BACKGROUND AND AIM: Bleeding from gastroesophageal varices is a life-threatening complication of cirrhosis. Prophylactic therapy for large varices considerably reduces such bleeding. Current guidelines recommend upper GI...BACKGROUND AND AIM: Bleeding from gastroesophageal varices is a life-threatening complication of cirrhosis. Prophylactic therapy for large varices considerably reduces such bleeding. Current guidelines recommend upper GI endoscopy as the gold standard for detecting high-grade varices. However, in peripheral centers, this is often unfeasible or inaccessible thus requiring non-endoscopic predictors of large oesophageal varices. METHODS: This prospective study involved 100 newly diagnosed cirrhosis patients without any history of variceal bleeding. Demographic, clinical, bio-chemical and ultrasonographic parameters were recorded. Esophageal varices were classified endoscopically as small and large. Multivariate logistic regression was performed to identify predictors of variceal size and presence. Cut-offs of significant indicators were determined by ROC analysis. RESULTS: 69% patients had small and 31% had large varices. Univariate analysis revealed significant differences between the grade of spleen, blood parameters, platelet count, international normalized ratio, serum albumin, spleen size, portal vein diameter (PVD) and platelet count to spleen diameter ratio in the two groups. Multivariate analysis revealed that INR [OR: 2.432(95% CI: 1.192 - 4.958)], splenomegaly at USG [OR: 2.138 (95% CI: 0.662 - 6.911)] and PVD [OR: 1.318 (95% CI: 0.937 - 1.853)] were the most significant predictors for large varices. CONCLUSIONS: Multivariate prediction of large varices based on a combination of non-endoscopic parameters can be utilized in place of single parameter based predictions.
Ramya RS, Jayanthi N, Alexander PC
… +2 more, Vijaya S, Jayanthi V
Trop Gastroenterol
· 2014 · PMID 26012321
BACKGROUND: Gastroesophageal reflux (GER) symptoms are common in pregnancy. It often manifests for the first time in pregnancy during the first three months and ceases after delivery. AIM: To study the prevalence of gast...BACKGROUND: Gastroesophageal reflux (GER) symptoms are common in pregnancy. It often manifests for the first time in pregnancy during the first three months and ceases after delivery. AIM: To study the prevalence of gastroesophageal reflux in each of the three trimesters by follow-up of pregnant women. To examine the association between dietary factors and GER in pregnancy. METHODS: This was a prospective hospital-based study. Sixty four pregnant women in their first trimester attending an antenatal clinic were interviewed for symptoms of GER and for dietary details and followed up until term and delivery. RESULTS: Fifty women (83.4%) experienced either heartburn or regurgitation during pregnancy. GER was commoner in primi-gravida (69.3%) and 50% remained symptomatic until term. Regurgitation was more common than heartburn and was often associated with nausea/vomiting. Women with an antenatal history of GERD had 3.79 times the odds of developing symptoms in the third trimester. There was no difference in weight gain in those with and without GER. Spicy food significantly increased the risk of heartburn and green vegetables were protective. CONCLUSIONS: The incidence of GERD decreased over three trimesters. Weight gain did not increase the prevalence of GERD. Spicy food aggravated while green vegetables protected against GERD.
BACKGROUND: Recent reports indicate a decline in prevalence of classical tropical chronic pancreatitis (TCP). We studied the etiologies and risk factors over a 14-year period at a tertiary care university hospital. METHO...BACKGROUND: Recent reports indicate a decline in prevalence of classical tropical chronic pancreatitis (TCP). We studied the etiologies and risk factors over a 14-year period at a tertiary care university hospital. METHODS: We compared the etiology in chronic pancreatitis (CP) patients presenting and followed-up in our Pancreas Clinic over two time periods (2000-06 and 2007-13). RESULTS: Idiopathic chronic pancreatitis (ICP) was the predominant etiology seen over the two time periods. However an increase in prevalence of alcoholic chronic pancreatitis (ACP) during the latter time period suggests that it may be emerging as a dominant etiology over recent years. Hypertriglyceridemia and hyperparathyroidism were uncommon causes of non-alcoholic CP. Autoimmune pancreatitis was noted only during 2007-13, but remains a rare cause of CP. There are multiple risk factors for CP in our population. CONCLUSIONS: The high prevalence of ICP indicates need closer examination of risk factors and ICP pathogenesis. ACP appears to be emerging as a dominant cause of CP which suggests a need to reorient preventive strategies.
