Tropical gastroenterology: official journal of the Digestive Diseases Foundation

Print ISSN: 0250-636X
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Endoscopic dilatation of achalasia cardia is an effective nonsurgical management option. It requires costly pneumatic dilators which are used under fluoroscopic guidance. This study assesses the efficacy and safety of an indigenous pneumatic dilator used without fluoroscopic guidance. Over a period of eleven years, 113 patients (69M, 44F) ofachalasia cardia underwent dilatation with indigenous pneumatic dilators without fluoroscopic guidance. The dilatation was performed under endoscopic vision. The procedure was successful in all patients. After six weeks following dilatation, there was significant improvement in the mean dysphagia score 3.63 + 0.61 to 0.53 + 0.93 (P<0.01). The response was still significant (0.78 + 1.03, P <0.05) at the end of one year. Excellent response with single dilatation was seen in 70.7% patients. After two dilatation sessions 92% of patients showed an excellent response. One patient had perforation. There was no mortality. Pneumatic dilatation under endoscopic vision without fluoroscopic assistance with the indigenous dilator is very effective and safe for short term treatment of achalasia carida.
 
Aggressive surgical treatment is now being advocated even for advanced carcinoma gall bladder (GBC). We reviewed our data of GBC over the last 5 years to analyse patient and survival characteristics in our patients. Case records of all cases of GBC admitted to surgical wards in our hospital between 1994 to 1998 were reviewed for details such as age, sex, religion, symptoms, signs, investigations, treatment and survival. World literature was reviewed by using Medline search of the subject. A total of 116 patients with confirmed GBC were admitted during these five years. Their mean age was 54 +/- 11 years. Females greatly outnumbered males. The commonest symptom was abdominal pain (95%) followed by GB mass (78%). Associated gallstones were present in 67% cases. Adenocarcinoma was the commonest variety (79%). CT scan and USG were helpful in 78% and 89% cases respectively. Maximum patients (67%) presented with Nevins' stage V and most of these were treated with supportive therapy only. Our patients were at least a decade younger than patients in other series and presented at an advanced stage. Radiological investigations (USG and CT scan) played a vital role in diagnosing or suspecting the disease. Curative resections were performed in few cases. Our own results, though limited favour an aggressive surgical approach. Based on our observations we have recommended certain cancer preventive steps and future treatment strategies.
 
Spastic Colitis (SC) of the fifties has been deleted and included in the Irritable Bowel Syndrome, as inflammation is not present, and the disturbed intestinal motility may involve the small and large intestine. With the advent of colonoscopy, we could investigate this generalized common term. Between 1983 and 1988 we have studied 120 documented cases of SC by colonoscopy with multiple biopsies. In every patient, we relied on consecutive procedures to confirm the diagnosis. They included: Stool examination, barium enema, small bowels series, colonoscopy with multiple biopsies. Serological diagnosis of Amebiasis has been applied to 41 patients only. With a normal small bowels, barium enema revealed a severe spasm of the whole colon, or a segmental spasm in one part of the colon. In 53 cases (44%,) we have noted virtual absence of haustra in the tubular descending colon. Colonoscopy in all cases has revealed an active contraction with some congestion of the mucosa or hyperemia. Different degrees of inflammatory reaction shown on multiple biopsies make the diagnosis of SC in these cases more relevant. In the Afro-Asiatic countries where amebiasis is endemic, SC is to be considered, as colonoscopy is proving the prevalence of congested or inflammatory process in the colonic mucosa, even when stool examination is repeatedly negative for amebiasis.
 
Tumor markers have an increasing significance in the diagnosis and evaluation of tumor, but their role in gallbladder cancer has not been established. The present study was undertaken to determine the utility of serological markers in carcinoma of the gallbladder (CaGB). This study was carried out in 55 cases and 8 healthy controls presenting to a single surgical unit of the University Hospital, Varanasi, India. CA242, CA19-9, CA15-3 and CA125 were assayed preoperatively in serum of patients with carcinoma of the gallbladder (39), cholelithiasis (16) and healthy controls (8) using ELISA technique. Mean concentration of all tumor markers was significantly raised in carcinoma of the gallbladder when compared with cholelithiasis. CA 242 was 12.10 vs 42.19 u/ ml, CA19-9 was 211.27 vs 86.06 uml, CA 15-3 was 71.42 vs 1.93u/ml and CA125 was 253.61 vs 65.5 u/ml <0.05). Sensitivity and specificity were calculated at various cut off points. Significant changes in CAl9-9 and CA242 occurred with advanced stage (p <0.05) and grade of tumor (p<0.00 1). When two tumor markers were combined, like CA242 and CA125, sensitivity and specificity improved to 87.5% and 85.7% respectively. Diagnostic accuracy is highest with a combination of CA 19-9 and CA 125 (80.65%). However, combination of tumor markers did not improve any further sensitivity or specificity of markers. Assay of CA242, CA15-3, CA19-9 and CA 125 are fairly good markers for discriminating patients of carcinoma of the gallbladder from cholelithiasis. CA242 and CA125 when used together achieved best sensitivity and specificity. Serum markers seem to be less sensitive when used individually in carcinoma of the gallbladder but may prove useful in combination.
 
