Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Prevalence, Clinical Characteristics, and Treatment Response in Patients with Post Cricoid Inlet Patch—A Descriptive Retrospective Study

Objectives The aim of this study was to determine the incidence of post cricoid inlet patch (PC-IP) and to assess the clinical characteristics, pathological features, and treatment response.

Materials and Methods A retrospective cross-sectional study was conducted from April 2016 to April 2021 in the tertiary gastroenterology unit of urban India. All patients with symptoms of globus sensation, chronic cough, heartburn, hoarseness, throat pain, dysphagia, and acid regurgitation after a thorough clinical examination underwent esophagogastroduodenoscopy by experienced endoscopists including biopsy. Sociodemographic data, symptoms and its duration, previous hospital visits, and chronic proton pump inhibitor (PPI) use were noted during the study.

Results  Three-thousand two-hundred fifty upper gastrointestinal endoscopies were performed during the study period. The prevalence of PC-IP was 2.7%, comprising 36.3% males and rest females. Mean age was 36.2 ± 17years. The most common symptom among these patients was globus sensation (81.8%) followed by acid regurgitation (75%), dyspepsia (64.7%), dysphagia (48.8%), throat pain (29.54%), chronic cough (22.72%), hoarseness (22.72%), and others (6.81%). Mean diameter of PC-IP was 1.5 ± 0.5 cm, more than one patch was found in 23.76% of patients. Histopathological examination showed heterotrophic gastric mucosa in 77.27%, out of which 38.23% had oxyntic type, 44.11% had mucoid type, and the rest had mixed cell type. On median follow-up after 20 months, 68.18% of patient had persistent symptoms, 77.27% were PPI responsive, and 22.73% were PPI refractory. On follow-up, 38.63% of patients had a repeat endoscopic procedure and biopsy (20.45%); none showed any changes in size or dysplasia.

Conclusion Prevalence of PC-IP could be higher than the estimated. Careful examination of upper esophagus and use of narrow band imaging will increase the possibility of identifying IP. Those symptomatic patients need treatment with PPI, sometimes for long term. Ablative therapy with radiofrequency or argon plasma coagulation needs further clarification.

Sociodemographic and Clinical Profiles of Patients with Irritable Bowel Syndrome: A Cross-sectional, Multi-centric, Epidemiological Study in India

AIMS

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by impaired gut-brain interaction. Considering the paucity of evidence in the Indian setting, the current study was conducted to determine the sociodemographics, clinical profiles, management practices, and patients' perception among newly diagnosed patients with IBS.

METHODS

This was a cross-sectional, single-visit, observational, non-interventional, epidemiological study conducted across 12 centres. The primary objective was evaluation of sociodemographic and clinical profiles. The key secondary objective was assessment of gastrointestinal symptom severity including evaluation of anxiety and depression using the hospital anxiety and depression scale (HADS) scores. Knowledge, attitude, and practices (KAP) were evaluated as an exploratory objective.

RESULTS

Out of 300 enrolled patients, 120 (40%) were aged 31-45 years (mean age: 38.55±12.45 years), and 204 were men (68%). Overall, 40% of patients belonged to the upper-middle-class, with a Kuppuswamy score of 16-25. Most patients (91%) did not work in night shifts. Only 13% of patients performed more than recommended physical activity. Stress and food were the leading triggers for IBS (29%). Abdominal pain and diarrhoea as cardinal symptoms were reported by 43.3% and 33.0% patients, respectively. Borderline abnormal anxiety and depression were reported by 21.3% and 26.7% of patients, respectively. KAP assessment revealed that 56.0% of patients had poor knowledge, 26.3% had moderate knowledge, and 17.7% had good knowledge about IBS; nevertheless, 43% of patients maintained high levels of precaution towards managing symptoms.

CONCLUSION

Given the limited knowledge about IBS in India among newly diagnosed patients, strategies to enhance awareness about the condition are warranted.

Efficacy and safety of vedolizumab in ulcerative colitis in patients from Asian countries in the GEMINI 1 study

BACKGROUND/AIMS

The efficacy and safety of vedolizumab in moderate to severely active ulcerative colitis (UC) have been demonstrated in the GEMINI 1 study (NCT00783718). This post-hoc exploratory analysis sought to establish the efficacy and safety of vedolizumab in a subgroup of patients from Asian countries with UC from GEMINI 1.

