Capsule endoscopy for obscure gastrointestinal bleed in the tropics: A single-center experience on 350 patients.

BACKGROUND: Obscure gastrointestinal bleed (OGIB), now called small bowel bleed (SBB), comprises 5% to 10% of all gastrointestinal (GI) bleed episodes and capsule endoscopy (CE) is a tool for its evaluation. Studies on CE in a large sample of SBB patients from the tropics are limited. METHODS: We did a retrospective analysis of a prospectively maintained database of patients with SBB undergoing CE using PillCam or MiroCam CE. RESULTS: Of 350 patients (age 52.4 ± 17.4 years; 248 [70.9%] male) undergoing CE, 243 (69.4%) and 107 (30.6%) had overt and occult SBB, respectively. CE detected lesions in 244 (69.7%) patients (single lesion in 172 [49.1%]; multiple in 72 [20.6%]). The single lesions included vascular malformations (52, 14.9%), ulcer/erosion (47, 13.4%), tumor (24, 6.9%), hookworm (19, 5.4%), stricture (15, 4.3%), hemobilia (1, 0.3%) and blood without identifiable lesion (9, 2.6%). Of 72 with multiple lesions, ulcer with stricture was the commonest finding (n = 43, 12.3%). No abnormality was detected in 106 (30.3%) patients. The frequency of lesion detection was comparable among patients with overt and occult SBB (173/243, 71.2% vs. 71/107, 66.3%, respectively; p = 0.4). Younger patients (0 to 39 years) more often had multiple lesions on CE than the older (≥ 40 years) ones (26/76, 34.2% vs. 46/228, 20.2%, respectively; p = 0.001). CONCLUSION: CE has a high diagnostic yield in SBB in the tropics, regardless of the type of bleed or of CE brand and the duration of recording. Multiple lesions associated with SBB are commoner among younger (< 40 years) patients.

Post-infection irritable bowel syndrome following Coronavirus disease-19: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Persistent gastrointestinal (GI) symptoms and functional gastrointestinal disorders (FGIDs) are increasingly being recognized after Coronavirus disease-19 (COVID-19). Though quite a few studies addressed irritable bowel syndrome (IBS) following COVID-19, the disorders' prevalence varies greatly. We evaluated, (i) overall frequency of post-COVID-19 IBS, (ii) relative risk of development of IBS among COVID-19 patients compared to healthy controls using systematic review and meta-analysis techniques. METHODS: Literature search was performed for studies on GI symptoms and FGIDs after COVID-19 using electronic databases (Medline, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar and Web of Science) till April 28, 2023. We included studies reporting IBS after COVID-19 with any duration of follow-up and any number of subjects. Studies on pediatric population and those not providing relevant information were excluded. Relative risk of development of IBS using Rome criteria among COVID-19 patients compared to healthy controls was calculated. Analysis was done using MedCalc (Applied Math, Mariakerke, Belgium, version 7.2) and Comprehensive Meta-Analysis version 3.3.070 (Biostat Inc. Englewood, NJ 07631, USA). RESULTS: Of the available studies, 13 (four case-control) reporting on IBS after COVID-19 met inclusion criteria. Among 3950 COVID-19 patients and 991 controls, 7.2% of COVID-19 patients and 4.9% of healthy controls developed IBS. Of the four case-control studies reporting post-COVID-19 IBS, patients with COVID-19 were 2.65 (95% confidence interval [CI] 0.538 to 13.039) times more likely to have post-COVID-19 IBS as compared to healthy controls. CONCLUSIONS: Patients with COVID-19 are more likely to develop post-COVID-19 IBS than healthy controls. The heterogeneity of studies, different criteria used by various studies to diagnose post-COVID-19 IBS and some studies not meeting the six-month follow-up duration of the Rome criteria for diagnosing IBS are limitations of this systematic review.

Budd Chiari Syndrome with Portal Vein Thrombosis Managed Successfully with Direct Intrahepatic Portosystemic Shunt: A Case Report and Review of the Literature.

Budd -Chiari syndrome (BCS) is a hepatic vascular disorder which affects hepatic veins or inferior vena cava. Portal vein thrombosis (PVT) occurs in around 15%-25% of patients with BCS. The presence of PVT in patients with BCS makes it more difficult to intervene radiologically. We present a case of a BCS-related chronic liver disease that presented with a history of variceal upper gastrointestinal bleeding and worsening ascites. The patient had thrombosed hepatic veins (HV) and partial right portal vein thrombosis. He was started on anticoagulation, and treatment for portal hypertension was initiated. Given the inaccessibility of all the HVs for trans-jugular intrahepatic portosystemic shunts (TIPS), the patient underwent direct intrahepatic portosystemic shunts (DIPS). Next-generation sequencing identified the factor V Leiden mutation. Following DIPS, the patient's ascites disappeared, and liver function tests improved. On a nine-month follow-up, the patient was symptom-free with a patent DIPS. DIPS has been widely used in patients with BCS with thrombosed hepatic veins, but there are only a few case reports on the feasibility of DIPS in BCS patients with PVT. This is one of the very few case reports where a patient with BCS-PVT was successfully managed with DIPS.

