Search

Background: Acute pancreatitis (AP) is the commonest complication of endoscopic retrograde cholangiopancreatography (ERCP). Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease., Objective: To examine the clinical course, disease severity, and outcome of patients with post-ERCP-AP., Methods: All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, infectious complications, need for surgery and mortality. The clinical course and outcome of patients with post-ERCP-AP were also compared with those of patients with gallstone pancreatitis (GS-AP)., Results: Of the 1497 de novo ERCP procedures, 57 (3.8%) patients developed AP. Their mean age was 40.2 years (13.1), 16 were males of them, 54 (95%) patients had mild pancreatitis. Only 2 patients developed organ failure. Fifty-four (95%) patients recovered with conservative management. One of the 57 patients died. As compared with patients with GS-AP (n=174), APACHE II scores at admission [3.3 (3.1) vs. 5.8 (4.8); P=0.011], occurrence of pancreatic necrosis (17.5% vs. 39.1%; P=0.020), organ failure (3.5% vs. 19.0%; P=0.015), infectious complications (8.7% vs. 24.7%; P=0.040), and mortality (1.8% vs. 13.2%; P=0.044) were significantly less among patients with post-ERCP-AP., Conclusion: Unlike previous belief, we found that post-ERCP AP was a mild disease with a favorable outcome in most cases.

The clinical profile of antituberculosis treatment (ATT)-induced hepatotoxicity is variable, and the reintroduction of ATT in patients who have developed such injury is controversial. We conducted a prospective study to determine the clinical profile in patients with ATT-induced hepatotoxicity and to test a predefined strategy of reintroduction of ATT. Seventy-two consecutive patients with clinical evidence of ATT-induced hepatotoxicity were included. Jaundice was the presenting symptom in 44 (61%) patients; prodromal symptoms were present in 28 (39%). Serious complications developed in 12 (16.6%) patients (fulminant hepatic failure in seven, subacute hepatic failure in four, hepatic encephalopathy in one). Nine patients (three males, six females) died from these complications. The mean duration of treatment before the onset of hepatitis was significantly longer in the group that died (53.22 +/- 36.22 days) than in the rest of the patients (31.07 +/- 30.30 days; p < 0.01). Malnutrition was present in 37 of the 72 patients. After resolution of drug induced hepatitis, reintroduction of isoniazid and rifampicin was possible in 41 of 44 patients. Thus, our results showed that ATT-induced hepatitis carried significant morbidity and mortality, that malnutrition was common in patients with ATT-related hepatitis, and that potentially hepatotoxic antituberculosis agents could be safely reintroduced after recovery from hepatitis.

Dietary intake and plasma lipids were estimated in 200 patients with gallstones and 98 control subjects from a hospital in Northern India and were matched for age, sex, and social class. The intake of total calories and carbohydrates and the plasma triglyceride values were higher in all gallstone patients as compared with controls (p < 0.05 and p < 0.01, respectively). The dietary intake of refined carbohydrates was higher than in controls, but only in the female patients with gallstones (35.6 +/- 32.9 g/day compared with 24.5 +/- 11.8 g/day; p < 0.001). By contrast, the male patients with gallstones had an increased intake of fat (patients 79.0 +/- 38.1 g/day vs. controls 60.2 +/- 24.3 g/day; p < 0.05) and had increased plasma cholesterol values (patients 166.4 +/- 54.2 mg/dl vs. controls 140.3 +/- 32.8 mg/dl; p < 0.01). Such sex differences in the dietary intake and plasma lipid values may form a special feature of gallstone disease in Northern India and should be studied further.

Common bile duct stones are usually associated with stones in the gallbladder. During the period 1989-1991, however, we encountered 17 patients with common bile duct (CBD) stones without gallbladder stones who had presented with obstructive jaundice and cholangitis. Their ages ranged between 30 and 72 years; 10 were female and seven male. Five of them had a deceptive presentation and were initially misdiagnosed as having a malignant lesion. It was endoscopic retrograde cholangiopancreatography that correctly diagnosed the presence of CBD stones in all 17 patients. Therapeutic sphincterotomy led to subsidence of cholangitis in 16 patients and retrieval of stones in 13 of them. Three patients required nasobiliary decompression because stones could not be retrieved. One patient required emergency surgery due to flare-up of cholangitis. Cholesterol concentration of the retrieved stones was 70-92% of the dry weight. Thus, these 17 patients formed a distinct subgroup who had cholesterol CBD stones with stoneless gallbladder, and five of these 17 patients had presentations mimicking malignant lesions.