A 14 year old boy with well differentiated squamous cell carcinoma of the upper oesophagus is being presented because of its rarity. The patient presented with dysphagia for 8 months. Barium swallow and endoscopy revealed a narrowing in the upper oesophagus with a proximal dilatation diverticulum. No definite aetiologic factor could be demonstrated. The case was treated with definitive irradiation with excellent immediate response.
 
Annual incidence of appendicectomy in urban black and white children of 0-14 yr. for 1985-1987 were estimated from hospital data obtained in Potchefstroom and Bloemfontein, also for black children at Baragwanath Hospital, Johannesburg. Rates per 10,000 children remain low for blacks, varying from 0.5, to 1.9: but were high for whites, 21.5 to 39.5. The latter are within the range of rates published in the West. As to diet, for blacks, mean daily fibre has fallen over several years to 10-14 g, similar to that of whites. Because of progressive fibre depletion, a marked rise in appendicectomies in blacks would be expected. The dietary fibre and the hygiene hypotheses afford only partial explanations for the disease's occurrence. Neither explains puzzling epidemiological differences including the recent fall in whites, nor throws light on the nature of precipitating factors.
 
14C-urea breath test has been widely used for diagnosis of Helicobacter pylori (H. pylori) infection. There is no general agreement on the cutoff values for determination of H. pylori negative subjects. We studied baseline values in subjects who were proved to be H. pylori negative and calculated the cutoff value of normalcy. A comparison of this test with other tests for diagnosis of H. pylori infection was also done. 12 patients (mean age 34 +/- 14, range 22-65 years; 8 men) of non-ulcer dyspepsia were studied, who were proved to be H. pylori negative by rapid urease test, Gram's staining, histopathology and culture of gastric mucosal biopsies obtained four each from the antrum, body and fundus of the stomach. The controls included 12 patients (mean age 40 +/- 13, range 22-65 years, 9 men), who were positive for H. pylori on culture or combination of rapid urease test and histopathology or rapid urease test and Gram's stain. 14C-urea breath test was performed using 5 uCi of 14C-urea dissolved in 300 ml of water. Breath samples were collected once before ingestion of 14C urea and subsequently at 5, 15 and 30 minutes after ingestion and 14C-contents in the breath samples measured. Results were expressed as 14 CO2/mmol CO2 exhaled as percent of administered urea. The mean +/- SD 14-C value in H. pylori negative vs H. pylori positive patients at 5 minutes, 15 minutes and 30 minutes were found to be 0.003 +/- 0.003 vs 0.064 +/- 0.042 (p < 0.001), 0.002 +/- 0.001 vs 0.056 +/- 0.039 (p < 0.001) and 0.001 +/- 0.002 vs 0.041 +/- 0.026 (p < 0.001) respectively. The mean values of 14C-urea breath test were significantly lower in H. pylori negative patients as compared to H. pylori positive patients. Using receiver operating characteristic (ROC) analysis of the data, the cutoff values obtained were 0.01, 0.007 and 0.009 at 5 minutes, 15 minutes and 30 minutes respectively. 14C-urea breath test levels at 5, 15 and 30 minutes intervals are significantly lower in H. pylori negative patients as compared to H. pylori positive patients. This test has high sensitivity and specificity in detecting H. pylori infection.
 
BACKGROUND: 14C-urea breath test (14C-UBT) is employed as a 'gold standard' technique for the detection of active gastric Helicobacter pylori infection and is recommended as the best option for "test-and-treat" strategy in primary health care centers. AIM: To compare the performance of capsulated and non-capsulated 14C-UBT protocols for the detection of H. pylori infection in patients. METHODS: Fifty eight H. pylori infected patients underwent routine upper GI endoscopy and biopsies were processed for rapid urease test (RUT) and histopathology examination. Capsulated 14C-UBT was done in a novel way by using 74 kBq of 14C-urea along with 6.0 MBq of 99mTc-diethylene triamine penta-acetic acid (99mTc-DTPA) to simultaneously monitor the movement and the fate of ingested capsule after delineating the stomach contour by using 20.0 MBq of 99mTechnetium pertechnetate (99mTcO4-) under dual head gamma camera. Non-capsulated 14C-UBT was performed within 2 days of the previous test and the results of these protocols were compared. Results: In 3 out of 58 H. pylori positive cases (5.17%), 14C-UBT results were found to be negative by using the capsulated method. Interestingly, on monitoring the real time images of the capsule in these cases it was found that misdiagnosis of H. pylori infection occurred mainly due to either rapid transit of the 14C-urea containing capsule from the upper gastric tract or its incomplete resolution in the stomach during the phase of breath collection. Conclusion: Use of non-capsulated '4C-UBT protocol appears to be a superior option than the conventional capsule based technique for the detection of H. pylori infection.
 
