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The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.

Cirrhotic patients are prone to infections due to underlying immune dysfunction in them. We aimed to study the role of inflammatory markers, serum C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), in predicting infection, blood culture positivity, and short-term (1 month) mortality in hospitalized cirrhotic patients. This prospective study was done over a period of 14 months (October 2017 to November 2018). Patient data included age, gender, etiology of cirrhosis, reason for admission, and comorbidity. Laboratory tests included blood chemistry and blood cell counts, and blood and urine culture. The specific tests included were CRP and NLR. Survival of patients in the following 1 month was noted. Area under receiver operating characteristic curve (AUROC), sensitivity, specificity, predictive values, diagnostic accuracy were calculated and logistic regression analysis performed. A p-value < 0.05 was considered significant. Two hundred and eight patients formed the study cohort. The median age was 51.5 years and male predominance was noted. Alcohol-related liver disease (49%) was the commonest etiology. The infection rate was 62%, culture positivity was 58.5%, and mortality was 30.8%. NLR and CRP were significantly higher in those with documented infection (culture positive or negative) and among nonsurvivors. Optimal cutoffs for NLR and CRP to predict infection were 5.86 and 33.7, respectively. The risk of having an infection was 7.5 times and about 15 times if NLR and CRP were above the cutoffs. The risk of 1-month mortality was 2–3 times higher if patients had NLR and CRP above the cutoffs. The combination of NLR and CRP (≥ 5.86 and ≥ 33.7, respectively) increased specificity and diagnostic accuracy for infection. NLR and CRP were independently good predictors of infection and 1-month survival among the patients with cirrhosis of liver included in this study.

BACKGROUND: Etiology of and outcomes following idiosyncratic drug-induced liver injury (DILI) vary geographically. We conducted a prospective study of DILI in India, from 2013 to 2018 and summarize the causes, clinical features, outcomes and predictors of mortality. METHODS: We enrolled patients with DILI using international DILI expert working group criteria and Roussel Uclaf causality assessment method. Follow-up was up to 3 months from onset of DILI or until death. Multivariate logistics regression was carried out to determine predictors of non-survival. RESULTS: Among 1288 patients with idiosyncratic DILI, 51.4% were male, 68% developed jaundice, 68% required hospitalization and 8.2% had co-existing HIV infection. Concomitant features of skin reaction, ascites, and encephalopathy (HE) were seen in 19.5%, 16.4%, and 10% respectively. 32.4% had severe disease. Mean MELD score at presentation was 18.8 ± 8.8. Overall mortality was 12.3%; 65% in those with HE, 17.6% in patients who fulfilled Hy's law, and 16.6% in those that developed jaundice. Combination anti-TB drugs (ATD) 46.4%, complementary and alternative medicines (CAM) 13.9%, anti-epileptic drugs (AED) 8.1%, non-ATD antimicrobials 6.5%, anti-metabolites 3.8%, anti-retroviral drugs (ART)3.5%, NSAID2.6%, hormones 2.5%, and statins 1.4% were the top 9 causes. Univariate analysis identified, ascites, HE, serum albumin, bilirubin, creatinine, INR, MELD score (p < 0.001), transaminases (p < 0.04), and anti-TB drugs (p = 0.02) as predictors of non-survival. Only serum creatinine (p = 0.017), INR (p < 0.001), HE (p < 0.001), and ascites (p = 0.008), were significantly associated with mortality on multivariate analysis. ROC yielded a C-statistic of 0.811 for MELD and 0.892 for combination of serum creatinine, INR, ascites and HE. More than 50 different agents were associated with DILI. Mortality varied by drug class: 15% with ATD, 13.6% with CAM, 15.5% with AED, 5.8% with antibiotics. CONCLUSION: In India, ATD, CAM, AED, anti-metabolites and ART account for the majority of cases of DILI. The 3-month mortality was approximately 12%. Hy's law, presence of jaundice or MELD were predictors of mortality.

Inflammatory bowel disease (IBD) in recent times is causing a significant healthcare burden as both ulcerative colitis and Crohn's disease (CD) require lifelong therapy and constant monitoring. The current review highlights the concerns in a country like India with special reference to the changing trends of IBD, risk attribution and the financial issues. Indian immigrants behave like residential Indians, whereas their children show IBD prevalence similar to the West, highlighting the role of environmental triggers. However, the environmental and genetic factors in Indians with IBD are not well understood. Men appear to be more frequently affected than women in India. The disease severity is milder in the patients, both males and females, but the risk for colorectal cancer (CRC) is similar to the West. The incidence of paediatric IBD is on the rise. The major burden of IBD in the Indian subcontinent at present is in children, adolescents and teens. Cost towards the management of complications, non-adherence to treatment, differentiating tuberculosis from CD and finally screening for CRC in patients with IBD are the points to ponder in the Indian scenario.

