Dietary survey and total dietary fiber intake in patients with irritable bowel syndrome attending a tertiary referral hospital.

BACKGROUND: Based on their chemical extraction, dietary fibers are classified into crude fibers and total dietary fibers (TDF). TDF gives the best estimate of fiber content in the diet. Whereas data on intake of crude fibers are available, there is a lack of data on intake of TDF in patients with irritable bowel syndrome (IBS). AIM: We assessed the TDF and its source in the diet of patients with IBS and healthy controls (HC). METHODS: Based on their predominant symptoms, 81 patients with IBS (according to Rome II criteria) were categorized into constipation-predominant (IBS-C, n=48), diarrhea-predominant (IBS-D, n=16) and mixed type (IBS-M, n=17). Information was collected on fiber supplementation and preference for high-fiber food. A pretested, open-ended, semi-quantitative food frequency questionnaire was used to collect dietary information on food groups and TDF. Age- and sex-matched healthy individuals (n=89) were recruited as HC. The mean (SD) age of patients and HC was 36.5 (11.4) years (59 men), and 36 (12) years (62 men), respectively. RESULTS: Thirty-nine patients (48%) were taking medicinal fiber supplements, of which 28 patients were taking supplements daily (2.10 [0.84] teaspoon full). The mean daily TDF intake was 51.7 (23.1) g vs. 52.3 (21.6) g for patients and HC, respectively (p=0.8). The intake of TDF was similar in patients having less (n=41) or more (n=40) preference for fiber-rich foods (55 [23] g vs. 47 [22] g, p=0.16). The daily mean cereal intake in patients was significantly lower than that in HC (322 g vs. 404 g, p=0.001). However, consumption of fruits (150 g vs. 80 g, p=0.001) and vegetables (348 g vs. 219 g, p=0.006) was higher in patients in comparison with HC. There was a positive correlation between TDF with cereals (p=0.001), pulses (p=0.001), vegetables and fruits (p=0.033) in patients with IBS but only with cereals (p=0.001) in HC. CONCLUSION: The intake of TDF in patients with IBS and HC is much higher than the dietary recommendation for healthy Indians. Patients with IBS consumed more fruits and vegetables rather than cereals as compared with HC.

A randomized trial of oral refeeding compared with jejunal tube refeeding in acute pancreatitis.

BACKGROUND: Relapse of pain during refeeding in acute pancreatitis may have a relation to the route of refeeding. AIM: To compare the efficacy of oral refeeding with jejunal tube refeeding in patients with acute pancreatitis, and determine the frequency of refeeding pain and factors associated with it. METHODS: Consecutive patients with acute pancreatitis, severe enough to stop oral feeding for 48 hours, were randomized to receive either oral or jejunal tube refeeding. The feeds were similar in calorie, lipid and protein content (400 Kcal on day 1, 1000 Kcal on day 2, 1400 Kcal on day 3, 1500 Kcal on day 4, and 1700 Kcal on day 5). Clinical and biological factors (serum amylase, lipase, C-reactive protein) and Balthazar CT severity index were recorded. Frequency of pain relapse and factors associated with it were analyzed. RESULTS: 28 patients with acute pancreatitis (biliary 14, alcohol 9, idiopathic 3, post-ERCP 2) were included. Fifteen patients received oral and 13 received enteral tube refeeding. Four patients in the oral group and none in the enteral tube group had relapse of pain (p=0.06). The factors associated with refeeding pain were longer duration of initial pain (p<0.02) and higher CT severity index (p<0.02). Pain relapse increased the total hospital stay (p<0.004) and hospital stay after the first attempt at feeding (p<0.001). CONCLUSIONS: Jejunal tube refeeding may reduce the frequency of pain relapse as compared to oral refeeding although the difference was not significant in this study. Longer duration of pain and higher CT severity index score were associated with occurrence of refeeding pain.

Nutrition in the management of hepatic encephalopathy.

Nutritional factors play a major role both in the pathogenesis as well as management of hepatic encephalopathy (HE). Physicians treating patients with chronic liver disease often restrict the intake of dietary protein to prevent a rise in blood ammonia levels. The role of protein restriction in patients with chronic hepatic encephalopathy (CHE) has been questioned recently as the efficacy of protein withdrawal in patients with CHE has never been subjected to a controlled trial. Evidence suggests that protein intake plays only a limited role in precipitating encephalopathy. In fact, measures taken to suppress endogenous protein breakdown are more effective than dietary restrictions in reducing the load of amino acids on the decompensated liver. A protein intake of less than 40 g per day, as has been indicated, contributes to a negative nitrogen balance, which along with increased endogenous protein breakdown, worsens encephalopathy. A positive nitrogen balance may have positive effects on encephalopathy. Rather, depressed plasma branched-chain amino acid (BCAA) levels, implicated in the pathogenesis of HE, also supervene in cirrhosis only when malnutrition is present as well. Therefore, the emphasis in the nutritional management of patients with HE should not be on the reduction of protein intake. Instead, the goal should be to promote synthesis by making available ample amounts of amino acids, while instituting other measures to reverse the ongoing catabolism. Different protein sources have varying effects on HE and efforts should be made to identify the most tolerated protein source to prevent malnutrition and maintain these patients on a long-term basis.