The incidence of peptic ulcer disease has steadily declined throughout the world. The influence of seasonal changes on the incidence of peptic ulcer disease is not well established. The aim of the study was to identify the changing trends in the occurrence of peptic ulcer disease from a tertiary referral center in south India and to study the seasonal Correspondence: variation in the occurrence of peptic ulcer. Retrospective analysis of the endoscopic records between the years 1989 to 2004. There was a significant decrease in the endoscopic diagnosis of duodenal and gastric ulcers (DU and GU) over the years. Both duodenal and gastric ulcers were more common in men than women. Over the years, there was a steady increase in the proportion of women affected with both DU and GU. A steady increase in the meanage of endoscopic diagnosis of GU and DU was seen over the years. The adjusted seasonal index revealed an increase in the endoscopic diagnosis of GU and DU in the months October-March. The endoscopic diagnosis of DU and GU has shown a decreasing trend over the past 16 years. The adjusted seasonal index has shown an increasing trend between the months of October-March.
 
Two percent of all malignant pancreatic tumors are metastases from other primaries, with small cell lung cancer, colorectal cancer, breast cancer and hematological neoplasms being the commonest. Renal cell carcinoma (RCC) metastasizing to the pancreas is rare and occurs in 2.8% of patients with metastatic RCC. However, RCC is the most common primary leading to solitary pancreatic metastasis. Metastases often present many years after nephrectomy for primary RCC (median time of 8 years) and should therefore be looked for on surveillance or when patients present with upper abdominal symptoms. Complete surgical resection when possible offers the best chance for cure.
 
PG-I (A), PG-II (B), PG-I/PG-II ratio (C) and G-17 levels (D) among patients with (n=44) or without intestinal metaplasia (n=116) 
H. pylori positivity by RUT, histopathology and ELISA 
Intestinal metaplasia (IM), a precursor of gastric cancer (GC), may be amenable to non-invasive assessment. We evaluated the diagnostic utility of serum PG-I, PG-II, PG-I/PG-II ratio and gastrin-17 (G-17) to detect IM and atrophy. The study was conducted at a tertiary care center located in low-incidence area of GC, endemic for H. pylori. The evaluation was designed as a prospective case-control study. Patients with GC and dyspepsia were evaluated by endoscopy, histology for IM (H&E, PAS and Alcian blue stains) and H. pylori (H&E and Giemsa stains), rapid urease test and IgG antibody (positive results in any two assays). Serum levels of PG-I, PG-II and G-17 were estimated using ELISA. Of the 98 patients with GC and 62 with dyspepsia, 35 (36%) and 9 (14%) had IM, respectively (p = 0.004). Patients with IM (n = 44) had lower PG-UPG-II ratio than those without IM (n = 116; median 4.4, 0.37-23.6 vs. 6.3, 0.19-38.6, respectively; p = 0.005). A cut-off value of PG-I/PG-II ratio of 6.0 had 64% sensitivity and 52% specificity for detecting IM (area under ROC curve 0.64). 26/44 (60%) patients with IM and 52/98 (53%) with GC had PG-I/PG-II ratio < 6. Serum G-17 was comparable among patients with and without IM. Though the PG-I/PG-II ratio was lower in patients with IM, only 60% had a lower ratio suggesting that this test and G-17 may not be useful to detect IM in low-incidence areas of GC, endemic for H. pylori infection.
 
Primary gastrointestinal malignancies constitute only 1% of all paediatric neoplasms. The aim of this study was to describe our 18 years' experience with non-familial paediatric colorectal malignancies, outlining pertinent features of diagnosis, treatment and outcome. 9 patients of non-familial paediatric colorectal malignancies were admitted in PGIMS, Rohtak, Haryana between 1990 and 2008. After the initial surgical management, the advanced cases underwent chemotherapy and radiation therapy where required and were followed up. There were six male and three female patients (age range: 7 to 16 years). Three tumours arose in the rectum, three in the sigmoid colon, one each in the splenic flexure and appendix, and there was one case of diffuse colonic polyposis. All cases presented with obstruction and rectal bleeding. Two cases of sigmoid carcinoma were unresectable and expired 4 months post-surgery. The rest responded to radical resection. Three patients required palliative radiation therapy. Due to the advanced stage, chemotherapy was given to all the carcinoma patients. One patient had local recurrence after 5 months and another developed distant metastasis. The rest are on follow-up and clinically and radiologically disease free. Paediatric colorectal malignancy is a rare entity, usually diagnosed in the later stages, culminating in advanced disease. A majority of cases undergo radical resection due to the advanced stage of presentation. Advanced stages may also require chemotherapy and radiation therapy.
 
