Intestinal ultrasound in inflammatory bowel disease: New kid on the block.

Intestinal ultrasound is an emerging technique for diagnosing and monitoring patients with inflammatory bowel disease (IBD). It is a simple, non-invasive, inexpensive, safe and reliable tool for monitoring patients with IBD. This technique has good diagnostic accuracy in the assessment of the extent and severity of IBD and its complications. The most commonly used parameters are bowel wall thickness, color Doppler flow, bowel wall stratification and peri-bowel inflammation. Various scoring systems have been developed utilizing the above parameters to monitor patients with IBD. It is a good tool to monitor response to therapy and follow-up for post-operative recurrence. Early response on intestinal ultrasound (IUS) predicts long-term clinical remission and mucosal healing in patients with Crohn's disease. In patients with ulcerative colitis (UC), the response to IUS can be assessed as early as two weeks. Recent data has emerged to predict the response to corticosteroids and colectomy in patients with acute severe UC. Point of care IUS in the outpatient clinic is an excellent tool to follow-up patients and guide clinical decision-making and has good acceptability among patients. It is an underutilized technique in spite of its appeal and the availability of evidence. Underutilization can be attributed to the lack of awareness, expertise and training centres. This review discusses the technical details and the evidence to support the use of IUS in IBD. We aim to increase awareness and use of intestinal ultrasound and build local expertise and data.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship.

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Does eosinophilic esophagitis exist in India?

Eosinophilic esophagitis (EoE) has evolved over the last three decades with a better understanding of the natural course of the disease. The prevalence of EoE is higher in Western countries with increasing reports of the incidence of EoE in the east. There is less data on EoE in India. We have noticed an increase in the number of cases of EoE diagnosed in our center over the last few years. In this study, all patients with high clinical suspicion of EoE were included and prospectively evaluated with endoscopic features and esophageal biopsies. Seventeen of 73 patients were diagnosed with EoE based on clinical, endoscopic and histopathologic features. One patient was lost to follow-up and 16 of the 17 patients were initiated on standard-of-care treatment and followed up for a minimum of four weeks. Treatment with proton pump inhibitors with six-food elimination diet is highly effective in most patients with a few patients requiring systemic steroids and endoscopic treatment. In conclusion, this study highlights that EoE exists in India with varied manifestations and a high index of clinical suspicion is necessary for diagnosis. It also emphasizes the need for increasing awareness of the entity of EoE, among both patients and doctors. Further, large-scale, multi-centric population-based studies are necessary to estimate the prevalence in our country.

Image-enhanced endoscopy and endoscopic resection practices in the colon among endoscopists in India.

Background and study aims Clinical practice patterns for image-enhanced endoscopy (IEE) and colonic endoscopic resection practices vary among endoscopists. We conducted a survey to understand the differences in IEE and colonoscopic resection practices among endoscopists from India. Methods An online cross-sectional survey comprising 40 questions regarding quality control of colonoscopy, IEE, and colonic endoscopic resection practices was circulated through the registry of the Indian Society of Gastroenterology and Association of Colon and Rectal Surgeons of India. Participation was voluntary and response to all questions was compulsory. Results There were 205 respondents to the survey (93.2 % gastroenterologists, 90.2 % male, 54.6 % aged 30 to 40 years, 36.1 % working in academic institution, 36.1 % working in corporate hospitals). Of the endoscopists, 50.7 % had no training in IEE and 10.7 % performed endoscopy on systems without any IEE modalities. Endoscopists with more experience were more likely to use IEE modalities in practice routinely ( P  = 0.007). Twenty percent never used IEE to classify polyps. Sixty percent of respondents did not use dye-chromoendoscopy. Less experienced endoscopists used viscous solutions as submucosal injectate ( P  = 0.036) more often. Of the respondents, 44 % never tattooed the site of endoscopic resection. Ablation of edges post-endoscopic mucosal resection was not done by 25.5 % respondents. Most respondents used electronic chromoendoscopy (36.1 %) or random four-quadrant sampling (35.6 %) for surveillance in inflammatory bowel disease. Surveillance post-endoscopic resection was done arbitrarily by 24 % respondents at 6 months to 1 year. Conclusions There are several lacunae in the practice of IEE and colonic endoscopic resection among endoscopists, with need for programs for privileging, credentialing and proctoring these endoscopic skills.

Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding.

Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.

Utility of bowel ultrasound in assessing disease activity in Crohn's disease.

