EUS of the neck: A comprehensive anatomical reference for the staging of head and neck cancer (with videos).

The use of EUS has application in the nodal staging of head and neck cancer. The technique and the anatomy of head and neck region using EUS have not been described. EUS from three stations in thoracic esophagus, cervical esophagus, and hypopharynx can allow imaging of head and neck. In this article we describe the normal structures from the three stations. The EUS imaging of head and neck can give relevant and additional information in malignancies of head and neck.

The Role of Biochemical Variations and Genotype Testing in Determining the Virological Response of Patients Infected with Hepatitis C Virus.

BACKGROUND: In hepatitis C virus (HCV), infection viral and IL28B genotype along with many clinical and biochemical factors can influence response rates to pegylated interferon plus ribavirin (Peg-IFN-a/R) therapy and progression to chronic hepatitis C (CHC). AIMS: The present study was conducted to determine the effect of biochemical and risk factors on treatment outcome in CHC patients in relation to their viral and host genotype. SETTINGS AND DESIGN: The present study was a prospective Pe- IFN efficacy study consisting of Peg-IFN-a/R therapy for 24-48 weeks including 250 HCV infected patients. MATERIALS AND METHODS: Biochemical parameters were determined by Beckman Coulter AU680 automated analyzer. HCV and Interleukin 28B (IL28B) genotyping were carried out by polymerase chain reaction-restriction fragment length polymorphism and viral load was determined by quantitative real-time PCR. RESULTS: Wild outnumbered the variant genotypes in rs12979860, rs12980275, and rs8099917 SNP of IL28B gene. Sustained virological response (SVR) SVR and viral genotype were significantly associated with age, hepatic steatosis, low-grade varices, and serum aspartate transaminase levels (at the end of treatment) (P < 0.05). In addition, SVR was significantly influenced by body mass index (BMI), insulin resistance, serum low-density lipoprotein , and ferritin levels (P < 0.05). Viral genotype 1 infected patients had higher serum cholesterol and triglyceride levels (P < 0.05). CONCLUSIONS: Although the IL28B sequence variation is the major factor that can influence response rates to antiviral therapy, viral and biochemical factors also have a definite role to play in the diagnosis, etiology, and treatment outcome in HCV-infected patients.

Impact of IL28B genetic variant's and viral genotype on treatment outcome of hepatitis C infected patients.

INTRODUCTION: Viral genotype and variation in host genes involved in the immune response may predict the treatment response in patients infected with HCV. The present study was designed to determine the distribution pattern of HCV and host genotypes in Chronic Hepatitis C (CHC) patients and their association with virological response and other risk factors. METHODOLOGY: Two hundred and fifty (n = 250) HCV positive patients were included in the study. HCV and Interleukin 28B (IL28B) genotyping was carried out by PCR-RFLP. RESULTS: Viral genotype 3 was the predominant genotype seen in 187 (74.8%) patients. Wild genotype predominated in rs12979860, rs12980275 and rs8099917 SNP of IL28B gene. A significant difference was found in end stage virological response (EVR) between HCV genotype 1 infected patients with wild and variant genotype for rs12980275 and rs8099917 SNPs respectively (P < 0.05). On multivariate analysis all the SNPs were found to be associated with each other (P < 0.05) with rs12980275 SNP associated with history of Jaundice (P < 0.05). Viral genotype 3 was significantly associated with age (< 50 years) and rapid virological response (RVR) while as viral genotype 1 was significantly associated with history of surgery on multivariate analysis (P < 0.05). CONCLUSIONS: The viral genotype and IL28B polymorphisms are important factors to personalize antiviral therapy of patients with CHC.

Imaging of spaces of neck and mediastinum by endoscopic ultrasound.

Endoscopic ultrasound (EUS) of the mediastinum was pioneered by gastroenterologists, and it was taken up by pulmonologists when the smaller-diameter endobronchial ultrasound (EBUS) scope was designed after a few years. The pulmonologists' approach remained largely confined to entry from the trachea, but they soon realized that the esophagus was an alternative route of entry by the EBUS scope. The new generations of interventionists are facing the challenge of learning two techniques (EUS and EBUS) from two routes (esophagus and trachea). The International Association for the Study of Lung Cancer (IASLC) proposed a classification of mediastinal lymph nodes at different stations that lie within the boundaries of specific spaces. These interventionists need clear definitions of landmarks and clear techniques to identify the spaces. There are enough descriptions of spaces of the neck and the mediastinum in the literature, yet the topic mentioned above has never been discussed separately. The anatomical structures, landmarks, and boundaries of spaces will be important to interventionists in the near future during performances of endosonography. This article combines the baseline anatomy of the spaces with the actual imaging during EUS.

