Impaired gastric accommodation in patients with postprandial distress syndrome type of functional dyspepsia assessed by 2D ultrasonography.

BACKGROUND AND PURPOSE: The pathophysiology of postprandial distress syndrome includes impaired gastric accommodation, hypersensitivity to gastric distension and delayed gastric emptying. 2D-ultrasonography is one of the methods to assess gastric accommodation by measuring proximal gastric area and we evaluated its role in calculating proximal gastric area and thus assessing gastric accommodation in Indian patients with postprandial distress syndrome. METHODS: In a hospital-based comparative analysis, proximal gastric area was measured with 2D-ultrasonography of postprandial distress syndrome (PDS) patients and compared with healthy controls. Five readings were measured every five minutes till 25 minutes after 400 mL of vegetable soup. The Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life (PAGI-QOL score) and diets aggravating PDS symptoms were studied through detailed questionnaires. Sample size was calculated at 80% study power and alpha error of 0.05 to be 30 subjects in each group. RESULTS: The mean age of patients (18 males) vs. 30 healthy controls (25 males) was 40.8 ± 11.50 years vs. 36.37 ± 7.58, respectively, (p = 0.084). Proximal gastric area was significantly lower in patients versus healthy controls at five minutes (22.54 ± 2.77 vs. 30.66 ± 2.55 cm2), 10 minutes (23.03 ± 2.45 vs. 31.10 ± 2.06 cm2), 15 minutes (23.06 ± 2.27 vs. 30.31 ± 2.11 cm2), 20 minutes (22.21 ± 2.31 vs. 29.73 ± 1.71 cm2) and 25 minutes (22.02 ± 2.33 vs. 28.39 ± 1.55 cm2); p < 0.001 at all intervals of time, indicating impaired gastric accommodation. The QOL was poor in all patients with PDS with mean PAGI-QOL score of 31.30 ± 15.05, median of 30, minimum score of 12 and maximum score of 66. CONCLUSIONS: Measurement of proximal gastric area with 2D-ultrasonography is simple and non-invasive. Proximal gastric area in patients was lower than controls, indicating impaired gastric accommodation. Poor quality of life was universal in patients with postprandial distress syndrome.

Outcomes of integrating quitline methodology in tobacco cessation delivered through a model tobacco treatment clinic of a private sector hospital at Rajasthan, India.

India despite progress in tobacco cessation delivery in government sector has lagged in private health sector. Adopting a two-fold approach of intensive intervention-based counseling with (or without) pharmacotherapy; and prescheduled proactive follow-ups over the subsequent year, this study reports 337 tobacco patients, each followed for a period of 1 year. It observed a quit rate (QR) of 40.9% for total abstinence at 1 year but with a drop of 15.9% when patients were followed up, up to 6 months (49.6%) versus 6-12 months (34.7%). The pharmacotherapy did not benefit to whom it was prescribed (196 [58.2%] patients; QR: 34.7%) versus the rest to who it was either not prescribed or was declined (141 [41.8%] patients; QR 49.6%). Countrywide tobacco cessation clinics (TCCs) may be established in private sector hospitals, and the component of quitline methodology of making proactive calls may be integrated to improve QR in India.

Histopathological and Immunohistochemical Findings in Congenital Pouch Colon: A Prospective Study.

BACKGROUND: There is a paucity of literature on the histopathological aspects of congenital pouch colon (CPC) and immunohistochemical (IHC) assessment has not been reported. So we planned to study the histopathological and IHC findings within the spectrum of CPC and compare the findings with the normal colon. METHODS: This is a descriptive prospective study on CPC patients. There were 49 cases of CPC (42 males and 7 females) and 13 controls. Histological examination was done using hematoxylin and eosin and Masson trichrome stain. IHC analysis was done with actin, myosin, and desmin antibodies, and neuron-specific enolase and S100 markers for counting ganglionic cells. RESULTS: Histologically, congestion, edema and hemorrhage were seen in mucosa, submucosa, and serosa. Muscle layers were disrupted and divided into bands. An additional muscle coat inside of the muscularis propria was seen in CPC types 1 and 2. Mature ganglionic cells were reduced and muscle layers showed reduced and patchy positivity for smooth muscle actin, myosin, and desmin compared to a normal colon. CONCLUSIONS: Histopathological and IHC findings suggest that CPC has distinct defects in the neuromusculature.

Role of endoscopic ultrasonography in patients with first episode of idiopathic acute pancreatitis.

