Rodenticide ingestion, a common mode of suicide in Tamil Nadu and other states in southern and western parts of India, can lead to hepatotoxicity and death. Most rodenticide agents contain phosphorus, a potent toxin. The only definitive management in a patient who develops rodenticide induced acute liver failure is urgent liver transplantation. A study conducted across Tamil Nadu in 2019 documented that the majority (>99%) of rodenticide hepatotoxicity patients cannot access urgent liver transplantation. The current guidelines proposed by the Tamil Nadu chapter of the Indian Society of Gastroenterology are focused on improving survival in these patients, especially by nontransplant treatments. The indications for the use of plasma exchange, an emerging treatment which improves survival in acute liver failure, are described. In resource-constrained settings, it is preferable to avoid the use of sedative drugs, in rodenticide hepatotoxicity patients, who do not have encephalopathy. These management guidelines are specifically meant for use by doctors in primary health centers and in secondary hospitals who care for patients with rodenticide ingestion and hepatotoxicity. We hope these guidelines may also help inform health care policy in Tamil Nadu state to improve survival in patients with rodenticide hepatotoxicity by cost-effective interventions.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

High-volume plasma exchange (PLEX) to treat acute liver failure is now categorized as a Category I indication (i.e., first-line treatment as a stand-alone treatment or with other treatment modalities) by the American Society for Apheresis after a randomized controlled trial of 183 patients demonstrated survival benefit by this treatment. In this review, we provide an introduction to PLEX to treat acute liver failure syndromes for hepatologists and gastroenterologists. From our recent experience of treating 188 patients with acute liver failure syndromes with low-volume PLEX and low-dose steroid, we present five illustrative case histories of patients who benefitted from this management protocol. We discuss some postulated mechanisms how PLEX benefits patients with acute liver failure syndromes. PLEX appears to provide survival benefit in patients with acute liver failure syndromes (severe acute liver injury, acute liver failure, and acute-on chronic liver failure) and may be a nontransplant treatment option for some of these patients, especially in resource-constrained settings.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Renal dysfunction is not uncommon in patients with cirrhosis, particularly as disease advances and the liver function decompensates. This review discusses the various types of renal dysfunction that may occur, the current classification of these kinds of kidney injury, and the rational management of these disorders based on the pathophysiology of these conditions.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Probiotic bacteria have become increasingly popular in the last two decades because of expanding scientific evidence pointing to their beneficial effects on human health. Currently it has become an attractive area of research in communicable and non communicable diseases. Their benefits are not only seen in GI diseases which are expected, but also seen in life style diseases like NAFLD and Cancer. This article provides a review of available information and summarizes the recent knowledge on the effects of prebiotics, probiotics and synbiotics on human health.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

High-resolution esophageal manometry (HREM) is a technique to determine the function of esophageal musculature and the integrity of the lower esophageal sphincter. This test is commonly used for evaluation of nonobstructive dysphagia, assessment of peristaltic reserve before anti-reflux surgery, symptoms of regurgitation, and noncardiac chest pain unexplained by endoscopic evaluation. The current review deals with the spectrum of esophageal motility disorders in India and reviews the technique and reporting of HREM. The clinical utility of HREM in Indian setting with special reference to challenges faced has been discussed in detail.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Diarrhea is not uncommon in immunocompromised patients We report here four renal transplant patients in whom a molecular testing panel for gastrointestinal pathogens revealed positive test for norovirus.