Pazhanivel Mohan

Prevalence and risk factors for gastroesophageal reflux in pregnancy.

Background and aimPrevalence of gastroesophageal reflux (GER) increases during pregnancy, due to several factors like decreased lower esophageal sphincter pressure, increased intra-abdominal pressure secondary to the enlarged gravid uterus and alteration in gastrointestinal transit. The present study aimed to determine the prevalence of GER in pregnancy in a southern State of the Indian subcontinent and determine the risk factors associated with it.MethodsConsecutive pregnant females (n = 400) at various stages of pregnancy attending the antenatal clinic or admitted in the antenatal wards were enrolled. Patients with heartburn or regurgitation or both (n = 182) for at least a week were defined as cases, and controls were those without these symptoms (n = 218). Data on demographic variables and symptoms were analyzed using Pearson chi-square, Yates corrected chi-square and Fischer exact test and student independent t-test as appropriate; p < 0.05 was considered significant.ResultsDemographic characteristics between cases and controls were similar. The mean age of cases (23.68±3.37 years) was similar to that of controls (23.25±3.31 years). The overall prevalence of GER was 45.5% (182/400), 77 (19.3%) had heartburn (GER-HB), 54 (13.5%) had regurgitation (GER-R) and 51 (12.8%) had both (GER-HB + R). Age and gravida did not influence the frequency of symptoms. Symptoms were more frequent in the second (43.1%) and third trimester (54.1%) as compared to the first trimester (9.5%) in pregnant women with GER (p < 0.001). Atypical symptoms were uncommon. GER was common among non-vegetarians (p = 0.02) and frequent aerated beverage users (p = 0.001).ConclusionsGER prevalence was high in pregnancy, often in second and third trimester. Non-vegetarianism and aerated beverages increased the risk of reflux in pregnancy.

Prevalence and risk factors for unsuspected spontaneous ascitic fluid infection in cirrhotics undergoing therapeutic paracentesis in an outpatient clinic

BackgroundSpontaneous bacterial peritonitis (SBP) has been typically described in hospitalized patients. There are little data on ascitic fluid infection in asymptomatic outpatients. The present study was aimed at determining the prevalence and risk factors for asymptomatic ascitic fluid infection among patients with liver cirrhosis attending an outpatient clinic.MethodsBetween January 2008 and December 2009, consecutive patients with cirrhosis (n = 110) undergoing therapeutic paracentesis in an outpatient setting were studied. Patients with fever, abdominal pain, hepatic encephalopathy, recent gastrointestinal bleeding, impaired renal function, previous history of SBP and on antibiotic treatment were excluded. Baseline demographic details, and etiology and severity of liver disease were recorded. Ascitic fluid cell count, culture and biochemical tests were done using standard laboratory techniques.ResultsThe causes of cirrhosis were alcohol (55.5%), hepatitis B (21.8%), hepatitis C (9.1%) and others (13.6%). A total of 278 paracenteses were done in them (average 2.5 [1.1] times per patient). Spontaneous ascitic fluid infection was found in 7 (2.5%) paracentesis, including spontaneous bacterial peritonitis in one (0.4%), monomicrobial nonneutrocytic bacterascites (MNB) in two (0.7%) and culture-negative neutrocytic ascites (CNNA) in four (1.4%). Escherichia coli, Klebsiella spp. and Staphylococcus aureus were grown. There was no difference between cirrhotic outpatients with and without infection in age, gender, alcohol consumption, etiology of cirrhosis, Child-Pugh score, serum albumin and ascitic fluid total protein. There was no death due to spontaneous ascitic fluid infection.ConclusionAsymptomatic ascitic fluid infection was very infrequent in patients with cirrhosis attending an outpatient clinic and undergoing therapeutic paracentesis.

Prevalence of hepatitis C virus antibodies in systemic lupus erythematosus.

Raimondo et al. [7] searched for HBV DNA in liver from 98 liver-disease-free individuals who underwent liver resection or needle biopsy during abdominal surgery. OBI was detected in 16 of the 98 cases (16.3%), and majority of OBI cases were seropositive. They concluded that about one in six of the Italian general population might be carriers of OBI. Taking together, the introduction of more sensitive tests and/or inclusion of liver samples revealed that OBI prevalence is really higher even in healthy participants.

Recurrent abdominal pain in a 16-year-old girl.

A 16-year-old girl was admitted with acute onset of abdominal pain associated with vomiting. There was no abdominal distension, fever, jaundice or gastrointestinal bleeding. She had two similar episodes in the preceding 6 months. On examination, there was mild tenderness in the epigastrium. Her blood sugar, renal parameters, results of liver function tests and serum amylase were normal. The blood samples collected for analysis are shown in Figure 1. Upper gastrointestinal endoscopy was unremarkable.

