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Though small intestinal bacterial overgrowth (SIBO) is known in inflammatory bowel disease (IBD), the data on it are scanty and have limitations. Data on IBD patients undergoing glucose hydrogen breath test (GHBT) were retrospectively analyzed to evaluate the frequency and risk factors of SIBO in IBD compared to 66 healthy controls. Patients with IBD (n=86; 45 ulcerative colitis [UC] and 41 Crohn’s disease [CD]) more often had SIBO on GHBT than the healthy subjects (16/86 [18.6%] vs. 1/66 [1.5%]; p=0.002). SIBO was commoner among patients with CD than UC (14/41 [34.1%] vs. 2/45 [4.4%]; p=0.001). The frequency of SIBO among UC patients was comparable to healthy subjects (2/45 [4.4%] vs. 1/66 [1.5%]; p=not significant [NS]). Patients with CD than those with UC had higher values of maximum breath hydrogen and a greater area under the curve for breath hydrogen. Other factors associated with SIBO included female gender (11/16 [68.8%] with vs. 21/70 [30%] without SIBO; p=0.003), and having undergone surgery (8/16 [50%] vs. 6/70 [8.6%]; p=0.0002). SIBO patients had lower levels of total serum protein and albumin than those without SIBO (6.2 ± 1.5 g/dL vs. 7.0 ± 0.9 g/dL, respectively; p=0.009 and 3.5 ± 0.9 g/dL vs. 4.0 ± 0.6 g/dL, respectively; p=0.02). CD, female gender, and surgery for IBD tended to be the independent factors associated with SIBO among IBD patients on multivariate analysis. Patients with IBD, particularly CD, female, and those having undergone surgery, have a higher risk of SIBO than the healthy controls.

In the clinical setting, small intestinal bacterial overgrowth (SIBO) is a frequent, but under-diagnosed entity. SIBO is linked to various gastrointestinal (GI) and non-GI disorders with potentially significant morbidity. The optimal management of SIBO is undefined while there is a lack of published consensus guidelines. Against this background, under the auspices of the Indian Neurogastroenterology and Motility Association (INMA), formerly known as the Indian Motility and Functional Diseases Association (IMFDA), experts from the Asian-Pacific region with extensive research and clinical experience in the field of gut dysbiosis including SIBO developed this evidence-based practice guideline for the management of SIBO utilizing a modified Delphi process based upon 37 consensus statements, involving an electronic voting process as well as face-to-face meetings and review of relevant supporting literature. These statements include 6 statements on definition and epidemiology; 11 on etiopathogenesis and pathophysiology; 5 on clinical manifestations, differential diagnosis, and predictors; and 15 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservations was 80% or higher, the statement was regarded as accepted. The members of the consensus team consider that this guideline would be valuable to inform clinical practice, teaching, and research on SIBO in the Asian-Pacific region as well as in other countries.

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.

Though biofeedback therapy is often effective in patients with fecal evacuation disorder (FED), a common cause of chronic constipation (CC) in tertiary practice, data on anorectal physiological parameters following it are scanty. Consecutive patients with FED with CC diagnosed by abnormalities in at least two of the three tests (anorectal manometry, defecography, and balloon expulsion test [BET]) undergoing biofeedback (two sessions per day, 30 min each, for 2 weeks) during a 3-year period were analyzed. Clinical evaluation, anorectal manometry (ARM), and BET were performed at the beginning and after biofeedback. Incomplete evacuation 42/43 (98%), straining 40/43 (93%), and feeling of outlet obstruction 35/43 (81%) were the most common symptoms among these 43 patients (median age 44 years, range 18–76, 30 [71%] male). All the three tests (defecography, BET, and ARM) were abnormal in 17 (40%) patients and the others had two abnormal tests. Improvement in physiological parameters was noted following biofeedback (median residual anal pressure during defecation 99 mmHg (range 52–148) vs. 78 mmHg (37–182), p = 0.03; maximum intra-rectal pressure 60 mmHg (90–110) vs. 76 mmHg (31–178); p = 0.01; defecation index 1.1 (0.1–23.0) vs. 3.2 (0.5–29.0); p = 0.001). Dyssynergia on ARM and BET got corrected in 22/34 (65%) and 18/30 (60%) patients. At a 1-month follow up, 23/37 (62%) patients reported satisfactory symptomatic improvement. Biofeedback not only improves symptoms but also anorectal physiological parameters in patients with FED.

Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India. Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed. Of 249 patients (43.7 ± 16.2 years, 174 males), 135/242 (55.8 %), 57/249 (22.9 %), and 83/136 (61.0 %) had abnormal balloon expulsion test (>200 g), anorectal manometry [>100 mmHg resting pressure (n = 4), >167 mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4 cm, and/or rectocele), respectively. Though 181/249 (72.6 %) had one test abnormality, 86/249 (34 %) had FED (greater than or equal to two abnormalities), 44/65 (67.6 %) of whom had a defecation index ≤1.4. Rome III criteria for irritable bowel syndrome were equally fulfilled by patients with and without FED [74/83 (89 %) vs. 117/144 (81.2 %); p = ns]. On univariate analysis, straining duration, prolonged straining [≥30 min; 21/39 (53.8 %) vs. 15/65 (23.1 %); p = 0.002], incomplete evacuation [75/77 (97.4 %) vs. 95/114 (83.3 %); p = 0.004], and >3 stools/week [60/75 (80 %) vs. 76/128 (60 %); p = 0.004] were commoner among the FED patients though age, gender, symptom duration, mucus, manual evacuation, and stool forms were comparable. Resting and squeeze pressures and balloon volume at maximum tolerable limit were higher, and the sphincter tended to be shorter in FED. Prolonged straining, incomplete evacuation, and squeeze pressure were significant on multivariate analysis. Manometry and defecography abnormalities were commoner among the female FED patients. FED is not uncommon, which fulfills the Rome III criteria for IBS, and prolonged straining may be suggestive; abnormal defecography and manometry are commoner in female.

Facial expressions are direct means of communication of human’s emotional state. Hence facial expression recognition (FER) has always been a topic of great interest of researchers specially for smart applications. Numerous approaches have been proposed for FER using Local binary patterns (LBP). This chapter presents an analysis of LBP feature descriptor for FER. State of the art approaches have been discussed that use LBP as their main component. Here, basic LBP operator along with several variants and their main properties are described that have been proved useful for FER. A general framework for FER is described which includes four consecutive modules. These modules are preprocessing, feature extraction, dimensionality reduction and classification. LBP based FER results have been reported on three benchmark datasets JAFFE, CK+ and Yale. Experimentation demonstrates usefulness of LBP in FER.