Endoscopic ultrasound in mediastinal tuberculosis.

BACKGROUND: Tubercular lymphadenitis is the commonest extra pulmonary manifestation in cervical and mediastinal locations. Normal characteristics of lymph nodes (LN) have been described on ultrasonography as well as by Endoscopic Ultrasound. Many ultrasonic features have been described for evaluation of mediastinal lymph nodes. The inter and intraobserver agreement of the endosonographic features have not been uniformly established. METHODS AND RESULTS: A total of 266 patients underwent endoscopic ultrasound guided fine needle aspiration and 134 cases were diagnosed as mediastinal tuberculosis. The endoscopic ultrasound location and features of these lymph nodes are described. CONCLUSION: Our series demonstrates the utility of endoscopic ultrasound guided fine needle aspiration as the investigation of choice for diagnosis of mediastinal tuberculosis and also describes various endoscopic ultrasound features of such nodes.

Imaging of pancreas divisum by linear-array endoscopic ultrasonography.

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. Endoscopic ultrasound (EUS) is often performed to evaluate idiopathic pancreatitis and has been shown to have high accuracy in diagnosis of PD. The different techniques to identify PD by linear EUS have been described differently by different authors. If EUS is done with a proper technique it can be a valuable tool in the diagnosis of PD. The anatomical and technical background of different signs has not been described so far. This article summarizes the different techniques of imaging of pancreatic duct in a suspected case of PD and gives a technical explanation of various signs. The common signs seen during evaluation of pancreatic duct in PD are stack sign of linear EUS, crossed duct sign on linear EUS, the dominant duct and ventral dorsal duct (VD) transition. Few other signs are described which include duct above duct, short ventral duct /absent ventral duct, separate opening of ducts with no communication, separate opening of ducts with filamentous communication, stacking of duct of Santorini and indirect signs like santorinecele. The principles of the sign have been explained on an anatomical basis and the techniques and the principles described in the review will be helpful in technical evaluation of PD during EUS.

Imaging of common bile duct by linear endoscopic ultrasound.

Imaging of common bile duct (CBD) can be done by many techniques. Endoscopic retrograde cholangiopancreaticography is considered the gold standard for imaging of CBD. A standard technique of imaging of CBD by endoscopic ultrasound (EUS) has not been specifically described. The available descriptions mention different stations of imaging from the stomach and duodenum. The CBD lies closest to duodenum and choice of imaging may be restricted to duodenum for many operators. Generally most operators prefer multi station imaging during EUS and the choice of selecting the initial station varies from operator to operator. Detailed evaluation of CBD is frequently the main focus of imaging during EUS and in such situations multi station imaging with a high-resolution ultrasound scanner may provide useful information. Examination of the CBD is one of the primary indications for doing an EUS and it can be done from five stations: (1) the fundus of stomach; (2) body of stomach; (3) duodenal bulb; (4) descending duodenum; and (5) antrum. Following down the upper 1/3(rd) of CBD can do imaging of entire CBD from the liver window and following up the lower 1/3(rd) of CBD can do imaging of entire CBD from the pancreatic window. This article aims at simplifying the techniques of imaging of CBD by linear EUS.

Prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin in Kashmir (India).

OBJECTIVES: The purpose of this study was to evaluate the prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin. METHODS: One hundred and sixty-one consecutive patients with iron-deficiency anemia of obscure origin were evaluated. Tissue transglutaminase antibodies levels were done and duodenal biopsies were scored according to Marsh classification. Diagnosis was based on positive IgA anti-tissue transglutaminase antibodies and abnormal histopathology. Gluten-free diet (GFD) was adviced for celiac disease patients. One hundred and sixty healthy blood donors were tested for IgA anti-tissue transglutaminase antibodies, and positive controls were subjected to endoscopic duodenal biopsy. RESULTS: Tissue transglutaminase antibodies were positive in 13 (8 %) patients with iron-deficiency anemia of obscure origin and 4 (2.5 %) in control group (p = 0.026) (odds ratio 3.42; 95 % confidence interval [CI]: 1.092-10.743). All 13 patients (8 %) and 2 out of 4 positive controls (1.25 %) had histopathology findings of celiac disease (p = 0.004). Duodenal biopsy showed Marsh grade 1 in 4, grade 2 in 4 (30.77 %), 3a in 1 (7.70 %), 3b in 2 (15.38 %), and 3c in 2 (15.38 %) patients. A statistically significant correlation was found between lower hemoglobin concentration and higher Marsh grading (Spearman's rho = -0.946, p = 0.001). Celiac disease patients adhered to GFD and after 6 months mean (SD) hemoglobin levels increased from 7.42 ± 0.96 to 10.47 ± 0.80 g/dL (p- < 0.001). CONCLUSION: Patients with iron-deficiency anemia of obscure origin had increased prevalence of celiac disease. Gluten-free diet improved anemia in celiac disease patients irrespective of grade of duodenal involvement.

