Vallath Balakrishnan

Spontaneous rupture of giant gastric stromal tumor into gastric lumen

BackgroundGastrointestinal stromal tumors (GIST) constitute a large majority of mesenchymal tumors of the gastrointestinal (GI) tract, which express the c-kit proto-oncogene protein, a cell membrane receptor with tyrosine kinase activity. GI stromal tumors of the stomach are usually associated with bleeding, abdominal pain or a palpable mass.Case presentationA 75-year-old male presented with upper abdominal pain and palpable mass. Computed tomographic (CT) scan of the abdomen showed a large mass arising in the posterior aspect of fundus, body, and greater curvature of the stomach. Second day after the admission, there was significant reduction in the size of the tumor, clinically as well as radiologically. Endoscopic biopsy showed large bulge in fundus and corpus of the stomach posteriorly with an opening in the posterior part of the corpus, and biopsy from the edge of the opening reveled GIST. Patient underwent curative resection.ConclusionSpontaneous ruptured of giant gastric stromal tumor is very rare presentation of stomach GIST. Thorough clinical examination and timely investigation can diagnose rare complication.

Assessment of oxidative status in chronic pancreatitis and its relation with zinc status

BackgroundOxidative stress-induced free radicals have been implicated in the pathology of chronic pancreatitis (CP).AimWe aimed to estimate oxidative stress and antioxidant status in tropical chronic pancreatitis (TCP) and alcoholic chronic pancreatitis (ACP) and correlate with zinc status.MethodsOne hundred and seventy-five CP patients (91 TCP, 84 ACP) and 113 healthy subjects were prospectively studied. Disease characteristics and imaging features were recorded. Erythrocyte reduced glutathione, glutathione peroxidase (GPx), superoxide dismutase (SOD), plasma vitamin C, and erythrocyte thiobarbituric acid reactive substance (TBARS) were estimated by spectrophotometry. Erythrocyte zinc was estimated by flame atomic absorption spectrophotometry.ResultsEnhanced lipid peroxidation with concomitant decrease in antioxidant status was observed in both TCP and ACP patients (p < 0.05). The findings were comparable in both diabetic and non-diabetic CP patients. Significantly, lower plasma vitamin C and elevated levels of erythrocyte TBARS was noted in TCP as compared to ACP patients. The erythrocyte zinc significantly correlated with SOD activity (r = 0.450, p < 0.001).ConclusionsOur study corroborates the role of oxidative stress in CP and suggests some differences in oxidative status in TCP and ACP patients. Zinc deficiency appears to affect oxidative status in CP patients.

Fecal elastase1 and acid steatocrit estimation in chronic pancreatitis

BackgroundMeasurement of pancreatic exocrine function and steatorrhea in chronic pancreatitis in the clinical setting has not received much attention.AimTo assess pancreatic exocrine function and fecal fat excretion in a cohort of patients with chronic pancreatitis.MethodsStool elastase1 levels were measured in 101 patients using polyclonal ELISA and acid steatocrit was measured in 86 chronic pancreatitis patients. Associations with etiology, clinical and radiological features, and diabetic status were examined.ResultsLow pancreatic stool elastase1 (<200 μg/g stool) was observed in two-thirds of chronic pancreatitis patients and correlated with ductal dilatation, pancreatic atrophy and calcification (p<0.05). Diabetes was more prevalent in chronic pancreatitis patients with low elastase1 (p=0.045). There was no difference in mean acid steatocrit between diabetics and non-diabetics (p=0.069). Elastase1 levels had a negative correlation with acid steatocrit (r=−0.606, p<0.001), and a positive correlation (r=0.412) with body mass index (p=0.013). Fiftythree percent of chronic pancreatitis patients with normal BMI had low elastase1.ConclusionsFecal elastase1 levels correlated with fecal fat excretion and BMI. Fecal elastase1 estimation may be helpful in early detection of malabsorption in chronic pancreatitis.

Alterations in plasma amino acid levels in chronic pancreatitis.

CONTEXT Dietary proteins and amino acids can modulate pancreatic function. OBJECTIVE Our aim was to estimate the levels of plasma amino acids in chronic pancreatitis patients and study their relationship with disease characteristics as well as exocrine and endocrine insufficiency. PATIENTS One hundred and seventy-five consecutive adult patients with chronic pancreatitis: 84 patients with alcoholic chronic pancreatitis and 91 patients with tropical chronic pancreatitis. One hundred and thirteen healthy controls were also studied. DESIGN Prospective study. MAIN OUTCOME MEASURES Disease characteristics and imaging features were recorded. Plasma-free amino acid levels were estimated using reverse-phase high-performance liquid chromatography. Polyclonal antibody ELISA was used to assess pancreatic fecal elastase-1. RESULTS The majority of the plasma free amino acid levels decreased in chronic pancreatitis patients whereas glutamate, glycine, proline and lysine were elevated as compared to the controls. Multivariate logistic regression analysis revealed that the decrease in branched chain amino acid concentration was significantly associated with the presence of diabetes and low fecal elastase-1. In addition, a significant positive correlation was observed between branched chain amino acids and pancreatic elastase-1 (rs=0.724, P<0.001). CONCLUSION Reductions of plasma amino acid levels are seen in chronic pancreatitis, particularly sulphur containing amino acids and branched chain amino acids. Selective amino acid deficiencies seem to correlate with exocrine and endocrine insufficiency.

Colorectal cancer distribution in 220 Indian patients undergoing colonoscopy

AimColorectal cancer is one of the major cancers in the developed world. The incidence of colorectal cancer is low in India. The aim of the present study was to describe the anatomical distribution and age at diagnosis of colorectal cancer in India.MethodsRetrospective descriptive analysis of anatomical distribution, age at diagnosis and demography of 220 cases (149 [67.7%] men) of adenocarcinoma of the colon or rectum diagnosed at colonoscopy over a period of five years.ResultsThe mean age at diagnosis was 58.4 years (SD 13.3; range 23–85 years). Twenty-eight (12.7%) cases were below the age of 40 years. The majority (31.8%) cases were aged between 61–70 years. Most of the tumors (n=163, 74%) were located distal to the splenic flexure. Multivariate logistic regression analysis showed that bleeding per rectum (OR 2.8; 95% CI 1.2–6.2) was associated with distal cancer, and palpable mass (OR 3.9; 95% CI 1.7–8.6) was associated with proximal cancer.ConclusionsAlmost one-third of the colorectal cancers in this series occurred in the seventh decade and were located distal to the splenic flexure.

Genotype-phenotype correlation in 9 patients with tropical pancreatitis and identified gene mutations.

The etiopathogenesis of tropical chronic pancreatitis (TCP) remains unclear. Malnutrition, dietary toxins like cyanogens in cassava and micronutrient deficiency are proposed factors. The description and characterization of genetic factors in TCP has added a new dimension to the understanding of pathogenesis of the disease. However, there is sparse data on the association of TCP with cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations. We report 8 patients of TCP with CFTR gene mutations, including one with a novel mutation, and describe the clinical profile of these patients. Further prospective genetic studies on the association of CFTR gene mutations are essential in order to unravel the genetic basis of TCP.