Gut microbe-derived methane may slow colon transit causing chronic constipation (CC). Effect of rifaximin on breath methane and slow-transit CC was evaluated. Bristol stool form, frequency, colon transit time (CTT), and breath methane were evaluated in 23 patients with CC (10 patients with constipation-predominant irritable bowel syndrome [IBS-C], 13 functional constipation, Rome III) and m-ethane production compared with 68 non-constipating IBS. Methane-producing CC (basal ≥ 10 PPM and/or post-lactulose rise by > 10 PPM) was randomized (double-blind) to rifaximin (400-mg thrice/day, 2-weeks) or placebo. Stool forms, frequency, breath methane, and CTT were recorded afterward. CC patients tended to be methane producer more often (13/23 [56.5%] vs. 25/68 [36.5%], p = 0.07) and had greater area under curve (AUC) for methane (2415 [435–23,580] vs. 1335 [0–6562.5], p = 0.02) than non-constipating IBS. Methane producers (8/13 [61.5%]) and 5/10 (50%) non-producers had abnormal CTT (marker retention: 36-h, 53 [0–60] vs. 19 [8–56], p = 0.06; 60-h, 16 [0–57] vs. 13 [3–56], p = 0.877). Six and 7/13 methane producers were randomized to rifaximin and placebo, respectively. Rifaximin reduced AUC for methane more (6697.5 [1777.5–23,580] vs. 2617.5 [562.5–19,867.5], p = 0.005) than placebo (3945 [2415–12,952.5] vs. 3720 [502.5–9210], p = 0.118) at 1 month. CTT normalized in 4/6 (66.7%) on rifaximin (36-h retention, 54 [44–57] vs. 36 [23–60], p = 0.05; 60-h, 45 [3–57] vs. 14 [11–51], p = 0.09) but none on placebo (p = 0.02) (36-h, 31 [0–60] vs. 25 [0–45], p = 0.078; 60-h, 6 [0–54] vs. 12 [0–28], p = 0.2). Weekly stool frequency (3 [1–9] and 7 [1–14], p = 0.05) and forms improved with rifaximin than placebo. Rifaximin improves CC by altering methane production and colon transit. Clinical Trial Registry, India: REF/2012/01/003216

Obscure gastrointestinal bleeding (OGIB), particularly occult, has been reported to be caused by hookworm infestation rarely from tropical countries, particularly India. Hence, we undertook a retrospective study evaluating frequency, clinical spectrum, and outcome of patients with OGIB associated with worm infestation. Data of consecutive patients with OGIB undergoing capsule endoscopy in a multilevel university hospital in northern India were retrospectively analyzed. Twenty-one out of 163 (13 %) patients with OGIB had hookworm infestation detected on capsule endoscopy. Of 21 patients (median age 65 years [range 19-82], 17 [81 %] male), 16 had overt and 5 had occult OGIB. Another lesion that could explain OGIB was present in 8/21 patients, 3/5 with OGIB occult, and 5/16 overt (p = ns). All the patients received treatment with albendazole and appropriate measures for the associated lesion, if any. Patients with hookworm infestation with another lesion experienced recurrent bleeding more often than those with worm infestation only. Hookworm infestation is an important cause of occult as well as overt OGIB and may be present even in association with another lesion. Those with additional lesion had recurrent bleeding more often than those with worm infestation alone.

BACKGROUND/AIMS Achalasia is known to result from degeneration of inhibitory neurons, which are mostly nitrinergic. Characteristic features of achalasia include incomplete lower esophageal sphincter (LES) relaxation and esophageal aperistalsis. Nitric oxide (NO), pro-duced by NO synthase (NOS), plays an important role in peristalsis and LES relaxation. Therefore, we evaluated genetic poly-morphisms of NOS gene isoforms (endothelial NOS [eNOS], inducible NOS [iNOS], and neuronal NOS [nNOS]) in patients with achalasia and healthy subjects (HS). METHODS Consecutive patients with achalasia (diagnosed using esophageal manometry) and HS were genotyped for 27-base pair (bp) eNOS variable number of tandem repeats (VNTR), iNOS22G/A (rs1060826), nNOS C/T (rs2682826) polymorphisms by polymer-ase chain reaction (PCR) and PCR-restriction fragment length polymorphism (RFLP), respectively. RESULTS Among 183 patients (118 [64.5%] male, age 39.5 ± 13.0 years) with achalasia and 366 HS (254 [69.4%] male, age 40.8 ± 11.0 years), eNOS4a4a genotype of 27-bp VNTR was more common among achalasia than HS (20 [10.9%] vs 13 [3.6%]; P < 0.001; OR, 3.72; 95% CI, 1.8-7.7). Patients with achalasia had iNOS22GA genotypes more often than HS (95 [51.9%] vs 93 [25.4%]; P < 0.001; OR, 3.0; 95% CI, 2.1-4.4). Frequency of genotypes GA + AA was higher in patients than HS (97 [53%] vs 107 [29.2%]; P < 0.001; OR, 2.7; 95% CI, 1.8-3.9). Also, nNOS29TT variant genotype in rs2682826 was more com-mon among patients compared to HS (14 [7.7%] vs 6 [1.6%]; P < 0.001; OR, 5.91; 95% CI, 2.2-15.8). CONCLUSIONS Achalasia is associated with eNOS4a4a, iNOS22GA, and nNOS29TT genotypes. This may suggest that polymorphisms of eNOS, iNOS, and nNOS genes are risk factors for achalasia.

BACKGROUND Technique and functional outcomes of anorectal reconstruction using an antropyloric graft have been reported previously. This technique had reasonable initial outcomes but lacked voluntary function. OBJECTIVE We hereby report the initial results of patients who underwent gracilis muscle wrapping around the perineally transposed antropyloric valve in an attempt to improve voluntary fecal control. SETTING This study was conducted at a single tertiary care institution. PATIENTS Eight adult patients (7 men and 1 woman) with a median age of 38 years (range, 19-51 years) underwent this procedure. Seven patients already had anorectal reconstruction with a transposed antropyloric valve, and 1 patient with severely damaged anal sphincter complex underwent single-stage composite antropylorus transposition with a gracilis muscle wrap. MAIN OUTCOME MEASURES The primary outcome measures were anatomical integrity and functional status of the composite graft in the perineum. RESULTS No operative mortality or serious procedure-related morbidity occurred in any patient. The median postoperative resting pressure was 29 mmHg (range, 22-38 mmHg) and squeeze pressure was 72.5 mmHg (range, 45-267 mmHg). There was a significant improvement in the squeeze pressure following surgery (p = 0.039). Also, the St. Mark's incontinence scores significantly improved in all patients and varied between 7 and 9 (p = 0.003). The ability to defer defecation and the reduced frequency of leakage accidents were the prime reasons for improved postgraciloplasty outcomes in these patients. On personal interviews, all patients who underwent this procedure were satisfied with the results of their surgery. LIMITATIONS A longer follow-up with a larger sample size is required. Quality-of-life data have not been evaluated in this study. CONCLUSIONS Gracilis muscle wrapping around a perineally transposed antropyloric valve is possible and improves the voluntary control and overall functional outcomes in a select group of patients with end-stage fecal incontinence requiring anal replacement (Supplemental Digital Content 1, http://links.lww.com/DCR/A173).

