Saroj K. Sinha

Comparison of Lactulose and Glucose Breath Test for Diagnosis of Small Intestinal Bacterial Overgrowth in Patients with Irritable Bowel Syndrome

Background and Aims: Validity of the lactulose breath test (LBT) to diagnose small intestinal bacterial overgrowth (SIBO) has been questioned. Therefore, a study was planned to compare LBT with glucose breath test (GBT) to diagnose SIBO in irritable bowel syndrome (IBS) patients and controls. Methods: 175 diarrhea-predominant IBS patients and 150 apparently healthy controls were enrolled. IBS was diagnosed according to Rome II criteria. Breath samples were collected every 10 min up to 180 min. Breath H2 and CH4 were measured using an SC MicroLyzer. SIBO was positive with a sustained increase in breath H2 or CH4 or both ≥10 ppm over a baseline value within <90 min in case of LBT and within <120 min in GBT. Results: SIBO was positive in 60/175 (34.3%) patients by lactulose and in 11/175 (6.2%) patients by GBT. In controls, LBT was positive for SIBO in 45/150 (30%) patients and in 1/150 (0.66%) patients by GBT. Positive LBT for SIBO was not significantly different in patients and controls; while using GBT, SIBO was significantly higher (p < 0.01) in patients as compared to controls. By using GBT as gold standard for SIBO, sensitivity, specificity, positive predictive value and negative predictive value of LBT in IBS patients was 63.6, 67.7, 11.7 and 96.6% respectively. Conclusion: LBT is not a good test to discriminate SIBO in IBS patients from controls.

Abdominal tuberculosis of the gastrointestinal tract: Revisited

Abdominal tuberculosis is an increasingly common disease that poses diagnostic challenge, as the nonspecific features of the disease which may lead to diagnostic delays and development of complications. This condition is regarded as a great mimicker of other abdominal pathology. A high index of suspicion is an important factor in early diagnosis. Abdominal involvement may occur in the gastrointestinal tract, peritoneum, lymphnodes or solid viscera. Various investigative methods have been used to aid in the diagnosis of abdominal tuberculosis. Early diagnosis and initiation of antituberculous therapy and surgical treatment are essential to prevent morbidity and mortality. Most of the patients respond very well to standard antitubercular therapy and surgery is required only in a minority of cases. Imaging plays an important role in diagnosis of abdominal tuberculosis because early recognition of this condition is important. We reviewed our experience with the findings on various imaging modalities for diagnosis of this potentially treatable disease.

Clinical Profile of Idiopathic Chronic Pancreatitis in North India

BACKGROUND & AIMS Tropical pancreatitis, a form of idiopathic chronic pancreatitis (ICP) with unique features, has been described in South and North India. We investigated the clinical profile of ICP patients in North India. METHODS Detailed demographic data were recorded; hematological and biochemical analyses were performed on samples from 155 patients (mostly from North India) who had been diagnosed with chronic pancreatitis. Ultrasonography and computed tomography were performed on all patients. Magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, glucose tolerance tests, and fecal fat studies were performed on some patients. Patients were divided into groups based on early- or late-onset ICP (before or after 35 years of age). RESULTS ICP was reported in 41.3% of patients and alcoholic chronic pancreatitis in 38.1%. The mean age of ICP patients was 33.0 +/- 13.0 years and the mean duration of symptoms at the time of presentation was 40.2 +/- 34.4 months. Pain was the dominant symptom in patients with early- (95.1%) and late-onset (100%) ICP; pseudocyst was the most common local complication. Diabetes was observed in 17.1% of patients with early-onset ICP and 34.8% with late-onset ICP. Pancreatic calcification was noted in 46.3% of patients with early-onset and 47.8% with late-onset ICP. Pseudocyst and segmental portal hypertension occurred more frequently in non-calcific ICP, whereas diabetes mellitus and abnormal fecal fat excretion occurred more frequently in patients with calcific ICP. CONCLUSIONS In North India, ICP differs from the classical tropical pancreatitis described in the literature. It is associated with a higher prevalence of pain and lower frequencies of diabetes, calcification, and intraductal calculi.

