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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 45-46

In this issue of the journal

Institute of Gastroenterology, SRM Institutes for Medical Science, Chennai, Tamil Nadu, India

Date of Submission04-Mar-2021
Date of Acceptance09-Mar-2021
Date of Web Publication23-Mar-2021

Correspondence Address:
B S Ramakrishna
SRM Institutes for Medical Science, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_9_21

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How to cite this article:
Ramakrishna B S. In this issue of the journal. Gastroenterol Hepatol Endosc Pract 2021;1:45-6

How to cite this URL:
Ramakrishna B S. In this issue of the journal. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2021 Apr 22];1:45-6. Available from: http://www.ghepjournal.com/text.asp?2021/1/2/45/311740

This second issue of the journal brings to the reader several articles that are relevant to clinical practice in our specialty. Gastroenterology and hepatology practice in low- and middle-income countries requires the adaptation of the current technology to local needs and local resource constraints.

Acute liver failure syndromes are common in clinical practice and require immediate and intensive treatment. The availability of liver transplantation as an option for the management of acute liver failure continues to be unavailable to the vast majority of patients in this country who meet criteria for liver transplantation. Under the circumstances, there has been an effort to search for alternative therapies that may avert the need for liver transplantation. Plasma exchange is one such option that is now available for the management of these patients. In this issue of the Journal, Professor Eapen et al. from the Christian Medical College, Vellore, provide a short overview of the use of low-volume plasma exchange and low-dose steroid in the management of liver failure syndromes including severe acute liver injury, acute liver failure, and acute on chronic liver failure. Plasma levels of von Willebrand factor (vWF) multimers rise significantly in acute liver failure, resulting in large proteins that clog the microcirculation in vital organs. The authors suggest that the success of plasma exchange and steroids lies in their ability to reduce vWF multimer levels quickly leading to recovery of organ function. The fresh frozen plasma provides adequate amounts of a protein called ADAMTS13 that cleaves the vWF multimers and thereby restores the microcirculation. The CMC protocol calls for approximately 50% of plasma volume to be exchanged with fresh frozen plasma daily for 3 days. The requirement of approximately 18 units of fresh frozen plasma per treated patient is likely to be available in most practice settings in our country. By contrast, the recommended high-volume plasma exchange protocols may be beyond the reach of many patients with these illnesses in our country. The authors illustrate the use of PLEX in different settings of liver failure by highlighting details of individual cases where this treatment modality was used.

Esophageal disorders including noncardiac chest pain, swallowing disorders, and regurgitation/rumination syndromes are common in clinical practice. The majority of gastroenterologists and physicians dealing with these disorders provide empiric and symptomatic treatment without an assessment or understanding of the cause of the symptoms. In a review in this issue of the journal, Dr. Jain from Arihant Hospital, Indore, gives a perspective on the use of high resolution esophageal manometry (HREM) to elucidate these disorders. The author identifies the lack of awareness of these motor disorders as well as the lack of familiarity with HREM as the reasons for the suboptimal management of many of the patients suffering from these disorders. The pitfalls of HREM and its utility in clinical practice in swallowing disorders and noncardiac chest pain are well reviewed by the author.

Maintaining nutrition long term in patients with swallowing disorders was revolutionized by the introduction of percutaneous endoscopic gastrostomy (PEG). Despite its wide availability, it remains underutilized in many parts of the country primarily due to the fact that physicians, particularly neurologists and neurosurgeons, remain unaware of its ability to improve the nutrition of their patients with swallowing disabilities. Dr. Babu Vinish et al. from SIMS Hospital, Chennai, in this edition of the journal, review their experience with 80 PEG procedures done in a single hospital over a 28-month period. The majority of the patients had a neurological or neurosurgical condition that required long-term nutrition without the risk of pulmonary aspiration. The authors review the procedural steps and discuss considerations for proper tube placement. PEG site infection was the most common complication but was easily managed in all patients. One of the major advantages of PEG feeding remains its ability to accommodate the use of blenderized home feeds in contrast to nasojejunal or nasogastric tube feeding which usually requires the use of commercially available preparations to maintain adequate nutrition.

Gastrointestinal bleeding is a common situation faced by physicians, surgeons, and gastroenterologists. Although this can be life threatening and should always be treated as an emergency, very often these patients present to overburdened emergency rooms where the understanding of the care of these patients may or may not be adequately appreciated. The question often arises of intervention in these patients and the timing of intervention, which is often dictated by the availability of persons and teams with adequate expertise in the management. Several scoring systems have been used to triage patients with upper gastrointestinal bleeding to receive acute care or semi-emergent elective care. In this issue of the journal, Dr. Totagi et al. from Apollo Hospital, Chennai, compare the ability of three scores – the complete Rockall score, the Glasgow Blatchford score, and AIMS65 score – for predicting in-hospital mortality, rebleeding, and transfusion requirements in 207 patients admitted with upper gastrointestinal bleeding in their hospital. From their data, it is clear that all of these scores perform adequately in recognizing patients at greatest risk and therefore requiring emergency management and intervention. Internists and emergency physicians should be made aware of these scores and their utility and their use should be instituted in hospitals that receive and treat patients with upper gastrointestinal hemorrhage.

Constipation and disordered defecation are major problems in all parts of the world. In recent years, there has been an increasing understanding of the physiology underlying these disorders that cause so much trouble among afflicted individuals. The role of biofeedback and pelvic floor physiotherapy in the management of these disorders is increasingly understood. However, a lack of trained and motivated caregivers who can impart this treatment is sadly lacking in the country. Ms. Venkatesa et al. from Global Health City, Chennai, provide a simplified account of how this training, tailored to a setting in Chennai, is imparted in their institute. This can be easily adapted in any part of the country. The exercises for individual muscles or muscle groups are illustrated. If there is increased awareness of the nature and utility of this form of treatment among gastroenterologists, it will likely lead to greater use of this form of therapy for people with defecatory disorders in this country.


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