Epidemiology of dyspepsia in the general population in Mumbai.

BACKGROUND AND AIMS: Dyspepsia is a common complaint in the general population. The prevalence, demography and economic implications of dyspepsia in India are not known; we studied these using a detailed symptom questionnaire. METHODS: 2549 presumably healthy adults (mean age 37.2 [14.1] years; 1441 men) were interviewed. Gastrointestinal symptoms, their investigation and treatment, dietary history and history of addictions were noted. Dyspepsia was defined as abdominal fullness or upper abdominal pain present for at least one month; irritable bowel syndrome (IBS) was defined by Manning's criteria. Based on the symptom profile, subjects were divided into three broad groups: no dyspepsia (n=1695; 945 men), dyspepsia with (110; 63 men) or without (664; 382 men) IBS, and IBS alone (80; 51 men). RESULTS: 774 subjects (30.4%) had dyspepsia; the median (range) duration of symptoms was 24 (1-360) months. Abdominal fullness (n=614), abdominal pain (374), heartburn (272) and belching (271) were the most common symptoms; significant symptoms (present at least once a week) occurred in 306 subjects (12.0% of the population). More than half the subjects had symptoms suggestive of mixed type of dyspepsia; dysmotility-like dyspepsia was the next most common (n=257; 33.2%). The frequency of dyspepsia was not related to type of diet or consumption of spices. Dyspepsia was more prevalent in subjects who abused tobacco or alcohol. Three hundred and twenty-one subjects with dyspepsia (41.4%) had visited a physician for their complaints and had received treatment with antacids, acid suppressors or prokinetic drugs; 4.5% and 7.2% had undergone previous endoscopy and ultrasonography, respectively; dyspeptic subjects underwent more investigations (p<0.001) than those with IBS. CONCLUSIONS: Dyspepsia is reported by almost one-third of the population in Mumbai; significant symptoms occur in 12%. Forty percent of these subjects receive treatment and only a small number undergo endoscopy or ultrasonography.

Effect of cold pressor test and a high-chilli diet on rectosigmoid motility in irritable bowel syndrome.

AIM: Visceral hypersensitivity characterizes the irritable bowel syndrome (IBS). We evaluated the effect of a cold pressor test (CPT)--hand immersion in ice water for 1 minute, which evokes a sympathetic response--on rectosigmoid motility in patients with IBS and normal volunteers. Since many Indian patients with IBS complain of worsening of symptoms following a spicy meal, we also evaluated whether a high-chilli diet affects symptoms or changes rectosigmoid motility. METHODS: Fifteen men with IBS and 13 normal volunteers (all men) were studied. Baseline rectosigmoid manometry was done for 2 h, i.e., 1 h pre- and 1 h post-CPT. The subjects were then kept in hospital on a regular diet (approximately 5 g chilli daily) for 3 days, following which symptoms were reassessed and manometry repeated for 1 h. This was followed by a high-chilli diet (approximately 15 g/day) for 3 days, after which symptoms were reassessed and manometry repeated for 1 h. RESULTS: There was no difference in the baseline study in the pre-CPT period between patients and control subjects. CPT did not change rectosigmoid motility in either group. IBS patients had varied effect on symptoms but no change in rectosigmoid motility after the high-chilli diet. In the normal volunteers, there was increased activity in the low rectum after the high-chilli diet. CONCLUSIONS: Cold pressor test does not affect rectosigmoid motility in patients with IBS or normal subjects. A high-chilli diet has varied effect on symptoms in patients with IBS and does not affect rectosigmoid motility.

Effect of tense ascites on esophageal body motility and lower esophageal sphincter pressure.

BACKGROUND: Esophageal motility and lower esophageal sphincter (LES) pressure change with rapid changes in intraabdominal pressure (IAP); the response of these to slow change in IAP is not known. AIMS: To study esophageal body motility and LES pressures in patients with cirrhosis with tense ascites in the basal state and after paracentesis. METHODS: Twenty four patients with cirrhosis of liver and tense ascites and 13 with cirrhosis without ascites (controls) were studied. Basal intragastric (IGP) and LES pressures, and esophageal body response to water swallows, were recorded using a water perfusion system; IAP was measured in patients with ascites. In patients with ascites, the study was repeated twice: after paracentesis of two liters of fluid and after adequate control of ascites. RESULTS: Basal IGP (p = 0.002) and duration of esophageal contraction (p = 0.01) were lower in controls, but basal LES pressures were similar in the two groups. After control of ascites, IAP (p = 0.02) and IGP (p = 0.005) decreased; amplitude and duration of distal esophageal contraction decreased (p < 0.05). The frequency of high-amplitude waves also decreased (p = 0.04). LES pressure remained unaltered. CONCLUSIONS: Esophageal contraction duration is increased in the presence of ascites, and decreases after control of ascites; LES pressure is not affected by ascites.

