Bowel Habit Pattern of Patients with Self-Reported Constipation at Out Patient Department in North East Part of Bangladesh

The aim of this study was to observe the symptoms and bowel habit pattern experienced by patients presenting with self reporting constipation at Out Patient Department in a tertiary care hospital. It was a cross-sectional study which was conducted in Out Patient Department of gastroenterology in North East Medical College Hospital, Sylhet, Bangladesh from January 2017 to December 2018. Total 228 consecutive patients with self reported constipation were enrolled in this study. Patients with history of abdominal surgery, known chronic disease, age below 18 years, pregnant women, patients using drugs like anti-depressant, anti-psychotic and patients unwilling to take part in the study were excluded. Demographic data, symptoms, bowel habit pattern and character of stool were recorded at enrollment in a pre-designed data sheet. Total 228 patients, male 130(57.0%) and female 98(43.0%), age varying from 18-81 years (mean age 38.7±15.10 years) were included. Among them 127 patients (55.7%) was experienced daily bowel motion with frequency varying from one to seven and 99 patients (44.3%) had infrequent stools. Sixteen (16) patients (7.0%), 182 patients (79.8%) and 30 patients (13.2%) had feeling of complete bowel evacuation all time, few days in a week and almost never respectively. Among the patients 127(55.7%), 29(12.7%), 06(2.6%), 02(0.9%) and 64(28.1%) complained of hard, soft, semi liquid, liquid and stool of variable consistency respectively. In this study 159(63.73%), 21(9.21%) and 43(18.85%) patients were regularly taking Proton pump inhibitor (PPI), anti- diabetic drugs and anti-hypertensive drugs respectively. The finding suggests that there was a wide variation of self perception of constipation among the patient. The study concludes that patient's perception regarding constipation does not always match the traditional medical definition. Overall findings signify that symptoms like stool consistency, volume, and feeling of incomplete evacuation are more important rather than frequency of bowel per week in patients' perception regarding constipation. However, further study with large sample size in different hospitals in different areas could explain this observation more precisely.

Medical Knowledge versus Perception of Patients with Abdominal Gas in a Tertiary Level Hospital of Bangladesh

Every human being has gas in abdomen. But patients try to correlate varieties of symptoms with abdominal gas. So this cross sectional symptom based study was designed to see the patients view regarding abdominal gas and its relation with medically explained symptoms at the out patient department of North East Medical College, Sylhet from January 2017 to December 2019. Consecutive patients presenting with complain of abdominal gas were included in this study. Their demographic information and explanation of symptoms resulting from abdominal gas were recorded on a pre-designed data sheet. Statistical analysis was done using SPSS 20.0 version. Total 346 patients, male 239(69.1%), female 107(30.9%), age varying from 17-83 years (mean 38.27) were enrolled. Common symptoms were bloating (fullness) of abdomen (194, 56.1%), abdominal pain (164, 47.41%), belching or eructation (149, 43.1%), heart burn (137, 39.6%), anorexia (124, 35.8%), nausea (120, 34.7%), noisy bowel (88, 25.4%), chest pain (79, 22.8%), headache (56, 16.2%), whole body pain (58, 16.8%), incomplete bowel evacuation (185, 53.5%), excess flatus (76, 22.4%), movement of gas to different part of body including head 87(25.1%) and expulsion of hot air from ear, nose and head in 69(19.9%) patients. Among them 107(30.9%) patients believed abdominal gas to be a curable disease with treatment and 222(64.2%) believed it to be a relapsing disease even after treatment. And 307(88.7%) patients were taking proton pump inhibitor (PPI) as its remedy regularly. Most of the symptoms of patients can be explained by abdominal gas. Again some patients have a misperception regarding some symptoms like heart burn, noisy bowel and sense of incomplete bowel evacuations are also related with abdominal gas. But in some instances causal relations with patients' symptoms and abdominal gas could not be explained by medical knowledge. These differences in perceptions might be related to their personal thinking and social, cultural, educational, economic condition.

