Microscopic colitis in patients presenting with chronic diarrhea.

Aim: To investigate the prevalence of microscopic colitis among patients presenting with chronic watery diarrhea. Material and Methods: Colonic biopsies from 400 patients presenting with chronic watery diarrhea and other symptoms pertaining to lower gastrointestinal tract were studied. After a detailed clinical history and thorough physical examination full length colonoscopy was done using flexible colonoscope. Colonic biopsies were taken from abnormal and normal areas. Three to five micron thick sections were cut and stained with hematoxylin and eosin and Masson's trichrome stain to highlight sub epithelial collagen. Results: Fifteen out of 400 (3.7%) colonic biopsies from patients presenting with chronic diarrhea had evidence of microscopic colitis. Five out of fifteen biopsies (33%) were diagnosed as collagenous colitis, 10 biopsies (67%) had evidence of lymphocytic colitis; 14/400(3.5%) histologically normal biopsies were taken as controls to compare various demographic and risk factors. Ten out of 15 patients (67%) were clinically diagnosed as irritable bowel syndrome. In the remaining five an infective etiology was suspected. On colonoscopy12/15 (80%) had no abnormality and 3/15 (20%) had mild hyperemia. Conclusion: A possibility of microscopic colitis should be considered while examining colonoscopic biopsy of a patient with chronic watery diarrhea and normal colonoscopy to avoid the misdiagnosis that may affect the treatment of patients

Management of chronic hepatitis B virus infection: a promising approach using small interfering RNA (siRNA).

Hepatitis B virus infection continues to be a major global health problem with an estimated 350 million carriers. The response to available treatment modalities is not impressive. The advent of RNA Interference--a phenomenon of sequence-specific degradation of RNAs mediated by double-stranded RNA--holds promise as a potential therapy for chronic hepatitis B virus infection. Synthetic preparations of short RNA (21-23 bp long) can be used to mediate this process of gene silencing with a lower immune response. The duration of suppression can be further increased by using a vector delivery system. Small interfering RNA (siRNA) has several advantages over conventional therapy, which include fewer side-effects, a lower chance of developing escape mutants and non-requirement of viral replication for its action. A potent knockdown of the gene of interest with high sequence specificity makes RNA interference a powerful tool that has shown antiviral effect against hepatitis B virus. However, the 'off-target effect', i.e. suppression of genes other than the intended target, poor siRNA stability, inefficient cellular uptake, widespread biodistribution and non-specific effects need to be overcome. The problem of long-term toxicity of siRNA should be addressed and an ideal vector delivery system needs to be designed before it can be put to clinical use.

Prevalence of H. pylori in patients with gastric cancer.

The present study was taken with an aim to assess the prevalence of H. pylori in patients with gastric carcinoma and correlate it with gross appearance and histological type. Endoscopic biopsies from 54 patients with gastric carcinoma and 50 age and sex matched controls were taken after thorough upper gastrointestinal examination. Gross appearance of the tumour was noted and two biopsies each from the site of malignancy and from normal appearing areas were taken. Sections were stained with Haematoxylin & Eosin and Loeffler's methylene blue for histopathological details and presence of H. pylori. Prevalence of H. pylori in controls was slightly higher than the patients group (80% Vs 78%). Ulcerated type of gross appearance had maximum prevalence of H. pylori (88%). Prevalence of H. pylori was more in diffuse type of gastric cancer than intestinal type (86% Vs 68%). A significant association between H. pylori and grades of gastritis was noted (P < 0.01) in controls as well as in patient group but it failed to show a significant association with tumour grades, intestinal metaplasia, site of the tumour and age of the patients. So, it can be inferred that prevalence of H. pylori infection is not directly associated with pathogenesis of gastric cancer but it may act as a co-carcinogen by damaging the mucosa and thereby making it more susceptible to effects of carcinogen.

Is conventional sphincterotomy possible in patients with common bile duct stones impacted at the ampulla of Vater?

