Sudipta Dhar Chowdhury

Prevalence of Adult Celiac Disease in India: Regional Variations and Associations.

Objectives:Although celiac disease (CeD) affects 1% of people in the northern part of India, it is believed to be uncommon in the southern and northeastern parts because of significant differences in dietary pattern and ethnicity. We estimated the prevalence of CeD in these three populations. In a subset, we also investigated differences in the prevalence of HLA-DQ 2/8 allelotype and dietary grain consumption.Methods:A total of 23,331 healthy adults were sampled from three regions of India—northern (n=6207), northeastern (n=8149), and southern (n=8973)—and screened for CeD using IgA anti-tissue transglutaminase antibody. Positive tests were reconfirmed using a second ELISA. CeD was diagnosed if the second test was positive and these participants were further investigated. A subsample of participants was tested for HLA-DQ2/-DQ8 and underwent detailed dietary evaluation.Results:Age-adjusted prevalence of celiac autoantibodies was 1.23% in northern, 0.87% in northeastern, and 0.10% in southern India (P<0.0001). Prevalence of CeD and latent CeD, respectively, was 8.53/1,000 and 3.70/1,000 in northern, 4.66/1,000 and 3.92/1,000 in northeastern, and 0.11/1,000 and 1.22/1,000 in the southern part. The population prevalence of genes determining HLA-DQ2 and/or -DQ8 expression was 38.1% in northern, 31.4% in northeastern, and 36.4% in southern India. Mean daily wheat intake was highest in northern (455 g) compared with northeastern (37 g) or southern part (25 g), whereas daily rice intake showed an inverse pattern.Conclusions:CeD and latent CeD were most prevalent in northern India and were the least in southern India. The prevalence correlated with wheat intake and did not reflect differences in the genetic background.

Clinical profile and outcome of chronic pancreatitis in children.

ObjectiveTo evaluate the etiology, presentation, complications and management of chronic pancreatitis in children.DesignRetrospective chart review.SettingGastroenterology department at Christian Medical College and Hospital, Vellore, India between January 2005 and December 2010.Participants99 Children (<18 yrs) diagnosed with chronic pancreatitis based on clinical and imaging features.Main outcome measuresEtiology, clinical presentation, complications and management of chronic pancreatitis in children.ResultsOf 3887 children who attended the Gastroenterology department, 99(2.5%) had chronic pancreatitis, of which 60 (60.6%) were males. In 95(95.9%) patients no definite cause was detected and they were labeled as Idiopathic chronic pancreatitis. All patients had abdominal pain, while 9(9.1%) had diabetes mellitus. Of the 22 children tested for stool fat, 10(45.5%) had steatorrhea. Pancreatic calcification was seen in 69 (69.7%). 68 (71.6%) patients with idiopathic chronic pancreatitis had calcification. Calcific idiopathic chronic pancreatitis was more frequent in males (67.6% vs. 48.1%, P=0.07), and was more commonly associated with diabetes mellitus (13.2% vs. none, P=0.047) and steatorrhea (61.5% vs. 16.7%, P=0.069). Pseudocyst (17.1%) and ascites (9.1%) were the most common complications. All children were treated with pancreatic enzyme supplements for pain relief. 57 patients were followed up. With enzyme supplementation, pain relief was present in 32 (56.1%) patients. Of those who did not improve, 10 underwent endotherapy and 15 underwent surgery. Follow up of 8 patients who underwent endotherapy, showed that 5 (62.5%) had relief. Follow up of 11 patients who underwent surgery showed that only 3 (27 %) had pain relief. There was no death.ConclusionsIdiopathic chronic pancreatitis is the predominant form of chronic pancreatitis in children and adolescents. It can present with or without calcification. The calcific variety is an aggressive disease characterized by early morphological and functional damage to the pancreas.

Intermittent Directly Observed Therapy for Abdominal Tuberculosis: A Multicenter Randomized Controlled Trial Comparing 6 Months Versus 9 Months of Therapy

BACKGROUND The duration of treatment of gastrointestinal tuberculosis continues to be a matter of debate. The World Health Organization advocates intermittent directly observed short-course therapy (DOTs), but there is a lack of data of its efficacy in abdominal tuberculosis. We therefore conducted a multicenter randomized controlled trial to compare 6 months and 9 months of antituberculosis therapy using DOTs. METHODS One hundred ninety-seven patients with abdominal tuberculosis (gastrointestinal, 154; peritoneal, 40; mixed, 3) were randomized to receive 6 months (n = 104) or 9 months (n = 93) of antituberculosis therapy using intermittent directly observed therapy. Patients were followed up 1 year after completion of treatment to assess recurrence. Patients were evaluated for primary endpoint (complete clinical response, partial response, and no response) and secondary endpoint (recurrence of the disease at the end of 1 year of follow-up). RESULTS Baseline characteristics were similar between the 2 randomized groups. There was no difference between the 6-month group and 9-month group in the complete clinical response rate on per-protocol analysis (91.5% vs 90.8%; P = .88) or intent-to-treat analysis (75% vs 75.8%; P = .89). Only 1 patient in the 9-month group and no patients in the 6-month group had recurrence of disease. Side effects occurred in 21 (21.3%) and 16 (18.2%) patients in the 6-month and 9-month groups, respectively. CONCLUSIONS There was no difference in efficacy of antituberculosis therapy delivered for either 6 months or 9 months in either gastrointestinal or peritoneal tuberculosis, confirming the efficacy of intermittent directly observed therapy. CLINICAL TRIALS REGISTRATION NCT01124929.