METHODS

Efficacy outcomes of interest were clinical response, clinical remission and mucosal healing at week 6 (induction phase); and clinical remission, durable clinical response, durable clinical remission, mucosal healing and glucocorticoid-free remission at week 52 (maintenance phase). Differences in outcome rates between vedolizumab and placebo in Asian countries (Hong Kong, India, Malaysia, Singapore, South Korea, and Taiwan) were assessed using descriptive analyses, and efficacy and safety compared between Asian and non-Asian countries.

RESULTS

During induction, in Asian countries (n = 58), clinical response rates at week 6 with vedolizumab and placebo were 55.2% and 24.1%, respectively (difference 31.0%; 95% confidence interval: 7.2%-54.9%). In non-Asian countries (n = 316), response rates at week 6 with vedolizumab and placebo were 45.9% and 25.8%, respectively. During maintenance, in Asian countries, clinical remission rates at 52 weeks with vedolizumab administered every 8 weeks, vedolizumab administered every 4 weeks and placebo were 9.1%, 36.8%, and 31.6%, respectively; corresponding rates for mucosal healing were 45.5%, 47.4%, and 47.4%, respectively. Vedolizumab was well-tolerated; adverse event frequency was comparable in Asian and non-Asian countries.

CONCLUSIONS

In patients from Asian countries, the efficacy and safety of vedolizumab in treatment of UC were broadly consistent with that in the overall study population.

Management of Acute Variceal Bleed by Esophageal Variceal Ligation in an Unconventional Position—An Urban-Center Insight

Background Acute variceal bleed is a fatal complication in patients with liver cirrhosis, and it is important to achieve hemostasis at the earliest. Endoscopic variceal ligation (EVL) is a preferred modality in controlling variceal bleed. The blood pool in esophagus and oozing of blood from varices cause hindrance for variceal ligation leading to failure of therapy. In sitting position, it is hoped that visualization of esophagus may be better. With this background, EVL of patients in sitting position was done and results were analyzed.

Methods Cirrhotics presenting with hematemesis and/or melena were included in the study. Clinical and endoscopic parameters were assessed. Among them, patients having hypotension and hepatic encephalopathy were excluded. Initial endoscopic assessment was done in left lateral position. In case of obscured visualization of esophagus due to flooding, if time taken to achieve hemostasis > 5 minutes, position was changed to sitting from left lateral decubitus. Patients with isolated gastric variceal and ulcer bleed were further excluded.

Results Among 78 acute bleed patients selected, 41fulfilled the inclusion criteria for the study. During endoscopy, in 20 patients, EVL was done in left lateral decubitus position with head end elevation. Twenty-one patients were shifted from conventional left lateral position to sitting posture. Study revealed that patients undergoing EVL in sitting position had better visibility aiding the procedure and no aspiration during the procedure. There was no difference in the left lateral with head raised or without it. Duration of EVL was comparable to that of nonbleeders and additional sclerotherapy was not required in any case in both the groups. Following the procedure, patients were observed for 5 days. There was no failure of therapy which was analyzed according to Baveno VI consensus. However, there was delayed complication in one case due to sepsis and metabolic acidosis causing death.

Conclusion This study suggests, in acute variceal bleed cases, EVL in sitting position aids in better visibility and helps in achieving hemostasis early with least complications.

A hairy intruder into colon

Ovarian dermoid cysts are benign tumors, which develop from totipotent germ cells and grow into mature tissue types consisting of hair, teeth, fat and neural tissue. Ovarian dermoid cyst fistulizing to the sigmoid is rare and presenting with bleeding per rectum is extremely rare. We present a case of middle-aged woman with bleeding per rectum who had the right adnexal tumor fistulating to sigmoid.

Oral pH in gastroesophageal reflux disease

AIMS AND OBJECTIVES

The aim of this study is to compare surface pH in various parts of the oral cavity between patients with gastroesophageal reflux disease (GERD) and healthy controls.