Helicobacter Pylori Infection and Endoscopic Findings in Bangladeshi Dyspeptic Patients

Helicobacter Pylori (H Pylori) that infects about 90% people of developing countries causes dyspepsia and upper gastrointestinal lesions. The aim of this study was to detect the trend of H Pylori active infection and to investigate the endoscopic findings of H Pylori infected dyspeptic patient of Bangladesh. In this prospective study, 360 dyspeptic patients (Male-251, Female-109) were recruited. Patients having alarm features, history of gastrectomy and malignancy were excluded from this study. Non-invasive fecal antigen test for H Pylori was done of all patients. All selected patients were sent for upper gastrointestinal endoscopy. Helicobacter Pylori fecal antigen was found positive in 134(37.2%) from 360 dyspeptic patients (age 14-80 years). Among 360 patients 303 (80.16%) had macroscopic endoscopic mucosal lesions. H Pylori infected 114 patients had endoscopic mucosal abnormality. H Pylori non-infected 189 patients also had mucosal lesion. Twenty patients (35.08%) had H Pylori infection among the 57 patients having endoscopic normal looking mucosa. This study revealed that active H Pylori infection rate is declining in Bangladesh. Risk of endoscopic mucosal lesion is more expected in H Pylori active infection.

Pancreatobiliary Diseases: Evaluation by Transabdominal and Endoscopic Ultrasound

Pancreaticobiliary diseases are the important causes of morbidity and mortality worldwide. Among the imaging modalities, Transabdominal ultrasound (TUS) is cheap, available, and noninvasive but it has some limitations. Endoscopic ultrasound (EUS) is invasive but it has some diagnostic and therapeutic advantages over TUS. This study was aimed to see the diagnostic yields of EUS and TUS in the pancreatobiliary diseases. This cross sectional study was conducted in Sir Salimullah Medical College Mitford Hospital (SSMC&MH), Dhaka, Bangladesh from March 2017 to February 2019. All (n=222) patients were evaluated clinically and with relevant investigations. TUS and EUS were done in all patients. Endoscopic retrograde cholangiopancreatography (ERCP) was done in 60 patients. Among 222 patients 56.8% were males; mean age was 46±16 years; the main presenting symptoms were abdominal pain and jaundice. In diseases of biliary tree, EUS showed dilated CBD alone or in combination with stone in 50 and 67 cases and TUS showed 37, 63 patients respectively. The difference between the findings of EUS and TUS was statistically significant (p=0.00). In gall bladder, EUS found microlithiasis in 6(2.6%) and sludges in 24(10.8%) cases whereas TUS found microlithiasis in 1(0.5%) and sludges in 17(7.7%) cases respectively (p=0.00). Both EUS and TUS detected cholelithiasis in equal number of patients 46(20.3%). On pancreatic evaluation, EUS and TUS detected pancreatic parenchymal abnormalities in 24(10.8%) and 12(5.5%) patients respectively with significant p value (0.00). In cases of pancreatic and cholangiocarcinoma the difference between the findings of EUS and TUS were statistically significant (p<0.05). EUS detected 7 cases of ampullary/peri-ampullary neoplasms whereas TUS detected only 2 cases. The sensitivity of EUS for detecting CBD dilatation, CBD stones, CBD SOL and pancreatic SOL was 85%, 91%, 93%, and 92% respectively. The sensitivity of TUS for detecting CBD dilatation, CBD stones, CBD SOL and pancreatic SOL was 42%, 52%, 40%, and 37% respectively. EUS is more sensitive than TUS in diagnosing pancreaticobiliary disorders. It is of paramount importance in patients in diagnosing CBD dilatation, choledocholithiasis, biliary microlithiasis and pancreaticobiliary neoplasm. EUS has important role before proceeding to further management by more invasive techniques like ERCP or surgery.

Comparative Study of Alginate and Omeprazole in Symptomatic Treatment of Non-erosive Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is widely reported most prevalent disease of the gastrointestinal tract. The burden of gastroesophageal reflux disease (GERD) is increasing in Asia and the majority of patients have non-erosive reflux disease. This prospective, open label, non random (consecutive), experimental study was performed due to compare the therapeutic efficacy of alginate and omeprazole in relieving symptoms of non erosive reflux disease (NERD) and was carried out in the Outpatient Department of Gastroenterology, Dhaka Medical College Hospital, Dhaka, Bangladesh from December 2013 to May 2014. Sixty patients were enrolled for this study and were divided into two groups. Among them, 30 subjects were assigned to the omeprazole group (Group I) and 30 subjects to the alginate group (Group II). Omeprazole 20mg enteric coated capsule daily and alginate 10ml three times daily were administered 14 days in this study. In ITT analysis, achieving complete symptom relief (heart burn) was 56.7% in alginate group & 60% in omeprazole group. Statistically which was not significant (p=0.793). In PP analysis, this was 65.4% and 66.7% respectively. In this study, the overall satisfaction of omeprazole & alginate was more than 86% and the mean duration of heart burn free was found 5.0±4.0 days in Group I and 3.65±2.8 days in Group II. The difference was not statistically (p>0.05) significant between two groups in this study. Therapeutic efficacy and safety profiles of alginate were comparable to omeprazole after two weeks treatment in NERD subjects. So alginate may be considered as a relevant and effective alternative medication in non-erosive reflux.

