Role of trace elements in hepatic encephalopathy: zinc and manganese.

Apart from increased blood ammonia, alterations in various other substances have been implicated in the pathogenesis of hepatic encephalopathy (HE). The role of trace elements like zinc and manganese has been described recently. Zinc is an essential trace element and functions as an antioxidant. Low zinc concentrations have been reported in patients with cirrhosis of the liver, particularly those with HE. Patients with fulminant hepatic failure and subacute hepatic failure have also been shown to have low serum zinc levels. In animal experiments, zinc supplementation leads to a reduction in blood ammonia. Zinc deficiency also leads to alteration of neurotransmitters like gamma aminobutyric acid and norepinephrine. Zinc supplementation has been tried in HE. It may have a role in mild chronic HE, though further trials are necessary. Increased serum manganese levels have been shown in acute and chronic hepatitis, cirrhosis and congenital disorders like Alagille's syndrome. High manganese content has been reported in the globus pallidus in animals as well as brain tissues of patients dying of HE. Miners with chronic manganese exposure have encephalopathy and extra-pyramidal features similar to HE. It has been postulated that manganese impairs neuronal oxidative metabolism. The role of manganese in the pathogenesis of HE and the possibility of its chelation as treatment need further study.

Fighting cancer in the information age: the role of Internet.

Cancer is a major health problem worldwide which is likely to assume alarming proportions in the next two decades. Communication and information have increasingly been considered important in helping people to cope with cancer. The arrival of Internet offers the opportunity to fundamentally reinvent medicine and health care delivery. Medical professionals can now use the Internet for continuing medical education, access latest medical information, for fast confirmation of diagnosis, exchange opinion on treatment strategies and in palliative care. Internet can provide cost-effective and timely ways to deliver a complex mix of interesting and high-quality information and expertise to cancer patients. Patients can also independently search the Internet to know about their illness and treatment options. However, of concern is the quality of information that is available in the 'Net'. Some Internet sites may contain erroneous information on cancer and can pose serious problems. There are also many good sites, which provide quality information on cancer for medical professionals, researchers and patients. This article focuses on how the Internet will aid us in fight against cancer.

The clinical spectrum of fibrocalculous pancreatic diabetes in north India.

BACKGROUND: Fibrocalculous pancreatic diabetes (FCPD) is a secondary form of diabetes, unique to tropical countries. In earlier reports, patients with FCPD had severe insulin-requiring diabetes, malnutrition and a dismal prognosis. With Improvements in nutrition and medical care, the presentation and prognosis of FCPD may have changed. We report on the clinical profile and prognosis of a cohort of FCPD patients from north India and compare our findings with earlier reports. METHODS: Eighty consecutive FCPD patients who presented to the Diabetes, Gastroenterology and Surgical Gastroenterology services were evaluated for their nutritional status, clinical presentation, beta-cell function (fasting C-peptide) and exocrine function (faecal chymotrypsin). All patients diagnosed between 1994 and 2000 (n = 32) were followed prospectively for weight gain and glycaemic control. RESULTS: Only 55% of FCPD patients had a low body mass index (< 18 kg/m2). At the time of diagnosis of diabetes, only 26 (33%) patients presented with severe insulin-requiring diabetes; these patients were younger [23.7 (8.3) years v. 28.7 (10.6) years, p = 0.04], and had higher haemoglobin A1c [9.7 (3.8)% v. 7.3 (2.6)%, p = 0.005] than those requiring diet control or oral hypoglycaemic agents. FCPD patients had a wide range of fasting serum C-peptide (0.03-0.76 nmol/L). C-peptide was negatively associated with increasing duration of diabetes (r = -0.48, p = 0.001), but there was no correlation with faecal chymotrypsin. On prospective follow up (mean 2.3 years), there was significant improvement in body mass index [19.4 (2.9) kg/m2 v. 17.0 (3.7) kg/m2, p < 0.01] and haemoglobin A,c [6.4 (1.6)% v. 8.0 (3.0)%, p < 0.001]. CONCLUSION: FCPD patients differed from those described in earlier reports in many respects, Including improved nutritional status, a wide range of 3cell function and a more favourable prognosis.

Pseudoaneurysm of gastroduodenal artery associated with mitral valve prolapse presenting as haemobilia.

Pseudoaneurysms of the hepatic or gastroduodenal arteries may cause Haemobilia. Mitral valve prolapse associated with mycotic pseudoaneurysm of cerebral and extracerebral arteries have been reported. We report a case of gastroduodenal artery pseudoaneurysm presenting as haemobilia. The patient was successfully treated with indigenously fabricated steel coil embolization followed by surgery.

Is immunoproliferative small intestinal disease uncommon in India?

