Role of Immunohistochemistry and serology in subclassifying the Inflammatory Bowel Disease cases diagnosed as Inflammatory Bowel Diseases---unclassified on colonic biopsies

BACKGROUND

Inflammatory bowel diseases (IBDs) mainly consist of Crohn's Disease (CD) and Ulcerative Colitis (UC). These two categories have overlapping histopathological features and sometimes it is difficult to diagnose them into distinct category and such biopsies are categorised as Inflammatory Bowel Disease (IBD-U). Recently, there has been an increase in interest to discover new biomarkers of IBD to differentiate UC and CD and predict their prognosis.

METHOD

In the present study, 273 non-neoplastic colonic biopsies with clinicoendoscopic features of IBD were studied and categorized into UC (88; 32.3%) and CD (03; 1.1%) but a major chunk remained in category of IBD-U (182; 66.6%). 161 (58.9%) of these biopsies were then subjected to IHC for RB protein and β-catenin and Serology for pANCA and ASCA was done in only 85 (31.13%) of these selected cases for identification of UC and CD on colonic biopsies.

RESULT

161 biopsies that were subjected to IHC analysis included 57 cases of UC, 03 cases of CD, and rest 101 cases of IBD-U. Out of 101 cases of IBD-U, 87 (86.13%) cases were reclassified as UC (61; 60.3%) and CD (14; 13.86%) on the basis of results of IHC and Serology.

CONCLUSION

The two major tools IHC for β-catenin and RB protein and the assay of serum ASCA and p-ANCA along with proper history and clinical presentation can act as a good adjunct to conventional H and E in subclassifying cases of IBD-U into UC and CD.

Colitis and Crohn's Foundation (India) consensus statements on use of 5-aminosalicylic acid in inflammatory bowel disease

Despite several recent advances in therapy in inflammatory bowel disease (IBD), 5-aminosalicylic acid (5-ASA) therapy has retained its place especially in ulcerative colitis. This consensus on 5-ASA is obtained through a modified Delphi process, and includes guiding statements and recommendations based on literature evidence (randomized trials, and observational studies), clinical practice, and expert opinion on use of 5-ASA in IBD by Indian gastroenterologists. The aim is to aid practitioners in selecting appropriate treatment strategies and facilitate optimal use of 5-ASA in patients with IBD.

Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Differentially localized survivin and STAT3 as markers of gastric cancer progression: Association with Helicobacter pylori

BACKGROUND

Localization and differential expression of STAT3 and survivin in cancer cells are often related to distinct cellular functions. The involvement of survivin and STAT3 in gastric cancer has been reported in separate studies but without clear understanding of their kinetics in cancer progression.

METHODS

We examined intracellular distribution of STAT3 and survivin in gastric adenocarcinoma and compared it with normal and precancer tissues using immunoblotting and immunohistochemistry.

RESULTS

Analysis of a total of 156 gastric samples comprising 61 histologically normal, 30 precancerous tissues (comprising intestinal metaplasia and dysplasia), and 65 adenocarcinomas, collected as endoscopic biopsies from treatment naïve study participants, revealed a significant (P < .001) increase in overall protein levels. Survivin expression was detectable in both cytoplasmic (90.8%) and nuclear (87.7%) compartments in gastric adenocarcinomas lesions. Precancerous dysplastic gastric lesions exhibited a moderate survivin expression (56.7%) localized in cytoplasmic compartment. Similarly, STAT3 and pSTAT3 expression was detected at high level in gastric cancer lesions. The levels of compartmentalized expression of survivin and STAT3/pSTAT3 correlated in precancerous and adenocarcinoma lesions. Although overexpression of these proteins was found associated with the tobacco use and alcohol consumption, their expression invariably and strongly correlated with concurrent Helicobacter pylori infection. Receiver operating characteristic analysis of nuclear survivin, STAT3, and pSTAT3 in different study groups showed acceptable positive and negative predictive values with area under the curve above 0.8 (P < .001).

CONCLUSION

Overall, our results suggest that overall increase in survivin and STAT3 and their subcellular localization are key determinants of gastric cancer progression, which can be collectively used as potential disease biomarkers and therapeutic targets for gastric cancer.

Levels of interleukins 2, 6, 8, and 10 in patients with irritable bowel syndrome

Irritable bowel syndrome (IBS) was previously considered as a psychosomatic disorder. But recent studies indicate that inflammation plays a significant role. The present study was undertaken to evaluate role of pro-inflammatory (IL 2, IL 6 and IL 8) and anti-inflammatory (IL 10) cytokines in clinically diagnosed patients of IBS. 51 patients and 29 controls were included in this study. On the basis of history of gastrointestinal infection, patients were divided into Post Infectious (PIIBS) and Non Post Infectious (NPIIBS) groups. All subsequently underwent colonoscopy and a rectosigmoid biopsy as well as measurement of levels of IL 2, 6, 8 and 10. The levels of IL 2 and IL 8 were significantly raised in IBS patients compared to controls with the mean level of IL 2,6 and 8 higher in PIIBS group than NPIIBS group but statistically significant for IL 8 only. The mean level IL-10 was reduced in patients compared to controls but statistically insignificant. Present study shows that Interleukin levels are altered in patients suffering from IBS and may have a key role in its pathogenesis.

Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Irritable Bowel Syndrome and Bronchial Asthma: Are They Associated in Indian Population?

INTRODUCTION

Irritable Bowel Syndrome (IBS), a common gastrointestinal (GI) disorder has been linked with asthma implying a clue to its pathophysiology as being some form of allergic response. Previous studies from other parts of the world have shown both the presence as well as an absence of an association between them.

AIM

We conducted a cross-sectional study to find an association between IBS and asthma, in an Indian cohort.

MATERIALS AND METHODS

Seventy patients of IBS diagnosed by exclusion and ROME III criteria with a matched control group were questioned for GI, respiratory symptoms along with their spirometry analysis. Those having reversible bronchoconstriction were categorized as asthmatic.

RESULTS

The prevalence of asthma in the IBS group of 16 females and 54 males was 12 (17.14%) as compared to 14 (20%) in control group. Chi-square test revealed the Odds Ratio (OR) for prevalence of asthma in IBS as 0.828 with 95% Confidence Interval (CI) between 0.320 and 2.121 (p=0.664) which was non-significant (p>0.05).

CONCLUSION

This study denies the presence of association between IBS and asthma among Indian cohorts and suggests that regional variations are present in the above association.

Vitamin D status in patients with cirrhosis of the liver and their relatives-A case control study from North India

BACKGROUND AND AIM

Liver diseases interfere with the production of the metabolites of vitamin D required for activation, thus resulting in abnormal calcium and bone metabolism. Previous studies show inconsistent results of vitamin D level in non-cholestatic liver diseases. Our aim was to determine the prevalence of vitamin D insufficiency in cirrhosis as compared to apparently normal relatives and its relationship with etiology and severity.