Introduction: Malaria is a growing global threat and a major cause of mortality in the tropics. The gold standard diagnosis is peripheral blood smear examination. It has been demonstrated that melatonin acts as messenger molecule in malaria pathophysiology. This concept was used to evolve a clinical study wherein use of exogenous melatonin could improve the chance of detection of the parasite. Methodology: In a prospective study, 80 consecutive patients seen in the Department of Medicine at Kasturba Hospital, Manipal, suspected to have malarial fever were enrolled with proper informed consent, and randomly assigned to the groups given oral melatonin 3mg (melatonin group, n = 40) or placebo (control group, n = 40). Blood samples were collected for peripheral smear examination at baseline and then at two, three, four and five hours after drug administration. The primary end point was the parasite detection index. Results: Baseline characteristics of patients were comparable. In the melatonin group, there was a significant increase of 0.0943 ± 0.22 in the mean parasite index from 0.217 ± 0.42 pre-melatonin to 0.3114 ± 0.5 post-melatonin (p = 0.001), compared to a difference of 0.0025 ± 0.22 in mean parasite index before and after placebo in the control group (p = 0.95). The maximum rise in parasite detection was seen at five hours after melatonin. Conclusions: In a single centre study, for the first time, it has been shown that a significantly higher proportion of patients was diagnosed with malaria on peripheral smear after oral melatonin administration, maximal at five hours after administration of melatonin.

Background Achalasia cardia is a rare esophageal motor disorder that is frequently diagnosed late. Aim The aim of this study was to study the symptoms, treatment given, and response to treatment in patients with achalasia cardia in an Indian setting. Materials and methods This retrospective study included all patients diagnosed with achalasia cardia on high‐resolution esophageal manometry, using Chicago Classification v 3.0. On follow up, patients were contacted by telephone, and details of the treatment given and response were recorded in a predesigned pro forma. We excluded overseas patients, postoperative cases of achalasia, and those in whom the manometry catheter could not be passed across the gastroesophageal junction. Results A total of 452 patients (260 males, median age 44.5 years) were included in the study cohort. The major symptoms included dysphagia for solids and liquids (428, 94.7%), regurgitation (360, 79.6%), naso‐oral regurgitation (182, 40.3%), weight loss (322, 71.3%), and chest pain (158, 35%). Type 2 achalasia (229, 50.6%) was the most common subtype, followed by type 3 (154, 34.1%). Chest pain was more common in type 3, and weight loss and naso‐oral regurgitation were more common in type 2 achalasia. A majority of patients underwent Heller's myotomy and pneumatic dilatation. Of 280 patients for whom treatment details were available, 98% reported good response to endoscopic/surgical management. Conclusion The predominant symptoms of achalasia cardia vary per the manometric subtype. Heller's myotomy and pneumatic dilatation are the most commonly used treatment options. Response to treatment is good. The choice of treatment modality was likely influenced by financial reasons and availability of local expertise., The present study is a multicentre study involving five centres in various parts of India. The aim of the study is to determine the clinical symptoms, treatment given and response to treatment in patients with achalasia cardia in Indian setting.

There is scarce data from the Indian subcontinent on the outcomes following spontaneous bacterial peritonitis (SBP). To study the immediate (within 30 days) and short-term mortality (31–90 days) associated with SBP and to determine the predictors of the same. This prospective observational study was done among patients with liver cirrhosis who underwent paracentesis. Patient data included age, gender, co-morbidity, cirrhosis-related complications, model of end-stage liver disease (MELD), and Child-Turcotte-Pugh (CTP) scores. SBP was diagnosed based on ascitic fluid polymorphonuclear leukocyte count > 250/mm3 with or without ascitic fluid culture positivity. Of the 870 patients with cirrhosis and ascites registered during the study period, 610 fulfilled the criteria for inclusion. Altogether, 122 patients with SBP were identified: 52 (42.6%) died, 40 (32.8%) survived without liver transplant, and 30 (24.6%) underwent liver transplantation within 3 months. Thirty-two patients (26.2%) were blood culture posi tive for bacteria and 7 (5.7%) demonstrable bacterial growth in ascitic fluid. Blood culture positivity was significantly higher in the group with immediate mortality (p

The major drawback of conventional white light endoscopy (WLE) is that it lacks accuracy in diagnosis and differentiation of various benign and premalignant mucosal gastrointestinal lesions. To overcome this, image-enhanced endoscopy techniques, which provide high-definition images with good resolution and contrast enhancement, have been developed. One such technique is narrow-band imaging (NBI). NBI functions by filtering the illumination light. The red component of the standard red, green, and blue filters is rejected and the selected bandwidth of the blue and green light is transmitted. The present review highlights the role of NBI in diagnosis of benign gastric lesions like atrophic gastritis, Helicobacter pylori–related gastritis, intestinal metaplasia, and other rarer conditions. NBI is a simple procedure which does not require any additional equipment and does not have a long learning curve. Use of NBI in daily practice is likely to improve detection of mucosal abnormalities.

Background and Aim To determine the concordance of liver explants with the pretransplant diagnosis. Methods This was a retrospective analysis of 251 liver explants. Patient information included demography, comorbidity, and etiological diagnosis. Final diagnosis was based on morphological and histological findings. For non‐alcoholic steatohepatitis (NASH) and cryptogenic cirrhosis, we investigated comorbid states such as obesity, hypertension, and diabetes. Chi square test and Cohen's Kappa value were used. A P value of, A significant concordance of explant diagnosis with pretransplant diagnosis was present in alcohol, hepatitis B, hepatitis C, autoimmune liver disease, biliary cirrhosis, and Budd–Chiari syndrome. For 37 patients with a pretransplant diagnosis of cryptogenic cirrhosis, major discordance was observed in 23 (62.1%). Cohen's Kappa for concordance of pretransplant diagnosis and explant diagnosis in non‐alcoholic steatohepatitis and cryptogenic cirrhosis patients was 0.75 and 0.47, respectively. An incidental hepatocellular carcinoma was observed in 16 explants, and 18 had granulomas.

