Mayank Jain

Biofeedback therapy—Challenges in Indian setting

Sir, Constipation is a common complaint at all ages [1] and affects around 20% of people in the USA [2]. Though constipation is a common complaint among Indian patients, the exact prevalence is unknown [3]. Dyssynergic defecation is common and affects up to half of the patients with chronic constipation [4]. Several randomized controlled trials have demonstrated the utility of biofeedback therapy in this subgroup of patients [4]. Biofeedback uses neuromuscular training and visual, audio, or verbal feedback to improve coordination. Though anorectal manometry is being done at many centres in India, the data regarding the acceptability and use of biofeedback therapy is unknown. We reviewed the data of two centres located in Indore and New Delhi. We studied all patients, evaluated using anorectal manometry, over a period of 18 months from May 2015 to September 2016. Both the hospitals are teaching hospitals and cater to middle class population. A total of 178 patients underwent anorectal manometry during the study period. Chronic constipation was the commonest indication for the procedure (145, 81.5%). Most of the patients were males (75.8%) and the mean age was 39.4 years. After an manometric evaluation and balloon expulsion test, dyssyngergic defecation was diagnosed in 85 patients (59%). Though biofeedback therapy was explained and offered to all patients with pelvic floor dyssynergia, only 19 (22.35%) came for one or more sessions. Only four patients completed six sessions of biofeedback and they reported partial relief in symptoms. The rest did not continue the treatment. The reasons reported for non-compliance were repeated hospital visits (11/15), high cost (8/15), lack of belief in the treatment (4/15), and embarrassment (2/15). Our experience paints a dismal picture regarding biofeedback therapy in Indian setting. Although constipation is a common problem in our country, we do not have well defined and validated criteria in our population to define and address the problem. There is lack of awareness regarding biofeedback therapy among patients and referring doctors. The therapy requires time, understanding, and regular visits to hospital. This seems to be exactly opposite of what most of our patients desire—instant relief! Moreover, the testing and therapy are not approved by many funding agencies and insurance. Homebased training devices are also not available in India. Apart from www.spreadnet.in website, there is no online/published data from India that can be used for patient education. Though biofeedback has proven benefits, its acceptability among Indian patients, especially in private hospitals, is highly limited. Efforts are required, on the part of gastroenterology organizations and physicians, to increase awareness and improve its acceptability in Indian setting.

Dyssynergic defecation: Demographics, symptoms, colonoscopic findings in north Indian patients

Sir, Chronic constipation is commonly encountered in clinical practice. The prevalence in Indian setting ranges from 12% to 17%. While patients presenting to primary care have lifestyle and dietary issues, a large number of those presenting to tertiary care facilities may have slow colonic transit, fecal evacuation disorder (FED) or a combination of the two [1]. Anorectal manometry is used to investigate anorectal function. It quantifies anal sphincter tone and assesses sensory response, anorectal reflexes, rectal compliance, and defecatory function. On attempted defecation or bearing down, the normal response consists of an increase in rectal pressure that is coordinated with a relaxation of the anal sphincter. Inability to perform this coordinated manoeuvre suggests dyssynergic defecation (DD) [2]. This response can be quantified using the defecation index=maximum rectal pressure during attempted defecation/minimum anal residual pressure during attempted defecation. A normal defecation index is >1.5 [2]. DD is subclassified into four types [3]. Most patients show paradoxical increase in anal sphincter pressure during attempted defecation with normal adequate pushing force (type 1). When patients are unable to generate an adequate pushing force, and exhibit a paradoxical anal contraction, a diagnosis of type 2 DD is made. In type 3, the patient can generate an adequate pushing force, but has absent or incomplete (<20%) sphincter relaxation. In type 4 DD, patient is unable to generate an adequate pushing force and demonstrates an absent or incomplete anal sphincter relaxation. We prospectively evaluated the demography, clinical symptom profile and colonoscopic findings in northern Indian patients who were diagnosed as DD on anorectal manometry. This prospective study was done at two centres—Pushpavati Singhania Hospital and Research Institute, New Delhi and Choithram Hospital and Research Centre, Indore. All adult (>18 years) patients who underwent anorec ta l manomet ry be tween June 2014 and December 2015 were included. Patients who were detected to have DD based on diagnostic inclusion criteria (Table 1) were studied for age distribution, sex distribution, symptom profile and colonoscopic findings. The symptom profile and colonoscopic findings were collected by interview by the primary investigators. The collected data were tabulated in Microsoft excel sheet and analyzed using appropriate statistical tests. A total of 208 patients were referred for anorectal manometry. Ninety-six (46.1%) fulfilled the inclusion criteria. Seventy-eight (81.2%) were males and the median age was 45.6 years (range 20–77 years). Based on the Rome III definition, most patients were labelled as functional constipation (64 total, 55 male) and others were classified as IBS-constipation predominant (28 total, 23 male). Based on Bristol stool forms, stool type III was the commonest (70.7%), followed by type II (20, 2%) and type IV (6, 6%), respectively. On * Mayank Jain mayank4670@rediffmail.com