Peter G, George PC, Villyoth MP
… +9 more, Sivaraman S, Hamza RE, Bahuleyan S, Srijith K, Haridas A, Abdul Sathar S, Sreesh S, Narayanan P, Vinayakumar KR
BACKGROUND: This study aimed to assess whether QT interval prolongation is an independent risk factor for development of hepatorenal syndrome (HRS) in cirrhotic patients with acute variceal bleeding. METHODS: 78 consecut...BACKGROUND: This study aimed to assess whether QT interval prolongation is an independent risk factor for development of hepatorenal syndrome (HRS) in cirrhotic patients with acute variceal bleeding. METHODS: 78 consecutive cirrhotic patients with acute variceal bleeding were included in the study. All patients were evaluated before bleeding (T0), during bleeding (T1) and 6 weeks later (T2). RESULTS: HRS developed in 14 (17.9%) patients. QT corrected by heart rate (QTc) prolonged at T1, returning towards baseline at T2 (mean ± SD; from 424.0 ± 10.2 to 461.2 ± 17.6 to 426.1 ± 8.8ms, P < 0.001). At T1, patients who developed HRS had longer QTc (P = 0.017) and lower serum sodium (P = 0.039). QTc and serum sodium independently predicted HRS; the best cut-off values were QTc > 468 ms and sodium < 120 mEq/L. Patients on beta-blocker were found to have significant risk for developing HRS (p = 0.040). Based on these three factors, the risk for HRS was nil for patients without risk factors; 6.1%, 11.1%, and 83.3% for those with one, two or three risk factors, respectively (p < 0.001). CONCLUSIONS: Acute variceal bleeding causes further prolongation of QTc in cirrhosis. The combination of beta-blocker, QTc interval and serum sodium can aid in early detection of patients at increased risk of developing bleed-precipitated HRS, thus improving their outcome.
BACKGROUND: The relationship between age and serum HBV DNA levels with histological activity in chronic hepatitis B inactive carriers is still unclear. We evaluated the correlation between age and hepatitis B viral DNA l...BACKGROUND: The relationship between age and serum HBV DNA levels with histological activity in chronic hepatitis B inactive carriers is still unclear. We evaluated the correlation between age and hepatitis B viral DNA levels with Metavir score in inactive chronic HBV carriers. METHODS: 50 patients (30 males and 20 females) were enrolled in the study after informed consent. Their blood samples were taken for routine investigations and specific tests for the study. Serum HBV DNA levels were quantified by real-time PCR. Metavir score was used for histologic grading. RESULTS: A1F0, A1F1, A1F2, A2F2 and A2F3 metavir scores were found in 41 (82%), 4 (8%), 1 (2%), 3 (6%), and 1 (2%) patients, respectively. There was significant correlation between age > 40 years and Metavir scores (p < 0.001). However there was no significant correlation between HBV DNA level with Metavir score (p = 0.074). CONCLUSION: Inactive carriers of 40 years of age or more should undergo liver biopsy to look for presence of significant histological findings despite having low HBV DNA level and normal SGPT level.