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Background: Multiple risk assessment scores are available to triage and stratify patients presenting with upper gastrointestinal (GI) hemorrhage. This study was conducted to compare the accuracy of complete Rockall score (CRS), Glasgow–Blatchford score (GBS), and AIMS65 score (AIMS65-albumin, INR >1.5, impaired mental status, systolic pressure <90 mm Hg, and age >65) in predicting in-hospital mortality in patients presenting with upper GI hemorrhage to the gastroenterology department at a tertiary care hospital in Southern India. The secondary objectives were to compare these three scores in predicting the need for blood transfusion, any intervention (endoscopic or radiological or surgical intervention), or rebleeding in patients presenting with upper GI hemorrhage. Materials and Methods: This was a retrospective analysis of prospectively recorded data which included 207 patients with acute upper GI hemorrhage admitted at a tertiary care hospital at Chennai over 2 years. Demographic, clinical, laboratory, and endoscopic parameters were recorded. CRS, GBS, and AIMS65 scores were calculated. Data regarding in-hospital mortality, need for blood transfusion, endoscopic intervention, radiological intervention, surgical intervention, and rebleeding were collected. Area under receiver operating characteristic curve (AUROC) was compared between the three scores in predicting in-hospital mortality, need for blood transfusion, intervention, and rebleeding. Results: AIMS 65 score >3 (AUROC 0.92) was a better predictor of in-hospital mortality than GBS (AUROC 0.77) and CRS (AUROC 0.69). AIMS65 was a better predictor of rebleeding (AUROC 0.804) than GBS (AUROC 0.676) or CRS (AUROC 0.623). GBS was a better predictor for need of blood transfusion (AUROC 0.785) than AIMS65 (AUROC 0.691) or CRS (AUROC 0.629). Conclusion: AIMS 65 score (>3) was a better predictor of in-hospital mortality than GBS or CRS in patients presenting with acute upper GI hemorrhage due to either variceal and nonvariceal etiology. AIMS 65 was also a better predictor of risk of rebleeding. GBS was a better predictor of need for blood transfusion and need for intervention.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Background: Defective innate immune recognition of gut microbes may be one reason for the genesis of inflammatory bowel disease (IBD). Genetic defects in IBD show considerable variation between populations. This study evaluated three single-nucleotide polymorphisms (SNP) in the toll-like receptor (TLR) genes in patients with IBD and healthy controls. Methods: DNA isolated from peripheral blood of 200 IBD patients (100 Crohn’s disease and 100 ulcerative colitis) and 100 healthy controls were subjected to polymerase chain reaction and restriction enzyme digestion for three SNPs in TLR4 (D299G, rs4986790), TLR5 (392 stop codon, rs5744168) and TLR9 (-1486 T/C, rs187084) genes, and genotypes assigned according to the restriction fragment length polymorphism pattern. Results: Minor allele frequencies for the 3 polymorphisms were not significantly different between IBD patients and healthy controls. The TLR4 rs4986790 minor allele (G) frequency was 27/200 in controls compared to 48/400 in IBD (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.52–1.44, P = 0.6007). The TLR5 rs5744168 minor allele (T) frequency was 19/200 in controls compared to 45/400 in IBD (OR 1.20, 95% CI 0.63–2.12, P = 0.5132). The TLR9 rs187084 minor allele (C) frequency was 71/200 in controls compared to 129/400 in IBD (OR 0.88, 95% CI 0.61–1.26, P = 0.4261). Conclusion: These three polymorphisms in the TLR genes were not associated with IBD in the Indian population.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Inflammatory cap polyposis (CP) is a uncommon, non-malignant condition characterized by the presence of sessile and pedunculated polyps in the colon and rectum. The histology of these polyps reveals a “cap” of inflammatory granulation tissue with fibrinopurulent exudate that covers the polyps, hence the name “inflammatory cap polyposis”. The pathogenesis of this non-malignant condition is poorly understood and while several associations have been made, causality has yet to be elucidated. The mainstay of initial treatment is conservative, however complicated and refractory cases usually benefit from endoscopic or surgical intervention followed by close surveillance for disease recurrence and progression. We present a 12 yr old girl with a large cap polyposis which was resected successfully by EMR and literature review.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Nocardia is an emerging infection in the era of biological therapy with a fatal outcome without treatment. Risk of dissemination and multisystem involvement demands an early diagnosis from the treating physician. We share our experience of such opportunistic infection (pulmonary nocardiosis) in a young male with Crohn's disease on injection adalimumab. The patient was managed with appropriate antibiotics and after therapy, prophylaxis with cotrimoxazole was initiated. Adalimumab was re-introduced, as he developed flare-up of the perianal disease on follow-up. Atypical opportunistic infection requires a meticulous approach to reach early diagnosis to prevent poor outcomes.