Indian J Gastroenterol

What priority for prevention of hepatitis A in India?

John TJ. Chandy GM.
No information.

Portal hypertensive gastropathy and gastric varices before esophageal variceal sclerotherapy and after obliteration.

De BK. Ghoshal UC. Das AS. Nandi S. Mazumder DN.
Department of Medicine, Institute of Postgraduate Medical Education and Research, Calcutta.
OBJECTIVES: To evaluate the frequency and clinical importance of portal hypertensive gastropathy (PHG) and gastric varices (GV) before endoscopic sclerotherapy (EST) and after esophageal variceal obliteration. METHODS: Patients with portal hypertension (PHT) with variceal bleed were prospectively evaluated for PHG and GV before EST with intravariceal injection of absolute alcohol and after esophageal variceal obliteration. Gastric varices and PHG were characterized and graded according to previously established criteria. Patients were followed up for 12-48 (mean 37) months after variceal obliteration. RESULTS: Of 70 patients with PHT 26 had PHG before (severe in two) [18/37 in cirrhosis, 6/20 in non-cirrhotic portal fibrosis (NCPF), and 2/13 in extrahepatic portal vein obstruction (EHPVO)] and 50 had PHG after variceal obliteration (severe in 22) (27/37 in cirrhosis, p = 0.03 before versus after esophageal variceal obliteration; 16/20 in NCPF, p < 0.01; and 7/13 in EHPVO, p = ns). Type I GV (continuation of esophageal varix into the stomach) was found in 25/70 before and 5/70 after esophageal variceal obliteration (p < 0.001); in contrast, other types of GV were seen in 14/70 before and 29/70 after (p < 0.01). Overt bleeding from GV and PHG during follow-up after variceal obliteration occurred in 6 and 4 patients, respectively. CONCLUSIONS: Esophageal variceal obliteration by EST increases the frequency of PHG and GV (except type I GV which get obliterated); both PHG and GV have potential to cause rebleeding.

Percutaneous pigtail catheter drainage of pancreatic pseudocysts.

Mathur SK. Shah SR. Balsarkar DJ. Rane S. Khemani R.
Gastroenterology Surgical Services, King Edward Memorial Hospital, Mumbai.
AIM: To evaluate the efficacy of percutaneous pigtail catheter drainage (PCD) in the management of pancreatic pseudocysts otherwise meriting surgical intervention. METHODS: Fourteen consecutive patients with pancreatic pseudocysts (five following acute pancreatitis and nine with chronic pancreatitis) were subjected to PCD. For uncomplicated chronic pseudocysts, an algorithm using endoscopic retrograde pancreaticography to demonstrate ductal communication with obstruction was followed. Five patients had complicated pseudocysts and nine uncomplicated cysts persisting > 6 weeks and > 6 cm in size. RESULTS: All uncomplicated and two complicated pseudocysts resolved in 6-58 days (mean 19.7). No recurrences were seen. Three patients with complicated cysts had pancreatic fistulae; two of these were treated by surgery and one by pancreatic stenting. Sepsis required sump drainage in two patients. Four patients required early surgery: two for pancreatic fistula and one each for hemorrhage and residual cyst. Two patients were subjected later to pancreatico-jejunostomy for pain of chronic pancreatitis. CONCLUSIONS: Patients with acute pseudocysts and uncomplicated noncommunicating chronic pseudocysts respond to PCD. In complicated chronic pseudocysts, sepsis may be controlled by PCD.

Seroprevalence of hepatitis A virus in Mumbai, and immunogenicity and safety of hepatitis A vaccine.

