Polycythemia: a mystery solved by history

Testosterone is responsible for increased muscle mass. Leaner body mass helps control weight and increases energy. High levels of testosterone help build muscles and also stimulate growth in strength. Androgenic-anabolic steroids (AAS) are drugs that are structurally related to the cyclic steroid rings system and have similar effects to testosterone in the body. Athletes who abuse steroids do so for muscle growth and quick recovery. Testosterone - whether it's injected, applied via a patch or cream, or taken orally - allows athletes to rapidly increase muscle mass beyond their usual capacity, and also reduces their recovery time which allows them to train continuously with little need to rest their bodies in between workouts. Physiologically, erythrocytosis is defined by an erythrocyte mass that exceeds 125% of that predicted for sex and body mass. Much of the concern with the use of testosterone involves increase in blood viscosity, resulting from increased red blood cell mass causing a potential increased risk for venous thromboembolism (VTE), myocardial infarction (MI), and cerebrovascular accidents (CVA). We report a case of secondary polycythemia related to testosterone therapy.

A rare case of cranial metastasis from an initial presentation of hepatocellular carcinoma

Cranial metastases from hepatocellular carcinoma (HCC) has been seldom reported. Reported herein is the case of a painless parietal bone mass as an initial presentation of HCC in a 63-year-old female patient who was subsequently diagnosed to have HCV related cirrhosis. The biopsy from cranial lesion was confirmatory of HCC on immunohistochemistry. The patient had no known history of chronic liver disease. The presented diagnosis was made through detailed history, laboratory parameters and cross sectional imaging.

Nutritional status and prognosis in cirrhotic patients.

Background and aims: Malnutrition is commonly associated with chronic liver disease. The presence of protein–calorie malnutrition has been shown to be associated with increased short- and long-term mortality in patients with acute and chronic liver disease. We undertook this study to assess the prognostic value of nutritional status in predicting survival in cirrhotic patients. The aim of our study was to determine whether assessment of nutritional status using the RFH-SGA score adds significantly to CP (Child-Pugh) and MELD scores in predicting patient prognosis and survival in cirrhotic patients. Methods: Diagnosed cases of cirrhosis were enrolled and their nutritional assessment was done using the RFH-SGA score. All patients were followed up for a period of 6 months. The mortality rates in the various groups were compared with respect to their nutritional status. Multivariate analysis was used to determine the factors associated with mortality. Results: A total of 73 cirrhotic patients were taken up for this study. Of these, 23 patients (31.5%) were well nourished, 21 (28.8%) had mild to moderate malnourishment and 29 (39.7%) were severely malnourished. Multivariate analyses of various parameters identified poor nutritional status, increased CP grade, increased creatinine, lower sodium levels and longer prothrombin time as being independently associated with poorer survival. Conclusions : RFH-SGA is a simple and inexpensive tool for assessing the nutritional status in cirrhotic patients and can reliably predict their disease prognosis and survival.

Epidemiology and symptom profile of gastroesophageal reflux in the Indian population: Report of the Indian Society of Gastroenterology Task Force.

Background Gastroesophageal reflux disease (GERD) and its complications are thought to be infrequent in India; there are no data from India on the prevalence of and risk factors for GERD. The Indian Society of Gastroenterology formed a task force aiming to study: (a) the frequency and profile of GERD in India, (b) factors including diet associated with GERD. Methods In this prospective, multi-center (12 centers) study, data were obtained using a questionnaire from 3224 subjects regarding the frequency, severity and duration of heartburn, regurgitation and other symptoms of GERD. Data were also obtained regarding their dietary habits, addictions, and lifestyle, and whether any of these were related or had been altered because of symptoms. Data were analyzed using univariate and multivariate methods. Results Two hundred and forty-five (7.6%) of 3224 subjects had heartburn and/or regurgitation at least once a week. On univariate analysis, older age (OR 1.012; 95% CI 1.003–1.021), consumption of non-vegetarian and fried foods, aerated drinks, tea/coffee were associated with GERD. Frequency of smoking was similar among subjects with or without GERD. Body mass index (BMI) was similar in subjects with and without GERD. On multivariate analysis, consumption of non-vegetarian food was independently associated with GERD symptoms. Overlap with symptoms of irritable bowel syndrome was not uncommon; 21% reported difficulty in passage of stool and 9% had mucus in stools. About 25% of patients had consulted a doctor previously for their gastrointestinal symptoms. Conclusion 7.6% of Indian subjects have significant GERD symptoms. Consumption of non-vegetarian foods was an independent predictor of GERD. BMI was comparable among subjects with or without GERD.

