Long term efficacy and safety of N-butylcyanoacrylate in endoscopic treatment of gastric varices.

Introduction: Endoscopic glue (N-butyl-2-cyanoacrylate) injection has emerged as promising therapy for bleeding gastric varices (GV). We evaluated safety and long term efficacy of this technique in patients with portal hypertension and large bleeding GV. Patient and Methods: 170 patients (mean age 40.9±14y; 132 male; 142 had cirrhosis, 40 Child A, 62 Child B, 40 Child C) underwent glue injection into GV (F3 140, F2 30; fundal 114) as emergency procedure for active bleeding in 62 and electively for prevention of rebleeding in 108. Glue was injected intra-variceally under endoscopic vision, 0.5-4ml/aliquot, repeated at 3 weeks till varices were eradicated/solidified. The efficacy was assessed by hemostasis at 48 h, primary, secondary, definitive success and treatment failure. Results: The overall hemostasis rate at 48h was 82.3% (51/62). Follow up was available in 158 patients for mean of 30.7 + 17.2 months. Repeat injections were performed in 76. The mean number of injections were 1.9±1.0 (1-4); total volume was 2.5±1.7 ml / patient. The status of GVs at last follow up was : disappeared in 32 (22.6%); F1 solidified in 46 (32.3%); F2 solidified in 64 (45.0%). Bleeding recurred in 14.5% (23/158); 60% within 2 weeks of injection. The primary, secondary and definitive success rates were 85.4% (135/158), 4.4% (7/158) and 89.9% (142/158) respectively and treatment failure rate was 10% (16/158). No significant complications were noticed except for injection site ulceration in 32. Twenty patients died on follow up (9 died of uncontrolled bleeding, 11 died of liver failure) Conclusion: Endoscopic glue injection into bleeding GVs was effective in achieving hemostasis in 82% with a definitive success rate of 90% and had a good safety profile on long term follow up.

Antroduodenal manometry: experience from a tertiary care center.

BACKGROUND: Though antroduodenal manometry (ADM) is an important research tool, experience on its clinical utility is scanty. METHODS: All ADM performed as a clinical service, using an 8-channel water perfusion system were retrospectively analyzed. Impact on clinical management was classified as: (1) new diagnosis made, (2) change in management (new drug, decision regarding surgical treatment), (3) further special investigation done, (4) referral to another specialty. RESULTS: ADM was successful in 32/33 (97%) patients (age 30 years [range 8-71]); 6 patients were < 12 years old. Clinical impression before ADM was: chronic intestinal pseudo-obstruction (CIPO) in 16 (50%), suspected gastroparesis in 11 (34.3%), dyspepsia in 5 (15.6%). Consequent to ADM in patients with CIPO, a new diagnosis was made in two (intestinal neuronal dysplasia and celiac disease), new drugs were started in five, surgery was performed in three and specific referral was sought in three. ADM confirmed gastroparesis in 9 of 11 patients. A new diagnosis was made in three patients, new drugs were started in three, and three were referred. In five dyspeptic patients, ADM was normal and no therapy was suggested. Overall, eleven patients with CIPO and four with gastroparesis benefited after ADM. CONCLUSION: ADM was found useful in CIPO and gastroparesis, helped in decision making regarding surgery; however in nonspecific indications its utility was limited.

Acute hemorrhagic ascites: look beyond the gastrointestinal tract.

A 33-year-old alcoholic man presented with acute abdominal pain and hemorrhagic, high serum-ascitic albumin gradient ascites following an alcoholic binge, accompanied by hyperkalemia and azotemia. Spontaneous rupture of urinary bladder was diagnosed. The patient recovered uneventfully with conservative management.

Malabsorption syndrome due to various causes is associated with antroduodenal hypomotility.

BACKGROUND: Patients with celiac disease who present with symptoms of gastrointestinal hypomotility have abnormal antroduodenal manometry. There are no data on antroduodenal manometry in malabsorption syndrome (MAS) due to causes other than celiac disease. METHODS: Fasting, post-prandial and post-octreotide antroduodenal motility parameters were compared in 18 untreated patients with MAS presenting with chronic diarrhea (tropical sprue 10, small bowel bacterial overgrowth 3, celiac disease 2, common variable immunodeficiency 1, AIDS with isosporidiasis and bacterial overgrowth 1, giardiasis 1) and 8 healthy subjects. RESULTS: Number of patients with MAS and controls having spontaneous migratory motor complexes (MMC) during fasting was comparable (11/18 vs 7/8; p=ns). Fasting contraction amplitude was weaker in MAS than in controls in the gastric antrum (median 42 [range 17-90] vs 80 [31-120] mmHg; p=0.001), proximal duodenum (50 [18-125] vs 72 [48-107]; p=0.013) and distal duodenum (45 [20-81] vs 76 [51-98]; p=0.001). In the fed state too, contraction amplitudes were weaker in patients with MAS in the antrum (32 [15-110] vs 76 [61-103] mmHg, p=0.002), proximal duodenum (57 [20-177] vs 73 [56-113]; p=0.07) and distal duodenum (45 [24-87] vs 75 [66-97]; p<0.0001). Patients with MAS had lower fasting and post-prandial antral and duodenal motility indices than healthy subjects. Intravenous octreotide induced MMC in all patients and controls. CONCLUSIONS: MAS due to various causes is associated with antroduodenal hypomotility typical of myopathic disorders.

