Celiac disease in osteoporotic Indians.

OBJECTIVE: 1) The aim of the study was to identify the atypical celiac disease (CD) in a cohort of symptomatic osteoporotic patients, younger than 55 years of age and 2) To study associated clinical and laboratory features and outcome with gluten-free diet. MATERIAL AND METHODS: We studied 33 patients (F:M = 28:5), mean age 29 years (range 15-52 years) with osteoporosis (WHO diagnostic criteria, T-score less than -2.5 on DEXA scan) from January 2000 - June 2002. Serological screening for CD was done by detecting circulating IgA antibodies to tissue transglutaminase by ELISA. Patients with presence of antibodies to transglutaminase were subjected to biopsy from the 2nd part of the duodenum by upper GI endoscopy. The biopsies were reported independently by two pathologists who were blinded for the serology report. Measurement of mucosal thickness, crypts and villi were done with an ocular micrometer. Other parameters like complete hemogram, serum iron, total iron binding capacity (TIBC), calcium profile, 25-OH-D, parathyroid hormone (PTH) were evaluated. Assessment of clinical and laboratory parameters was performed within 4-12 weeks of starting gluten-free diet (GFD). RESULTS: Thirteen patients had circulating IgA antibodies to transglutaminase. Intestinal biopsies were performed on 11 patients and were consistent with the diagnosis of CD (total villous atrophy--two, subtotal villous atrophy with crypt hyperplasia--nine). Patients with CD had significant anaemia when compared with non-CD osteoporotic patients. Other important observations in these 11 patients were low serum calcium and phosphorus, low 25-OH-D, high PTH. Significant improvement in clinical and laboratory parameters was noted in all patients within 6-12 weeks of starting GFD. CONCLUSION: Symptomatic osteoporotic patients (younger than 55 years of age) especially with associated anaemia should be investigated for CD. Simple measures like omission of wheat from diet (GFD) lead to significant improvement in symptoms within weeks.

Rectal lymphogranuloma venereum in association with rectal adenocarcinoma.

Rectal involvement in lymphogranuloma venereum (LGV) is more common in women. Inguinal bubo is often absent and the patient seeks medical attention only at a late stage when rectal stricture has developed. LGV rectal stricture resembles and is known to predispose to rectal cancer. Hence it is necessary to rule out rectal malignancy in patients with LGV stricture. We report a case of rectal LGV associated with rectal adenocarcinoma.

Multiple esophageal webs.

Multiple esophageal webs are rare and are described in association with gastroesophageal reflux disease (GERD). We describe a case of multiple esophageal webs secondary to GERD.

Unusual features of Helicobacter (Campylobacter) pylori--associated gastritis in India. A study of 200 cases.

Helicobacter (Campylobacter) pylori has been cultured from the antral biopsies of 85-90% of patients of gastritis, gastric ulcer and duodenal ulcer at different centres. Studies conducted all over the world have firmly implicated this organism in the aetiology of active superficial gastritis and recurrences of duodenal ulcer. Two hundred patients with upper abdominal pain, distension, vomiting and/or haemetemesis were subjected to OGD scopy. In 163 of these patients there was endoscopic evidence of gastritis; in 24 there was DU; in 3, GU and in 10 it was normal. Diagnosis of H pylori infection was made by the rapid biopsy urease test which is nearly 100% specific and 98% sensitive. 170 out of 200 patients were positive for H pylori. Among these were 138 patients of gastritis (84.6%); 22 cases of DU (91.6%); 2 cases of GU (66.6%) and 8 in whom endoscopy was normal. Histological examination of the antral biopsy specimens showed mild to severe infiltration of mucosa with lymphocytes and plasma cells. None of the 170 H pylori positive cases showed polymorphonuclear infiltration which has been stressed repeatedly by most Western authors to be characteristic of "active" superficial gastritis associated with H pylori infection. Even in those with a history of dyspepsia of barely 4 weeks duration or less there was no PMN infiltration in the mucosa. Thus the local response to infection by H pylori of the gastric mucosa is different in Indian patients.

Relapse of Helicobacter pylori infection after different treatment regimens. A 3-month follow-up study.