Dhawan PS. Shah SS. Alvares JF. Kher A. Shankaran. Kandoth PW. Sheth PN. Kamath H. Kamath A. Koppikar GV. Kalro RH.
Department of Gastroenterology, BYL Nair Hospital, Mumbai.
OBJECTIVES: Since epidemiologic trends of hepatitis A are changing worldwide, we studied its seroprevalence in Mumbai, which is thought to be a high-endemicity area. The immunogenicity and safety of a hepatitis A vaccine were also studied. METHODS: Six hundred and seventy subjects (456 men; age range 6 mo-60 y) answered a questionnaire on social and medical history. Qualitative analysis of total anti-HAV was performed in all subjects by ELISA. One hundred and seven of 147 anti-HAV negative subjects received hepatitis A vaccine at months 0, 1 and 6. Subjects were followed up (months 1, 2, 6, 7) to look for side-effects and seroconversion. RESULTS: The seroprevalence of HAV was 523/670 (78%); 38% of children < 5 years were anti-HAV negative. Seroprevalence rates of 80% were reached by 15 years. Prevalence was lower in the higher socio-economic group (151/234; 64.5%) compared with the lower socio-economic group (372/436; 85%) (p < 0.001). One month after doses 1, 2 and 3 of the hepatitis A vaccine, seropositivity was 92%, 99% and 100%, respectively. Minor self-limited side-effects occurred in 19.5% of subjects; there were no major side-effects. CONCLUSIONS: The seroprevalence of anti-HAV is high in Mumbai. Seroprevalence is lower in the higher socio-economic groups. The hepatitis A vaccine is safe and immunogenic.

Relationship of manometric findings to symptomatic response after pneumatic dilation in achalasia cardia.

Shahi HM. Aggarwal R. Misra A. Agarwal DK. Naik SR.
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow.
BACKGROUND: Achalasia cardia is usually treated by pneumatic dilation or surgical esophagomyotomy. The role of esophageal manometry for objective assessment of symptom response is controversial. AIM: To study the relationship between symptoms and manometric parameters before and after pneumatic dilation in patients with achalasia cardia. METHODS: Sixteen patients with achalasia cardia underwent esophageal manometry before and after undergoing pneumatic dilation. At each time, lower esophageal sphincter (LES) pressure and mean basal esophageal-gastric pressure gradient (MIEP-MIGP) were measured. RESULTS: Good symptom response was obtained in 12 of 16 patients. Median (range) LES pressure fell from 42 (17-51) mmHg to 18 (8-39) mmHg in those patients with a good response, and from 51 (25-68) mmHg to 29.5 (23-42) mmHg in those who responded poorly. Mean intraesophageal pressure fell below mean intragastric pressure in both the groups. CONCLUSIONS: Esophageal manometry does not correlate with symptom improvement after pneumatic dilation in achalasia cardia. Dysphagia may persist in spite of reversal of the MIEP-MIGP gradient.

Vagal dysfunction following endoscopic variceal sclerotherapy.

Mistry FP. Sreenivasa D. Narawane NM. Abraham P. Bhatia SJ.
Department of Gastroenterology, K E M Hospital, Mumbai.
BACKGROUND: Sclerotherapy is associated with complications which involve adjacent structures like the pleura. The effect of sclerotherapy on function of the vagus nerve, which lies in close proximity to the thoracic esophagus, is not clear. AIM: To study gastric acid secretion as a marker of vagal function in portal hypertensive patients who have undergone sclerotherapy. METHODS: Portal hypertensive patients who had undergone at least three sessions of sclerotherapy were evaluated by mapping gastric acid-secreting mucosa by the Congo red test and by estimating gastric acid secretion using the modified sham feeding test. Patients with portal hypertension who had never been subjected to endoscopic sclerotherapy were recruited as controls. RESULTS: On Congo red test, complete or substantial reduction in acid-secreting mucosa was observed in eight patients in comparison to none of the controls. Significantly lower acid secretion on modified sham feeding test was observed in these eight patients. CONCLUSION: A lower gastric acid secretion, probably secondary to vagal dysfunction, is seen in patients who have undergone multiple sessions of sclerotherapy; vagus nerve involvement may be secondary to periesophageal inflammation.

Epidemiology of digestive tract cancers in India. II. Stomach, and gastrointestinal lymphomas.

Mohandas KM. Nagral A.
Division of Digestive Diseases and Nutrition, Tata Memorial Hospital, Mumbai. medimail@tmc.ernet.in
The incidence of stomach cancer and GI lymphomas is low in most parts of India. There is paucity of analytical epidemiologic data on these from India. While the time trends for the incidence of gastric cancer are encouraging, most cancers are diagnosed in an advanced stage when long-term cure is only a remote possibility. Multi-center epidemiologic studies should be undertaken to solve some of the enigmas and observations peculiar to India.

