Neonatal perforated appendicitis: a presentation of necrotising enterocolitis?

In this case report, we present a late preterm growth-restricted neonate who developed signs of feeding intolerance on the second day of life, which progressed to frank peritonitis with perforation by the end of the second week of life. As necrotising enterocolitis was considered the most likely diagnosis, a glove drain was placed in the flanks. The neonate did not improve, and surgical exploration was done after medical stabilisation. On exploration, the neonate was found to have appendicular perforation and an appendicectomy was performed. During surgery, the rest of the gut was noted to be healthy. Histopathological examination of the appendix showed transmural inflammation, focal infarction and perforation. The postoperative period was uneventful, and the neonate showed rapid improvement and reached full enteral feeding in the next 5 days. Antibiotic therapy promptly resolved bacterial peritonitis, and the neonate was discharged successfully.

Infantile inflammatory myofibroblastic tumour of the sigmoid colon: a diagnostic dilemma.

An inflammatory myofibroblastic tumour (IMT) is an uncommon neoplasm composed of inflammatory cells and myofibroblasts in a fibrous stroma. They are mostly seen in the lungs and rarely involve the gastrointestinal tract. An 8-month-old infant presented with a history of lower abdominal lump for 2 months. Her CT scan confirmed a large, lobulated mass in the retroperitoneum arising from the pelvis. The mass was found to be arising from the sigmoid colon on laparotomy which was excised. Histopathology showed a cellular tumour composed of spindle cells and inflammatory lymphocytic infiltrate. Immunohistochemistry revealed positive staining for anaplastic lymphoma kinase and smooth muscle actin, confirming the diagnosis of IMT. The patient is doing well at her 6-month follow-up. Ours is the youngest case of sigmoid IMT among the only other series of eight cases reported in the literature indicating its rarity.

Congenital Spigelian Hernia With Ipsilateral Ectopic Testis.

Background: The association between congenital spigelian hernia and ipsilateral ectopic testis has been debated in the literature, and the management of such cases has yet to be standardized. Both pediatric surgeons and sonographers should be aware of this entity to allow for prompt diagnosis and monitoring/repair because congenital spigelian hernias have a high risk of incarceration. Case Report: A 3-month-old male presented with left-sided abdominal wall swelling present since birth with coexisting left-sided undescended testis. Ultrasound confirmed the suspicion of a congenital spigelian hernia with undescended testis but failed to locate the ectopic testis. Diagnostic laparoscopy and open repair of the spigelian hernia were performed when the patient was 9 months of age. Left-sided orchidopexy was also performed as the left testis was located within the spigelian sac. The patient was asymptomatic at 1-year follow-up. Conclusion: The association between congenital spigelian hernia and ipsilateral ectopic testis requires the surgeon and sonographer to pay special attention to the spigelian hernia sac as it may contain the ectopic testis. Orchidopexy and hernia repair in very young children may be delayed while closely monitoring for incarceration to allow for improvement in immunity, an increase in size of the spermatic cord and vasculature, and avoidance of the stress of 2 separate surgeries. The surgical approach can be laparoscopic or open depending on the experience of the surgeon and the complexity of intraoperative findings.

Hepatocellular Carcinoma Evaluation and Management for Physicians: Joint Gastroenterology Research Society and Association of Physicians of India Guidelines.

Hepatocellular carcinoma (HCC) is the most common cause of, and accounts for almost 90% of all liver cancers. Data from India is limited especially due to cancer not being a reportable disease and in view of wide variation in diagnostic modalities. This document is a result of a consensus meeting comprising Hepatologists, Interventional Radiologists, Hepatobiliary surgeons, medical and surgical Oncologists nominated by the Association of Physicians of India and Gastroenterology Research Society of Mumbai. The following Clinical Practice Guidelines for practicing physicians is intended to act as an up to date protocol for clinical management of patients with hepatocellular carcinoma. The document comprises seven sections with statements and sub-statements with strength of evidence and recommendation.

Duplication cyst with midgut volvulus in a neonate: an unusual presentation.

Incomplete intestinal fixation or malrotation of gut with midgut volvulus is one of the important causes of bilious vomiting in neonates. The incidence of malrotation of gut in population is 4% and that of duplication cyst is 1:4500. Patients with malrotation are prone to develop midgut volvulus due to their narrow mesenteric base demanding urgent surgical intervention. Common associated anomalies are intrinsic duodenal obstruction, internal hernias, caecal volvulus, anorectal malformations and Hirschsprung's disease. The present case refers to a 4-day-old neonate who presented with malrotation of gut with reverse volvulus and an associated gastrointestinal duplication cyst, which is a rare association with only few reported case reports. After imaging with ultrasound and contrast radiograph, the baby underwent prompt surgical intervention in the form of Ladd's procedure with resection and anastomosis of jejunal duplication cyst.