Background/Aims Data on frequency of fecal evacuation disorder (FED) among patients with solitary rectal ulcer syndrome (SRUS), hitherto an enigmatic condition, are scanty. Moreover, most such studies had limitations due to small sample size and lack of inclusion of healthy controls (HC). Methods Forty patients with SRUS underwent symptom assessments, sigmoidoscopy, anorectal manometry, defecography, balloon expulsion test (BET); endoscopic ultrasound (EUS) of anal sphincter complex was performed in a subgroup. Physiological tests (anorectal manometry and BET) were also performed in 19 HC. Results Patients with SRUS (26/40 male, age 37 [18–80] years) more often had FED than HC (10/19 male, age 43 [25–72] years) as shown by weight needed to expel the balloon (300 [0–700] g vs. 100 [0–400] g; P = 0.006), a trend towards abnormal BET (need of > 200 g weight for expulsion) (21/40 [53%] vs. 5/19 [26%], P = 0.058) and impaired anal relaxation (14/40 [35%] vs 2/19 [10.5%]; P = 0.048). Using Rome III criteria, most patients with SRUS reported having chronic constipation (36/40 [90%]) in spite of having normal (Bristol stool type IV, 21/40 [53%]) and diarrheal (types V, VI, VII, 6/40 [20%]) stool forms (Asian classification). SRUS patients more often (17/40 [43%]) had functional defecation disorder (Rome III criteria). Patients with SRUS with abnormal BET had thicker internal anal sphincter than those without (3.9 [3.4–7.0] mm vs 2.8 [2.0–4.0] mm; P = 0.01). Conclusions FED was commoner among patients with SRUS as evidenced by abnormal BET and sphincter relaxation. Those with abnormal BET had thicker internal sphincter on EUS than those without.

Small intestinal bacterial overgrowth (SIBO) is reported in 4-78% patients with irritable bowel syndrome (IBS). This wide range of percentages might be because of the different techniques and criteria used to define the condition. We studied the utility of early (breath hydrogen increase 20 ppm above basal within 90 min) and double peaks on lactulose and glucose hydrogen breath tests (LHBT and GHBT, respectively) to diagnose SIBO (gold standard: upper gut aspirate culture). We also studied the clinical parameters that are associated with SIBO among them.Overall, 80 patients with IBS (Rome 3) were evaluated for SIBO using aspirate culture, GHBT, and LHBT (with methane).A total of 15/80 (19%) patients had SIBO (≥ 10 CFU/ml) on culture compared with 0/10 historical controls; 4/15 (27%) with and none of 65 without SIBO had positive GHBT (sensitivity 27%, specificity 100%). None of 15 with and one of 65 without SIBO had double peaks on LHBT (sensitivity 0%, specificity 98%); 5/15 (33%) with and 23/65 (35%) without SIBO had an early peak on LHBT (sensitivity 33%, specificity 65%); and 2/15 (13.3%) with and 26/63 (41.3%) without SIBO had high methane on LHBT (sensitivity 13.3%, specificity 58.7%). Patients with SIBO on culture more often had diarrhea [6/15 (40%) vs. 8/65 (12.3%), P=0.011], higher weekly stool frequency [21 (3-28) vs. 14 (4-49), P=0.003], and looser forms [Bristol 5-6, 11/15 (73.3%) vs. 33/65 (50.8%), P=0.116].On the basis of culture, 19% patients with IBS had SIBO. The specificity of GHBT was 100%, but the sensitivity of this test and the diagnostic performances of LHBT and breath methane were all very poor. SIBO was more common in IBS patients with diarrhea than in patients with other bowel habits.

Background: Some studies investigated the association between depressive symptoms and arthritis; however, no longitudinal studies have documented the relationship between developing depressive symptoms and the risk of arthritis. Therefore, this study evaluated whether the development of depressive symptoms was associated with an elevated risk of arthritis. Materials and Methods: A survival analysis using Cox regression models was applied to osteoarthritis initiative data obtained over 6 years from adults (n = 3,662) aged ≥45 years at baseline. Developing depressive symptoms was defined using the 20-item Center for Epidemiologic Studies Depression scale (cutoff 16 points) between baseline and 1 year. Arthritis was defined answering “yes” to the following self-reported question: “Did the doctor say you developed arthritis since the last clinic visit about 1 year ago?” over the 6-year follow-up period. Results: The hazard ratios for developing arthritis were 3.51 (95% confidence interval [CI] = 2.32–5.29) and 2.03 (95% CI = 1.45–2.85) for men and women, respectively, as compared to those who did not develop depressive symptoms. There was a significantly (χ2 = 73.672, P < 0.0001) lower survival probability at each time point throughout the study among men and women who developed depressive symptoms. Conclusion: In both men and women, developing depressive symptoms increased the risk of arthritis, and the survival probability decreased at each time point.

Dysphagia, regurgitation, and chest pain are common achalasia, with a variable report of pulmonary symptoms possibly due to micro-aspiration. Pneumatic dilation (PD) may improve pulmonary function. Data on pulmonary dysfunction among achalasia patients are scanty, and the effect of PD is unknown. To evaluate pulmonary dysfunction in patients with achalasia based on clinical and radiologic evaluation and spirometry and to study the effect of PD at 1-month follow-up. Patients with achalasia (diagnosed using high-resolution manometry and the Chicago classification) were evaluated prospectively by spirometry before (n = 38) and 1 month after PD (n = 31). All patients received a chest X-ray, and patients with respiratory abnormality before PD received high-resolution computed tomography of the thorax. Of the 38 patients, 17 and 21 had type I and II achalasia, respectively. The respiratory symptoms, such as pharyngeal symptoms [27/38 (71 %) vs. 8/31 (26 %); P = 0.0001], cough [23/38 (60.5 %) vs. 5/31 (16 %), P = 0.0001], and dyspnea [8/38 (21 %) vs. 0/31 (0 %), P = 0.006], improved after treatment with PD. Spirometry showed abnormalities in 17/38 (45 %) patients before and in 8/15 (53 %) after PD. Median FEV1, FVC, PEFR, and percentage of predicted MEF25–75, improved from 78 % (36–85), 74 % (48–100), 62 % (18–72), and 48 % (15–66) before to 83 % (58–94), 86 % (55–99), 69 % (38–81), and 59 % (33–78) after PD, respectively (P

Background Lactose malabsorption (LM), diagnosed currently using lactose hydrogen breath and tolerance tests (LHBT, LTT) with a high, nonphysiological dose (50-g), may mimic irritable bowel syndrome (IBS). In LM-endemic areas, clinically significant malabsorption (lactose intolerance) may be better diagnosed using a lesser dose, and positive results so obtained may predict response to milk withdrawal more effectively. Methods Fifty patients each with IBS (Rome III) were evaluated using LHBT and LTT with 50-g, 25-g, and 12-g lactose. Sensitivity and specificity of LHBT and LTT with different dosages (gold standard: lactase gene C/T-13910 polymorphism) and symptom development were evaluated. Effect of milk withdrawal was studied. Result Of 150 patients, 37/50 (74%) and 28/50 (56%) had LM by LHBT and LTT using 50-g lactose; 41/50 (82%) and 31/50 (62%) had LM using 25-g lactose, and 14/50 (28%) and 29/50 (58%) using 12-g lactose, respectively. Sensitivity and specificity of LHBT using 50-g, 25-g, and 12-g lactose were 92.6%, 52.0%, and 94%, 60%, and 36.4%, 88.2%, and those of LTT, 92%, 80.0%, and 84.8%, 82.4%, and 66.7%, 58.8%, respectively. Breath hydrogen correlated with lactose dose. Though patients developing symptoms with 50-g lactose exhaled more hydrogen than those remaining asymptomatic, hydrogen levels did not differ following 25-g and 12-g dosages in relation to symptom development. Patients' milk intake was 335 ± 92 mL/d (≈ 16.7 ± 9.6-g lactose). Positive LHBT using 25-g dose better predicted symptom resolution than by 50-g and 12-g lactose. Conclusion Twenty-five gram is the ideal dose of lactose for LHBT and LTT in LM-endemic areas.

