Randomized trial of high-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND AND AIMS: High-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla during endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. We performed randomized trial to compare the effect of combination of rectal diclofenac and epinephrine spray on papilla (group A) vs. combination of rectal diclofenac with saline spray (group B) for prevention of post-ERCP pancreatitis. METHODS: We performed a double-blind trial at tertiary care center from April 2018 to May 2020 on 882 patients with naive papilla undergoing ERCP. The patients were randomly assigned to groups, A (n=437) or B (n=445). All patients received a single dose of rectal diclofenac 100 mg within 30 minutes before ERCP; 20 mL of diluted epinephrine 0.02% (group A) or saline (group B) was then sprayed on the duodenal papilla at the end of ERCP. The primary outcome was to compare incidence of post-ERCP pancreatitis (PEP) in two groups. RESULTS: The groups had similar baseline characteristics. PEP developed in 28 patients in group A (6.4%) and 35 patients in group B (7.9%) (relative risk, 1.1; 95% CI, 0.87-1.39; p=0.401). CONCLUSION: Our study showed that addition of epinephrine spray on duodenal papilla did not reduce the risk of post-ERCP pancreatitis. There is need for further studies to evaluate the role of different concentrations of epinephrine spray on papilla for prevention of post-ERCP pancreatitis. TRIAL REGISTRATION: Clinical Trials Registry- India (CTRI/2018/04/013396).

Fecaloma presenting as huge abdominal mass.

Fecal impaction is common in elderly, bed ridden, schizoaffective patients on antipsychotics. Intestinal obstruction due to distal colonic fecaliths is rare as it is amenable to digital manual evacuation and enemas. Our patient presented with abdominal distention, with last bowel evacuation reported 3 months ago. Computed tomography (CT) abdomen demonstrated a huge sigmoid fecalith causing bilateral hydronephrosis. He was managed through laparotomy with sigmoid colon resection and end colostomy.

Noradrenaline versus terlipressin in the management of type 1 hepatorenal syndrome: A randomized controlled study.

BACKGROUND: Hepatorenal syndrome (HRS) occurs in decompensated liver disease and carries high mortality. Vasoconstrictors are the drug of choice. Terlipressin is widely used and is expensive. In this study, we compared noradrenaline and terlipressin in the management of type 1 HRS. METHODS: Sixty consecutive patients with type 1 HRS were managed with noradrenaline (Group A, n = 30) or terlipressin (Group B, n = 30) with albumin in a randomized controlled trial at a tertiary center. RESULTS: Reversal of type 1 HRS was achieved in 16 (53%) patients in group A and 17 (57%) in group B. There was statistically insignificant difference between the two groups in decreasing serum creatinine and increasing urine output (p > 0.05). On univariate analysis, Child-Turcotte-Pugh (CTP) score, serum sodium, serum urea, serum albumin, prothrombin time, International normalized ratio (INR), serum alanine aminotransferase (ALT), ascitic fluid protein, and history of bleeding were associated with response to treatment (noradrenaline/terlipressin). However, on multivariate analysis, only baseline CTP score, serum urea, serum albumin, and prothrombin time were independent predictors of response. All patients who responded were discharged alive with no mortality within 30 days. CONCLUSIONS: There is no difference in outcome of patients with type 1 HRS treated with noradrenaline or terlipressin. Thus, noradrenaline, which is cheaper, can be used instead of terlipressin (Clinical Trials Registry-India [CTRI] No. CTRI/2011/09/002032).

The efficacy of accelerated, multiple, double-dose hepatitis B vaccine against hepatitis B virus infection in cancer patients receiving chemotherapy.