BACKGROUND/AIMS: Acute pancreatitis (AP) evades an etiological diagnosis in up to 10 % to 30 % of patients. This group, ie. idiopathic acute pancreatitis (IAP) is prone to a high recurrence (up to 70 %). Endoscopic ultrasound (EUS) is promising, but there is limited data on elucidating the cause of IAP, from India. This observational study was designed to study the role of EUS after the first episode of IAP. METHODS: All patients diagnosed to have first episode of IAP were included in the study and taken up for EUS examination after 6 weeks. Patients with conditions known to predispose or precipitate AP, like alcohol binge, drugs, metabolic or autoimmune conditions, or even a positive family history, were excluded from the study. RESULT: A total of 51 patients were included. EUS positivity was found in 29 (56.9 %) patients. It included common bile duct (CBD) calculus in 5 (9.8 %), CBD sludge in 4 (7.8 %), gallbladder calculus in 2 (3.9 %), gallbladder sludge in 2 (3.9 %), and chronic pancreatitis (CP) in 16 (31.4 %) patients. Fourteen patients had a normal study and eight patients had indeterminate CP. CONCLUSIONS: EUS is safe and has a reasonable diagnostic yield in patients with first episode of IAP. CP and biliary lithiasis are the most frequent positive findings on EUS. EUS should be included in the diagnostic protocol after the first episode of IAP, rather than waiting for recurrent episodes.

Comparison of Manning, Rome I, II, and III, and Asian diagnostic criteria: report of the Multicentric Indian Irritable Bowel Syndrome (MIIBS) study.

BACKGROUND: Attempts to diagnose and subtype irritable bowel syndrome (IBS) by symptom-based criteria have limitations, as these are developed in the West and might not be applicable in other populations. OBJECTIVES: This study aimed to compare different criteria for diagnosing and subtyping of IBS in India. METHOD: Manning's and the Rome I, II, and III criteria as well as the Asian criteria were applied to 1,618 patients (from 17 centers in India) with chronic lower gastrointestinal (GI) symptoms with no alarm features and negative investigations. RESULTS: Of 1,618 patients (aged 37.5 [SD 12.6] years; 71.2% male), 1,476 (91.2%), 1,098 (67.9%), 649 (40.1%), 849 (52.5%), and 1,206 (74.5%) fulfilled Manning's, Rome I, II, and III, and the Asian criteria, respectively. The most common reason for not fulfilling the criteria was absence of the following symptoms: "more frequent stools with onset of pain," "loose stool with onset of pain," "relief of pain with passage of stool," "other abdominal discomfort/bloating," and, in a minority, not meeting the duration criterion of 3 months/12 weeks. By stool frequency, constipation-predominant IBS (<3 stools/week) was diagnosed in 319 (19.7%), diarrhea-predominant IBS (>3 stools/day) in 43 (2.7%), and unclassified in 1,256 (77.6%). By Bristol stool form, constipation, diarrhea, and unclassified were diagnosed in 655 (40.5%), 709 (43.8%), and 254 (15.7%) patients, respectively. By their own perception, 462 (28.6%), 541 (33.4%), and 452 (27.9%) patients reported constipation-predominant, diarrhea-predominant, and alternating types, respectively. CONCLUSION: By Manning's and the Asian criteria, a diagnosis of IBS was made frequently among Indian patients with chronic functional lower GI symptoms with no alarm features; the Rome II criteria gave the lowest yield. By the stool frequency criteria, a majority of patients had unclassified pattern, unlike by the stool form and patients' perception of their symptoms.

Regression of immunoproliferative small intestinal disease after eradication of Helicobacter pylori.

A 20-year-old male presented with low-grade fever, abdominal pain, anorexia, and weight loss of 4-month duration. On examination, he was emaciated. Barium meal follow-through examination showed extensive nodularity and thickening of duodenal and jejunal folds. Contrast-enhanced computed tomography of the abdomen revealed extensive proximal small-bowel thickening with mesenteric lymphadenopathy. Upper gastrointestinal endoscopy and enteroscopy revealed thickening of folds with multiple small superficial ulceration involving antrum, duodenum, and jejunum. The duodenal and jejunal biopsy was suggestive of immunoproliferative small intestinal disease, stage 0 (Salem) or stage A (Galian). Antral biopsy showed presence of Helicobacter pylori infection. He underwent H. pylori eradication following which he had significant clinical improvement; repeat evaluation at 6 months showed dramatic improvement in his clinical, radiological, and histological parameters.

Cervical esophageal web and celiac disease.