METHODS

One hundred and sixty cirrhotic patients attending the Department of Gastroenterology and Hepatology, M L N Medical College, Allahabad, were enrolled, and 25-hydroxy vitamin D [25(OH)D] and calcium levels assessed. Vitamin D status was graded as insufficiency (20-30 ng/mL), deficiency (<20 ng/mL), and severe deficiency (<7 ng/mL). 25(OH)D levels of patients were compared with those of their healthy family members.

RESULTS

Forty-six percent of the normal population had 25(OH)D inadequacy, whereas 51.85% of patients with cirrhosis had 25(OH)D deficiency, and 28.12% had insufficiency. Thus, 80% of patients with cirrhosis of the liver had some form of vitamin D inadequacy. 12.5% of cirrhotics had severe vitamin D deficiency. Serum calcium (Ca⁺⁺) was not significantly different between the patients and control group. The etiology of cirrhosis had no relation with vitamin D levels. Prevalence of deficiency and insufficiency increased with increasing age and mean Child-Turcotte-Pugh and model for end-stage liver disease scores.

CONCLUSION

Vitamin D insufficiency is highly prevalent in patients with cirrhosis irrespective of etiology and significantly more common than their healthy relatives. Measurement of 25(OH) vitamin D and replacement may be considered as part of the overall management of patients with cirrhosis of the liver as well as apparently healthy individuals.

Expression of Alpha Methylacyl CoA Racemase (AMACR) in Gastric Adenocarcinoma and Its Correlation with Helicobacter pylori Infection

INTRODUCTION

Gastric cancer develops in a multistep progression and is determined by genetic and environmental factors. Over-expression of Alpha Methylacyl CoA Racemase (AMACR) is useful in diagnosis of prostate cancer. There is plenty of genetic alteration that occurs in gastric adenocarcinoma. The present study was planned to determine if AMACR can be used as a diagnostic marker in gastric adenocarcinoma similar to prostate cancer.

AIM

To study the expression of AMACR in gastric adenocarcinoma and correlate its expression with density of Helicobacter pylori.

MATERIALS AND METHODS

This cross-sectional, prospective study was conducted from August 2013-2015. Fifty gastric cancer biopsies were taken. Adjacent biopsy from normal/reactive mucosa was also taken from 21 cases. Samples were stained with H&E for morphological details, Loeffler's methylene blue for Helicobacter pylori and immunohistochemistry (IHC) was done to check for the expression of AMACR proteins. Statistical analysis was done using chi square test, Spearman's correlation coefficient and Fisher's exact test. The p-value ≤ 0.05 was taken as critical level of significance.

RESULTS

Overexpression of AMACR was observed in 88.89% of intestinal type and 78.05% of diffuse type adenocarcinoma. AMACR expression was significantly less in adjacent reactive/dysplastic mucosa. Helicobacter pylori were seen in 8/9 (88.89%) and 35/41(85.36%) cases of intestinal adenocarcinoma and diffuse adenocarcinoma respectively. When grades of Helicobacter pylori were compared with the positivity of AMACR, no significant association and correlation was found.

CONCLUSION

The expression of AMACR in neoplastic tissue was significantly higher as compared to adjacent dysplastic, reactive or normal tissue. Thus, IHC for AMACR can be used for differentiating the cases of reactive atypia from early neoplastic lesions similar to its role in prostatic tissue. Helicobacter pylori does not affect the expression of AMACR in neoplastic gastric lesions.

Berberine and Curcumin Target Survivin and STAT3 in Gastric Cancer Cells and Synergize Actions of Standard Chemotherapeutic 5-Fluorouracil

Aberrantly expressed survivin and STAT3 signaling have emerged as major determinants of chemoresistance in gastric cancer. We evaluated effects of potent herbal derivatives curcumin, berberine, and quercetin on STAT3 signaling, survivin expression, and response to 5-fluorouracil (5-FU) treatment in gastric cancer cells (AGS). Cytotoxic and inhibitory effects of berberine, curcumin, and quercetin alone or in combination with 5-FU were examined by MTT assay, and their effect on survivin, STAT3, and the phosphorylated active STAT3 (pSTAT3) expression was examined by western blotting. Effect of these herbal derivatives on STAT3 DNA binding activity was measured by electrophoretic mobility shift assay. Curcumin, berberine, and quercetin effectively downregulated pSTAT3 levels, survivin expression, and gastric cancer cells viability in a dose-dependent manner (with corresponding IC50 values of 40.3μM, 29.2μM and 37.5μM, respectively). Berberine was more effective in inhibiting survivin expression as compared to other herbal agents. 5-FU in combination with berberine or curcumin showed a synergistic inhibition of survivin and STAT3 level resulting in enhanced cell death in gastric cancer cells. Overall, our data suggest use of berberine and curcumin as adjunct therapeutics to overcome chemoresistance during treatment of gastric malignancies.

Helicobacter pylori infection and a P53 codon 72 single nucleotide polymorphism: a reason for an unexplained Asian enigma

AIM

P53, the most commonly mutated tumor suppressor gene in all types of human cancer, is involved in cell cycle arrest and control of apoptosis. Although p53 contains several polymorphic sites, the codon 72 polymorphism is by far more common. There are divergent reports but many studies suggest p53 pro/pro SNP may be associated with susceptibility to developing various cancers in different regions of the world. The present study aimed to find any correlation between H. pylori infection and progression of carcinogenesis, by studying apoptosis and the p53 gene in gastric biopsies from north Indian population.

MATERIALS AND METHODS

A total of 921 biopsies were collected and tested for prevalence of H. pylori by rapid urease test (RUT), imprint cytology and histology. Apoptosis was studied by the TUNEL method. Analysis of p53 gene polymorphism at codon 72 was accomplished by PCR using restriction enzyme BstU1.

OBSERVATION

Out of 921 samples tested 56.7% (543) were H. pylori positive by the three techniques. The mean apoptotic index (AI) in the normal group was 2.12, while gastritis had the maximum 4.24 followed by gastric ulcer 2.28, gastropathy 2.22 and duodenal ulcer 2.08. Mean AI in cases with gastric cancer (1.72) was less than the normal group. The analysis of p53 72 SNP revealed that p53 (Arg/Arg), (Pro /Arg) variant are higher (40.59% and 33.66%) as compared to p53 pro/pro variant (25.74%) in the healthy population.

