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.

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.

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.

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.

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.

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.

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 malnutrition among patients with achalasia and effect of pneumatic dilation.

BACKGROUND: Although achalasia patients are undernourished, studies are scant. We studied: (i) the frequency of malnutrition among these patients and (ii) the effect of pneumatic dilatation (PD) on malnutrition. METHODS: A total of 70 adult achalasia patients and 70 healthy controls were evaluated through dietary recall, anthropometry, and biochemical parameters, and patients were reevaluated 6 months after PD. RESULTS: Patients had lower intake of calories (median, interquartile range [IQR]: 1835.0 [1682.5-1915.0] vs 2071.5 [1950-2276.2] kcal/day, P < 0.001), protein (40.9 [36.3-42.2] vs 52.9 [45.7-62] g/day, P < 0.001), calcium (310 [192.5-392.4] vs 477.5 [350-560] mg/day, P < 0.001), and iron (6.7 [4.7-8.8] vs 10.1 [7.5-11.50] mg/day, P < 0.001) than controls. Patients had lower body mass index (BMI: 19.6 [16.6-22] vs 22.8 [19.5,29.1], P < 0.001), midarm circumference (MAMC; 20 [17.5-23] vs 24.1 [21.4-28.5], P < 0.001), biceps (BSFT; 3.1 [1.9-3.9] vs 5.5 [3.8-9.2] mm, P < 0.001), triceps' skin fold thickness (TSFT; 5 [2.4-7] vs 7.8 [5.1-9.4] mm, P < 0.001), serum protein (7.2 ± 0.8 vs 7.6 ± 0.8 g/dL, P = 0.005), and albumin (4.0 [3.5-4.4] vs 4.1 [3.9-4.2] g/dL, P = 0.009). PD increased calories (1803 [950-2400] vs 2050 [1470-2950] kcal/day), protein intake (41.0 [22-70] vs 45.0 [37.5-80.0] gm/day), BMI (19.6 [12.8-30.0] vs 22.2[15.9-30.0] P = 0.001 for all), and MAMC (21 [14.1-32.0] vs 24.2 [15-32.0] cm, P = 0.03). Reduced intake was a determinant of malnutrition. CONCLUSIONS: Malnutrition is common in achalasia patients, and PD improved it.

Depressive symptoms and the risk of arthritis: A survival analysis using data from the osteoarthritis initiative.

BACKGROUND: Some studies investigated the association between depressive symptoms and arthritis; however, no longitudinal studies have documented the relationship between developing depressive symptoms and the risk of arthritis. Therefore, this study evaluated whether the development of depressive symptoms was associated with an elevated risk of arthritis. MATERIALS AND METHODS: A survival analysis using Cox regression models was applied to osteoarthritis initiative data obtained over 6 years from adults (n = 3,662) aged ≥45 years at baseline. Developing depressive symptoms was defined using the 20-item Center for Epidemiologic Studies Depression scale (cutoff 16 points) between baseline and 1 year. Arthritis was defined answering "yes" to the following self-reported question: "Did the doctor say you developed arthritis since the last clinic visit about 1 year ago?" over the 6-year follow-up period. RESULTS: The hazard ratios for developing arthritis were 3.51 (95% confidence interval [CI] = 2.32-5.29) and 2.03 (95% CI = 1.45-2.85) for men and women, respectively, as compared to those who did not develop depressive symptoms. There was a significantly (χ 2 = 73.672, P < 0.0001) lower survival probability at each time point throughout the study among men and women who developed depressive symptoms. CONCLUSION: In both men and women, developing depressive symptoms increased the risk of arthritis, and the survival probability decreased at each time point.

A randomized double-blind placebo-controlled trial showing rifaximin to improve constipation by reducing methane production and accelerating colon transit: A pilot study.