Digital rectal examination—A reliable screening tool for dyssynergic defecation

Sir, Dyssynergic defecation (DD) is an important cause of chronic constipation among patients seen at centers offering gastrointestinal motility services. However, it is difficult for primary physicians, surgeons, and gastroenterologists to determine which patients are likely to have DD based on symptom profile and refer them to specialist centers for further testing. Digital rectal examination (DRE) has been reported to be a reliable tool to detect dyssynergia and facilitate selection of patients for further manometry testing [1, 2]. However, the utility of DRE in Indian setting for detection of DD remains untested. The present study was done with the aim to determine the utility of DRE in detecting DD in Indian patients. The present study was done at Choithram Hospital and Research Centre, Indore. It included all patients with constipation referred for anorectal manometry (ARM) between December 2012 and March 2016. Patients who were referred for evaluation for causes other than constipation like incontinence and post-surgical cases, age < 18 years, and those who did not cooperate for rectal examination were excluded. The DRE and ARM were performed by a single observer as no other technician/doctor was trained in performing and reporting ARM at the study center. Both the tests were done on the same day. Before ARM, DRE was performed in the left lateral position with the hips flexed. Protocol mentioned by Rao et al. [1] was followed for the same. Examination of the skin for excoriation, blood, skin tags, fissures, or hemorrhoids was performed. Anocutaneous reflex was tested by stroking the skin around the anus in all four quadrants with a cotton bud. Presence of reflex was determined by the brisk contraction of the perianal skin, the anoderm, and the external anal sphincter. DRE was performed using local anesthetic jelly and consisted of three steps: (a) palpation for tenderness, mass, stricture, and presence of stool; (b) resting anal tone assessment; and (c) squeeze evaluation for 30 s for intensity and sustainability. After this, the patient was asked to bear down. The examiner placed his left hand on the patient’s abdomen to assess the pushing effort. The ability to relax the anal sphincter and perineal descent was noted. A normal response consisted of contraction of abdominal muscles along with the relaxation of the external anal sphincter and perineal descent. Anorectal manometry was performed in the left lateral position with the hips flexed. Sixteen-channel silicone-rubber water perfusion manometry assembly (Ready Stock, Australia) was used. Data were recorded at 25 Hz and analyzed using Trace Version 1.3v (Hebbard, Melbourne, Australia). The parameters included the following: anorectal pressures at rest (60 s), squeeze pressures (three attempts for a maximum duration of 20 s each), the rectoanal inhibitory reflex, and rectal sensations. Balloon expulsion test was recorded after distending a rectal balloon with 50 mL of air [3] and asking the patient to expel the balloon in the left lateral position [3, 4]. The criteria for the diagnosis of dyssynergia by DRE and ARM are mentioned in Table 1. The collected data were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Detection rate and agreement of DREwith ARMwere calculated using Cohen’s kappa coefficient. A total of 96 cases were referred for ARM during the study period; 36 were excluded and 60 patients (median age 43.6 years, range 19–72, 48 males) formed the study cohort. * Mayank Jain mayank4670@rediffmail.com

Clinical predictors and gender-wise variations in dyssynergic defecation disorders

BackgroundThere is insufficient data from India regarding clinical predictors of dyssynergic defecation.AimTo identify demography, symptom, and colonoscopic parameters that can predict dyssynergic defecation (DD) among patients with chronic constipation (CC) and to compare the profile among male and female patients with DD.MethodsData collected from three centers during June 2014 to May 2017 included age, gender, symptom duration, form and consistency of stools, digital examination, colonoscopy, and anorectal manometry (ARM). Patients were grouped based on ARM diagnosis: group I (normal study) and group II (DD). The two groups were compared for demography, symptom profile, and colonoscopy findings. Gender-wise subset analysis was done for those with the normal and abnormal ARM using chi-square and unpaired t tests.ResultsOf 236 patients with CC evaluated, 130 (55%) had normal ARM and 106 (45%) had DD. Male sex, straining during defecation, bleeding per rectum, and abnormal colonoscopic diagnosis were significantly more common in group II. While bleeding per rectum and absence of urge to defecate were more common in males (pu2009<u20090.02), straining, digital evacuation, and hard stools were commoner in females with DD.ConclusionStraining during defecation, bleeding per rectum, and abnormal colonoscopy findings were more common in patients with DD. Symptoms of bleeding per rectum and absence of urge to defecate in men and straining during defecation in female patients were significantly associated with DD. Symptoms differ in males and females with DD.

