Pre and post eradication gastric inflammation in Helicobacter pylori-associated duodenal ulcer

BACKGROUND

Distribution and nature of gastritis are major determinants of clinical outcome of H. pylori infection. The gastric inflammatory changes associated with this infection in developing countries have not been systematically studied.

AIMS

To evaluate the inflammatory changes in gastric antrum and corpus in patients with duodenal ulcer and H. pylori infection, before and after H. pylori eradication therapy.

METHODS

Histology and H. pylori density were studied in gastric biopsies obtained from 53 consecutive patients with active duodenal ulcer and H. pylori infection. Biopsies were obtained before and 4 weeks after H. pylori eradication therapy, from the anterior and posterior walls of the antrum and corpus, and were evaluated according to the Sydney system.

RESULTS

In the pre-H. py/ori eradication antral biopsies, chronic gastritis, active gastritis, atrophy, intestinal metaplasia (IM) and lymphoid follicles / aggregates were seen in 53 (100%), 49 (92%), 11 (21%), 7 (13%) and 28 (53%) patients, respectively. In the corresponding biopsies from gastric corpus, these changes were seen in 49 (92%), 23 (43%), 2 (4%), 2 (4%) and 8 (15%), respectively. All changes except IM were significantly more frequent and of higher grade in the antrum. The grade of chronic gastritis was significantly higher in antrum than corpus; the frequency of gastritis in the antrum and corpus was similar (100% vs. 92%). H. pylori density was also higher in the antrum and correlated well with the grades of chronic gastritis and activity at both sites. Eradication of H. pylori was achieved in 39 patients (74%), and led to significant decrease in gastritis; no change was seen in patients who did not eradicate the organism.

CONCLUSIONS

Antral-predominant chronic gastritis and activity are present in more than 90% of patients with H. pylori infection associated with duodenal ulcer, and the grade of gastritis correlates with the density of the organism. Eradication therapy results in improvement of both chronic gastritis and activity.

Symptom score does not correlate with gastritis grade and Helicobacter pylori infection in non ulcer dyspepsia

BACKGROUND

Non ulcer dyspepsia (NUD) is being postulated as one of the gastroduodenal manifestations of H. pylori infection. H. pylori infection may result in clinical symptoms as well as histological changes in NUD.

AIM

To compare clinical symptom score and histological changes in H. pylori (Hp) positive and negative untreated NUD patients.

METHODS

Forty six patients with dyspeptic symptoms and normal upper GI endoscopic examinations were included in this study. During endoscopy 2 biopsies each were taken from the antrum and body of the stomach. These biopsies were used for rapid urease test (RUT) and histological examination. Patients were diagnosed to have Hp infection if either of two tests were positive. There were two groups of patients: Hp positive and Hp negative NUD patients. Clinical scoring using Glasgow dyspepsia score (Max. 20) and histological analysis, using Sydney system (Max score 11) was done and compared for both the groups of patients. Clinical scoring, RUT and histological scoring were blinded to each other.

RESULTS

H. pylori was present in 29(63%) of the 46 patients. Mean clinical score for H. pylori positive patient was 10.9 while for Hp negative patient was 11.4. Total histological score for Hp positive and Hp negative patients was 3.37 Vs 1.76 (antrum) and 3.68 Vs 1.29(body) (p < .001), respectively. The only histological change found to be statistically significant between Hp positive and Hp negative patients was presence of lymphoid follicles (p < .05).

CONCLUSION

Clinical scoring does not correlate with the presence of H pylori or histological severity. In NUD patients positive for H. pylori, there is a significant increase in the severity of gastritis both in the antrum and the body.

Randomized trial of a quadruple-drug regimen and a triple-drug regimen for eradication of Helicobacter pylori: long-term follow-up study

BACKGROUND

In developing countries, H. pylori eradication rates are suboptimal. A quadruple-drug regimen may improve on the eradication rate achieved with triple-drug regimen.

