Sri Prakash Misra

Colonic tuberculosis : Clinical features, endoscopic appearance and management

Background: Although rare in the West, colonic tuberculosis is not an uncommon disease in developing countries. However, the clinical manifestations and radiological appearance of the disease are non‐specific. In recent years, colonoscopy has been found to be very useful in diagnosing patients with colonic tuberculosis.

Ileal varices and portal hypertensive ileopathy in patients with cirrhosis and portal hypertension

BACKGROUND The endoscopic appearance of portal hypertensive intestinal vasculopathy is well described in the stomach, the jejunum, and the colon, but there is no description of changes that occur in the ileum. METHODS The terminal ileum was intubated at colonoscopy in 44 patients with cirrhosis and portal hypertension and 46 control patients. Changes in the terminal ileum were noted. In addition, anorectal varices and colopathy were carefully noted and recorded. RESULTS Ileal varices and/or portal hypertensive ileopathy were present in 16 of 44 (36%) patients with cirrhosis and portal hypertension but not in any control patient ( p < 0.01). Ileal varices were present in 8 patients (18%) with cirrhosis/portal hypertension and none of the control patients ( p < 0.05). Portal hypertensive ileopathy was noted in 11 patients (25%) with cirrhosis and portal hypertension and in none of the control patients ( p < 0.05). Ileal varices had no association with any other parameter studied. However, ileopathy was observed in 9 of the 23 patients with colopathy and in only two of the 21 patients without colopathy ( p < 0.05). CONCLUSIONS Ileal varices and mucosal changes of portal hypertensive ileopathy occur in patients with cirrhosis and portal hypertension. In the population studied, ileopathy was significantly more common in patients who had portal hypertensive colopathy.

Endoscopic and histologic appearance of the gastric mucosa in patients with portal hypertension

To assess reliability of the endoscopic and histologic appearance of the gastric mucosa for diagnosing portal hypertension, 50 patients with portal hypertension and 1323 controls were studied. Endoscopic evidence of mild gastritis was seen more frequently in patients with portal hypertension than in the control group (42% vs. 13.1%, p less than 0.001). The mosaic sign was also seen more frequently in patients with portal hypertension compared with controls (14% vs. 0.9%, p less than 0.001). However, the mosaic sign was found to be nonspecific, and the sensitivity for diagnosis of portal hypertension was only 14%. Biopsy specimens from the stomach of all patients with portal hypertension and 100 controls with a normal endoscopic appearance revealed mucosal vascular congestion in 72% of patients with portal hypertension compared with 59% of controls (NS). There was no correlation between endoscopic and histologic evidence of congestive gastropathy. Similarly, there was no correlation between the severity of mucosal vascular congestion and the degree of inflammatory changes observed in the biopsy specimens; both in the control (r = 0.1) and in patients with portal hypertension (r = 0.14). It is concluded that endoscopic and histologic features of the gastric mucosa in patients with portal hypertension are of low sensitivity and nonspecific and cannot be used to diagnose portal hypertension.

Reflux of duodenal contents and cholangitis in patients undergoing self-expanding metal stent placement.

BACKGROUND It has been reported that the occurrence of acute cholangitis is common, especially when the self-expanding metal stent (SEMS) is placed across the main duodenal papilla. OBJECTIVE To determine the incidence of duodenobiliary reflux and acute cholangitis after placement of SEMSs across the main duodenal papilla. DESIGN A prospective study. SETTING A tertiary-care teaching hospital. PATIENTS One hundred consecutive patients with malignant bile-duct obstruction. INTERVENTIONS A barium meal examination was performed 21 days after placement of SEMSs. Reflux of barium was monitored by using fluoroscopy. The patients were also monitored for the occurrence of fever. Serum bilirubin, alanine aminotransferase, alkaline phosphatase, and total and differential leukocyte counts were evaluated before and after the barium study. MAIN OUTCOME MEASUREMENTS The occurrence of duodenobiliary reflux and acute cholangitis. RESULTS Two patients developed acute cholangitis because of the failure of the function of the SEMS, and they died during the first week. Severe reflux of barium was evident in all the patients. However, none of them developed features of acute cholangitis because of reflux. After a mean (SD) follow-up of 6.4 +/- 1 months, 6 patients developed acute cholangitis because of blockage of the SEMS from ingrowth of tumor or collection of debris at the lower end of the SEMS. LIMITATIONS Unblinded study. CONCLUSIONS After placement of SEMSs across the main duodenal papilla, reflux of duodenal contents is a universal phenomenon. Acute cholangitis was observed only in cases with blockage of the SEMS from tumor ingrowth or debris.

Corrosive oesophageal strictures following acid ingestion: Clinical profile and results of endoscopic dilatation

There are several reports on oesophageal strictures caused by alkali ingestion, but information on oesophageal strictures due to acid ingestion is scarce. Endoscopic dilatation, which has been found to be quite safe and effective in the treatment of benign oesophageal strictures of other aetiology, has also not been evaluated adequately in the treatment of these strictures. Over a period of 2 years, of 47 patients treated at this centre of benign oesophageal strictures, 17 (36.2%) patients had strictures following ingestion of corrosive agents. Thirteen patients had ingested acids and only four gave a history of alkali ingestion. The age range of these 13 patients was 14–50 years (mean = 25.5 years, s.d. = 2.6). The amount of acid ingested varied from 10 to 100 ml (median = 50 ml). The interval between acid ingestion and presentation to hospital ranged from 1 to 60 months (median = 2 months). Ten patients had multiple strictures, and the most common site of involvement was the upper third followed by the lower third of the oesophagus. Only five‐of these 13 patients had evidence of gastric involvement in the form of antral stricture (four) and hour glass deformity (one). Strictures were dilated using Eder‐Puestow metal olives passed over a guide wire. The total number of sittings required to achieve adequate dilation in this group ranged from 1 to 30 (median = 14). Most patients were managed successfully with dilatation (good response 63.6%, satisfactory response 18.2%). On follow‐up, recurrence of dysphagia was seen in a high number of patients (66%), but this could be managed easily with repeat dilatation. It is concluded that, in contrast to reports from the West, acid ingestion is a common cause of oesophageal strictures in India. These strictures are usually tight and multiple. The patients not only require several sittings to achieve adequate dilatation, but they also have a high recurrence rate.