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure for establishing enteral access for nutrition. There is a paucity of literature on PEG from the Indian subcontinent. With the rate of complications in the literature showing a downward trend, we aimed to analyze the same in our institute following a standard procedure of PEG tube placement. Methods: The prospective study was conducted including patients referred for PEG placement from August 2017 to December 2019. Data were recorded on a proforma. The primary aim of the study was to determine the rate of complications in patients undergoing PEG, whereas the secondary aim was to determine whether early feeding was associated with increased rate of infection or other complications. Patients were reviewed after 3 days, 1 month, and every 3 months thereafter later with clinical examination. Results: Sixty-seven (83.75%) males and 13 (16.25%) females with a median age of 51 years (range 1–85) were included in the study. Forty-one (51.25%) patients had comorbidities with hypertension being the most common (n = 28). Postoperative placement of the PEG tube was done in 47 (58.75%) patients. Seventy-four patients had underlying neurological or neurosurgical conditions. At the time of PEG placement, 59 (73.75%) had tracheostomy. All procedures were performed in the endoscopic suite, of which two were performed as day care procedures. There were no intraprocedural complications. Feed was started within 2 h in 45 (56.25%) patients and all tolerated feed well. There were no major postprocedural complications. Thirteen patients had clinically suspected PEG site infection, of which 11 patients had a culture-positive organism. All responded to conservative management. Thirty-two patients were on follow-up at a median follow-up period of 2 years. Conclusion: The incidence of complications following PEG tube placement is low. With the standardization of the PEG technique, no major complications were seen in our study. Early PEG feeding was not associated with an increase in the rate of complications.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Tuberculosis (TB) of the gastrointestinal tract is common in India. The most common site is the ileocecal region. TB involving the duodenum is rare. It can present as duodenal ulcer, gastric outlet obstruction, and rarely with periduodenal lymph nodal involvement and bile duct erosion. Here, we report a patient who presented with pain abdomen and significant weight loss. Evaluation revealed a duodenal ulcer with paraduodenal nodal mass with probable contained perforation. Endoscopic ultrasound with fine-needle aspiration cytology of the nodal mass revealed the diagnosis of TB. She was started on anti-TB therapy and responded well with complete resolution. This case report emphasizes the need for having TB as a differential diagnosis for duodenal ulcer in an endemic country like India.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Adenoid cystic carcinoma (ACC) is an uncommon tumor of the salivary glands and is known for its delayed presentation of distant metastasis. However, delayed presentation of metastatic ACC in the liver without primary recurrence is rare, and literature is limited. In this case report, we present a case of metastatic ACC involving the liver without primary recurrence 6 years after radical excision of submandibular ACC.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Objectives: Inflammatory arthritis or enteropathic arthropathy (EA) is a common extra-intestinal manifestation in patients with inflammatory bowel disease (IBD). We aimed to determine whether EA in patients with IBD was associated with changes in the gut microbiome. Methods: Consecutive patients with ulcerative colitis (UC) or Crohn's disease (CD) were prospectively recruited and characterized. Stool samples were collected and real-time polymerase chain reaction targeting 16S ribosomal RNA genes was used to quantitate specific communities of “beneficial”; (Clostridium coccoides, bifidobacteria, and lactobacilli) or “aggressive” (Bacteroides and Enterobacteriaceae) bacterial flora. In 12 patients with UC and 12 with CD, fecal 16S ribosomal RNA gene was subjected to next-generation sequencing (NGS) and bacterial taxa were enumerated and compared between IBD patients with and without EA. Results: Sixty-eight patients with UC and 60 with CD were included in the study. Arthropathy was noted in 13 (21.6%) patients with CD and 11 (16.1%) patients with UC. Arthritis was peripheral in 12, axial in 7, and mixed in the rest. The most prevalent commensal bacteria in IBD patients were Bacteroides and Bifidobacterium. Enterobacteriaceae count was significantly higher in patients with UC than in CD. UC patients with EA had relatively higher Enterobacteriaceae and lesser C. coccoides than UC patients without EA. The NGS analyses showed a significant reduction in alpha diversity in patients with EA compared to IBD without EA. Patients with EA had significantly greater abundance of enterococci compared to IBD without EA. Conclusions: EA in IBD patients is characterized by gut microbiome changes including dysbiosis, reduction in alpha diversity, and increased abundance of enterococci.