Primary squamous carcinoma of liver: presentation as liver abscess.

Doctor N. Dafnios N. Jones A. Davidson BR.
University Department of Surgery, Royal Free Hospital and School of Medicine, London, England.
Primary keratinizing squamous carcinoma of the liver has been reported as arising in a hepatic cyst, in association with prolonged cholestasis or chronic biliary sepsis. We describe the occurrence of such a tumor without predisposing factors, with presentation similar to that of hepatic abscess.

Bleeding duodenal varix in splenic vein thrombosis and chronic pancreatitis.

Dhadphale S. Sawant P. Rathi P. Shirhatti RG. Gupta R. Gopanpallikar A. Patrawala V.
Department of Gastroenterology, L T M Medical College and General Hospital, Mumbai.
Isolated duodenal varix is rare. We report a patient with bleeding duodenal varix with splenic vein thrombosis due to chronic pancreatitis.

Multiple iniobezoars causing acute intestinal obstruction.

Somani AK. Malpani NK. Vardhan V.
Department of Surgery, R N T Medical College, Udaipur.
We report multiple coirbezoars (iniobezoars) causing acute intestinal obstruction in a woman with a history of surgery for trichobezoar.

Bilioma secondary to choledocholithiasis.

Parikh RS. Sanjana MK. Mehta C. Merchant H. Parikh SS.
Department of Surgery, B Y L Nair Charitable Hospital, Mumbai.
Bilioma secondary to choledocholithiasis is rare. We report a patient in whom a large common bile duct stone was responsible for leak from the infraduodenal segment of the bile duct. Choledochotomy with extraction of stone followed by T-tube drainage of the bile duct and evacuation of the bilioma resulted in complete recovery.

Multiple diverticula of gall bladder.

Garg P. Dass B.
Department of Surgery, Postgraduate Institute of Medical Sciences, Rohtak.
Diverticula of the gall bladder are of no clinical significance unless associated with stones. Isolated location on Hartmann's pouch, body or neck have been explained on disordered embryogenesis but diffuse location all over the gall bladder is difficult to explain. We report a patient in whom multiple gall bladder diverticula were associated with a stone in the common bile duct.

Pedunculated large leiomyoma of esophagus.

Gupta NM. Dhavan S. Bambery P. Goenka MK.
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh.
We report a patient with pedunculated esophageal leiomyoma which was 20 cm in length. Barium swallow had shown a grossly dilated esophagus with filling defect along its whole length, giving an appearance suggesting achalasia and retained food. The patient is doing well after transhiatal esophagectomy.

Predictors of outcome in fulminant hepatic failure in children.

Year 1998
Srivastava KL. Mittal A. Kumar A. Gupta S. Natu SM. Kumar R. Govil YC.
Department of Pediatrics, King George's Medical College, Lucknow.
OBJECTIVE: To identify the predictors of outcome in fulminant hepatic failure (FHF) in children. STUDY DESIGN: Prospective cohort study. METHODS: 41 children with FHF were studied. Patient characteristics and findings on examination at the time of hospitalization were noted. Serum biochemistry and screening for hepatotropic viruses (A, B and C) were done in each patient. Patients were treated using a predefined protocol and followed up till death or discharge. Univariate and multivariate analysis was done to find the predictors of outcome. RESULTS: Hepatitis B was the commonest cause of FHF (11 children; 26.9%). Markers for hepatitis A and C viruses were present in one and two patients, respectively. Serology was negative in 27 children (65.9%), of whom two had history of ingestion of hepatotoxins (antitubercular drugs). The overall mortality was 61%. Irrespective of etiology, the following factors were associated with poor outcome on univariate analysis: presence of gastrointestinal (GI) hemorrhage, serum bilirubin more than 10 mg/dL, age 6 years or less, coma of grade 3 or more, presence of infection, prolongation of prothrombin time > 8 s over control, prothrombin concentration < 50%, hypoglycemia (blood glucose < 45 mg/dL), hyponatremia (serum sodium < 125 mEq/L) and hyperkalemia (serum potassium > 5.5 mEq/L). On multiple logistic regression analysis, presence of GI hemorrhage (p = 0.005), degree of coma (p = 0.02) and serum bilirubin level (p = 0.025) were identified as independent predictors of mortality.