Outcome of patients with primary hepatic venous obstruction treated with anticoagulants alone.

Background Outcome of patients with hepatic venous outflow tract obstruction (HVOTO) has improved with newer treatments, including anticoagulants, radiological interventions and liver transplant. In India, however, liver transplant and radiological interventions are costly and have limited availability. Hence, patients often opt for anticoagulation alone. We followed up a group of such patients to determine the clinical outcome with such treatment. Methods Consecutive patients with HVOTO, treated with oral anticoagulation and supportive medical therapy but no radiological or surgical intervention, were followed up for at least 12 months. Diagnosis of HVOTO was based on color Doppler, and either angiography or magnetic resonance venography. Warfarin dose was adjusted to maintain international normalized ratio (INR) between 2.0 and 3.0. Patients with secondary HVOTO and those with baseline INR >2.0 were excluded. Response was defined as absence of ascites and/ or encephalopathy, normal AST/ALT, bilirubin <1.5 mg/dL, and no portal hypertension related bleed after starting therapy. Results Of 43 patients (mean [SD] age=28.7 [8.4] years; 20 men), 26 (61%) had a response during a median follow up of 23 (range 15-33) months. The response first appeared within 2 months of the start of treatment in 18 patients and between 2 and 5 months from the start of treatment in eight patients. Seven patients died of progressive liver failure (6 patients) or GI bleed (1 patient). Nine patients had anticoagulationrelated complications. On univariate analysis, short duration of symptoms, high serum albumin, low baseline INR, and low baseline Child-Pugh’s (CP) or Clichy scores predicted response. Presence of hepatic encephalopathy, portal vein thrombosis, obstruction of all hepatic veins, low albumin, high INR, high serum bilirubin, high baseline CP score, Murad score and adverse Clichy index were associated with higher mortality rate. However, on multivariate analysis, only low CP score was associated with response, and no factor was found to predict death. Conclusions More than half of patients with HVOTO show response with only supportive medical therapy and anticoagulants. This occurs more often in patients with low CP score. Some patients may have delayed response.

Pathogenesis and management of irritable bowel syndrome.

The exact cause of irritable bowel syndrome (IBS) is not known. Multiple factors, like genetic, gut motility, visceral hypersensitivity, psychosocial factors and immune-mediated factors, are thought to contribute to the symptom complex of IBS. Till date an ‘IBS gene’ has not been defined, and there is a need for further studies. The concept that IBS as a diagnosis of exclusion is not acceptable any more. The treatment of IBS is targeted at the management of constipation, diarrhoea and abdominal pain and includes pharmacotherapy with tegaserod, alosetron and lubiprostone. Cognitive behavioral therapy is very beneficial.

Transjugular liver biopsy using Tru-cut biopsy needle: KEM experience.

BACKGROUND AND AIM: Transjugular liver biopsy is accepted procedure in patients in whom percutaneous liver biopsy is contraindicated. We report our experience with this procedure, its indications, efficacy and safety in Indian population over 5 years. MATERIAL & METHODS: A retrospective study of 145 consecutive patients who had undergone transjugular liver biopsy from May 2002 to Nov. 2007 was done from the database maintained in our department. We evaluated the indications, technical success, complication and impact of histological diagnosis on the management of those patients. RESULTS: 145 Transjugular liver biopsies were performed of which 74 were males and 71 were females aged between 5 and 74 years. Two procedures were abandoned due to failed hepatic vein cannulation because of venous occlusion. Out of 143 biopsies, 4 were inadequate while 139 yielded adequate tissue for histopathological diagnosis. Histopathological examination in our study showed cirrhotic changes in 56, hepatitis including both acute and chronic in 48, periportal fibrosis in 9, Wilson's disease in 5 and obstructive cholangiopathy in 2 patients. The remaining 19 were normal. Minor complications occurred in 2 patients. CONCLUSION: Transjugular liver biopsy is a safe procedure in the trained hands and provides adequate tissue for diagnosis when percutaneous liver biopsy is contraindicated.

Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force.

AIMS: To study the profile of irritable bowel syndrome (IBS), and the frequency of such symptoms among the general population, in India. METHODS: In this prospective, multi-center study, data were obtained from 2785 patients with chronic lower gastrointestinal symptoms (complainants) with no alarm feature and negative investigations for organic causes visiting physicians at 30 centers, and from 4500 community subjects (non-complainants), using separate questionnaires. RESULTS: Most complainants were middle-aged (mean age 39.4 years) and male (1891; 68%). The common symptoms were: abdominal pain or discomfort (1958; 70%), abdominal fullness (1951; 70%); subjective feeling of constipation (1404 of 2656; 53%), or diarrhea (1252 of 2656, 47%), incomplete evacuation (2134; 77%), mucus with stools (1506; 54%), straining at stools (1271; 46%), epigastric pain (1364; 49%) and milk intolerance (906; 32%). Median stool frequency was similar in patients who felt they had constipation or those who felt they had diarrhea. Information to subtype symptoms using standard criteria was available in 1301 patients; of these, 507 (39%) had constipation-predominant IBS ( 3 <or= stools/week), 50 (4%) had diarrhea-predominant IBS (>3 stools/day) and 744 (57%) had indeterminate symptoms. Among non-complainants, most subjects reported daily defecation frequency of one (2520 [56%]) or two (1535 [34%]). Among non-complainants, 567 (12.6%) reported abdominal pain, 503 (11%) irregular bowel, 1030 (23%) incomplete evacuation, 167 (4%) mucus and 846 (18%) straining at stools; a combination of abdominal pain or discomfort relieved by defecation, and incomplete evacuation was present in 189/4500 (4.2%) community subjects. CONCLUSIONS: Most patients with IBS in India are middle-aged men, and have a sense of incomplete evacuation and mucus with stools. Abdominal pain or discomfort is frequent but not universal. Importantly, stool frequency was similar irrespective of whether the patients felt having constipation or diarrhea. Most (90%) non-complainant subjects had 1 or 2 stools per day; symptoms complex suggestive of IBS was present in 4.2% of community subjects.

Impact factor of Indian Journal of Gastroenterology for the years 2005 and 2006.

OBJECTIVE: To determine the impact factor (IF) of the Indian Journal of Gastroenterology (IJG) for the years 2005 and 2006. METHODS: For each of the two years, the number of citations received during that year in the journals included in the Science Citation Index (SCI), obtained by searching the online SCI database, divided by items published in the IJG in the previous two calendar years was determined. Self-citations in the IJG of the items published during the preceding two calendar years were determined by manual search. IF was calculated from these data. RESULTS: The IF of IJG for the year 2005 was 0.384 and that for the year 2006 was 0.667. The latter may be an underestimate because some citations during the year 2006 may not yet have appeared in the database. These values were higher than the previously reported IF of IJG of 0.192 in 1990. CONCLUSION: The IF of IJG has shown significant improvement over time.

Outcome of acute liver failure due to acute hepatitis E in pregnant women.

INTRODUCTION: Acute liver failure due to acute hepatitis E carries a high mortality. METHODS: Clinical and laboratory parameters of 42 pregnant women (median age 25.5 years) with acute liver failure due to acute hepatitis E were retrospectively analyzed. RESULTS: 22 women delivered, whereas pregnancy continued in 20 women. The maternal mortality in these two groups was similar (9/22 [41%] versus 14/20 [70%], p=0.056). However, in patients with grade I, II or III hepatic encephalopathy, delivery of fetus was associated with reduced mortality in those who delivered as against those who continued pregnancy (5/16 (31%) vs. 13/20 (65%), p=0.046). On multivariate analysis, higher grade of encephalopathy at admission was associated with risk of death (p=0.005). CONCLUSION: Mortality in pregnant women with acute liver failure with acute hepatitis E is high, especially in patients who present with higher grades of encephalopathy.

Spontaneous esophageal perforation in a patient with achalasia cardia and rheumatoid arthritis.