Pancreatic trauma: A concise review

Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities, and these injuries are often overlooked in cases with extensive multiorgan trauma. The most evident findings of pancreatic injury are post-traumatic pancreatitis with blood, edema, and soft tissue infiltration of the anterior pararenal space. The alterations of post-traumatic pancreatitis may not be visualized within several hours following trauma as they are time dependent. Delayed diagnoses of traumatic pancreatic injuries are associated with high morbidity and mortality. Imaging plays an important role in diagnosis of pancreatic injuries because early recognition of the disruption of the main pancreatic duct is important. We reviewed our experience with the use of various imaging modalities for diagnosis of blunt pancreatic trauma.

Serotonin transporter promoter variant: Analysis in Indian IBS patients and control population.

Background Studies of serotonin reuptake transporter (SERT-P) polymorphism and irritable bowel syndrome (IBS) have shown diverse results among different populations, which might be due to racial and ethnic difference. Aim This study was to investigate the potential association between the SERT-P polymorphism and clinical subtypes of IBS patients in the Indian population. Method This prospective case-control study included 151 IBS patients. Ninety-two patients were diarrhea-predominant IBS, 44 were constipation-predominant IBS (C-IBS), 15 were alternating diarrhea and constipation IBS, and 100 were healthy controls. SERT gene polymorphism was studied by polymerase chain reaction. Result A genotypic association was observed between SS genotype of SERT-P polymorphism and C-IBS (P<0.05). When the L/S and L/L genotypes were combined into one group, the frequency of the S/S genotype was significantly higher than that of the non-S/S genotype between C-IBS and the control group (P<0.05). There was no significant difference in the SERT-P genotype and allele frequency between c-ibs, alternating diarrhea and constipation IBS, all types of IBS cases, and controls. Conclusions A significant association was observed between the SS genotype of SERT-P polymorphism and C-IBS in the Indian population.

Endoscopic balloon dilation in caustic-induced chronic gastric outlet obstruction

BACKGROUND The standard treatment of caustic-induced gastric outlet obstruction (GOO) is surgery. There are only a few reports in the medical literature on endoscopic balloon dilation (EBD) for caustic-induced GOO. OBJECTIVE To study the short-term and long-term response of EBD in patients with caustic-induced GOO. SETTING Tertiary-care center in India. DESIGN Retrospective analysis of data. PATIENTS Of the 49 patients with caustic-induced GOO seen by us between January 1998 and December 2003, 41 were treated by EBD. Thirty-seven patients had consumed an acid and 4 had consumed an alkali a mean (SD) of 19.5 +/- 14.5 weeks earlier. EBD was performed every 3 weeks by using through-the-scope balloons under endoscopic guidance. INTERVENTION The balloon was negotiated across the narrowed segment and inflated for 60 seconds by using a pressure gun. Balloons of incremental diameters, up to a maximum of 3 sizes, were used in each sitting. The end point of dilation was 15 mm, after which patients were assessed for recurrence. The patients were observed until August 2007. RESULTS All 41 patients (23 men; mean [SD] age 29.6 +/- 8.5 years) could be successfully taken for EBD. Thirty-nine patients underwent successful repeated dilations, which required a mean (SD) of 5.8 +/- 2.6 dilations (range 2-13) to achieve the end point of 15 mm. All 39 patients were followed up for an average (SD) of 35.4 +/- 11.1 months (range 18-58 months). The mean (SD) size of the first dilator was 8.2 +/- 0.6 mm (range 8-10 mm). One patient had a perforation and was subjected to antrectomy; another patient had pain every time he received EBD; he also had surgery. Other complications were minor: self-limiting pain (n = 8) or bleeding (n = 7). CONCLUSIONS EBD is a safe, effective, and long-lasting alternative to surgery for caustic-induced GOO.

Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone.