Background and aim Regional differences in gallstone (GS) composition are well documented in the Indian subcontinent. The reasons for the same are unknown. Etiopathogenesis of GS remains elusive despite advances in instrumentation. This was an in-depth analysis of the chemical, structural, and elemental composition of GS with special reference to synchroton studies. Methods We used high-end sensitive analytical complementary microscopic and spectroscopic methods techniques, such as X-ray diffraction, scanning electron microscopy, Fourier transform infrared, synchrotron X-ray fluorescence spectroscopy (SR-XRF), and 2D and 3D synchrotron microtomography (SR-μCT), to study the ultra structure and trace element composition of three major types of GS (cholesterol, mixed, and pigment). SR-XRF quantified the trace elements in GS. Results The cholesterol GS (monohydrate and anhydrate) were crystalline, with high calcium content. The pigment GS were amorphous, featureless, black, and fragile, with high calcium bilirubinate and carbonate salts. They had the highest concentration of iron (average 31.50 ppm) and copper (average 92.73 ppm), with bacterial inclusion. The mixed stones had features of both cholesterol and pigment GS with intermediate levels of copper (average 20.8 ppm) and iron (average 17.78 ppm). Conclusion SR-μCT has, for the first time, provided cross-sectional computed imaging delineating the framework of GS and mineral distribution. It provided excellent mapping of cholesterol GS. SR-XRF confirmed that pigment GS had high concentrations of copper and iron with bacterial inclusions, the latter possibly serving as a nidus to the formation of these stones.

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being

Background: There is scanty data from India regarding MUC protein expression from colorectal cancers (CRC) among Indian patients. Aim of the Study: The aim of this study is to assess the alterations in the expression of MUC2 and MUC5AC in 25 patients with CRC by site of the tumor location and differentiation at histology. Materials and Methods: Patients with proven adenocarcinoma of the colon alone were included for the study. Biopsy specimens obtained from tumorous lesions in the colon were classified based on histopathology as well differentiated, moderately, and poorly differentiated adenocarcinoma. Immunohistochemistry was done in the 4 μm thick sections to identify the expression of MUC2 and MUC5AC mucins. Results: MUC2 was uniformly expressed with near similar intensity while MUC5 was moderately (56%) to highly expressed (36%) in mucinous tumors. In nonmucinous tumors, MUC2 was least expressed (68%) with a significant expression on MUC5AC (88%). Except for rectosigmoid growth which had greater expression of MUC5AC (31%), both proximal and distal carcinomas had significant MUC2 and MUC5AC expression. Conclusion: MUC2 and MUC5AC are expressed in colonic cancers, the former showing mildtomoderate expression and the latter moderatetointense expression. The expression is more in mucinous adenocarcinoma.

IntroductionThese Asian Working Group guidelines on diet in inflammatory bowel disease (IBD) present a multidisciplinary focus on clinical nutrition in IBD in Asian countries.MethodologyThe guidelines are based on evidence from existing published literature; however, if objective data were lacking or inconclusive, expert opinion was considered. The conclusions and 38 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.ResultsDiet has an important role in IBD pathogenesis, and an increase in the incidence of IBD in Asian countries has paralleled changes in the dietary patterns. The present consensus endeavors to address the following topics in relation to IBD: (i) role of diet in the pathogenesis; (ii) diet as a therapy; (iii) malnutrition and nutritional assessment of the patients; (iv) dietary recommendations; (v) nutritional rehabilitation; and (vi) nutrition in special situations like surgery, pregnancy, and lactation.ConclusionsAvailable objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 38 recommendations.

Though rodenticidal hepatotoxicity is reported from India, there is no systematic study to assess its magnitude. This study aimed to assess exposure to rodenticide as a risk factor for acute hepatotoxicity in Tamil Nadu, India. We retrospectively analyzed acute hepatotoxicity caused by ingestion of hepatotoxin or potentially hepatotoxic drug overdose across 15 hospitals in 6 districts of Tamil Nadu from 1 January 2019 to 30 June 2019. Study exclusion criteria were idiosyncratic drug-induced liver injury and chronic liver diseases. Of the 702 patients, 685 gave history of consuming rodenticide; hepatotoxicity in the other patients resulted from paracetamol overdose (n=10) and due to other drugs (n=7); 97% patients had a suicidal intent. Of 671 patients with complete data, ratio of number of patients with hepatotoxicity due to rodenticide to paracetamol overdose was 450:6 (i.e. 75:1). The 451 rodenticidal hepatotoxicity patients (255 males, 75% were 15–34 years old) underwent conservative management (n=396), plasma exchange (n=54) and plasma exchange followed by liver transplant (n=1); 159 patients (35%) had poor outcome (131 died, 28 discharged in moribund state). Based on our observations, we estimate a case burden of 1584 rodenticidal hepatotoxicity patients (95% CI: 265–6119) with poor outcome in 554 patients in Tamil Nadu from January 2019 to June 2019. Population attributable risk for rodenticide as cause of hepatotoxicity was 22.7%. Rodenticide ingestion was an important cause of acute hepatotoxicity in Tamil Nadu. Most patients were young and one-third had poor outcome. Public health interventions are needed to address this.