Adult with intestinal malrotation and colocolic intussusception: an unusual combo.

Intestinal malrotation is a congenital anomaly that results from an abnormality in the rotation and fixation of the gut as it returns to the abdominal cavity during development. Intussusception is a condition characterised by telescoping of one segment of the bowel into another segment. The combination of malrotation and intussusception is frequently a cause of intestinal obstruction in the paediatric age group. The coexistence of these two conditions is termed as Waugh syndrome and is uncommon in adults. We share our experience with an elderly woman who was admitted with diarrhoea and anaemia. Investigations revealed a large colonic polyp, colocolic intussusception and malrotation. The adenomatous polyp and mobile right colon would have lead to intussusception. The diagnosis was based on the findings of colonoscopy and contrast-enhanced CT scan of the abdomen. She was managed with a transverse colectomy with an uneventful recovery.

Recurrent gastrointestinal bleeding in a patient with type 1 neurofibromatosis.

Type 1 neurofibromatosis (NF1) is a hereditary disorder with an incidence of approximately 1:3000 at birth. Gastrointestinal (GI) lesions occur in approximately one-third of the patients, with most being asymptomatic and diagnosed incidentally. Symptomatic lesions leading to GI bleeding are uncommon. We share our experience of an elderly man with NF1, who presented with massive recurrent GI bleeding secondary to jejunal neurofibromas. The lesions were identified on CT scan of abdomen, and the patient was managed with resection of the involved bowel segment.

Pegylated interferon alfa-2b plus ribavirin for treatment of chronic hepatitis C.

AIM: To study the safety and efficacy of pegylated interferon alfa-2b, indigenously developed in India, plus ribavirin in treatment of hepatitis C virus (HCV). METHODS: One-hundred HCV patients were enrolled in an open-label, multicenter trial. Patients were treated with pegylated interferon alfa-2b 1.5 µg/kg per week subcutaneously plus oral ribavirin 800 mg/d for patients with genotypes 2 and 3 for 24 wk. The same dose of peginterferon plus weight-based ribavirin (800 mg/d for ≤ 65 kg; 1000 mg/d for > 65-85 kg; 1200 mg/d for > 85-105 kg; 1400 mg/d for > 105 kg body weight) was administered for 48 wk for patients with genotypes 1 and 4. Serological and biochemical responses of patients were assessed. RESULTS: Eighty-two patients (35 in genotypes 1 and 4 and 47 in 2 and 3), completed the study. In genotype 1, 25.9% of patients achieved rapid virologic response (RVR): while the figures were 74.1% for early virologic response (EVR) and 44.4% for sustained virologic response (SVR). For genotypes 2 and 3, all patients bar one belonged to genotype 3, and of those, 71.4%, 87.5%, and 64.3% achieved RVR, EVR, and SVR, respectively. In genotype 4, 58.8%, 88.2%, and 52.9% of patients achieved RVR, EVR, and SVR, respectively. The majority of patients attained normal levels of alanine aminotransferase by 4-12 wk of therapy. Most patients showed a good tolerance for the treatment, although mild-to-moderate adverse events were exhibited; only two patients discontinued the study medication due to serious adverse events (SAEs). Eleven SAEs were observed in nine patients; however, only four SAEs were related to study medication. CONCLUSION: Peginterferon alfa-2b, which was developed in India, in combination with ribavirin, is a safe and effective drug in the treatment of HCV.

Randomized, double-blind, comparative study of dexrabeprazole 10 mg versus rabeprazole 20 mg in the treatment of gastroesophageal reflux disease.