Grey scale ultrasound (US) is the first line imaging modality used for the evaluation of liver by the radiologists and clinicians worldwide. It is a simple, inexpensive, safe and an easily available technique. US has the...Grey scale ultrasound (US) is the first line imaging modality used for the evaluation of liver by the radiologists and clinicians worldwide. It is a simple, inexpensive, safe and an easily available technique. US has the ability to delineate the hepatic parenchyma and differentiate the cystic from solid hepatic lesions. However, it has limited accuracy in the detection and characterization of focal liver lesions (FLL). CEUS is a major breakthrough in ultrasound imaging which evolved with the aim of overcoming these limitations of US. With the use of ultrasound contrast agents (UCAs), CEUS has the ability to detect the intranodular hemodynamics and thereby provide information of the enhancement pattern of the lesion resulting in reliable characterization of the FLL. This capability brings it at par with the cross sectional contrast enhanced imaging techniques of computed tomography and magnetic resonance imaging. UCAs are safe, non-nephrotoxic and thus can be used to evaluate patients with renal failure as well. The technique of CEUS is simple, requires few minutes to perform, portable, lacks ionising radiation and above all is a cost-effective modality. These advantages have made CEUS an established modality for hepatic imaging. Besides detection and characterization of FLL, it also plays a vital role in the management and repeated follow up of treated patients of FLL. Newer clinical applications of CEUS with promising results are also being unravelled . This review highlights the multifaceted role of CEUS in hepatic imaging and its upcoming clinical applications.
Inflammatory bowel disease (IBD) including Crohn's disease (CD) and ulcerative colitis (UC), is an immunologically mediated chronic disease. The key underlying pathology is a deregulated immune response to commensal flor...Inflammatory bowel disease (IBD) including Crohn's disease (CD) and ulcerative colitis (UC), is an immunologically mediated chronic disease. The key underlying pathology is a deregulated immune response to commensal flora in a genetically susceptible host. Advances in genomics, epigenomics and understanding of the microbiome have brought forth the role of these spheres in the pathogenesis of IBD. Yet these factors explain only a small fraction of disease risk and our ability to predict relapses and response to treatment remains dismal. The external environment plays an important role in modifying the risk of IBD and in precipitating relapses in patients with established disease. The term 'exposome' was proposed to reflect a life-course of environmental influences beginning in-utero and proceeding right through childhood to adulthood. While the exposome is still a concept which needs practical perspective to enable better patient care, this review examines the gaps in our understanding that the IBD exposome helps explain. We further highlight the definition and parameters of this metric which can be incorporated for its application in research and clinical practice.
Acute severe ulcerative colitis as defined by Truelove Witt's criteria is a medical emergency which requires hospitalization. Patient requires close clinical monitoring with assessment of daily vital parameters, stool fr...Acute severe ulcerative colitis as defined by Truelove Witt's criteria is a medical emergency which requires hospitalization. Patient requires close clinical monitoring with assessment of daily vital parameters, stool frequency, serum electrolytes and daily abdominal examination Intravenous corticosteroids are the mainstay of therapy. Approximately two thirds of patients will respond to steroids. Response to steroids should be assessed at day 3 of admission and partial/non-responders should be considered for alternative medical therapy/surgery. Medical rescue therapies include intravenous cyclosporin and infliximab. This article provides an time bound step up algorithm for management of acute severe ulcerative colitis.
Biologicals have a well established role as rescue therapy in management of steroid refractory cases of Ulcerative colitis and Crohn's disease. However, high cost and potential risk of infections like tuberculosis limits...Biologicals have a well established role as rescue therapy in management of steroid refractory cases of Ulcerative colitis and Crohn's disease. However, high cost and potential risk of infections like tuberculosis limits their use in developing countries. As there is paucity of data on the use of various biological agents from developing countries like India, we are reporting the limited Indian experience with the available agents. Infliximab has been used as a rescue therapy for severe refractory Ulcerative colitis while other agents have been used as a part of multicentre clinical trials.
Approximately 15-20% patients with ulcerative colitis (UC) suffer from a severe flare during their lifetime which required hospitalization. Intravenous corticosteroids are the first line of therapy for acute severe UC. W...Approximately 15-20% patients with ulcerative colitis (UC) suffer from a severe flare during their lifetime which required hospitalization. Intravenous corticosteroids are the first line of therapy for acute severe UC. While almost 70-80% of patients respond to corticosteroids 20% do not. Although colectomy for UC is curative, it has its problems such as increased frequency of stool and pouchitis, which led to search for colon rescue therapy. Cyclosporine and anti-tumor necrosis factor-alpha (anti-TNF á) have emerged as effective colon rescue therapy. While the short-term efficacy of cyclosporine in preventing colectomy is 64-86%, the long-term efficacy is not as good and almost 70% eventually require colectomy over 1-7 years. The efficacy of cyclosporine is equivalent both at a high and low doses and cyclosporine is now used most often as a low dose regime in patients with steroid refractory acute severe UC. Furthermore, recent data suggest that the both cyclosporine and infliximab are equally effective in steroid refractory acute severe UC. Monitoring patients for adverse events and serum cyclosporine levels is mandatory. The response to both cyclosporine and infliximab is rapid and usually occurs within 4-5 days. Despite mounting evidence of its efficacy, cyclosporine remains largely underused because it requires intense monitoring for toxicity especially at higher dosage. Gastroenterologists need to be more familiar with cyclosporine for the management of steroid refractory acute severe UC.