Using CA 19-9 and CEA (elevated > 2 times of normal) as predictors in determining operability and survival in pancreatic tumors. Levels of CA 19-9 and CEA were measured (pre and post operatively) in 49 patients of pancreatic malignancy. CECT was performed for diagnosis and staging. An experienced surgeon determined the operability. The levels of tumor markers were correlated with the operability and the survival based on CECT and intra-operative findings. 16/24 (67%) patients with CA 19-9 levels (< 2 times) and 19/24 (79%) patients with CEA levels (< 2 times) were found to be resectable. 22/25 (88%) patients having elevated CA 19-9 levels (p = 0.0002-t) and 17/25 (70%) patients having elevated CEA levels (p = 0.003) were found to be non-resectable. Of the 27 patients, found resectable on CECT, 5 were non-resectable intra-operatively. All of these had elevated levels of CA 19-9 and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) non-resectable patients, with elevated levels of CA 19-9 reported at 1 year follow up. None of the non-resectable patients with CA 19-9 levels > 1000 U/ml reported at 6 month follow-up. None of the resectable patients pre-operatively showed evidence of recurrence. All achieved normal values post surgery. Elevated levels of CA 19-9 and CEA (> 2 times) predict increased chances of inoperability and poor survival in pancreatic tumors. Levels > 3 times had increased risk of inoperability even in patients deemed resectable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients. Levels of CA 19-9 (> 1000 U/ml) indicate a dismal survival in non-resectable group of patients.
 
Measurement of lower esophageal sphincter (LES) length 
LES and acid exposure 
Three lower esophageal sphincter (LES) characteristics associated with gastro-esophageal reflux disease (GERD) are, LES pressure = 6 mmHg, abdominal length (AL) <1 cm and overall length (OL) <2 cm. The objective of this study was to validate this relationship and evaluate the extent of impact various LES characteristics have on the degree of distal esophageal acid exposure. A retrospective review of a prospectively maintained database identified patients who underwent esophageal manometry and pH studies at Creighton University Medical Center between 1984 and 2008. Patients with esophageal body dysmotility, prior foregut surgery, missing data, no documented symptoms or no pH study, were excluded. Study subjects were categorized as follows: (1) normal LES (N-LES): patients with LES pressure of 6-26 mmHg, AL = 1.0 cm and OL = 2 cm; (2) incompetent LES (Inc-LES): patients with LES pressure <6.0 mmHg orAL <1 cm or OL <2 cm; and (3) hypertensive LES (HTN-LES): patients with LES pressure >26.0 mmHg with AL = 1 cm and OL = 2 cm. The DeMeester score was used to compare differences in acid exposure between different groups. Two thousand and twenty patients satisfied study criteria. Distal esophageal acid exposure as reflected by the DeMeester score in patients with Inc-LES (median=20.05) was significantly higher than in patients with an N-LES (median=9.5), which in turn was significantly higher than in patients with an HTN-LES. Increasing LES pressure and AL provided protection against acid exposure in a graded fashion. Increasing number of inadequate LES characteristics were associated with an increase both in the percentage of patients with abnormal DeMeester score and the degree of acid exposure. LES pressure (=6 mmHg) and AL (<1 cm) are associated with increased lower esophageal acid exposure, and need to be addressed for definitive management of GERD.
 
Little data is available regarding the 24-week therapy with pegylated interferon and ribavirin in Egyptian patients with hepatitis C virus (HCV) genotype 4 infection. We aimed to investigate the efficacy of 24-week versus 48-week peginterferon alpha-2a plus ribavirin therapy in patients with HCV genotype 4 infection with with rapid virological response. This trial included 102 patients with HCV genotype 4 infection and low viral load. They were treated with peginterferon alpha-2a (180 microg/week) plus ribavirin. Patients (87/102) with a rapid virological response were randomized for a total treatment duration of 24 weeks (group A: 43) or 48 weeks (group B:44). Virological responses (EVR: early virological response, EOTR: end of treatment response, and SVR: sustained virological response) were assessed for each group. In group A, EVR was achieved in 37/43 (84%) patients, while EOTR was achieved in 34/43 (79%) patients and SVR in 30/43 (70%) patients. In group B, on the other hand EVR was achieved in 38/44 (84%) patients, while EOTR was achieved in 35/44 (80%) patients and SVR in 32/44 (73%) patients. No significant difference in SVR rates was observed between the two groups. The rate of adverse events was higher in group B, with lower adherence rates than group A. In patients with chronic HCV genotype 4 infection with rapid virological response and low viral loads, a 24-week peginterferon alpha-2a plus ribavirin therapy is as effective as a 48-week therapy with lower rate of adverse events.
 
