Nutritional Anemia in the Medical Students.

Background: Nutritional anaemia is very much prevalent and largely undiagnosed among students in Professional Institutes. Various socio-demographic characteristics like age, sex, social class, dietary habits, and infections are the etiological factors for nutritional anaemia. Objectives: To study the nutritional anaemia and its correlates among the MBBS. Medical Students of Rohilkhand Medical College and Hospital, Bareilly in Western U.P. Materials and Methods: The study was done on 100 MBBS students. Haemoglobin estimation was performed by Sahli’s Haemoglobinometer and observations were interpreted as per the WHO criteria. The data was analyzed by SPSS Statistical software. Results: In the present study on 100 Medical students, 32.0% students were anaemic, out of which 44.0% were girls and 20.0% boys. 25.0% students had mild anaemia. Majority (81.8%) of anaemic students were undernourished as per their Body Mass Index. Conclusions: Haemoglobin estimation of students at the time of entrance to Medical Colleges should be done. Iron and folic acid tablets and deworming drugs in therapeutic doses should be provided to anaemic students. The students should be motivated and educated to take balanced diet, rich in green leafy vegetables and fruits as nutritional anaemia is totally preventable.

Cholestatic liver injury due to ibuprofen.

Ibuprofen is a member of the propionic acid class of NSAID. We report a 35-year-old man with ibuprofen-induced acute severe cholestatic liver injury. He recovered after seven months.

Diaphragm disease of duodenum following long-term NSAIDs use: endoscopic management.

We report our experience with endoscopic management of 3 men (aged 62, 63 and 65 years) with duodenal diaphragm disease following NSAID use for 5-15 years. In the first patient a 24 F through-the-scope balloon dilatation was attempted but failed; he subsequently underwent gastro-jejunostomy. The other two patients subsequently underwent radial incisions of the web with mixed cutting and coagulation current using a standard 5 F sphincterotome.

Goblet cell status in idiopathic ulcerative colitis--implication in surveillance program.

Idiopathic ulcerative colitis (IUC) patients have higher incidence of dysplasia and malignancy. Close follow-up with biopsy at regular interval is mandatory. The study was done to correlate incidence of atypical epithelium, goblet cell hyperplasia (GCH) and disease duration (DD) with Ki67, AgNOR and p53 expression in IUC with disease for 5 or more years. Ki67 and AgNOR are good indicators of cellular proliferation and p53 tumour suppressor protein is a marker for neoplastic cell. Of 130 cases studied, 40 cases showed atypical epithelium and were selected for further study. DD in these 40 cases ranged from 60 to 228 months. All had GCH and showed histological features of chronicity. Low-grade dysplasia (LGD) was seen in 15 cases, indefinite for dysplasia (ID) in 8 and inflammatory atypia in 17 cases. Disease duration showed no influence in the type of atypical epithelium. A positive staining of lining epithelium by Ki67 and p53 was not restricted to dysplasia. LGD and ID showed stronger p53 nuclear staining. AgNOR appeared to be a more sensitive marker than Ki67. GCH showed a positive correlation with DD and AgNOR index. p53 expression correlated positively with goblet cell hyperplasia. Conclusion- goblet cell hyperplasia could indicate presence of epithelial cell dysplasia.

Effect of eradication of Helicobacter pylori on gastric antrum histology.

BACKGROUND: Helicobacter pylori is a leading cause of gastritis. Some of the histological changes revert after eradication of H. pylori. There is paucity of reports from India. AIM: To study the effect of H. pylori eradication on the histopathological changes. METHODS: Endoscopically obtained antral biopsies from 164 consecutive H. pylori positive cases of dyspepsia were analysed before and 4 weeks after completion of treatment. RESULTS: Treatment for H. pylori resulted in eradication of the organism as confirmed histologically in 123 out of 164 (76.22%) cases. Analysis of histopathological changes in pre and post treatment biopsies from the same patient revealed a significant reduction in neutrophils, eosinophils, chronic inflammatory cells, acute epithelial changes and regenerative foveolar hyperplasia (p < 0.001) There was no difference in these findings in cases where H. pylori eradication failed when compared with their pre-treatment biopsies (p > 0.05). Similarly the pre and post treatment biopsies revealed, no difference in frequency of intestinal metaplasia and gastric atrophy in cases where H. pylori was eradicated or persisted after treatment. CONCLUSION: There was significant reduction in neutrophils, eosinophils, chronic inflammatory cells, acute epithelial changes and regenerative foveolar hyperplasia, following eradication of H. pylori.

Functional protein C and anti-cardiolipin antibody in children with portal vein thrombosis.

