Harshal S. Mandavdhare

Telmisartan-induced sprue-like enteropathy: a case report and a review of patients using non-olmesartan angiotensin receptor blockers.

Recent studies have identified sprue-like illness associated with the use of the antihypertensive agent olmesartan medoxomil. However, whether this condition is specific to the use of olmesartan or is associated with the use of drugs belonging to the class of “sartans” remains to be clarified. A 45-year-old woman with chronic kidney disease along with hypothyroidism and hypertension presented with chronic diarrhea and significant weight loss. Endoscopy of the upper gastrointestinal tract showed scalloping and grooving of the duodenum, and histopathological examination showed subtotal villous atrophy. She was on telmisartan for hypertension, which was discontinued. Subsequently, diarrhea ameliorated dramatically, and she regained weight. To our knowledge, this is the first study to report telmisartan-associated sprue-like enteropathy. Further, we have reviewed the cases of patients with sprue-like enteropathy caused by valsartan, irbesartan, and eprosartan.

Prevalence and clinical impact of vitamin D deficiency on abdominal tuberculosis.

Background: Vitamin D is recognised to have multiple actions, including role in immune modulation. The prevalence and impact of vitamin D deficiency (VDD) in abdominal tuberculosis is unknown. Methods: We report the prevalence and clinical impact of VDD in patients with abdominal tuberculosis. The patients were divided into two groups: VDD (<20 ng/ml) or vitamin D sufficient (VDS) (⩾20 ng/ml). Groups were compared for extent (abdominal alone or extra-abdominal also) of disease and pattern of involvement (intestinal, peritoneal or both) and inflammatory response [serum C-reactive protein (CRP)]. Results: Of 63 patients, 53 had complete data (mean age: 36.3 ± 14.43, 31 males). Fourty-five (84.9%) patients had VDD and mean VD levels were 11.1 ± 10.1 ng/ml. Of 8 patients with VDS, 1 (12.5%) had extra-abdominal involvement while 13 (28.9%) with VDD had extra-abdominal involvement (p = 0.066). The mean CRP in patients with VDD was 42.9 ± 34.9 mg/dl vis-a-vis 105.38 ± 64.8 in VDS (p ⩽ 0.05). All seven patients with both intestinal and peritoneal involvement had VDD. Conclusion: VDD is common in abdominal tuberculosis and may be associated with more extensive involvement albeit a reduced inflammatory response.

Surgery for Abdominal Tuberculosis in the Present Era: Experience from a Tertiary-Care Center

BACKGROUND The role of surgery in abdominal tuberculosis is being redefined, as many patients will be candidates for endoscopic dilatation rather than open surgery. METHODS A retrospective analysis was done of the surgical procedures performed in patients with abdominal tuberculosis in a large tertiary-care center in North India. Details such as clinical presentations, previous history of tuberculosis, any anti-tubercular therapy (ATT), Mantoux skin test results, and the surgical procedures and findings were recorded. Short-term outcomes also were analyzed. RESULTS Thirty-five patients (26 male) were included, and the median age at presentation was 24 years (range 12-80 years). Sixteen patients had received prior ATT for abdominal tuberculosis. The indication for surgery was intestinal obstruction, perforation, and bleeding in 23 (66%), 10 (29%), and 2 (6%) respectively. Twenty-eight patients had intestinal strictures, with the ileum being the most common site (n = 21). Perforation was present in 10 patients, of which six had multiple perforations. Cocoon abdomen was present in four patients, two of whom had associated small-bowel stricture. Among 33 patients who underwent bowel resection, 14 had ileo-cecal resection/right hemicolectomy. The rest had small-bowel resection. Primary anastomosis and stoma creation was performed in 12 (36%) and 21 (64%), respectively. Post-operative intra-abdominal collections (p = 0.02) and incision dehiscence (p = 0.05) were more common in patients having stoma creation. CONCLUSION Surgical intervention is warranted in a subset of patients with abdominal tuberculosis and may be required in patients with recurrent intestinal obstruction or pain, intestinal perforation, or gastrointestinal bleeding.

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 ± 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 Crohns 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.

Chylous ascites due to idiopathic chronic pancreatitis managed with endoscopic stenting

Chylous ascites is an uncommon clinical entity, which usually results from congenital or acquired abnormality in proper lymphatic flow. While the common causes are related to trauma, malignancy or tuberculosis, pancreatic disorders can occasionally result in chylous ascites. Sporadic cases of chylous ascites due to acute or chronic pancreatitis or surgery for pancreatitis have been reported. The usual management is with medium chain triglycerides (MCT), total parenteral nutrition and octreotide. We report a case of a young male with idiopathic chronic pancreatitis who presented with chylous ascites which did not respond to MCT based diet and octreotide. The patient improved with endoscopic pancreatic duct stenting.

Tubercular gastric fistula: apropos of two cases

intestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol 2014; 5: 467–478. 9. Cuffari C. Diagnostic considerations in pediatric inflammatory bowel disease management. Gastroenterol Hepatol 2009; 5: 775–783. 10. Patel F, Fitzmaurice S, Duong C, et al. Effective strategies for the management of pyoderma gangrenosum: a comprehensive review. Acta Derm Venereol 2015; 95: 525–531.