Nonrotation of the intestine

A 20-year-old man presented to our department with complaints of abdominal pain over his epigastrium and around his umbilicus that had lasted for several years. He reported vomiting for 2 hours after each meal in the 2 days before presentation. Results of plain abdominal radiography, ultrasonography

Dysphagia Due to Kindler Syndrome

A 51-year-old man with recently diagnosed acute myeloid leukemia on chemotherapy complicated by pancytopenia and neutropenic fever developed progressively worsening abdominal distension along with nausea, vomiting, and loose watery bowel movements. Abdominal X-ray showed pneumatosis intestinalis of the right colon (red arrows) with gaseous distension of the transverse colon along with loss of haustration of the descending colon (a). Computed tomography (CT) of the abdomen without contrast showed diffuse dilation of the large bowel, with the exception of a short segment of the descending colon compressed between the abdominal wall and a large, exophytic left renal cyst (green line), which measured approximately 18 cm. The CT also showed pneumatosis intestinalis of the right colon (red arrow) (b). Percutaneous drainage of the cyst was performed via placement of an 8 Fr pigtail catheter, which resulted in decompression of the colon. Colonoscopy showed the dilated colon with no obstructing mass. The patient improved symptomatically following the decompression, and an abdominal X-ray showed a reduction in the degree of distension of the colon (c). The pigtail drain was removed one week following the clinical improvement and radiological resolution of the colonic distension. (Informed consent was obtained from the patient to publish these images.)

Minimal hepatic encephalopathy in noncirrhotic portal hypertension

The major chemoprotective bioactive in the broccoli sprout is sulforaphane, which is found in very small amounts in the mature vegetable. The main bioactive in the mature vegetable is indole-3-carbinol, which exhibits some different properties from sulforaphane. Indole-3carbinol downregulates the elements of the CytP450 family, which may lead to the generation of toxic intermediates. In some situations, indole-3-carbinol has been found to be pro-oxidant and carcinogenic.

Cutaneous marker of an internal malignancy

A 32-year old woman presented with progressively increasing aundice, intractable pruritus and pale stools for 2 months. There as no fever, prodromal symptoms, abdominal pain, vomiting or astrointestinal bleeding. She had also noticed a rapid increase n abdominal girth over the last month. Examination of her skin Fig. 1A) showed brownish hyperpigmented macules and subcuaneous nodules suggestive of neurofibromatosis type 1 (NF1). he was deeply icteric with moderate ascites. Ultrasound of the bdomen showed a dilated common bile duct, intrahepatic biliary adicles and ascites. Side viewing endoscopy demonstrated a perimpullary growth (Fig. 1B) with histology comprising of intestinal ucosa with adjacent malignant glands infiltrating the underlyng submucosa and muscularis consistent with adenocarcinoma Fig. 2A and B). Ascitic fluid cytology was positive for malignant ells.

An Uncommon Complication of Savary Gilliard Dilation

To the Editor: Fluoroscopy is recommended for safe and eff ective stricture dilation in the esophagus. A 32-year-old man, with a known case of corrosive stricture of the esophagus, was referred aft er the breakage of the tip of the Savary Gilliard guidewire during endoscopic dilation without fl uoroscopy. Upper gastrointestinal endoscopy showed the spring tip of the guidewire in the esophagus at the site of the stricture. ( Figure 1 ) An endoscopic retrieval of the broken guidewire was carried out with a pair of crocodile forceps. ( Figure 2 ). Fluoroscopy is recommended for monitoring the position of the guidewire and dilator during stricture dilation in the esophagus. It has been emphasized by the American and German gastrointestinal endoscopic societies to use fl uoroscopy for at least the initial dilation sessions. However, several studies have reported successful esophageal dilation without fl uoroscopy (1) . Perforation, aspiration, and bleeding are the principal complications of esophageal dilation. Th e risk is greater with complex strictures and when dilation is carried out blindly without fl uoroscopy. However, it has been shown that even tight strictures can be safely and eff ectively dilated without fl uoroscopy, using a tracer guidewire (1) . Aft er positioning the guidewire in the stomach, it is important to be aware of its length outside the oral cavity throughout dilation when fl uoroscopy is not used. In the case described, in which stricture dilation was carried out without fl uoroscopy, the guidewire might have been displaced during dilation to the site of the stricture. Th e breakage was probably because of forceful advancement of the dilator over the spring tip, which was at the level of the stricture. Th is complication might have been prevented by ensuring a constant length of the guidewire from the patients bite block to a reference point outside the oral cavity during the entire process of dilation.

Management of HBV-related cirrhosis: Role of nucleoside analogs

In the management of HBV related cirrhosis of the liver, viral suppression with safe and effective antiviral agents is essential. Besides, antiviral therapy for long term use in cirrhotics should be safe and affordable with low risk of drug resistance. Treatment of compensated HBV cirrhosis can diminish the risk of hepatic decompensation and progression to hepatocellular carcinoma [HCC]. Regression of fibrosis and reversal of cirrhosis have also been reported with antiviral therapy. Further, in decompensated cirrhosis, although liver transplantation is considered as the definitive therapy, inhibition of viral replication before transplantation can delay the need for liver transplant and also prevent HBV recurrence in the post-transplantation period. These patients while on antiviral therapy need close monitoring for viral resistance and adverse events, besides continued surveillance for HCC. This article reviews the literature on the role of nucleoside analogues in the management of HBV related chronic liver disease.