BACKGROUND: Portal vein thrombosis (PVT) is a common cause of portal hypertension in children from developing countries. Deficiencies of proteins C and S and elevated anticardiolipin antibody (aCL) levels have been shown to predispose to venous thrombosis. We studied these factors in children with idiopathic PVT. METHODS: 19 children with PVT (mean [SD] age 5.7 [2.1] y; 15 boys) were studied; all had had variceal bleeding, and had PVT on ultrasonography. Functional protein C activity was measured using a clotting assay; if it was normal, a clotting assay for functional protein S activity was performed. IgG aCL levels were measured in all sera using an in-house standardized solid-phase ELISA. RESULTS: Protein C functional activity ranged from 4% to 109%. Eight children had activity below 70%, the lower cut-off of the normal range. Protein S assay, done in 10 of the 11 children with normal protein C activity levels, was normal (above the cut-off level of 65% of the normal range). IgG aCL levels were abnormally elevated (>mean + 2SD of 16 healthy control children) in nine children; of these, three had associated protein C deficiency. Thus, of the 19 children with idiopathic PVT, 14 had abnormality in one or more tests. CONCLUSION: A majority of children with PVT of unknown etiology have functional protein C deficiency or abnormally elevated levels of aCL antibodies.

Helicobacter pylori infection in chronic smokers with non ulcer dyspepsia.

BACKGROUND/AIMS: Both H. pylori infection and smoking are risk factors for acid peptic disorders. There is paucity of data on relationship between smoking and H. pylori infection. Therefore, we studied prevalence of H. pylori infection in smokers with non-ulcer dyspepsia (NUD). PATIENTS AND METHODS: 30 smokers with NUD (age 29.5 +/- 1.2 years; all men) and 30 non-smokers with NUD (age 29.2 +/- 1.6 years; all men) were included. None was on antiulcer drugs or antibiotics for more than 2 weeks. Upper gastrointestinal endoscopy was performed and antral biopsies obtained were subjected to rapid urease test, Gram's staining, culture and histopathology. Patient was considered H. pylori positive, if culture was positive or combination of histopathology plus rapid urease test or Gram's staining plus rapid urease test was positive. RESULTS: 24 of 30 (80%) smokers and 13 of 30 (43%) non smokers were positive for H. pylori infection (p < 0.001). There was no significant difference in the positivity of H. pylori in light (78%), moderate (81%) and heavy smokers (80%). All the 37 patients who were positive for H. pylori had histological gastritis compared to 65% in H. pylori negative patients. However there was no difference in presence of histological gastritis among H. pylori negative smokers (33%) and non smokers (70%; p = NS). CONCLUSIONS: H. pylori infection is more common in smokers with NUD than in non-smokers. However duration and amount of smoking has no relationship with H. pylori positivity.

Prevalence of Helicobacter pylori infection in patients with reflux oesophagitis.

In this prospective study 30 patients of reflux esophagitis were studied to detect if there was any association between presence of esophagitis and H. pylori infection. 30 patients of non-ulcer dyspepsia acted as controls. In both the groups esophageal and antral biopsies were studied for the presence of H. pylori infection. None of the esophageal biopsies showed H. pylori infection in either group. H. pylori positivity was similar in the antrum of the patients with esophagitis (20 out of 30) and non ulcer dyspepsia (19 out of 30) (p > 0.05). There was no significant association between presence of H. pylori infection in antrum and severity of esophagitis (p > 0.05). In conclusion, this study has shown that H. pylori did not colonise esophagus in patients of esophagitis or patients of non-ulcer dyspepsia. There was no significant association between H. pylori colonization in the antrum and esophagitis and the grade of esophagitis with H. pylori infection.

Extended survival of carcinoma head of pancreas following palliative treatment.

A 48 year old woman presented with obstructive jaundice 10 years back. Upper gastrointestinal endoscopy revealed a growth infiltrating the ampulla of Vater, which was confirmed to be adenocarcinoma on cytology. At laparotomy, a large nodular growth was seen in the head of pancreas. Surgical resection could not be done because of encasement of superior mesenteric vessels, hence a cholecystojejunostomy was performed. The patient remained asymptomatic for 9 years, when she developed cholangitis. Duodenoscopy at this stage revealed an ulcerated growth at the ampulla and biopsy from the growth confirmed a well differentiated adenocarcinoma. A straight flap 10 F stent was placed in the common bile duct. Thereafter the patient has remained asymptomatic for more than a year.

Helicobacter pylori in gastric cancer in India.

