Gourdas Choudhuri

Long-Term Follow-Up after Pneumatic Dilation for Achalasia Cardia: Factors Associated with Treatment Failure and Recurrence

BACKGROUND:Though most patients with achalasia cardia (AC) respond to pneumatic dilation (PD), one-third experienced recurrence. Long-term follow-up studies on factors associated with various outcomes are scanty.METHODS:In this retrospective study, 126 patients (36.5 ± 14.6 yr, 76 male) with AC (diagnosed by esophagoscopy, barium esophagogram, and/or manometry) were followed up in person or through mail. The median dysphagia-free duration was calculated by Kaplan–Meier analysis. Factors associated with nonresponse and recurrence after PD were determined using univariate and multivariate analyses.RESULTS:Symptoms were dysphagia (126, 100%), chest pain (21, 17%), regurgitation (61, 48%), weight loss (33, 26%), and pulmonary symptoms (23, 18%); 5 of 126 (4%) had megaesophagus (≥7 cm). The mean lower esophageal sphincter (LES) pressure was 38.7 ± 16.8 mmHg. One hundred and fifteen of 126 (91%) patients responded to PD (90 (71%) to first session); 25 of these had recurrence of dysphagia after 15 ± 17 months. Post-PD chest pain requiring hospitalization occurred in 21 of 126 (17%; one had an esophageal perforation). Post-PD LES pressure, which was assessed in 48 of 126 patients, had decreased by >50% from baseline in 14 of 29 responders, 0 of 11 nonresponders (p= 0.004, χ2 test), and 5 of 8 relapsers. The median dysphagia-free duration by Kaplan–Meier analysis was 60 months (SE 2.7, 95% CI 54.7–65.3). On univariate analysis, male gender, pulmonary symptoms (nocturnal coughing spell, history of respiratory infection), absence of chest pain, and failure to achieve a reduction in LES pressure >50% after PD were associated with poor outcome; whereas age, grade of dysphagia, regurgitation, megaesophagus, and LES pressure before PD were not. Male gender was associated with poor outcome by multivariate-analysis.CONCLUSIONS:PD is an effective and safe treatment for AC. Post-PD LES pressure measurement may be helpful in assessing response. Male patients have poorer outcomes following PD.

Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

BackgroundAcute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6xa0weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live.MethodsThe expert working party, predominantly from the Asia–Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted.ResultsAVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24xa0h of presentation, and/or ongoing melena, with last melanic stool within last 24xa0h. The time frame for the AVB episode is 48xa0h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (<30xa0min of hospitalization) and endoscopic variceal ligation (door to scope time <6xa0h) is accepted as first-line therapy. Rebleeding (48xa0h of T0) is further sub-classified as very early rebleeding (48 to 120xa0h from T0), early rebleeding (6 to 42xa0days from T0) and late rebleeding (after 42xa0days from T0) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of non-response to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients.ConclusionManagement of acute variceal bleeding in Asia–Pacific region needs special attention for uniformity of treatment and future clinical trials.

Endosonographic, endoscopic, and histologic evaluation of alterations in the rectal venous system in patients with portal hypertension☆☆☆

BACKGROUNDnColorectal varices and congestive rectopathy or colopathy have been erratically reported in patients with portal hypertension. The clinical importance of these entities has not been described. We assessed the changes in the venous system of the rectum by endoscopy and rectal endosonography (EUS). We also assessed the role of factors such as etiology of portal hypertension, grade of esophageal varices, sclerotherapy, and liver disease severity on the occurrence of these vascular changes.nnnMETHODSnWe studied changes in the venous system of the rectum using endoscopy and EUS in 60 patients with portal hypertension (cirrhotic 41, noncirrhotic 19). Ten patients with irritable bowel syndrome and 6 patients with hemorrhoids served as controls. Rectal varices were classified as tortuous, nodular, and tumorous. Corresponding appearances on rectal EUS were classified as single or discrete multiple, multiple, and innumerable submucosal veins, respectively. Evidence of congestive rectopathy was also recorded.nnnRESULTSnPrevalence of rectal varices was 43.3% on endoscopy (73% tortuous, 19% nodular, and 8% tumorous) and 75% on EUS (p < 0.0005). The latter showed corresponding appearances of submucosal veins in 25 of 26 patients and detected submucosal veins not identified at endoscopy in 19 other patients. Congestive rectopathy was found in 38.3% of patients. Multiple small dilated vessels in the submucosa were seen in 23.3% patients on rectal EUS. The development of these vascular changes was significantly influenced by sclerotherapy, but not by higher grade of esophageal varices, the etiology of portal hypertension, or severity of liver disease.nnnCONCLUSIONSnChanges in the rectal venous system are common, with rectal EUS being superior to endoscopy in detecting early, as well as florid, changes.

Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL). Part I: Status Report of HCV Infection in India

Globally, around 150 million people are infected with hepatitis C virus (HCV). India contributes a large proportion of this HCV burden. The prevalence of HCV infection in India is estimated at between 0.5% and 1.5%. It is higher in the northeastern part, tribal populations and Punjab, areas which may represent HCV hotspots, and is lower in western and eastern parts of the country. The predominant modes of HCV transmission in India are blood transfusion and unsafe therapeutic injections. There is a need for large field studies to better understand HCV epidemiology and identify high-prevalence areas, and to identify and spread awareness about the modes of transmission of this infection in an attempt to prevent disease transmission.

Basiliximab Does Not Increase Efficacy of Corticosteroids in Patients With Steroid-Refractory Ulcerative Colitis

BACKGROUND & AIMSnBasiliximab is a chimeric monoclonal antibody that binds CD25 and thereby inhibits interleukin (IL)-2-mediated proliferation of lymphocytes. IL-2 might contribute to the resistance of T cells to corticosteroids. We investigated the efficacy and safety of basiliximab as a corticosteroid-sensitizing agent in patients with corticosteroid-refractory ulcerative colitis (UC).nnnMETHODSnWe studied 149 patients with moderate to severe UC (Mayo score ≥6 and endoscopic subscore ≥2) despite treatment for at least 14 days with oral prednisone (40-50 mg/day). Subjects were randomly assigned to groups that were given 20 mg (n = 46) or 40 mg (n = 52) basiliximab or placebo (n = 51) at weeks 0, 2, and 4. All subjects received 30 mg/day prednisone through week 2; the dose was reduced by 5 mg each week to 20 mg/day, which was maintained until week 8. At week 8, we compared the rates of clinical remission (Mayo score ≤2, no subscore >1) for patients given basiliximab with the rate for patients given placebo.nnnRESULTSnTwenty-eight percent of patients given placebo, 29% of those given the 40-mg dose of basiliximab, and 26% of those given the 20-mg dose of basiliximab achieved clinical remission (P = 1.00 vs placebo for each dose). Basiliximab was generally well tolerated. Six subjects who received basiliximab had serious adverse events (6.1%) compared with 2 who received placebo (3.9%; P = .72). In subjects given basiliximab, incomplete saturation of CD25 (<50%) on peripheral T cells was associated with the presence of anti-basiliximab antibodies (odds ratio, 21; 95% confidence interval, 2.4-184).nnnCONCLUSIONSnBasiliximab does not increase the effect of corticosteroids in the induction of remission in outpatients with corticosteroid-resistant moderate to severe UC.

Frequency and Factors Associated with Small Intestinal Bacterial Overgrowth in Patients with Cirrhosis of the Liver and Extra Hepatic Portal Venous Obstruction

Spontaneous bacterial peritonitis (SBP), a common complication of cirrhosis of liver, might result from translocation of bacteria from the small bowel. However, there is scanty data on frequency of small intestinal bacterial overgrowth (SIBO) in patients with cirrhosis of the liver. There are no data on SIBO in patients with extra-hepatic portal venous obstruction (EHPVO) in the literature. A total of 174 patients with cirrhosis of the liver, 28 with EHPVO and 51 healthy controls were studied for SIBO using glucose hydrogen breath test (GHBT). Persistent rise in breath hydrogen 12xa0ppm above basal (at least two readings) was considered diagnostic of SIBO. Of 174 patients (age 47.2xa0±xa011.9xa0years, 80.5% male) with cirrhosis due to various causes, 67 (38.5%) were in Child’s class A, 70 (40.2%) class B and 37 (21.7%) class C. Of the 174 patients with cirrhosis, 42 (24.14%) had SIBO as compared to 1 of 51 (1.9%) healthy controls (Pxa0<xa00.0001). Patients with EHPVO had similar frequency of SIBO compared to healthy controls [2/28 (7.14%) vs 1/51 (1.97%), Pxa0=xa0ns]. Frequency of SIBO in Child’s A, B and C was comparable [13 (18.6%) vs 16 (23.9%) and 13 (35.1%), respectively; Pxa0=xa0ns]. Presence of SIBO were not related to ascites, etiology of cirrhosis, and degree of liver dysfunction. SIBO is common in patients with cirrhosis of the liver. Patients with EHPVO do not have higher frequency of SIBO than healthy subjects. SIBO in cirrhosis is not related to the degree of derangement in liver function or of portal hypertension.