Vector borne diseases spread rapidly in the population. Hence their control intervention must work quickly and target large area as well. A rational approach to combat these diseases is mobilizing people and making them aware through media campaigns. In the present paper, a non-linear mathematical model is proposed to assess the impact of creating awareness by the media on the spread of vector borne diseases. It is assumed that as a response to awareness, people will not only try to protect themselves but also take some potential steps to inhibit growth of vectors in the environment. The model is analyzed using stability theory of differential equations and numerical simulation. The equilibria and invasion threshold for infection i.e., basic reproduction number, has been obtained. It is found that the presence of awareness in the population makes the disease invasion difficult. Also, continuous efforts by the media along with the swift dissemination of awareness can completely eradicate the disease from the system.

Background/Aims Though nocturnal acid-breakthrough (NAB) is common in gastroesophageal reflux disease (GERD) patients, its clinical importance results from esophageal acidification, which has been shown to be uncommon. Ilaprazole, a long-acting proton pump inhibitor, may cause NAB infrequently. Accordingly, we studied prospectively, (1) frequency and degree of esophageal acidification during NAB, and (2) frequency and severity of NAB while on ilaprazole versus omeprazole. Methods Fifty-eight consecutive patients with GERD on once daily ilaprazole, 10 mg (n = 28) or omeprazole, 20 mg (n = 30) for > one month underwent 24-hour impedance-pH monitoring prospectively. NAB was defined as intra-gastric pH one hour during night, and esophageal acidification as pH < 4 for any duration. Nocturnal symptoms (heartburn, regurgitation, and chest pain) were also recorded. Results Of the 58 patients (age 35.5 [inter-quartile range 26.5-46.0] years, 38 [65.5%], 42 (72.4%) had NAB. Though patients with NAB had lower nocturnal intra-gastric pH than without (2.8 [1.9-4.1] vs 5.7 [4.6-6.8], P < 0.001), frequency and duration of nocturnal esophageal acidification (17/42 vs 4/16, P = 0.360 and 0.0 [0.0-1.0] vs 0.0 [0.0-0.3] minutes, P = 0.260, respectively) and symptoms were comparable (13/42 vs 6/16, P = 0.750). Though ilaprazole was associated with less NABs (1 [range 1-2, n = 19] vs 1 [range 1-3, n = 23], P = 0.010) than omeprazole, the frequency, duration, and mean intra-gastric pH during NAB were comparable (19/28 vs 23/30, P = 0.560; 117 [0-315] vs 159 [69-287] minutes, P = 0.500; 1.02 [0.7-1.4] vs 1.04 [0.44-1.3], P = 0.620, respectively). Conclusions Though NAB was common while patients were on a proton pump inhibitor, esophageal acidification was uncommon. Frequency and severity of NAB were comparable among patients on ilaprazole and omeprazole, except for the lesser number of NABs with ilaprazole. (J Neurogastroenterol Motil 2017;23:208-217)

BACKGROUND Antibiotics relieve symptoms in half of the unselected patients with irritable bowel syndrome (IBS); however, their efficacy if selected according to small-intestinal bacterial overgrowth (SIBO) is unknown. AIMS The aim of this study was to evaluate (a) symptom resolution among IBS patients with or without SIBO on norfloxacin treatment, and (b) its efficacy in obtaining negative SIBO test results as compared with placebo. METHOD Eighty IBS patients (Rome III) were evaluated for SIBO by gut aspirate culture. Patients with (≥10 CFU/ml) and those without SIBO were separately randomized (computer-generated stratified) to 800 mg/day norfloxacin for 10 days or placebo. Global symptom score (blindly), Rome III criteria, aspirate culture, and glucose hydrogen breath test (GHBT) were assessed before and 1 month after treatment, and patients were followed up for 6 months. RESULTS Although norfloxacin was more effective at reducing the symptom score at 1 month among patients with compared with those without SIBO [15/80, 19% on culture, four on GHBT too; 6.5 (2-13) vs. 2 (0-10), P=0.01; 8.5 (2-16) vs. 5 (0-12), P

There are many upper and lower gastrointestinal (GI) disorders in which either the cause or the result is abnormal motility. Naturally, the study of motor functions of the gut in normal and abnormal conditions is of great help in understanding the pathophysiology and management of these disorders. Motor functions of the GI tract can be assessed by a variety of recording techniques including radiology, scintigraphy, manometry, and most recently intraluminal electrical impedance monitoring. In many instances the techniques are complementary to each other. However, manometry is the most reliable and reproducible method of studying motor functions of the esophagus. In this chapter we will elaborate principles, technique, and interpretation of esophageal manometry.

Gastrointestinal (GI) manometry has evolved prodigiously during the last decade. The introduction of high-resolution manometry (HRM) has been a true innovation in the field of gastrointestinal physiology. HRM has greatly simplified the job of acquisition, analysis and interpretation of motility related data. As with conventional manometry, there is a need for minimum standards for reporting in the case of HRM as well. Standardized reporting formats for GI manometry would be useful for (a) streamlining day-to-day functioning in GI physiology laboratories; (b) providing a standard template for collection, analysis, and publication of data from across the globe; and (c) providing benchmark resources to young gastroenterologists planning to set up a new manometry laboratory. This chapter provides a description of standard reporting formats for esophageal, antroduodenal, and anorectal manometry.

BACKGROUND/AIMS Studies evaluating the human pylorus as a sphincter are scanty and contradictory. Recently, we have shown technical feasibility of transposing the human pylorus for end-stage fecal incontinence. This unique cohort of patients provided us an opportunity to study the sphincter properties of the pylorus in its ectopic position. METHODS Antro-pylorus transposition on end sigmoid colostomies (n = 3) and in the perineum (n = 15) was performed for various indications. Antro-pylorus was assessed functionally (digital examination, high resolution spatiotemporal manometry, barium retention studies and colonoscopy) and by imaging (doppler ultrasound, MRI and CT angiography) in its ectopic position. RESULTS The median resting pressure of pylorus on colostomy was 30 mmHg (range 28-38). In benign group, median resting pressure in perineum was 12.5 mmHg (range 6-44) that increased to 21.5 mmHg (range 12-29) (P = 0.481) and 31 mmHg (range 16-77) (P = 0.034) on first and second follow-up, respectively. In malignant group, median post-operative pressures were 20 mmHg (range 14-36) and 21 mmHg (range 18-44) on first and second follow-up, respectively. A definite tone and gripping sensation were felt in all the patients on digital examination. On distal loopogram, performed through the diverting colostomies, barium was retained proximal to the neo-pyloric valve. Both perineal ultrasound and MRI showed viable transposed graft. CT angiography and color doppler studies confirmed vascular flow in the transposed position. CONCLUSIONS The human pyloric valve can function as a tonic sphincter when removed from the gastroduodenal continuity.