BACKGROUND: Gastrointestinal ultrasound (GIUS) has been used increasingly for monitoring inflammatory bowel disease (IBD) patients. The aim of this study was to assess the utility of GIUS in assessing disease activity in Crohn's disease (CD). METHODS: Consecutive patients with CD (diagnosis established for at least 6 months) between July 2017 and July 2018 requiring assessment of disease activity were prospectively assessed by magnetic resonance enterography, colonoscopy (CS), and GIUS within a 2-week period and without any change in ongoing treatment. Features on GIUS which correlated with disease activity were assessed. Sensitivity and specificity of the GIUS in assessing disease activity and localization were calculated. RESULTS: Thirty-five patients were enrolled in the study. Bowel wall thickness (BWT) ≥ 3 mm and Doppler activity ≥ 2 had the highest sensitivity (100% and 95.6%, respectively) for detecting active disease on CS. BWT ≥ 3 mm had sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 83.3%, 92%, and 100%, respectively for assessing active disease. Combination of median BWT, Doppler activity, and loss of bowel wall stratification correlated with simplified endoscopic score (SES) for CD (r = 0.8, p 0.009) and Harvey-Bradshaw index (HBI, r = 0.76, p 0.04). For localizing active disease in the ileum, GIUS had a sensitivity of 93.7%, 80% for lesions in the right colon, 100% for transverse colon, and 89% for the left colon. Specificity was 100% for ileal and colonic lesions. CONCLUSION: Loss of stratification, BWT, and Doppler activity in the bowel wall correlate with endoscopic and clinical disease activity in CD. GIUS is a sensitive modality in assessing disease activity in CD.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology.

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Cross-Sectional, Clinicoepidemiological, Multicenter, Nationwide Study in India: The PREDICT Study.

BACKGROUND: The study aimed at assessing the prevalence and clinical profile of minimal hepatic encephalopathy (MHE) in patients with cirrhosis using neuropsychological assessment and at understanding the management practices of MHE in the Indian clinical setting. METHODS: This cross-sectional, clinicoepidemiological study conducted at 20 sites enrolled liver cirrhosis patients with Grade 0 hepatic encephalopathy according to West-Haven Criteria. Patients were subjected to mini-mental state examination and those with a score of ≥24 were assessed using psychometric hepatic encephalopathy score. Short Form-36 questionnaire was administered to assess the impact on health-related quality of life. RESULTS: Of the 1260 enrolled patients, 1114 were included in the analysis. The mean age was 49.5 years and majority were males (901 [81%]). The prevalence of MHE was found to be 59.7% (665/1114) based on the psychometric hepatic encephalopathy score of ≤-5. Alcohol-related liver disease was the most common etiology (482 [43.27%]) followed by viral infection (239 [21.45%]). Past smokers as well as those currently smoking were more likely to have MHE than nonsmokers. A significant association was found between tobacco chewing, smoking, alcohol consumption, diabetes, and the presence of MHE. Multivariable analysis revealed smoking as the only parameter associated with MHE. A total of 300 (26.9%) patients were on prophylaxis with lactulose/lactitol or rifaximin. These patients were less likely to have MHE as compared to those not on prophylaxis (odds ratio, 0.67; 95% confidence interval, 0.50-0.88; P = 0.005). CONCLUSION: The disease burden of MHE is quite substantial in patients with cirrhosis with no apparent cognitive defect. Smoking, whether past or current, has significant association with the presence of MHE. Although MHE has been shown to adversely affect quality of life, prophylaxis for MHE is not routinely practiced in the Indian setting.The study has been registered under clinical trials registry of India (CTRI/2014/01/004306).

Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology.

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Olmesartan-related sprue-like enteropathy.

Chronic diarrhea is a common clinical problem in gastroenterology practice and often difficult to diagnose the cause. Presence of villous atrophy in these subjects is not specific as differential diagnosis can be broad. Drug-induced diarrhea is often overlooked during the evaluation. We report a short series of such challenging small bowel diarrhea secondary to olmesartan-related sprue-like enteropathy.

Antibiotic use in acute pancreatitis: an Indian multicenter observational study.

