Endoscopic Yield, Appropriateness, and Complications of Pediatric Upper Gastrointestinal Endoscopy in an Adult Suite: A Retrospective Study of 822 Children.

BACKGROUND/AIMS: This study aimed to study the endoscopic yield, appropriateness, and complications of pediatric endoscopy performed by adult gastroenterologists in an adult endoscopic suite. METHODS: This a retrospective study in which records of all the patients less than 18 years of age who underwent endoscopy in the last 5 years were studied. The indications of endoscopy in children were categorized as appropriate or inappropriate per the latest guidelines by American Society for Gastrointestinal Endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Positive endoscopic yield was defined as the presence of any abnormality on endoscopy. RESULTS: Among the total of 822 children (age <18 years), the most common indications were variceal surveillance/eradication in 157 (19.1%), followed by dyspepsia in 143 (17.4%), upper gastrointestinal (UGI) bleeding in 136 (16.5%), recurrent abdominal pain in 94 (11.4%), unexplained anemia in 74 (9%), recurrent vomiting in 50 (6.08%), chronic refractory gastroesophageal reflux disease in 34 (4.1%) and others; 780 out of 822 endoscopic procedures (94.9%) done in children were appropriate as per the guidelines. The endoscopic yield was 45.8%, highest in patients with UGI bleeding (71.3%), followed by variceal surveillance (54.8%), recurrent vomiting (38%), dyspepsia (37.8%), and recurrent abdominal pain (36%). Minor adverse events occurred in 7.3% of children. CONCLUSION: Pediatric endoscopy performed by an experienced adult gastroenterologist may be acceptable if done in cooperation with a pediatrician.

Addition of simvastatin to carvedilol non responders: A new pharmacological therapy for treatment of portal hypertension.

AIM: To determine whether addition of simvastatin could be an important pharmacological rescue therapy for carvedilol non-responders. METHODS: One hundred and two consecutive patients of cirrhosis of liver with significant portal hypertension were included. Hepatic venous pressure gradient (HVPG) was measured at the base line and after proper optimization of dose; chronic response was assessed at 3 mo. Carvedilol non-responders were given simvastatin 20 mg per day (increased to 40 mg per day at day 15). Carvedilol plus simvastatin was continued for 1 mo and hemodynamic response was again measured at 1 mo. RESULTS: A total of 102 patients with mean age of 58.3 ± 6.6 years were included. Mean baseline HVPG was 16.75 ± 2.12 mmHg and after optimization of dose and reassessment of HVPG at 3 mo, mean reduction of HVPG from baseline was 5.5 ± 1.7 mmHg and 2.8 ± 1.6 mmHg among responders and non-responders respectively (P < 0.001). Addition of simvastatin to carvedilol non-responders resulted in significant response in 16 patients (42.1%) and thus overall response with carvedilol and carvedilol plus simvastatin was seen in 78 patients (80%). Two patients were removed in chronic protocol study with carvedilol and three patients were removed in carvedilol plus simvastatin study due to side effects. CONCLUSION: Addition of simvastatin to carvedilol non-responders may prove to be an excellent rescue therapy in patients with portal hypertension.

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.

Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer.

BACKGROUND AND AIMS: After successful endoscopic hemostasis in bleeding peptic ulcer, addition of proton pump inhibitors reduce the rate of recurrent bleeding by maintaining intragastric pH at neutral level. The aim of the present study was to evaluate the effect of various proton pump inhibitors given through different routes on intragastric pH over 72 h after endoscopic hemostasis in bleeding peptic ulcer. METHODS: Ninety consecutive patients who had successful endoscopic therapy of bleeding peptic ulcer underwent 72-h continuous ambulatory intragastric pH study, were randomly assigned to receive p.o. omeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg omeprazole followed by infusion 8 mg/h for 72 h. Oral pantoprazole 80 mg bolus followed by 80 mg every 12 h for 72 h or i.v. 80 mg pantoprazole followed by infusion of 8 mg/h for 72 h. Oral rabeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg rabeprazole followed by infusion 8 mg/h for 72 h. Five patients received no treatment after successful endoscopic therapy and underwent 72-h pH study. RESULTS: Mean 72-h intragastric pH for p.o. omeprazole was 6.56 versus 6.93 for omeprazole infusion (P = 0.48). Mean 72-h intragastric pH for p.o. pantoprazole was 6.34 versus 6.32 for pantoprazole infusion (P = 0.62). Mean 72-h intragastric pH for rabeprazole p.o. was 6.11 versus 6.18 rabeprazole i.v. (P = 0.55). Mean 72-h pH for the no proton pump inhibitor group was 2.04. CONCLUSION: There was no significant difference among various proton pump inhibitors given through different routes on raising intragastric pH above 6 for 72 h after successful endoscopic hemostasis in bleeding peptic ulcer.