Epidemiology and symptom profile of gastroesophageal reflux in the Indian population: report of the Indian Society of Gastroenterology Task Force.

BackgroundGastroesophageal reflux disease (GERD) and its complications are thought to be infrequent in India; there are no data from India on the prevalence of and risk factors for GERD. The Indian Society of Gastroenterology formed a task force aiming to study: (a) the frequency and profile of GERD in India, (b) factors including diet associated with GERD.MethodsIn this prospective, multi-center (12 centers) study, data were obtained using a questionnaire from 3224 subjects regarding the frequency, severity and duration of heartburn, regurgitation and other symptoms of GERD. Data were also obtained regarding their dietary habits, addictions, and lifestyle, and whether any of these were related or had been altered because of symptoms. Data were analyzed using univariate and multivariate methods.ResultsTwo hundred and forty-five (7.6%) of 3224 subjects had heartburn and/or regurgitation at least once a week. On univariate analysis, older age (OR 1.012; 95% CI 1.003–1.021), consumption of non-vegetarian and fried foods, aerated drinks, tea/coffee were associated with GERD. Frequency of smoking was similar among subjects with or without GERD. Body mass index (BMI) was similar in subjects with and without GERD. On multivariate analysis, consumption of non-vegetarian food was independently associated with GERD symptoms. Overlap with symptoms of irritable bowel syndrome was not uncommon; 21% reported difficulty in passage of stool and 9% had mucus in stools. About 25% of patients had consulted a doctor previously for their gastrointestinal symptoms.Conclusion7.6% of Indian subjects have significant GERD symptoms. Consumption of non-vegetarian foods was an independent predictor of GERD. BMI was comparable among subjects with or without GERD.

Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL). Part I: Status Report of HCV Infection in India

Globally, around 150 million people are infected with hepatitis C virus (HCV). India contributes a large proportion of this HCV burden. The prevalence of HCV infection in India is estimated at between 0.5% and 1.5%. It is higher in the northeastern part, tribal populations and Punjab, areas which may represent HCV hotspots, and is lower in western and eastern parts of the country. The predominant modes of HCV transmission in India are blood transfusion and unsafe therapeutic injections. There is a need for large field studies to better understand HCV epidemiology and identify high-prevalence areas, and to identify and spread awareness about the modes of transmission of this infection in an attempt to prevent disease transmission.

Non-alcoholic Fatty Liver Disease and Metabolic Syndrome—Position Paper of the Indian National Association for the Study of the Liver, Endocrine Society of India, Indian College of Cardiology and Indian Society of Gastroenterology

Non-alcoholic fatty liver disease (NAFLD) is closely associated with metabolic syndrome. Prevalence of metabolic risk factors including diabetes mellitus, obesity, etc. is rapidly increasing in India putting this population at risk for NAFLD. Patients with NAFLD are at increased risk for liver-related morbidity and mortality and also cardiovascular disease risk and increased incidence of diabetes mellitus on long-term follow-up. Management of patients with NAFLD may require a multi-disciplinary approach involving not only the hepatologists but also the internists, cardiologists, and endocrinologists. This position paper which is a combined effort of the Indian National Association for Study of the Liver (INASL), Endocrine Society of India (ESI), Indian College of Cardiology (ICC) and the Indian Society of Gastroenterology (ISG) defines the spectrum of NAFLD and the association of NAFLD with insulin resistance and metabolic syndrome besides suggesting preferred approaches for the diagnosis and management of patients with NAFLD in the Indian context.

Colonic mucosa in patients with portal hypertension

Background and Aims: To do a histomorphometric study of vascular changes in colonic mucosa of patients with portal hypertension (PHT) and to find their association with clinical and upper and lower gastrointestinal endoscopic observations.

Berberine and Curcumin Target Survivin and STAT3 in Gastric Cancer Cells and Synergize Actions of Standard Chemotherapeutic 5-Fluorouracil

Aberrantly expressed survivin and STAT3 signaling have emerged as major determinants of chemoresistance in gastric cancer. We evaluated effects of potent herbal derivatives curcumin, berberine, and quercetin on STAT3 signaling, survivin expression, and response to 5-fluorouracil (5-FU) treatment in gastric cancer cells (AGS). Cytotoxic and inhibitory effects of berberine, curcumin, and quercetin alone or in combination with 5-FU were examined by MTT assay, and their effect on survivin, STAT3, and the phosphorylated active STAT3 (pSTAT3) expression was examined by western blotting. Effect of these herbal derivatives on STAT3 DNA binding activity was measured by electrophoretic mobility shift assay. Curcumin, berberine, and quercetin effectively downregulated pSTAT3 levels, survivin expression, and gastric cancer cells viability in a dose-dependent manner (with corresponding IC50 values of 40.3μM, 29.2μM and 37.5μM, respectively). Berberine was more effective in inhibiting survivin expression as compared to other herbal agents. 5-FU in combination with berberine or curcumin showed a synergistic inhibition of survivin and STAT3 level resulting in enhanced cell death in gastric cancer cells. Overall, our data suggest use of berberine and curcumin as adjunct therapeutics to overcome chemoresistance during treatment of gastric malignancies.