INTRODUCTION: Prophylactic antibiotics are used frequently for acute pancreatitis (AP). Consensus guidelines do not recommend this currently, based on moderate quality evidence. In this study, we aimed to evaluate the antibiotic use pattern in AP in India and propose a risk-directed approach to antibiotic use in AP. MATERIAL AND METHODS: This multicenter study was conducted from 1 May 2013 to 31 July 2013. Eleven participants from eight tertiary centers completed a questionnaire that captured patient demographics, etiology, admission status, presence of (peri)pancreatic necrosis, severity of pancreatitis, details of antibiotic use, and clinical outcomes (total hospital stay, persistent organ failure, need for ICU, total days in ICU, development of infections, in-hospital mortality). RESULTS: A total of 200 proformas were analyzed. Seventy-three (36.5 %) had acute necrotizing pancreatitis (ANP). Eighty-nine (44.5 %), 52 (26 %), and 55 (27.5 %) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. Forty-five (22.5 %) patients developed infections (unifocal 29; multifocal 16). One hundred thirty-four (67 %) patients received antibiotics, of which 89 (66.4 %) received prophylactic, while 45 (33.6 %) received therapeutic antibiotics. The distribution of antibiotic use according to the severity of AP was 43 (48.3 %) in patients with MAP (prophylactic in 41; therapeutic in 2), 36 (69.2 %) in patients with MSAP (prophylactic in 29; therapeutic in 7), and 55 (100 %) in patients with SAP (prophylactic in 19; therapeutic in 36). Therapeutic antibiotics were prescribed based on culture and sensitivity in 21 (46.7 %) patients. CONCLUSIONS: Despite nonrecommendation, prophylactic antibiotics are used frequently in AP. We emphasize on the need for multicenter randomized controlled trials on prophylactic antibiotics for AP based on a risk-directed approach, rather than a "blanket approach."

Acute necrotizing pancreatitis associated with vildagliptin.

CONTEXT: To report a case of acute necrotizing pancreatitis in a patient receiving vildagliptin. CASE REPORT: A 49-year-old man presented to us with severe abdominal pain and was diagnosed to have pancreatitis three weeks after the commencement of vildagliptin for the treatment of uncontrolled type 2 diabetes mellitus. His serum amylase was 2,215 U/L at admission, with contrast enhanced computed tomography (CECT) of the abdomen and pelvis showing features of acute pancreatitis. The patient had a prolonged hospital course and underwent laparoscopic pancreatic necrosectomy to relieve him of his biliary obstruction and an endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting as he had an avulsion of the cystic duct during surgery. CONCLUSIONS: Acute pancreatitis as a complication of other incretin-based therapy like sitagliptin and exenatide is known and well reported, and has prompted the US Food and Drug Administration to issue an alert on these drugs. This appears to be the first reported case of acute necrotizing pancreatitis in a patient receiving vildagliptin in India and reinforces the need to be more judicious in the use of this medication.

Incidental colorectal polyps in positron emission tomography.

Fluorodeoxy glucose positron emission tomography/computed tomography (FDG PET/CT) is increasingly being used for diagnosing various malignancies and surveillance of cancer recurrence, staging and screening in high-risk individuals. Due to its high sensitivity in picking up small dysplastic lesions, incidental lesions are detected frequently. We present two patients who underwent PET CT as part of cancer screening and were incidentally detected with adenomatous colonic polyps. Colonoscopy and biopsy confirmed the diagnosis.

Epidemiology and symptom profile of gastroesophageal reflux in the Indian population: report of the Indian Society of Gastroenterology Task Force.

BACKGROUND: Gastroesophageal reflux disease (GERD) and its complications are thought to be infrequent in India; there are no data from India on the prevalence of and risk factors for GERD. The Indian Society of Gastroenterology formed a task force aiming to study: (a) the frequency and profile of GERD in India, (b) factors including diet associated with GERD. METHODS: In this prospective, multi-center (12 centers) study, data were obtained using a questionnaire from 3224 subjects regarding the frequency, severity and duration of heartburn, regurgitation and other symptoms of GERD. Data were also obtained regarding their dietary habits, addictions, and lifestyle, and whether any of these were related or had been altered because of symptoms. Data were analyzed using univariate and multivariate methods. RESULTS: Two hundred and forty-five (7.6%) of 3224 subjects had heartburn and/or regurgitation at least once a week. On univariate analysis, older age (OR 1.012; 95% CI 1.003-1.021), consumption of non-vegetarian and fried foods, aerated drinks, tea/coffee were associated with GERD. Frequency of smoking was similar among subjects with or without GERD. Body mass index (BMI) was similar in subjects with and without GERD. On multivariate analysis, consumption of non-vegetarian food was independently associated with GERD symptoms. Overlap with symptoms of irritable bowel syndrome was not uncommon; 21% reported difficulty in passage of stool and 9% had mucus in stools. About 25% of patients had consulted a doctor previously for their gastrointestinal symptoms. CONCLUSION: 7.6% of Indian subjects have significant GERD symptoms. Consumption of non-vegetarian foods was an independent predictor of GERD. BMI was comparable among subjects with or without GERD.

Double-barrel common bile duct: a rare cause of extrahepatic biliary obstruction.

Double-barrel common bile duct is rare. We report a 50-year-old woman with defective canalization of the common bile duct, presenting with extrahepatic biliary obstruction due to stones in one compartment. CT scan highlighted this anomaly. After failed attempts at stone extraction at ERCP, she was successfully operated on.