Acute pancreatitis and hyperparathyroidism: A case series

Primary hyperparathyroidism is a rare cause of acute pancreatitis. Five consecutive patients with acute or recurrent acute pancreatitis and primary hyperparathyroidism were included. All patients had elevated serum calcium on admission and high levels of circulating parathyroid hormone. Both ultrasonography and Sestamibi scan was used to localize parathyroid adenoma. Except for one, all patients underwent parathyroidectomy and postoperative histology was consistent with parathyroid adenoma. One patient died while on treatment. Metabolic causes of acute pancreatitits, though uncommon, are important as early recognition helps management and prevents recurrence.

Prevalence of cardiac autonomic neuropathy in Asian Indian patients with fibrocalculous pancreatic diabetes.

Background: It was formerly believed that since fibrocalculous pancreatic diabetes (FCPD) is a secondary form of diabetes, specific diabetic complications were uncommon. This is no longer considered to be true. Our objective was to study the prevalence and pattern of cardiac autonomic neuropathy (CAN) in patients with FCPD. Materials and Methods: A cross-sectional study on consecutive male patients with FCPD was performed. Using an automated CAN System Analyzer, heart rate response to deep breathing, Valsalva maneuver, standing and blood pressure response to standing were measured. The standard Ewings criteria were used to define normal, borderline, and abnormal values. Prevalence rates were calculated and the patients were defined to have normal autonomic function, parasympathetic, sympathetic, and combined dysfunction. Results: The prevalence of CAN in this study population was 63.3%. Isolated parasympathetic dysfunction (42.3%) was the most common abnormality. Combined sympathetic and parasympathetic dysfunction was noted in 13.3% of patients. Isolated borderline dysfunction was noted among 13.3% of patients. CAN was detected in six patients with a duration of diabetes of less than 1 year after diagnosis. Patients with autonomic dysfunction were found to have a lower body mass index (BMI) and low density lipoprotein (LDL)-cholesterol when compared to those with normal autonomic functions, which was not statistically significant. Conclusion: The prevalence of abnormal cardiac autonomic function is as high as 63.3% in the present study population which warrants regular screening of patients with FCPD for autonomic dysfunction. Patients with FCPD and autonomic dysfunction were found to have a lower BMI and lower LDL-cholesterol, which may be indicators of malnutrition in the group with autonomic dysfunction. Whether this malnutrition contributes to autonomic dysfunction needs further exploration.

Cyclosporine in steroid refractory acute severe colitis.

This is a pilot study to test the hypothesis that polymorphisms that may be linked to cyclooxygenase production may affect the likelihood and the nature of bleeding in patients with ulcer disease. Of the two polymorphism that have previously been studied for links we chose the A842G polymorphims. Of the 50 patients with ulcer bleeding who were studied, 8 had a heterozygous polymorphisms and 42 had the normal configuration. On comparing these two groups. there were no significant differences in clinical presentation except that there was a tendency to have less gastric ulcers among those with the A842G/C50T polymorphism. Based on these studies we need to undertake a larger studies comparing these groups with those with ulcers without GI bleeding and those without ulcers

Squamous papilloma of esophagus

Esophageal papillomas are rare benign epithelial lesions, occurring in 0.01 % to 0.45 % of people undergoing endoscopy [1]. These are more common in middle-aged men. Proposed possible etiologies are chronicmucosal irritation (due to gastroesophageal reflux, smoking, alcohol, chronic food impaction, caustic injury, and mechanical irritants like nasogastric tubes or post bougie assisted esophageal dilatation) and infection with human papilloma virus. Esophageal papillomas are generally single, but multiple lesions have been described [2]. Shown here is a lesion from a 36-year-old lady with dyspepsia without alarm symptoms. White light examination showed small, white-pink, warty exophytic projections in mid esophagus (Fig. 1). On narrow band imaging, the lesion appeared as papillary projections of mucosa without dilated microvessels (Fig. 2). Histopathology confirmed the diagnosis of squamous cell papilloma.

A gastric submucosal mass

A 42-year-old male was referred with epigastric pain of insidious onset, progressive over a duration of 3 months. Pain was non-radiating, continuous, with no specific aggravating or relieving factors. There was no loss of appetite or loss of weight. …

Plasma hydrogen sulphide does not predict severity of acute pancreatitis in humans.

The primary aim of this study was to assess the usefulness of plasma hydrogen sulphide (H2S) level at admission as a predictor of severity of acute pancreatitis. The secondary aims were to examine whether the level of H2S after 48 h correlated with severity and whether level of H2S correlated with pulmonary, renal or infectious complications. Plasma hydrogen sulphide was measured within 24 h of admission and 48 h later, in patients with acute pancreatitis. Patients were classified as having mild or severe pancreatitis, and H2S levels in the two groups were compared. A total of 55 patients had H2S estimation carried out within 24 h of admission. H2S levels were similar in patients with mild (mean 31.8 ± 18.8, range 7.1 to 81.4 µmol/L) and severe pancreatitis (mean 28.2 ± 21.6, range 6.1 to 74.4 µmol/L; p = 0.339). There was no difference found between the groups after 48 h (mild n = 28, mean 26.8 ± 19.4 µmol/L, and severe n = 20, mean 34.6 ± 21.0 µmol/L; p = 0.127). There was also no difference in the levels between patients with or without lung injury, kidney injury or sepsis. Performing H2S estimation to predict severity in acute pancreatitis is not beneficial.

Metastasis of renal cell carcinoma to the duodenal papilla.

Metastatic tumors of the duodenal papilla (ampulla of Vater) are rare. The images here are from a middle-aged gentleman with progressive cholestatic jaundice and recurrent cholangitis, with a past history of nephrectomy for renal cell carcinoma (RCC) 6 years earlier. Endoscopy revealed a bulky duodenal papilla, and the biopsy showed features consistent with RCC (Figs. 1 and 2). Metastatic tumors of the duodenal papilla are rare. RCC constitute 80 % to 85 % of primary