Background Transarterial chemoembolization (TACE) is the most common locoregional therapy for hepatocellular carcinoma (HCC). Postembolization syndrome is not an uncommon complication. At present, there is no specific treatment for management of this complication. We aimed to study the role of N-acetyl cysteine (NAC), an antioxidant, in management of this complication. Methods In a prospective observational study, consecutive patients with HCC undergoing TACE from January 2016 to January 2017 were included. Patients with postembolization syndrome, defined as an elevation of transaminase levels more than 3–4 times the upper limit of normal, were administered intravenous NAC for 72 h (150 mg/kg for 1 h, then 12.5 mg/kg/h for 4 h, and continuous infusion 6.25 mg/h for the remaining 67 h). The other group received only supportive standard of care. The primary end point was reduction in post-TACE transaminitis. Results Of 112 patients with HCC, 53 (47.3%) received NAC. The majority were cirrhotics in both the groups. Both groups were well matched in demographic, laboratory, and tumor characteristics. In the NAC group, there was significant reduction in Aspartate transaminase (AST) and Alanine transaminase (ALT) levels from day 1 to day 3 (p = 0.000) compared with the non-NAC group, with no significant change in bilirubin or international normalized ratio levels. The duration of hospital stay was similar in both the groups. None had any major adverse events to NAC. Conclusion This is a prospective, single-center experience, showing that early initiation of N-acetyl cysteine in those with post-TACE embolization syndrome reduces the transaminase level significantly.

Aim: Retrospective analysis of medical records to determine whether diabetes mellitus (DM) was a risk factor for hepatocellular carcinoma (HCC) and whether it enhances the neoplastic potential of hepatotropic virus-related chronic liver disease (CLD). Materials and Methods: Patients registered between April 2017 and March 2018 with a clinical diagnosis of HCC in a pre-existing CLD were included. Controls were patients with CLD registered during the same period but with no HCC. Prevalence of DM, hypertension and coronary artery disease (CAD) alone or in combinations was noted in the two groups. The odds ratio (OR) of developing HCC was calculated independently for DM, hepatitis B and hepatitis C infection alone and in combinations. Chi-square test, Mann–Whitney test and OR calculation were done. A P < 0.05 was considered statistically significant. Results: The study population consisted of 150 cases of CLD with HCC and 812 controls (CLD with no HCC). CLD patients with HCC were significantly older (P < 0.0001) with a male preponderance, but no gender predisposition (P = NS). The overall prevalence of DM in patients with CLD was 31.9%, more significant amongst cases than in controls (50.7% vs. 28.7%) (P < 0.0001) and also for a significant duration (10.6 vs. 3.8 years; P < 0.03). Amongst the cases, comorbid conditions such as hypertension and CAD and diabetes in combination with hypertension and CAD was also more frequent among cases (P = 0.0001).The odds of developing HCC in CLD was higher for DM. The OR for HCC was highest for DM with hypertension and/or CAD at 4.69 (3.19–6.88, P < 0.0001). Conclusion: DM and other constituents of metabolic syndrome such as hypertension and CAD are significantly more common in CLD patients with HCC. DM is of prolonged duration and is a risk factor increasing the neoplastic potential of CLD.

Background: A good bowel preparation for colonoscopy is the most important factor that has an impact on visualization and outcome of the procedure. Aim: The primary aim of the study was to assess the quality of bowel preparation as reported by the Boston Bowel Preparation Score (BBPS). The secondary aim of the study was to analyze the patient feedback on ease of administration, palatability, and side effects with the bowel preparation. Materials and Methods: Patients undergoing colonoscopy between March 2018 and September 2018 were enrolled in the study. Patients

Aim of the study The recommended high dose albumin treatment for spontaneous bacterial peritonitis (SBP) is not possible in the Indian setting due to financial constraints. Aim of the study was the retrospective audit to determine the outcome of patients with SBP on combination treatment of low dose albumin and appropriate antibiotics. Material and methods Patients undergoing abdominal paracentesis in the period 2016-2018 were included. Patient details including age, gender, co-morbidity profile, details of previous hospitalisation and antibiotics, MELD score, and ascitic fluid analysis were noted. Details of albumin use and antibiotics were retrieved. SBP was classified based on mode of acquisition of infection and severity risk based on laboratory parameters. Statistics – χ2 test, Mann-Whitney U test, relative risk calculation. A p value of < 0.05 was considered as significant. Results 24 (18.8%), 38 (29.7%) and 66 patients (51.5%) belonged to low, intermediate and high risk SBP groups, respectively. The median dose of albumin was 20 g/day for a median duration of 5 days (range 1-8). Between the 3 subgroups, there was no significant difference in the median age; the majority were men. Antibiotic escalation was necessary in intermediate and high risk cases (42.1% vs. 84.8%, p < 0.0001). The mortality rate in intermediate and high risk groups was 29% and 42%, respectively (p = 0.18). Between the 2 subgroups of intermediate risk, patients with serum bilirubin < 4 mg/dl and serum creatinine > 1 mg/dl were significantly older (54 vs. 49 years, p = 0.02), and had high mortality (40.7% vs. 0%). Cirrhosis-related complications (CRC; one or more in combinations) were more frequent in high risk and intermediate risk patients (p = 0.001) with a 7-8 times higher risk of mortality compared to those who had no CRC. Conclusions Our protocol is associated with high mortality in intermediate and high risk SBP patients. Presence of one or more CRC increases the risk of mortality several fold.