Efficacy and safety of sequential therapy versus standard triple therapy in Helicobacter pylori eradication in Kashmir India: a randomized comparative trial.

BACKGROUND: Increasing resistance against Helicobacter pylori has resulted in reduced eradication rates. OBJECTIVE: This study aims to determine whether eradication rates for H. pylori infection with sequential therapy is better than standard triple therapy. PATIENTS: Patients with endoscopy documented peptic ulcer and H. pylori infection confirmed by histology and rapid urease test. INTERVENTION: Patients were randomized into two groups; 134 received standard triple therapy (pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1 g each administered twice daily) for 10 days and 138 received sequential regimen (pantoprazole 40 mg plus amoxicillin 1 g twice daily for 5 days followed by 40 mg pantoprazole, 500 mg clarithromycin, and 500 mg tinidazole each administered twice daily for 5 days). Eradication was confirmed by histology and rapid urease test. Compliance and adverse effects were determined by the recovery of empty medicine strips and questioning. RESULTS: The eradication rates with sequential therapy were significantly greater than with standard therapy on both intention-to-treat analysis (76.0 % vs. 61.9 %, p = 0.005; difference, 14.1 % [95 % CI, 6.5-19 %] and per protocol analysis (84.6 % vs. 67.4 %, p = 0.002; difference, 17.2 % [95 % CI, 8.5-23.5 %]). The incidence of side effects did not differ between the two therapy groups. One patient in standard therapy discontinued treatment due to side effects. LIMITATION: Cultures were not performed. Loss to follow up was 5.2 % in standard therapy and 6.5 % in sequential therapy. CONCLUSION: Sequential therapy was significantly more effective than standard therapy for eradicating H. pylori infection in peptic ulcer disease in Asian patients. Side effects were similar.

Etiology and outcome of acute pancreatitis in children in Kashmir (India). An endemic area of hepatobiliary ascariasis.

BACKGROUND: The purpose of the present study was to determine the etiology, management, and outcome of acute pancreatitis (AP) in children in an endemic area of hepatobiliary ascariasis (HBA). METHODS: This was a prospective, hospital-based study over a 9-year period that included 156 children younger than 12 years of age who had a diagnosis of AP. RESULTS: Of the 156 patients, 71 were boys and 85 were girls with a mean age of 8.4 ± 1.5 years (range 3-12 years). The various factors contributing to AP were biliary ascariasis in 93 cases (60 %), gallstones 16 (10 %), trauma 5 (3 %), choledochal cyst 4 (3 %), impacted bile duct stone 3 (2 %), and gallbladder sludge 2 (1 %). Idiopathic group 33 cases (21 %). Diagnosis was based on clinical picture, abdominal ultrasonography, and elevated serum amylase level. Pancreatitis was mild in 113 (72 %) patients and severe in 43 (28 %). With conservative therapy, 123 patients (79 %) improved, whereas the remaining 33, who had intractable abdominal pain, cholangitis, or worsening cholecystitis, underwent emergency endoscopic retrograde cholangiopancreatography for removal of worms (26 patients) and stones in the bile duct (7 patients). Bile duct stones were extracted in all 7 patients with that condition, and worms were extracted from 23 of the 26 patients with ascariasis. Emergency surgery was performed in five patients. Three patients died. Pancreatitis recurred in 16 patients due to HBA. CONCLUSIONS: Pancreatitis is not uncommon in children. Ascariasis is a leading cause of AP in endemic areas. Patients usually respond to conservative management, but endoscopic treatment is effective. Surgery is rarely required.

Prevalence of Helicobacter pylori infection and the effect of its eradication on symptoms of functional dyspepsia in Kashmir, India.