Till date only three series of immunoproliferative small intestinal disease (IPSID) describing 22 patients have been reported from India. Seven patients with IPSID in two tertiary referral centers in India are included in the study. Diagnosis was based on typical clinical features [diarrhoea (7/7), weight loss (7/7), clubbing (6/7), fever (3/7), abdominal pain and lump (3/7)], biochemical evidence of malabsorption and duodenal biopsy findings. All patients were young males (mean age 29.8 +/- 11.8 years, range 17-53). Atypical features included gastric involvement (1/7), colonic involvement (1/7) and appearance of pigmented nails following anti-cancer chemotherapy (1/7) which disappeared six months after omitting doxorubin from chemotherapy regimen. Parasitic infestation was common. Ascaris lumbricoides (1/7), Giardia lamblia and hookworm (1/7), Strongyloides stercoralis and Trichuris trichura (1/7). In the latter patient S. stercoralis became disseminated after anti-malignant chemotherapy. One patient had gastric H. pylori infection. Four of the seven patients who were misdiagnosed as tropical sprue were treated with tetracycline. This raises doubt on efficacy of tetracycline alone in treatment of IPSID. One other patient was misdiagnosed and treated as intestinal tuberculosis. Early diagnosis and administration of chemotherapy may improve survival in this disease.

Gastric tuberculosis presenting as non-healing ulcer: case report.

Tuberculous infection of the stomach is uncommon and the diagnosis is often missed due to its non-specific presentation. We report a case of gastric tuberculosis which presented as a non-healing gastric ulcer.

Gastroenterology and the Internet.

BACKGROUND: The Internet has come to play a significant role in health care across the world. Simple specific how-to-use information about the Internet for Gastroenterologists is lacking in the literature. AIM: To explain the origin, functions, use and impact of the Internet and to provide a list of important web site addresses related to Gastroenterology. METHODS: We undertook a detailed scan of the Internet and identified a large number of web sites pertaining to Gastroenterology. The sites were then thoroughly searched to evaluate their potential usefulness to Gastroenterology clinicians and researchers. A list of web site addresses were then compiled according to specific sub-areas of Gastroenterology. CONCLUSION: This overview of Internet and compliation of important web site addresses is expected to stimulate and instruct Gastroenterologists in the use of the Net in health care delivery and research. The list of web sites according to subspecialities provided in this article is expected to facilitate their search.

Percutaneous transhepatic biliary drainage in the management of obstructive jaundice.

BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) has been employed for decompression of the obstructed biliary tract to palliate jaundice and pruritus and for the management of cholangitis. We present our data to review the indications, therapeutic results and associated mortality and complications of this procedure. We have also studied the effect of size of drainage catheters on the improvement in liver functions and procedure related complications. METHODS: PTBD was attempted in 41 patients (18 men, age 56 +/- 12 years; 23 women, age 55 +/- 11 years) with obstructive jaundice (37 malignant, 4 benign). RESULTS: PTBD was successful in 39 (95%) patients. Mean serum bilirubin and alkaline phosphatase concentration declined significantly (p < 0.000001 for both) after 1 week, however thereafter decline was slow. Complete relief of pruritus and cholangitis was noted in most patients. Major complications such as cholangitis, bile leak into the peritoneum, malfunction of drainage catheter, intraperitoneal haemorrhage and renal failure, occurred in 11 (28%) patients, 2 (5%) of whom died. Large catheters (> 10 Fr) were superior to small size catheters (< 10 Fr) in relief of jaundice and had lower catheter related cholangitis. CONCLUSIONS: We conclude that PTBD is useful for palliation of malignant obstructive jaundice with intractable symptoms and cholangitis. Catheters larger than 10 Fr should be used.

Does Entamoeba histolytica cause irritable bowel syndrome?

BACKGROUND: Symptoms of patients with irritable bowel syndrome (IBS) closely mimic those of patients with non-dysenteric amebic colitis. AIM: To examine the clinical relevance of presence and types of Entamoeba histolytica in stools of patients with IBS. METHODS: IBS was diagnosed by Manning's criteria. Stool examination was done 4-weekly for 48 weeks to detect E. histolytica cysts or trophozoites. Patients underwent initial sigmoidoscopy. Sera of 22 IBS patients, 23 asymptomatic cyst passers and 36 healthy volunteers whose stools were also examined were tested for presence of antiamebic antibodies. Stools were cultured for amebae; positive cultures were subjected to polyacrylamide-gel electrophoresis (PAGE) using hexokinase (HK) isoenzyme to distinguish between pathogenic (fast-moving band) E. histolytica infection and nonpathogenic (slow band) species of Entamoeba dispar. RESULTS: E. histolytica cultured from stool samples of four IBS patients had slow-moving band of HK on PAGE. All patients spontaneously eradicated the infection during the next eight to 24 weeks; all had negative serology for antiamebic antibodies, and normal rectal mucosa on sigmoidoscopy. No change in symptom score occurred on follow up in IBS patients, although all of them cleared the infection. Three additional E. histolytica isolates from IBS patients obtained from another laboratory also showed nonpathogenic isoenzyme pattern. CONCLUSION: Bowel symptoms in IBS patients were not related to E. histolytica infection. The term non-dysenteric amebic colitis thus appears to be inappropriate, since it may be used erroneously for patients with IBS with nonpathogenic ameba, leading to injudicious treatment with antiamebic drugs.