Evaluation of a new recombinant DNA hepatitis B vaccine (Shanvac-B).

We assessed the efficacy and safety of Shanvac-B, a new recombinant hepatitis B vaccine developed in India. Eighty-one healthy volunteers (75 women, 6 men; aged 18-40 yr), negative for markers for hepatitis B and HIV, received 20 microg of the vaccine intramuscularly at 0, 1 and 2 months. Forty-three (53%) seroconverted at one month after dose 1; of these, 26% were seroprotected (anti-HBs> 10 mIU/mL). Seroprotection at one month after doses 2 and 3 was 99% and 100%, respectively. Geometric mean titres of anti-HBs in subjects who seroconverted were 11 (range 2-366), 266 (8-7469) and 2246 (102-23680) mIU/mL, respectively. One subject developed urticarial rash after the second dose; there was no other adverse event. We conclude that this vaccine is safe and efficacious, providing significant protection even after two doses.

Early changes in esophageal motility after endoscopic variceal sclerotherapy or ligation.

INTRODUCTION: Endoscopic variceal sclerotherapy (EVS) and ligation (EVL) are reported to be associated with altered esophageal motility. Most studies have been in patients with alcoholic cirrhosis and ascites. AIMS: To study the early effect of EVS and EVL in patients with portal hypertension without ascites. METHODS: Forty six portal hypertensive patients without ascites underwent esophageal manometry 24 h prior to EVS or EVL and within 24 h of two subsequent sessions. Nineteen such patients but without prior gastrointestinal bleed were studied once as controls. RESULTS: The protocol was completed in 35 patients (cirrhosis--16, noncirrhotic portal hypertension--19; 27 men; mean age 36 years). Basal midexpiratory lower esophageal sphincter pressure was similar in the study group (mean [SD] 20.1 [9.1] mmHg) and controls (17.6 [6.0] mmHg); the pressure did not change following EVS or EVL. Amplitude of contractions in the lower 5 cm of the esophageal body was similar in the two groups (84.8 [43.1] mmHg and 95.9 [59.6] mmHg), and decreased (63.6 [34.0] mmHg; p = 0.03) after two sessions of variceal therapy. The duration of contraction did not change following intervention. Nonperistaltic waves > 2 of 10 swallows were present during the baseline study in 9 patients in each group; 13 and 21 patients (p < 0.02 compared to baseline) developed them after the first and second sessions of therapy, respectively. Percentage of abnormal waves also increased following therapy. Thirteen patients developed esophageal ulcers; there was no correlation between the presence of ulcers and dysmotility. There was no difference in the changes between the EVS and EVL groups, and between patients with cirrhosis and noncirrhotic portal hypertension. CONCLUSION: Both EVS and EVL affect esophageal motility; these changes do not cause significant esophageal symptoms.

Profile of extrahepatic portal venous obstruction in Mumbai.

AIM OF THE STUDY: To study the clinical profile of extrahepatic portal venous obstruction (EHPVO) in a tertiary referral centre in Mumbai. METHODOLOGY: Retrospective analysis of records of 113 patients with EHPVO, treated between January 1984 and May 1996. RESULTS: Thirty eight of 54 (70.4%) patients in whom information was available were delivered at home. Eleven of the 50 (22%) had umbilical sepsis after birth. Median disease duration was 5 years (range 4 months-31 years), with age at initial presentation 13 (range 0.5-45) years; 24 (20%) patients presented after age 20 years. Eleven presenting initially with splenomegaly bled after 3 (1-14) years. Number of bleeding episodes per patient was 2.5 (1-12). 13 of 44 (29.6%) patients bled (first bleed or recurrence) after age 20 years. Twenty five (22.3%) had ascites at some time, 17/102 (16.7%) had hypersplenism, and hypoalbuminaemia was present in 20/103 (19.2%). Endoscopic sclerotherapy obliterated varices in 47/52 (90.4%) in 10.5 (3-40) sessions over 7 (1-100) months. Twenty three patients underwent surgery: devascularisation in 20 (with splenectomy in seven), distal lieno-renal shunt in two, and meso-caval shunt in one patient. Follow-up was available in 68 (60.2%) patients. Rebleeding after sclerotherapy occurred in 27/64 (42.2%), with median one (1-5) per patient; recurrence of varices was noted in 15/35 (42.9%) patients over 12 (3-39) months. Varices were present in 12 patients 163 (33-305) months after surgery. CONCLUSIONS: Home delivery and umbilical sepsis may be risk factors in the development of EHPVO. A significant number of patients present or continue to bleed from varices after age 20. Variceal sclerotherapy is effective for eradication of oesophageal varices.