An Insight into Antibiotic Resistance to Bacterial Infection in Chronic Liver Disease

BackgroundnEnd stage liver disease leads to immune dysfunction which predisposes to infection. There has been a rise in antibiotic resistant infections in these patients. There is scanty data f from India or idea regarding the same.nnnAim of the studynThe present study was undertaken to determine the type of infection acquired and the prevalence of antibiotic resistant infections in cirrhotic patients at a tertiary referral center in South India.nnnMaterials and methodsnIn this retrospective study, all consecutive cirrhotic patients hospitalized between 2011 and 2013 with a microbiologically-documented infection were enrolled. Details of previous admission and antibiotics if received were noted. In culture positive infections, the source of infection (ascites, skin, respiratory tract: sputum/endotracheal tube aspirate, pleural fluid; urine and blood) and microorganisms isolated and their antibiotic susceptibility was noted.nnnResultsnA total of 92 patients had 240 culture positive samples in the study period. Majority were Klebseilla followed by Escherichia coli and Enterococcus in nosocomial and health care associated infections. However, Enteroccocus was followed by E. coli and Klebsiella in community acquired infections. The antibiotic sensitivity pattern was analyzed for the major causative organisms such as E. coli, Klebsiella and Enterococcus. Most common resistant strains were extended spectrum beta lactamase producing enterobacteriacae (ESBL) followed by carbapenemase producing Klebsiella and methicillin resistant Staphylococcus aureus.nnnConclusionnNoscomial infection is the most common type, with Klebsiella and E. coli and there is significant rise in ESBL producing organism.

HRQOL using SF36 (generic specific) in liver cirrhosis

Health-related quality of life (HRQOL) is influenced by the disease state, associated complications and their management. In patients with liver cirrhosis co-morbidity, severity of liver disease and their complications are likely to affect the QOL. The aim of the study was to determine the factors that are likely to influence the domains of HRQOL using SF-36 in patients with liver cirrhosis. For the study, 149 patients with liver cirrhosis were compared with age-gender matched healthy controls for physical and mental components of SF-36 score and the effects of age, co-morbidity severity of liver disease and complications of liver cirrhosis on HRQOL were assessed using the same questionnaire. Results of the study showed that except for body pain, all the patients had a significantly low individual and composite domain score (p-valueu2009<0.0001) compared to age-gender matched controls. Patients below 45xa0years, Child-Turcotte-Pugh (CTP) C, a high model for end-stage liver disease (MELD) and higher rates of complication had low scores for body pain (KW pu2009<0.005) and those above 55xa0years, for physical function (pu2009<0.05). Both the physical components had a major impact on mental composite score (MCS) (KW pu2009<0.05). Co-morbidity that included diabetes, hypertension and hypothyroid states in various combinations had no effect on SF-36 scores while co-morbid conditions like musculoskeletal pain, arthralgia etc. affected physical domains (physical function, body pain and role physical) and physical component score (PCS) (KW pu2009<0.01 to <0.0001). By linear regression, MELD had a direct and significant association with overall PCS and mental component score (MCS).

Gastric cancer in India: epidemiology and standard of treatment

India has a low incidence of gastric cancer. It ranks among the top five most common cancers. Regional diversity of incidence is of importance. It is the second most common cause of cancer related deaths among Indian men and women in the age between 15 and 44. Helicobacter pylori carcinogenesis is low in India. Advanced stage at presentation is a cause of concern. Basic and clinical research in India reveals a globally comparable standard of care and outcome. The large population, sociodemographic profile and challenges in health expenditure, however, remain a major challenge for health care policy managers. The newer formation of National Cancer Grid, integration of national databases and the creation of social identification database Aadhaar by The Unique Identification Authority of India are set to enhance the health care provision and optimal outcome.

Vitamin D levels in ulcerative colitis at first diagnosis: Does it “bell the cat”?