Mycobacterial chylous ascites: report of three cases and systematic review:

Background: Chylous ascites is an uncommon presentation of mycobacterial infection. Methods: We report three cases of tubercular chylous ascites, and in addition, we performed a systematic review of the published literature for the clinical presentation, treatment, and outcomes of mycobacterial chylous ascites. We followed the PRISMA guidelines for the systematic review. Results: A total of 33 cases (including three of ours) were included. The mean age of the reported cases was 32.54 ± 17.56 years, and a male predominance (76%) was noted. The predominant clinical features were abdominal distension, abdominal pain, fever and loss of appetite and weight. Mycobacterium tuberculosis (MTB) and Mycobacterium avium-intracellulare (MAC) infection were responsible for 16 and 15 cases, respectively. All patients with MAC related chylous ascites had HIV infection. The mechanisms were related to lymph nodal enlargement, constrictive pericarditis and remote scrofuloderma. Overall, there was 29% mortality. Use of anti-mycobacterial therapy with use of total parenteral nutrition, octreotide and medium chain triglyceride-based diet resulted in improvement in the rest of the cases. The cause of death in our case was anti-tubercular therapy-induced hepatitis; three deaths were due to disseminated mycobacterial infection, one due to cardiopulmonary failure and unknown in four patients. Conclusion: Chylous ascites due to mycobacterial infection is uncommon and associated with poor outcome. However, early diagnosis and nutritional management along with antimycobacterial therapy can improve outcome.

Successful ERCP for management of traumatic pancreatic disruption in a patient with situs inversus

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for treatment of pancreaticobiliary diseases. However, ERCP may be difficult in patients who have altered gastrointestinal anatomy due to congenital or surgical reasons. A 40-year-old male with HIV infection presented with abdominal pain following abdominal trauma. The patient was diagnosed to have traumatic pancreatic injury and underlying situs inversus. The pancreatic fluid collection was drained using radiology guided pigtail placement done for the symptoms of abdominal pain and vomiting. The resulting external pancreatic fistula was successfully managed with ERCP and stenting. The patient improved with disappearance of ascites and resolution of pigtail output which was then removed. We report the technique used for ERCP in this patient. We also review the literature on pancreatic endotherapy in patients with situs inversus. The published literature suggests that with modifications in the standard ERCP technique like mirror image technique, 180 degree turn technique, left lateral technique etc. these patients can be managed successfully.

Underlying etiology determines the outcome in atraumatic chylous ascites

Chylous ascites is an uncommon entity and infectious etiology is the most common cause in developing countries. However, recently, whether there is any change in trend of etiologies in developing countries is not known. In this study, a retrospective analysis of the data of cases of atraumatic chylous ascites was conducted. Twelve patients of atraumatic chylous ascites with a mean age of 35 years were studied and 6 of them were males. The mean duration of symptoms was 9.6 months and the clinical presentation was abdominal distension (12 cases), pain abdomen (10 cases), loss of appetite and weight (9 cases), peripheral lymphadenopathy (4 cases) and fever (3 cases). Etiologies were tuberculosis (3 cases), malignancy (2 cases), radiotherapy related (2 cases), pancreatitis related (2 cases), lymphatic malformation (2 cases) and multifactorial (1 case). Eight improved with conservative measures, 2 were lost to follow up and 2 died. Our outcomes found infectious etiology still as the most common cause of atraumatic chylous ascites. Benign treatable causes could be managed successfully with conservative measures while malignant etiology had a poor prognosis. Underlying etiology determines the outcome in atraumatic chylous ascites.

Gastrointestinal histoplasmosis: a case series from a non-endemic region in North India

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 149 Six patients with GIH were diagnosed over 1 year. Mean age was 43 ± 13.08 years (range, 25–60 years) and 3 patients (50%) were male. The presenting complaints in decreasing order were abdominal pain (5 patients), weight loss (5 patients), fever (4 patients), diarrhea (2 patients), dysphagia (2 patients) and hematochezia (1 patient). Two patients had HIV as a risk factor for GIH but none were previously diagnosed. One patient had history of gradually increasing dysphagia for last 6 months for which upper GI endoscopy was done which revealed presence of multiple deep ulcers in upper esophagus (Fig. 1A) and CT thorax showed long segment mild asymmetric circumferential thickening of mid-esophagus with multiple variable sized nodules in both lobes of lung and the histology was consistent with histoplasmosis (Fig. 1B). Other patient had intermittent colicky abdominal pain, for which contrast-enhanced CT (CECT) abdomen was done which revealed presence of circumferential mural thickening of terminal ileum, ileocecal (IC) junction and cecum. Colonoscopy showed circumferential ulcers in cecum. On evaluation they have been diagnosed with HIV with low CD4 counts (143 and 125 cells/mm respectively). Neither of the patient was on highly active antiretroviral therapy. The third patient had presented with abdominal pain, weight loss and bloody diarrhea over last 6 months. On CECT abdomen there was asymmetric mural thickening in terminal ileum and IC junction with dilatation of terminal ileum along with thickening of antropyloric region. On endoscopy patient had a large ulcero-proliferative growth near IC valve and nonnegotiable growth near antrum. Histology confirmed the prespISSN 1598-9100 • eISSN 2288-1956 https://doi.org/10.5217/ir.2018.00111 Intest Res 2019;17(1):149-152