BACKGROUND AND AIM: There is paucity of prospective data on association between cervical esophageal webs and celiac disease. It is not clear whether all patients with cervical esophageal web need screening for celiac disease. Hence, the present study was carried out to determine the association of cervical esophageal web with celiac disease. METHODS: This prospective study included consecutive patients with symptomatic cervical esophageal web diagnosed over a period of 4.5 years. Tissue transglutaminase antibody was measured in serum of each patient. Patients with elevated tissue transglutaminase antibody titer were subjected to esophagogastroduodenoscopy and biopsies were obtained from the descending duodenum to look for histological changes of celiac disease. Esophageal web was treated with bougie dilatation. Celiac disease was diagnosed on the basis of elevated tissue transglutaminase antibody and suggestive duodenal histology. RESULTS: Twenty one patients were diagnosed to have cervical esophageal web. Eighteen (85.7%) had evidence of iron deficiency. Five (23.8%) patients with cervical esophageal web fulfilled criteria for diagnosis of celiac disease. All five had evidence of iron deficiency. None of these patients gave a history of chronic diarrhea. All patients were treated with bougie dilatation. Patients with celiac disease were advised of a gluten-free diet. All five celiac disease patients are free of dysphagia without recurrence after a mean follow up of 10 months (range: 3 to 16 months). CONCLUSIONS: There is association between cervical esophageal web and celiac disease. All adult patients with cervical esophageal web and iron deficiency need screening for celiac disease even in the absence of chronic diarrhea.

Seroepidemiology and role of polymerase chain reaction to detect viremia in an epidemic of hepatitis E in Western India.

AIM: In an outbreak of hepatitis E affecting 859 individuals, we evaluated the titres of serological markers (IgM anti-HEV and IgG anti-HEV) and hepatitis E virus (HEV) RNA by reverse transcriptase polymerase chain reaction. METHODS: Serological markers for acute hepatitis were evaluated in 294 icteric patients (Group A) and 300 apparently healthy controls (Group B). HEV RNA was measured by RT nPCR in 19 patients in the first week of illness in patients with negative IgM anti-HEV. FINDINGS: None of the patients were positive for hepatitis A or B. In Group A, IgM anti-HEV was positive in 80.2%, 71.4% and 26.8% and IgG anti-HEV was positive in 58.3%, 77.1% and 86% of patients who were in their first, second and third weeks of illness, respectively. In Group A, amongst the 19 IgM anti-HEV negative patients in their first week of illness, 16 were positive for HEV RNA. In Group B 63.6% cases were positive for IgM anti-HEV. In the same village there had been a similar epidemic 4 years ago; none of the 93 patients traced from that time developed acute hepatitis during the present epidemic and all demonstrated the presence of IgG anti-HEV. This suggests that IgG anti-HEV was perhaps protective. CONCLUSION: During the first week of illness patients may display HEV viremia while testing negative for IgM and IgG anti-HEV. The presence of IgG anti-HEV may play a protective role against HEV infection and in the absence of IgM may help in diagnosing acute hepatitis E. Over 3 weeks of illness the IgM anti-HEV titres fall progressively whilst IgG anti-HEV titres gradually rise.

Chronic pancreatitis in primary hyperparathyroidism: comparison with alcoholic and idiopathic chronic pancreatitis.

BACKGROUND: Primary hyperparathyroidism is a rare cause of chronic pancreatitis and there is a paucity of data on this interesting association. There is also no data comparing the clinical profile of chronic pancreatitis secondary to primary hyperparathyroidism with that of alcohol related and idiopathic chronic pancreatitis. METHODS: The clinical and biochemical spectrum of chronic pancreatitis secondary to primary hyperparathyroidism was evaluated retrospectively and compared with nine age-matched patients with alcohol related and idiopathic chronic pancreatitis. RESULTS: Renal colic, nephrolithiasis, nephrocalcinosis, bone disease, palpable neck nodule, and psychiatric abnormality were significantly more common in chronic pancreatitis due to hyperparathyroidism in comparison to alcoholic and idiopathic groups. The corrected calcium (10.8 +/- 0.9 vs 9.3 +/- 0.6 vs 9.2 +/- 0.8 mg/dL; P = 0.001) and intact parathormone (425 +/- 130 [SE]vs 22.2 +/- 14.3 [SE]vs 30 +/- 27.3 [SE] pg/mL; P = 0.009) levels were significantly elevated, while levels of serum phosphate were significantly less (3.1 +/- 0.4 vs 3.9 +/- 0.5 vs 3.4 +/- 0.7 mg/dL, respectively; P = 0.04) in chronic pancreatitis due to hyperparathyroidism in comparison to the alcoholic and idiopathic groups. No significant difference was observed in the frequency of steatorrhea, diabetes mellitus, pancreatic calcification, and pseudocyst between the three groups. Six out of nine patients underwent parathyroidectomy and none had recurrence of pancreatic pain over 14.3 +/- 13.8 months. CONCLUSIONS: Chronic pancreatitis due to hyperparathyroidism has important characteristics in its biochemical and clinical manifestations. Parathyroidectomy relieves pancreatic pain in majority of patients.