To study the efficacy and tolerability of pegylated interferon alpha 2b and ribavirin therapy in a cohort of chronic hepatitis C patients. In a prospective, open label, uncontrolled trial pegylated interferon alpha 2b (Viraferon Peg) 1.5 microgram/ kg subcutaneously weekly plus daily ribavirin 800mg for 24 weeks in genotypes 2 & 3 and 1000mg for 48 weeks in genotypes 1 and 4 was administered to 16 patients of chronic hepatitis C. The primary end point was the sustained viral response. Therapy was prolonged by 3 months if the end of therapy response was not attained. Drug dosage was modified or temporarily discontinued if anaemia or bone marrow suppression developed. Both virological end of therapy response and sustained viral response were seen in 75% cases but not every patient who achieved end of therapy response had a sustained viral response. Relapse was seen in 31% cases and a pattern of delayed response was seen in 2 patients who later experienced a sustained viral response. Biochemical and virological responses were similar. A lower baseline viral load, genotype 3, a high ALT and the parenteral mode of viral acquisition were associated with higher sustained viral response rates. A good response was also seen in men, those over 50 years of age and those with normal baseline ALT. Most relapses occurred in genotype 3 patients whose age was less than 50 years; however the relapsing viral load was very low. 66% of previous interferon and ribavirin non-responders achieved sustained viral response. Treatment was well tolerated; temporary dose modification was required in 3 patients. In Indian patients, a combination of peginterferon alpha 2b and ribavirin is safe and effective both as initial treatment of chronic hepatitis C and for use in previous non-responders.
 
Interferon treatment is the established option for the treatment of patients with chronic hepatitis B without decompensated liver disease. However, such treatment is expensive. We report here our data of a multi-center, open-label trial of the use of an indigenously produced interferon in the treatment of chronic HBeAg-positive chronic hepatitis B. Adult patients with chronic HBeAg-positive hepatitis B with elevated serum transaminase activity and positive serum HBV DNA test were treated with 5 MU/day of an indigenously produced interferon (Shanferon; Shantha Biotechnics, Hyderabad, India) for 4 months, and were then followed up for 6 months. Of the 39 patients enrolled, 36 completed the treatment and 33 completed the post-treatment follow-up. Of the 33 patients who completed the study, end-of-treatment biochemical and virological responses were observed in 10 (30%) and 5 (15%) respectively. Sustained biochemical and virological responses were observed in 15 (45%) and 7 (21%), patients respectively. Adverse effects led to the discontinuation of treatment in only one patient. Our data suggest that safety and efficacy of the indigenously produced interferon were similar to those previously reported results with interferon from other sources.
 
A combination of Peginterferon and Ribavirin is the standard treatment for patients with chronic hepatitis C viral infection (HCV). Ribavirin is contraindicated in patients with chronic renal failure (CRF). Conventional Interferon monotherapy is effective in around 30% of such patients. There is scanty data on the use of Peginterferon monotherapy in them. We describe our preliminary experience of monotherapy with Peginterferon alpha- 2b {12 kDa} (Peg-IFN) for HCV patients undergoing haemodialysis for CRF. They were treated with Peg-IFN 1 microg/kg body weight subcutaneously once a week for 24 weeks. In all patients, clinical (age, sex, mode of acquiring HCV, pattern of haemodialysis) and virological (HCV RNA quantitative-PCR and genotype) profile was noted at baseline. Early virological response at 12 weeks (EVR), end-of-treatment virological response at 24 weeks (ETVR) and sustained virological response after 6 months of stopping treatment (SVR) were noted during the follow-up period. The clinical and virological characteristics of patients were as follows: Of a total number of 6 patients, 5 were male and 1 was female with an age range of 35 to 62 years. The duration of haemodialysis was from between 5 and 12 months before the start of treatment and its frequency lay between 1 and 3 times a week. The mode of acquiring HCV was blood transfusion (100%). All 6 cases suffered from chronic hepatitis. The genotype distribution was genotype 3 in 3 (50%), genotype 1 in 1 (16.7%) and genotype none of 6 in 2 (33.3%) patients. All the patients (100%) completed treatment. EVR was seen in all 6 patients (100%). ETVR was seen in 5 of 6 patients (83.3%). A follow-up period of more than 1 year was available in 4 patients. 3 of these 4 patients (75%) had SVR. A virological response was maintained in all 3 (100%) patients with SVR even after 6 months of renal transplantation. Peg-IFN monotherapy is safe and effective in patients with HCV who are on haemodialysis for CRF.
 