BACKGROUND: Needle knife precut papillotomy has been used to gain access or remove impacted common bile duct stones at the ampulla of Vater. However, precut papillotomy is a risky procedure with high complication rates and is presumably best dealt with by the expert. We attempted to find out the feasibility of performing conventional endoscopic sphincterotomy in patients with impacted stones at the ampulla. METHODS: All patients undergoing endoscopic retrograde cholangiopancreatography for stones impacted at the ampulla between the years 2000 and 2005 were enrolled in the study. All attempts were made to achieve biliary cannulation through the conventional route including use of the long route or guidewire to cannulate the papilla. Needle knife papillotomy was resorted to only if attempts to cannulate the papilla through the conventional route failed. The success and complications of the procedures were recorded. RESULTS: Thirty-two patients were enrolled. The impacted bile duct stone could be removed in all the patients. Conventional endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed in 23 patients with impacted stones. The long route had to be employed in seven patients while guidewire cannulation of the papilla was needed in four patients. Needle knife papillotomy was needed in only nine patients. None of the patients in whom the conventional route was employed developed complications, whereas bleed requiring endoscopic management was observed in three (33%) of the nine patients in whom needle knife papillotomy was performed. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy can be performed by the conventional route in the majority of patients with impacted stones at the ampulla. This approach appears to be safer than needle knife papillotomy. However, needle knife papillotomy may be required in patients in whom biliary access cannot be gained through the conventional approach.

Jejunogastric intussusception--a rare cause of recurrent upper gastrointestinal bleeding: case report and review of literature.

Jejunogastric intussusception is a known complication following gastrojejunostomy. However, only occasionally have they presented with haematemesis and we are unaware of any case where it led to recurrent haematemesis. We describe a case where the patient developed recurrent upper gastrointestinal bleeding due to recurrent episodes of jejunogastric intussusception following gastrojejunostomy performed 12 years earlier for duodenal ulcer disease.

Giardia lamblia trophozoites in gastric biopsies.

To assess the prevalence of gastric giardiasis in gastric biopsies of patients with carcinoma stomach and in patients taking treatment for duodenal ulcer. Gastric biopsy specimens from 54 patients of carcinoma stomach and 100 antral biopsies from patients taking treatment for duodenal ulcer were included in the study. Sections were stained with haematoxylin and eosin, methylene blue and May Grunwald-Giemsa stains and examined for presence of Giardia lamblia trophozoites. Eight out of 54 (14.9%) biopsies of gastric carcinoma patients harboured trophozoites of Giardia lamblia. Associated H. pylori infection was present in all biopsies (8/8; 100%). Atrophy and intestinal metaplasia was present in 62.5% (5/8) and 25% (2/8) cases respectively. Sections from seven out of 35 patients (20%) taking treatment for duodenal ulcer showed presence of G. lamblia. H. pylori infection, gastritis and atrophy were found in 85.7% (6/7), 71.4% (5/7) and 28.6% (2/7) cases respectively. First gastric biopsy in these patients was negative for G. lamblia but 2nd and 3rd biopsies were positive. A careful search for G. lamblia trophozoites should be made while examining the gastric biopsies, especially in patients with carcinoma stomach, intestinal metaplasia, atrophic gastritis and those taking treatment for duodenal ulcer. This may help in indirect diagnosis of clinically unsuspected cases of intestinal giardiasis and may explain persistence of vague upper gastrointestinal tract (UGIT) symptoms despite clearance of H. pylori in patients on anti-ulcer therapy.

Duodenal metastases from squamous cell carcinoma of the lung: endoscopic management of bleeding and biliary and duodenal obstruction.

Intestinal metastases from cancer of the lung are rare. We report a 65-year-old man with duodenal metastases from squamous cell cancer causing GI bleeding and biliary and duodenal obstruction; these were managed endoscopically.

Endoscopic and histological changes in upper gastrointestinal tract of patients with chronic renal failure.