AIM: To compare the efficacy and safety of dexrabeprazole 10 mg versus rabeprazole 20 mg in the treatment of gastroesophageal reflux disease (GERD). METHODS: This was a randomized, double-blind clinical study. Fifty patients with GERD were randomly assigned to receive dexrabeprazole 10 mg or rabeprazole 20 mg once daily. Efficacy was assessed by evaluating improvement in visual analog scale (VAS) scores of heart-burn and regurgitation and safety was assessed by recording incidence of any adverse drug reactions. Laboratory investigations and upper gastro-intestinal endoscopy was conducted at baseline and after 28 d of therapy. RESULTS: A total of 50 patients (n = 25 in dexrabeprazole group and rabeprazole group each) completed the study. There were no significant differences in the baseline characteristics between the two groups. The VAS score (mean +/- SD) of heartburn and regurgitation in dexrabeprazole (64.8 +/- 5.1 and 64 +/- 8.1, respectively) and rabeprazole (64.4 +/- 8.7 and 57.6 +/- 9.7, respectively) groups significantly reduced (P < 0.0001) to 30 +/- 11.5, 24 +/- 10 and 32 +/- 9.5, 29.2 +/- 11.9, respectively on d 28. A significantly higher (P = 0.002) proportion of patients showed >or= 50% improvement in regurgitation with dexrabeprazole 10 mg (96%) compared to rabeprazole 20 mg (60%). Onset of symptom improvement was significantly earlier with dexrabeprazole than with rabeprazole (1.8 +/- 0.8 d vs 2.6 +/- 1.4 d; P < 0.05). The incidences of esophagitis in the dexrabeprazole group and rabeprazole group before therapy were 84% and 92%, respectively (P = 0.38). The incidence of improvement/healing of esophagitis after therapy was more (P = 0.036) in the dexrabeprazole group (95.2%) compared to the rabeprazole group (65.2%). No adverse drug reaction was seen in either group. CONCLUSION: In the treatment of GERD, efficacy of dexrabeprazole 10 mg is better than rabeprazole 20 mg, with regards to improvement/healing of endoscopic lesions and relief from symptoms of regurgitation.

Recent advances in chirally pure proton pump inhibitors.

Chirality is a ubiquitous natural phenomenon resulting because of a differential spatial orientation of molecules around its chiral centre. This leads to the existence of two or more spatially dissimilar forms, known as stereoisomers or enantiomers, which are non-superimposable images of each other and may significantly differ from each other with respect to pharmacokinetic and pharmacodynamic properties and molecular interaction. Thus one isomer may offer significant pharmacokinetic and therapeutic advantages as compared to the other isomer or the racemic mixture (mixture containing both enantiomers). Proton pump inhibitors are a class of drugs which have been very effective in the management of acid-related disorders. The proton pumps currently available in the market including omeprazole, pantoprazole, rabeprazole and lansoprazole are racemic mixtures of the S and R isomers. Chirally pure forms of proton pump inhibitors show a superior metabolic and pharmacokinetic profile as compared to their racemates. The therapeutic efficacy is also superior to the parent racemate. This has been clearly demonstrated with the development of esomeprazole- the S-isomer of omeprazole. S-pantoprazole and dexrabeprazole also offer therapeutic advantages as compared to racemic pantoprazole and racemic rabeprazole respectively. This article reviews the chiral developments in the proton pump inhibitors and their clinical applications.

Comparative clinical trial of S-pantoprazole versus racemic pantoprazole in the treatment of gastro-esophageal reflux disease.

AIM: To compare the efficacy and tolerability of S-pantoprazole (20 mg once a day) versus racemic pantoprazole (40 mg once a day) in the treatment of gastro-esophageal reflux disease (GERD). METHODS: This multi-centre, randomized, double-blind clinical trial consisted of 369 patients of either sex suffering from GERD. Patients were randomly assigned to receive either one tablet (20 mg) of S-pantoprazole once a day (test group) or 40 mg racemic pantoprazole once a day (reference group) for 28 d. Patients were evaluated for reduction in baseline on d 0, GERD symptom score on d 14 and 28, occurrence of any adverse effect during the course of therapy. Gastrointestinal (GI) endoscopy was performed in 54 patients enrolled at one of the study centers at baseline and on d 28. RESULTS: Significant reduction in the scores (mean and median) for heart burn (P < 0.0001), acid regurgitation (P < 0.0001), bloating (P < 0.0001), nausea (P < 0.0001) and dysphagia (P < 0.001) was achieved in both groups on d 14 with further reduction on continuing the therapy till 28 d. There was a statistically significant difference in the proportion of patients showing improvement in acid regurgitation and bloating on d 14 and 28 (P = 0.004 for acid regurgitation; P = 0.03 for bloating) and heart burn on d 28 (P = 0.01) between the two groups, with a higher proportion in the test group than in the reference group. Absolute risk reductions for heartburn/acid regurgitation/bloating were approximately 15% on d 14 and 10% on d 28. The relative risk reductions were 26%-33% on d 14 and 15% on d 28. GI endoscopy showed no significant difference in healing of esophagitis (P = 1) and gastric erosions (P = 0.27) between the two groups. None of the patients in either group reported any adverse effect during the course of therapy. CONCLUSION: In GERD, S-pantoprazole (20 mg) is more effective than racemic pantoprazole (40 mg) in improving symptoms of heartburn, acid regurgitation, bloating and equally effective in healing esophagitis and gastric erosions. The relative risk reduction is 15%-33%. Both drugs are safe and well tolerated.