CONCLUSIONS

The North Indian population harbors Arg or Pro/Arg SNP that is capable of withstanding stress conditions; this may be the reason of low incidence of gastric disease in spite of high infection with H. pylori. There was no significant association with H. pylori infection and AI. However, there is increased apoptosis in gastritis which may occur independent of H. pylori or p53 polymorphism.

Indian Society of Gastroenterology consensus statements on Crohn's disease in India

In 2012, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on Crohn's disease (CD). This consensus, produced through a modified Delphi process, reflects our current recommendations for the diagnosis and management of CD in India. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.

A comparative evaluation of scoring systems for assessing necro-inflammatory activity and fibrosis in liver biopsies of patients with chronic viral hepatitis

INTRODUCTION

To compare the five scoring systems in assessing grading and staging of liver biopsies from patients with chronic viral hepatitis and their problems and pitfalls.

MATERIALS AND METHODS

Liver biopsies from 25 patients with chronic viral hepatitis were studied. Sections were stained with Haematoxylin and Eosin, Reticulin and Masson's Trichrome stains. Van Gieson, Perl's and Shikata's Orcein stains were used as and when required. Coded histological sections were scored independently by three histopathologists using the Knodell Histology Activity Index (HAI), the Scheuer scoring system, Ishak's system, Metavir system and Ishak modified HAI.

RESULTS

There were 15 males and 10 females. Their mean age was 51.24 years. On histological examination, hepatocytes showed degenerative changes with varying grades of necrosis (spotty and confluent). Widening of portal tracts with varying severity of mononuclear inflammatory infiltrate and interface hepatitis was observed. Fibrosis appeared as periportal, portal-portal and portal-central septa. A significant agreement was found by kappa statistics for both grading (p< 0.001) as well as staging (p < 0.001) among all the five scoring systems. Lobular activity was the only parameter that showed some discrepancy. No significant intra observer difference was observed.

CONCLUSION

It is concluded that all the scoring systems are equally good for grading and staging in the hands of an experienced hepatopathologists.

Carcinogenic Helicobacter pylori in gastric pre-cancer and cancer lesions: Association with tobacco-chewing

AIM: To investigate the low gastric cancer incidence rate relative to the highly prevalent Helicobacter pylori (H. pylori) infection; data relevant to H. pylori infection during gastric carcinogenesis in Indian patients is currently lacking.

METHODS: The present study examines the prevalence of H. pylori infection in DNA derived from 156 endoscopic gastric biopsies of different disease groups that represent gastric pre-cancer [intestinal metaplasia (n = 15), dysplasia (n = 15)], cancer [diffuse adenocarcinoma (n = 44), intestinal adenocarcinoma (n = 21)], and symptomatic but histopathologically-normal controls (n = 61). This was done by generic ureC polymerase chain reaction (PCR) and cagA-specific PCR that could specifically identify the carcinogenic H. pylori strain.

RESULTS: Our analysis showed the presence of H. pylori infection in 61% of symptomatic histopathologically-normal individuals, however only 34% of control tissues were harboring the cagA⁺ H. pylori strain. A similar proportion of H. pylori infection (52%) and cagA (26%) positivity was observed in the tumor tissue of the gastric cancer group. In comparison, H. pylori infection (90%) and cagA positivity (73%) were the highest in gastric pre-cancer lesions. In relation to tobacco and alcohol abuse, H. pylori infection showed an association with tobacco chewing, whereas we did not observe any association between tobacco smoking or alcohol abuse with prevalence of H. pylori infection in the tissue of any of the patient groups studied.

CONCLUSION: High incidence of H. pylori infection and carcinogenic cagA positive strain in pre-cancer lesions during gastric carcinogenesis may be associated with the habit of chewing tobacco.

Helicobacter pylori and gastric cancer: Indian enigma

Helicobacter pylori (H. pylori) is a gram negative microaerophilic bacterium which resides in the mucous linings of the stomach. It has been implicated in the causation of various gastric disorders including gastric cancer. The geographical distribution and etiology of gastric cancer differ widely in different geographical regions and H. pylori, despite being labeled as a grade I carcinogen, has not been found to be associated with gastric cancer in many areas. Studies in Asian countries such as Thailand, India, Bangladesh, Pakistan, Iran, Saudi Arabian countries, Israel and Malaysia, have reported a high frequency of H. pylori infection co-existing with a low incidence of gastric cancer. In India, a difference in the prevalence of H. pylori infection and gastric cancer has been noted even in different regions of the country leading to a puzzle when attempting to find the causes of these variations. This puzzle of H. pylori distribution and gastric cancer epidemiology is known as the Indian enigma. In this review we have attempted to explain the Indian enigma using evidence from various Indian studies and from around the globe. This review covers aspects of epidemiology, the various biological strains present in different parts of the country and within individuals, the status of different H. pylori-related diseases and the molecular pathogenesis of the bacterium.

The budd-Chiari syndrome in a child: a case report and review of the literature

The Budd-Chiari Syndrome is associated with hepatic venous outflow obstruction. This syndrome is rare in infants and children. As this syndrome is uncommon, especially in the paediatric age group, misdiagnoses and delays in the diagnosis are frequent. A high index of clinical suspicion along with a radiological aid and a histopathological correlation can lead to an early diagnosis and an appropriate management in such cases.This case report highlights the occurrence of this rare condition in the paediatric age group as well as it redefines the salient features of this syndrome.

Colon tumors and colonoscopy

A large number of abstracts dealing with colonoscopy were presented at Digestive Disease Week (DDW; 7-10 May 2011; Chicago, Illinois, USA). Topics included: new techniques in colonoscopy, recent innovations in endoscopic ultrasonography (EUS), prevention of postpolypectomy bleeding, Raman spectroscopy, bowel preparation during colonoscopy, risk factors for high grade dysplasia (HGD) in colonic adenoma, recent advances in endoscopic treatment of colorectal cancer (CRC), and follow-up of HGD and CRC after endoscopic treatment. This review focuses on the most relevant presentations dealing with colon tumours and colonoscopy.

Seroprevalence of hepatitis B infection during pregnancy and risk of perinatal transmission

OBJECTIVES

To investigate the seroprevalence of hepatitis B surface antigen (HBsAg) in pregnant women and possible risk factors for perinatal hepatitis B virus (HBV) transmission.

METHODS

Four thousand pregnant women were evaluated using history, examination, and test for serum HBsAg using commercial enzyme immunoassay kits. For HBsAg positive women, liver function tests and a test for hepatitis B e antigen (HBeAg) was done. HBV DNA analysis was done by polymerase chain reaction (PCR).

