Effect of H. pylori density by histopathology on its complications and eradication therapy.

INTRODUCTION: Helicobacter pylori (H. pylori) infection causes chronic gastritis and is a major risk factor for duodenal and gastric ulceration, gastric adenocarcinoma, and primary gastric lymphoma. Increased gastric bacterial density may lead to increased levels of inflammation and epithelial injury. AIMS AND OBJECTIVES: 1) To study the effect of H. pylori density by histological changes in stomach. 2) To study the effect of H. pylori density on the efficacy of standard triple drug eradication treatment. 3) To study the effect of H. pylori density on the complication related to H. pylori. MATERIAL AND METHODS: All the patients visiting gastroenterology OPD with the symptoms of dyspepsia not responding to proton pump inhibitor or having alarm symptoms were subjected to upper GI endoscopy and biopsy. If H. pylori was present they were included in the study. The patients were given standard 14 day triple antibiotic combination for H. pylori eradication. H. pylori eradication was confirmed by urea breath test after six weeks of completion of treatment. RESULTS: Out of 250 patients screened, 120 patients enrolled in the study. On clinical history 41.5% patients had symptoms of heart burn where as 63.3% patients had dyspeptic symptoms. Success rate of anti H. pylori triple drug therapy was 80%. Rate of eradication was significantly lower among the patients with higher H. pylori density (p < 0.05) on histopathology by Sydney classification. Duodenal ulcer, Gastric ulcer and gastric erosion were noted in higher frequencies among the patients with higher H. pylori density (p < 0.05). CONCLUSION: H. pylori density by histopathology correlates with the complication related to H. pylori i.e. duodenal ulcer, reflux esophagitis and antral erosions. It also correlates with the success of the standard triple drug eradication treatment.

Early atherosclerosis in ulcerative colitis: cross-sectional case-control study.

OBJECTIVE: To study the extent of early atherosclerosis in ulcerative colitis (UC) patients by measuring carotid intima-media thickness (CIMT) and the correlation between CIMT, serum homocysteine level and homeostasis model assessment-insulin resistance (HOMA-IR) in UC. METHODS: We studied 60 UC patients and 60 healthy controls. Individuals with risk factors for atherosclerosis were excluded from the study. Fasting blood glucose, lipid profile, HOMA-IR, erythrocyte sedimentation rate (ESR), serum vitamin B12 and homocysteine levels were measured in all participants. CIMT was measured using a B-mode duplex imaging study. RESULTS: UC patients had significantly higher CIMT than controls (P < 0.05). ESR, fasting insulin, HOMA-IR and serum homocysteine levels were also significantly higher in UC patients (P < 0.05). Pearson's correlation coefficient showed significant correlations between: (i) CIMT and patients' age, duration of UC, HOMA-IR, and homocysteine level (P < 0.05); (ii) serum homocysteine and duration of UC, fasting insulin level, HOMA-IR and CIMT (P < 0.01); (iii) HOMA-IR and age, duration of UC, serum homocysteine and CIMT (P < 0.01). Multi-regression models showed that serum homocysteine affects CIMT and duration of UC independently, whereas participants' age and duration of UC affects HOMA-IR independently. CONCLUSIONS: Higher CIMT might indicate subclinical atherosclerosis in UC patients. Patients' age, duration of UC, HOMA-IR and homocysteine levels are important factors associated with increased CIMT.

Biliary sphincteroplasty facilitates retrieval of proximally migrated plastic biliary stent.

BACKGROUND AND AIM: Proximal migration of biliary stents presents a technical challenge for the therapeutic endoscopist. It may require multiple, complicated corrective procedures resulting in significant morbidity to the patients. In this study we evaluated the utility of balloon biliary sphincteroplasty with CRE (Controlled Radial Expansion) Balloon Dilator on retrieval of proximally migrated biliary stents. METHODS: We identified patients from our ERCP database who presented with proximal migration of biliary stent, between August 2011 and October 2013. Patients in whom the stent could not be retrieved with conventional methods, balloon sphincteroplasty was performed with a 12 mm CRETM Balloon Dilator (Boston Scientific). Stent removal was attempted with extraction balloon or basket thereafter. RESULTS: We identified 28 patients with proximal migration of biliary stents, placed for benign diseases of the common bile duct. Stent removal was successful in 18 patients (64.28%) with help of an extraction balloon or basket. Of the remaining 10 patients, balloon sphincteroplasty was successfully followed by stent removal in eight patients. CONCLUSIONS: Balloon biliary sphincteroplasty increases the success rate of retrieving proximally migrated biliary stents. The procedure is safe, technically easy and yields a good success rate in our experience.