Serological response to vaccination against coronavirus disease-19 in patients with inflammatory bowel disease.

Vaccination against coronavirus disease-19 (COVID-19) is effective in preventing the occurrence or reduction in the severity of the infection. Patients with inflammatory bowel disease (IBD) are on immunomodulators, which may alter serological response to vaccination against COVID-19. Accordingly, we studied (i) the serological response to vaccination against COVID-19 in IBD patients and (ii) a comparison of serological response in IBD patients with that in healthy controls. A prospective study was undertaken during a 6-month period (July 2021 to January 2022). Seroconversion was assessed among vaccinated, unvaccinated IBD patients and vaccinated healthy controls using anti-severe acute respiratory syndrome coronavirus 2 immunoglobulin G (anti-SARS-CoV-2 IgG) antibody detection enzyme-linked immunosorbent assay (ELISA) kit, and optical density (OD) was measured at 450 nm. OD is directly proportional to the antibody concentration. One hundred and thirty-two blood samples were collected from 97 IBD patients (85 [87.6%] ulcerative colitis and 12 [12.4%] Crohn's disease). Forty-one of the seventy-one (57.7%) unvaccinated and 60/61 (98.4%) vaccinated IBD patients tested positive (OD > 0.3) for SARS-CoV-2 IgG antibodies. Fourteen of the sixteen (87.5%) healthy controls tested positive for SARS-CoV-2 IgG antibodies. Vaccinated IBD patients had higher ODs than unvaccinated IBD patients (1.31 [1.09-1.70] vs. 0.53 [0.19-1.32], p < 0.001) and 16 vaccinated healthy controls (1.31 [1.09-1.70] vs. 0.64 [0.43-0.78], p < 0.001). Three of the seventy-one (4.2%) unvaccinated IBD patients reported having recovered from COVID-19. Most IBD patients seroconvert after vaccination against SARS-CoV-2, similar to a healthy population. A large proportion of IBD patients had anti-SARS-CoV-2 antibodies even before vaccination, suggesting the occurrence of herd immunity.

Spectrum of Primary Gastric Lymphoma in India: A Series of 30 Patients.

BACKGROUND: Primary gastric lymphoma is uncommonly reported in India. We retrospectively analyzed their data in a northern Indian teaching hospital. METHODS: During a 12-year period (2000-2012), endoscopic and surgical biopsies were assessed for gastric neoplasm. Gastric biopsies from normal-looking areas, rapid urease test, and Helicobacter pylori serology were done, with 2 of 3 tests positive being considered diagnostic. We aimed to study (i) the frequency of primary gastric lymphoma among gastric neoplasm patients, (ii) its clinical profile, (iii) the diagnostic procedures needed, and (iv) the frequency of H. pylori infection among them. RESULTS: Thirty out of 324 (9.2%) patients (age 56 years, range 25-72, 73.3% male) with gastric neoplasm had primary gastric lymphoma. Presentations included dyspepsia (n = 9, 30%), gastric outlet obstruction (n = 7, 23.3%), upper gastrointestinal bleeding (n = 5, 16.7%), dysphagia (n = 4, 13.3%), malignant ascites (n = 3, 10%), and others (n = 2, 6.7%). H. pylori infection was confirmed in 7 (23.3%), 12 (40%), and 21/29 (72.4%) patients by rapid urease test and histopathology and positive anti-H. pylori IgG serology, respectively. By 2 tests, H. pylori was detected in 12 (40%) patients. Though in 60% primary gastric lymphoma was diagnosed on endoscopic biopsy, in 40%, surgical resection was required. The endoscopic and surgical diagnosis groups were comparable in age (53.4 years vs. 52.7 years), sex (male 77.8% vs. 66.7%), H. pylori infection (38.9% vs. 16.7%), presentation with dyspepsia (38.9% vs. 16.7%), organic symptoms (61.1% vs. 83.3%), and the need for repeated endoscopic biopsies before diagnosis (12.% vs. 33.3%). CONCLUSION: Primary gastric lymphoma is not uncommon (9.2%) in India, often missed on endoscopic biopsy and is associated with H. pylori infection (40%).

Post-infection functional gastrointestinal disorders following coronavirus disease-19: A case-control study.