RESULTS

Of 4,000 women studied, 37 (0.9%) tested positive for HBsAg. Of these 37 women, 6 (16%) presented with acute hepatitis and 31 (84%) were asymptomatic. The highest HBsAg positivity rate was seen in the age group of 21-25 years (1.15%) followed by 26-30 years (0.86%). Assessment of risk factors revealed history of tattooing in 29/37 (78.4%) women. HBeAg was positive in 21 of 37 (56.8%) women. Of the 16 HBeAg negative women, 5 were positive for HBV DNA and anti-HBe antibody, 6 had only anti-HBe antibody and 5 had neither HBV DNA nor anti-HBe. Vertical transmission was seen in 65% (13/20) of babies born to mothers who were positive for HBeAg and HBV DNA. In contrast, it was only 9.1% (1/11) for babies born to mothers who were negative for both HBeAg and HBV DNA. Of the 25 babies delivered vaginally, 15 (60%) developed vertical transmission. None of the four babies delivered by elective cesarean section had evidence of vertical transmission.

CONCLUSIONS

Seroprevalence of HBsAg in antenatal women was found to be 0.9%. HBe-antigen and HBV DNA positivity was associated with a higher chance of vertical transmission.

Microscopic colitis in patients presenting with chronic diarrhea

AIM

To investigate the prevalence of microscopic colitis among patients presenting with chronic watery diarrhea.

MATERIAL AND METHODS

Colonic biopsies from 400 patients presenting with chronic watery diarrhea and other symptoms pertaining to lower gastrointestinal tract were studied. After a detailed clinical history and thorough physical examination full length colonoscopy was done using flexible colonoscope. Colonic biopsies were taken from abnormal and normal areas. Three to five micron thick sections were cut and stained with hematoxylin and eosin and Masson's trichrome stain to highlight sub epithelial collagen.

RESULTS

Fifteen out of 400 (3.7%) colonic biopsies from patients presenting with chronic diarrhea had evidence of microscopic colitis. Five out of fifteen biopsies (33%) were diagnosed as collagenous colitis, 10 biopsies (67%) had evidence of lymphocytic colitis; 14/400(3.5%) histologically normal biopsies were taken as controls to compare various demographic and risk factors. Ten out of 15 patients (67%) were clinically diagnosed as irritable bowel syndrome. In the remaining five an infective etiology was suspected. On colonoscopy12/15 (80%) had no abnormality and 3/15 (20%) had mild hyperemia.

CONCLUSION

A possibility of microscopic colitis should be considered while examining colonoscopic biopsy of a patient with chronic watery diarrhea and normal colonoscopy to avoid the misdiagnosis that may affect the treatment of patients.

Helicobacter pylori and gastric cancer

Helicobacter pylori has been the subject of intense investigation since its culture from a gastric biopsy in 1982. From the beginning, this gram-negative bacterium has provoked the interest of bacteriologists, gastroenterologists, infectious disease specialists, cancer biologists, epidemiologists, pathologists, and pharmaceutical scientists. Pathologists were among the first groups of scientists to reevaluate their data in the context of the newly discovered bacterial etiological agent. Chronic inflammation elicited by the bacterium provided the missing link in the progression to gastric carcinoma; accordingly, H. pylori was named as a class 1 carcinogen by the World Health Organization. Two key papers published in 1991 in the Journal of the National Cancer Institute reported a positive association between gastric cancer and H. pylori infection. This fact provided a strong rationale to treat all who tested positive for H. pylori. Antibiotic regimens have been largely successful, but some agents such as metronidazole and clarithromycin have been rendered ineffective in several countries and geographical areas of the United States by the emergence of strains resistant to these compounds. Although there was some skepticism initially, within few years numerous research groups verified the association of H.pylori with gastric carcinoma. Host related factors for the development of disease can indicate genetic susceptibility (or resistance) or acquired influences, which may stimulate defenses of the host against environmental carcinogens like H.pylori. The present article is a mini-review of the history and epidemiology of the bacterium and its suggested association with the development and progression of gastric cancer.

Effects of postural changes and removal of vestibular inputs on blood flow to and from the hindlimb of conscious felines

Considerable data show that the vestibular system contributes to blood pressure regulation. Prior studies reported that lesions that eliminate inputs from the inner ears attenuate the vasoconstriction that ordinarily occurs in the hindlimbs of conscious cats during head-up rotations. These data led to the hypothesis that labyrinthine-deficient animals would experience considerable lower body blood pooling during head-up postural alterations. The present study tested this hypothesis by comparing blood flow though the femoral artery and vein of conscious cats during 20-60 degrees head-up tilts from the prone position before and after removal of vestibular inputs. In vestibular-intact animals, venous return from the hindlimb dropped considerably at the onset of head-up tilts and, at 5 s after the initiation of 60 degrees rotations, was 66% lower than when the animals were prone. However, after the animals were maintained in the head-up position for another 15 s, venous return was just 33% lower than before the tilt commenced. At the same time point, arterial inflow to the limb had decreased 32% from baseline, such that the decrease in blood flow out of the limb due to the force of gravity was precisely matched by a reduction in blood reaching the limb. After vestibular lesions, the decline in femoral artery blood flow that ordinarily occurs during head-up tilts was attenuated, such that more blood flowed into the leg. Contrary to expectations, in most animals, venous return was facilitated, such that no more blood accumulated in the hindlimb than when labyrinthine signals were present. These data show that peripheral blood pooling is unlikely to account for the fluctuations in blood pressure that can occur during postural changes of animals lacking inputs from the inner ear. Instead, alterations in total peripheral resistance following vestibular dysfunction could affect the regulation of blood pressure.

Reflux of duodenal contents and cholangitis in patients undergoing self-expanding metal stent placement

BACKGROUND

It has been reported that the occurrence of acute cholangitis is common, especially when the self-expanding metal stent (SEMS) is placed across the main duodenal papilla.

OBJECTIVE

To determine the incidence of duodenobiliary reflux and acute cholangitis after placement of SEMSs across the main duodenal papilla.

DESIGN

A prospective study.

SETTING

A tertiary-care teaching hospital.

PATIENTS

One hundred consecutive patients with malignant bile-duct obstruction.

INTERVENTIONS

A barium meal examination was performed 21 days after placement of SEMSs. Reflux of barium was monitored by using fluoroscopy. The patients were also monitored for the occurrence of fever. Serum bilirubin, alanine aminotransferase, alkaline phosphatase, and total and differential leukocyte counts were evaluated before and after the barium study.

MAIN OUTCOME MEASUREMENTS

The occurrence of duodenobiliary reflux and acute cholangitis.

RESULTS

Two patients developed acute cholangitis because of the failure of the function of the SEMS, and they died during the first week. Severe reflux of barium was evident in all the patients. However, none of them developed features of acute cholangitis because of reflux. After a mean (SD) follow-up of 6.4 +/- 1 months, 6 patients developed acute cholangitis because of blockage of the SEMS from ingrowth of tumor or collection of debris at the lower end of the SEMS.