Sir, Higher vitamin D levels in inflammatory bowel disease (IBD) are shown to be associated with improved quality of life [1], reduced rates of Clostridium difficile infection [2], reduced surgical rates [3], and lowered risk of cancers including colorectal cancer [4]. However, the presence and impact of vitamin D deficiency in treatment-naïve ulcerative colitis (UC) patients remain unexplored. Thus, the present casecontrol study was undertaken to compare the blood levels of vitamin D in patients with UC at the time of the first diagnosis and those in ageand sex-matched healthy controls. This prospective study was done at two centers: Choithram Hospital and Research Centre, Indore (MJ) and Gleneagles Global Health City, Chennai (MJ, VJ) between 2012 and 2016. We included 30 treatment-naïve patients with UC with a confirmed diagnosis at registration. The diagnosis was based on clinical, endoscopic, and histopathological confirmation; we compared their data with 60 ageand sex-matched controls who were attending master health check-up at the respective centers during the study period. The healthy controls were between 18 and 60 years of age, with no comorbidity (diabetes, hypertension, dyslipidemia, coronary heart disease, bronchial asthma, or hypothyroidism). We excluded previously diagnosed UC, indeterminate colitis, patients or controls on steroids or vitamin D supplementation or combination of calcium with vitamin D (present or recent past) supplements, and complications of UC, e.g. colorectal cancer, postoperative cases, and severe UC. Patient data included age, gender, body mass index (BMI), clinical presentation, disease severity (Truelove and Witts’ criteria), colonoscopy for the extent of the disease, and vitamin D levels. Data recorded among controls included age, gender, BMI, and vitamin D levels. Estimation of vitamin D was done using chemiluminescent microparticle immunoassay (CMIA). Vitamin D status was graded as follows: insufficiency (20–30 ng/mL), deficiency (8–19 ng/mL), and severe deficiency (< 7 ng/mL). The data were analyzed using unpaired t test for quantitative variables, Fisher’s exact test for categorical variables, and one-way analysis of variance (ANOVA) test for comparison of means. A p-values <0.05 were considered significant. All UC cases had mild to moderate disease activity by the Truelove andWitts’ criteria. The nutritional status of cases and controls was similar as per BMI assessment (Table 1). The median time interval between onset of symptoms and diagnosis was 45 days (15–135 days). Predominant symptoms at presentation included bleeding per rectum (24, 80%), increased stool frequency (22, 73.3%), weight loss (15, 50%), and urgency (10, 33.3%). ByMontreal classification, 10 cases had proctitis (E1), 9 had left-sided colitis (E2), and 11 had pancolitis (E3), respectively. Vitamin D levels were significantly lower in cases compared to the controls (Table 1; pvalue <0.001). None of the cases had normal vitamin D levels (Table 1). Seventy-three percent of patients in pancolitis group had vitamin D levels < 7 ng/mL while only two cases each with left-sided colitis and proctitis had severe deficiency (p 0.03). Majority of the cases with left-sided colitis and proctitis had vitamin D levels between 8 and 19 ng/mL (Table 2). The mean vitamin D levels were least in patients with pancolitis (11 cases, 6.5 ng/mL), followed by left-sided colitis (9 cases, 10.2 ng/mL) and proctitis (10 cases, 14.2 ng/mL). The values of vitamin D were significantly higher in proctitis group (p < 0.003). As noted from Table 1, even 50% of the controls had low vitamin D levels. Vitamin D deficiency is common in India and various factors like food fads, high fiber intake, modernization and indoor stay, cultural factors like Bpurdah/burqa^, and repeated pregnancies have been implicated for the same [5]. * Mayank Jain mayank4670@rediffmail.com

SX-Ella Danis stent in massive upper gastrointestinal bleeding in cirrhosis – a case series

We report our experience of three cases of decompensated cirrhosis with massive upper gastrointestinal bleeding, which required insertion of an SX-Ella Danis stent for hemostasis. The procedure is safe and effective.

Cellulitis in liver cirrhosis – a series of 25 cases from southern India

Introduction Cirrhosis of the liver predisposes patients to serious bacterial infections including cellulitis. The aim of the study was to determine the clinical and bacteriological profile of cellulitis in patients with liver cirrhosis. Material and methods In this prospective study, consecutive cirrhotic patients hospitalized between February and September 2017 were enrolled. Data retrieved included demographics, aetiology, co-morbidity, cirrhosis-related complications, site of cellulitis, baseline investigations, and wound and blood culture. Results Three hundred and thirty-eight patients were admitted, of whom 25 had cellulitis (mean age 52.8 ± 10.4 years, men 88.0%, median MELD [model of end-stage liver disease] 18.8 ± 10.4). Non-alcoholic steatohepatitis and alcohol were each the cause of cirrhosis in 40% of cases. Nine patients (36%) had diabetes mellitus. Cultures were positive in 13 cases (52%; 1 – blood, 11 – wound, 1 – both blood and skin). The majority of the cultures showed monomicrobial growth (9; 70%). Escherichia coli was the commonest isolate (6/13), followed by Klebsiella (4). 61% of isolates had multidrug resistant organisms. The outcome was favourable. Conclusions Prevalence of cellulitis was 7.4% in hospitalised cirrhotics. Culture positivity was 52%. Escherichia coli and Klebsiella were the most common isolates and three fifths of isolates were multidrug resistant.