Hypogammaglobulinemic sprue (HGS), which may predispose to infection, is uncommon. Twelve patients (all men; median age 29 years, 15-50) with HGS (4%) of 296 with chronic small bowel diarrhea and malabsorption syndrome (MAS) during a 10-year period were analyzed. Treatment of HGS was delayed due to misdiagnosis as intestinal tuberculosis (n = 7) and diarrhea-predominant irritable bowel syndrome (n = 1). All had diarrhea and weight loss (median loss 12 Kg). Associated conditions were clubbing, bronchiectasis, and seizure (2 patients each), and hypothyroidism (n = 1). Laboratory parameters were urinary D-xylose median 0.46 g/5 g/5 h (range 0.2-1.6; normal ≥ 1), fecal fat 11.9 g/day (3.8-16.7; normal ≤ 7 g), serum IgA, IgG, and IgM: 23.5 mg/dL (17-114; normal 90-450), 584 mg/dL (145-1051; normal 800-1800), and 23 (0-40.3; normal 60-280). IgA, IgG, and IgM were low in 10, 10, and 11, respectively. Duodenal biopsy was normal in 6 patients and showed partial villous atrophy in 6 and nodular lymphoid hyperplasia in two. Associated infections were giardiasis (n = 1), disseminated strongyloidiasis (1), small intestinal bacterial overgrowth (3), septicemia (2), and septic arthritis (1). Two patients died of sepsis, five are well on immunoglobulin and specific anti-infective treatment, and five are lost to follow up. Approximately 4% patients with MAS have hypogammaglobulinemia, which is often associated with infection and is diagnosed late.

Background: Data on utility of post-pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long-term efficacy of dilation, which tears the non-relaxing LES in achalasia, are scanty. Methods: Post-PD LES pressure was measured in 72/98 patients with achalasia. The best cut-off pressure classifying responders and non-responders was determined by receiver operating characteristic (ROC) curve. Factors associated with non-response and recurrence were evaluated. Results: Of 98 patients (41.1 ± 13.3 years, 58 male), 75 improved, three had perforation requiring surgery, and 20 did not respond to the first PD session. Of 18/20 patients undergoing a second PD, 11 improved and six non-responders needed myotomy. 37/58 (71%) male and 17/40 (42.5%) female patients had a first PD with a 35-mm balloon (P = 0.03). Age and gender of patients did not influence outcome. LES pressure was lower in responders or in those having recurrence than in non-responders (17 mmHg [6.4–75], 11 mmHg [4.6–31]vs 25 mmHg [13–55]). On the ROC curve, 22.5 mmHg was the best cut-off value differentiating responders and non-responders (area under curve [AUC] 0.73). Of the 86 patients responding to PD, 20 had recurrence. Patients who responded to one session of PD or had LES pressure

Background: Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited. Methods: Eighty-six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64-month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3 ± 14.1 months) were considered to confirm CE findings. Results: Of 86 patients (aged 54.5 ± 16.3 years, 63 males), 64 and 22 had OGIB-overt and OGIB-occult, respectively. Lesions were equally detected in OGIB-overt and OGIB-occult patients (48/64, 75% vs 18/22, 81.8%, P = ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively. Conclusion: CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.

Though tropical sprue (TS) is common in tropics, studies on small intestinal permeability (SIP) in TS are scant.SIP was evaluated using (1)H nuclear magnetic resonance (NMR) spectroscopy of urinary lactulose and mannitol in 24 patients with TS (22 before and 15 after treatment with tetracycline and folate) and in 31 healthy subjects (HS). Effect of treatment of TS on SIP and its relationship with outcome were studied.Subjects were comparable in terms of age and gender. Before treatment, urinary lactulose (0.24 mmol, 0-1.09 mmol versus 0.09 mmol, 0-0.68 mmol, P=0.02) and lactulose-to-mannitol (L/M) ratio (0.11, 0-0.41 versus 0.042, 0-0.26, P=0.001) were higher in TS than in HS, though mannitol was comparable (2.7 mmol, 0.61-10.5 mmol versus 3.8 mmol, 1.3-16.4 mmol, P=0.08). Patients improved after treatment [stool frequency (9, 4-20/day versus 1, 1-2/day, P0.0001), weight (44.4, 32-69 kg, versus 56, 39-84 kg, P0.0001), fecal fat (10.1, 6-26 g/24 h versus 4.4, 3.0-6.7 g/24 h, P0.0001), D-xylose (0.57, 0.28-1.2 g/5 g/5 h versus 1.1, 0.2-2.1 g/5 g/5 h, P0.0001), and small intestinal bacterial overgrowth (SIBO) resolved in 10/24 (41.7%) versus 1/15 (6.6%), P=0.02]. Though urinary lactulose (0.17, 0-4.3 mmol versus 0.09, 0-0.68 mmol, P=0.11) and mannitol (2.17, 0.8-36.7 mmol versus 3.84, 1.3-16.4 mmol, P=0.06) were comparable, L/M ratio was higher in TS than in HS (0.09, 0-0.22 versus 0.042, 0-0.26, P=0.002). L/M ratio was more often abnormal (cutoff 0.078) in TS than in HS [14/22 (63.6%) versus 3/31 (9.7%); P=0.0001], which persisted even after treatment [9/15 (60%) as compared with HS; P=0.0006]. Persistently abnormal SIP was associated with less weight gain and frequent stools following treatment.SIP is often abnormal in TS and remains unchanged even after successful treatment that was associated with less weight gain and more frequent stool.

Introduction Small intestinal bacterial overgrowth (SIBO) occurs in varying frequency in irritable bowel syndrome (IBS). We studied the frequency of SIBO in IBS and chronic non-specific diarrhea (CNSD). Methods 129 patients with IBS (Manning's criteria), 73 with CNSD (≥ 4 weeks diarrhea with two of these tests normal [urine D-xylose, fecal fat and duodenal biopsy]) and 51 healthy controls (HC) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Diarrhea-predominant IBS (D-IBS) was grouped into CNSD. Rise in breath hydrogen 12 ppm above basal following 100 g glucose was diagnostic of SIBO. Results Of 129 patients with IBS, 7 were constipation (C-IBS), and 122 were of indeterminate type (I-IBS). Patients with IBS were younger than HC and CNSD (IBS vs. HC: 36.6 yr ± 11.4 vs. 44.1 yr ± 13.6, p = 0.001; IBS vs. CNSD: 36.6 yr ± 11.4 vs. 42 yr ± 14.5, p = 0.003). Patients with CNSD were comparable to HC in age (42 yr ± 14.5 vs. 44.1 yr ± 13.6, p = ns). Patients with IBS were more often male than HC [108/129 (83.7%) vs. 34/51 (66.7%) p = 0.02]; gender of CNSD and HC was comparable [male 39/73 (53.4%) vs. 34/51 (66.7%) p = ns]. SIBO was commoner in CNSD than HC [16 (21.9%) vs. 1 (2%), p = 0.003], but was comparable in IBS and HC [11 (8.5%) vs. 1 (2%), p = 0.18]. Patients with CNSD more often had SIBO than IBS [16 (21.9%) vs. 11 (8.5%), p = 0.007]. Conclusions SIBO was more common in CNSD including D-IBS than other types of IBS and HC.