BACKGROUND: Hepatitis B virus (HBV) infection in cancer patients receiving chemotherapy carries high morbidity and mortality. Conventional hepatitis B vaccination with three doses at 0, 1, and 6 months apart is ineffective in prevention of HBV infection. OBJECTIVES: To compare the efficacy of accelerated, multiple, double-dose HB vaccine with conventional HB vaccine in cancer patients receiving chemotherapy (CT). METHODS: Patients of cancer who were planned for CT were screened for HBV markers (HBsAg, total anti-HB core, anti-HBs antibody and HBV DNA). Patients with negative HBV serum markers received HB vaccine in two groups. Group A received three double doses (40 µg) of recombinant HB vaccine at 0, 1, and 3 weeks before CT and additional three double doses post CT. Group B received HB vaccine (20 µg) at 0, 1, and 6 months. Efficacy of vaccine in the two groups was compared by anti-HBs titers achieved at 3, 6, and 9 months and by HBsAg positivity following CT at 1 year follow up. RESULTS: Protective anti-HBs titers (>10 mIU/mL) at 3, 6, and 9 months in group A and B was 41.1 %, 66.2 %, and 76% and 26 %, 37.7 %, and 49% respectively (p = 0.001). Seven of 454 (1.5%) patients in group A became HBsAg positive after vaccination compared to 19/472 (4.0%) in group B (p = 0.022). CONCLUSION: Accelerated, multiple, double-dose HB vaccine increases seroprotection and is more effective than conventional HB vaccine in preventing HBV infection.

Prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin in Kashmir (India).

OBJECTIVES: The purpose of this study was to evaluate the prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin. METHODS: One hundred and sixty-one consecutive patients with iron-deficiency anemia of obscure origin were evaluated. Tissue transglutaminase antibodies levels were done and duodenal biopsies were scored according to Marsh classification. Diagnosis was based on positive IgA anti-tissue transglutaminase antibodies and abnormal histopathology. Gluten-free diet (GFD) was adviced for celiac disease patients. One hundred and sixty healthy blood donors were tested for IgA anti-tissue transglutaminase antibodies, and positive controls were subjected to endoscopic duodenal biopsy. RESULTS: Tissue transglutaminase antibodies were positive in 13 (8 %) patients with iron-deficiency anemia of obscure origin and 4 (2.5 %) in control group (p = 0.026) (odds ratio 3.42; 95 % confidence interval [CI]: 1.092-10.743). All 13 patients (8 %) and 2 out of 4 positive controls (1.25 %) had histopathology findings of celiac disease (p = 0.004). Duodenal biopsy showed Marsh grade 1 in 4, grade 2 in 4 (30.77 %), 3a in 1 (7.70 %), 3b in 2 (15.38 %), and 3c in 2 (15.38 %) patients. A statistically significant correlation was found between lower hemoglobin concentration and higher Marsh grading (Spearman's rho = -0.946, p = 0.001). Celiac disease patients adhered to GFD and after 6 months mean (SD) hemoglobin levels increased from 7.42 ± 0.96 to 10.47 ± 0.80 g/dL (p- < 0.001). CONCLUSION: Patients with iron-deficiency anemia of obscure origin had increased prevalence of celiac disease. Gluten-free diet improved anemia in celiac disease patients irrespective of grade of duodenal involvement.

Prevalence of gallstone disease in patients with type 2 diabetes and the risk factors in North Indian population: a case control study.

BACKGROUND: Age, female sex, and obesity are considered to be risk factors for gallstone disease. The role of type 2 diabetes (T2D) in gallstone formation is still uncertain, and data in Indians is limited. OBJECTIVES: This is a case-control study to determine the prevalence of gallstones (GS) in patients with T2D, risk factors, and the relative risk compared with subjects without diabetes, selected from the general population. METHODS: Among 450 cases with T2D of a ≥2-year duration, 377 (88.8 %) participated. Diagnosis of GS was made at ultrasonography and history of cholecystectomy for GS. Controls were selected from the general population and diabetes excluded by oral glucose tolerance test. Cases and controls were matched for age, gender, and body mass index (BMI). RESULTS: Gallstones were seen in 67 (17.7 %) cases compared to 40 (5.8 %) in controls (p = 0.001). Prevalence increased with increasing age with peak in the sixth decade (23.4 % in cases and 4.4 % in controls (p = 0.001) and was higher in women (27.9 %) in cases and (7.8 %) in controls, (p = 0.001). In univariate analysis, risk factors for GS included age, female sex, BMI, multiparity, family history of GS, and high triglycerides and cholesterol with low high-density lipoprotein cholesterol. In multivariate analysis, age, (relative risk [RR] 1.54, confidence interval [CI] 1.1-2.1), female sex (RR 1.6, CI 1.0-1.9), and BMI (RR 1.5, CI 1.3-2.5) were the independent risk factors in gallstone formation. CONCLUSION: Patients with T2D had higher probability of having GS compared to the general population. Increasing age, female sex, and higher BMI were independently associated with gallstone disease.