Perforation of stasis ulcers in achalasia cardia has not been reported in literature. We report a 45-year-old lady with achalasia and rheumatoid arthritis who developed perforation and esophago-mediastinal sinus at the site of stasis ulcers. She succumbed to respiratory infection after resection of the sinus tract, Heller's cardiomyotomy, cervical esophagostomy and feeding jejunostomy.

Effect of Helicobacter pylori eradication on serum ammonia levels in patients with chronic liver disease.

BACKGROUND: Helicobacter pylori infection has been implicated in the development of encephalopathy in chronic liver disease (CLD); this is possibly due to increased production of ammonia by the action of bacterial urease on urea in the gastric lumen. AIM: To evaluate whether H. pylori eradication in patients with CLD affects arterial ammonia levels. METHODS: Forty-six patients with CLD (40 alcoholic, 6 post hepatitis B; Child's class A 7, B 17, C 22) and 36 patients with symptoms of acid-peptic disease (APD) underwent gastrointestinal endoscopy and biopsy; gastric biopsies were evaluated for H. pylori status using rapid urease test and histology. H. pylori-positive subjects received quadruple-drug eradication therapy for 2 weeks. Fasting arterial plasma ammonia levels were estimated before and after eradication of H. pylori. RESULTS: H. pylori infection was present in 21 of 46 (45.7%) patients with CLD and 23 of 36 (63.9%) with APD. At baseline, mean (SD) ammonia levels were higher in the CLD group (97.4 [10.9] versus 81.3 [7.7] mcg/dL in the APD group; p = 0.0001), irrespective of H. pylori status. Amongst patients with liver disease, arterial ammonia levels were similar in the H. pylori-positive and -negative patients (94.1 [9.7] and 100.2 [11.3] mcg/dL, respectively); however, ammonia levels were higher in patients in Child's class C (102.7 [11.4] mcg/dL/dL) than in those in class A (88.4 [1.6] mcg/dL; p < 0.002) or B (94.1 [9.7] mcg/dL; p < 0.002). In patients with APD, ammonia levels were higher in H. pylori-positive patients (85.3 [6.4] versus 74.1 [3.3] mcg/dL; p < 0.001). After eradication of H. pylori infection, ammonia levels decreased to 88.4 (10.0) mcg/dL in CLD and 76.7 (4.8) mcg/dL in APD (p = 0.001 as compared to baseline). There was no difference in post-eradication ammonia levels between Child's classes. CONCLUSION: Levels of arterial blood ammonia are higher in CLD than in APD, and correlate with severity of liver disease. H. pylori eradication was associated with reduction in arterial ammonia levels in patients with CLD.

Effect of red chillies on small bowel and colonic transit and rectal sensitivity in men with irritable bowel syndrome.

BACKGROUND: Altered motility and threshold for pain have been incriminated in the pathogenesis of the irritable bowel syndrome (IBS). Capsaicin affects visceral sensory perception and chillies, which contain capsaicin, have been shown to accelerate gut transit. AIMS: To evaluate the effect of red chillies on small bowel transit (SBT) and colonic transit (CT) and rectal sensitivity in normal men and men with IBS. METHODS: Twenty-nine men with IBS diagnosed using Manning's criteria, and 21 healthy men, were studied before and after ingestion of 10 g red chilli powder (capsaicin equivalent 14 mg). SBT time was measured as the time taken for 99mTc-sulfur colloid to reach the cecum after leaving the stomach. Total and segmental CT times were assessed using radio-opaque markers. Rectal sensitivity and pain threshold to intrarectal balloon distension were measured. RESULTS: The median (range) bowel frequency in patients and healthy men was 2 (1-6) and 1 (1-3) per day (p=0.03), respectively. After ingestion of chillies, it increased to 3 (1-8) per day and 2 (1-4) per day (p=0.01), respectively. There was no difference in transit times between patients and healthy men; chilli ingestion did not alter SBT time, total or segmental CT time. IBS patients had a lower threshold to balloon distension for both discomfort and pain in the basal state (p<0.01). Chillies increased this threshold in healthy men (p<0.01). CONCLUSIONS: Men with IBS do not have SBT or CT abnormalities, but have a lower rectal balloon sensitivity threshold. Chilli powder does not alter either SBT or CT in men with IBS or healthy men; however, it increases the rectal threshold for pain in the latter.