BACKGROUND/AIMS: Helicobacter pylori infection has been implicated in pathogenesis of gastric cancer. Since there is paucity of reports from developing countries on association of H. pylori with gastric cancer, we performed case control study to find out the relationship between H. pylori and gastric cancer and also compared characteristics of gastric cancer and H. pylori positivity in younger and older patients. PATIENTS AND METHODS: Gastrectomy (n = 37) or endoscopic biopsy (n = 43) samples from area adjoining the cancer were collected from 80 patients of gastric cancer. Tissue specimens were stained with hematoxylin-eosin and Giemsa stains and histological type of cancer was determined according to Lauren, as intestinal or diffuse type. The presence of H. pylori was assessed by Giemsa staining. Eighty age and sex matched patients with non-ulcer dyspepsia (NUD) served as controls. RESULTS: Of 80 patients, 48 had intestinal type, 28 diffuse type and 4 had mixed type of gastric cancer. Tumour was located in antrum in 37, in body in 31, and at other sites in 12 cases. H. pyolri infection was present in 29 of patients compared to 36 patients with non-ulcer dyspepsia (p > 0.05, odd ratio 0.69, confidence interval 0.37-1.32). The positivity for H. pylori was higher in intestinal type than in diffuse type (p < 0.05) of gastric cancer but similar in patients with growth in antrum and body (p = NS) of stomach. There was no significant difference in tumor type, tumor site, frequency of intestinal metaplasia and H. pylori positivity (39% vs 35%, P > 0.05, odd ratio 1.19, confidence interval 0.44-3.23) in younger (< 45 yrs) and older (> 45 yrs) patients. CONCLUSIONS: Approximately one-third of patients with gastric cancer show presence of H. pylori infection on histological examination. No difference in H. pylori positivity were observed in young and old patients of gastric cancer.

Retained surgical sponge: an unusual cause of malabsorption.

Retained surgical sponge is an unpleasant surprise in clinical practice. Intraluminal migration of the retained sponge, though rare, can lead to intestinal obstruction and other complications. We describe two cases of retained surgical sponge, both following gynaecological surgery, presenting several years after surgery with features of subacute intestinal obstruction, malabsorption and several years after surgery with features of subacute intestinal obstruction, malabsorption and sever hypoproteinemia which reverted after surgical removal.

Normal limits of 14C-urea breath test.

BACKGROUND/AIMS: 14C-urea breath test has been widely used for diagnosis of Helicobacter pylori (H. pylori) infection. There is no general agreement on the cutoff values for determination of H. pylori negative subjects. We studied baseline values in subjects who were proved to be H. pylori negative and calculated the cutoff value of normalcy. A comparison of this test with other tests for diagnosis of H. pylori infection was also done. PATIENTS AND METHODS: 12 patients (mean age 34 +/- 14, range 22-65 years; 8 men) of non-ulcer dyspepsia were studied, who were proved to be H. pylori negative by rapid urease test, Gram's staining, histopathology and culture of gastric mucosal biopsies obtained four each from the antrum, body and fundus of the stomach. The controls included 12 patients (mean age 40 +/- 13, range 22-65 years, 9 men), who were positive for H. pylori on culture or combination of rapid urease test and histopathology or rapid urease test and Gram's stain. 14C-urea breath test was performed using 5 uCi of 14C-urea dissolved in 300 ml of water. Breath samples were collected once before ingestion of 14C urea and subsequently at 5, 15 and 30 minutes after ingestion and 14C-contents in the breath samples measured. Results were expressed as 14 CO2/mmol CO2 exhaled as percent of administered urea. RESULTS: The mean +/- SD 14-C value in H. pylori negative vs H. pylori positive patients at 5 minutes, 15 minutes and 30 minutes were found to be 0.003 +/- 0.003 vs 0.064 +/- 0.042 (p < 0.001), 0.002 +/- 0.001 vs 0.056 +/- 0.039 (p < 0.001) and 0.001 +/- 0.002 vs 0.041 +/- 0.026 (p < 0.001) respectively. The mean values of 14C-urea breath test were significantly lower in H. pylori negative patients as compared to H. pylori positive patients. Using receiver operating characteristic (ROC) analysis of the data, the cutoff values obtained were 0.01, 0.007 and 0.009 at 5 minutes, 15 minutes and 30 minutes respectively. CONCLUSIONS: 14C-urea breath test levels at 5, 15 and 30 minutes intervals are significantly lower in H. pylori negative patients as compared to H. pylori positive patients. This test has high sensitivity and specificity in detecting H. pylori infection.

Membranous glomerulonephritis in association with ulcerative colitis.

Glomerulonephritis is a rare association of ulcerative colitis. We report a patient with ulcerative colitis who developed proteinuria due to membranous glomerulonephritis which responded to colectomy.

Silent gastroesophageal reflux in patients with bronchial asthma.