Ascitic fluid filtration and intravenous infusion versus total-volume paracentesis with infusion of plasma expander in cirrhosis with tense or intractable ascites.

BACKGROUND: Patients with cirrhotic ascites have low serum albumin levels, and paracentesis of ascitic fluid could compromise them further. AIM: We compared the therapeutic efficacy of ascitic fluid filtration and concentrate infusion (AFI) versus total-volume paracentesis (TVP) with colloid infusion in control of tense or intractable cirrhotic ascites. METHODS: Ten patients underwent AFI; their ascitic fluid was filtered repeatedly through hollow-fiber hemodialyzer, and the concentrate reinfused intravenously. In ten patients TVP was done with simultaneous intravenous colloid infusion. Follow-up was done weekly and the study terminated if the patient needed diuretics or developed complications. RESULTS: Pre-study parameters were similar in the two groups. In the AFI and TVP groups, the duration of procedure was median 12 hours and 5.5 hours; fluid removed by paracentesis was 10.2 L and 8.0 L, respectively; and fluid infused intravenously was 0.5 L [with mean (SD) protein content 5.7 (1.3) g/dl] and 1.1 L, respectively. Glomerular filtration rates were lower than normal in the two groups but did not change significantly with the procedure; body weight remained significantly lower up to week 3 and week 2, respectively. The study was terminated at median week 3 (range 1-8) and week 2 (1-4), respectively. Fever was an accompaniment of AFI and one patient developed peritonitis. CONCLUSION: Patients undergoing AFI remained diuretic-free longer; the procedure is cost-effective but needs to be further evaluated to minimize the side-effects.

Manometric mapping of normal esophagus and definition of the transition zone.

BACKGROUND: The normal esophagus has not been manometrically mapped. The transition zone between esophageal smooth and skeletal muscles has also not been defined manometrically. AIMS: To manometrically map the normal esophagus and to define the transition zone. METHODS: Thirty normal adults [23 men; mean age 34.8 (10.4) years] underwent manometry using a water-perfused system. The lower esophageal sphincter (LES) was studied by station pull-through, and esophageal body musculature was evaluated at 1-cm intervals with five wet swallows at each level. The transition zone was identified as an area where the wave-forms did not resemble typical skeletal or smooth muscle wave-forms. RESULTS: The basal mid-expiratory LES pressure was 18.7 (7.2) mmHg, and its length was 3.6 (1.2) cm. Based on our findings, we defined the transition zone as an area where either the amplitude of contraction was < 40 mmHg or, if the amplitude was 40-50 mmHg, the rate of change of pressure from baseline to peak of the wave was < 50 mmHg/s. The lengths of the skeletal, transition and smooth muscle zones were 2.8 (1.2), 4.0 (1.7) and 12.5 (2.7) cm, respectively. The amplitude and dp/dt of contraction and transmission velocity were lowest in the transition zone (p < 0.05). CONCLUSIONS: We have manometrically mapped the normal esophageal muscle zones; the parameters obtained may be used as reference values. The manometric criteria for the transition zone have also been defined.

Vagal dysfunction following endoscopic variceal sclerotherapy.

BACKGROUND: Sclerotherapy is associated with complications which involve adjacent structures like the pleura. The effect of sclerotherapy on function of the vagus nerve, which lies in close proximity to the thoracic esophagus, is not clear. AIM: To study gastric acid secretion as a marker of vagal function in portal hypertensive patients who have undergone sclerotherapy. METHODS: Portal hypertensive patients who had undergone at least three sessions of sclerotherapy were evaluated by mapping gastric acid-secreting mucosa by the Congo red test and by estimating gastric acid secretion using the modified sham feeding test. Patients with portal hypertension who had never been subjected to endoscopic sclerotherapy were recruited as controls. RESULTS: On Congo red test, complete or substantial reduction in acid-secreting mucosa was observed in eight patients in comparison to none of the controls. Significantly lower acid secretion on modified sham feeding test was observed in these eight patients. CONCLUSION: A lower gastric acid secretion, probably secondary to vagal dysfunction, is seen in patients who have undergone multiple sessions of sclerotherapy; vagus nerve involvement may be secondary to periesophageal inflammation.