Association between copper excess, zinc deficiency, and TP53 mutations in esophageal squamous cell carcinoma from Kashmir Valley, India--a high risk area.

Trace element deficiency or excess is implicated in the development or progression in some cancers. Here we report the elevated level of copper and low level of zinc in the plasma of esophageal cancer patients in Kashmir India--a high incidence area. The average level of copper was significantly higher (P < 0.0001) for patients than for controls, with a mean concentration of 169 microg/dl and 149 microg/dl for patients and controls, respectively. The control group consisted of 55 healthy individuals matched for age, sex, and place of residence of the patients. In contrast, the average level of zinc in patients was significantly lower than in controls (P < 0.0001), with a mean concentration of 86.8 microg/dl and 96.1 microg/dl for patients and controls, respectively. The levels of both copper and zinc showed significant differences based on gender and age in patients as compared to controls. Similarly, smokers depicted a significant increase in serum copper (N = 39, P = 0.002) and a decrease in serum zinc approaching level of significance in the patient group as compared to controls. The copper and zinc levels were significantly altered in patients (N = 40) when compared to controls as a function of snuff consumption. The differences in the levels of copper and zinc showed significant association with the consumption of local salted tea up to 1,500 ml per day, but the changes were insignificant beyond that. Patients with poorly differentiated tumors (N = 7) had a higher copper concentration than those with moderately or well-differentiated tumors (P < 0.0001). To validate the general notion that imbalance in copper and zinc levels may lead to higher prevalence of TP53 mutations, we compared the 3 variables, and no association was found between copper concentration and TP53 mutation status; but patients with TP53 mutant tumor had lower zinc levels than those with no mutation. In conclusion, our results point toward a role of the trace element imbalance in the esophageal tumorigenesis in high-risk Kashmiri population exposed to a range of nitroso compounds or their precursors. Further prospective cohort studies are warranted to determine whether change in the plasma zinc and copper homeostasis may represent an independent risk factor for this malignancy as well as a possible target for preventive intervention.

Studies on Association Between Copper Excess, Zinc Deficiency and TP53 Mutations in Esophageal Squamous Cell Carcinoma From Kashmir Valley, India-A High Risk Area.

Trace element deficiency or excess is implicated in the development or progression in some cancers. Here we report the elevated levels of copper and low level of zinc in the plasma of esophageal cancer patients in Kashmir India- a high incidence area. The average level of copper was significantly higher for patients than for controls (p<0.0001) with a mean concentration of 169 µg/dl and 149 µg/dl for patients and controls, respectively. In contrast, the average level of zinc in patients was significantly lower than in controls (p<0.0001) with a mean concentration of 86.8 µg/dl and 96.1 µg/dl for patients and controls, respectively. No significant difference in copper and zinc levels was observed for different age groups in controls or patients. For controls, the level of copper was not significantly different in males and females (median: 155 µg/dl for males and 144 µg/dl for females, p=0.10), but we observed a higher level of zinc in females (median: 90.5 µg/dl for males and 101 µg/dl for females, p=0.03). Copper or zinc concentrations were not significantly associated with gender, tumor site, green tea with salt (nun chai) consumption, smoking habits or snuff in cases. Patients with poorly differentiated tumors had a higher copper concentration than those with moderately or well-differentiated tumors (p<0.0001). No association was found between copper concentration and TP53 mutation status but patients with TP53 mutant tumor had lower zinc levels than those with no mutation. Our results point towards a role of the trace element imbalance in the esophageal tumorigenesis in high risk Kashmiri population exposed to a range of nitroso compounds or their precursors. Further prospective cohort studies are warranted to determine whether change in the plasma zinc and copper homeostasis may represent an independent risk factor for this malignancy as well as possible target for preventive intervention.