Gastroesophageal reflux (GER) is a common occurrence in patients with asthma. We performed a prospective study to detect GER in patients with asthma using pH monitoring. Twenty consecutive patients (mean age 48 +/- 14 yr, range 23-70; 13 men) with asthma of unexplained etiology were evaluated. Esophageal and gastric pH were studied both while introducing and pulling out pH probe. Upper GI endoscopy was done in all the patients before doing pH monitoring. Esophageal pH was recorded at 25 cm, 30 cm and 35 cm from the incisors. Mean esophageal pH values while introducing pH probe were 2.9 +/- 1.08 (0-5.1), 2.5 +/- 1.2 (0-5) and 1.6 +/- 1.5 (0-4.6) at 25 cm, 30 cm and 35 cm from incisors respectively. The gastric pH was 0.5 +/- 0.4 (0-2). While pulling out pH probe, pH values were 1.5 +/- 1.4 (0-4.7), 2.4 +/- 1.5 (0-5.1) and 2.9 +/- 1.4 (0-5.4) at 35 cm, 30 cm, and 25 cm from incisors respectively. Of 20 patients, 19 had pH of 4 or lower at 25 cm, 30 cm and 35 cm from incisors. The mean pH value was lower at 35 cm than at 30 cm and 25 cm (1.6 +/- 1.5 vs 2.5 +/- 1.2 and 2.9 +/- 1.08, p < 0.04). In conclusion majority of adults with asthma have silent GER as detected on pH monitoring.

Current spectrum of hepatobiliary disorders in northern India.

OBJECTIVE: To evaluate the current spectrum of hepatobiliary disorders in children in Northern India. SETTING: Tertiary level referral hospital. METHODS: All children with hepatobiliary disorders presenting between January 1992 through July 1995 were evaluated by clinical assessment, liver function tests, viral and autoimmune markers, liver biopsy, copper studies and other relevant investigations. RESULTS: Two hundred and thirty five children with hepatobiliary disorders were seen over three and a half years period (67 cases per year). Acute hepatitis (28%), chronic liver disease (36%) and neonatal cholestasis syndrome (NCS) (26%) were the most common patterns of liver diseases. Chronic liver diseases were constituted by ICC (2%), post-hepatitic etiology (13%), Wilson's disease (21%), autoimmune (4%), non-Wilsonian metabolic diseases (16%), hepatic venous outflow obstruction (2%) and non-cirrhotic portal fibrosis (1%). Cirrhosis was documented in 71% and chronic hepatitis in 12% of cases with chronic liver disease. Fulminant hepatic failure was the presentation in 4% of children with liver diseases. CONCLUSION: Chronic liver diseases in Northern India are mainly constituted by post hepatitic, metabolic and cryptogenic etiology and ICC is rarely encountered. NCS is also one of the major subgroups of liver diseases in children.

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.

Therapeutic gastrointestinal endoscopy.

The safety, efficacy and utility of various therapeutic gastrointestinal (GI) endoscopic procedures performed on children (January 1992 to July 1995) at a tertiary referral centre in India were studied. A total of 1,030 sessions (upper GI 972 and lower GI 58) of therapeutic GI endoscopy were performed in 162 children (mean age 7.4 +/- 4 years; upper GI 115, lower GI 47). Various upper GI endoscopic procedures done were injection sclerotherapy (EIS), endoscopic variceal ligation (EVL), bougie dilatation of oesophageal strictures, balloon dilatations of oesophageal stricture/pyloric obstruction and retrieval of foreign bodies in 75%, 6%, 9%, 4% and 12% of children respectively. Therapy for bleeding from oesophageal varices constituted the major group (75%). Repeated EIS (sessions total--876, mean 8, range 5-15) performed on 86 children resulted in control of bleeding in all and eradication of oesophageal varices in 85% of cases. Minor complications (oesophageal ulcers and oesophageal strictures) due to EIS were observed in 9% of children. EVL (10 sessions in 7 children) was effective in controlling bleeding and substantial decrease of varices in all without any complication. Oesophageal dilation either by bougie (61 sessions in 10 children) or balloon (6 sessions in 3 children) were performed for benign strictures. Balloon dilatation of pyloric obstruction was successfully done in 2 children. Foreign bodies (retained or sharp) were retrieved from upper GI tract in 14 children. No complications were observed with stricture dilatation/foreign body retrieval. Therapeutic lower GI endoscopies were performed in 47 children (colonoscopic polypectomy in 92%, anal dilatation and piles banding in 4% each). One child with juvenile polyposis coli developed sigmoid colon performation following colonoscopic polypectomy which required surgical correction. We conclude that upper and lower GI endoscopic therapeutic procedures in children are highly effective and safe. The risk of major complication is very small in experienced hands and occasional minor complications, can be managed conservatively.