BACKGROUND AND AIM: Epidemiology of Helicobacter pylori infection has regional variation. Effect of eradication of H. pylori on symptoms of functional dyspepsia is uncertain, and the data in Asian scenario are scanty. The study aimed to see H. pylori positivity rate in patients of functional dyspepsia and the effect of its eradication on symptoms. METHODS: Randomized, double-blind, placebo-controlled study was the study design used. Patients of functional dyspepsia defined as per Rome 2 criteria were tested for H. pylori infection by rapid urease test and gastric biopsy. H. pylori-positive patients were randomly allocated to triple therapy (20 mg of omeprazole, 500 mg of clarithromycin, and 1000 mg of amoxicillin orally two times daily) and omeperazole plus identical placebo for 2 weeks. Symptoms were assessed with the weekly Likert scale. RESULTS: H. pylori positivity rate in functional dyspepsia was 1160/2000 (58%). At 6 weeks, the eradication rate for H. pylori in triple therapy and placebo group was (181/259 [69.8%] and 13/260 [5.0%], P = 0.001), respectively. On intention-to-treat analysis, the symptom resolution at 1 month was (157/259 [60.7%] and 136/260 [52.3%], P = 0.38), respectively. At 12 months, H. pylori eradication and healing of gastritis in triple therapy and placebo group were (116/174 [66.7%] and 12/180 [6.7%], P = 0.001) and (132/174 [75.9%] and 11/180 [6.1%], P = 0.001), respectively. On intension to treat, the resolution of symptoms in triple therapy and placebo group was (95/217 [43.7%] and 72/195 [36.9%], P = 0.13). CONCLUSION: There is high H. pylori positivity rate in patients of functional dyspepsia. The eradication of H. pylori does not resolve the symptoms despite healing of gastritis.

Safety and efficacy of 1-week levofloxacin-based triple therapy in first-line treatment for Helicobacter pylori-related peptic ulcer disease in Kashmir, India.

BACKGROUND AND OBJECTIVES: There is no ideal therapy for eradication of Helicobacter pylori infection. We evaluated the efficacy and safety of 1-week triple therapy with rabeprazole, levofloxacin, and tinidazole in a metronidazole resistance prevalent region for eradicating H. pylori infection in patients with gastroduodenal ulcers. METHODS: This was an open-label, prospective study. Consecutive patients with endoscopy-proven duodenal or gastric ulcer and who were H. pylori-positive were treated with levofloxacin 500 mg once a day, rabeprazole 20 mg twice a day, and tinidazole 500 mg twice daily for 7 days followed by rabeprazole 20 mg OD for 8 weeks. Endoscopy was repeated 8 weeks after the end of therapy to check for ulcer healing and H. pylori status. RESULTS: One hundred and thirty-one patients with gastroduodenal ulcers (duodenal 118, and gastric 13) were included. Drug compliance was 97.7 %. The eradication rate of H. pylori by intention-to-treat analysis was 85.5 % (95 % confidence interval 79.5-91.5) (112 of 131 patients) and by per-protocol analysis was 91.8 % (95 % confidence interval 86.9-96.7) (112 of 122 patients). Adverse effects were reported in 17 %: abdominal pain in 3.05 %, metallic taste in 6.87 %, and nausea and vomiting in 4.58 %. CONCLUSIONS: Levofloxacin-tinidazole-based triple therapy was highly effective and safe as a first-line regimen in Indian patients with gastroduodenal ulcer disease associated with H. pylori infection. The regimen was well tolerated.

Predictors of intestinal parasitosis in school children of Kashmir: a prospective study.

OBJECTIVES: To identify the factors associated with intestinal parasitosis in rural and urban school children of Kashmir. METHODS: Single fresh stool samples from rural and urban school children in three age groups: a) 5 to < 8 years, b) 8 to < 11 years and c) 11-14 years were taken. Various demographic characteristics considered were source of drinking water, type of toilet used and social classes as per the Kuppuswamy social scale. Personal hygiene was assessed by the visiting physician based on length of nails, hair and frequency of bathing. Stool samples were analyzed for detection of motile forms of E. histolytica and microscopic examination under low power detected eggs of intestinal helminths. Concentration methods were used if egg count was low. RESULTS: 274 stool samples from rural school children and 240 samples were taken from urban school children respectively. 214 (46.7%) students had stool tests positive for parasitosis. Ascariasis was the most prevalent parasitosis (28%) followed by Giardiasis (7%), Trichuriasis( 5%) and Taeniasis( 4%). There was higher prevalence of parasitosis among rural orphanage children compared to urban orphanage students (76% vs. 48% p < or = 0.05). Highest prevalence of 70% was seen in the age group 8-11years. Students using river/stream water had higher rates of parasitosis compared to those who were using tap water. 202 students were found to have poor personal hygiene and parasitosis was higher in them compared to students with good personal hygiene (p < 0.05). CONCLUSION: Poor environmental sanitation, personal hygiene, type of toilet and water used were associated with recurrent intestinal infestation besides socio economic status. Regular deworming programmes need to be adopted at school level especially in 8-11 years old children to check the surge of intestinal parasites and their subsequent morbidities.