To evaluate the endoscopic and histological changes in upper gastrointestinal tract of patients with chronic renal failure 50 patients and 50 controls were studied. Upper gastrointestinal endoscopy was done and 2 biopsies each were taken from oesophagus, corpus and antrum of the stomach and duodenum. Sections were stained with haematoxylin & eosin, Alcian blue--Periodic acid Schiff's (pH 2.5), and Loeffler's methylene blue stains. Oesophagus was endoscopically normal in most of the patients. Predominant histological finding was chronic oesophagitis which was significantly higher in patients than controls (47.1% Vs 26%; p<0.05). Significantly higher (p<0.001) number of patients had gastritis, oedema and pale mucosa on endoscopic examination of stomach. Predominant histological changes were mucosal oedema (82.35%), gastritis (23.5%) and increase in number of bi- and multinucleated parietal cells with vacuolation and fragmentation of the cytoplasm (29%). Prevalence of H. pylori was less in patients as controls (35.2% Vs 54%; p< 0.01). Endoscopic examination of duodenum mainly showed duodenitis, pale mucosa, oedema and nodularity. Brunner's gland hyperplasia (82.4%), duodenitis (70.6%) and gastric metaplasia (29.4%) were the main histological features. H. pylori was seen in 5.9% cases of gastric metaplasia in duodenum. Patients with CRF have significant upper gastrointestinal tract abnormalities which mainly occur due to metabolic changes in response to high urea concentration in gastric juice and are not related to H. pylori infection.

AgNOR counts are not altered in alcoholic cirrhosis.

One hundred and two liver biopsy specimens were stained for Argyrophilic nucleolar organizer regions and associated proteins to assess its utility in differentiating normal, cirrhotic and neoplastic liver tissue. A statistically significant (p < 0.001) difference was observed between mean AgNOR counts of normal (1.53 +/- 0.4), post-hepatitic cirrhosis (3.65 +/- 0.53) and hepatocellular carcinoma (7.94 +/- 1.18). In contrast the mean AgNOR count of biopsies with alcoholic cirrhosis (1.57 +/- 0.06) was significantly less (p < 0.001) than post-hepatitic cirrhosis and was similar to that of normal liver tissue. It is concluded that AgNORs can act as a good adjuvant to histology in diagnosing liver diseases especially in differentiating post-hepatitic and alcoholic cirrhosis.

Percutaneous treatment of hepatic hydatid cysts using hypertonic saline.

BACKGROUND: Due to improvements in imaging techniques and immunodiagnostic methods there has been a spurt of cases of hepatic hydatidosis. Till now surgical management in the form of marsupialization and tube drainage, omentoplasty or hepatectomy was the mainstay of treatment. Recently treatment options have improved considerably after introduction of the PAIR (precutaneous aspiration, injection of scolicidal agent and reaspiration) procedure. In this study we report the results of ultrasound guided PAIR procedure in 39 hepatic hydatid cysts. METHOD: All patients with hepatic hydatid cysts underwent the PAIR procedure under ultrasound guidance. The scolicidal agent used was 20% hypertonic saline. Type I and II (n=24) cysts were managed by precutaneous aspiration while type III and IV showing a multiloculated or pseudotumour appearance (n=15) cysts were managed by the percutaneous placement of a Malecot's catheter which was removed after 3-7 days. RESULTS: All patients responded to the PAIR procedure. The commonest ultrasonographic appearance in hepatic hydatid cyst patients was a solitary uniloculated cyst with prominent back wall echoes in the right lobe of the liver. The complications encountered were in the form of mild hypotension (two cases), urticaria in one patient and severe hypotension leading to shock in one case. CONCLUSIONS: The PAIR procedure was found to be effective, cheap and safe in the non-surgical management of hepatic hydatid cysts.

Complications of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy: diagnosis, management and prevention.

Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy are carried out for a variety of billo-pancreatic diseases. These procedures were earlier performed at only a handful of tertiary centres in India. However, of late, they are being performed at several centres and even smaller clinics. Although, endoscopic sphincterotomy is one of the most commonly performed endoscopic procedure, there are no data on the number of procedures performed each year in India. It is estimated that in the USA alone more than 200,000 procedures are performed each year. The procedure has the dubious distinction of being considered as one of the most hazardous of all endoscopic procedures and is associated with a small but significant morbidity and mortality. The immediate complications of endoscopic sphincterotomy include pancreatitis, haemorrhage, perforation and cholangitis in addition to those associated with the use of sedation and anaesthesia. There are also reports of the long term adverse effects of the destruction of the sphincter of Oddi. There is also controversy as to what should be the minimum requirements for training and who should be allowed to perform these procedures.