Efficacy and safety of sequential therapy versus standard triple therapy in Helicobacter pylori eradication in Kashmir India: a randomized comparative trial.

BACKGROUND: Increasing resistance against Helicobacter pylori has resulted in reduced eradication rates. OBJECTIVE: This study aims to determine whether eradication rates for H. pylori infection with sequential therapy is better than standard triple therapy. PATIENTS: Patients with endoscopy documented peptic ulcer and H. pylori infection confirmed by histology and rapid urease test. INTERVENTION: Patients were randomized into two groups; 134 received standard triple therapy (pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1 g each administered twice daily) for 10 days and 138 received sequential regimen (pantoprazole 40 mg plus amoxicillin 1 g twice daily for 5 days followed by 40 mg pantoprazole, 500 mg clarithromycin, and 500 mg tinidazole each administered twice daily for 5 days). Eradication was confirmed by histology and rapid urease test. Compliance and adverse effects were determined by the recovery of empty medicine strips and questioning. RESULTS: The eradication rates with sequential therapy were significantly greater than with standard therapy on both intention-to-treat analysis (76.0 % vs. 61.9 %, p = 0.005; difference, 14.1 % [95 % CI, 6.5-19 %] and per protocol analysis (84.6 % vs. 67.4 %, p = 0.002; difference, 17.2 % [95 % CI, 8.5-23.5 %]). The incidence of side effects did not differ between the two therapy groups. One patient in standard therapy discontinued treatment due to side effects. LIMITATION: Cultures were not performed. Loss to follow up was 5.2 % in standard therapy and 6.5 % in sequential therapy. CONCLUSION: Sequential therapy was significantly more effective than standard therapy for eradicating H. pylori infection in peptic ulcer disease in Asian patients. Side effects were similar.

Occult hepatitis B virus infection as a cause of posttransfusion hepatitis in patients with cancers.

BACKGROUND: Prevalence of hepatitis B virus (HBV) infection is increased in patients of cancer with increased mortality. Multiple transfusions of blood and blood-related products are a potential source. AIMS: This study aims to assess the incidence of hepatitis B surface antigen (HBsAg) seroconversion in cancer patients receiving transfusion of blood or blood-related products and identify possible reasons for infection in these patients. MATERIAL AND METHODS: Patients of cancer receiving blood products, who were HBsAg-, anti-hepatitis B core (HBc)-, and HBV DNA-negative prior to transfusion, were tested for HBsAg by ELISA at 6, 12, and 24 weeks after the last transfusion. Blood donors were screened for HBsAg by ELISA. RESULTS: Twenty of 3,600 (0.56 %) blood donors tested positive for HBsAg and were rejected. Nine of 150 (6 %) cancer patients became HBsAg-positive posttransfusion which included seven patients who presented with acute hepatitis B and other two patients who remained HBsAg-positive without hepatitis. In 6/9 (66.6 %) patients, HBsAg positivity was related to blood transfusion as their corresponding blood donors on retesting the stored samples were positive for anti-HBc antibody and HBV DNA. In other three patients, the cause of their HBsAg positivity could not be ascertained. CONCLUSION: Occult HBV infection in blood donors is a potential source of posttransfusion HBV infection in recipients. Anti-HBc antibody and HBV DNA should be tested in blood donors especially when blood is given to cancer patients receiving chemotherapy.

Etiology and outcome of acute pancreatitis in children in Kashmir (India). An endemic area of hepatobiliary ascariasis.