Dapsone induced cholangitis as a part of dapsone syndrome: a case report

BackgroundDapsone can rarely cause a hypersensitivity reaction called dapsone syndrome, consisting of fever, hepatitis, exfoliative dermatitis, lymphadenopathy and hemolytic anemia. Dapsone syndrome is a manifestation of the DRESS (drug rash with eosinophilia and systemic symptoms) syndrome which is a serious condition that has been reported in association with various drugs. Cholangitis in dapsone syndrome has not been reported so far in the world literature.Case presentationWe report a patient who presented with fever, exfoliative dermatitis, jaundice and anemia within three weeks of starting of dapsone therapy. These features are typical of dapsone syndrome, which is due to dapsone hypersensitivity and is potentially fatal. Unlike previous reports of hepatitic or cholestatic injury in dapsone syndrome we report here a case that had cholangitic liver injury. It responded to corticosteroids.ConclusionWe conclude that cholangitis, though unusual, can also form a part of dapsone syndrome. Physicians should be aware of this unusual picture of potentially fatal dapsone syndrome.

Endoscopic ultrasonographic evaluation of the rectum in cirrhotic portal hypertension

Rectal endoscopic ultrasonography was performed using an ultrasound fiberscope in 20 patients with cirrhotic portal hypertension (6 alcoholic patients, 4 patients with hepatitis B surface antigen positive, and 10 cryptogenic patients) and in 10 patients with irritable bowel syndrome as controls. Rectal varices were diagnosed endoscopically when either tortuous or saccular distended veins were seen beneath the mucosa. At rectal endoscopic ultrasonography rectal varices were seen as rounded or oval echo-free structures in the submucosa. Rectal endoscopic ultrasonography also showed perirectal veins outside the rectal wall. Rectal varices were detected by endoscopy in 9 patients and by rectal endoscopic ultrasonography in 17 patients. Rectal endoscopic ultrasonography also detected submucosal veins in 3 of 10 controls. The number and size of submucosal veins seen on rectal endoscopic ultrasonography in patients with portal hypertension were greater than in controls (p < 0.01 for both number and size). The size of perirectal veins was greater in patients than in controls (p < 0.05), although their number was no different (p = NS). A perforating vein communicating between a submucosal and perirectal vein was seen in only one patient. Rectal wall thickness was not different in patients and controls (p = NS). Rectal endoscopic ultrasonography was superior to endoscopy in detecting the presence (85% versus 45%, p < 0.01), and number (p < 0.01) of rectal varices. Our study suggests that rectal endoscopic ultrasonography is useful in detecting changes in rectal and perirectal vasculature in patients with cirrhotic portal hypertension.

Piperacillin induced bone marrow suppression: a case report

BackgroundPiperacillin (and piperacillin/tazobactam) is a commonly prescribed antibiotic and is generally considered safe. We report a case of piperacillin induced bone marrow suppression.Case presentationA 19-year-old boy was being treated with piperacillin followed by piperacillin/tazobactam for infected pancreatic pseudocyst. After 21 days of treatment, he developed neutropenia and thrombocytopenia. These reversed promptly after stopping piperacillin/tazobactam. The time course of events suggested that piperacillin was the cause of bone marrow suppression in this patient.ConclusionBone marrow suppression is a serious adverse effect of piperacillin, which should be kept in mind while treating patients with this drug.

Percutaneous catheter drainage of amebic liver abscesses with and with out intrahepatic biliary communication: a comparative study

Influence of communication with the intrahepatic biliary system on the clinical picture of amebic liver abscesses in 33 consecutive patients resistant to medical therapy, and their response to percutaneous catheter drainage was evaluated. Abscess-biliary communication was found in 27% of the sample. Patients with abscesses communicating with the biliary tree presented more frequently with jaundice (67% vs. 0%, P < 0.005), with a longer duration of illness (median 20 vs. 12 days, P < 0.001), had larger lesions (median 600 vs. 320 ml, P < 0.001) and required catheter drainage for longer periods (median 17 vs. 6.5 days, P < 0.000001). However the presence of a biliary communication did not materially affect the cure rate with catheter drainage (89% vs 100%, P > or = 0.05). In conclusion, an abscess-biliary communication is not uncommon in refractory amebic liver abscesses, and can be clinically detected by the presence of jaundice. Though a prolonged period of drainage may be necessary in the presence of this complication, catheter drainage can be expected to result in cure.