Role of biliary scintigraphy in management of bile leak.

BACKGROUND: Endoscopic biliary drainage is effective in the management of patients with postoperative bile leak. Evidently, it cannot be used in patients with completely tied-off common bile duct (CBD). AIM: To ascertain whether biliary excretion scintigraphy could reliably detect patients with tied-off CBD so that endoscopic retrograde cholangiography (ERC), an invasive test, could be avoided. METHODS: Twelve patients with active bile leak (11 postcholecystectomy, one posttraumatic), in whom the biliary system was imaged by both 99m technetium mebrofenin biliary scintigraphy and ERC, were evaluated. RESULTS: Bile leak was demonstrated in all the 12 patients by scintigraphy. In six of these, there was no visualization of radionuclide activity in the intestines; in three of these six patients, ERC showed a patent CBD potentially amenable to endoscopic drainage, whereas in the remaining three, there was complete obstruction presumably due to CBD tie-off during surgery. CONCLUSION: Biliary excretion scintigraphy is unreliable for detecting complete biliary obstruction in patients with bile leak.

Primary biliary cirrhosis without pruritus--an Indian variant.

Primary biliary cirrhosis (PBC) is extremely rare in India. We report three cases of PBC without pruritus. The absence of pruritus in the present cases and in those reported earlier from India is highlighted.

Falciparum malaria with acute liver failure.

INTRODUCTION: Falciparum malaria occasionally presents with encephalopathy, jaundice and fever mimicking fulminant hepatic failure. PATIENTS: We recently managed seven cases (mean age 34 years, range 20-45; all men) of acute falciparum malaria presenting with a short history [mean duration 8.1 (4-15) days] of fever, jaundice, altered sensorium and oliguria. Only one patient had splenomegaly. Investigations revealed jaundice (bilirubin 1.9-30.7 mg/dl), moderate to severe anaemia (Hb 4-8 gm/dl), increased liver enzymes (2-4 times normal) and azotaemia (serum creatinine 1.6-7.4 mg/dl). Coagulation parameters were deranged in 3 with clinical bleeding in two cases. One patient without a past history of diabetes had increased blood glucose values with ketonuria. HBsAg was negative in all cases. Patients received supportive therapy along with intravenous quinine. Peritoneal dialysis was done in one patient. Three patients showed rapid recovery and four succumbed to the disease. Post-mortem liver biopsy showed Kupffer cell hyperplasia, pigment deposition, foci of steatosis and necrosis along with submassive necrosis in one case. CONCLUSIONS: In areas endemic for malaria, awareness of this entity is a must. In a patient with jaundice and altered sensorium, disproportionate anaemia, azotaemia and only mild elevation of liver enzymes should help differentiate these patients from cases of fulminant hepatic failure. The diagnosis can be confirmed by peripheral blood examination. Early institution of specific therapy may be the only life saving measure in these patients.

Immunoproliferative small intestinal disease: a frequently missed diagnosis.

Immunoproliferative small intestinal disease (IPSID) is a poorly recognized cause of malabsorption syndrome in India. Clinicopathological features of five patients with IPSID seen over a two-year period are described. Our data suggest that IPSID is commonly misdiagnosed as intestinal tuberculosis due to lack of awareness and reluctance to obtain small bowel biopsies. Empirical institution of anti-tubercular chemotherapy not only leads to delayed diagnosis but also possibly alters the natural history of the disease, resulting in an intermediate phase of amelioration followed by a terminal phase of lymphomatous transformation. The disease is therefore usually diagnosed at an advanced stage and hence is associated with a relatively poor outcome.

Biliary ascariasis associated with periampullary carcinoma.

A 65 year old man presented with obstructive jaundice, biliary colics and recurrent cholangitis. Sonography revealed dilated intrahepatic biliary radicles and common bile duct. Bile duct also showed linear parallel intraluminal structures suggesting biliary ascariasis. The lower end of common bile duct and pancreatic region showed a mass which proved to be a coexistent periampullary carcinoma.

Association of digital clubbing with corrosive stricture of esophagus.

We report a young woman who developed digital clubbing following corrosive esophageal injury. The clubbing regressed with effective dilatation of the esophageal stricture.