We studied the spectrum of motor dysphagia in a northern Indian tertiary referral center. In this retrospective study, consecutive patients with motor dysphagia referred to the Gastrointestinal Pathophysiology and Motility Laboratory from 2002 to 2007 were evaluated clinically and with eight-channel water-perfusion manometry. Causes of dysphagia were diagnosed using standard criteria. Of 250 patients (age 41.3 [15.0] years, 146 men), 193 (77%) had achalasia cardia (AC) and 57 (23%) had other causes (11, 4.4%: diffuse esophageal spasm [DES]; 9, 3.6%: hypertensive lower esophageal sphincter [Hy LES]); manometry was normal in 37 patients. Twenty-seven patients (14%) had vigorous AC. Duration of dysphagia at presentation was longer in those with AC and Hy LES than in normal manometry (NM) (21 months [1–180] vs. 6 [1–360], p = 0.000; 24 months [7–48] vs. 6 [1–360], p = 0.015). Regurgitation and bolus obstruction were more frequent in those with AC than in NM (89/154, 57.79% vs. 3/27, 11.11%, p = 0.000001). Heartburn was less frequent in patients with AC than in others (AC: 4/146, 2.73% vs. normal: 4/27, 14.8% [p = 0.02] and others: 3/15, 20% [p = 0.018]). Chest pain was reported by 74/135 (54.8%) classic and 12/19 (63.2%) vigorous AC (p = NS). Patients with NM had lower LES pressure than those with classic AC, Hy LES and vigorous AC (p < 0.0001 in each case). Patients with DES had lower LES pressure than in classic AC, Hy LES and vigorous AC (p = 0.043, p < 0.0001, and p = 0.002, respectively). Patients with classic AC had lower LES pressure than in Hy LES and vigorous AC (p = 0.024, p = 0.001, respectively). Classic AC was the commonest cause of motor dysphagia in our center. AC was associated with higher LES pressure, longer duration of dysphagia, frequent regurgitation and bolus obstruction.

Spontaneous bacterial peritonitis (SBP), a common complication of cirrhosis of liver, might result from translocation of bacteria from the small bowel. However, there is scanty data on frequency of small intestinal bacterial overgrowth (SIBO) in patients with cirrhosis of the liver. There are no data on SIBO in patients with extra-hepatic portal venous obstruction (EHPVO) in the literature. A total of 174 patients with cirrhosis of the liver, 28 with EHPVO and 51 healthy controls were studied for SIBO using glucose hydrogen breath test (GHBT). Persistent rise in breath hydrogen 12 ppm above basal (at least two readings) was considered diagnostic of SIBO. Of 174 patients (age 47.2 ± 11.9 years, 80.5% male) with cirrhosis due to various causes, 67 (38.5%) were in Child’s class A, 70 (40.2%) class B and 37 (21.7%) class C. Of the 174 patients with cirrhosis, 42 (24.14%) had SIBO as compared to 1 of 51 (1.9%) healthy controls (P < 0.0001). Patients with EHPVO had similar frequency of SIBO compared to healthy controls [2/28 (7.14%) vs 1/51 (1.97%), P = ns]. Frequency of SIBO in Child’s A, B and C was comparable [13 (18.6%) vs 16 (23.9%) and 13 (35.1%), respectively; P = ns]. Presence of SIBO were not related to ascites, etiology of cirrhosis, and degree of liver dysfunction. SIBO is common in patients with cirrhosis of the liver. Patients with EHPVO do not have higher frequency of SIBO than healthy subjects. SIBO in cirrhosis is not related to the degree of derangement in liver function or of portal hypertension.

Background and Aim: Symptoms of irritable bowel syndrome (IBS) and lactose intolerance (LI) overlap. Data on the frequency of LI in patients with IBS from India are scanty. The aim of this study was to evaluate: (i) the frequency of LI in patients with IBS and its various subtypes as compared with healthy subjects (HS) from northern India; (ii) the relationship between self-reported milk intolerance and laboratory evidence of LI; and (iii) the role of small intestinal bacterial overgrowth in LI in patients with IBS. Methods: 124 patients with IBS (Rome II criteria) and 53 age- and gender-matched HS were studied for LI using the lactose hydrogen breath test (LHBT) and the lactose tolerance test (LTT). Symptoms following lactose ingestion (diarrhea, bloating or distension) during the test and history of milk intolerance were recorded. Sixty-nine of the patients with IBS also underwent a glucose hydrogen breath test (GHBT). Patients with IBS were classified into those with diarrhea (IBS-D; >3 loose stools/d), constipation predominant (IBS-C

At the West Bokaro Washery of Tata Steel, India, the coarse coal is dewatered in a vibrating basket centrifuge and fine clean coal is dewatered in a screen bowl centrifuge. Due to the higher amount of fine fraction (0.038 mm) treated in the flotation circuit of the washery (about 9% of ROM), the moisture content of the clean coal fines is high. A polyacrylate surfactant reduced the fine coal moisture content by 8% and it was found to be the best among the various reagents tested in the laboratory. The chemical was found very effective for dewatering the coarse clean coal. Laboratory and plant trials showed that through treating only the coarse clean coal by the surfactant, the moisture in the composite clean coal could be reduced from 12.0% to 9.8%. The optimum dosage of the reagent was 0.24 kg/t dry coal. Laboratory-scale filtration using coagulant and surfactant increased filtration rate of centrifuge centrate. Also, the final moisture content was found to be 10% less than that obtained without addition...

We present an immunocompetent patient with herpes zoster, multiple cranial nerves paralysis and persistent dysphagia, which is rarely reported.1,2 A 50-year male presented with absolute dysphagia, odynophagia, nasal regurgitation, hoarseness of voice and painful eruptions on left ear for 10 days and fever and cough for 5 days. Examination revealed vesicular rash on left ear and oropharynx, crepitations in the chest, left infra-nuclear facial, glossopharyngeal and vagus nerve palsy. Investigations: hemoglobin 13 g/dL, total lymphocyte count 2.9 × 106/mm3 (85% neutrophils). Liver and kidney function tests and glucose were normal. Chest X-ray revealed pneumonia, blood, sputum culture and HIV serology were negative. Upper endoscopy revealed right-ward deviation of uvula, left vocal cord palsy, whitish vesicular lesions over oropharynx and vocal cords and circumferential ulceration of esophagus (Fig. 1). Esophageal tissue revealed intra-nuclear inclusion bodies on Tzanck smear (Fig. 2), acute inflammatory exudates on biopsy and negative Varicella zoster virus culture. Figure 1 Upper gastrointestinal endoscopy showing, (A) ulceration in laryngopharynx and (B) circumferential ulcers in the esophagus. Figure 2 Tzanck smear from crushed esophageal tissue showing revealed intra-nuclear inclusion bodies (H&E, ×400). Intravenous acyclovir (10 mg/kg 8 hourly for 10 days), antibiotics and parental nutrition were started. Hoarseness and dysphagia persisted. Endoscopy repeated on the seventh day revealed mild erythema without any vesicle or ulceration; intranuclear inclusions with minimal inflammation persisted in biopsy. Esophageal manometry (water perfusion system, Redtech, Calabasas, CA, USA) in second week revealed hypomotility. On the third week, percutaneous endoscopic gastrostomy (PEG) was done. Patient complained of epigastric pain, early satiety and vomiting on PEG feeds, raising a suspicion of gastroparesis. Nuclear scan was not feasible. Antroduodenal manometry (Redtech) revealed fasting antral, duodenal hypomotility and failure of conversion to fed pattern (Fig. 3), for which metoclopramide was added and diet was appropriately modified. He tolerated feeds without vomiting. He gained 3 kg weight, symptoms improved and cranial nerve palsy recovered on 3-month follow-up. Figure 3 Antroduodenal manometry tracing showing fasting antral and duodenal hypomotility along with failure of conversion to fed pattern, suggestive of gastroparesis. A denotes antral port and D denotes duodenal port. In immunocompetent patients, reactivated varicella zoster virus spreads into proximal nerve roots adjacent to dorsal root ganglia, causing neuritis or plexitis.3 Cranial neuritis can cause nerve palsy.4 Although esophagobronchial fistula has been reported in a patient with acquired immunodeficiency syndrome and herpes zoster,5 severe esophageal involvement has not been described previously in immunocompetent individual. Prolonged dysphagia has been reported previously in a patient with polycranial involvement by herpes zoster virus.2 Gastroparesis in our patient was documented by antroduodenal manometry that revealed lack of conversion of fasting to fed pattern on standard meal suggesting vagal neuropathy due to possible neuritis caused by this neurotropic virus.