Correlation of hepatic venous pressure gradient with variceal bleeding, size of esophageal varices, etiology, ascites and degree of liver dysfunction in cirrhosis of liver.

An elevated hepatic venous pressure gradient (HVPG) has been associated with risk of variceal bleeding, and outcome and survival after variceal bleeding. In this pilot study, we measured HVPG in 40 patients with liver cirrhosis and studied its relationship with etiology of liver disease, esophageal variceal size, history of variceal bleeding or ascites, biochemical liver tests and Child-Pugh class. There was no procedurerelated complication. The mean (SD) HVPG was similar in patients who had history of variceal bleeding as compared to those who did not (15.4 [2.8] mmHg vs. 13.9 [2.7] mmHg, p=0.1); HVPG had no significant association with etiology of cirrhosis (p=0.4). HVPG levels were significantly higher in patients with larger esophageal varices (grade III/IV vs. I/II: 15.2 [2.7] mmHg vs.13.1 [2.8] mmHg, p=0.04), poorer Child-Pugh class (B or C versus A), and presence of ascites (p=0.04). Thus, HVPG correlated with variceal size, Child-Pugh class, and presence of ascites, but not with variceal bleeding status.

Effect of bending exercise on gastroesophageal reflux in symptomatic patients.

BACKGROUND: Recumbency and bending are thought to provoke symptoms of reflux in patients with gastroesophageal reflux disease (GERD). The effect of exercise which involved bending and abdominal contractions was evaluated in symptomatic patients of GERD using continuous 24-hour ambulatory esophageal pH test. METHODS: Twenty-five patients with GERD, confirmed by abnormal 24-hour esophageal pH study, performed exercise for 30 minutes consisting of 5 sessions of 6 minutes each. The exercise involved toe touching from supine, sitting and standing position of 2 minutes' duration each. Each 2 minutes' period included 8 repetitions of the same exercise of 15 seconds' duration. 24-hour esophageal pHmetry was done on day 1 without exercise and on day 2 with 30-minute exercise. Reflux time percent (RT%) pH <4 was compared between days 1 and 2 and 30 minutes before and during exercise. RESULTS: Fourteen patients were upright refluxers and 11 patients were combined refluxers, which included 4 patients with supine reflux and 7 patients who refluxed both in supine and upright positions. The median (range) 24-hour RT% on day 1 and day 2 was 7 (5-40) and 7 (4-46), respectively (p=0.15). RT% during 30 minutes exercise compared with 30 minutes before exercise was 6.6 (0-60) and 0.0 (0.0-80) (p=0.02), respectively. In combined and upright refluxers, RT% during and before exercise was 13 (0-53) and 0.0 (0.0-42) (p=0.008), respectively and 0.0 (0-60) and 0.0 (0-80), (p=0.71), respectively. RT% between upright and combined refluxers during exercise was 0.0 (0-60) and 13 (0-53), respectively (p=0.004). The mean (SD) LES pressure in mmHg in combined and upright refluxers was 7 (2.9) and 19.6 (6.8), respectively (p=0.008). Esophagitis in combined and upright refluxers was seen in 8 patients (72.7%) and 2 patients (14.3%), respectively. Two patients (8%) developed symptoms during exercise. CONCLUSION: Exercise which involves bending precipitates reflux in patients with moderate-to-severe GERD.

Successful treatment of niclosamide- and praziquantel-resistant beef tapeworm infection with nitazoxanide.

BACKGROUND: Beef tapeworm (Taenia saginata) infection is acquired by eating inadequately cooked beef that contains the larvae or cysticerci of T. saginata. Niclosamide and praziquantel have proved effective for its treatment but treatment failures are well known. We report herein the results of nitazoxanide therapy. METHODS: A prospective study was conducted in 18 children and 34 adults to assess the efficacy and safety of nitazoxanide in the treatment of niclosamide- and praziquantel-resistant T. saginata infection. Nitazoxanide was administered twice daily for 3 days in 500-mg doses for those aged over 14 years and at 20mg/kg body weight/day in children aged 5-14 years. Post-treatment follow-up was undertaken at 1, 2, 4, 8, and 12 weeks for fecal samples for proglottides, and to check the presence, number, and viability of Taenia eggs. RESULTS: Nitazoxanide cured 51 of 52 (98.1%) patients. Mild side effects occurred in seven patients, which resolved spontaneously. There were no abnormalities in laboratory parameters. CONCLUSIONS: Nitazoxanide is a safe, effective, inexpensive, and well-tolerated drug for the treatment of niclosamide- and praziquantel-resistant beef tapeworm infection.