METHODS

64 consecutive patients with active duodenal ulcer associated with H. pylori infection were randomized to receive either a one-week triple-drug regimen (lansoprazole, clarithromycin, secnidazole) or a one-week quadruple-drug regimen (lansoprazole, amoxycillin, colloidal bismuth subcitrate, secnidazole). H. pylori eradication and ulcer healing were assessed 4 weeks after completion of therapy. Patients were followed up at 24 weeks and 52 weeks for H. pylori recurrence.

RESULTS

Both the regimens eradicated H. pylori in 75% (95% CI 0.6-0.9) of patients. The ulcer-healing rate with the triple-drug regimen was 97% (95% CI 0.91-1.0) and 91% (95% CI 0.91-1.0) with the quadruple-drug regimen. No ulcer or H. pylori recurrence occurred in patients eradicated with the triple-drug regimen, whereas 8.3% of patients eradicated with the quadruple-drug regimen had ulcer as well as H. pylori recurrence during the 52-week follow up.

CONCLUSION

Triple-drug regimen achieves similar eradication rates as quadruple-drug regimen in H. pylori infection.

14C urea breath test does not predict density of Helicobacter pylori in duodenal ulcer disease

BACKGROUND & OBJECTIVES

The density of Helicobacter pylori in the gastric mucosa has prognostic significance, higher densities being associated with greater chances of development of duodenal ulcer and chronic atrophic gastritis as well as poor eradication by drug therapy. The aim of this study was to assess if 14C-urea breath test counts reflect bacterial density.

METHODS

Sixty patients with endoscopically proven active duodenal ulcer and H. pylori positivity as determined by rapid urease test and gastric histology were studied. Gastric antral and corpus biopsies were graded for chronic gastritis, activity (presence of polymorphonuclear cells) and bacterial density (at surface and in pits) based on the Sydney system on a scale of four grades ranging from 0 to 3 (absent, mild, moderate and severe). 14C urea breath test was performed in all the patients.

RESULTS

Chronic gastritis as well as activity was more prevalent as well as severe in the antrum as compared to the corpus. H. pylori density was also significantly more in the antrum as compared to the corpus both at the surface as well as in the pits. H. pylori density correlated with the grade of chronic gastritis and activity both in the antrum and in the corpus. Urea breath test counts ranged from 331.3 cpm (counts per minute) to 8770.5 cpm and these did not correlate with histological H. pylori density at any of the sites.

INTERPRETATION & CONCLUSIONS

14C urea breath test does not reflect H. pylori density on histology in patients of duodenal ulcer disease.

New pentacyclic triterpenes from the roots of Hemidesmus indicus

Phytochemical studies on the roots of Hemidesmus indicus resulted in the isolation of six new pentacyclic triterpenes including two oleanenes identified as olean-12-en-21 beta-yl acetate, and olean-12-en-3 alpha-yl acetate, three ursenes characterized as 16(17)-seco-urs-12,20(30)-dien-18 alpha H-3 beta-yl actetate, urs-20(30)-en-18 beta H-3 beta-yl acetate and 16(17)-seco-urs-12,20(30) dien-18-alpha H-3 beta-ol and a lupene formulated us lup-1,12-dien-3-on-21-ol including a known compound, beta-amyrin acetate, on the basis of spectroscopic techniques and chemical means.

Management of amebic and pyogenic liver abscess

The management of pyogenic liver abscess differs radically from that of amebic liver abscess. Medical management is the cornerstone of therapy in amebic liver abscess while early intervention in the form of surgical therapy or catheter drainage and parenteral antibiotics is the rule in pyogenic liver abscess. The prognosis of amebic abscess is much better than that of pyogenic abscess and usually a quick response to therapy is seen in amebic abscess.

Ultrasonographic assessment of gall bladder kinetics in the elderly

BACKGROUND

The incidence of gallstones increases with age but the factors that influence gallstone formation in the elderly are poorly understood. Proposed factors include changes in bile composition and hypomotility of the gall bladder. Studies on gall bladder motility in the elderly have provided conflicting results, and none has been reported from India.

AIM

To determine gall bladder contractility in healthy elderly subjects and compare it with that in young healthy volunteers.

METHODS

Thirty healthy elderly (above the age of 60 years) and 30 young volunteers with no abdominal complaints were studied. Using real-time ultrasonography and the ellipsoid method, gall bladder volume was measured after overnight fast and at 10, 20, 30, 40, 50 and 60 minutes after a standard fatty meal. Residual volume, delta volume and ejection fraction were calculated.

