Ratnakar Kini

Patulous upper esophageal sphincter - an unusual endoscopic finding

The upper esophageal sphincter (UES) has various important functions, such as protection of the airway from aspiration and conduct of bolus into esophagus, which are controlled by complex neuronal mechanisms. The functions will be affected when there is malfunction of the UES due to various etiologies. Here we present an 80-year-old male with non-progressive dysphagia and patulous UES incidentally found on esophagoduodenoscopy. There are no documented cases of idiopathic patulous UES in literature. Endoscopists must be aware of this rare condition while evaluating a patient presenting with oropharyngeal dysphagia.

A simplified technique of esophageal self-expandable metallic stent placement without fluoroscopic and endoscopic guidance for treating esophageal carcinoma

BACKGROUND/AIMS Self-expandable metallic stent (SEMS) placement with fluoroscopic guidance is a commonly used technique to relieve obstruction in patients with esophageal carcinoma. However, it has disadvantages such as radiation exposure. SEMS placement with endoscopic guidance also has the disadvantages of causing discomfort to patients as the endoscope and SEMS assembly are simultaneously used and it needs two experts for the procedure to be performed. To overcome these disadvantages, a simplified technique for SEMS placement was developed that does not require fluoroscopic or endoscopic guidance. Our objective was to compare the efficacy and safety of this simplified technique with the conventional SEMS placement method. MATERIALS AND METHODS This is a retrospective study including patients with esophageal carcinoma who underwent SEMS placement for the palliation of dysphagia. RESULTS Sixty-two patients were placed on stents for the palliation for esophageal carcinoma, with 46 patients in the conventional technique group (group A) and 16 in the simplified technique group (group B). The duration of the procedure was considerably lesser in group B than in group A (2 min 53 s vs. 15 min 4 s, p=0.001). The technical success rate achieved in groups A and B were 97.82% and 100%, respectively. SEMS placement required two experts in the conventional technique whereas the simplified technique required only one expert. CONCLUSION The advantages of the simplified technique are as follows: technical ease, cost-effectiveness, no exposure to radiation, requirement of minimal manpower, and less time-consuming; these advantages make it the technique day-care procedure.

Prevalence and clinical significance of small intestinal bacterial overgrowth in patients with chronic liver disease

Aim: To study the prevalence of small intestinal bacterial overgrowth (SIBO) in chronic liver disease patients. To analyze its relationship with the etiology, severity and complications (Spontaneous bacterial peritonitis, hepatic encephalopathy) of chronic liver disease. Materials & methods: Cases were 60 chronic liver disease patients (20 CHILD CHILD-C). 60 Controls were healthy persons who were not on any recent or probiotics. All patients underwent routine laboratory investigations, upper gastrointestinal endoscopy and glucose hydrogen breath test as per the protocol. included in our study. 20 numbers included in each child status A, B and C. 44 males and 16 females were included in both cases and controls. The age ranged between 28 to 71 years), 22 to 65 years (mean age 50.47 years) among cases and controls respectively. 44 (73.30%) males and 16 (26.70%) females were present in both case and control group. CLD was found to be 30 ethanol related, 9 HBV related, 5 HCV related and 16 cryptogenic. Turcot Pugh score varied from 6 to 12 with mean value 8.3. Model For End Stage Liver Disease score value ranged from 7 to 16 with mean 10.14. GHBT was positive in 20 out of 60 patients (33.3%). In controls only 2 out of 60 were positive for hydrogen breath test. Comparing the GHBT between two groups p value was found to be <0.001 which was statistically significant. GHBT breath testwas positive in 12 (20%) alcoholic liver disease, 1(1.7%) HBV related, 2 (3.3%) HCV related and 5 (8.3%) cryptogenic CLD. Presence of SIBO was not correlated with the etiology of liver disease (p value 0.435). Prevalence of SIBO among CTP class A was 20% (4/20), CTP class B was 35% (7 ⁄ 20), CTP class C was 45% (9 ⁄ 20). The prevalence of SIBO increased with the s liver disease (p = 0.013). Increased prevalence of small intestinal bacterial overgrowth in patients with decompensated (CTP score more than 7) cirrhosis than in patients with compensated cirrhosis was noted. Conclusion: Small intestinal bacterial overgrowth was prevalent in about 33% of cirrhotic patients. The frequency of small intestinal bacterial overgrowth increases with severity of liver disease. Severity of portal hypertension does not correlate with small intestinal bacterial overgrowth. of ascites and high serum bilirubin can reliably predict presence of small intestinal bacterial overgrowth.