Nilesh Pandav

The role of capsule endoscopy in etiological diagnosis and management of obscure gastrointestinal bleeding

Background/Aims To investigate the various etiologies, yields, and effects of capsule endoscopy (CE) on management and complications, along with follow up of patients with obscure gastrointestinal (GI) bleeding. Methods The study group of patients included those having obscure, overt, or occult GI bleeding. The findings were categorized as (A) obvious/definitive, (B) equivocal, or (C) negative. Any significant alteration in patient management post CE in the form of drug or surgical intervention was noted. Results Total patients included in the study were 68 (48 males and 20 females). The ratio of male:female was 2.4:1. The age ranged between 16 years to 77 years. Mean age for males was 62±14 years, for females 58±16 years. The total yield of CE with definitive lesions was in 44/68 (65.0%) of patients. In descending order (A) angiodysplasia 16/68 (23.53%), (B) Crohns disease 10/68 (14.70%), (C) non-steroidal anti-inflammatory drug enteropathy 8/68 (11.76%), (D) small bowel ulcers 4/68 (5.88%), (E) jejunal and ileal polyps 2/68 (2.94%), (F) intestinal lymphangiectasis 2/68 (2.94%), and (G) ileal hemangiomas 2/68 (2.94%) were followed. Equivocal findings 12/68 (17.65%) and negative study 12/68 (17.65%) was found. Complications in the form of capsule retention in the distal ileum were noted in 2/68 (2.94%) subjects. Statistically, there was a higher probability of finding the etiology if the CE was done during an episode of bleeding. Conclusions CE plays an important role in diagnosing etiologies of obscure GI bleeding. Its role in influencing the management outcome is vital.

Spectrum of chronic small bowel diarrhea with malabsorption in Indian subcontinent: is the trend really changing?

Background/Aims This study aimed to document the recent etiological spectrum of chronic diarrhea with malabsorption and also to compare features that differentiate tropical sprue from parasitic infections, the two most common etiologies of malabsorption in the tropics. Methods We analyzed 203 consecutive patients with malabsorption. The etiological spectrum and factors that differentiated tropical sprue from parasitic infections were analyzed. Results The most common etiology was tropical sprue (n=98, 48.3%) followed by parasitic infections (n=25, 12.3%) and tuberculosis (n=22, 10.8%). Other causes were immunodeficiency (n=15, 7.3%; 12 with human immunodeficiency virus and 3 with hypogammaglobulinemia), celiac disease (n=11, 5.4%), Crohns disease (n=11, 5.4%), small intestinal bacterial overgrowth (n=11, 5.4%), hyperthyroidism (n=4, 1.9%), diabetic diarrhea (n=4, 1.9%), systemic lupus erythematosus (n=3, 1.4%), metastatic carcinoid (n=1, 0.5%) and Burkitts lymphoma (n=1, 0.5%). On multivariate analysis, features that best differentiated tropical sprue from parasitic infections were larger stool volume (P=0.009), severe weight loss (P=0.02), knuckle hyperpigmentation (P=0.008), low serum B12 levels (P=0.05), high mean corpuscular volume (P=0.003), reduced height or scalloping of the duodenal folds on endoscopy (P=0.003) and villous atrophy on histology (P=0.04). Presence of upper gastrointestinal (GI) symptoms like bloating, nausea and vomiting predicted parasitic infections (P=0.01). Conclusions Tropical sprue and parasitic infections still dominate the spectrum of malabsorption in India. Severe symptoms and florid malabsorption indicate tropical sprue while the presence of upper GI symptoms indicates parasitic infections.

Role of Rectal Diclofenac Suppository for Prevention and Its Impact on Severity of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients

Background The aim was to study the role of rectal diclofenac in prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and its impact on severity of post-ERCP pancreatitis. Methods We conducted a single-center, prospective, open-labeled, randomized trial for evaluating the use of rectal diclofenac in prevention of post-ERCP pancreatitis in high-risk patients. We assessed 526 patients coming for ERCP for different indications. Four hundred patients were eligible for the study. Those not fitting the high-risk criteria and with acute pancreatitis were excluded. These patients were randomized in two groups: 200 patients received rectal diclofenac prior to or during the procedure, while 200 patients received placebos. Serum amylase was measured at 2 and 36 hours. Post-ERCP pancreatitis was defined as serum amylase > 3 times upper limit of normal with associated severe abdominal pain. Severity was graded according to days of hospitalization and complications. Results Twenty-nine out of 400 (7.2%) patients developed post-ERCP pancreatitis. Six out of 200 (3%) patients in rectal diclofenac group developed post-ERCP pancreatitis compared to 23 out of 200 (11.5%) patients in placebo group. The difference was statistically significant (P = 0.001). All patients (six) in rectal diclofenac group developed mild pancreatitis as compared to severe pancreatitis in four and moderate pancreatitis in five patients in the placebo group. Conclusion Rectal diclofenac prior to or during ERCP in high-risk patients reduces the incidence as well as severity of post-ERCP pancreatitis compared to placebo.