Hepatic osteodystrophy and fracture risk prediction using FRAX tool in Indian patients with cirrhosis.

BACKGROUND AND AIM: The main clinical relevance of hepatic osteodystrophy is the increased risk of fractures. Dual-energy X ray absorptiometry (DEXA)-based assessment of bone mineral density, the current gold standard for diagnosing osteoporosis, is not the sole determinant of fracture risk. Other clinical risk factors also play an important role. This study was carried out to assess the prevalence and risk factors of hepatic osteodystrophy and estimate the entailed fracture risk by using the FRAX tool in a cohort of Indian cirrhotics. METHODS: Consecutive patients with cirrhosis (n = 120) were recruited. Etiologic workup, liver function tests, serum calcium, phosphate, 25(OH)D, HbA1c, and DEXA scan were performed. Hepatic osteodystrophy was defined as a T score of < -1. FRAX scores were calculated using the Indian calculator. RESULTS: The study cohort was predominantly male (86.7%) with a median age of 49 (40-65) years. Alcohol was the most common etiology (80%). All patients had Child-Turcotte-Pugh class B (63.3%) or class B (36.7%) cirrhosis. Hepatic osteodystrophy was present in 83.3% patients. On multivariate analysis, smoking (odds ratio [OR]: 3.1 [1.76-4.7], P < 0.001) and serum 25(OH)D (OR: 0.23 [0.09-0.94]; P = 0.03) showed significant association with hepatic osteodystrophy. The 10-year probability of major osteoporotic fracture and hip fracture was 5.7% (2.1-28.9) and 2.5% (1.4-7.4), respectively. Using a FRAX probability cut-off of 20% for major osteoporotic fracture and 3% for hip fracture, 30% patients qualified for osteoporosis treatment. CONCLUSION: Hepatic osteodystrophy is widely prevalent among Indian patients with cirrhosis and entails a high risk of fractures. Approximately one-third of patients with cirrhosis need treatment to reduce the risk of osteoporotic fractures.

Serial C-reactive protein measurements in patients treated for suspected abdominal tuberculosis.

BACKGROUND: Response to treatment is often used as a criterion for the diagnosis of abdominal tuberculosis. AIM: To determine utility of serum C reactive protein (CRP) in assessment of response to anti-tubercular therapy (ATT) in abdominal tuberculosis (ATB). METHODS: We retrospectively analysed the database of patients with suspected ATB (intestinal and/or peritoneal). Response to ATT was assessed using subjective and objective (ulcer healing or ascites resolution) parameters. Serum CRP levels were estimated at baseline and then at 2 months and 6 months of ATT. RESULTS: One hundred and twelve patients were included in the analysis. The mean age was 36.57 ±â€¯15.04 years and 54.46% (61/112) were males. Sixty-six patients (58.92%) had intestinal, 28 (25%) had peritoneal and 18 (16.07%) had both. Eleven patients had a normal CRP at baseline while 101 had elevated levels. The CRP levels declined in 94 patients at 6 months. One patient with increased levels at 2 months had multi-drug resistant TB. Seven patients showed elevated or plateaued CRP levels on follow-up. These patients had underlying Crohn's disease (3 patients), peritoneal carcinomatosis (1), inter-current infection (1), lymphoma (1) and non-healing ulcers (1). CONCLUSION: Lack of decline in CRP may suggest alternative diagnosis or drug-resistant tuberculosis.

Baclofen-responsive hiccups after esophageal stenting for malignancy-related dysphagia.

Hiccups can have multiple causes, including esophageal lesions. Hiccups after insertion of self-expanding metallic stents have been reported occasionally following stenting for lesions of the gastroesophageal junction. We report a patient who developed hiccups after insertion of a stent for squamous cell carcinoma of the proximal esophagus. The hiccups responded only to the initiation of baclofen therapy.

Peptic esophageal stricture in an adolescent with Barrett's esophagus.

Barrett's esophagus (BE) is characterized by the replacement of distal esophageal stratified squamous epithelium by columnar epithelium. It is rare in children and the risk factors may include mental retardation, cerebral palsy, esophageal atresia, etc. Apart from corrosive ingestion, peptic stricture is the other leading cause of esophageal strictures in children. However, BE has not been well characterized in the pediatric population and in children presenting with esophageal strictures. A 16-year-old Indian boy presented with a history of gradually progressive dysphagia to solids (but not liquids) for 12 years along with heartburn and poor weight gain. Physical examination and routine blood investigations were unremarkable. Previously performed barium meal studies were suggestive of stricture in the mid and lower esophagus. Upper gastrointestinal (GI) endoscopy revealed a non-negotiable stricture with circumferential ulceration at 26 cm. The stricture was traversed using an ultrathin scope and the distal mucosa was found to be columnar. Biopsies revealed cardiac mucosa. The patient was treated with proton pump inhibitors (PPI) and four series of segmental dilatations with Savary Gilliard esophageal dilators. Peptic strictures occurring in the mid-upper esophagus should raise concerns about BE or malignancy. Here, we report a case of peptic esophageal stricture in a child without neurodevelopmental or trachea-esophageal abnormalities.

Gastrostomy tube replacement by endoscopic cannulation of a narrowed previous tube site.

Percutaneous endoscopic gastrostomy is warranted when oral feeding is not feasible. Indications include central nervous system disorders, head trauma and occasionally malignancies of upper gastrointestinal tract. If tube replacement after accidental dislodgement is delayed, the track may become narrowed. This may compromise routine replacement and may require repeated procedures. Occasionally no further external dilation is possible. We describe the endoscopic cannulation of the previously used track after its internal cannulation and subsequent external dilation and the successful replacement of a gastrostomy tube.