Reduction in height of barium column in timed barium esophagogram (TBE) and lower esophageal sphincter (LES) pressure on manometry has been used to assess efficacy of pneumatic dilation (PD) in patients with achalasia; data comparing these two methods to assess efficacy of PD are scanty.Sixty-two patients with achalasia undergoing PD were evaluated clinically (Eckardt's score), high-resolution manometry (HRM), and TBE (films at 1 and 5 min) before and 4 weeks after PD using 30 and 35 mm Rigiflex balloon (Microvasive, Milliford, MA, USA) in female and male patients, respectively. Response was defined clinically as Eckardt's score3, by manometry as LES pressure22.5 mmHg, and by TBE as adequate esophageal emptying (reduction in height of barium column by more than 50 % of pretreatment value in 5-min radiograph).Forty-three out of sixty-two (69 %) patients [age 34 ± 12 years, 36 (58 %) male] responded, and 19 (31 %) did not respond to the first session of PD as assessed by post-PD Eckardt's score. Thirty-eight out of 43 (88 %) responders had adequate esophageal emptying of barium in TBE, while 31/43 (72 %) had LES pressure below 22.5 mmHg on HRM (p = ns). Eight out of 19 (42 %) nonresponders showed failure in esophageal emptying (defined by lack of reduction in height of barium column by 50 %) in TBE, and 11/19 (58 %) had LES pressure22.5 mmHg (p = ns). Kaplan-Meier analysis showed that response on TBE and HRM at 1 month predicted clinical response well during 6 months follow up.TBE and esophageal HRM were comparable in assessing efficacy of PD in treatment of achalasia.

Fructose malabsorption (FM) is reported in 38 % to 75 % patients with irritable bowel syndrome (IBS). Most of these studies, however, had limitations due to use of variable dose of fructose, small sample size, and lack of control population. Moreover, there is no study on this issue from India. Hence, in this prospective study, we evaluated the frequency of FM on an adequately powered sample of patients with IBS and healthy controls (HC) from India. Ninety-seven patients with IBS (diagnosed using Rome III criteria) and 41 healthy controls were evaluated for FM by fructose hydrogen breath test (FHBT) using 25 g fructose. Persistent rise (at least two readings) in breath hydrogen 20 parts per million (PPM) above basal was considered diagnostic of FM. Patients and controls were comparable in age (37 years [21–66] vs. 33 years [15–56]; p = 0.1) and gender (76/97 [78.4 %] vs. 29/41 [70.7 %] male; p = 0.3). Of 70 patients reporting data on Bristol’s stool forms, 10 (14 %), 43 (61 %), and 17 (25 %) had constipation, diarrhea predominant and unclassified IBS (Asian classification), respectively. Patients with IBS more often had FM than controls on FHBT (14/97 [14.4 %] vs. 1/41 [2.4 %]; p = 0.04). Patients with FM more often had diarrhea-predominant IBS than those without FM (10/11 [91 %] vs. 33/59 [56 %]; p = 0.02). Though FM was not very common among Indian patients with IBS, it was higher among them than controls. Patients with FM more often had diarrhea-predominant IBS.

Background Small intestinal bacterial overgrowth (SIBO) is known to occur in patients with chronic pancreatitis, particularly of alcoholic etiology. There are, however, scanty data on frequency of SIBO in patients with chronic idiopathic pancreatitis and factors associated with its occurrence. Methods 68 patients with chronic pancreatitis and 74 age and gender-matched healthy subjects (HS) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Persistent rise in breath hydrogen 12 ppm above basal (at least two recordings) was diagnostic of SIBO. Result SIBO was diagnosed more often among patients with chronic pancreatitis than controls (10/68 [14.7%] vs. 1/74 controls [1.3%]; p = 0.003). Of 68 patients, 22 (32.3%) had alcoholic and 46 (67.6%) had idiopathic chronic pancreatitis. SIBO was as commonly detected among patients with alcoholic as idiopathic pancreatitis (3/22 [13.6%] vs. 7/46 [15.2%]; p = 0.86). Age, gender, body mass index (BMI), steatorrhoea, pain, analgesic use, pancreatic calcifications and use of pancreatic enzyme supplements had no relationship with the presence of SIBO. Diabetes mellitus tended to be commoner among patients with chronic pancreatitis with than without SIBO (6/10 [60%] vs. 18/58 [31%]; p = 0.07). Conclusion SIBO was commoner among patients with chronic pancreatitis, both alcoholic and idiopathic, than HS. Though presence of SIBO among patients with chronic pancreatitis tended to be commoner among those with diabetes mellitus, there was no relationship with age, gender, BMI, steatorrhoea, pain, analgesic use, pancreatic calcifications and use of pancreatic enzyme supplements.

Epidural is of course the best form of labour analgesia. Aim is to find out an alternative method of labour analgesia where epidural is not a choice.

The objective of our study was to establish VIA as an effective screening method for diagnosing pre-malignant and malignant cervical lesions in low economic setups. A total no. of 300 patients with cervical lesions were recruited in the study. All the patients had Pap smear, followed by VIA (using 2% acetic acid). Cervical biopsies were taken from all VIA positive lesions. In our study Pap smear sensitivity was 54.68% and false positive cases were 3.30%. The sensitivity of VIA was found 90.62% and falls positive cases were 00.0%. Our study proves that VIA is a more sensitive and economic test than Pap smear or cervical biopsy for screening cervical cancer.

Anemia is the most common nutritional deficiency disorder in the world. The aim of study was to determine the prevalence and the various sociodemographic factors associated with anemia among pregnant women at Rama Medical College, Hospital, Pilkhwa, Hapur, U.P., India. This study was carried out from Jan 2015 to Feb 2016. A total of 482 pregnant women were selected using a systematic random sampling technique. Sociodemographic characteristics of the mothers were extracted using an already prepared proforma. The blood haemoglobin concentration of the women were determined and the results were analysed. Pregnant women who had hemoglobin (Hb) value of < 11gm were selected in study. Overall prevalence of anemia among the pregnant women was found to be 65.15%. Factors such as level of education of women and socioeconomic status were found to be significantly associated with the prevalence of anemia in pregnancy in this area. There is a need to monitor hemoglobin during pregnancy and there by improve the outcome of pregnancy. This research work presents the magnitude of anemia and its determinant factors among pregnant women. As far as this research is done in the western part of U. P. India, where there is a different cultural issue related to pregnancy and dietary habit, it will help the researchers to know the problem in different parts of the country.