Helicobacter pylori and associated histopathological changes in gastric biopsies of patients with leprosy.

Two antral biopsies each from 104 patients of leprosy and 100 controls were studied to find out the prevalence of H. pylori and associated histopathological changes. Sections were stained with hematoxylene and eosin, AB/PAS (Ph 2.5) and Loeffler's methylene blue stains. Infection by H. pylori, inflammation and atrophy were found to be significantly more in leprosy patients as compared to controls (p < 0.01, < 0.005 and < 0.02 respectively). On comparing the histopathological changes in various subgroups of leprosy, H. pylori, inflammation and activity showed a statistically decreasing trend from tuberculoid to lepromatous subgroups (p < 0.05, < 0.001, < 0.01 respectively). Atrophy showed a significant increasing trend from tuberculoid to lepromatous group (< 0.001), it is concluded that despite a low prevalence of H. pylori and associated gastritis in patients with lepromatous leprosy, gastric epithelial damage is more marked due to altered immune response.

Japanese Encephalitis epidemic in Anantapur district, Andhra Pradesh (October-November, 1999).

Epidemic of Japanese Encephalitis has occurred in Andhra Pradesh during October-November, 1999 affecting 15 out of 23 districts. In total, 873 cases with 178 deaths have been recorded up to the day 29.11.99. The epidemiological investigation has been done in Anantapur district in western Andhra Pradesh, where the outbreak has started in the third week of October. In the district 47 PHC have been affected. On an average 4.5 per cent of 3175 villages have been affected. Average number of cases per affected village have been 1.5. Rural population has been primarily affected. Age groups 1-14 years including infants have been affected but nearly 86.8% of cases have been among 1-9 year age group. The overall case fatality rate has been 18.4 per cent. Clinical features have been high fever, headache, altered sensorium, convulsions and coma. A marked seasonal onset of a few cases per village and 93.75 per cent of human serum samples collected from hospitalised cases showed the evidence of J.E. virus infection indicating that the present outbreak was due to JE virus. High density of Culex vishnui complex mosquitoes has been observed in the area. All the environmental and ecological conditions, temperature, rainfall and relative humidity have been in favour of JE transmission. Analysis of the data for the last 10 years showed that the human JE cases occurred in Anantapur in September-October months, which shifted to October-November, 99. Prolonged draught conditions were observed till October. Possibly the delayed monsoon and congenial atmospheric conditions after monsoon were favourable to the vector species for extra-human cycle of transmission in 1999. Low level transmission leading to small number of cases continued during the succeeding years every September-October till the present epidemic. In all 24 PHCs and urban towns were identified with 212 cases and 39 deaths till 29.11.99.

Gall stones and carcinoma gall bladder.

One hundred and fifty surgically resected gall bladder specimens were included in the study to evaluate the relationship between the prevalence of gall stones and histochemical alteration in sequential changes of metaplasia, dysplasia and neoplasia in gall bladder epithelium. Multiple sections were processed and stained with haematoxylin and eosin, Periodic acid Schiff's stain, Alcian blue (pH 2.5)/Periodic acid, Orcein/Alcian blue (pH 2.5) and Alcian Blue/Periodic acid/Potassium borohydride saponifications stains. Details of gall stones present were also noted. Prevalence of gall stones in gall bladders with metaplastic, dysplastic and neoplastic mucosal changes was significantly higher (P < 0.001) than those gall bladders which had no epithelial changes. Increase in sialomucin with a corresponding decrease in sulphomucin was observed from metaplasia to malignancy. Neutral mucin increased in metaplastic cells but was significantly reduced in neoplastic cells. Loss of O-acylation in sialmucin was also present in neoplastic cells. The histochemical changes suggest that chronic injury due to cholelithiasis induces appearance of neutral mucin positive metaplastic cells, which may further dedifferentiate to sialomucin containing dysplastic or neoplastic cells if the stimulation persists.

Clinical and ultrasonographic findings of carcinoma of gallbladder in Indian patients.