Background Therapeutic plasma exchange (TPE) has been utilized in various liver disorders. There is limited data on the efficacy of TPE in patients with acute liver failure (ALF). Methods Study group consisted of patients who underwent TPE for ALF due to yellow phosphorous poisoning (YPP) between 2015 and 2019. Demographic data and biochemical parameters were recorded before and after TPE. Overall survival and transplant-free survival (based on King’s College Hospital Criteria [KCHC]) were analyzed. Results Forty-three patients underwent TPE for ALF due to YPP. Most of them were young males. Overall survival was 34 (79.06%). In our study population, 20 patients fulfilled KCHC (Group A) and 23 did not fulfill KCHC (Group B). Both the groups showed significant improvement in alanine aminotransferase, aspartate aminotransferase, and international normalized ratio (INR) after TPE (p

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Manometry and 24-h pH interpretation have seldom been studied. Our aim was to study these parameters as gold standard in reflux disease and to identify predictors of pathological acid reflux. Retrospective case record review of all patients with reflux disease evaluated using endoscopy, manometry, and 24-h pH testing from 2010 to 2016. Patients were categorized using Johnson-DeMeester score into two groups—group I (score > 14.7, normal study) and group II (< 14.7, normal study). These groups were compared for the above-mentioned parameters. Appropriate statistical tests were applied. P-value < 0.05 was considered significant. The study group includes 94 patients (median age 44 years, 63.8% males). Sixty (63.8%) and 34 patients belonged to groups I and II, respectively, 76.6% patients had normal endoscopy while the remaining had mild esophagitis. Peristalsis was normal in 66%, followed by ineffective esophageal motility (19.1%) and fragmented peristalsis (14.9%). Demography, symptoms, endoscopy findings, and peristalsis characteristics were similar between the two groups. Group II patients had significantly lower basal lower esophageal sphincter (LES) pressure (11.9 vs. 16.6; p < 0.02), lower integrated relaxation pressure (5.7 vs. 7.4; p < 0.01), and larger separation between LES and crural diaphragm (1.7 vs. 1.4 cm; p < 0.003). Basal LES pressure < 10 mmHg had the highest likelihood ratio (2.2) to predict an abnormal pH study. Basal LES pressure, integrated relaxation pressure, and hiatus size correlated with pathological acid reflux. Hypotensive basal lower esophageal sphincter pressure was the best predictor of an abnormal pH study but with negative linear correlation.

There is insufficient data from India regarding clinical predictors of dyssynergic defecation. To identify demography, symptom, and colonoscopic parameters that can predict dyssynergic defecation (DD) among patients with chronic constipation (CC) and to compare the profile among male and female patients with DD. Data collected from three centers during June 2014 to May 2017 included age, gender, symptom duration, form and consistency of stools, digital examination, colonoscopy, and anorectal manometry (ARM). Patients were grouped based on ARM diagnosis: group I (normal study) and group II (DD). The two groups were compared for demography, symptom profile, and colonoscopy findings. Gender-wise subset analysis was done for those with the normal and abnormal ARM using chi-square and unpaired t tests. Of 236 patients with CC evaluated, 130 (55%) had normal ARM and 106 (45%) had DD. Male sex, straining during defecation, bleeding per rectum, and abnormal colonoscopic diagnosis were significantly more common in group II. While bleeding per rectum and absence of urge to defecate were more common in males (p

India has a low incidence of gastric cancer. It ranks among the top five most common cancers. Regional diversity of incidence is of importance. It is the second most common cause of cancer related deaths among Indian men and women in the age between 15 and 44. Helicobacter pylori carcinogenesis is low in India. Advanced stage at presentation is a cause of concern. Basic and clinical research in India reveals a globally comparable standard of care and outcome. The large population, sociodemographic profile and challenges in health expenditure, however, remain a major challenge for health care policy managers. The newer formation of National Cancer Grid, integration of national databases and the creation of social identification database Aadhaar by The Unique Identification Authority of India are set to enhance the health care provision and optimal outcome.

Aim: This study aims to determine the clinical presentation, and ileal mucosal changes during colonoscopy for which terminal ileal (TI) biopsies were taken at our center and to determine the specific histopathology which had the best yield for specific colonoscopy findings. Materials and Methods: Retrospective audit of all patients who underwent colonoscopy with ileoscopy between 2012 and 2016. All patients with TI mucosal changes and normal colonic mucosa, who underwent ileal biopsy, were included in this study. Patient data regarding age, gender, indication for ileocolonoscopy (screening for colorectal cancers, inflammatory bowel disease [IBD], or irritable bowel syndrome [IBS]) and histopathology changes were collected. Appropriate statistical tests were used and P < 0.05 was considered statistically significant. Results: One hundred and nine patients had isolated ileal lesions. The median age was 44.1 years (range 8–80 years). Men outnumbered women in a ratio of 82:27. The major clinical indications for ileocolonoscopy were IBS (64.2%), followed by IBD (22%). Ulcers (aphthoid) were the most frequent finding followed by mucosal nodularity and nonspecific findings. Ulcers in ileum were most often reported as chronic ileitis (46.2%), followed by nonspecific changes (35.2%) Biopsy from nodular ileal lesions, were predominantly nonspecific (74.4%), followed by acute (15.4%) and chronic ileitis (10.2%). About 50% of specimens with nonspecific ileal changes had nonspecific histological changes. Ileal ulcers had the highest sensitivity, PPV, and NPV for significant histological findings. Conclusion: Ileal ulcers are the significant colonoscopy findings where tissue biopsy is likely to yield a definitive diagnosis and justify specific management. Biopsies from nonspecific ileal changes and nodularity should be discouraged as it is unlikely to pick up any major abnormality.