Mother-to-child transmission of hepatitis E virus infection.

OBJECTIVES: Water borne or enterically transmitted non-A-non-B hepatitis is a major public health problem in India. Many of these cases carry fatal outcome. The hepatitis E virus (HEV) has been considered to be the most important causative agent of this entity. The severity and fatality rates of HEV infection are reported to be rather more in pregnant women. However, there is meager information from India, on mother to child transmission of this agent. METHODS: During 1997-98, we studied 60 pregnant women suspected to have acute viral hepatitis to understand the frequency of various viral etiologies, disease course and outcome of the pregnancy. Six cord blood samples were tested for IgG, and IgM antibodies against hepatropic viral agents and also for hepatitis E virus RNA by RT-nested PCR using ORF-1 as target. RESULTS: Of the 60 pregnant patients hospitalised at All India Institute of Medical Sciences, New Delhi for acute hepatitis, 22 (37%) were positive for IgM anti-HEV antibodies and 10% were infected with hepatitis B virus. Co-infection of HEV with Hepatitis B and C was seen in 1 and 2 patents, respectively. Most (72%) of the HEV infected patients were in third trimester of pregnancy (P<0.05). Of the 6 cord blood samples tested 3 (50%) were positive for HEV RNA. Though, all mothers were RNA positive, half of the babies did not get infected in utero with HEV. Fourteen of the 22 (63.6%) HEV infected mothers developed fulminant hepatic failure and all died. CONCLUSION: The mortality rate in HEV [corrected] infected mothers was 100%. Mother to child transmission of hepatitis E virus infection was established in 50%.

Nutritional risk factors in esophageal cancer.

OBJECTIVE: The present case-control study was undertaken with the objective to study the nutritional risk factors associated with esophageal cancer. METHODOLOGY: One hundred and fifty diagnosed esophageal cancer patients and an equal number of healthy individuals constituted the patient and control groups, respectively. Dietary consumption pattern during the preceding 20 years prior to the diagnosis of esophageal cancer was assessed utilising the standard food frequency questionnaire method. Information on alcohol consumption, smoking habits, chewing of betel leaf with tobacco was also collected. RESULTS: Multivariate analysis revealed that the risk of esophageal cancer was 7.81 times (p < 0.01) higher with daily consumption of alcohol. The risk increased to 3.16 times (p < 0.01) with the daily habit of chewing of betel leaf with tobacco. Nearly a two fold risk was observed when the consumption of "other vegetables" was less than four times per week. A 1.95 times (p < 0.01) increase in risk was observed with the daily habit of bidi smoking. CONCLUSION: Cancers in general are multifactorial in origin, and several environmental interactions are possible. It is not easy to quantify the contribution of diet to cancer risk. However, the results of the present study suggested that nutritional factors do play a role.

A prospective study on the incidence of hepatitis B & C infections amongst patients with lymphoproliferative disorders.

Fifty one patients with acute lymphoblastic leukaemia (ALL) and non-Hodgkins lymphoma (NHL) undergoing chemotherapy were studied prospectively to determine the incidence, aetiology and natural course of hepatitis. Of 51 patients (31 NHL and 20 ALL), 22 developed hepatitis. Hepatitis B (IgM anti HBc positive) was the cause in 11 patients (50%), hepatitis C in 4 patients, and septicaemia and cytotoxic drugs in 3 patients each. Malignant infiltration of the liver was the cause in the remaining 1 patient. Hepatitis was predominantly (75%) anicteric. Mean duration of hepatitis was 21 days. Of 51 patients, 21 acquired hepatitis B and/or C virus infection. They had received 6.4 (+/- 3.4) units of packed red cells and 5.3 (+/- 11) units of platelet concentrate as compared to 3.4 (+/- 4.8) units of red cells and 5.3 (+/- 12.1) units of platelet concentrate received by those who did not acquire virus infection (P < 0.05 for packed red cells). Only transient stoppage of chemotherapy was necessary following development of hepatitis and most of the patients who developed hepatitis could complete their chemotherapy schedule. None of the patients who developed viral B or C infection cleared the infection. We conclude that there was a high incidence of hepatitis B and C infection amongst patients with lymphoproliferative disorders with an increased carrier rate. Transfusion was a major risk factor for such infections.

