Non-invasive predictors of esophageal varices

BACKGROUND/AIM

Current guidelines recommend screening cirrhotic patients with an endoscopy to detect esophageal varices and to institute prophylactic measures in patients with large esophageal varices. In this study, we aimed at identifying non-endoscopic parameters that could predict the presence and grades of esophageal varices.

PATIENTS AND METHODS

In a prospective study, 229 newly diagnosed patients with liver cirrhosis, without a history of variceal bleeding, were included. Demographic, clinical, biochemical and ultrasonographic parameters were recorded. Esophageal varices were classified as small and large, at endoscopy. Univariate analysis and multivariate logistic regression analysis were done to identify independent predictors for the presence and grades of varices.

RESULTS

Of the 229 patients (141 males; median age 42 years; range 17-73 years) with liver cirrhosis, 97 (42.3%) had small and 81 (35.4%) had large varices. On multivariate analysis, low platelet count (Odd's Ratio [OR], 4.3; 95% confidence interval [CI], 1.2-14.9), Child Pugh class B/C (OR, 3.3; 95% CI, 1.8-6.3), spleen diameter (OR, 4.3; 95% CI, 1.6-11.9) and portal vein diameter (OR, 2.4; 95% CI, 1.1-5.3) were independent predictors for the presence of varices. Likewise, for the presence of large esophageal varices, low platelet count (OR, 2.7; 95% CI, 1.4-5.2), Child Pugh class B/C (OR, 3.8; 95% CI, 2.3-6.5) and spleen diameter (OR, 3.1; 95% CI, 1.6-6.0) were the independent risk factors.

CONCLUSION

The presence and higher grades of varices can be predicted by a low platelet count, Child-Pugh class B/C and spleen diameter. These may be considered as non-endoscopic predictors for the diagnosis and management of large grade varices.

Distinguishing tuberculosis and Crohn's disease in developing countries: how certain can you be of the diagnosis?

Distinguishing tuberculosis and Crohn's disease in patients presenting with chronic abdominal pain and diarrhea is a huge diagnostic challenge, particularly in tuberculosis endemic countries. A large number of patients with Crohn's disease are initially misclassified as having Intestinal tuberculosis in places where tuberculosis is endemic before they are treated for Crohn's disease. Although a variety of endoscopic, radiological and histological criteria have been recommended for the differentiation, it often proves difficult in routine clinical practice. Future prospective studies are required in patients with granulomatous colitis to prevent unnecessary inappropriate anti tuberculous therapy for patients with Crohn's disease and appropriate early treatment for a patient with tuberculosis.

Predictors of variceal bleed among patients with liver cirrhosis in the era of sclerotherapy

INTRODUCTION

Variceal bleed is a common complication of portal hypertension. The bleed pattern has changed considerably with the introduction of variceal band ligation. The bleed pattern in developing countries where sclerotherapy continues to remain a viable option is not known. The aim of the study was to determine the predictors of first and subsequent bleed in individuals with liver cirrhosis.

METHODS

205 subjects with liver cirrhosis and portal hypertension registered in the liver clinic between January and June 2004, were followed-up for 18 months after registration. Bleeders already on pharmacotherapy or endotherapy were excluded. Patient details included age, gender, duration of illness, aetiology, Child-Pugh-Turcotte score and grades of oesophageal varices, details of index and subsequent variceal bleed, and complications during follow-up. Logistic regression multivariate analysis was applied to predict the factors influencing variceal bleed.

RESULTS

There were 95 variceal bleeders and 110 non-bleeders. Age at presentation and gender did not predict a variceal bleed. Grades III and IV oesophageal varices and fundal varices were the significant risk factors for an index bleed (p-value is 0.001). 27 of the 95 bleeders (28.3 percent) had a second bleed after a mean interval of 8 (+/- 7.7) months. Predictors of rebleed were similar to the index bleed. Predictors of index bleed were also similar to those who had bled for the first time after registration. Overall bleed-related mortality was low (2.1 percent).

CONCLUSION

Higher grades of varices, presence of cherry-red spots and fundal varices predicted variceal bleed in patients with liver cirrhosis. Variceal bleed-related mortality was low in the era of sclerotherapy.

Carcinoma of the esophagus in Tamil Nadu (South India): 16-year trends from a tertiary center

BACKGROUND

In the Western world, esophageal adenocarcinoma has surpassed in incidence squamous cell carcinoma.

AIM

To determine the trend changes in histology and site distribution of esophageal malignancy between 1989 and 2004 in a southern state of the Indian subcontinent.

METHOD

A retrospective study on 994 patient records with esophageal carcinoma esophagus. Age, gender, clinical presentation and duration of illness were recorded in a prestructured proforma. The site of the tumor was classified as upper, mid, lower esophagus and esophagogastric junction. The 16 year study period was divided into four equal cohorts. Statistical analysis was performed using the chi-square test and the one way ANOVA wherever appropriate; p < 0.05 was considered significant.

RESULTS

Squamous cell carcinoma was the most common malignancy, seen in 912 (92%) patients. 82 patients (8%) had adenocarcinoma. 65 of these 82 patients (79%) had an esogastric junction malignancy and 17 (21%) a tumor in the distal third of the esophagus. No time trends were discernible with regard to the clinical presentation, frequency, mean age or gender. However, an increase in the number of patients below the age of 40 was noted (p=0.008). In squamous cell carcinoma of the esophagus, there was an overall increase in the mean age of occurrence (p=0.05), but no significant changes in the gender ratio. The lower esophageal cancers outnumbered the midesophageal cancers in the 4th cohort and the former represent the most common site of malignancy.

CONCLUSION

Squamous cell carcinoma is the most common type of esophageal cancer in the Indian subcontinent, located with a predilection in the distal third. Adenocarcinoma is uncommon and affects more frequently men younger than 40.

ERCP in acute pancreatitis

BACKGROUND

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute pancreatitis has evolved over years since its introduction in 1968. Its importance in diagnosing the etiology of pancreatitis has steadily declined with the advent of less invasive diagnostic tools. The therapeutic implications of ERCP in acute pancreatitis are many fold and are directed towards management of known etiological factors or its related complications. This article highlights the current status of ERCP in acute pancreatitis.

DATA SOURCES

An English literature search using PubMed database was conducted on ERCP in acute pancreatitis, the etiologies and complications of pancreatitis amenable to endotherapy and other related subjects, which were reviewed.

RESULTS

ERCP serves as a primary therapeutic modality for management of biliary pancreatitis in specific situations, pancreatitis due to microlithiasis, specific types of sphincter of Oddi dysfunction, pancreas divisum, ascariasis and malignancy. In recurrent acute pancreatitis and smoldering pancreatitis it has a definite therapeutic utility. Complications of acute pancreatitis including pancreatic-duct disruptions or leaks, benign pancreatic-fluid collections and pancreatic necrosis can be beneficially dealt with. Intraductal ultrasound and pancreatoscopy during ERCP are useful in detecting pancreatic malignancy.

CONCLUSIONS

The role of ERCP in acute pancreatitis is predominantly therapeutic and occasionally diagnostic. Its role in the management continues to evolve and advanced invasive procedures should be undertaken only in centers dedicated to pancreatic care.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females

PURPOSE

This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females.

METHODS

A representative sample of multiparous United Arab Emirates females aged 20 years or older (N = 450) were randomly selected from the community (n = 225) and health care centers (n = 225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire.

RESULTS

Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P < 0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent).

CONCLUSIONS

Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.