Introduction Cirrhosis of the liver predisposes patients to serious bacterial infections including cellulitis. The aim of the study was to determine the clinical and bacteriological profile of cellulitis in patients with liver cirrhosis. Material and methods In this prospective study, consecutive cirrhotic patients hospitalized between February and September 2017 were enrolled. Data retrieved included demographics, aetiology, co-morbidity, cirrhosis-related complications, site of cellulitis, baseline investigations, and wound and blood culture. Results Three hundred and thirty-eight patients were admitted, of whom 25 had cellulitis (mean age 52.8 ± 10.4 years, men 88.0%, median MELD [model of end-stage liver disease] 18.8 ± 10.4). Non-alcoholic steatohepatitis and alcohol were each the cause of cirrhosis in 40% of cases. Nine patients (36%) had diabetes mellitus. Cultures were positive in 13 cases (52%; 1 - blood, 11 - wound, 1 - both blood and skin). The majority of the cultures showed monomicrobial growth (9; 70%). Escherichia coli was the commonest isolate (6/13), followed by Klebsiella (4). 61% of isolates had multidrug resistant organisms. The outcome was favourable. Conclusions Prevalence of cellulitis was 7.4% in hospitalised cirrhotics. Culture positivity was 52%. Escherichia coli and Klebsiella were the most common isolates and three fifths of isolates were multidrug resistant.

Background: The histological nature of polyps by site prevalence and size is unclear. Aim: To determine the prevalence of polyps in patients undergoing routine lower gastrointestinal (LGI) endoscopy and identify the histological types and their characteristics by age, location and size. Materials and Methods: For this retrospective study, patients undergoing ileocolonoscopy or sigmoidoscopy between 2014 and 2016 were included. Data on age, gender, test indication, site and size of polyps and histology type were collected. Results: Two hundred and ninety (12.7%) of 2303 patients who underwent LGI endoscopy had colonic polyps (n= 317; single in 272 patients). The median age was 61.1 years (range 5-99 years) and 223 (76.4%) were men. Polyps were rare 60 years age. High grade dysplasia and carcinoma were rare (10.3%). While two-thirds of polyps

Background: The interface between tuberculosis (TB) and Crohn’s disease (CD) is relevant as TB complicates both the diagnosis and management of CD. Aim: This study aimed to identify the distinctive characteristics of ileocaecal and colonic TB (C‑TB) and colonic CD (C‑CD) at colonoscopy and to correlate the colonoscopy findings with histology. Materials and Methods: This prospective study included consecutive patients presenting with classical symptoms of TB or CD. The colonoscopic findings were compared with histology, which was taken as gold standard. Appropriate statistical tests were applied. Results: Fifty‑eight individuals fulfilled the inclusion criteria. Nine and 16 patients with C‑TB and C‑CD, respectively, had histological confirmation of respective diagnosis. In 33 specimens, the histological diagnosis was inconclusive. The sensitivity of colonoscopy for diagnosing C‑TB was high at 88.9% (95% confidence interval [CI]: 51.8–99.7). It was 50% (95% CI: 24.7–75.4) for CD. The reverse was true for CD whose specificity was high at 71.4% (95% CI: 55.3–84.3) and low for TB at 46.9% (95% CI: 32.5–61.7). All the patients diagnosed as confirmed CD or TB responded well to respective treatment. Six of the thirty patients with failed response to anti‑TB treatment required surgery or change in treatment after 2 months. Conclusion: Colonoscopic findings of isolated ileal involvement, aphthous ulcer, cobble stoning, long‑segment strictures, skip lesions and perianal involvement favored a diagnosis of CD. Correlation of colonoscopy with histology is poor for both CD and TB. The accuracy, sensitivity and specificity of colonoscopy were better and superior for the diagnosis of CD, than in the diagnosis of TB.

The recommendations 31 which recommend "VSL#3®", refer only to the product used in the cited literature and equivalent products independent from the present product labelings. This product is now known by the generic name "De Simone Formulation".

We report our experience of three cases of decompensated cirrhosis with massive upper gastrointestinal bleeding, which required insertion of an SX-Ella Danis stent for hemostasis. The procedure is safe and effective.

Background Various scoring systems have been developed to assess the severity and survival in end-stage liver disease. Aim of the study Prospective study to compare and analyze the efficacy of scoring systems in predicting mortality in ESLD patients who present with cirrhosis specific complications to the emergency room. Materials and methods This prospective, single point study was conducted over a two year period from September 2014 to August 2016 among 162 ESLD patients seeking admission to the emergency unit of Gleneagles Global Health City, Chennai. Baseline investigations incorporated hemogram, liver biochemical parameters, coagulation parameters (PT/INR), serum creatinine, serum electrolytes and blood gas analysis, to calculate the CTP score, MELD, MELD-Na, MESO, iMELD, Updated MELD, UKELD, SOFA and APACHE II. Comparison of MELD snd non MELD scores were done between survivors and nonsurvivors. The mortality rate for the same admission was calculated. Results Of the 162 patients requiring emergency admision, 148 were men (91.4%). The median age of patients was 56 years (range 25–75 years). The cause for liver cirrhosis was alcohol followed by nonalcoholic steatohepatitis and hepatitis B. The indications for emergency admissions were fever, tense ascites, reduced urine output and altered sensorium. Thirty patients (18.5%) expired during the same admission. The predictive accuracy of all scores for predicting mortality by ROC curves was between 0.7 and 0.8 (p < 0.05). Conclusion Although, all scores appear to be equally good, simple scores like CTP and MELD is all that is required to ascertain the prognosis of patients seeking emergency admission. How to cite this article Mangla N, Bokarvadia R, Jain M, Varghese J, Venkataraman J. Scoring Systems that Predict Mortality at Admission in End-stage Liver Disease. Indian J Crit Care Med 2019;23(10):445–448.