LIMITATIONS

Unblinded study.

CONCLUSIONS

After placement of SEMSs across the main duodenal papilla, reflux of duodenal contents is a universal phenomenon. Acute cholangitis was observed only in cases with blockage of the SEMS from tumor ingrowth or debris.

Nodular gastritis in adults: clinical features, endoscopic appearance, histopathological features, and response to therapy

BACKGROUND AND AIMS

The present study aims to determine the prevalence of nodular gastritis (NG) and ascertain its clinical presentation and histopathological features in adults. It also assesses its association with Helicobacter pylori and the normalization of endoscopic features, symptoms, and histology after anti H. pylori therapy.

METHODS

A total of 7140 patients undergoing upper gastrointestinal endoscopy were studied. Patients showing nodularity of the gastric mucosa at endoscopy and an age- and sex-matched control group with normal gastric mucosa underwent biopsies from the gastric antrum and fundus. The biopsies were assessed for the presence of mucosal inflammation, activity, eosinophils, atrophy, lymphoid follicles, H. pylori, and the presence of intestinal metaplasia. Patients with NG were given triple therapy. Endoscopy and biopsy was repeated after 4 weeks of stopping therapy. The symptoms of the patients and histology were assessed pre- and post-therapy.

RESULTS

Thirty-two patients with an age range of 20-65 years presenting with NG and 40 age- and sex-matched controls were included in the study. Presenting symptoms were epigastric pain (56%), nausea (75%), vomiting (50%) and abdominal bloating (62.5%). All these symptoms regressed significantly after 2 week of triple therapy against H. pylori. A marked improvement in histopathological features was seen post-therapy where the presence of lymphoid aggregates, eosinophils in the mucosa, atrophy, and intestinal metaplasia improved significantly (P < 0.05) after therapy, as compared to the control group of patients.

CONCLUSION

The symptoms of NG and endoscopic features regress significantly after H. pylori therapy with a proton pump inhibitor and two antibiotics and should routinely be given to treat this form of gastritis. This may prevent progression to further complications.

Management of chronic hepatitis B virus infection: a promising approach using small interfering RNA (siRNA)

Hepatitis B virus infection continues to be a major global health problem with an estimated 350 million carriers. The response to available treatment modalities is not impressive. The advent of RNA Interference--a phenomenon of sequence-specific degradation of RNAs mediated by double-stranded RNA--holds promise as a potential therapy for chronic hepatitis B virus infection. Synthetic preparations of short RNA (21-23 bp long) can be used to mediate this process of gene silencing with a lower immune response. The duration of suppression can be further increased by using a vector delivery system. Small interfering RNA (siRNA) has several advantages over conventional therapy, which include fewer side-effects, a lower chance of developing escape mutants and non-requirement of viral replication for its action. A potent knockdown of the gene of interest with high sequence specificity makes RNA interference a powerful tool that has shown antiviral effect against hepatitis B virus. However, the 'off-target effect', i.e. suppression of genes other than the intended target, poor siRNA stability, inefficient cellular uptake, widespread biodistribution and non-specific effects need to be overcome. The problem of long-term toxicity of siRNA should be addressed and an ideal vector delivery system needs to be designed before it can be put to clinical use.

Isolation of urease-positive Ochrobactrum intermedium in the stomach of a non-ulcer dyspeptic patient from north India

Ochrobactrum intermedium is an opportunistic human pathogen found in immunocompromised individuals. We report the case of a north Indian patient with non-ulcer dyspepsia whose gastric biopsy revealed the presence of O. intermedium, along with Helicobacter pylori. Further description of O. intermedium was performed with 16S rRNA (1500 nucleotides) and RecA (1065 nucleotides) gene sequencing, and the identity and phylogenetic affiliation of the isolate was confirmed by 100% nucleotide similarity with O. intermedium LMG3301. Further investigation is required in order to evaluate the link between H. pylori and O. intermedium in the gastric niche.

Intramural incision technique: a useful and safe procedure for obtaining ductal access during ERCP

BACKGROUND

Intramucosal incision technique is a useful procedure to achieve ductal access in patients undergoing ERCP. However, the procedure has been underused.

OBJECTIVE

Our purpose was to evaluate the efficacy and safety of the intramucosal incision technique and to compare it with standard precut needle-knife papillotomy.

SETTING

A large teaching hospital.

PATIENTS

Patients undergoing endoscopic sphincterotomy.

INTERVENTIONS

If a complete or an incomplete false tract formed during probing for the biliary ductal system, the intramucosal incision technique was attempted. Needle-knife precut papillotomy was performed in those in whom bile duct access could not be obtained even after 4 attempts at cannulating the bile duct.

MAIN OUTCOME MEASUREMENTS

The success rate and complications of the intramucosal incision technique were compared with those for kneedle-knife papillotomy.

RESULTS

The intramucosal incision technique was attempted in 23 patients and was successful in 22. A definitive procedure could be performed in all 22 patients, and mild pancreatitis developed in only one of them (4.5%). During the same period, needle-knife papillotomy was attempted in 169 patients. Biliary access was gained in 159 (94%) patients. Complications occurred in 14 (8.2%) patients (mild pancreatitis in 6, moderate pancreatitis in 2, bleeding requiring endoscopic therapy in 5, and perforation in 1 patient).

LIMITATIONS

Single center study.

CONCLUSIONS

Intramucosal incision technique is a very useful and safe procedure and should be performed if a false tract has formed during probing for ductal access during ERCP.

Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones

BACKGROUND AND STUDY AIMS

Endoscopic sphincterotomy followed by extraction using a Dormia basket or an extraction balloon catheter is the procedure that is generally used for the removal of bile duct stones. This is not successful in all patients, however, and some stones have to be extracted using lithotripsy devices. In an attempt to avoid mechanical lithotripsy, we used large-diameter balloons after sphincterotomy for removing stones that could not be extracted using the conventional methods.

PATIENTS AND METHODS

In this retrospective pilot study, large-diameter (15-mm, 18-mm, or 20-mm maximum sizes) balloon dilation of the sphincterotomy site was performed in 50 patients in whom bile duct stones could not be removed by endoscopic sphincterotomy and Dormia basket or balloon catheter extraction.

RESULTS

The stones varied in size from < 15 mm to 25 mm. Common bile duct stones could be removed in all the patients using the large-diameter balloon technique. A Dormia basket or an extraction balloon catheter was required for removal of stones in 29 patients (58 %); and mechanical lithotripsy was required in five patients (10 %). Minor oozing of blood was seen in 16 patients (32 %), but the ooze stopped spontaneously during the endoscopy. Melena occurred in two patients and major bleeding requiring surgery occurred in one patient. Mild acute pancreatitis that resolved with conservative management occurred in four patients (8 %). There were no perforations and no deaths.

