Sharma Mp

Characterization of Newer Subgroups of Fulminant and Subfulminant Pancreatitis Associated With a High Early Mortality

BACKGROUND:Risk stratification of acute pancreatitis (AP) is important.OBJECTIVE:To characterize patients with early severe pancreatitis, identify risk factors of severity, and assess their outcome.METHODS:All consecutive patients with AP were included in the study. Severity assessment was done by APACHE II score, and presence and intensity of organ failure (OF). OF was graded from 1 to 4. Patients with severe pancreatitis were divided into early severe and late severe AP. The criterion for early severe AP (ESAP) was severe OF within 7 days of pancreatitis. Patients with ESAP were subdivided into fulminant and subfulminant AP based on timing of OF, i.e., <72 h and between 4 and 7 days of pancreatitis, respectively.RESULTS:Of 282 patients with AP, 144 (51%) had mild AP, 32 (11.34%) had ESAP, and 106 (37.58%) had late severe AP. Of the ESAP patients (mean age 45.4 yr, 22 men), 10 patients had fulminant AP and 22 had subfulminant AP. Patients with ESAP had higher admission APACHE II compared to patients with late severe AP (14.9 vs 8.8, P < 0.001). The proportion of patients with multiorgan failure was significantly higher in ESAP compared with late severe AP (75% vs 26%, P < 0.001). The difference in mortality was significant in the fulminant, subfulminant, and late severe AP (90%, 72.7%, and 30%; P < 0.001). Patients with ESAP accounted for 44% of all deaths. Predictors of mortality were development and early onset of organ failure.CONCLUSIONS:We have characterized newer subgroups of patients with fulminant and subfulminant AP with important prognostic and management implications.

Primary Conservative Treatment Results in Mortality Comparable to Surgery in Patients With Infected Pancreatic Necrosis

BACKGROUND & AIMSnThe standard treatment for patients with infected pancreatic necrosis (IPN) is surgical necrosectomy. We compared the outcomes of surgical treatment versus primary conservative treatment (patients kept in intensive care unit and treated with antibiotics, organ support, intensive nutritional support, and, if required, percutaneous drainage) among patients with IPN.nnnMETHODSnWe performed retrospective comparative (with prospectively acquired database) and prospective observational studies; data were collected from all consecutive patients with acute pancreatitis (n = 804), and those with IPN formed the study group. Patients with IPN were divided into 2 groups on the basis of diagnosis of IPN during 1997-2002 (group 1, n = 30) or 2003-2006 (group 2, n = 50). Eighteen patients in group 1 were treated by surgical necrosectomy, and 40 patients in group 2 were given primary conservative treatment; surgery was performed on patients if conservative treatment failed (n = 10). The primary outcome measure was mortality.nnnRESULTSnThe mortality was comparable in group 1 versus group 2 (43% vs 28%; P = .22). During a period of 10 years, the patients who received primary conservative treatment had significantly higher survival rates than those who received surgery (76.9% vs 46.4%; P = .005). In the prospective study during 2007-2008, the mortality from infected necrosis was 29.6% after primary conservative treatment, confirming the results of the comparative study.nnnCONCLUSIONSnIn treating patients with IPN, a primary conservative strategy resulted in mortality that was comparable with that after surgery, and 76% of the patients were able to avoid surgery; 54.5% of IPN patients were successfully managed with the primary conservative strategy.

Microscopic colitis is a cause of large bowel diarrhea in Northern India.

Chronic diarrhea is a common clinical problem. To determine the possible causes in North India, we studied prospectively 71 patients with chronic diarrhea of the large bowel type. A definite diagnosis could be established in 70 patients. Ulcerative colitis was found in 18 patients, colorectal malignancies in three, colonic polyps in three, and irritable bowel syndrome in 32. In addition, seven patients with seronegative polyarthritis and chronic diarrhea were found to have chronic inflammation of the colon on histology. Two patients had pseudodiarrhea, and no diagnosis could be established in one patient. The remaining five patients with chronic diarrhea showed histologic evidence of chronic colonic inflammation with predominantly mononuclear cell infiltration of the lamina propria and increased intraepithelial lymphocytes, but results of their radiologic and endoscopic studies were normal. These five patients were classified as having microscopic (lymphocytic) colitis. We conclude that the causes of chronic diarrhea in North India patients are similar to a large extent to those seen in Western populations. Microscopic (lymphocytic) colitis is a definite clinicopathologic entity that should be considered in the differential diagnosis of chronic diarrhea.

Randomized, single-blind, placebo-controlled multicenter trial to compare the efficacy and safety of metronidazole and satranidazole in patients with amebic liver abscess.

The aims of our randomized, single-blind trial involving 49 patients were to study the efficacy, side effects, and tolerance of metronidazole and satranidazole in patients of amebic liver abscess. Twenty-five patients received metronidazole (800 mg TID) and 24 received satranidazole (300 mg TID with placebo at mealtime). Patients recorded side effects and tolerability through a performa. The time taken for resolution of fever and pain and the fall in abscess size was not significant. However, tolerance of satranidazole as reported by the patients was significantly better than metronidazole (P < .005). The incidence of adverse effects was significantly lower in the group given satranidazole (P < .005). The incidence of nausea and metallic taste was significantly lower in the patients given satranidazole (P < .005). Thus, despite having a similar efficacy, satranidazole showed a far lower incidence of side effects and had a significantly better tolerance than Metronidazole.

Omeprazole versus famotidine in the healing and relapse of duodenal ulcer

Sixty patients with symptomatic duodenal ulcer were randomized to receive either omeprazole (20 mg each morning) or famotidine (40 mg at night time) for 2–4 weeks in a double‐blind parallel group clinical trial. Healing rates were higher with omeprazole in comparison with famotidine after 2 weeks (77%vs. 40%, P < 0.001) and 4 weeks (93%vs. 80%, P= 0.2) of treatment. Assessment of daily diary cards completed by all patients revealed that omeprazole rapidly relieved ulcer‐related day pain and nocturnal pain in comparison to famotidine. Treatment with omeprazole for 2 weeks was also associated with lower cumulative antacid intake (P < 0.05) and reduced absenteeism from work. Helicobacter pylori infection was present in all patients and remained unaffected by treatment with either of the drugs. None of the drugs produced any significant adverse effects. During 6 months follow‐up of all the patients after ulcer healing (without maintenance therapy), ulcer relapse was seen in 40% of omeprazole‐ and 37% of famotidine‐treated patients (P > 0.1). The duration of ulcer‐free period following initial healing of ulcer was also similar in both the groups (median time: 22 weeks for omeprazole, 21 weeks for famotidine). We conclude that omeprazole is superior to famotidine in rapidly healing duodenal ulcers and achieving more rapid pain relief, but does not influence subsequent ulcer relapse.