Peptic Ulcer Disease in Bangladesh: A Multi-centre Study

The incidence of peptic ulcer has steadily declined through out the world. This decreasing trend is also noticeable in this subcontinent. The point prevalence of peptic ulcer (PUD) in Bangladesh was around 15% in eighties. The aim of this study was to see the present prevalence of peptic ulcer at endoscopy and to identify changing trends in the occurrence of peptic ulcer in Bangladesh. This retrospective analysis of the endoscopic records of multiple tertiary referral centres of Dhaka city were done from January 2012 to July 2013. A total of 5608 subjects were the study samples. We included those patients having peptic ulcer in the form of duodenal ulcer, benign gastric ulcer including pre-pyloric ulcer and gastric outlet obstruction due to peptic ulcer. Duodenal ulcer and benign gastric ulcer were found in 415(7.4%) and 184(3.28%) patients respectively and gastric outlet obstruction due to peptic ulcer was found in 23(0.40%) patients.

Pattern of Changes in the Findings among the Patients Undergoing Diagnostic Esophagogastroduodenoscopy in Bangladesh

This cross-sectional observational study was conducted in the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University, Sir Salimullah Medical College and Mitford Hospital, Holy family Red Crescent Medical College and Hospital and Popular Diagnostic Centre, Shantinagar branch, Dhaka, Bangladesh from January 2012 to July 2013. Study subjects were included in the study irrespective of age and sex having different upper GI tract. Complaints like dysphagia, heart burn, abdominal pain/dyspepsia, nausea, vomiting, haematemesis and/or malena, anorexia, unexplained anemia, weight loss etc. All the findings of oesophagus, stomach and duodenal lesions were observed and data were recorded. The results were considered positive based on the macroscopic appearance using standard diagnostic criteria. During the study period endoscopy was performed in 5608 subjects. Among which 2968(52.92%) were male and 2640(47.07%) were female. The patients age range from 7 years to 108 years. The majority of the patients were from 40-50 years. Normal findings were observed among 3321(59.21%) cases. Gastroduodenal erosions were present among 684(12.19%) cases, Oesophageal varices in 444(7.91%) cases, duodenal ulcer diseases in 415(7.40%) cases and gastric ulcer in 184(3.28%) cases. Ca stomach was found among 165(2.94%) cases. A number of diseases were identified through this procedure. Current study observed a large proportion of patients (40.79%) had positive upper GI endoscopy.