The early and late results of the Smead-Jones (SJ) technique of closure of emergency vertical midline laparotomies was compared with other conventional methods of closure such as anatomical repair (AR), mass closure (MC) and single layer (SL) closure. Four Hundred and Three patients who underwent emergency laparotomy were studied prospectively. The results of SJ closure of laparotomy in them were compared with other techniques of abdominal closure. Ninety percent of patients with SJ were in wound class IV and at high risk of wound complications. It was seen that the overall infection rate for SJ at 12.4% was significantly less than all other types of closure. The wound dehiscence rate for SJ at 3.0% was the lowest. This protective effect of SJ against dehiscence was also seen in the presence of post operative chest infection and abdominal distension. The incisional hernia rate for SJ was also lowest (4%). The appearance of the scar was comparable to the other techniques of follow up. The present study concluded that the Smead-Jones techniques of laparotomy closure had very low incidence of early and late complications and was superior to other conventional methods of closure.
 
Dyspepsia is a frequent presenting symptom amongst patients attending medical clinics worldwide. However their aetiologies differ geographically. The present study was conducted to identify the aetiologies of dyspepsia of our centre and to determine their clinical characteristics. Five hundred consecutive patients presenting with dyspepsia were studied at our Institute. All patients underwent detailed structured questionnaire, stool examination, upper gastrointestinal endoscopy, ultrasound scan of upper abdomen and sigmoidoscopy when necessary. Among 500 patients, 34% suffered from essential dyspepsia, 28% had peptic ulcer, 19.2% had cholelithiasis, 10.8% had irritable bowel syndrome and 6% had gastro-oesophageal reflux. Significantly more patients with peptic ulcer experienced night paints, pain relief with food, milk, antacids or H2 receptor antagonists and periodic pain. In patients with essential dyspepsia, pain was continuous, mild to moderate in intensity, aggravated by food or alcohol, without relief with milk, antacids or H2 receptor antagonists and night pains were absent in them.
 
The study includes 61 cases which were subjected to ultrasound (US) guided fine needle aspiration cytology (FNAC) to find out the utility of this technique in the diagnosis of pancreatic lesions. Age of the patients ranged from 23 to 85 years with a median of 50 years. Male to female ratio was 36:25. One or more clinical diagnoses were offered in 16 and in 9 of these, the disease was related to pancreas. Subsequent to US, the lesions were localized to pancreas in 57 and the nature of pathology in the pancreatic lesion could be diagnosed in 31. By FNAC, 31 cases (50.8%) were diagnosed to have pancreatic malignancy which included adenocarcinoma (23 cases), papillary cystic tumour (1), muco-epidermoid carcinoma (1), acinic cell carcinoma (1), islet cell tumor (1), and non Hodgkin lymphoma (4). FNAC of liver in 2 cases and retroperitoneal lymph node in a case of pancreatic adenocarcinoma revealed metastasis. During follow up, 1 case of non Hodgkin's lymphoma showed CSF involvement. Three cases (4.9%) were suspected to have epithelial malignancy of which one was confirmed as an adenocarcinoma following surgery and histology. Four (6.6%) were benign lesions which included nonspecific inflammation (2 cases), tuberculous pancreatitis (1) and pseudopancreatic cyst (1). The remaining 23 cases (37.7%) had normal or inadequate cytology. Of these, FNAC of liver showed metastasis in 2 cases and one case each were diagnosed as adenocarcinoma and pseudopancreatic cyst respectively following surgery. None of the patients had any complication following FNAC. We recommend US guided FNAC to be routinely used for diagnosis of pancreatic lesion.
 
Patients with a traumatic or non-traumatic acute abdominal conditions often have equivocal findings regarding the need for surgery. Ultrasound and computed tomography, though useful, have limitations and not always available in peripheral hospitals. Diagnostic peritoneal lavage (DPL) was investigated as an aid to decision-making in such patients. After preliminary X-ray and ultrasound, DPL was performed in 50 patients with an equivocal acute abdomen (18 trauma, 32 non-trauma). It was found that overall sensitivity, specificity, accuracy, and positive and negative predictive values were high for patients with trauma. All the above parameters except specificity and negative predictive value (NPV) were also found to be high for the non-trauma group. DPL was found to be a bedside investigation, which helped in taking the decision to operate on patients with both traumatic and non-traumatic acute abdomen.
 
Abdominal cocoon, which is characterised by encasement of bowel by a fibrous membrane, is a rare cause of intestinal obstruction. It occurs primarily in females with only three cases reported earlier in males. We report a male patient presenting with small bowel obstruction and detected to have abdominal cocoon at surgery. Incision of thick membrane and lysis of adhesions led to relief of obstruction without any recurrence.
 