METHODS

Using a flat pH meter sensor, fixed electrode pen type digital pH meter, oral pH levels were assessed at different mucosal sites among 34 GERD patients and 32 healthy controls. Salivary flow rates and buffering capacity were also assessed in them. A thorough oral examination was performed to screen for any oral and dental changes.

RESULT

A significantly lower pH of 6.65 ± 0.13 (mean ± SD) was found in the GERD group compared to control group 7.23 ± 0.12 (p < 0.05). Least pH was found in the floor of the mouth 6.594 ± 0.17 and highest in the lower labial mucosa among the GERD patients. Salivary flow rate and buffering capacity were low in these patients. Significant changes were noticed in the hard and soft tissues of the oral cavity among the GERD group.

CONCLUSION

Oral mucosal pH is altered in GERD patients and may contribute to effects on the oral cavity.

Colonoscopic band ligation for internal hemorrhoids - A tertiary care experience

Background and objectives: Rubber band ligation (BL) is the most widely used technique for treatment of symptomatic internal haemorrhoids (IH) that are refractory to conservative treatment. The aim of this study is to assess the efficacy of colonoscopic BL as therapy for symptomatic IH.

Methods: Patients seen at our center with symptomatic IH who underwent BL between January 2006 and December 2011 were included in this prospective study. The clinical and colonoscopic details were entered in uniform structured data forms.

Results: Two hundred and eighteen consecutive patients with symptomatic IH were enrolled in the study. The presentations were rectal bleeding in 150 (69%) and prolapse in remaining 68 (31%) patients. Twenty-four patients (11%) had chronic liver disease (child B-C). Same operator treated all the patients. The severity of the IH was classified by using Goligher grading system. The mean age of patients was 48.3 + 15 years with range of 22 - 85 years. The mean follow up was 3months (range 1 month - 36 months). In 209 patients (96%) there was at least 1 grade reduction in hemorrhoids as well the symptoms were controlled. Two patients required surgery and another 7 patients required repeat session of banding. After banding session 32 (15%) patients had perianal pain and 13 (6%) had mild bleeding.

Conclusions: Colonoscopic BL is a safe, and effective outpatient therapeutic procedure for symptomatic internal hemorrhoids. Furthermore, the BL is safe and effective in patients of coagulopathy associated with chronic liver disease. (J Dig Endosc 2013;4(1):6–9)

Clinical and endoscopic spectrum of upper gastrointestinal manifestations in HIV patients

BACKGROUND

Human Immunodeficiency Virus (HIV) infected patient frequently report upper gastrointestinal (GI) symptoms; however their prevalence and diagnostic approach is not well known.

OBJECTIVE

The objective of this study was to study clinical, endoscopic and histopathological changes in HIV infected patients with upper GI symptoms and their correlation with CD4 count.

MATERIALS AND METHODS

We evaluated 50 HIV infected patients who presented to M.S. Ramaiah hospital with upper GI symptoms. All patients answered questionnaire assessing upper GI symptoms and underwent upper GI endoscopy. Mucosal biopsy was taken wherever mucosal abnormality seen.

RESULTS

In our study, the mean age of patients was 40.98 yrs, of which 80% were males. Vomiting (36%), epigastric pain (36%), weight loss (34%) and anorexia (34%) were the predominant symptoms. Esophagogastroduodenoscopy (EGD) findings revealed--Oesophageal candidiasis in 28.0%, esophagitis in 22.0%, gastritis in 20.0%, duodenitis in 14%, normal upper GI mucosa in 18 % patients. Oesophageal candidiasis was the most common finding on histopathological examination and the mean CD4 count was 157.92 cells/μl.

CONCLUSION

Vomiting, epigastric pain, weight loss and anorexia were most frequent symptoms. Oral candidiasis was the most common oral lesion. Oesophageal candidiasis, oesophagitis and oesophageal ulcers were the common findings on EGD. Patient with CD4 count less than 200 cells/μl had more frequent upper GI mucosal involvement than in patients with CD4 count more than 200. Majority of the patients with GI symptoms had upper GI mucosal changes and opportunistic infections. Thus endoscopic and histopathological evaluation is advisable for the early diagnosis and treatment of upper GI complications in patients with HIV infection.