Metronidazole relieves symptoms in irritable bowel syndrome: the confusion with so-called 'chronic amebiasis'.

BACKGROUND: Metronidazole is often administered to patients with irritable bowel syndrome with an erroneous diagnosis of 'chronic amebiasis'. AIMS: To assess how patients with irritable bowel syndrome respond to metronidazole in the absence of amebae in their stools. METHODS: We randomly allocated 45 patients (35 men; aged 15-59 years) with irritable bowel syndrome to receive isapghul (10 g bid x 60 days), metronidazole (400 mg tid X 10 days, followed by placebo x 50 days), or placebo (1 capsule bid x 60 days). Symptoms were evaluated and scored on days 0, 15, 30, 45 and 60. Rectosigmoid manometry was performed in 5 of 15 patients in each group on days 0 and 60. RESULTS: There was a significant time effect and treatment effect on the symptom scores in all groups (isapghul > metronidazole > placebo); total score decreased from mean 25.8, 24.0 and 24.6 on day 0 to 7.2, 10.9 and 18.1 on day 60, respectively. Severity, duration and frequency of pain; and mucus in stool were all significantly reduced in all treatment groups (p < 0.001 for each). Treatment with isapghul increased the mean amplitude of propagated activity from 26.2 mmHg to 30.1 mmHg at 20 cm (p < 0.025) and from 23.1 mmHg to 27.4 mmHg at 10 cm (p < 0.05) from the anal verge, as well as the total duration of propagated activity at both sites (p < 0.05), with decrease in number of propagated contractions per 10 min (p < 0.025). Metronidazole and placebo had no effect on manometric findings. CONCLUSIONS: Metronidazole provides symptom relief in irritable bowel syndrome, without affecting rectosigmoid motility. This symptom response may be misinterpreted as supporting a diagnosis of 'chronic amebiasis'.

Existence of a high pressure zone at the rectosigmoid junction in normal Indian men.

PURPOSE: A hypertonic, electrically hyperactive segment has been described in the rectosigmoid region mainly in constipated persons. Anatomic or manometric evidence to satisfy the criteria for a sphincter here is, however, inconclusive. We evaluated the pressure profile of the rectosigmoid region in normal Indian men. METHODS: Fifteen male volunteers with regular bowel habits were studied. Rectosigmoid manometry (1 cm station pull-through) was done in the fasting state using a water-perfused system and three-lumen catheter with radially oriented recording ports 5 cm apart. RESULTS: Eight volunteers had a zone of high pressure. Proximal extent of this zone was identified as the station with a rise in basal pressure of at least 10 mmHg over the previous station. A further rise of at least 10 mmHg in subsequent distal stations was considered essential for defining the existence of the zone. This zone had a median length of 3 cm, with midpoint at median 18 cm from the anal verge and median highest pressure of 36 mmHg. There was no antegrade pressure gradient across the zone; rectal pressures were higher than those in the sigmoid in 12 of 15 volunteers. CONCLUSIONS: Approximately one-half of normal Indian men with regular bowel habits have a high pressure zone in the rectosigmoid region. The role of diet or defecation posture in its etiology and its effect on bowel habit need to be studied.

Total and segmental colonic transit time in non ulcer dyspepsia.

BACKGROUND: Patients with non ulcer dyspepsia (NUD) often have associated lower alimentary tract symptoms which are labelled as due to the irritable bowel syndrome. AIMS: To asymptomatic colonic dysmotility is present in patients with NUD. METHODS: We studied total and segmental colonic transit times in 25 patients with NUD (14 men age range 20-70 yr), and 25 matched normal controls (13 men; 18-50 yr), using the multiple-marker, single-film technique. Twenty markers each were administered at 0, 9 and 18 h and an abdominal film taken at 27 h. RESULTS: Total colonic transit time was shorter (median 9 h) in patients with NUD as compared to controls (median 15.8 h) p = 0.0018, with similar segmental motility pattern as in controls. There was no significant difference between the symptom subgroups of NUD. CONCLUSIONS: Patients with NUD often have altered colonic transit even in the absence of symptoms. NUD may therefore be only a subset of diffuse gastrointestinal dysmotility with predominant proximal alimentary tract symptoms, whereas the term irritable bowel syndrome is used when lower tract symptoms predominate.

Intrapulmonary vascular dilatations with hypoxemia in extrahepatic portal vein obstruction.