Acute severe exacerbation of ulcerative colitis is a potentially life threatening medical emergency. The management of acute severe ulcerative colitis depends on early recognition and prompt initiation of intensive intra...Acute severe exacerbation of ulcerative colitis is a potentially life threatening medical emergency. The management of acute severe ulcerative colitis depends on early recognition and prompt initiation of intensive intravenous treatment along with continuous objective monitoring for possible medical failure. The intensive regime is the accepted standard of care. This includes primarily a) intravenous corticosteroids, b) intravenous supportive management, and d) intravenous antibiotics in instances. This review discusses the timing, duration and dosage of the intensive intravenous treatment including the evidence based protocol for effective monitoring to enable timely escalation to second line therapy & colectomy.
Ulcerative colitis is characterized by mucosal inflammation of a variable length of the colon starting from the rectum. The precise etiopathogenesis is unknown but it occurs in genetically susceptible individuals who man...Ulcerative colitis is characterized by mucosal inflammation of a variable length of the colon starting from the rectum. The precise etiopathogenesis is unknown but it occurs in genetically susceptible individuals who manifest an abnormal immunological response against gut commensal bacteria. The disease course is-characterized by multiple spontaneous relapses and remissions. Two pathogens namely CMV and C. difficile have been associated with disease exacerbation in specific clinical situations. Whereas C. difficile may produce worsening of the disease in those exposed to broad spectrum antibiotics, CMV reactivation is seen only in patients with moderate to severe steroid refractory disease. The importance of these two super-infections can be gauged by the fact that both the ACG and the ECCO recommend testing for these two pathogens in appropriate clinical situations. The applicability of these guidelines in the Indian scenario has yet to be determined in view of the bacterial and parasitic infections endemic in tropical countries. The guidelines for diagnosis and management of these two super-infections in the presence of ulcerative colitis are discussed in this review.
The first attack of ulcerative colitis can be acute and severe in 2-50% of patients. Acute severe colitis needs to be distinguished from various other conditions including severe infective colitis and ischaemic colitis....The first attack of ulcerative colitis can be acute and severe in 2-50% of patients. Acute severe colitis needs to be distinguished from various other conditions including severe infective colitis and ischaemic colitis. In those treated traditionally with intravenous corticosteroids, 30-40% require colectomy within a period of 6 months. The use of rescue therapies has modified this paradigm. Cyclosporine use averts early colectomy but most of these patients eventually require colectomy. The use of infliximab also averts early colectomy, but its long-term efficacy remains uncertain. Data suggests that the colectomy rate has reduced in recent years. Whether this is due to the increasing use of early aggressive therapy or whether or is part of the natural evolution of the disease, remains to be determined.
It is important to assess the severity of ulcerative colitis (UC) in order to decide the intensity of treatment and predict outcome. The criteria instituted by Truelove and Witts almost 60 years back are still being used...It is important to assess the severity of ulcerative colitis (UC) in order to decide the intensity of treatment and predict outcome. The criteria instituted by Truelove and Witts almost 60 years back are still being used. However, they lack a scoring system and offer no clear definition for the moderate group. The criteria with scoring system and endoscopic criteria (Mayo Score) seems to be more useful clinically. Endoscopic assessment is very important and a cautious attempt should always be made even if it enables a limited colonoscopic examination. Proctosigmoidoscopy is advocated at initial stages and after 5 to 7 days. The criteria for severity in general are same for pan-colitis and limited disease.