In a prospective case controlled study, we evaluated the adverse effects of long-term fluoride ingestion on the gastrointestinal tract. Ten patients with otosclerosis who were receiving sodium fluoride 30 mg/day for a period of 3-12 months, and 10 age- and sex-matched healthy volunteers were included. They were all evaluated clinically and subjected to a real time ultrasound examination, upper gastrointestinal endoscopy, and biopsies from the gastric antrum and duodenum. The biopsies were subjected to a rapid urease test as well as light and electron microscopic examinations. Ionic fluoride was estimated in the serum, urine, and drinking water using an ION 85 Ion Analyzer. Seven subjects (70%) ingesting fluoride had abdominal pain, vomiting, and nausea. Petechiae, erosions, and erythema were seen on endoscopy in all the subjects, but not in the controls. Histological examination of the gastric antral biopsy showed chronic atrophic gastritis in all the subjects but in only one (10%) healthy volunteer. Scanning electron microscopic examination showed "cracked-clay" appearance, scanty microvilli, surface abrasions, and desquamated epithelium in the subjects ingesting fluoride, but not in the controls. We conclude that long-term fluoride ingestion is associated with a high incidence of dyspeptic symptoms as well as histological and electron microscopic abnormalities.

We analyzed retrospectively the characteristics of 87 patients with ulcerative colitis seen in a tertiary care center in north India. Ulcerative colitis was diagnosed on the basis of clinical features, sigmoidoscopy, rectal biopsy, and exclusion of microbiological causes of colitis. Severe clinical disease was seen in 53 (60%) patients that correlated with extensive colonic involvement (p < 0.001), severe changes on sigmoidoscopy (p < 0.001) and histology (p < 0.001), erythrocyte sedimentation rate (ESR) of > 30 mm for the first hour, and serum albumin of < 3 g/dl (p < 0.001). Remission of the disease was maintained on sulfasalazine in 18 (20.7%) patients, whereas 47 (54%) required steroids. Proctocolectomy with ileoanal anastomosis was done in 22 (25.3%) patients in whom there was poor response to medical treatment. Postoperative complications were seen in seven (31.8%) patients, and death occurred in four (18.1%) patients. Ulcerative colitis thus commonly presents as severe disease, with the majority of patients requiring surgery due to poor response to medical therapy. This pattern of disease as seen in an academic referral hospital in north India is virtually indistinguishable from that seen in similar centers in the West. However, in our setting, proctocolectomy and ileoanal anastomosis is cost-effective in patients unresponsive to, or unable to afford, drug treatment.

Twenty-five patients with bleeding peptic ulcers were randomized to receive either ranitidine 50 mg 8 hourly i.v. (control group) or a continuous nasogastric antacid infusion at the rate of 0.5 ml/min along with an i.v. injection of cimetidine 100 mg/h (treatment group). Twelve patients were included in the control group and 13 in the treatment group. The mean gastric pH on therapy was significantly higher in the treatment group (7.88 +/- 0.37) than in the control group (5.00 +/- 0.55) (p less than 0.001), and the gastric pH was noted to be greater than 7 on 95% of the occasions in the treatment group and on 8.6% of the occasions in the control group. An overall control of bleeding was achieved in 92.3% of the patients in the treatment group and 50% of the patients in the control group (p less than .05). Thus, the failure of therapy was significantly more common in the control group than in the treatment group (p less than 0.05), and more patients of the control group had to undergo emergency surgery than that in the treatment group. None of the patients in the treatment group, but 16.6% of the patients in the control group, died during the study period in the hospital stay. We conclude that in patients with bleeding peptic ulcer an intensive medical therapy comprising hourly injections of cimetidine (or presumably of other H2 blockers) and continuous nasogastric antacid infusion can achieve sustained achlorhydria, better control of bleeding, and reduce the need for emergency surgery.

In a prospective study of 22 patients with solitary rectal ulcer, we tried to define the features of this condition, especially the associated systemic features, that may give some clues to its etiopathogenesis. In 15 of these patients a single rectal ulcer was found, whereas in seven patients two ulcers were present in each. Of the total 29 ulcers in these patients, 19 were located on the anterior or anterolateral wall of the rectum and 10 were on the posterior or posterolateral wall. The sigmoidoscopic appearance of the ulcer was quite characteristic, yet a biopsy was considered essential to rule out other pathologic processes. Histological features of the solitary rectal ulcer comprised fibrous obliteration of the lamina propria with disorientation of the muscularis mucosa and extension of muscle fibers into the lamina propria. Evident rectal prolapse was present in only three patients. Recurrent oral ulcerations occurred in four (18.2%) patients and erythema nodosum in one of them (4.5%). Sacroiliitis was present in six of 19 (31%) patients studied radiologically, and human leukocyte antigen (HLA)-B27 occurred in four of the 20 patients (20%) tested for HLA class I antigens. All the four HLA-B27-positive patients had associated sacroiliitis and showed good response to sulfasalazine. These associations raise the possibility that solitary rectal ulcers may be a part of a systemic disease or of several diseases with varied etiology.