Esophageal tuberculosis presenting with hematemesis.

Esophageal tuberculosis is rare, constituting about 0.3% of gastrointestinal tuberculosis. It presents commonly with dysphagia, cough, chest pain in addition to fever and weight loss. Complications may include hemorrhage from the lesion, development of arterioesophageal fistula, esophagocutaneous fistula or tracheoesophageal fistula. There are very few reports of esophageal tuberculosis presenting with hematemesis due to ulceration. We report a patient with hematemesis that was due to the erosion of tuberculous subcarinal lymph nodes into the esophagus. A 15-year-old boy presented with hemetemesis as his only complaint. Esophagogastroduodenoscopy (EGD) revealed an eccentric ulcerative lesion involving 50% of circumference of the esophagus. Biopsy showed caseating epitheloid granulomas with lymphocytic infiltrates suggestive of tuberculosis. Computerised tomography of the thorax revealed thickening of the mid-esophagus with enlarged mediastinal lymph nodes in the subcarinal region compressing the esophagus along with moderate right sided pleural effusion. Patient was treated with anti-tuberculosis therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for 6 mo. Repeat EGD showed scarring and mucosal tags with complete resolution of the esophageal ulcer.

Uncomplicated spontaneous rupture of pancreatic pseudocyst into stomach: A case report.

Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography (CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.

Retrospective and prospective validation of model for end-stage liver disease (MELD) score in predicting mortality in patients of alcoholic liver disease.

BACKGROUND AND AIM: Patients with alcoholic hepatitis and alcoholic cirrhosis have significant morbidity and mortality. The model for end-stage liver disease (MELD) score is used to predict mortality in patients with liver disease. Our study aimed to validate the utility of MELD score versus Child Pugh Turcotte (CPT) and modified CPT (CPT+creatinine; CPTC) scores in predicting mortality among alcoholic liver disease (ALD) patients. METHODS: We examineda retrospective (n=110; mean age 44.5years; 109 men) and a prospective (n=96; mean age 45 years; 92 men) cohort of patients suffering from ALD, with varying disease severity, and compared the ability of MELD, CTP and CPTC scores to predict the 1-, 3- and 6-month mortality using concordance (c-) statistics. RESULTS: The median MELD, CPT and CPTC scores were 21, 10 and 11 in the retrospective group and 21, 10 and 10 in prospective groups, respectively. The 1-month, 3-month and 6-month mortality was 41 (37.3%), 59 (53.6%) and 81 (73.6%) in the retrospective group and 27 (28.1%), 41 (42.7%) and 65 (67.7%) in the prospective group. The predictive ability of MELD, CPT and CPTC was 0.72, 0.67, 0.68 for 1-month mortality, 0.73, 0.70, 0.68 for 3-month mortality and 0.83, 0.75, 0.73 for 6-month mortality in retrospective group and 0.86, 0.56, 0.63 for 1-month mortality, 0.80, 0.57, and 0.60 for 3-month mortality, and 0.88, 0.51, and 0.64 for 6-month mortality in the prospective cohort, respectively. The predictive accuracy of MELD was significantly better than CPT and CPTC scores in the prospective group. CONCLUSIONS: MELD is a valid prognostic score compared to CPT and CPTC scores for predicting short-term mortality in patients of alcoholic liver disease.

Pseudomelanosis Duodeni of Undetermined Etiology.

Pseudomelanosis duodeni is a rare, benign condition of unknown etiology. It is characterized by collection of pigment-laden macrophages in the tips of duodenal villi. The pigment, originally interpreted as melanin, pseudomelanin, lipomelanin or hemosiderin, has now been demonstrated to be mostly ferrous sulfide. There is a strong association with chronic renal failure, arterial hypertension, diabetes mellitus and the use of medications such as ferrous sulfate, hydralazine, propranolol, hydrochlorothiazide and furosemide. We reported a case of a 48 years old female who only had dyspeptic symptoms and no history of hypertension or drug history. Laboratory tests showed normal serum electrolytes and renal function. On endoscopy we found multiple tiny brownish-black pigmentation throughout proximal duodenum. Histopathological examination showed mild inflammation in lamina propria with haemosiderin-laden macrophages. Stain for iron was positive and that for melanin was negative.