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.

Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening complication noted after solid organ transplantation and is frequently related to Epstein-Barr virus infection. The present case highlights an unusual presentation of PTLD - gastrointestinal bleeding - in the absence of systemic symptoms.

There are scanty data from India on the prevalence and clinical profile of cirrhotic cardiomyopathy (CCM).To identify the prevalence and clinical presentation of CCM in patients with liver cirrhosis.Five hundred and eighty-six patients with liver cirrhosis were recruited based on inclusion criteria and evaluated for cardiac parameters using electrocardiography, 2-dimensional echocardiography, dobutamine stress test and coronary angiography as needed. Baseline demographic data, liver biochemistry, endoscopic and radiological findings were recorded in all the patients. Appropriate statistical analyses were performed. RESULTS: Four thousand eight hundred and seventy-seven patients with liver disease were registered during the study period. Five hundred and eighty-six cirrhotic patients had cardiac evaluation as per the study protocol. One hundred fifty-nine had coronary artery disease and were excluded. One hundred and ninety-eight of 427 remaining patients (46.4%) had CCM. The median age of patients with CCM was higher compared with those without CCM (52 years vs. 46 years; p-value 0.00001). Likewise, cirrhosis-related complications ([isolated or in combination], lower pulse rate [60/min] and prolonged corrected QT interval [QTc]; p0.00001) were more frequent in patients with CCM. After excluding known risk factors for CCM such as alcohol, diabetes, hypothyroidism, hypertension, the true prevalence of CCM was 8.2% (48 out of 586). Hepatotropic viral infections (p 0.03) and prolonged QTc (p 0.0004) were commoner in CCM.Prevalence of CCM in our setting is 33.8%. CCM is commoner in males and is independent of the etiology of cirrhosis, comorbidity and severity of liver disease. Diastolic dysfunction and prolonged QTc interval are common in CCM.

Aim of the study To determine risk factors predicting nosocomial, healthcare-associated and community-acquired infection in spontaneous bacterial peritonitis (SBP) and survival outcome. Material and methods This prospective observational study included confirmed cases of cirrhosis with ascites requiring paracentesis, age > 18 years, either gender, any aetiology and Child-Turcotte-Pugh (CTP) stage, with or without cirrhosis-related complications. Patient data included age, gender, co-morbidity, model for end-stage liver disease (MELD) score, CTP score, cirrhosis-related complications, details of previous hospitalization, ascitic tapping and antibiotics instituted. SBP was diagnosed as ascitic fluid polymorphonuclear leucocyte count greater than 250/mm3 (0.25 × 109/l) and/or culture positivity for a single organism. Statistics - chi square test, Mann-Whitney U test, ANOVA, survival plot. A p value < 0.05 was statistically significant. Results 610 cases fulfilled the criteria for inclusion. 122 (20%) patients had SBP: community-acquired SBP 37 (30.3%), nosocomial SBP 19 (16.5%) and healthcare-associated SBP 66 (54.5%). The majority were men (106; 86%) with median age of 51.5 (27-78) years. A significantly higher percentage of community-acquired SBP belonged to CTP class B. Thirtytwo and 7 patients respectively were blood and ascitic fluid culture positive. Significant nosocomial SBP were blood culture positive (p < 0.02). The most common isolates were E. coli followed by Klebsiella. Survival plot analysis at 3 months showed the worst survival for nosocomial SBP (p = 0.0009). Conclusions Prevalence of SBP in our study was 20%, the majority with healthcare-associated SBP belonging to CTP C. Patients with nosocomial SBP had significant bacteremia with high mortality.

Patients with gastroesophageal reflux disease are commonly referred to a gastrointestinal motility unit for assessment of esophageal physiology tests prior to an anti-reflux procedure. On esophageal manometry, most patients have normal peristalsis; however, minor disorders of motility such as ineffective esophageal motility and fragmented peristalsis are not uncommon. Multiple rapid swallow (MRS) test is a provocative method for assessing peristaltic reserve in such patients. We report our single-center experience on MRS testing. ᅟ ᅟ.

Background The aim of this study was to study the determinants of nonadherence to immunosuppressant drugs in liver transplant (LT) recipients using personalised interview and questionnaire methods. Methods The study was conducted on adult LT recipients (deceased donor liver transplant [DDLT] and living donor liver transplant [LDLT]) from the Indian subcontinent, at post-LT clinic visit between July and December 2016. Recipient details included baseline demography, comorbidity, psychological status, details of addiction, indication and type of transplant. Details on financial support for transplantation, admissions for rejection, infection and posttransplant complications were obtained from the hospital records. An adherence questionnaire was completed by direct interview and using a questionnaire. Results Sixty-seven LT recipients (56 males, median age 48.17 years) constituted the study group. Overall, 11 patients (16.47%) were nonadherent to treatment. LDLT recipients were more adherent than DDLT recipients. Nonadherent recipients were believers in alternative systems of medicine. Medication-related factors such as improper dosing, meagre drug knowledge difficulty in remembering drug dose and timings and economic constraints in continuing medical treatment were statistically significant in nonadherent recipients. Although variation in the tacrolimus levels were significantly more common in the nonadherent group, acute cellular rejection and infection were not statistically different. Conclusions The prevalence of nonadherence was 16.5%. Determinants of nonadherence were DDLT, belief in alternative medications, high regimen complexity, poor knowledge about medications and cost issues with long-term medications.