Abdominal cocoon, a rare condition in which the small bowel is encased in a membrane, resembles peritoneal fibrsis. There are only 16 case reports of this condition in the world literature. A 15-year-old girl presented with recurrent abdominal pain due to distal small bowel obstruction. Abdominal X-ray showed multiple air fluid levels like small intestinal obstruction. Contrast study revealed segregation of the small bowel loops with a dilatedproximal small intestine and gradual narrowing of the distal ileum with the obstruction; the mucosal pattern was preserved till the distal ileum. Contrast was not flowing into the colon. At laparotomy, the small intestine was seen to be encased and coiled up in a membrane. The membrane was excised, resulting in release of the obstruction.
 
As laparoscopic cholecystectomy has become one of the most commonly performed operations, radiologists increasingly encounter complications resulting from these. Late abdominal abscesses developing as a result of dropped gallstones albeit unusual, have been described. Abdominal wall tuberculosis following laparoscopy has also been reported. We report a rare case of intraabdominal and abdominal wall abscesses of tubercular aetiology associated with dropped stones following laparoscopic cholecystectomy.
 
Bacterial infection is a problem in the intensive care unit (ICU). We conducted the present study in the surgical ICU over a period of 5 months to determine the prevalence of nosocomial infection. Our ICU has a bed strength of 7 with an average occupancy rate of 5.46 patients. Mechanical ventilation associated pneumonitis was the commonest nosocomial infection. Older patients, patients with organ system failure and patients with co-morbid conditions were at high risk of developing nosocomial infections. E. coli was the commonest and most resistant organism grown in our study.
 
Recurrent biliary pancreatitis is described as episodes of new abdominal pain after diagnosis of pancreatitis. Few studies have analyzed the abdominal pain before the diagnosis of acute pancreatitis. Our study aimed to analyze factors associated with previous abdominal pain episodes in patients with biliary pancreatitis, and elucidate its possible pancreatic origin. Data from direct interrogation and medical records was analyzed from 48 hospitalized female patients with diagnosis of acute biliary pancreatitis. Mean age of our patients was 31.6 years (SD +/- 13.9). Forty one (85.4%) patients gave history of at least one previous abdominal pain episode. During the episode 37 (90.2%) patients received H2 receptor antagonist or proton pump inhibitors as treatment; 26 (63.4%) had epigastric pain; 23(56.1%) gave association with cholecystokinetic food; 21 (51.2%) complained of nausea and/or vomiting; 23 (56.1%) had jaundice, acholia and/or dark urine; and 20 (48.9%) patients had microlithiasis and/or biliary sludge. Previous abdominal pain episodes had similar characteristics to a pancreatic episode in a high percentage of our patients. These characteristics suggest that these episodes are often undiagnosed pancreatic attacks.
 
The role of Helicobacter pylori (HP) as a cause of recurrent abdominal pain (RAP) and gastrointestinal symptoms is controversial and there still remains a big debate whether to test and treat or not. To investigate the correlation between HP infection and RAP as well as other GI symptoms. We conducted a case control study at the Jeddah Clinic Hospital from January 2009 to December 2010. It included 244 cases (group I) aged 2-16 years with RAP after exclusion of any organic disease. Cases receiving antibiotics, bismuth, H2 antagonists or proton pump inhibitors during last 45 days were excluded. 122 age and gender matched asymptomatic children (group II) were enrolled as controls. Both groups were tested for Helicobacter pylori infection using stool antigen and/or urea breath test. The mean age of cases was 7.76 +/- 3.38 years. 48% of cases were males. There was no significant statistical difference between both groups regarding age and sex distribution, nationality and body weight (BW). 42.6% cases were positive for H. pylori infection in group I and 45% in group II. Comparison between HP positive cases and HP negative cases in group I revealed a statistically significant difference in incidence of vomiting, epigastric pain, history of infected family member and iron deficiency anemia (p = 0.001, 0.000, 0.000 and 0.025 respectively). HP infection is documented in more than 40% of both symptomatic and asymptomatic children. There is no association between RAP and HP.
 
The Abdominal Cocoon is a very rare cause of small bowel obstruction. It is caused by encapsulation of the small bowel by a fibrous membrane. This tropical disease, seen in young females, has also been reported in males. This is one of the largest series of the Abdominal Cocoon, with five new patients (3 males and 2 females) being reported. The traditional surgical treatment of choice is by lysis of adhesions. All patients in this case series had small bowel intubation done in addition to adhesiolysis. Although small bowel intubation is an established procedure for various causes of recurrent small bowel obstruction, to our knowledge this is the first report of its use in the management of the Abdominal Cocoon. We report our surgical technique in the management of this rare disease.
 
