Indian consensus statements on irritable bowel syndrome in adults: A guideline by the Indian Neurogastroenterology and Motility Association and jointly supported by the Indian Society of Gastroenterology

The Indian Neurogastroenterology and Motility Association (INMA), earlier named the Indian Motility and Functional Diseases Association developed this evidence-based practice guidelines for the management of irritable bowel syndrome (IBS). A modified Delphi process was used to develop this consensus containing 28 statements, which were concerning diagnostic criteria, epidemiology, etiopathogenesis and comorbidities, investigations, lifestyle modifications and treatments. Owing to the Coronavirus disease-19 (COVID-19) pandemic, lockdowns and mobility restrictions, web-based meetings and electronic voting were the major tools used to develop this consensus. A statement was regarded as accepted when the sum of "completely accepted" and "accepted with minor reservation" voted responses were 80% or higher. Finally, the consensus was achieved on all 28 statements. The consensus team members are of the view that this work may find use in teaching, patient care, and research on IBS in India and other nations.

In vivo appraisal of oxidative stress response, cell ultrastructural aberration and accumulation in Juvenile Scylla serrata exposed to uranium

In vivo studies were performed to evaluate the organ specific tissue accumulation and cellular toxicity of uranium to mud crab Scylla serrata. The specimens were acclimated in natural seawater and the exposure to 50-250 μg/L uranium was investigated up to 60 days. The present study examined the effects of concentration and duration of uranium exposure in the tissue of S. serrata at cellular and subcellular level using scanning electron microscopy and bright field transmission electron microscopy in addition to histological analysis. The results indicated that accumulation of U in S. serrata was organ specific and followed the order gills > hepatopancreas > muscle. The response of key antioxidant enzyme activities such as SOD, GPx and CAT in different organs of crabs indicated oxidative stress due to U in the ambient medium and tissue. At 50 and 100 μg/L of U exposure, individuals were able to acclimate the oxidative stress and withstand the uranium exposure. This acclimation could not be sustained at higher concentrations (250 μg/L), affecting the production of CAT in the tissues. Cellular and subcellular changes were observed in the hemocytes with reduction in their number in consonance with the antioxidant enzymes. Histological aberrations like lamellar disruption of gill, necrosis of hepatopancreas, disruption and rupture of muscle bundles were observed at different concentrations and were severe at higher concentration (250 μg/L). Necrosis was observed in the electron micrographs of tissues shortly after 15 days of exposure. SEM micrograph clearly shows disrupted lamellae, folding of marginal canal and reduction of inter lamellar spaces in the gills of crab exposed to high concentration of uranium. Mitochondrial anomalies are reported for the first time in the present study in addition to the subcellular changes and vacuoles on exposure uranium in the cells of gill and hepatopancreas.

Genetic diversity and multiple antibiotic resistance index study of bacterial pathogen, Klebsiella pneumoniae strains isolated from diseased Indian major carps

Intensive fish farming systems have led to increase in disease incidence, due to higher stocking density, high organic matter levels, and poor quality of the aquatic environment. Diseased fish samples showing hemorrhages and reddish lesions were collected from different freshwater fish farms located at three different districts of West Bengal, India (Burdwan, North 24 Parganas, and Nadia). The present study was conducted to evaluate the genetic diversity of ten different Klebsiella pneumoniae strains isolated from different infected freshwater fish samples based on 16S rRNA gene sequence analysis. Primarily, Klebsiella-specific media was used for the isolation and characterization of Klebsiella pneumoniae. Further, through a biochemical test, all the strains were confirmed as K. pneumoniae. PCR analysis of 16S-23S internal transcribed spacer (PCR ribotyping) was carried out to study the species variation within different Klebsiella pneumoniae isolates. For all the isolates, a conserved PCR ribotype pattern was observed while differing from other bacterial species. Phylogenetic study showed the high degree of homology with diverse source of other strains. The multiple antibiotic resistance (MAR) values of the present study for the isolates were found to be 0.468. MAR value above 0.2 indicates that the source of isolation was highly contaminated with antibiotics. Based on the 16S rRNA gene sequence analysis, the present study revealed the genetic diversity of Klebsiella pneumoniae isolated from the different diseased fish farms of West Bengal. All the strains were found to be hypermucoviscous and multidrug-resistant, thus making it pathogenic towards the host organisms. Further, the study revealed a high prevalence of K. pneumoniae in aquaculture farms, representing a risk towards successful aquaculture.