Several mechanisms have been suggested for the development of hypoxemia in cirrhosis. A few patients of portal hypertension due to non cirrhotic liver disease with cyanosis have also been reported earlier. We report probably the first documented case of portal hypertension with portal cavernoma and a normal liver, who had intrapulmonary vascular dilatations leading to hypoxemia and cyanosis. Our case suggests that changes leading to hypoxemia can occur due to portal hypertension alone, in the presence of a normal liver.

Congestive jejunopathy in portal hypertension.

Twenty six patients with portal hypertension of different aetiologies were studied for endoscopic evidence of congestive gastroduodenopathy and histological evidence of congestive gastropathy and jejunopathy. Per oral biopsies of jejunum were taken by Watson's capsule. Normal biopsy tissues obtained from the antrum (26), fundus (10), and jejunum (26) were used as controls. Endoscopy showed congestive changes in the fundus (17 cases), antrum (17), and duodenum (4). Duodenopathy correlated with changes in the antrum but not in the fundus. Histology showed an increase in the size and number of vessels in the jejunal villi ('congestive jejunopathy') in 22 patients. These correlated with histological evidence of gastropathy in the fundus but not in the antrum. The incidence of congestive jejunopathy did not correlate with the Child-Pugh score in patients with cirrhosis or with the number of sclerotherapy sessions received. Congestive jejunopathy is part of the spectrum of congestive gastroenteropathy and occurs at least as frequently as changes in the stomach and duodenum. The clinical import of these jejunal changes remains to be explained.

Oxygen desaturation and tachycardia during upper gastrointestinal endoscopy are transient and benign.

We continuously monitored the arterial oxygen saturation (SaO2) and pulse rate by pulse oximetry in 46 patients undergoing upper gastrointestinal endoscopy for diagnosis (21 cases) or variceal sclerotherapy (25). No premedication or prior topical anaesthesia was used. Significant hypoxaemia (percent drop in SaO2 > 2) occurred in 24 (52%) patients during the procedure; in 16 of these it occurred during introduction of the endoscope. Twenty seven (59%) patients had hypoxaemia during recovery, 25 of these immediately after withdrawal of the endoscope. All these episodes were short-lived and were probably due to gagging; basal levels were reached within 1 to 5 min. Tachycardia (> 100 beats/min) occurred in 41 (89%) patients. Sclerotherapy and history of smoking did not affect the incidence and magnitude of hypoxaemia and tachycardia. Transient cardio-respiratory changes occur during and immediately after endoscopy, but these appear to be clinically benign.

Colloidal bismuth subcitrate in non-ulcer dyspepsia.

The effect of colloidal bismuth subcitrate (De-Nol) on symptoms, Helicobacter pylori status and histological features was studied in 35 patients with non-ulcer dyspepsia. Pain (34 cases) and gas bloat (18) were the predominant symptoms. H pylori was present in 26 (74.3%) patients. Gastritis and duodenitis were present in 29 of 32 and 22 of 31 cases respectively in whom biopsies were available. Relief in symptoms after treatment was seen in 29 (82.8%) cases. Improvement in gastritis and duodenitis was noted in 60.8% and 58.8% respectively; over 70% of H pylori positive patients cleared the organism. These changes did not correlate with the relief in symptoms. We conclude that colloidal bismuth subcitrate is effective in the short term treatment of non-ulcer dyspepsia. It also clears H pylori infection and results in improvement of histological features.

A scoring system to differentiate cirrhotic from non-cirrhotic portal hypertension.

When it is not possible to perform a liver biopsy in cirrhosis, one has to rely on suggestive clinical and biochemical parameters and imaging procedures to arrive at a presumptive diagnosis. Based on the statistical method described by Spiegelhalter and Knill-Jones, we have devised a scoring system to reliably differentiate cirrhotic from non-cirrhotic portal hypertension without a liver biopsy. Age, presence of ascites, liver scan result and serum albumin, taken together, could confirm or rule out the diagnosis of cirrhosis in two-thirds of patients with portal hypertension. A score of 5 or more suggested cirrhosis (sensitivity 78%), and of 5 or more suggested cirrhosis (sensitivity 78%), and a score of -6 or less suggested a non-cirrhotic cause (sensitivity 64%) for portal hypertension, both with 100% specificity. Eliminating liver scan result reduced both sensitivity and specificity, suggesting that liver scan is an important component of the score. This score may be useful not only in the management of individual patients but also to classify them in clinical trials.

Leg ulcer in a case of thalassemia minor (a case report).

A rare case of leg ulcer in a 28 years old woman with thalassemia minor is reported.