 0.023; 5.7 ± 1.2 vs. 3.8 ± 1.5, p = 0.006). CONCLUSION: Dexlansoprazole is more effective than omeprazole in suppressing gastric acid secretion, resulting in lesser EA and NAB, particularly in the presence of H. pylori.

Small intestinal bacterial overgrowth in patients with inflammatory bowel disease: A case-control study.

BACKGROUND: Though small intestinal bacterial overgrowth (SIBO) is known in inflammatory bowel disease (IBD), the data on it are scanty and have limitations. METHODS: Data on IBD patients undergoing glucose hydrogen breath test (GHBT) were retrospectively analyzed to evaluate the frequency and risk factors of SIBO in IBD compared to 66 healthy controls. RESULTS: Patients with IBD (n=86; 45 ulcerative colitis [UC] and 41 Crohn's disease [CD]) more often had SIBO on GHBT than the healthy subjects (16/86 [18.6%] vs. 1/66 [1.5%]; p=0.002). SIBO was commoner among patients with CD than UC (14/41 [34.1%] vs. 2/45 [4.4%]; p=0.001). The frequency of SIBO among UC patients was comparable to healthy subjects (2/45 [4.4%] vs. 1/66 [1.5%]; p=not significant [NS]). Patients with CD than those with UC had higher values of maximum breath hydrogen and a greater area under the curve for breath hydrogen. Other factors associated with SIBO included female gender (11/16 [68.8%] with vs. 21/70 [30%] without SIBO; p=0.003), and having undergone surgery (8/16 [50%] vs. 6/70 [8.6%]; p=0.0002). SIBO patients had lower levels of total serum protein and albumin than those without SIBO (6.2 ± 1.5 g/dL vs. 7.0 ± 0.9 g/dL, respectively; p=0.009 and 3.5 ± 0.9 g/dL vs. 4.0 ± 0.6 g/dL, respectively; p=0.02). CD, female gender, and surgery for IBD tended to be the independent factors associated with SIBO among IBD patients on multivariate analysis. CONCLUSIONS: Patients with IBD, particularly CD, female, and those having undergone surgery, have a higher risk of SIBO than the healthy controls.

Asian-Pacific consensus on small intestinal bacterial overgrowth in gastrointestinal disorders: An initiative of the Indian Neurogastroenterology and Motility Association.

In the clinical setting, small intestinal bacterial overgrowth (SIBO) is a frequent, but under-diagnosed entity. SIBO is linked to various gastrointestinal (GI) and non-GI disorders with potentially significant morbidity. The optimal management of SIBO is undefined while there is a lack of published consensus guidelines. Against this background, under the auspices of the Indian Neurogastroenterology and Motility Association (INMA), formerly known as the Indian Motility and Functional Diseases Association (IMFDA), experts from the Asian-Pacific region with extensive research and clinical experience in the field of gut dysbiosis including SIBO developed this evidence-based practice guideline for the management of SIBO utilizing a modified Delphi process based upon 37 consensus statements, involving an electronic voting process as well as face-to-face meetings and review of relevant supporting literature. These statements include 6 statements on definition and epidemiology; 11 on etiopathogenesis and pathophysiology; 5 on clinical manifestations, differential diagnosis, and predictors; and 15 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservations was 80% or higher, the statement was regarded as accepted. The members of the consensus team consider that this guideline would be valuable to inform clinical practice, teaching, and research on SIBO in the Asian-Pacific region as well as in other countries.

Abnormal small intestinal permeability in patients with idiopathic malabsorption in tropics (tropical sprue) does not change even after successful treatment.