Prevalence of hepatitis C virus antibodies in the general population & in selected groups of patients in Delhi.

We report on the prevalence of anti-HCV antibodies in healthy individuals and patient groups with different liver diseases. The healthy population comprising 234 voluntary blood donors and 65 pregnant women with no history of liver diseases, had a per cent positivity of 1.5 anti-HCV in each group. The patients groups comprising 32 with acute viral hepatitis, 110 with fulminant hepatic failure, 65 with subacute hepatic failure, 33 with chronic active hepatitis, 45 with cirrhosis and 10 with hepatocellular carcinoma, had anti-HCV per cent positivity of 12.5, 43.6, 41.5, 48.5, 8.8 and 0 respectively. Anti-HCV was also tested in sera from 9 patients who had developed post-transfusion hepatitis and was recorded in 2 (22.2%) within one year of transfusion.

Prevalence of hepatitis B virus infection in healthy persons in North India.

BACKGROUND. There is scant information on the main methods through which hepatitis B virus infection is transmitted in India. We, therefore, studied the prevalence of hepatitis B surface antigen and antibody to hepatitis B surface antigen in voluntary blood donors as well as in those healthy groups who have a high risk of contracting this infection. METHODS. The groups at risk studied included commercial sex workers (635), eunuchs (28), truck drivers (217), professional blood donors (1117) and health care workers (1313). In addition, 20,435 voluntary blood donors were also studied. RESULTS. Hepatitis B surface antigen (and its antibody) was positive in 2.6% (14%) of voluntary blood donors, 3.6% (19%) of commercial sex workers, 5% (16%) of truck drivers, 12% (9%) of professional donors, 1.4% (19%) of health care workers and none (18%) of the eunuchs. Except professional donors and truck drivers, none of these groups had a higher positivity than the normal population (2.6%). CONCLUSIONS. Our results indicate that in India the so-called high risk groups, other than truck drivers and professional blood donors, are unlikely to represent major sources of infection.

Role of enteral hyperalimentation in patients of carcinoma oesophagus.

The nutritional status of 24 patients of carcinoma oesophagus was assessed before and after central hyperalimentation with a liquid blenderized diet containing 3000-3500 cal and 100-120 g protein. The overall prevalence of malnutrition was found to be 70.8 per cent before the initiation of therapy. Of the various parameters used for assessment of nutritional status weight loss was the most common finding (91.6%) followed by alteration in midarm circumference, haemoglobin, triceps skin fold thickness, midarm muscle circumference and serum albumin. Enteral hyperalimentation for 10 days improved nutritional status by inducing significant gain in body weight (74.1%), triceps skin fold thickness (50%), midarm circumference (58%), midarm muscle circumference (62.5%) and serum albumin levels (91.6%). There was no significant change in haemoglobin levels.

A preliminary open trial on interferon stimulator (SNMC) derived from Glycyrrhiza glabra in the treatment of subacute hepatic failure.

The efficacy of the interferon stimulator named Stronger Neo Minophagen-C (SNMC) derived form the plant G. glabra was studied at a dose of 40 or 100 ml daily for 30 days followed by thrice weekly intravenously for 8 wk in 18 patients of subacute hepatic failure due to viral hepatitis. The survival rate amongst these patients was 72.2 per cent, as compared to the earlier reported rate of 31.1 per cent in 98 patients who received supportive therapy (P < 0.01). Death in four of the five patients was due to associated infections leading to hepatorenal failure and terminal coma. Further studies are necessary to standardize the dose and duration of therapy with SNMC in subacute hepatic failure.

Hospital malnutrition: a prospective evaluation of patients during hospitalisation.

Nutritional Status of 89 patients was assessed during their course of hospitalisation. All patients consumed diet deficit in protein and calories. The mean daily intake of calories was 819 +/- 425 Kcals and of protein was 22 +/- 19 g per day. 74.13 per cent patients lost weight while 31.25 per cent gained. 50% patients had fall in SKFT values during their hospital stay.

Animal transmission of enteric non-A, non-B hepatitis infection to Macaca mulatta by faeco-oral route.

M. mulatta monkeys were inoculated faeco-orally by enteric non-A, non-B virus to study the development of clinical, biochemical, histopathological and serological changes in the blood and liver. Pooled stool samples positive for putative non-A, non-B viral antigen by micro-ELISA and aggregated viral particles by immune electron microscopy, were administered in two M. mulatta monkeys. Biochemical, histopathological and serological changes were seen in the blood and liver and excretion of 27 nm virus like particles around 27 days of inoculation in the experimental monkey but not in the control animal.