RESULTS

Mean fasting gall bladder volume in elderly subjects was higher than that in young subjects (13.5 [5.8] mL vs 10.9 [3.6] mL; p < 0.05). However, there was no difference in the 60-min postprandial residual gall bladder volumes in the two groups. Change in gall bladder volume and ejection fraction were also similar in the two groups.

CONCLUSION

There was no difference in gall bladder emptying between elderly and young subjects though the fasting gall bladder volume was higher in the elderly.

Granulocytic sarcoma of humerus, an unusual association of acute myeloblastic leukemia--a case report

Ganulocytic sarcoma (Chloroma) is a tumour of rare variety usually in assocoiation with granulocytic leukemia. It is related to soft tissue with extramedullay infiltration. We present a case of granulocytic sarcoma of humerus which preceded the initial clinical manifestation of acute myeloid leukemia in a young patient which ultimately proved to be FABM2 variety. Though many tissues are affected by this tumour but the most favoured site is the bone.

Colour Doppler flow imaging of focal hepatic lesions

Fifty-four patients with focal liver lesions were evaluated with colour Doppler flow imaging (CDFI) and CT to assess whether CDFI could be used to differentiate various types of lesions based on the flow pattern in terms of peritumoral and intratumoral blood flow. Peritumoral flow was found to be of no significance in the differential diagnosis of various liver lesions. Intratumoral flow was graded into mild, moderate or marked depending on the relative number of blood vessels demonstrated within the lesion. Marked intratumoral flow on CDFI was seen in 12.5% of primary hepatic malignancies and in infantile haemangioendothelioma, while a moderate flow pattern was seen in 56.2% of primary hepatic malignancies and in 18.7% of metastases. Mild flow was seen in 33.3% of primary malignancies; 18.7% of metastases; and 16.7% of haemangiomas. No intratumoral flow was seen in 100% of inflammatory lesions; 83.3% of haemangiomas; 62.5% of metastases; and only one hepatocellular carcinoma (5.6%). It was therefore concluded that the presence or absence of flow on CDFI is not a reliable feature for differential diagnosis of focal liver lesions when it is used alone. The flow pattern as assessed on CDFI may point to the nature of the lesion and, when used along with other morphological imaging features, can assist in diagnosis or in narrowing the list of different diagnoses in a particular clinical situation.

Autonomic nervous system reactivity in irritable bowel syndrome

BACKGROUND

Autonomic dysfunction has been implicated as one of the factors involved in the pathogenesis of irritable bowel syndrome (IBS).

AIM

To evaluate autonomic function in patients with IBS.

METHODS

Thirty-five patients with IBS and thirty healthy controls were evaluated by standard cardiovascular reflex tests. Parasympathetic function was assessed by measuring heart rate responses to deep and slow breathing (E:I ratio), Valsalva maneuver (Valsalva ratio) and head-up tilt tests (30:15 ratio). Sympathetic adrenergic function was assessed by measuring diastolic blood pressure responses to handgrip test at 4 min and cold pressor test at 1 min and also by change in systolic blood pressure in response to head-up tilt. Autonomic functions were tested twice, keeping at least a one-week interval, to find out stability over time. Anxiety status of the subjects was assessed by evaluating responses to a questionnaire.

RESULTS

Parasympathetic reactivity was significantly increased in IBS patients as compared to controls during visit 1 (E:I 1.7 [SD 0.2] vs 1.4 [0.1], p < 0.001; Valsalva ratio 2.0 [0.3] vs 1.5 [0.1], p < 0.001; 30:15 ratio 1.2 [0.1] vs 1.1 [0.01], p < 0.001). Similar results were obtained in visit 2. The diastolic blood pressure responses during handgrip and cold pressor tests were not different in comparison to controls during both the visits. However, tilting resulted in less marked rise in diastolic blood pressure (9.1 [4.1] vs 12.1 [6.8] mmHg, p < 0.01) at 0.5 min and less rise in heart rate (6.0 [2.5] vs 10.3 [6.3] per min, p < 0.01) at 1 min in IBS patients during visit 1. The anxiety score of IBS patients was significantly higher (46.2 [3.2] vs 21.6 [1.7], p < 0.001).