Data on utility of post-pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long-term efficacy of dilation, which tears the non-relaxing LES in achalasia, are scanty.Post-PD LES pressure was measured in 72/98 patients with achalasia. The best cut-off pressure classifying responders and non-responders was determined by receiver operating characteristic (ROC) curve. Factors associated with non-response and recurrence were evaluated.Of 98 patients (41.1 ± 13.3 years, 58 male), 75 improved, three had perforation requiring surgery, and 20 did not respond to the first PD session. Of 18/20 patients undergoing a second PD, 11 improved and six non-responders needed myotomy. 37/58 (71%) male and 17/40 (42.5%) female patients had a first PD with a 35-mm balloon (P = 0.03). Age and gender of patients did not influence outcome. LES pressure was lower in responders or in those having recurrence than in non-responders (17 mmHg [6.4-75], 11 mmHg [4.6-31]vs 25 mmHg [13-55]). On the ROC curve, 22.5 mmHg was the best cut-off value differentiating responders and non-responders (area under curve [AUC] 0.73). Of the 86 patients responding to PD, 20 had recurrence. Patients who responded to one session of PD or had LES pressure10 mmHg after the procedure recurred less often, although there was no relationship with age and gender.Post-PD LES pressure measurement is useful to assess treatment response. Patients responding to the first session and those with post-PD LES pressure10 mmHg tended to recur less. Age and gender did not influence outcome, which might be related to preferential use of a 35-mm balloon, particularly for male patients, during the first session.

Strongyloides stercoralis infestation is common in the tropics and is usually asymptomatic. Patients with immunocompromised states may develop hyperinfection and fulminant disease. It has been suggested that bacteria accompany S. stercoralis during its passage across the bowel wall, resulting in systemic sepsis. Herein is a report on a 30-year-old man with S. stercoralis infestation and small bowel bacterial overgrowth presenting as malabsorption syndrome. He developed extensive duodenojejunal ulceration, septicemia and fatal hypokalemia. Blood and jejunal fluid grew Escherichia coli with the same antibiotic sensitivity patterns. This supports the hypothesis of migration of bacteria from the intestinal lumen as a cause of septicemia in patients with fulminant S. stercoralis infestation.

Since, there is scanty data on manometric spectrum of fecal incontinence (FI) from India, ano-rectal manometry (ARM) parameters of patients with FI attending a tertiary care hospital were analyzed retrospectively.Data on 140 consecutive patients with FI (age 44.8 +/- 17.4 y, 89 male) referred for ARM were analyzed and interpreted according to standard criteria.Low resting pressure (mainly due to internal sphincter;40 mmHg) and squeeze pressure (mainly due to external sphincter;60 mmHg) were found in 88/140 (63%) and 44/140 (31.4%) patients, respectively. Low squeeze pressure indicating external sphincter defect was more commonly found in female than male [23/51 (45.1%) vs. 21/89 (23.6%), p = 0.013] though other parameters on ARM were comparable among the two genders.Parameters of ano-rectal functions were abnormal in varying combinations on ARM in a large proportion of patients with FI attending a tertiary care center and females more often had low squeeze pressure indicating external sphincter defect than males though anal resting pressure, length of the high pressure zone and tolerability to intra-rectal balloon distension were comparable.

Diseases of esophagus are common in gastroenterology practice. Improvement in diagnosis and better understanding in pathophysiology of these diseases have been possible recently of due to advancement in technology. Advancement made in the field of computer softwares is another key development aiding further improvement in these instruments. In this article, we review techniques, interpretation and clinical utility of various tests of esophageal function with special reference to manometry, ambulatory pH and impedance monitoring. Esophageal manometry is simple to perform. Recent, availability of commercial user-friendly software has made analysis of recorded data easy. High resolution spatio-temporal manometry is advancement over conventional manometry. Manometry is a useful tool for diagnosis, followup and research in esophageal motility disorders. Ambulatory 24-h pH metry and impedance monitoring are also easily analyzed by commercially available software. 24-h impedance combined with pH-metry is currently considered as the gold standard for diagnosis of gastroesophageal reflux disease (GERD). All patients with GERD may not require these investigations, but those with atypical symptoms, those refractory to medical treatment and requiring surgery do. Esophageal transit study is useful in understanding functional correlates of abnormalities in manometry and is particularly useful during follow up studies and in research.

Constipation, a common problem in gastroenterology practice, may result from slow colonic transit. Therapeutic options for slow transit constipations are limited. Excessive methane production by the methanogenic gut flora, which is more often found in patients with constipation, slows colonic transit. Thus, reduction in methane production with antibiotic treatment directed against methanogenic flora of the gut may accelerate colonic transit resulting in improvement in constipation. However, there is not much data to prove this hypothesis. We, therefore, report a patient with slow transit constipation associated with high methane production both in fasting state and after ingestion of glucose, whose constipation improved after treatment with non-absorbable antibiotic, rifaximin, which reduced breath methane values.

Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited.Eighty-six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64-month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3±14.1 months) were considered to confirm CE findings.Of 86 patients (aged 54.5±16.3 years, 63 males), 64 and 22 had OGIB-overt and OGIB-occult, respectively. Lesions were equally detected in OGIB-overt and OGIB-occult patients (48/64, 75% vs 18/22, 81.8%, P= ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively.CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.

The relationship between gastroesophageal reflux disease (GERD) and Helicobacter pylori is controversial. We evaluated endoscopic, 24-h gastric and esophageal acid profile among patients with GERD in relation to H. pylori, as the latter might alter gastric acid secretion. Patients with GERD (n = 123), who were not on acid-suppressive drugs, and had not received anti-H. pylori therapy, underwent gastroduodenoscopy and tests for H. pylori detection. Esophageal manometry, 24-h pH metry, serum pepsinogen-I (PG-I), PG-II and gastrin-17 ELISA were done in all these patients. Univariate and multivariate analyses were performed to assess independent predictors for erosive esophagitis (EE). Of 123 patients (mean age 40.5 [13.1] years, 85 [69.1%] men), 59 (47.9%) had H. pylori infection. EE was more common in H. pylori non-infected than infected (49 vs. 32, p

Objective To assess the effect of anthropometric characteristics related to weight on medical pregnancy termination with misoprostol. Methods In this prospective cohort study, 454 women admitted for medical pregnancy termination in the first or second trimester took 400 µg of misoprostol sublingually plus 800 µg of misoprostol vaginally or orally. The regimen was readministered after 24 hours if there was no response or the abortion was incomplete, and surgical evacuation was done when needed. Linear regression was performed for possible correlations between the studied characteristics and treatment process and outcome. Results There was no correlation between the number of misoprostol administrations and any of the studied anthropometric characteristics. The numbers of both misoprostol administrations and surgical interventions were associated with oral administration. Conclusion The route of misoprostol administration, but not anthropometric characteristics related to weight, were found to be associated with the success of pregnancy termination with misoprostol.