OBJECTIVE:Endoscopic drainage of a single pseudocyst is a well-known treatment modality. Its role in the management of multiple pseudocysts is not well established. We evaluated the role of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of multiple and large pseudocysts.METHODS:Over 3 yr (2001–2004), endoscopic transpapillary NPD placement was attempted in 11 patients (age range 12–50 yr, 10 men) with symptomatic communicating multiple pseudocysts of pancreas (three in two and two in nine cases). A 5Fr/7Fr NPD was placed across the most distal duct disruption or into one of the pseudocysts.RESULTS:Eight patients had an underlying chronic pancreatitis and three patients had pseudocysts as seque-lae of acute pancreatitis. The size of pseudocysts ranged from 2 to 14 cm (mean 7.5 cm). Eight patients (72.7%) had at least one pseudocyst more than 6 cm in size. Nine patients had a partial disruption and two patients had complete disruption of the pancreatic duct. The NPD was successfully placed in 10 of 11 (90.9%) patients. Postprocedure acute febrile illness in one patient was the only complication noted, which responded to intravenous antibiotics. All pseudocysts resolved in 4–8 wk in 7 of 7 patients with successful bridging of the most distal ductal disruption. There was no recurrence of the pseudocysts in a mean follow-up of 19.4 months. Two patients, in whom there was a complete disruption and the NPD could not bridge the disruption, required surgery for the nonresolution of pseudocysts. In one patient with partial ductal disruption that could not be bridged, there was complete resolution of one pseudocyst and a decrease in the size of the other pseudocyst from 12 to 4 cm. The NPD was replaced by a stent and both the pseudocysts resolved in 20 wk.CONCLUSION:Endoscopic transpapillary NPD placement is a safe and effective modality for the treatment of multiple and large pseudocysts, especially when there is partial ductal disruption, and the disruption can be bridged.

Bacteriology of infection in severe acute pancreatitis.

CONTEXT Severe acute pancreatitis is associated with high mortality with infectious complications being the most common cause of mortality. OBJECTIVE To analyze the prevalence and characteristics of pancreatic and extrapancreatic infection in patients with severe acute pancreatitis. DESIGN Prospective study over a one-year period. PATIENTS Fifty-one consecutive patients with severe acute pancreatitis. Setting Tertiary care centre, Northern India. MAIN OUTCOME MEASURES The presence of pancreatic and extrapancreatic infections were noted in consecutive patients with severe acute pancreatitis and their effect on disease outcome was assessed. RESULTS Pancreatic infection was noted in 19 (37.3%) patients; 14 (27.5%) patients had monomicrobial and 5 (9.8%) patients had polymicrobial infections. In the first week of hospitalization, all positive 6/6 (100%) cultures grew Escherichia coli, in the second week 5/8 (62.5%) grew Escherichia coli while after the second week, 2/5 (40.0%) cultures grew Escherichia coli. A total of 32 (62.7%) patients had evidence of extrapancreatic infections, with 53 positive cultures. Fifteen (29.4%) patients had monomicrobial infections while 17 (33.3%) had polymicrobial infections. The most common site was blood together with intravenous site with 21 positive cultures in 16 patients. Staphylococcus aureus was most commonly isolated in the blood cultures. There was a statistically significant increase in mortality with pancreatic (P=0.003) and extrapancreatic (P=0.041) infections. The antibiotic sensitivity pattern showed that most of the bacteria were sensitive to beta lactum antibiotics, aminoglycosides and imipenem. CONCLUSION Pancreatic infections are more often monomicrobial with a shift from gram-negative to gram-positive as the pancreatitis progressed. Extrapancreatic infections are more often polymicrobial; most commonly, the blood stream is invaded by gram-positive bacteria.

Endoscopic transpapillary nasopancreatic drainage alone to treat pancreatic ascites and pleural effusion

Background:  Pancreatic ascites and pleural effusion are uncommon sequelae of pancreatitis and are associated with significant morbidity and mortality. Endoscopic decompression of the pancreatic duct through transpapillary stent or nasopancreatic drain (NPD) has shown encouraging results but the experience is limited. The aim of the present study was to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage in patients with pancreatic ascites and pleural effusion.

Chronic pancreatitis in primary hyperparathyroidism: Comparison with alcoholic and idiopathic chronic pancreatitis

Background:  Primary hyperparathyroidism is a rare cause of chronic pancreatitis and there is a paucity of data on this interesting association. There is also no data comparing the clinical profile of chronic pancreatitis secondary to primary hyperparathyroidism with that of alcohol related and idiopathic chronic pancreatitis.