CONCLUSION

IBS patients have increased parasympathetic reactivity and a high level of anxiety trait.

Evaluation of endoscopy-based diagnostic methods for the detection of Helicobacter pylori

BACKGROUND

Helicobacter pylori is an etiological factor in duodenal ulcer. Few studies have objectively assessed the accuracy of diagnostic methods for the detection of H. pylori.

METHODS

The sensitivity and specificity of histology, touch smear, rapid urease test (RUT) and brush cytology of endoscopic antral biopsy from patients with duodenal ulcer were compared. Forty-nine patients were evaluated before, and 34 after, eradication therapy. Each time, sampling was done for all 4 tests. The infection status for each sample was established by a positive concordance of results of three of four tests.

RESULTS

The highest degree of agreement was between RUT and cytology (kappa = 0.69). Brush cytology (100%) followed by RUT (94.5%) were the most sensitive tests. Histology had the highest specificity (89.3%). A combination of RUT or brush cytology with histology had the maximum chance of detecting H. pylori. As single tests, brush cytology and touch smear had high diagnostic accuracies with a Youdin J value of 1.79 and 1.78, respectively.

CONCLUSION

The best method for diagnosis of H. pylori is a combination of the rapid urease test or brush cytology with histology. Brush cytology or touch smear are diagnostic tests of choice if a single test is desired.

Response of Eucalyptus tereticornis to inoculation with indigenous AM fungi in a semiarid alfisol achieved with different concentrations of available soil P

Eucalyptus tereticornis was grown in a green house in a low phosphorus (0.67 ppm Olsen's P) soil (Typic Haplustalf) inoculated with mixed indigenous arbuscular mycorrhizal (AM) fungi. Soil was amended to achieve P levels of 10, 20, 25, 30 and 40 ppm to evaluate the growth response and dependence of E. tereticornis to inoculation with AM fungi. A positive response to mycorrhizal inoculation was evident at the first two levels of soil P, i.e., at 0.67 and 10 ppm but not at the higher levels of soil P. Dry matter yield of inoculated plants beyond 20 ppm soil P was similar or even less compared to their uninoculated counterparts. Inoculated plants produced maximum dry matter (root and shoot) at 10 ppm soil P, whereas uninoculated plants did not produce until the level reached 20 ppm. The percentage root length colonized by AM fungi decreased from 31% to 3% as the concentration of P increased beyond 10 ppm soil P. Higher levels of soil P depressed the AM colonization significantly. Inoculated plants had higher shoot P and N contents compared to their uninoculated counterparts at all levels of soil P. However, at the first two lower levels of soil P, inoculated plants showed significantly higher shoot P and N contents over their respective uninoculated counterparts. The increasing shoot P accumulation beyond 10 ppm did not enhance dry matter yields. Inoculated plants had lower values of phosphorus utilization efficiency (PUE) and nitrogen utilization efficiency (NUE) at all levels of soil P except at the unamended level (0.67 ppm) where the inoculated plants showed higher values of NUE compared to uninoculated control plants. Taking dry matter yield into consideration, Eucalyptus plants were found to be highly dependent on 10 ppm of soil P for maximum dry matter production. Any further amendment of P to soil was not beneficial neither for AM symbiosis nor plant growth.

Herbal ethnomedicine of the gwalior forest division in madhya pradesh, India

Ethnomedicinal studies carried out in the Gwalior Forest Division, Madhya Pradesh, India, led to interesting therapeutic applications of 102 plant species. Information on medicinal claims was collected from the tribal people called 'Sahariya' and the traditional healers who had knowledge of the traditional uses of medicinal plants. This study describes details of botanical identity, local name, parts of the plants used, mode of preparation, administration of the drug, and diseases for which the given plants are used.