Utility of hydrogen breath tests in diagnosis of small intestinal bacterial overgrowth in malabsorption syndrome and its relationship with oro-cecal transit time.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO), which may result from intestinal stasis, is common in malabsorption syndrome (MAS). Quantitative culture of upper gut aspirate is used as a gold standard for the diagnosis of SIBO. Studies on diagnosis of SIBO using non-invasive hydrogen breath tests are contradictory. METHODS: 83 patients (age 35 [14-70] y; 50 men) with MAS due to various causes were investigated for SIBO using quantitative culture of upper gut aspirate obtained using a special endoscopic catheter and glucose and lactulose hydrogen breath tests (GHBT, LHBT). Sustained elevation in breath hydrogen of 12 ppm above basal and two separate peaks (one due to SIBO and the other from colon) were diagnostic of SIBO in GHBT and LHBT, respectively. Oro-cecal transit time (OCTT) was estimated using LHBT in 71 patients. RESULTS: Thirty two of 81 (39.5%) patients with MAS had SIBO on culture (>or= 10(5) CFU/mL). Using aspirate culture as the gold standard, sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of GHBT to diagnose SIBO were 44%, 80%, 62%, 67% and 65%, respectively; the corresponding values for LHBT were 31%, 86%, 62%, 54% and 55%, respectively. OCTT in patients with SIBO diagnosed on GHBT and/or aspirate culture (n=58) was longer than in those without (170 [60-250] vs. 120 [50-290] min, p=0.02); of others, 7 were hydrogen non-producers and in 6 OCTT could not be assessed due to sustained early peak because of SIBO. CONCLUSIONS: GHBT and LHBT are highly specific but insensitive for diagnosis of SIBO in MAS; OCTT is longer in patients with MAS and SIBO than in those without.

Primary gastric lymphoma and Helicobacter pylori infection with gastric amyloidosis.

Primary gastric lymphoma, an uncommon gastric tumor caused by infection with Helicobacter pylori, is rarely associated with gastric amyloidosis. Chronic bacterial infection is known to cause amyloidosis. We report a 53-year-old man who had an antral and duodenal mass with narrowing and ulceration on endoscopy and CT scan; endoscopic biopsy revealed gastric amyloidosis. Rapid urease test and serology for H. pylori were positive. Histology of resected specimen of distal stomach revealed primary gastric lymphoma, amyloid deposits and spiral organisms suggestive of H. pylori. Rectal biopsy was negative for amyloid. He remained well on follow-up after surgery and eradication of H. pylori.

Is vaccination against hepatitis A virus required in patients with cirrhosis of the liver?

Hepatitis A virus (HAV) superinfection can cause decompensation in patients with chronic liver disease. The risk of HAV superinfection depends on the endemicity of HAV in that particular population. Recommendations of vaccination against HAV in patients with cirrhosis of the liver in India are lacking. Our aim was to assess the seroprevalence of anti-HAV antibodies in our population of patients with cirrhosis of the liver. In a retrospective analysis, the serum of 55 patients with cirrhosis of the liver was tested for total anti-HAV antibodies by ELISA. In the 35 patients who presented with acute decompensation, the serum was also analysed for IgM anti-HAV antibodies. Fifty-four of the 55 cirrhotics (99%) were positive for total anti-HAV antibodies. All 35 patients with decompensated liver disease were also positive for total anti-HAV antibodies, and none of them tested positive for IgM anti-HAV antibodies. Most of the patients with cirrhosis of the liver in the population studied were already exposed to HAV. Routine vaccination against HAV cannot be recommended in these patients.

Role of socio-economic factors in tuberculosis prevalence.

Background: There is a need to re-assess the role of generally identifiable risk factors for development of tuberculosis (e.g. old age, poverty and poor socio-economic status). The present study was designed to look into the socio-economic and demographic characteristics of patients of tuberculosis (TB) vis-à-vis those with other respiratory diseases in the area in and around Chandigarh. Setting: Chest Clinic of a tertiary care hospital. Design: Case-control study Material and Methods: Two hundred and fifty consecutive cases of TB and an equal number of patients with pulmonary diseases other than tuberculosis as controls were interviewed as per a pre-designed, structured questionnaire that inquired into several socio-economic and demographic variables besides the clinical details. Univariate and multiple logistic regression analyses were carried out to obtain odds ratios separately for each variable. Results: The mean age of patients suffering from tuberculosis was 35.56 years (SD 13.69). There were 168 men (67.2%) and 82 (32.8%) women among the cases. Persons suffering from tuberculosis were more frequently found to have the worst of the socio-economic conditions for all the variables. Odds ratio (OR) increased by 3.14 (95% CI 2.48-3.98, p<0.001) for every decrease of Rs.500/- in the income level per person per month below Rs.2000/-. Similarly, the OR increased by 3.66 (CI 2.9-4.61,p<0.001) with increasing number of persons per room. The ORs for poorer housing, toilet facilities, water supply and consumer articles were also significant. In multivariate logistic regression analysis, the age, level of education, crowding, type of housing, water supply and number of consumer articles in the household was found to be independently and significantly associated with a higher risk of TB. Conclusion: There is a significant SES-health gradient in TB prevalence; tuberculosis risk increases with lowering of socio-economic status.