Helicobacter pylori infection of gastric antrum is associated with a majority of cases of peptic ulcer (70-100%). Studies have shown that when this organism is eradicated, the recurrence of ulcer falls to less than one-third of those in whom the infection persists or relapses. Monotherapy with bismuth salts, tinidazone or amoxycillin has been shown to result in early relapse and recurrence of ulcers. However, dual or triple therapy regimens are more effective. We conducted a randomised controlled study using tripotassium dicitrato bismuthate (TDB) (10 patients); amoxycillin (combined with ranitidine for ulcer healing) (9 patients) and dual therapy with both amoxycillin and TDB (10 patients). Our study showed that relapse rates at the end of 3 months was significantly less if dual therapy with TDB and amoxycillin is used as compared to TDB alone (p less than 0.05).

Association of peptic ulcer with Helicobacter pylori and the recurrence rate. A three year follow-up study.

Helicobacter pylori is associated with 70-100% of peptic ulcers. Relapse of infection has been shown to cause recurrences of ulcers in a large number of studies. We diagnosed 137 cases of peptic ulcer (121 DU; 16 GU) during a 3 year period. Of these, 117 were positive for H pylori. Sixty six of the 117 cases staying in the vicinity of the Hospital were followed up for a minimum period of 3 months upto a maximum period of 3 years. In 91 examinations there was relapse of H pylori infection and ulcer recurrence was seen in 58 (63%), whereas ulcer recurred only in 6 out of 61 examinations where H pylori had not relapsed (10%). The difference was highly significant by Chi square test. (P less than 0.001).

Double-blind comparison of the safety and efficacy of famotidine with ranitidine in patients with endoscopically diagnosed peptic ulcer.

In a double-blind randomised trial, 40 patients with active gastric or duodenal ulcer were treated with a single nocturnal dose of famotidine 40 mg or ranitidine 300 mg for 4 to 8 weeks. Antacid tablets were allowed as additional treatment, only if needed, for pain relief. Endoscopy was repeated after 4 weeks, and if the ulcer had not healed at 6 and/or 8 weeks. Relief of upper gastro intestinal symptoms with which the patient presented and the number of antacid tablets consumed, if any, were recorded on weekly basis. Two patients in famotidine group and 5 patients in ranitidine group did not complete the therapy and were considered dropouts. At the end of therapy, ulcers in 100% of the patients receiving famotidine & 93% of patients receiving ranitidine were healed. This difference was not statistically significant. Relief from ulcer related symptoms was rapid in both the groups. None of the patients in either group reported side effects. Overall opinion of investigator was comparable for both the treatments; however, significantly (P = 0.0334) larger proportion (100%) of patients from famotidine group rated it as an excellent therapy compared to only 73% from ranitidine group. Famotidine provides excellent healing of ulcers and early relief of upper gastrointestinal symptoms in Indian patients with peptic ulcer.

Spontaneous regression of large gastric carcinoid.

We report a female patient who presented with an epigastric lump proved on open biopsy to be a carcinoid tumor. She had raised serum glucagon level and increased excretion of 5-hydroxy indolacetic acid in the urine. She refused surgery and was followed up at 3 monthly intervals. At 6 months the tumor had decreased considerably in size. At one year it was no longer palpable and ultrasound examination clarified that there was no tumor. This was confirmed by the finding of normal levels of 5-HIAA in the urine.

Rapid diagnostic test of Campylobacter pylori infection in patients of gastritis, duodenal ulcer and gastric ulcer. A study of 100 cases.

Campylobacter pylori has been cultured from 85-90% of antral biopsies of patients of gastritis, duodenal ulcer and gastric ulcer at different centres in the world. It has been now firmly implicated in the aetiology of active gastritis as well as suspected to cause repeated recurrences of peptic ulcers. However, the organism is very fastidious and is difficult to grow by standard culture methods as a result of which low positivity is often obtained even in well equipped centres. The rapid biopsy urease test for the diagnosis of C pylori infection, in which the biopsy is directly cultured in a solid medium containing urea, is a very simple test. A change in colour indicates the growth of the organism. This test is 100% specific and 98% sensitive. We performed this test in 100 patients; 93 of gastritis, 6 of DU and 1 of GU during a three month period. 87 of 93 cases of gastritis (90%) and all 6 cases of DU (100%) were positive. The single case of gastric ulcer was negative. Treatment of C pylori positive cases showed that they responded poorly to 4 weeks therapy with tinidazole; 33% were cured after 2 weeks of 1.5 g amoxycillin daily, but all responded when the therapy was continued for 4 weeks.