Initial Experience with Endoscopic Ultrasound

Since its introduction in early 1990s, endoscopic ultrasound (EUS) has become integral to the diagnosis and staging of various luminal, extraluminal gastrointestinal (GI) and certain non-GI lesions. There is no data on EUS experience in Bangladesh. The aim of this paper is to evaluate the initial recent experience and clinical impact of EUS. All EUS procedures data were recorded prospectively from July 2013 to December 2014. These included patients' demographics, referral details, provisional diagnosis, management plan before and after EUS & indications of procedures. EUS-FNA data recorded included details regarding site, number of passes and histological diagnosis. Two hundred & four EUS procedures were carried out over one and half years. Male female ratio was 1.4:1, mean age was 46.4 ± 20 years. Of these procedures 148 (72.5%) were referrals from physicians and 56 (27.5%) were from surgeons. Most common indications were pancreatobiliary pathologies, esophageal & gastric pathologies. Pancreatobiliary lesions (n = 165, 80.9%) included patients with (A) Benign pathologies: Microliths in Gall baldder (n = 6), Gall stones (n = 12), Biliary ascarrisis (n = 22), Choledocholithiasis (n = 42), Acute Pancreatitis (n = 9), Chronic Pancreatitis (n = 15), Pancreatic pseudocysts(n = 4) (B) Malignant Pathologies : GB Carcinoma (n = 4), Cholangiocarcinoma (n = 29), Ca- pancreas (n = 9), Periampullary carcinoma (n = 12). Esophageal lesion was 9.3% (n = 19) of total procedures. Forty seven percent (n = 9) of EUS procedures on esophagus were for staging of esophageal malignancy, 10. 5% (n = 2) for restaging or recurrence after chemoradiation and 21% (n = 4) for submucosal lesions. Fifteen EUS procedures were carried out for gastric lesions, seven were for staging of gastric carcinoma, four were for assessment of submucosal lesions (e.g. GIST, lipoma or external compression), 02 for assessment of polyps and two for gastric ulcers.In clinical impact & outcome study, changes in diagnosis, management, avoidance of investigations and usefulness of EUS were evaluated. Diagnosis was changed in 34.4% (64/186) & management was changed in 45%(92/204). Additional investigation was avoided in 57.8% (118/204). This is the first report of Bangladesh experience of EUS to date. EUS is safe, accurate, cost effective & very useful tool for diagnosis and management of G.I. disorders.

Prevalence and Symptom Correlation of Lactose Intolerance in the North East Part of Bangladesh

This study was designed to see the prevalence of lactose intolerance and symptom correlation following oral lactose challenge in healthy volunteers in the north east part of Bangladesh. Symptoms of abdominal pain, nausea, borborygmi, flatulence, diarrhea and others were noted for 24 hours and blood glucose was estimated at 0 hour and 30 minutes after 50 gm oral lactose load to healthy volunteers. Failure to rise blood glucose level ≥1.1 mmol/l at 30 minutes after lactose intake from fasting level was taken as lactose malabsorption (LM) i.e., lactose intolerance. Sensitivity and specificity of different symptoms were then found out. A total of 171 volunteers (male 123, female 48) with a mean age 34.08 years participated in this study. Lactose intolerance was found among 82.5% (n=141, M=100, F=41) subjects. Symptoms mostly experience by the lactose malabsorbers were diarrhea 93(66.0%), borborygmi 80(56.7%), abdominal pain 31(22.0%) and flatulence 32(22.7%). LM prevalence was found to increase with increasing number of symptoms up to 3 symptoms. A week positive correlation (r=0.205, P=0.007) was found between the number of symptoms and proportion of subjects having positive lactose tolerance test. Lactose intolerance among healthy adults of North East part of our country is as common as in other Asian countries including China and Malaysia. But LM is higher than that of Europeans and south Indians. Diarrhea and borborygmi were mostly associated with LM.

Double balloon enteroscopy: Bangladesh experience

Double balloon enteroscopy (DBE) is a newly developed endoscopic modality for diagnosis and treatment of small bowel disorders. The aim of this study was to evaluate the diagnostic and therapeutic impact of DBE in patient with suspected small bowel disease. This was a prospective study. Sixty one double balloon enteroscopy procedures (30 antegrade 31 retrograde) were done in thirty six patients (20M/16F, mean age 40 ± 12.5 range 16-65 years ) at gastroenterology department, Sir Salimullah Medical College, Dhaka between October 2011 and September 2012. Indications for DBE included chronic abdominal pain 14 (38.9%), obscure GI bleeding 11 (30.56%), Small bowel obstruction 05 (13.89%), and chronic diarrhea 06 (16.67%). The morphologic findings were ulcerations 13 (36.11%), growth 03 (8.33%), vascular ectasia 03 (8.33%) and polyp 01 (2.78%). Therapeutic interventions were performed in one patient only. No serious complications were observed. Diagnostic yields in case of chronic abdominal pain, chronic diarrhea, obscure GI bleeding and small bowel obstruction were 50%, 66%, 63% and 40% respectively. The findings were adenocarcinoma 04 (11%), lymphoma 03 (8.4%), tuberculosis 03 (8.4%), non specific findings 05 (13.9%), IPSID 01(2.8%), Crohn's disease 01 (2.8%), vascular ectasia 03 (8.33%) and normal 16 (44.44%). DBE is well tolerated, feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.