OBJECTIVE: Gut microbe-derived methane may slow colon transit causing chronic constipation (CC). Effect of rifaximin on breath methane and slow-transit CC was evaluated. METHOD: Bristol stool form, frequency, colon transit time (CTT), and breath methane were evaluated in 23 patients with CC (10 patients with constipation-predominant irritable bowel syndrome [IBS-C], 13 functional constipation, Rome III) and m-ethane production compared with 68 non-constipating IBS. Methane-producing CC (basal ≥ 10 PPM and/or post-lactulose rise by > 10 PPM) was randomized (double-blind) to rifaximin (400-mg thrice/day, 2-weeks) or placebo. Stool forms, frequency, breath methane, and CTT were recorded afterward. RESULTS: CC patients tended to be methane producer more often (13/23 [56.5%] vs. 25/68 [36.5%], p = 0.07) and had greater area under curve (AUC) for methane (2415 [435-23,580] vs. 1335 [0-6562.5], p = 0.02) than non-constipating IBS. Methane producers (8/13 [61.5%]) and 5/10 (50%) non-producers had abnormal CTT (marker retention: 36-h, 53 [0-60] vs. 19 [8-56], p = 0.06; 60-h, 16 [0-57] vs. 13 [3-56], p = 0.877). Six and 7/13 methane producers were randomized to rifaximin and placebo, respectively. Rifaximin reduced AUC for methane more (6697.5 [1777.5-23,580] vs. 2617.5 [562.5-19,867.5], p = 0.005) than placebo (3945 [2415-12,952.5] vs. 3720 [502.5-9210], p = 0.118) at 1 month. CTT normalized in 4/6 (66.7%) on rifaximin (36-h retention, 54 [44-57] vs. 36 [23-60], p = 0.05; 60-h, 45 [3-57] vs. 14 [11-51], p = 0.09) but none on placebo (p = 0.02) (36-h, 31 [0-60] vs. 25 [0-45], p = 0.078; 60-h, 6 [0-54] vs. 12 [0-28], p = 0.2). Weekly stool frequency (3 [1-9] and 7 [1-14], p = 0.05) and forms improved with rifaximin than placebo. CONCLUSION: Rifaximin improves CC by altering methane production and colon transit. TRIAL REGISTRATION: Clinical Trial Registry, India: REF/2012/01/003216 ᅟ ᅟ.

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.

Low-grade small intestinal bacterial overgrowth is common in patients with non-alcoholic steatohepatitis on quantitative jejunal aspirate culture.

BACKGROUND: Though pathogenesis of non-alcoholic steatohepatitis (NASH) is unclear, association with small intestinal bacterial overgrowth [SIBO] and fecal dysbiosis is suggested. We evaluated SIBO in NASH using quantitative jejunal aspirate culture (conventional criteria: ≥ 105 colony forming unit (CFU)/mL and newer cutoff ≥ 103 CFU/mL) and glucose hydrogen breath test. METHODS: Thirty-eight patients with NASH (age 37.5 years, range 20-54, 9, 24% female), diagnosed by ultrasonography, alanine aminotransferase >1.5 times normal and liver biopsy (in 27/38, 71%) and exclusion of other causes and 12 constipation-predominant irritable bowel syndrome as historical controls (age 39.5-y, 26-44; 3, 25% female) without fatty liver were studied. RESULTS: Jejunal aspirates, obtained in 35/38 patients, were sterile in 14/35 (40%) and bacteria isolated in 21 (60%) (all aerobic, in one anaerobe also; Gram positive 5, negative 13, both 3). In contrast, bacteria (two Gram negative) were isolated in 3/12 (25%) controls (odds ratio 4.5, 95% CI 1.0-19.5; p = 0.04); colony counts were higher in NASH than controls (median 380 CFU/mL, 0-200,000 vs. 0 CFU/mL, 0-1000; p = 0.02). Gram negative bacteria tended to be commoner in NASH than controls (16/35 vs. 2/12; p = 0.07). Seven out of 35 (20%) patients with NASH (≥ 105 CFU/mL in 5 and 2 other on glucose hydrogen breath test) and no control had SIBO (p = ns); low-grade SIBO (≥103 CFU/mL) was commoner in NASH than controls (14/35, 40%, vs. 1/12, 8.3%; p = 0.04). There was no correlation between bacterial colony count and bacterial type and anthropometric and biochemical parameters. CONCLUSION: Low-grade bacterial overgrowth, particularly with Gram negative bacteria, was commoner in NASH than controls.