BACKGROUND AND AIM: Because acute infectious gastroenteritis may cause post-infection irritable bowel syndrome and functional dyspepsia and the severe acute respiratory syndrome coronavirus-2 affects gastrointestinal (GI) tract, coronavirus disease-19 (COVID-19) may cause post-infection-functional GI disorders (FGIDs). We prospectively studied the frequency and spectrum of post-infection-FGIDs among COVID-19 and historical healthy controls and the risk factors for its development. METHODS: Two hundred eighty patients with COVID-19 and 264 historical healthy controls were followed up at 1 and 3 months using translated validated Rome Questionnaires for the development of chronic bowel dysfunction (CBD), dyspeptic symptoms, and their overlap and at 6-month for IBS, uninvestigated dyspepsia (UD) and their overlap. Psychological comorbidity was studied using Rome III Psychosocial Alarm Questionnaire. RESULTS: At 1 and 3 months, 16 (5.7%), 16 (5.7%), 11 (3.9%), and 24 (8.6%), 6 (2.1%), 9 (3.2%) of COVID-19 patients developed CBD, dyspeptic symptoms, and their overlap, respectively; among healthy controls, none developed dyspeptic symptoms and one developed CBD at 3 months (P < 0.05). At 6 months, 15 (5.3%), 6 (2.1%), and 5 (1.8%) of the 280 COVID-19 patients developed IBS, UD, and IBS-UD overlap, respectively, and one healthy control developed IBS at 6 months (P < 0.05 for all except IBS-UD overlap). The risk factors for post-COVID-19 FGIDs at 6 months included symptoms (particularly GI), anosmia, ageusia, and presence of CBD, dyspeptic symptoms, or their overlap at 1 and 3 months and the psychological comorbidity. CONCLUSIONS: This is the first study showing COVID-19 led to post-COVID-19 FGIDs. Post-COVID-19 FGIDs may pose a significant economic, social, and healthcare burden to the world.

The Spectrum of Gastrointestinal Symptoms in Patients With Coronavirus Disease-19: Predictors, Relationship With Disease Severity, and Outcome.

INTRODUCTION: We prospectively studied the frequency, spectrum, and predictors of gastrointestinal (GI) symptoms among patients with coronavirus disease-19 (COVID-19) and the relationship between GI symptoms and the severity and outcome. METHODS: Consecutive patients with COVID-19, diagnosed in a university hospital referral laboratory in northern India, were evaluated for clinical manifestations including GI symptoms, their predictors, and the relationship between the presence of these symptoms, disease severity, and outcome on univariate and multivariate analyses. RESULTS: Of 16,317 subjects tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in their oropharyngeal and nasopharyngeal swabs during April-May 2020, 252 (1.5%) were positive. Of them, 208 (82.5%) were asymptomatic; of the 44 symptomatic patients, 18 (40.9%) had non-GI symptoms, 15 (34.1%) had a combination of GI and non-GI symptoms, and 11 (25.0%) had GI symptoms only. Thirty-three had mild-to-moderate disease, 8 severe, and 5 critical. Five patients (1.98%) died. On multivariate analysis, the factors associated with the presence of GI symptoms included the absence of contact history and presence of non-GI symptoms and comorbid illnesses. Patients with GI synptoms more often had severe, critical illness and fatal outcome than those without GI symptoms. DISCUSSION: Eighty-two percent of patients with COVID-19 were asymptomatic, and 10.3% had GI symptoms; severe and fatal disease occurred only in 5% and 2%, respectively. The presence of GI symptoms was associated with a severe illness and fatal outcome on multivariate analysis. Independent predictors of GI symptoms included the absence of contact history, presence of non-GI symptoms, and comorbid illnesses.(Equation is included in full-text article.).

A meta-analysis on small intestinal bacterial overgrowth in patients with different subtypes of irritable bowel syndrome.

BACKGROUND: Enteric microbiota is increasingly being recognized as an important factor in the pathogenesis of irritable bowel syndrome (IBS). The reported prevalence of small intestinal bacterial overgrowth (SIBO) in subjects with IBS is highly variable, and there is no consensus on the role of SIBO in different subtypes of IBS, and indications and methods of testing. METHODS: A comprehensive literature search was performed for studies applying tests for SIBO in subjects with IBS. After applying prospectively decided exclusion criteria, the eligible papers were examined using a meta-analysis approach for the prevalence of SIBO in subjects with IBS using different tests. The odds ratios of SIBO among subjects with IBS as compared with healthy controls using different tests were calculated. RESULTS: Of the available studies (22, 17, 5, and 3 using lactulose and glucose hydrogen breath tests [LHBT and GHBT], jejunal aspirate culture, and more than one tests, respectively) meeting the inclusion criteria, 36.7% (95% confidence interval [CI] 24.2-44.6) had a positive test for SIBO. Patients with IBS were 2.6 (95% CI 1.3-6.9) and 8.3 (95% CI 3.0-5.9) times more likely to have a positive test for SIBO as compared with healthy controls using GHBT and jejunal aspirate culture, respectively. Patients with diarrhea-predominant IBS were more likely to have positive GHBT as compared with the other subtypes. CONCLUSIONS: Patients with IBS were more likely to have SIBO as compared with healthy subjects using GHBT and jejunal aspirate culture but not using LHBT. Patients with diarrhea-predominant IBS more often have SIBO.