BACKGROUND: Though tropical sprue (TS) is common in tropics, studies on small intestinal permeability (SIP) in TS are scant. METHOD: SIP was evaluated using (1)H nuclear magnetic resonance (NMR) spectroscopy of urinary lactulose and mannitol in 24 patients with TS (22 before and 15 after treatment with tetracycline and folate) and in 31 healthy subjects (HS). Effect of treatment of TS on SIP and its relationship with outcome were studied. RESULT: Subjects were comparable in terms of age and gender. Before treatment, urinary lactulose (0.24 mmol, 0-1.09 mmol versus 0.09 mmol, 0-0.68 mmol, P=0.02) and lactulose-to-mannitol (L/M) ratio (0.11, 0-0.41 versus 0.042, 0-0.26, P=0.001) were higher in TS than in HS, though mannitol was comparable (2.7 mmol, 0.61-10.5 mmol versus 3.8 mmol, 1.3-16.4 mmol, P=0.08). Patients improved after treatment [stool frequency (9, 4-20/day versus 1, 1-2/day, P<0.0001), weight (44.4, 32-69 kg, versus 56, 39-84 kg, P<0.0001), fecal fat (10.1, 6-26 g/24 h versus 4.4, 3.0-6.7 g/24 h, P<0.0001), D-xylose (0.57, 0.28-1.2 g/5 g/5 h versus 1.1, 0.2-2.1 g/5 g/5 h, P<0.0001), and small intestinal bacterial overgrowth (SIBO) resolved in 10/24 (41.7%) versus 1/15 (6.6%), P=0.02]. Though urinary lactulose (0.17, 0-4.3 mmol versus 0.09, 0-0.68 mmol, P=0.11) and mannitol (2.17, 0.8-36.7 mmol versus 3.84, 1.3-16.4 mmol, P=0.06) were comparable, L/M ratio was higher in TS than in HS (0.09, 0-0.22 versus 0.042, 0-0.26, P=0.002). L/M ratio was more often abnormal (cutoff 0.078) in TS than in HS [14/22 (63.6%) versus 3/31 (9.7%); P=0.0001], which persisted even after treatment [9/15 (60%) as compared with HS; P=0.0006]. Persistently abnormal SIP was associated with less weight gain and frequent stools following treatment. CONCLUSION: SIP is often abnormal in TS and remains unchanged even after successful treatment that was associated with less weight gain and more frequent stool.

Capsule endoscopy for obscure gastrointestinal bleeding in the tropics: report from India.

BACKGROUND: Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited. METHODS: Eighty-six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64-month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3±14.1 months) were considered to confirm CE findings. RESULTS: Of 86 patients (aged 54.5±16.3 years, 63 males), 64 and 22 had OGIB-overt and OGIB-occult, respectively. Lesions were equally detected in OGIB-overt and OGIB-occult patients (48/64, 75% vs 18/22, 81.8%, P= ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively. CONCLUSION: CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.

Patients with Specific Gastrointestinal Motility Disorders are Commonly Diagnosed as Functional GI Disorders in the Early Stage by Community Physicians due to Lack of Awareness.

BACKGROUND: Data on specific gastrointestinal (GI) motility disorders, such as gastroparesis (GP), chronic intestinal pseudo-obstruction (CIPO), and colonic inertia (CI), as well as awareness among doctors about these disorders are scanty in Asia. METHOD: Prospectively maintained records of 60 patients were retrospectively analyzed, and knowledge, attitude, and practice (KAP) of 66 Indian physicians were surveyed electronically. RESULTS: A total of 60 (age 37.7 ± 18.4 years, 25 female) patients were included in the study (13 [21.7%] GP, 25 [41.7%] CIPO, 14 [23.3%] CI, and 8 [13.3%] overlap of GP and either CIPO [5] or CI [3]), of whom 40 had primary disorders and 20 had secondary disorders due to diabetes mellitus (n = 6), systemic sclerosis (n = 4), paraneoplastic (n = 2), infection (n = 3), Parkinson's disease (n = 1), hypothyroidism (n = 1), hyperparathyroidism (n = 1), celiac disease (n = 1), and amyloidosis (n = 1). Primary disorders were more often misdiagnosed as functional GI disorders, causing diagnostic delays and complications, than secondary disorders. More patients in the primary disorder group underwent surgery compared with those in the secondary group (25/40, 62.5% vs 1/20, 5%). A few rare infectious causes of GI motility disorders due to Strongyloides stercoralis, herpesvirus, and unidentified viruses were found. Of four patients treated with pyridostigmine with (n = 3) or without prucalopride (n = 1), three responded. Awareness about GI motility disorders, particularly the primary disorders, among 66 doctors participating in the KAP survey was inadequate. CONCLUSION: Awareness regarding specific GI motility disorders among physicians is lacking, which leads to delay in diagnosis and results in more complications in patients, such as surgery, particularly in those with primary disorders.