CONCLUSIONS

Large-diameter balloon dilation of the sphincterotomy site is an effective procedure for removal of bile duct stones that cannot be extracted by endoscopic sphincterotomy and conventional extraction devices. Mechanical lithotripsy could be avoided in the majority of these patients using this approach.

Helicobacter pylori in areas of gastric metaplasia in the gallbladder and isolation of H. pylori DNA from gallstones

AIMS

To assess if the areas of gastric metaplasia in the gallbladder are colonised by Helicobacter pylori and to conduct a molecular study of gallstones for presence of H. pylori DNA.

METHODS

Sections from 111 gallbladders with evidence of gastric metaplasia on H&E and Alcian blue-periodic acid-Schiff (pH 2.5) stain were stained with Loeffler's methylene blue and Warthin Starry stain for demonstration of H. pylori. Presence of H. pylori was confirmed by immunohistochemistry. Formalin fixed mucosal tissues and gallstones from 11 cases showing heavy colonisation were subjected to molecular analysis.

RESULTS

Helicobacter pylori was present in 50 of 111 (45%) sections with gastric metaplasia. Areas adjacent to gastric metaplasia in gallbladder showed acute inflammation (6%) and lymphoid follicle formation in 58% of cases with H. pylori that were significantly higher than those seen in sections without H. pylori. In molecular study, 8 of 11 gallstones showed 16S rDNA. Amplification of material from one stone showed positivity for atpA, efp, mutY, ppa, trpC, UreI and vacA genes. Phylogenetic affiliation study of the isolates indicated that H. pylori sequence from the gallstones clustered with Indian strains of H. pylori. No considerable difference was observed in phylogenetic affiliations of eight stones studied.

CONCLUSION

H. pylori colonises areas of gastric metaplasia in gallbladder producing histological changes similar to those seen in gastric mucosa. Isolation of H. pylori DNA from gallstones further support its presence in the gallbladder.

Jejunogastric intussusception--a rare cause of recurrent upper gastrointestinal bleeding: case report and review of literature

Jejunogastric intussusception is a known complication following gastrojejunostomy. However, only occasionally have they presented with haematemesis and we are unaware of any case where it led to recurrent haematemesis. We describe a case where the patient developed recurrent upper gastrointestinal bleeding due to recurrent episodes of jejunogastric intussusception following gastrojejunostomy performed 12 years earlier for duodenal ulcer disease.

Prevalence of H. pylori in patients with gastric cancer

The present study was taken with an aim to assess the prevalence of H. pylori in patients with gastric carcinoma and correlate it with gross appearance and histological type. Endoscopic biopsies from 54 patients with gastric carcinoma and 50 age and sex matched controls were taken after thorough upper gastrointestinal examination. Gross appearance of the tumour was noted and two biopsies each from the site of malignancy and from normal appearing areas were taken. Sections were stained with Haematoxylin & Eosin and Loeffler's methylene blue for histopathological details and presence of H. pylori. Prevalence of H. pylori in controls was slightly higher than the patients group (80% Vs 78%). Ulcerated type of gross appearance had maximum prevalence of H. pylori (88%). Prevalence of H. pylori was more in diffuse type of gastric cancer than intestinal type (86% Vs 68%). A significant association between H. pylori and grades of gastritis was noted (P < 0.01) in controls as well as in patient group but it failed to show a significant association with tumour grades, intestinal metaplasia, site of the tumour and age of the patients. So, it can be inferred that prevalence of H. pylori infection is not directly associated with pathogenesis of gastric cancer but it may act as a co-carcinogen by damaging the mucosa and thereby making it more susceptible to effects of carcinogen.

Is conventional sphincterotomy possible in patients with common bile duct stones impacted at the ampulla of Vater?

BACKGROUND

Needle knife precut papillotomy has been used to gain access or remove impacted common bile duct stones at the ampulla of Vater. However, precut papillotomy is a risky procedure with high complication rates and is presumably best dealt with by the expert. We attempted to find out the feasibility of performing conventional endoscopic sphincterotomy in patients with impacted stones at the ampulla.

METHODS

All patients undergoing endoscopic retrograde cholangiopancreatography for stones impacted at the ampulla between the years 2000 and 2005 were enrolled in the study. All attempts were made to achieve biliary cannulation through the conventional route including use of the long route or guidewire to cannulate the papilla. Needle knife papillotomy was resorted to only if attempts to cannulate the papilla through the conventional route failed. The success and complications of the procedures were recorded.

RESULTS

Thirty-two patients were enrolled. The impacted bile duct stone could be removed in all the patients. Conventional endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed in 23 patients with impacted stones. The long route had to be employed in seven patients while guidewire cannulation of the papilla was needed in four patients. Needle knife papillotomy was needed in only nine patients. None of the patients in whom the conventional route was employed developed complications, whereas bleed requiring endoscopic management was observed in three (33%) of the nine patients in whom needle knife papillotomy was performed.

CONCLUSIONS

Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy can be performed by the conventional route in the majority of patients with impacted stones at the ampulla. This approach appears to be safer than needle knife papillotomy. However, needle knife papillotomy may be required in patients in whom biliary access cannot be gained through the conventional approach.

Role of intravenously administered hyoscine butyl bromide in retrograde terminal ileoscopy: A randomized, double-blinded, placebo-controlled trial

AIM: To evaluate the role of hyoscine butyl bromide in facilitating retrograde ileoscopy.

METHODS: Retrograde terminal ileoscopy was attempted in 200 consecutive patients undergoing colonoscopy. After intubation of the cecum and visualization of the ileocecal valve, hyoscine butyl bromide injection or normal saline was given intravenously to the patients in a double blind random fashion. The pulse rate and oxygen saturation were measured continuously. After completion of the procedure, endoscopists were then asked to score the ease of intubation and the ease of visualization of the terminal ileum on a visual scale of 1 to 10. The patients were also asked to score the pain after receiving hyoscine butyl bromide injection on a score of 1 to 10.

RESULTS: Terminal ileoscopy could be performed in 188 patients. The mean (SD) visual analogue score for the ease of intubation of the cecum was 7.4 (0.65) in the injection group and 5.9 (0.8) in the placebo group (P < 0.001). The mean (SD) length of ileum visualized in the injection group was 14.4 (3.3) cm and 10.4 (2.7) cm in the placebo group (P < 0.001). The mean (SD) visual analogue score for ease of visualization of the terminal ileum was 7.5 (0.69) in the injection group and 5.9 (0.7) in the placebo group (P < 0.001). The pain score experienced by the patients was 6.5 (0.7) in the injection group and 6.7 (0.69) in the placebo group (P < 0.008). Although the pulse rate increased significantly in patients receiving the drug, no statistically significant difference was noted in the oxygen saturation between the two groups either before or after administration of the drug. No complications were observed in either of the groups.