The present study was performed to study the prevalence of Helicobacter pylori (H. pylori) infection in children with recurrent abdominal pain (RAP). Children above 3 years of age of both sexes attending the OPD of a teaching hospital, with complaints of at least three discrete episodes of abdominal pain of sufficient severity to interrupt normal daily activities, occurring over a period of one month or more and with out identifiable cause of pain were enrolled in the study. The subjects were divided into 3 age groups of 3-5 years, 5-8 years and 8-12 years. Thirty normal controls from each age group were also enrolled. Detailed history was taken and thorough physical examination was done. Estimation of haemoglobin and specific IgG antibodies to H. pylori by Immunocomb II was done. Upper gastrointestinal endoscopy was performed with a fibreoptic pediatric sized endoscope in RAP cases after obtaining informed parental consent. Multiple biopsy samples were taken and subjected to Rapid Urease Test (RUT), Gram's Staining, Culture and histology. Data obtained were analyzed, using Fisher's Z Test, Students t-test or Chi Square as applicable. Sixty-eight cases and 90 controls were enrolled, the number in various age groups being comparable (p >0.05). Seropositivity rate was significantly more in cases (60.3%) compared to controls (10%) (p <0.001) even among various age groups (<0.01). Prevalence increased with advancing age from 3.3% to 16.7% in controls, but not among cases. Seropositivity rates among males and females were comparable both among cases and controls. Incidence of malnutrition, stunting and anemia were similar irrespective of serological status. Total duration of illness, frequency, duration of each episode, and location of pain were also comparable. Among 10 seropositive children who underwent upper gastrointestinal endoscopy 80% showed one or more abnormalities, while the single seronegative child had no abnormal finding. Half the seropositive cases had gastritis, hyperemia or erosion on gross examination. Histopathological evidence of gastritis was present in 40%, but culture was negative in all. There is a significant association of H. pylori infection and RAP. But studies involving larger number of children undergoing endoscopy is required for definite evidence of a 'cause and effect'.
 
Slow intraperitoneal haemorrhage following blunt abdominal trauma may present as haemorrhagic ascites. Such haemorrhage is usually due to rupture of spleen, liver or damage to small bowel mesenteric vasculature. We encountered a patient with bleeding from ruptured exogastric leiomyoblastoma. Two cases of traumatic rupture of gastric leiomyosarcomas have been reported previously. The operative treatment is usually delayed and the diagnosis established only at laparotomy. We suggest a high level of suspicion and early laparotomy.
 
Patient characteristics and outcome analysis 
Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82% due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible. Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years). The risk factors for mortality were analyzed. The reasons for uncontrollable bleed were: liver trauma (8), liver tumours (3), following liver transplantation (4), pancreatic necrosectomy (17) and miscellaneous causes (17). There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <34 degrees C, metabolic acidosis and sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality. A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.
 
Myeloproliferative disorders (MPD) (like polycythemia vera, essential thrombocythemia and primary myelofibrosis) are responsible for 50% cases of Budd-Chiari syndrome (BCS) and 35% cases of portal venous thrombosis (PVT) in western series. A point mutation at Val617Phe of Janus kinase 2 tyrosine kinase gene (JAK2(V617F) mutation) occurs in high proportion with MPD. This may be useful in diagnosing overt and latent form of MPD in intra-abdominal venous thrombosis (IAVT), consisting of BCS and PVT. In a 4 year prospective study from 2006 to 2009, JAK2 mutations were assessed in all patients diagnosed with MPD and IAVT attending our institution. Twenty three healthy individuals and 31 patients with non-MPD hematological disorders served as controls. All patients of idiopathic IAVT were tested for the mutation. Test for JAK2(V617F) mutation was carried out by allele specific polymerase chain reaction. JAK2(V617F) mutation was significantly more common in MPD patients (76%) than in non-MPD hematological disorders (0%) and healthy controls (0%). There was no statistical difference in presence of JAK2(V617F) mutation in patients of MPD with or without thrombosis (80% vs. 74%). In 58 patients with IAVT, the JAK2(V617F) mutation was present in 40% with BCS, 14% with PVT and 100% combined BCS+PVT). The JAK2(V617F) mutation occurs at high frequency in patients with MPD and IAVT. All idiopathic IAVT patients must be screened for JAK2(V617F) mutation to detect latent MPD. Detection of latent MPD by JAK2(V61F) mutation in BCS may change treatment strategy and outcome.
 
Top-cited authors
Yogesh Chawla
  • Postgraduate Institute of Medical Education and Research
Krishneel Singh
  • University of Technology Sydney
Shivaram Prasad Singh
  • Kalinga Gastroenterology Foundation
Premashis Kar
Satyavati V Rana
  • All India Institute of Medical Sciences Rishikesh