Complicated sigmoid diverticulosis.

Year 1998
Balsara KP. Dubash C.
Department of Surgery, Parsee General Hospital, Mumbai.
BACKGROUND: To evaluate the outcome of patients treated for complications of sigmoid diverticular disease. METHODS: Fifteen patients (11 women; aged 54-80 years) were treated over a 6-year period in a community hospital. Five patients presented with perforation and peritonitis, 3 with colovesical fistula, 2 with colovaginal fistula, 2 with recurrent phlegmon and 3 with bleeding. Six patients (5 with perforation, 1 colovesical fistula with hematuria) underwent emergency surgery. Six patients (2 with colovesical fistula, 2 colovaginal fistula and 2 recurrent phlegmon) underwent planned sigmoid resection. All 3 patients with bleeding were treated conservatively. RESULTS: One patient with a colovesical fistula and severe hematuria died 72 hours later with septicemia. All 5 patients with peritonitis survived; two had an eventful post-operative period and were in hospital for nearly 3 months. All 5 developed wound sepsis. Six patients who had a planned procedure had uneventful recovery. The 3 patients who presented with bleeding recovered. CONCLUSION: Complicated diverticular disease carries a high morbidity and mortality especially when operated on as an emergency. Interval sigmoid resection should be offered to patients who have recovered from an acute complication.

Natural history of severe duodenal ulcer disease.

Year 1998
Konar A. Das AS. De PK. Roy A. Mazumder DN.
Department of Gastroenterology, Institute of Post Graduate Medical Education and Research, Calcutta.
BACKGROUND: A subset of patients with chronic duodenal ulcer has severe ulcer diathesis in the form of frequent relapses and complications like perforation and hemorrhage. We observed the effect of drug treatment on the natural history of this subset. METHODS: Of 526 patients diagnosed to have chronic duodenal ulcer by endoscopy, 23 patients with severe diathesis were available for long follow-up (mean period 36 months). Each patient was assessed clinically and endoscopically every 2 months for at least 12 months and then every 3 months or when symptomatic. Helicobacter pylori status was assessed during endoscopy. The effect of antisecretory drugs and anti-H. pylori therapy on natural history was determined. RESULTS: Thirteen of 23 patients (56%) had refractory ulcers; six responded to double dose of H2-receptor antagonists (H2RA) for 8 weeks and six to omeprazole 40 mg daily for 4-8 weeks. Of 20 patients (87%) who were H. pylori-positive, 15 completed triple-drug therapy; of these, 10 patients eradicated H. pylori. These 10 patients were followed up for 24 months; there were no ulcer relapses within the first 12 months but 8 of them relapsed between 12 and 24 months (total number of relapses 8). Reinfection with H. pylori occurred in 3 patients. In the other 10 patients who remained H. pylori-positive, there were 19 episodes of ulcer relapse in 7 patients over 24 months, in spite of maintenance therapy with H2RA (p < 0.05). CONCLUSIONS: Refractoriness in patients with severe ulcer disease is usually episodic and amenable to larger doses of omeprazole or H2RA. Anti-H. pylori therapy improves the natural history but its effect in preventing ulcer relapse is short lasting (less than 12 months). Recurrence of infection is a problem in our population.

Assessment of effects of propranolol on portal hemodynamics in cirrhosis by duplex ultrasonography.

Year 1998
Saigal S. Chawla Y. Dilawari JB.
Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh.
OBJECTIVE: To study the effect of propranolol on portal hemodynamics in cirrhotics using duplex ultrasonography. METHODS: Portal venous flow was measured by duplex ultrasonography in 12 healthy volunteers and ten men with cirrhosis. The cirrhotics were evaluated prior to and after ingestion of propranolol (60 mg twice daily for seven days) or placebo in a randomized cross-over fashion. Variations in heart rate, blood pressure, portal vein diameter, and portal venous flow and velocity were evaluated. RESULTS: The mean (SD) portal venous flow in the volunteers was 746 (280) mL/min, portal flow velocity was 18.5 (3.6) cm/s and portal vein diameter was 9.2 (1.4) mm. In cirrhotics, propranolol decreased portal blood flow from 586 (220) to 413 (120) mL/min (p < 0.03), the overall reduction being 29.5%. This effect was due to decrease in portal flow velocity, from 12.5 (3.3) to 9.7 (2.3) cm/s (p < 0.03) without significant change in portal vein diameter. No changes were observed with placebo. CONCLUSIONS: Propranolol decreases portal flow velocity and thus portal venous flow in cirrhotics.