CONCLUSION: Hyoscine butyl bromide injection is a useful adjunct in helping the intubation and visualization of terminal ileum during colonoscopy.

Ileoscopy in patients with ileocolonic tuberculosis

AIM: To study the role of retrograde terminal ileoscopy in patients suspected to have ileocolonic tuberculosis.

METHODS: A retrospective analysis was performed for patients undergoing colonoscopy for suspected ileocolonic tuberculosis between January 2000 and June 2004, in whom retrograde ileoscopy had been performed. Only patients diagnosed with tuberculosis on the basis of histological findings of either a caseating granuloma or those having non-caseating granuloma or a collection of epithelioid cells at a minimum of one endoscopic lesion (either in the colon or the terminal ileum) on histology with good responses to conventional anti-tuberculous drugs were enrolled for the study.

RESULTS: Fifty-three patients were included. The terminal ileum was involved in only 11 patients. Eight of these patients had involvement of the cecum too. Two patients had ileal lesions without cecal involvement; however, lesions were noted in the ascending colon. In one patient the whole colon was normal and only the terminal ileum showed nodularity and ulceration. Histological examination of the ileal biopsies obtained from the ileal lesions showed noncaseating granulomas in five, collection of epithelioid cells in four and nonspecific histology in two patients. Mucosal biopsies obtained from the lesion in the terminal ileum, in the patient in whom mucosal abnormality was observed to be confined to the ileum, showed noncaseating granulomas. In two other patients the ileal biopsies alone showed histological evidence of tuberculosis with biopsies from the colonic lesions showing non-specific inflammatory changes only.

CONCLUSION: Retrograde ileoscopy should be performed in all patients undergoing colonoscopy for suspected ileocolonic tuberculosis. In some patients only the terminal ileum may be involved and histological examination may reveal evidence of tuberculosis only from the lesions in the terminal ileum. This approach would lead to additional lesions being picked up and increasing the chances of well-timed diagnosis of tuberculosis.

Endoscopic management of a new entity-plastobezoar: A case report and review of literature

Foreign bodies and bezoars are commonly encountered in children. We describe a child aged 11 years who ingested large amounts of plastic material used for knitting chairs and charpoys. The conglomerate of plastic threads, entrapped food material and other debris, formed a huge mass occupying the whole stomach. Chronic irritation of the gastric antral mucosa led to ulceration and formation of hyperplastic polyps. We labeled this new entity as a “plastobezoar”. The entire bezoar could be removed endoscopically.

Giardia lamblia trophozoites in gastric biopsies

To assess the prevalence of gastric giardiasis in gastric biopsies of patients with carcinoma stomach and in patients taking treatment for duodenal ulcer. Gastric biopsy specimens from 54 patients of carcinoma stomach and 100 antral biopsies from patients taking treatment for duodenal ulcer were included in the study. Sections were stained with haematoxylin and eosin, methylene blue and May Grunwald-Giemsa stains and examined for presence of Giardia lamblia trophozoites. Eight out of 54 (14.9%) biopsies of gastric carcinoma patients harboured trophozoites of Giardia lamblia. Associated H. pylori infection was present in all biopsies (8/8; 100%). Atrophy and intestinal metaplasia was present in 62.5% (5/8) and 25% (2/8) cases respectively. Sections from seven out of 35 patients (20%) taking treatment for duodenal ulcer showed presence of G. lamblia. H. pylori infection, gastritis and atrophy were found in 85.7% (6/7), 71.4% (5/7) and 28.6% (2/7) cases respectively. First gastric biopsy in these patients was negative for G. lamblia but 2nd and 3rd biopsies were positive. A careful search for G. lamblia trophozoites should be made while examining the gastric biopsies, especially in patients with carcinoma stomach, intestinal metaplasia, atrophic gastritis and those taking treatment for duodenal ulcer. This may help in indirect diagnosis of clinically unsuspected cases of intestinal giardiasis and may explain persistence of vague upper gastrointestinal tract (UGIT) symptoms despite clearance of H. pylori in patients on anti-ulcer therapy.

Vestibular inputs elicit patterned changes in limb blood flow in conscious cats

Previous experiments have demonstrated that the vestibular system contributes to regulating sympathetic nervous system activity, particularly the discharges of vasoconstrictor fibres. In the present study, we examined the physiological significance of vestibulosympathetic responses by comparing blood flow and vascular resistance in the forelimb and hindlimb during head-up tilt from the prone position before and after the removal of vestibular inputs through a bilateral vestibular neurectomy. Experiments were performed on conscious cats that were trained to remain sedentary on a tilt table during rotations up to 60 deg in amplitude. Blood flow through the femoral and brachial arteries was recorded during whole-body tilt using perivascular probes; blood pressure was recorded using a telemetry system and vascular resistance was calculated from blood pressure and blood flow measurements. In vestibular-intact animals, 60 deg head-up tilt produced approximately 20% decrease in femoral blood flow and approximately 37% increase in femoral vascular resistance relative to baseline levels before tilt; similar effects were also observed for the brachial artery ( approximately 25% decrease in blood flow and approximately 38% increase in resistance). Following the removal of vestibular inputs, brachial blood flow and vascular resistance during head-up tilt were almost unchanged. In contrast, femoral vascular resistance increased only approximately 6% from baseline during 60 deg head-up rotation delivered in the first week after elimination of vestibular signals and approximately 16% in the subsequent 3-week period (as opposed to the approximately 37% increase in resistance that occurred before lesion). These data demonstrate that vestibular inputs associated with postural alterations elicit regionally specific increases in vascular resistance that direct blood flow away from the region of the body where blood pooling may occur. Thus, the data support the hypothesis that vestibular influences on the cardiovascular system serve to protect against the occurrence of orthostatic hypotension.

Endoscopic management of persistent biliary leakage resulting from complete transection of the bile duct at cholecystectomy

BACKGROUND AND STUDY AIMS

Injuries to the bile duct are not uncommon during cholecystectomy. While minor injuries are amenable to endoscopic therapy, major ones, such as complete transection of the duct, require surgical intervention. We report on the endoscopic management of such injuries.

PATIENTS AND METHODS

We included in the study ten patients who had persistent postoperative bile drainage (either through a surgically placed catheter or through a biliocutaneous fistula) after their cholecystectomy procedure had been complicated by complete transection of the bile duct. Plastic biliary endoprostheses were placed in the bilioma through the papilla of Vater. In one patient, both the right and the left hepatic ducts were opacified by injecting contrast material through the drainage catheter and it was possible to place stents in both the ducts.