BACKGROUND: The purpose of the present study was to determine the etiology, management, and outcome of acute pancreatitis (AP) in children in an endemic area of hepatobiliary ascariasis (HBA). METHODS: This was a prospective, hospital-based study over a 9-year period that included 156 children younger than 12 years of age who had a diagnosis of AP. RESULTS: Of the 156 patients, 71 were boys and 85 were girls with a mean age of 8.4 ± 1.5 years (range 3-12 years). The various factors contributing to AP were biliary ascariasis in 93 cases (60 %), gallstones 16 (10 %), trauma 5 (3 %), choledochal cyst 4 (3 %), impacted bile duct stone 3 (2 %), and gallbladder sludge 2 (1 %). Idiopathic group 33 cases (21 %). Diagnosis was based on clinical picture, abdominal ultrasonography, and elevated serum amylase level. Pancreatitis was mild in 113 (72 %) patients and severe in 43 (28 %). With conservative therapy, 123 patients (79 %) improved, whereas the remaining 33, who had intractable abdominal pain, cholangitis, or worsening cholecystitis, underwent emergency endoscopic retrograde cholangiopancreatography for removal of worms (26 patients) and stones in the bile duct (7 patients). Bile duct stones were extracted in all 7 patients with that condition, and worms were extracted from 23 of the 26 patients with ascariasis. Emergency surgery was performed in five patients. Three patients died. Pancreatitis recurred in 16 patients due to HBA. CONCLUSIONS: Pancreatitis is not uncommon in children. Ascariasis is a leading cause of AP in endemic areas. Patients usually respond to conservative management, but endoscopic treatment is effective. Surgery is rarely required.

Prevalence of Helicobacter pylori infection and the effect of its eradication on symptoms of functional dyspepsia in Kashmir, India.

BACKGROUND AND AIM: Epidemiology of Helicobacter pylori infection has regional variation. Effect of eradication of H. pylori on symptoms of functional dyspepsia is uncertain, and the data in Asian scenario are scanty. The study aimed to see H. pylori positivity rate in patients of functional dyspepsia and the effect of its eradication on symptoms. METHODS: Randomized, double-blind, placebo-controlled study was the study design used. Patients of functional dyspepsia defined as per Rome 2 criteria were tested for H. pylori infection by rapid urease test and gastric biopsy. H. pylori-positive patients were randomly allocated to triple therapy (20 mg of omeprazole, 500 mg of clarithromycin, and 1000 mg of amoxicillin orally two times daily) and omeperazole plus identical placebo for 2 weeks. Symptoms were assessed with the weekly Likert scale. RESULTS: H. pylori positivity rate in functional dyspepsia was 1160/2000 (58%). At 6 weeks, the eradication rate for H. pylori in triple therapy and placebo group was (181/259 [69.8%] and 13/260 [5.0%], P = 0.001), respectively. On intention-to-treat analysis, the symptom resolution at 1 month was (157/259 [60.7%] and 136/260 [52.3%], P = 0.38), respectively. At 12 months, H. pylori eradication and healing of gastritis in triple therapy and placebo group were (116/174 [66.7%] and 12/180 [6.7%], P = 0.001) and (132/174 [75.9%] and 11/180 [6.1%], P = 0.001), respectively. On intension to treat, the resolution of symptoms in triple therapy and placebo group was (95/217 [43.7%] and 72/195 [36.9%], P = 0.13). CONCLUSION: There is high H. pylori positivity rate in patients of functional dyspepsia. The eradication of H. pylori does not resolve the symptoms despite healing of gastritis.

Safety and efficacy of 1-week levofloxacin-based triple therapy in first-line treatment for Helicobacter pylori-related peptic ulcer disease in Kashmir, India.

BACKGROUND AND OBJECTIVES: There is no ideal therapy for eradication of Helicobacter pylori infection. We evaluated the efficacy and safety of 1-week triple therapy with rabeprazole, levofloxacin, and tinidazole in a metronidazole resistance prevalent region for eradicating H. pylori infection in patients with gastroduodenal ulcers. METHODS: This was an open-label, prospective study. Consecutive patients with endoscopy-proven duodenal or gastric ulcer and who were H. pylori-positive were treated with levofloxacin 500 mg once a day, rabeprazole 20 mg twice a day, and tinidazole 500 mg twice daily for 7 days followed by rabeprazole 20 mg OD for 8 weeks. Endoscopy was repeated 8 weeks after the end of therapy to check for ulcer healing and H. pylori status. RESULTS: One hundred and thirty-one patients with gastroduodenal ulcers (duodenal 118, and gastric 13) were included. Drug compliance was 97.7 %. The eradication rate of H. pylori by intention-to-treat analysis was 85.5 % (95 % confidence interval 79.5-91.5) (112 of 131 patients) and by per-protocol analysis was 91.8 % (95 % confidence interval 86.9-96.7) (112 of 122 patients). Adverse effects were reported in 17 %: abdominal pain in 3.05 %, metallic taste in 6.87 %, and nausea and vomiting in 4.58 %. CONCLUSIONS: Levofloxacin-tinidazole-based triple therapy was highly effective and safe as a first-line regimen in Indian patients with gastroduodenal ulcer disease associated with H. pylori infection. The regimen was well tolerated.