Randomized double-blind trial of metronidazole versus secnidazole in amebic liver abscess.

Year 1998
Bhatia S. Karnad DR. Oak JL.
Department of Medicine, King Edward Memorial Hospital, Mumbai.
OBJECTIVE: To compare the efficacy of secnidazole with metronidazole in the treatment of amebic liver abscess. METHODS: Thirty two patients with uncomplicated liver abscesses were studied in a randomized, double-blind trial. Fifteen received metronidazole (400 mg t.i.d. for 7 days) and 17 secnidazole (500 mg t.i.d. for 5 days). All abscesses were aspirated on day 1 and laboratory tests and ultrasonographic examination were done on days 1 and 10. RESULTS: One patient in the metronidazole group developed intraperitoneal rupture. The other 31 patients had 40 abscesses (19 in metronidazole group, 21 in secnidazole group). Complete resolution of signs occurred by day 10 in 10 patients on metronidazole and 12 on secnidazole, and in all others by day 28. On day 10 ultrasonography in the metronidazole group showed complete disappearance of abscess in one patient, decrease in 8 and increase in 5 (versus 2, 12 and 3, respectively in the secnidazole group). After 6 months, four asymptomatic patients (two from each group) had small abscess cavities on ultrasonography; there were no recurrences. CONCLUSIONS: Secnidazole is as effective in the treatment of amebic liver abscess as metronidazole; it is equally well tolerated.

Membranous glomerulonephritis in association with ulcerative colitis.

Year 1998
Dhiman RK. Poddar U. Sharma BC. Arora P. Saraswat VA. Pandey R. Naik SR.
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow.
Glomerulonephritis is a rare association of ulcerative colitis. We report a patient with ulcerative colitis who developed proteinuria due to membranous glomerulonephritis which responded to colectomy.

Periampullary carcinoma with bilateral ovarian cystadenoma in pregnancy.

Year 1998
Choudhury TK. Sen A.
Department of General Surgery, Institute of Post Graduate Medical Education and Research, Calcutta.
We report a 30-year-old woman with periampullary cancer and a large left ovarian cystadenoma presenting during pregnancy with features of duodenal obstruction. She had a right benign ovarian tumor removed a year back. She delivered an intrauterine-growth-retarded live baby. Laparotomy in the postpartum period revealed an unresectable periampullary growth with hepatic metastasis and a left ovarian cystadenoma. The ovarian tumor was removed and a palliative gastrojejunostomy performed.

Marked perisplenitis in gastric carcinoma.

Year 1998
Janaki M. Hayath MS. Rao GM. Chennappa Y.
Department of Pathology, Kurnool Medical College, Kurnool.
We report a patient with gastric carcinoma with marked perisplentis, on gross appearance resembling secondary deposit. On sectioning, the spleen showed a solitary metastasis in the red pulp.

Wandering spleen causing splenic flexure volvulus and obstruction.

Year 1998
Moorthy K. Deshpande A. Rao P. Vyas S. Supe A.
Department of Surgery, Seth G S Medical College, Mumbai.
A 48-year-old woman presented with symptoms of distal bowel obstruction. On examination she had abdominal distension and a lump in the left lumbar and iliac regions. X-ray revealed distension of the colon with dilated small bowel. Exploration revealed an enlarged ptotic spleen whose pedicle caused obstruction of the colon. There was concomitant partial volvulus of the splenic flexure around the splenic pedicle. The splenic vein was thrombosed. Splenectomy was performed.

Gall bladder carcinoma presenting as liver abscess.

Year 1998
Singla SL. Garg P. Tahlan RN.
Department of Surgery, PGIMS, Rohtak.
Perforation of malignant gall bladder resulting in liver abscess and presenting as pyrexia of unknown origin is rare. We report a patient who was diagnosed at surgery, which was undertaken with a diagnosis of liver abscess on CT scan.