RESULTS

All the patients improved clinically after the procedure. In one patient the stent became dislodged and an elective Roux-en-Y hepaticojejunostomy was performed, but it was possible to remove the stents from all the other patients. Two patients were referred for surgery but in both cases the bile flow through the bile duct was shown to be so good on nuclear imaging that they were not operated on. All the non-operated patients are well after a mean +/- SD follow-up of 22.3 +/- 5.5 months.

CONCLUSIONS

Placement of biliary stents in the bilioma is a useful adjunct to percutaneous drainage in patients with complete transection of the bile duct. After placement of a biliary stent in the bilioma the percutaneous drainage catheter may be removed. In one of our study patients it was also possible to place stents in the intrahepatic ducts and the bile duct was reconstructed. Long-term follow-up of these patients and further studies are required to assess the role of endoscopic management as an alternative to surgery in patients with this condition.

Ileocecal masses in patients with amebic liver abscess: Etiology and management

AIM: To assess the causes of ileocecal mass in patients with amebic liver abscess.

METHODS: Patients with amebic liver abscess and ileocecal mass were carefully examined and investigated by contrast-enhanced CT scan followed by colonoscopy and histological examination of biopsy materials from lesions during colonoscopy.

RESULTS: Ileocecal masses were found in seventeen patients with amebic liver abscess. The cause of the mass was ameboma in 14 patients, cecal tuberculosis in 2 patients and adenocarcinoma of the cecum in 1 patient. Colonic ulcers were noted in five of the six (83%) patients with active diarrhea at presentation. The ileocecal mass in all these patients was ameboma. Ulcers were seen in only one of the 11 (9%) patients without diarrhea. The difference was statistically significant from the group with diarrhea (P < 0.005).

CONCLUSION: Ileocecal mass is not an uncommon finding in patients with amebic liver abscess. Although, the ileocecal mass is due to ameboma formation in most cases, it should not be assumed that this is the case in all patients. Colonoscopy and histological examination of the target biopsies are mandatory to avoid missing a more sinister lesion.

Effects of postural changes and removal of vestibular inputs on blood flow to the head of conscious felines

Prior studies have shown that removal of vestibular inputs produces lability in blood pressure during orthostatic challenges (Holmes MJ, Cotter LA, Arendt HE, Cass SP, and Yates BJ. Brain Res 938: 62-72, 2002; Jian BJ, Cotter LA, Emanuel BA, Cass SP, and Yates BJ. J Appl Physiol 86: 1552-1560, 1999). Furthermore, these studies led to the prediction that the blood pressure instability results in susceptibility for orthostatic intolerance. The present experiments tested this hypothesis by recording common carotid blood flow (CCBF) in conscious cats during head-up tilts of 20, 40, and 60 degrees amplitudes, before and after the surgical elimination of labyrinthine inputs through a bilateral vestibular neurectomy. Before vestibular lesions in most animals, CCBF remained stable during head-up rotations. Unexpectedly, in five of six animals, the vestibular neurectomy resulted in a significant increase in baseline CCBF, particularly when the laboratory was illuminated; on average, basal blood flow measured when the animals were in the prone position was 41 +/- 17 (SE) % higher after the first week after the lesions. As a result, even when posturally related lability in CCBF occurred after removal of vestibular inputs, blood supply to the head was not lower than when labyrinthine inputs were present. These data suggest that vestibular influences on cardiovascular regulation are more complex than previously appreciated, because labyrinthine signals appear to participate in setting basal rates of blood flow to the head in addition to triggering dynamic changes in the circulation to compensate for orthostatic challenges.

Endoscopic band ligation as salvage therapy in patients with bleeding peptic ulcers not responding to injection therapy

BACKGROUND AND STUDY AIM

Endoscopic band ligation has recently been used to control bleeding from a variety of nonvariceal upper gastrointestinal sources. However, it has not been used as salvage therapy in patients with peptic ulcer in whom injection therapy has failed to control bleeding. The objective was to study the role of band ligation in patients with bleeding peptic ulcer where injection therapy had failed.

PATIENTS AND METHODS

Endoscopic band ligation was attempted in patients with upper gastrointestinal bleeding from peptic ulcers in whom at least two attempts to control bleeding by injection therapy failed. Anti- Helicobacter pylori therapy was given to patients who were infected with the bacteria.

RESULTS

Endoscopic band ligation could be performed in all the 11 patients in whom it was attempted. It was successful in controlling the bleeding in all patients. Over a mean (SD) follow-up of 23.1 (14.8) months none of the patients had recurrence of ulcer or bleeding.

CONCLUSIONS

Endoscopic band ligation is an effective means of controlling bleeding in patients with bleeding peptic ulcer in whom injection therapy is not successful. Band ligation followed by anti- H. pylori therapy is useful in preventing recurrence of ulcer and bleeding in such patients.

Colonic changes in patients with cirrhosis and in patients with extrahepatic portal vein obstruction

BACKGROUND AND STUDY AIMS

Figures for the prevalence of anorectal varices and portal hypertensive colopathy have varied considerably in the available studies of patients with cirrhosis, and few studies have observed these changes in patients with extrahepatic portal vein obstruction (EHPVO). Our aim was to investigate the colonic changes, if any, in patients with EHPVO and to compare them with those seen in patients with cirrhosis of the liver.

PATIENTS AND METHODS

A total of 50 patients with cirrhosis and 35 patients with EHPVO, all of whom had a history of at least one episode of bleeding from esophageal varices, underwent both upper gastrointestinal endoscopy and colonoscopy.

RESULTS

Anorectal varices were seen more commonly in patients with EHPVO than in patients with cirrhosis (63 % vs. 38 %, P < 0.03). Of the patients with anorectal varices, large anorectal varices were also more common in patients with EHPVO than in patients with cirrhosis (73 % vs. 32 %, P < 0.01). Colopathy was noted in 40 % of patients with EHPVO and in 62 % of patients with cirrhosis (P < 0.05). Of the patients with EHPVO, colopathy was noted in 27 % of patients who also had anorectal varices and in 61.5 % of patients without anorectal varices (P < 0.05). Similarly, patients with both cirrhosis and anorectal varices were found to have a lower prevalence of colopathy than cirrhotic patients without anorectal varices (42 % vs. 74 %, P < 0.03).

CONCLUSIONS

Anorectal varices are more common in patients with EHPVO, while portal hypertensive colopathy is more common in patients with cirrhosis. Large anorectal varices are also more common in patients with EHPVO than in patients with cirrhosis and there is an inverse relationship between anorectal varices and colopathy in both cirrhotic patients and patients with EHPVO.