OBJECTIVE: To determine the clinical and ultrasound appearances of carcinoma gallbladder in Indian patients. METHODS: The study included all patients suspected to have gallbladder malignancy, attending the gastroenterology department from January 1989 to February 1997. These patients underwent ultrasonographic examination with a grey scale sector scanner (Aloka SSD-630) with a 3.5 MHz transducer after an overnight fast. Histological confirmation was done at surgery, by US guided fine needle aspiration cytology or by direct biopsy/aspiration of the palpable mass. RESULTS: There were a total of 92 cases of cytologically and histologically proven carcinoma of gallbladder. A distinct female preponderance was seen with a male:female ratio of 1:3.6. The mean +/- SD age was 47.9 +/- 19.6 years (range 25-75 years). The histological confirmation was done at surgery in 10% of patients, by US guided fine needle aspiration cytology in 50 cases (54%) or by direct biopsy/aspiration of the palpable mass in 33 (36%) of cases. Pain in the right hypochondrium was the commonest presenting symptom (91%) followed by anorexia (88%) and weight loss (67%). Surgical obstructive jaundice was observed in 54% cases while 10.9% presented with biliary sepsis. A mass of mixed echogenicity protruding in the lumen of the gallbladder was seen in the majority of cases (52.8%). Less commonly infiltration of the gallbladder wall (33.7%) or a mass replacing the gallbladder (14.1%) was encountered. Gallstones were associated in 57% of patients with gallbladder malignancy. The elevated stone sign and peripancreatic nodal spread were important clues for gallbladder malignancy. CONCLUSION: A high index of suspicion of gallbladder malignancy in elderly Indian female patients presenting with features of choletithiasis, and awareness of the ultrasound findings may lead to early diagnosis and radical resection of this highly lethal malignancy.

Mallory-Weiss syndrome: clinical features and management.

OBJECTIVE: To report the clinical features, endoscopic appearance, management and outcome of patients with upper gastrointestinal bleeding due to Mallory-Weiss tear seen at our institution during the last seven years. METHODS: A retrospective study of all patients with upper gastrointestinal bleeding seen during the last seven years was performed. Patients who were bleeding from longitudinal non-perforating tear(s) of the gastro-oesophageal mucosa were included in the study and their clinical features, endoscopic appearance management and outcome were recorded. RESULTS: During the study period 426 patients with upper gastrointestinal bleeding were seen. Sixty-six (15.5%) of these were found to have bled or were bleeding from Mallory-Weiss tear(s). Twenty-seven (41%) patients with Mallory-Weiss tear had no antecedent nausea, retching, abdominal pain or vomiting. Two patients had portal hypertension and a solitary case bled from an iatrogenic tear induced during routine upper gastrointestinal endoscopy. Multiple bleeding episodes were seen in 12% of cases. Twenty (30%) patients needed endoscopic sclerotherapy. Haemostasis was achieved in all. Except retrosternal pain, no procedure related complications were seen. CONCLUSIONS: Mallory-Weiss tear is a common cause of upper gastrointestinal bleeding. Nearly half of the patients have no antecedent symptoms and presented for the first time with upper gastrointestinal bleeding. Endoscopic therapy is very effective and safe in producing haemostasis in these patients.

Spider angiomas are not found in the retina of patients with cirrhosis.

To determine the prevalence of spider angiomata in patients with cirrhosis, the factors influencing them and whether or not they are present in the retina of patients with cirrhosis, 93 cirrhotics were studied. Cutaneous spider angioma were seen in 19 (20%) patients. All patients with spiders had at least one episode of variceal bleeding and had grade III or IV oesophageal varices. Spiders were seen more commonly in patients with alcoholic cirrhosis than in those with non-alcoholic cirrhosis (53.5% vs 6%, p < 0.001), in patients with Child's C cirrhosis than those with Child's A and B cirrhosis (67% vs 4%, p < 0.001). However, although spiders were seen more often in patients undergoing sclerotherapy than those not, the difference was statistically not significant (23% vs 19%, p = NS). Spiders had no association with presence or absence of portal hypertensive gastropathy or gastric varices. None of the patients showed any abnormality or presence of spiders in the retina. It is concluded that spider angiomas are seen more commonly in patients with alcoholic cirrhosis, those with more severe liver disease and patients having large oesophageal varices and they are not seen in the retina of patients with cirrhosis.