Comparative evaluation of ERCP and endosonography in the diagnosis of extrahepatic biliary obstruction and a suggested algorithm.

BACKGROUND/AIMS: Endosonography is an effective diagnostic tool for evaluating pancreatobiliary diseases. However, it is scarcely used in our healthcare system because of limited resources and scarcity of trained personnel. The aim of this study was to evaluate the role of endosonography in patients presenting with extrahepatic biliary obstruction in the Indian subcontinent. METHODS: Fifty consecutive patients presenting with suspected obstructive jaundice of unknown cause were enrolled in the study. All the patients underwent abdominal ultrasound followed by endosonography and finally endoscopic retrograde cholangiopancreatography. Final diagnosis was obtained on endoscopic retrograde cholangiopancreatography or surgery, where indicated. RESULTS: Twenty-six patients had malignant cause for extrahepatic biliary obstruction and 24 patients had non-malignant cause for extrahepatic biliary obstruction. The etiological diagnosis was established by endosonography in 23/26 patients with malignant cause for extrahepatic biliary obstruction compared to in 21/26 patients with endoscopic retrograde cholangiopancreatography. For non-malignant cases of extrahepatic biliary obstruction, endosonography and endoscopic retrograde cholangiopancreatography were equally accurate (23/24 patients) in providing the correct etiological diagnosis. CONCLUSIONS: Endosonography and endoscopic retrograde cholangiopancreatography are equally efficient for diagnosing the cause of extrahepatic biliary obstruction. The evaluation of patients presenting with cholestasis should be based on careful clinical judgment supported by baseline investigations to suggest likely malignant or non-malignant etiology. Endosonography as first approach should be followed in patients with suspected malignant cause of extrahepatic biliary obstruction. Endoscopic retrograde cholangiopancreatography should be performed first in patients with suspected non-malignant cause of extrahepatic biliary obstruction.

64-section multiphase CT enterography as a diagnostic tool in the evaluation of obscure gastrointestinal bleeding.

BACKGROUND AND AIM: Small bowel follow through (SBFT) and enteroclysis have low sensitivity in picking up lesions in obscure gastrointestinal bleed (OGIB). Computed tomographic enterography (CT-EG), performed with 64-slice multiphase CT system by using large volumes of ingested neutral enteric contrast material, has high spatial and temporal resolution in visualization of the small bowel wall and lumen. The role of 64-slice multiphase CT-EG in the evaluation of OGIB is still evolving, and data on this role are scarce. We evaluated the efficacy of 64-slice multiphase CT-EG using polyethylene glycol (PEG) electrolyte solution as neutral contrast in patients of OGIB. METHODS: CT-EG was performed with 64-slice multiphase CT system using large volume (2,000 mL) of PEG electrolyte solution as oral contrast in patients of OGIB. RESULTS: Thirty-five patients (21 men, age 41.4 [13.5] y, range 19-70 year) with OGIB underwent CT-EG; 20 patients had overt OGIB whereas 15 patients had occult OGIB. Among 15 patients with occult OGIB, 10 patients had iron deficiency anemia (IDA) with fecal occult blood test (FOBT) positive and 5 had IDA with FOBT negative. Thirty-two patients (92 %) completed the procedure successfully. The total time taken for the ingestion of 2,000 mL of PEG electrolyte solution was median 64 (range 60-78) minutes. Adequate luminal distension of small bowel was seen in 29 (90.6 %) patients for successful interpretation of radiological images. Fifteen of 32 (46.9 %) patients had positive findings on CT-EG; 12 of them underwent exploratory laparotomy. The surgical findings were in conformity with CT-EG findings in all patients, which included gastrointestinal stromal tumors (GIST; n = 6), carcinoid (1), Meckel's diverticulum (1), small bowel adenocarcinoma (2) and jejunal vascular malformation (2). CONCLUSION: 64-slice multiphase CT-EG is a useful investigation in the evaluation of both occult and overt OGIB.

Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux.

BACKGROUND AND AIM: Nocturnal gastro-esophageal reflux causes heartburn and sleep disturbances impairing quality of life. Lifestyle modifications, like bed head elevation during sleep, are thought to alleviate the symptoms of gastroesophageal reflux. We tested the hypothesis that bed head elevation might decrease recumbent acid exposure compared to sleeping in a flat bed. METHODS: Patients of symptomatic nocturnal reflux and documented recumbent (supine) reflux verified by esophageal pH test entered the trial. On day 1, baseline pH was measured while the patient slept on a flat bed. Then patients slept on a bed with the head end elevated by a 20-cm block for the next 6 consecutive days from day 2 to day 7. The pH test was repeated on day 2 and day 7. Each patient acted as his own control. RESULTS: Twenty of 24 (83.3%) patients with mean age of 36 ± 5.5 years completed the trial. The mean (± SD) supine reflux time %, acid clearance time, number of refluxes 5 min longer and symptom score on day 1 and day 7 were 15.0 ± 8.4 and 13.7 ± 7.2; P = 0.001, 3.8 ± 2.0 and 3.0 ± 1.6; P = 0.001, 3.3 ± 2.2 and 1.0 ± 1.2; P = 0.001, and 2.3 ± 0.6 and 1.5 ± 0.6; P = 0.04, respectively. The sleep disturbances improved in 13 (65%) patients. CONCLUSIONS: Bed head elevation reduced esophageal acid exposure and acid clearance time in nocturnal (supine) refluxers and led to some relief from heartburn and sleep disturbance.

Incidence of colorectal cancer in Kashmir valley, India.

BACKGROUND: There is wide variation in the incidence of colorectal cancer globally and also within the same country among different racial or ethnic groups. The present population-based study was undertaken to determine the incidence of colorectal cancer in Kashmiri population which is non-migratory and ethnically homogeneous having stable food habits. METHODS: Over a period of one year, all newly diagnosed and histological proved cases of colorectal cancer in all possible areas, where such patients are diagnosed and treated were prospectively registered. RESULTS: A total of 212 cases of colorectal cancers were registered; of them 113 (53.3%) originated in the colon and other 99 (46.7%) in rectum. Male to female ratio was 1.2:1. The crude incidence rate of colorectal cancer was 3.65/100,000; it was 3.78 in males, and 3.50/100,000 in females. The incidence rates for colorectal cancer in Muslims and Hindus were different. The crude incidence rate for colorectal carcinoma was highest for district Srinagar 6.19/100,000 (urban area) and lowest for district Kupwara (rural area) 1.59/100,000. The highest numbers of cases were detected in the age group 55-59 years (n = 34). The age-specific rate for colorectal carcinoma was highest in the age group 55-59 years (17.21/100,000), followed by 65-69 years (14.86/100,000). The age standardized incidence rate was 4.52/100,000 per year. The truncated age adjusted incidence rates in age group 35-64 years was 8.31/100,000; while that for colorectal carcinoma was 8.77/100,000 in males and 7.66/100,000 in females. CONCLUSION: We conclude that the incidence of colorectal cancer in Kashmir valley is similar to that reported in the rest of India.

Correlation of hepatic venous pressure gradient with variceal bleeding, size of esophageal varices, etiology, ascites and degree of liver dysfunction in cirrhosis of liver.

An elevated hepatic venous pressure gradient (HVPG) has been associated with risk of variceal bleeding, and outcome and survival after variceal bleeding. In this pilot study, we measured HVPG in 40 patients with liver cirrhosis and studied its relationship with etiology of liver disease, esophageal variceal size, history of variceal bleeding or ascites, biochemical liver tests and Child-Pugh class. There was no procedurerelated complication. The mean (SD) HVPG was similar in patients who had history of variceal bleeding as compared to those who did not (15.4 [2.8] mmHg vs. 13.9 [2.7] mmHg, p=0.1); HVPG had no significant association with etiology of cirrhosis (p=0.4). HVPG levels were significantly higher in patients with larger esophageal varices (grade III/IV vs. I/II: 15.2 [2.7] mmHg vs.13.1 [2.8] mmHg, p=0.04), poorer Child-Pugh class (B or C versus A), and presence of ascites (p=0.04). Thus, HVPG correlated with variceal size, Child-Pugh class, and presence of ascites, but not with variceal bleeding status.

Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer.

BACKGROUND AND AIMS: After successful endoscopic hemostasis in bleeding peptic ulcer, addition of proton pump inhibitors reduce the rate of recurrent bleeding by maintaining intragastric pH at neutral level. The aim of the present study was to evaluate the effect of various proton pump inhibitors given through different routes on intragastric pH over 72 h after endoscopic hemostasis in bleeding peptic ulcer. METHODS: Ninety consecutive patients who had successful endoscopic therapy of bleeding peptic ulcer underwent 72-h continuous ambulatory intragastric pH study, were randomly assigned to receive p.o. omeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg omeprazole followed by infusion 8 mg/h for 72 h. Oral pantoprazole 80 mg bolus followed by 80 mg every 12 h for 72 h or i.v. 80 mg pantoprazole followed by infusion of 8 mg/h for 72 h. Oral rabeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg rabeprazole followed by infusion 8 mg/h for 72 h. Five patients received no treatment after successful endoscopic therapy and underwent 72-h pH study. RESULTS: Mean 72-h intragastric pH for p.o. omeprazole was 6.56 versus 6.93 for omeprazole infusion (P = 0.48). Mean 72-h intragastric pH for p.o. pantoprazole was 6.34 versus 6.32 for pantoprazole infusion (P = 0.62). Mean 72-h intragastric pH for rabeprazole p.o. was 6.11 versus 6.18 rabeprazole i.v. (P = 0.55). Mean 72-h pH for the no proton pump inhibitor group was 2.04. CONCLUSION: There was no significant difference among various proton pump inhibitors given through different routes on raising intragastric pH above 6 for 72 h after successful endoscopic hemostasis in bleeding peptic ulcer.

Effect of bending exercise on gastroesophageal reflux in symptomatic patients.

BACKGROUND: Recumbency and bending are thought to provoke symptoms of reflux in patients with gastroesophageal reflux disease (GERD). The effect of exercise which involved bending and abdominal contractions was evaluated in symptomatic patients of GERD using continuous 24-hour ambulatory esophageal pH test. METHODS: Twenty-five patients with GERD, confirmed by abnormal 24-hour esophageal pH study, performed exercise for 30 minutes consisting of 5 sessions of 6 minutes each. The exercise involved toe touching from supine, sitting and standing position of 2 minutes' duration each. Each 2 minutes' period included 8 repetitions of the same exercise of 15 seconds' duration. 24-hour esophageal pHmetry was done on day 1 without exercise and on day 2 with 30-minute exercise. Reflux time percent (RT%) pH <4 was compared between days 1 and 2 and 30 minutes before and during exercise. RESULTS: Fourteen patients were upright refluxers and 11 patients were combined refluxers, which included 4 patients with supine reflux and 7 patients who refluxed both in supine and upright positions. The median (range) 24-hour RT% on day 1 and day 2 was 7 (5-40) and 7 (4-46), respectively (p=0.15). RT% during 30 minutes exercise compared with 30 minutes before exercise was 6.6 (0-60) and 0.0 (0.0-80) (p=0.02), respectively. In combined and upright refluxers, RT% during and before exercise was 13 (0-53) and 0.0 (0.0-42) (p=0.008), respectively and 0.0 (0-60) and 0.0 (0-80), (p=0.71), respectively. RT% between upright and combined refluxers during exercise was 0.0 (0-60) and 13 (0-53), respectively (p=0.004). The mean (SD) LES pressure in mmHg in combined and upright refluxers was 7 (2.9) and 19.6 (6.8), respectively (p=0.008). Esophagitis in combined and upright refluxers was seen in 8 patients (72.7%) and 2 patients (14.3%), respectively. Two patients (8%) developed symptoms during exercise. CONCLUSION: Exercise which involves bending precipitates reflux in patients with moderate-to-severe GERD.

Vesicoperitoneal fistula--an unusual cause of tense ascites.

We report a 55-year-old man who developed tense ascites due to vesicoperitoneal fistula. He had undergone surgery 32 years ago for excision of an infected urachal cyst, the tract and the umbilicus.