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Pancreatic sepsis secondary to infected necrosis or pancreatic abscess is a well-known clinical entity. Acute obstructive suppurative pancreatic ductitis (AOSPD) in the setting of chronic calcific pancreatitis is a rare complication that is seldom reported. We report two cases of AOSPD who underwent successful pancreatic endotherapy.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Immunosuppression in immediate post liver transplantation (LT) setting is crucial to prevent rejection. Most immunosuppressant (IS) drugs have several adverse effects, necessitating dose adjustment, close monitoring of blood levels, and choosing the right drug on a case-to-case basis so as to achieve optimal immunosuppression with minimal side effects. Although guidelines are available for management, the IS regimen differs from center to center, especially with introduction of new agents. The calcineurin inhibitors (CNIs) are the most important class of IS regimen. However, the occurrence of major adverse effects with CNIs has necessitated the need for alternative drugs such as mammalian target of rapamycin inhibitors and antibody induction therapies. Early rejection episode management, especially within the first 3 months after LT, needs special consideration. The present review will highlight the current strategies in induction and maintenance of LT recipients in the immediate post-LT period and in a selective special situation.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Cholangitis is very rarely caused by impaction of a pancreatic stone in the papilla. An elderly male presented with obstructive jaundice and cholangitis that was caused by an impacted pancreatic stone. He presented as fever of 2 weeks duration and was referred as case of periampullary neoplasm for palliative stenting. However, an endoscopic retrograde cholangiopancreatogram was done which revealed the impacted stone. Precut papillotomy was done to release the stone, which led to the resolution of cholangitis.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

POEMS syndrome is a rare paraneoplastic condition associated with polyneuropathy, organomegaly, monoclonal gammopathy, and endocrine and skin changes. It is a fatal disease and associated with compromised quality of life through volume overload, neuropathy, thromboembolic events, and weight loss. A diagnosis of POEMS syndrome is made with three of the major criteria, two of which must include polyneuropathy and monoclonal plasma cell proliferative disorder and at least one minor criterion Gastrointestinal (GI) involvement with initial predominant presentation as chronic diarrhea is extremely rare and rarely reported in the literature. Here, we highlight a case of Castleman disease variant of POEMS syndrome with predominant GI involvement and discuss plausible pathogenesis mechanism in relevance to the available literature.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: The existing scores for predicting severity of acute pancreatitis (AP) underperform in sensitivity. The existing scores do not predict moderately severe pancreatitis. Methods: We performed a prospective observational study from August 2014 to April 2016 on patients hospitalized at Apollo Hospitals, Chennai, with a clinical diagnosis of AP (as per Atlanta 2012 classification). Three established scoring systems – Complete Ranson's (at 48 h), Acute Physiology and Chronic Health Evaluation (APACHE-II), Bedside Index of Severity in AP (BISAP) and new score BISAP + saturation of oxygen, hematocrit (BISAP + SHO) (packed cell volume [PCV]) and overweight by body mass index [BMI]) were calculated at admission. In BISAP + SHO score 5 points were given as in BISAP and 3 points were added 1 each for low oxygen saturation ≤92%, PCV ≥47% and BMI of ≥23 making BISAP + SHO an 8-point score. The prediction by scores was validated against the actual clinical outcome of severity. Results: Of 102 patients with AP, 34 (33%) patients had organ failure (OF) and in 17 patients (16.5%) it lasted >48 h, classified as severe AP. Remaining 17 were moderately severe AP as OF resolved within <48 h. Cut-off values to predict severe pancreatitis were - Ranson's score - ≥3, APACHE-II - ≥8, BISAP - ≥3, and BISAP + SHO - ≥5. Area under receiver operator curve (AUC) for Ranson's, APACHE-II, BISAP and BISAP + SHO were 0.958, 0.953, 0.899 and 0.989, respectively. With a score 3 or 4, BISAP + SHO predicted moderately severe AP with a sensitivity of 94.12%, specificity 97.6%. Conclusions: The BISAP + SHO (rephrased as BISSHOAP) stratifies AP with better AUC than existing scores and is also able to predict moderately severe pancreatitis in the ER.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]