A Prospective Study Evaluating the Etiologic Spectrum in Patients with Dysphagia in Coastal Odisha Using Clinical Features and Endoscopy

Background: There is scarcity of data on the etiological spectrum of dysphagia from India. The study was conducted to determine the etiological spectrum of dysphagia in coastal Odisha.

Materials and Methods: Consecutive patients presenting with dysphagia to the gastroenterology outpatient department in 2017 were studied. Patients were evaluated with meticulous history, clinical examination, esophagogastroduodenoscopy, and chest X-ray. Barium study and endoscopic biopsy were done when necessary.

Results: Of 216 consecutive patients, 122 (56.48%) were male and 94 (43.52%) were female with a mean age of 42.3 ± 17.4 years. The common etiologies were benign stricture in 68 (31.48%) and esophageal carcinoma in 51 (23.62%). Other etiologies included achalasia cardia in 11 (5.09%), esophageal candidiasis in 10 (4.63%), pharyngeal cancer in 4 (1.85%), and esophageal web in 3 (1.39%). In 63 (29.17%) cases, no etiology was detected. Most of the benign strictures were due to corrosive injury in 48 (70.59%); other causes included peptic stricture (8, 11.76%), postsurgery (4, 5.88%), sclerotherapy-induced stricture (2, 2.94%), and pill-induced stricture (2, 2.94%); in 4 (5.88%) cases, the cause of stricture was not known. The most common cause of corrosive injury was acid injury in 38 (79.17%), followed by alkali injury in 4 (8.34%). In 6 (12.5%) cases, the nature of corrosive was not known. Most of the corrosive injuries were due to suicidal intake.

Conclusion: In this study, the most common cause of dysphagia was benign corrosive stricture due to suicidal intake of corrosives. Esophageal carcinoma, achalasia cardia, and esophageal candidiasis were other significant etiologies. Uncommon causes of dysphagia included esophageal web, pharyngeal cancer, and reflux esophagitis.

A prospective study on incidence, risk factors, and validation of a risk score for post-infection irritable bowel syndrome in coastal eastern India

BACKGROUND AND AIM

Post-infection irritable bowel syndrome (PI-IBS) can occur following acute gastroenteritis (AGE). This study was designed to evaluate the incidence and risk factors of PI-IBS following AGE and to validate a PI-IBS risk score.

METHODS

This prospective study was performed between September 2014 and October 2016 on AGE patients by documenting their AGE severity and following up after 3 and 6 months to study the development of IBS (ROME III criteria). The risk score was calculated for all the subjects, and its discrimination ability was tested.

RESULTS

Out of 136 hospitalized AGE patients, 35 developed PI-IBS after 6 months. The factors associated with PI-IBS were younger age, longer duration of AGE, anxiety, depression, abdominal pain, bloody stool, vomiting, fever, family history of IBS, and positive stool culture (univariate analysis); however, on multivariate analysis, younger age (adjusted odds ratio [AOR] 0.5; p 0.03), prolonged duration of AGE (AOR 8.6; p 0.01), and abdominal cramps (AOR 2.1; p 0.02) were the independent factors influencing its occurrence. PI-IBS occurred even after infection with Vibrio cholerae. The PI-IBS risk score was significantly higher in patients who developed PI-IBS (72.4 ± 14.48 vs. 31.56 ± 20.4, p-value < 0.001); score > 50 had a sensitivity and specificity of 91.4% and 84.2%, respectively.

CONCLUSION

One fourth of AGE patients developed PI-IBS after 6 months. Factors influencing its development were younger age, long duration of AGE, and abdominal pain. The PI-IBS risk score had good predictive accuracy in our population.

Acute Kidney Injury at Admission Is a Better Predictor of Mortality than Its Persistence at 48 h in Patients with Acute-on-chronic Liver Failure

Background and Aims: Acute kidney injury (AKI) occurs commonly in patients with acute-on-chronic liver failure (ACLF). However, there are scant data regarding the impact of AKI on survival in ACLF. We performed a prospective study to evaluate the impact of AKI on survival in ACLF.