Aim of the study A subgroup of cirrhotic patients undergoing therapeutic paracentesis develop acute kidney injury (AKI) despite adequate colloidal replacement. The aim of the study was to determine the prevalence and predictors of paracentesis-induced AKI in cirrhotic patients with normal baseline renal parameters and adequate colloidal replacement. Material and methods This prospective, observational analytical study was undertaken between April 2015 and April 2017. All patients undergoing therapeutic paracentesis were enrolled as per inclusion and exclusion criteria. Based on Acute Kidney Injury Network (AKIN) criteria for AKI, comparative analysis was performed between those developing and not developing AKI for demography, renal parameters, frequency and quantity of paracentesis per session. Univariate and multivariate regression analyses were performed to determine the predictors of AKI. Results Altogether, 177 patients underwent 859 therapeutic paracenteses. Ninety-four paracentesis sessions resulted in an AKI (10.9%). The median number of paracenteses was 10 (range 1-25) and the median volume of fluid drained per paracentesis was 6 l (1-20 l). In univariate analysis, younger age (p < 0.02), higher MELD (Model For End-Stage Liver Disease) score (p < 0.0001), CTP (Child-Turcotte-Pugh) class C (p < 0.017) and prior history of renal dysfunction (p < 0.0001) were significantly associated with AKI. For each liter of fluid drained, the risk of AKI increased by 1.24 times. Frequency of paracentesis did not influence the AKI. In multivariate logistic regression, the significant predictors of AKI were past renal dysfunction, a higher MELD and volume of fluid tapped at paracentesis. Conclusions Post-paracentesis AKI occurs in 10.9% of cases, despite adequate colloid replacement. For each 1 l of fluid drained during paracentesis, the risk of AKI increased by 1.24 times.

Aim of the study To determine the factors that are likely to influence the domains of health-related quality of life (HRQOL) using SF-36 and CLDQ questionnaires in patients with liver cirrhosis. Material and methods Patients with liver cirrhosis were compared with age- and gender-matched healthy controls for physical and mental components of the SF-36 score. Effects of age, co-morbidity, namely diabetes, severity of liver disease and complications of liver cirrhosis on HRQOL using self-administered or by direct interview SF-36 and CLDQ questionnaires were studied. Statistical analysis: chi square test, ANOVA, Kruskal-Wallis test and stepwise linear regression analysis. A p value of < 0.05 was considered significant. Results Regarding SF-36 score, except for bodily pain, 149 patients had significantly low individual and composite domain scores (p value < 0.0001) compared to age/gender-matched controls. Patients below 45 years, the majority of whom belonged to Child-Turcotte-Pugh (CTP) class C with a high Model of End-Stage Liver Disease (MELD) and higher rates of complication had low SF-36 for bodily pain (KW p < 0.005) and those above 55 years for physical function (p < 0.05). Both the physical components had a major impact on mental composite score (MCS) (KW p < 0.05). The overall CLDQ score was also low in patients below 45 years old (p < 0.05). Diabetes with or without other co-morbid conditions had no effect on SF-36 or CLDQ scores, while non-diabetic co-morbid conditions did on physical domains (physical function, bodily pain and role physical) and the physical component score of SF-36 (KW p < 0.01 to < 0.0001). In linear regression, MELD had a direct and significant association with overall PCS, MCS and CLDQ. Conclusions Age below 45 years, higher MELD and CTP score with the presence of ascites and hepatic encephalopathy affect the overall CLDQ scores.

Metabolic syndrome (MS) is associated with fatty liver (FL) disease. Gender differences in this association are not known.The aim of the present study was to determine gender-wise association between FL and MS components (using Asia-Pacific guidelines 2007) in an urban south Indian cohort with normal liver function tests (LFT).Records of consecutive attendees of a Master Health Check up program were reviewed for age, gender, body mass index (BMI), blood pressure, fasting blood sugar (FBS), high-density lipoproteins, triglyceride (TG) levels, presence of FL by ultrasound. The cohort was grouped gender-wise as FL and nonfatty liver (NFL). Foreign nationals; those with alcohol intake20 g/day; and those with diabetes, hypertension, hypertriglyceridemia, chronic liver disease, or abnormal LFT were excluded.Chi-square, gender-wise univariate and logistic regression analyses of each MS component for FL, relative risk (RR), and 95 % confidence interval (CI) for significant factors (p 0.05 and RR or log odds1.5) were calculated.Of the 1,075 (63 % males) cases included, 45.8 % had FL. Gender (log odds 1.6 compared to women) and BMI ≥25 kg/m(2) (RR 1.6 % to 95 % CI 1.3 to 1.9; log odds 2.2) were the only factors associated with FL in men. In women, age ≥40 years (log odds 2.3), fasting blood sugar (FBS) ≥100 mg/dL (RR 1.8-1.4 to 2.3; log odds 1.9), and TG ≥150 mg/dL (RR 1.7-1.3 to 2.1; log odds 1.7) were independently associated with FL.There was a gender-wise difference in MS components associated with hepatic steatosis and normal LFT in a south Indian urban cohort.