Frequency and factors associated with small intestinal bacterial overgrowth in patients with cirrhosis of the liver and extra hepatic portal venous obstruction.

Spontaneous bacterial peritonitis (SBP), a common complication of cirrhosis of liver, might result from translocation of bacteria from the small bowel. However, there is scanty data on frequency of small intestinal bacterial overgrowth (SIBO) in patients with cirrhosis of the liver. There are no data on SIBO in patients with extra-hepatic portal venous obstruction (EHPVO) in the literature. A total of 174 patients with cirrhosis of the liver, 28 with EHPVO and 51 healthy controls were studied for SIBO using glucose hydrogen breath test (GHBT). Persistent rise in breath hydrogen 12 ppm above basal (at least two readings) was considered diagnostic of SIBO. Of 174 patients (age 47.2 +/- 11.9 years, 80.5% male) with cirrhosis due to various causes, 67 (38.5%) were in Child's class A, 70 (40.2%) class B and 37 (21.7%) class C. Of the 174 patients with cirrhosis, 42 (24.14%) had SIBO as compared to 1 of 51 (1.9%) healthy controls (P < 0.0001). Patients with EHPVO had similar frequency of SIBO compared to healthy controls [2/28 (7.14%) vs 1/51 (1.97%), P = ns]. Frequency of SIBO in Child's A, B and C was comparable [13 (18.6%) vs 16 (23.9%) and 13 (35.1%), respectively; P = ns]. Presence of SIBO were not related to ascites, etiology of cirrhosis, and degree of liver dysfunction. SIBO is common in patients with cirrhosis of the liver. Patients with EHPVO do not have higher frequency of SIBO than healthy subjects. SIBO in cirrhosis is not related to the degree of derangement in liver function or of portal hypertension.

Esophageal function tests in clinical practice: a review.

Diseases of esophagus are common in gastroenterology practice. Improvement in diagnosis and better understanding in pathophysiology of these diseases have been possible recently of due to advancement in technology. Advancement made in the field of computer softwares is another key development aiding further improvement in these instruments. In this article, we review techniques, interpretation and clinical utility of various tests of esophageal function with special reference to manometry, ambulatory pH and impedance monitoring. Esophageal manometry is simple to perform. Recent, availability of commercial user-friendly software has made analysis of recorded data easy. High resolution spatio-temporal manometry is advancement over conventional manometry. Manometry is a useful tool for diagnosis, followup and research in esophageal motility disorders. Ambulatory 24-h pH metry and impedance monitoring are also easily analyzed by commercially available software. 24-h impedance combined with pH-metry is currently considered as the gold standard for diagnosis of gastroesophageal reflux disease (GERD). All patients with GERD may not require these investigations, but those with atypical symptoms, those refractory to medical treatment and requiring surgery do. Esophageal transit study is useful in understanding functional correlates of abnormalities in manometry and is particularly useful during follow up studies and in research.

Manometric spectrum of fecal incontinence in a tertiary care center in northern India.

BACKGROUND: Since, there is scanty data on manometric spectrum of fecal incontinence (FI) from India, ano-rectal manometry (ARM) parameters of patients with FI attending a tertiary care hospital were analyzed retrospectively. METHODS: Data on 140 consecutive patients with FI (age 44.8 +/- 17.4 y, 89 male) referred for ARM were analyzed and interpreted according to standard criteria. RESULTS: Low resting pressure (mainly due to internal sphincter; < 40 mmHg) and squeeze pressure (mainly due to external sphincter; < 60 mmHg) were found in 88/140 (63%) and 44/140 (31.4%) patients, respectively. Low squeeze pressure indicating external sphincter defect was more commonly found in female than male [23/51 (45.1%) vs. 21/89 (23.6%), p = 0.013] though other parameters on ARM were comparable among the two genders. CONCLUSION: Parameters of ano-rectal functions were abnormal in varying combinations on ARM in a large proportion of patients with FI attending a tertiary care center and females more often had low squeeze pressure indicating external sphincter defect than males though anal resting pressure, length of the high pressure zone and tolerability to intra-rectal balloon distension were comparable.