Methods: This study was conducted in ACLF patients hospitalized in the Gastroenterology Department of Sriram Chandra Bhanja Medical College (India) between October 2016 and February 2018. Demographic, clinical and laboratory parameters were recorded, and outcomes were compared between patients with and without AKI and between patients with persistent AKI and AKI reversal at 48 h.

Results: We screened 439 chronic liver disease patients as per the Asian Pacific Association for the Study of the Liver criteria and found that 113 (25.7%) of them had ACLF and 78 (69%) of them had AKI as per the Acute Kidney Injury Network criteria. ACLF patients with AKI had reduced 28-day survival (44.9% vs. 74.3%; p = 0.004) and 90-day survival (25.6% vs. 51.4%; p = 0.007), in comparison to ACLF patients without AKI. However, when comparison was made between AKI reverters and AKI persisters at 48 h, survival was comparable for both at 28 days and 90 days. Further, about one-tenth of ACLF patients with AKI died within 48 h of hospitalization.

Conclusions: Over two-thirds of ACLF patients had AKI. Although ACLF itself is a predictor of reduced survival, a very small increase in serum creatinine further worsens survival. Importantly, AKI at admission is a better predictor of early mortality in ACLF patients since recovery from AKI at 48 h does not improve survival.

Leech Infestation Presenting as Severe Rectal Bleeding

Leech or Hirudinea is a major parasite in rural India. Normally, the leech attacks the skin and exposed areas. An 18‑year‑old child presented with bleeding per rectum for 1 day along with giddiness. A history revealed that while the boy was working in a field, had acrawling sensation in the perianal area. After admission, the patient was resuscitated with crystalloids and a limited colonoscopy revealed a rectal ulcer with a leech head attached to its base. The hooklets were removed using foreign body removal forceps and injection Adrenaline at 1:10,000 dilutions was injected in 1 ml aliquots into four quadrant to achieve hemostasis. There was no postprocedure complication. Leech infestation can present with exsanguinating acute severe lower gastrointestinal bleed.

A 10-year-old child presenting with syndromic paucity of bile ducts (Alagille syndrome): a case report

Background

Alagille syndrome, a rare genetic disorder with autosomal dominant transmission, manifests with five major features: paucity of interlobular bile ducts, characteristic facies, posterior embryotoxon, vertebral defects, and peripheral pulmonary stenosis. Globally, only 500 cases have so far been reported, with only five cases reported in the Indian subcontinent. Rarely, Alagille syndrome also presents with skin manifestations and early-onset chronic liver disease, which was found in our case. We believe that we report what could be the first case of Alagille syndrome presenting with café au lait spots, as no such published case report could be found in the literature.

Case presentation

We report an unusual case of childhood cholestatic jaundice with neonatal onset of jaundice. A 10-year-old boy from the Indian subcontinent presented with obstructive jaundice from early infancy. He also had recurrent fractures of his upper limb bones, intermittent bleeding from his nose, productive cough, decreased night vision, hyperpigmented spots over his skin, and progressive enlargement of his abdomen. Histological examination of a liver biopsy specimen revealed a paucity of bile ducts and changes suggestive of chronic liver disease. Our patient was diagnosed with Alagille syndrome and managed conservatively but died 1 year after the final diagnosis.

Conclusions

This particular syndromic form of paucity of bile duct disorder has been rarely reported in the Indian literature so far. Our case is notable because the child had café au lait spots and very early onset of chronic liver disease, which is quite rare in Alagille syndrome. We believe this to be the first case report on Alagille syndrome manifesting with café au lait syndrome and such early onset of chronic liver disease.

Syringocystadenoma papilliferum: report of first case on the pinna

Syringocystadenoma papilliferum is a benign adnexal skin tumour, which, in a third of cases, arises from an organoid nevus on the head and neck. We report on a 17-year-old man with a syringocystadenoma papilliferum on his right pinna of three-years duration. The clinical and histopathological features are described. Following excision and skin grafting, the patient remains asymptomatic four years after surgery. This is the first report of a syringocystadenoma papilliferum on the pinna.