Safety and efficacy of weekly versus three-weekly paclitaxel plus platinum neoadjuvant chemotherapy in patients with locally advanced squamous cell head and neck carcinoma: A pilot study.

BACKGROUND: Squamous cell carcinoma of head and neck (SCCHN) is one of the most common cancers seen in India and also the world. Majority of patients present in locally advanced (LA) disease where neoadjuvant combination chemotherapy with a taxane plus platinum with/without 5-Fluorouracil is the standard of care treatment. There are no/few prospective trials of weekly paclitaxel in SCCHN in spite of convincing evidence regarding safety and tolerability in other solid tumors such as breast, ovary, and lung carcinoma. In the present study, we prospectively assessed the safety and efficacy of weekly versus three-weekly paclitaxel plus platinum neoadjuvant chemotherapy in patients with LA-SCCHN. MATERIALS AND METHODS: We included 50 newly diagnosed patients of LA-SCCHN in the study and randomized them into two groups to receive either low-dose weekly (80 mg/sq. m) or standard three-weekly (175 mg/sq. m) paclitaxel along with standard dose carboplatin (AUC 5) and assessed response rates and toxicities. RESULTS: Age and sex were evenly matched in both groups. Oral and oropharyngeal cancers were the most common sites. Hematological toxicities were significantly more in the three-weekly group. Nonhematological toxicities, especially neuropathy, were also more in this group. The overall response rate (complete response + partial response) in the three-weekly arm was 36% versus 52% in the weekly arm. CONCLUSION: Data from our small study suggest that weekly paclitaxel plus platinum neoadjuvant chemotherapy may be superior to the standard every 3 weeks' administration in terms of safety as well as efficacy in patients with LA-SCCHN.

Na+ site in blood coagulation factor IXa: effect on catalysis and factor VIIIa binding.

During blood coagulation, factor IXa (FIXa) activates factor X (FX) requiring Ca2+, phospholipid, and factor VIIIa (FVIIIa). The serine protease domain of FIXa contains a Ca2+ site and is predicted to contain a Na+ site. Comparative homology analysis revealed that Na+ in FIXa coordinates to the carbonyl groups of residues 184A, 185, 221A, and 224 (chymotrypsin numbering). Kinetic data obtained at several concentrations of Na+ and Ca2+ with increasing concentrations of a synthetic substrate (CH3-SO2-d-Leu-Gly-Arg-p-nitroanilide) were fit globally, assuming rapid equilibrium conditions. Occupancy by Na+ increased the affinity of FIXa for the synthetic substrate, whereas occupancy by Ca2+ decreased this affinity but increased k(cat) dramatically. Thus, Na+-FIXa-Ca2+ is catalytically more active than free FIXa. FIXa(Y225P), a Na+ site mutant, was severely impaired in Na+ potentiation of its catalytic activity and in binding to p-aminobenzamidine (S1 site probe) validating that substrate binding in FIXa is linked positively to Na+ binding. Moreover, the rate of carbamylation of NH2 of Val16, which forms a salt-bridge with Asp194 in serine proteases, was faster for FIXa(Y225P) and addition of Ca2+ overcame this impairment only partially. Further studies were aimed at delineating the role of the FIXa Na+ site in macromolecular catalysis. In the presence of Ca2+ and phospholipid, with or without saturating FVIIIa, FIXa(Y225P) activated FX with similar K(m) but threefold reduced k(cat). Further, interaction of FVIIIa:FIXa(Y225P) was impaired fourfold. Our previous data revealed that Ca2+ binding to the protease domain increases the affinity of FIXa for FVIIIa approximately 15-fold. The present data indicate that occupancy of the Na+ site further increases the affinity of FIXa for FVIIIa fourfold and k(cat) threefold. Thus, in the presence of Ca2+, phospholipid, and FVIIIa, binding of Na+ to FIXa increases its biologic activity by approximately 12-fold, implicating its role in physiologic coagulation.