Effect of biofeedback therapy on anorectal physiological parameters among patients with fecal evacuation disorder.

BACKGROUND: Though biofeedback therapy is often effective in patients with fecal evacuation disorder (FED), a common cause of chronic constipation (CC) in tertiary practice, data on anorectal physiological parameters following it are scanty. METHODS: Consecutive patients with FED with CC diagnosed by abnormalities in at least two of the three tests (anorectal manometry, defecography, and balloon expulsion test [BET]) undergoing biofeedback (two sessions per day, 30 min each, for 2 weeks) during a 3-year period were analyzed. Clinical evaluation, anorectal manometry (ARM), and BET were performed at the beginning and after biofeedback. RESULTS: Incomplete evacuation 42/43 (98%), straining 40/43 (93%), and feeling of outlet obstruction 35/43 (81%) were the most common symptoms among these 43 patients (median age 44 years, range 18-76, 30 [71%] male). All the three tests (defecography, BET, and ARM) were abnormal in 17 (40%) patients and the others had two abnormal tests. Improvement in physiological parameters was noted following biofeedback (median residual anal pressure during defecation 99 mmHg (range 52-148) vs. 78 mmHg (37-182), p = 0.03; maximum intra-rectal pressure 60 mmHg (90-110) vs. 76 mmHg (31-178); p = 0.01; defecation index 1.1 (0.1-23.0) vs. 3.2 (0.5-29.0); p = 0.001). Dyssynergia on ARM and BET got corrected in 22/34 (65%) and 18/30 (60%) patients. At a 1-month follow up, 23/37 (62%) patients reported satisfactory symptomatic improvement. CONCLUSIONS: Biofeedback not only improves symptoms but also anorectal physiological parameters in patients with FED.

Esophageal Acidification During Nocturnal Acid-breakthrough with Ilaprazole Versus Omeprazole in Gastroesophageal Reflux Disease.

BACKGROUND/AIMS: Though nocturnal acid-breakthrough (NAB) is common in gastroesophageal reflux disease (GERD) patients, its clinical importance results from esophageal acidification, which has been shown to be uncommon. Ilaprazole, a long-acting proton pump inhibitor, may cause NAB infrequently. Accordingly, we studied prospectively, (1) frequency and degree of esophageal acidification during NAB, and (2) frequency and severity of NAB while on ilaprazole versus omeprazole. METHODS: Fifty-eight consecutive patients with GERD on once daily ilaprazole, 10 mg (n = 28) or omeprazole, 20 mg (n = 30) for > one month underwent 24-hour impedance-pH monitoring prospectively. NAB was defined as intra-gastric pH < 4 for > one hour during night, and esophageal acidification as pH < 4 for any duration. Nocturnal symptoms (heartburn, regurgitation, and chest pain) were also recorded. RESULTS: Of the 58 patients (age 35.5 [inter-quartile range 26.5-46.0] years, 38 [65.5%], 42 (72.4%) had NAB. Though patients with NAB had lower nocturnal intra-gastric pH than without (2.8 [1.9-4.1] vs 5.7 [4.6-6.8], P < 0.001), frequency and duration of nocturnal esophageal acidification (17/42 vs 4/16, P = 0.360 and 0.0 [0.0-1.0] vs 0.0 [0.0-0.3] minutes, P = 0.260, respectively) and symptoms were comparable (13/42 vs 6/16, P = 0.750). Though ilaprazole was associated with less NABs (1 [range 1-2, n = 19] vs 1 [range 1-3, n = 23], P = 0.010) than omeprazole, the frequency, duration, and mean intra-gastric pH during NAB were comparable (19/28 vs 23/30, P = 0.560; 117 [0-315] vs 159 [69-287] minutes, P = 0.500; 1.02 [0.7-1.4] vs 1.04 [0.44-1.3], P = 0.620, respectively). CONCLUSIONS: Though NAB was common while patients were on a proton pump inhibitor, esophageal acidification was uncommon. Frequency and severity of NAB were comparable among patients on ilaprazole and omeprazole, except for the lesser number of NABs with ilaprazole.