Prevalence of occult hepatitis B & C in HIV patients infected through sexual transmission.

BACKGROUND: Prevalence of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) markers including active and occult infection has not been described in diverse cohorts among HIV-infected patients in India. Earlier studies have explained the role of HBV/HCV co-infection in cohorts of injection drug users (IDUs) but the sexual co-transmission of HBV/ HCV is not completely understood. OBJECTIVE: The objective of this study was to assess the prevalence of occult HBV & HCV infection in HIV positive sexually acquired transmission risk group. MATERIALS AND METHODS: 58 sexually acquired HIV positive patients were taken up for the study of occult HBV/HCV co-infection. Data on demographics, sexual behaviour, sexually transmitted diseases (STD), medical history, laboratory tests viz., serum ALT and CD4 count were recorded. HBV serology included HBsAg, anti HBs, IgG anti HBc and HBV DNA (PCR). HCV serology included anti HCV & HCV RNA (RT-PCR). RESULTS: Occult HBV infection (HBV DNA) was observed in 12.2% (7/58 with HBsAg -ve and IgG anti HBc +ve subjects) while an overall prevalence of HBV DNA was 13.7% (12% occult & 1.7% in HBsAg+ve patients). Out of 58 HIV positive patients 29.3% demonstrated reactivity for any marker of past or current HBV infection. (HBsAg 1.7%, anti HBs 10.3% anti HBc IgG 17.2%). 4/58 (6.8%) revealed anti HCV positivity along with HCV RNA positivity by RT-PCR while 6/58 (10.3%) individuals revealed an occult HCV infection (anti HCV negative). The overall HCV RNA prevalence was 17.2%. 2 out of 58 (3.4%) individuals were positive for occult infection of both HBV DNA & HCV RNA (Triple infection HIV/HBV/ HCV). The HBV/HCV co-infected group (n = 18) showed a significantly high ALT (114.3 + 12.3 U/I) & low CD4 count (202.5 + 33.7 cells/mm3). The percent prevalence of HBV/ HCV co-infection was higher in the illiterate group, in men less than 30 years of age, and in those who were married and exhibited polygamous activity. CONCLUSIONS: The study demonstrated that in HIV infected patients testing only serological viral markers like HBsAg, antiHBcIgG & anti HCV, fails to identify the true prevalence of co-infection with HBV & HCV. Qualitative PCR for HBV DNA & HCV RNA detects co-infection in patients who are negative for serological markers. Also, in subjects who had only a sexual risk factor for parenterally transmitted infections, HIV may enhance the sexual transmission of HBV and HCV.

Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone.

OBJECTIVE: Endoscopic drainage of a single pseudocyst is a well-known treatment modality. Its role in the management of multiple pseudocysts is not well established. We evaluated the role of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of multiple and large pseudocysts. METHODS: Over 3 yr (2001-2004), endoscopic transpapillary NPD placement was attempted in 11 patients (age range 12-50 yr, 10 men) with symptomatic communicating multiple pseudocysts of pancreas (three in two and two in nine cases). A 5Fr/7Fr NPD was placed across the most distal duct disruption or into one of the pseudocysts. RESULTS: Eight patients had an underlying chronic pancreatitis and three patients had pseudocysts as sequelae of acute pancreatitis. The size of pseudocysts ranged from 2 to 14 cm (mean 7.5 cm). Eight patients (72.7%) had at least one pseudocyst more than 6 cm in size. Nine patients had a partial disruption and two patients had complete disruption of the pancreatic duct. The NPD was successfully placed in 10 of 11 (90.9%) patients. Postprocedure acute febrile illness in one patient was the only complication noted, which responded to intravenous antibiotics. All pseudocysts resolved in 4-8 wk in 7 of 7 patients with successful bridging of the most distal ductal disruption. There was no recurrence of the pseudocysts in a mean follow-up of 19.4 months. Two patients, in whom there was a complete disruption and the NPD could not bridge the disruption, required surgery for the nonresolution of pseudocysts. In one patient with partial ductal disruption that could not be bridged, there was complete resolution of one pseudocyst and a decrease in the size of the other pseudocyst from 12 to 4 cm. The NPD was replaced by a stent and both the pseudocysts resolved in 20 wk. CONCLUSION: Endoscopic transpapillary NPD placement is a safe and effective modality for the treatment of multiple and large pseudocysts, especially when there is partial ductal disruption, and the disruption can be bridged.