Aetiological spectrum of obstructive jaundice and diagnostic ability of ultrasonography: a clinician's perspective

BACKGROUND

A vast array of invasive and non invasive diagnostic tests are available to diagnose and establish the etiology of surgical obstructive jaundice (SOJ). Invasive tests may cause cholangitis and imaging techniques like computed tomography(CT) scan and MRI are expensive. The aim of the present study was to test ultrasonography as the primary investigation in patients with SOJ and to elucidate the aetiological spectrum of obstructive jaundice as seen at a tertiary referral center.

METHODS

429 patients diagnosed as having obstructive jaundice on the basis of either CT, endoscopic retrograde cholangiopancreatography(ERCP), fine needle aspiration cytology(FNAC) or surgery underwent real time sonography over a 10 year period from May 1988 to Dec 1997. The diagnostic accuracy of ultrasonography for SOJ was established.

RESULTS

Sonography correctly established the presence of obstructive jaundice in 380 of 429 patients. Of 429 patients (mean age 62.5 +/- 34.2 yrs, 229 males and 194 females) the sensitivity of ultrasound to correctly diagnose and establish the site of etiology of obstruction was 94% with a specificity of 96%. Malignant SOJ was much more common than benign causes (75.3% Vs. 24.7%). Carcinoma (Ca) of the gallbladder (28.7%) was the commonest aetiology followed by Ca pancreas (26.5%), choledocholithiasis (12.4%), cholangio Ca (10.8%) benign stricture (10.8%) and ampullary Ca (9.8%). A total of 167 subjects (44%) had high block while 213 (56%) had low block. Block at the porta hepatis was due to gallbladder Ca in 91% of patients. Ca pancreas was the cause of lower end block in 76% of patients.

CONCLUSION

SOJ, as seen in this large series of patients was most often due to malignant cause and gallbladder Ca was the commonest cause in North Indian patients. The clinician should utilize the ability of the ultrasound to diagnose the presence of obstructive jaundice and its location.

Lowered sympathetic reactivity in patients with non-bleeding duodenal ulcers

BACKGROUND

Autonomic dysfunction has been associated with duodenal ulcer. We assessed autonomic reactivity in patients with duodenal ulcer.

METHODS

Ten patients with non-bleeding active duodenal ulcers and ten age- and sex-matched healthy subjects were investigated for parasympathetic reactivity (heart rate response to deep breathing, Valsalva maneuver and head-up tilt test) and sympathetic reactivity (blood pressure response to hand grip, head-up tilt and cold pressor test). Anxiety status was measured by evaluating responses to a questionnaire.

RESULTS

The duodenal ulcer patients showed normal parasympathetic reactivity, lowered sympathetic reactivity and high anxiety score. When compared to control subjects, they had significantly lower diastolic blood pressure change in response to hand grip (median [range]; difference in values 12 [4-16] mmHg vs 16 [10-22] mmHg) and head up tilt (1 [-6-4] vs 6 [2-10] mmHg).

CONCLUSIONS

Patients with duodenal ulcer have lowered sympathetic reactivity; this may be involved in causation by decreasing mucosal protection.

Double blind controlled trial of effect of cisapride on gastric emptying in diabetics

AIMS

Diabetic gastroparesis is a common complication seen in 20-50% of patients due to autonomic neuropathy involving vagal supply. Cisapride, a specific gastrointestinal cholinomimetic agent may thus be effective.

METHODS

Fifty-one diabetic patients (age 12-65 years) of disease duration > 5 years were assessed for symptomatic gastroparesis, other diabetic complications and glycemic control. Gastric emptying time (GET) was estimated using a solid meal method (99mTc labeled rice based idli) and patients randomized to receive either cisapride or placebo for a period of 2 weeks. Cisapride was administered in a dose of 10 mg TID. GET and symptom scores were reassessed on the therapy after 2 weeks.

RESULTS

Twenty nine of 51 (56.8%) patients had gastroparesis. Mean GET in the gastroparesis group was 141 +/- 66 minutes compared to 24.53 +/- 10 minutes in the non gastroparesis group (p < 0.01). GET decreased by 72% amongst the patients who received cisapride compared to 23% in the placebo group (p < 0.001). Symptom scores also improved in the cisapride group; no adverse effects were noted.

CONCLUSIONS

Cisapride improves the symptom score and the solid gastric emptying time in patients suffering from diabetic gastroparesis.