Frequency, spectrum, and factors associated with fecal evacuation disorders among patients with chronic constipation referred to a tertiary care center in northern India.

BACKGROUND: Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India. METHODS: Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed. RESULTS: Of 249 patients (43.7 ± 16.2 years, 174 males), 135/242 (55.8 %), 57/249 (22.9 %), and 83/136 (61.0 %) had abnormal balloon expulsion test (>200 g), anorectal manometry [>100 mmHg resting pressure (n = 4), >167 mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4 cm, and/or rectocele), respectively. Though 181/249 (72.6 %) had one test abnormality, 86/249 (34 %) had FED (greater than or equal to two abnormalities), 44/65 (67.6 %) of whom had a defecation index ≤1.4. Rome III criteria for irritable bowel syndrome were equally fulfilled by patients with and without FED [74/83 (89 %) vs. 117/144 (81.2 %); p = ns]. On univariate analysis, straining duration, prolonged straining [≥30 min; 21/39 (53.8 %) vs. 15/65 (23.1 %); p = 0.002], incomplete evacuation [75/77 (97.4 %) vs. 95/114 (83.3 %); p = 0.004], and >3 stools/week [60/75 (80 %) vs. 76/128 (60 %); p = 0.004] were commoner among the FED patients though age, gender, symptom duration, mucus, manual evacuation, and stool forms were comparable. Resting and squeeze pressures and balloon volume at maximum tolerable limit were higher, and the sphincter tended to be shorter in FED. Prolonged straining, incomplete evacuation, and squeeze pressure were significant on multivariate analysis. Manometry and defecography abnormalities were commoner among the female FED patients. CONCLUSION: FED is not uncommon, which fulfills the Rome III criteria for IBS, and prolonged straining may be suggestive; abnormal defecography and manometry are commoner in female.

A proof-of-concept study showing antibiotics to be more effective in irritable bowel syndrome with than without small-intestinal bacterial overgrowth: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Antibiotics relieve symptoms in half of the unselected patients with irritable bowel syndrome (IBS); however, their efficacy if selected according to small-intestinal bacterial overgrowth (SIBO) is unknown. AIMS: The aim of this study was to evaluate (a) symptom resolution among IBS patients with or without SIBO on norfloxacin treatment, and (b) its efficacy in obtaining negative SIBO test results as compared with placebo. METHOD: Eighty IBS patients (Rome III) were evaluated for SIBO by gut aspirate culture. Patients with (≥10 CFU/ml) and those without SIBO were separately randomized (computer-generated stratified) to 800 mg/day norfloxacin for 10 days or placebo. Global symptom score (blindly), Rome III criteria, aspirate culture, and glucose hydrogen breath test (GHBT) were assessed before and 1 month after treatment, and patients were followed up for 6 months. RESULTS: Although norfloxacin was more effective at reducing the symptom score at 1 month among patients with compared with those without SIBO [15/80, 19% on culture, four on GHBT too; 6.5 (2-13) vs. 2 (0-10), P=0.01; 8.5 (2-16) vs. 5 (0-12), P<0.001] but not placebo, the scores were comparable at 6 months [3 (1-10) vs. 9 (5-19), P=NS]. Symptoms more often resolved to turn Rome III negative in SIBO patients treated with norfloxacin compared with placebo at 1 month (7/8, 87.5 vs. 0/7, P=0.004); of the other 65 patients, 8/32 (25%) treated with norfloxacin but none of the 33 treated with placebo turned Rome III negative. Patients without SIBO and a colony count of 10-10 CFU/ml responded more than those with a colony count less than 10 CFU/ml. Overall, 15/40 (37.5%) patients responded to norfloxacin. At 6 months, 2/8 (25%) with and 5/32 (15.6%) without SIBO remained Rome III negative following norfloxacin. All 4/8 consenting patients treated with norfloxacin became SIBO negative (two each by culture+GHBT and GHBT alone), but 0/7 patients treated with placebo became SIBO negative. CONCLUSION: Norfloxacin is superior to placebo in relieving symptoms of SIBO-associated IBS.

Hookworm infestation is not an uncommon cause of obscure occult and overt gastrointestinal bleeding in an endemic area: A study using capsule endoscopy.

Obscure gastrointestinal bleeding (OGIB), particularly occult, has been reported to be caused by hookworm infestation rarely from tropical countries, particularly India. Hence, we undertook a retrospective study evaluating frequency, clinical spectrum, and outcome of patients with OGIB associated with worm infestation. Data of consecutive patients with OGIB undergoing capsule endoscopy in a multilevel university hospital in northern India were retrospectively analyzed. Twenty-one out of 163 (13 %) patients with OGIB had hookworm infestation detected on capsule endoscopy. Of 21 patients (median age 65 years [range 19-82], 17 [81 %] male), 16 had overt and 5 had occult OGIB. Another lesion that could explain OGIB was present in 8/21 patients, 3/5 with OGIB occult, and 5/16 overt (p = ns). All the patients received treatment with albendazole and appropriate measures for the associated lesion, if any. Patients with hookworm infestation with another lesion experienced recurrent bleeding more often than those with worm infestation only. Hookworm infestation is an important cause of occult as well as overt OGIB and may be present even in association with another lesion. Those with additional lesion had recurrent bleeding more often than those with worm infestation alone.

Achalasia Is Associated With eNOS4a4a, iNOS22GA, and nNOS29TT Genotypes: A Case-control Study.

BACKGROUND/AIMS: Achalasia is known to result from degeneration of inhibitory neurons, which are mostly nitrinergic. Characteristic features of achalasia include incomplete lower esophageal sphincter (LES) relaxation and esophageal aperistalsis. Nitric oxide (NO), pro-duced by NO synthase (NOS), plays an important role in peristalsis and LES relaxation. Therefore, we evaluated genetic poly-morphisms of NOS gene isoforms (endothelial NOS [eNOS], inducible NOS [iNOS], and neuronal NOS [nNOS]) in patients with achalasia and healthy subjects (HS). METHODS: Consecutive patients with achalasia (diagnosed using esophageal manometry) and HS were genotyped for 27-base pair (bp) eNOS variable number of tandem repeats (VNTR), iNOS22G/A (rs1060826), nNOS C/T (rs2682826) polymorphisms by polymer-ase chain reaction (PCR) and PCR-restriction fragment length polymorphism (RFLP), respectively. RESULTS: Among 183 patients (118 [64.5%] male, age 39.5 ± 13.0 years) with achalasia and 366 HS (254 [69.4%] male, age 40.8 ± 11.0 years), eNOS4a4a genotype of 27-bp VNTR was more common among achalasia than HS (20 [10.9%] vs 13 [3.6%]; P < 0.001; OR, 3.72; 95% CI, 1.8-7.7). Patients with achalasia had iNOS22GA genotypes more often than HS (95 [51.9%] vs 93 [25.4%]; P < 0.001; OR, 3.0; 95% CI, 2.1-4.4). Frequency of genotypes GA + AA was higher in patients than HS (97 [53%] vs 107 [29.2%]; P < 0.001; OR, 2.7; 95% CI, 1.8-3.9). Also, nNOS29TT variant genotype in rs2682826 was more com-mon among patients compared to HS (14 [7.7%] vs 6 [1.6%]; P < 0.001; OR, 5.91; 95% CI, 2.2-15.8). CONCLUSIONS: Achalasia is associated with eNOS4a4a, iNOS22GA, and nNOS29TT genotypes. This may suggest that polymorphisms of eNOS, iNOS, and nNOS genes are risk factors for achalasia.

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).