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Oral cyclosporine has been reported to be useful in inducing remission in patients with active severe ulcerative colitis who fail to respond to intensive steroid therapy. We present our experience of its use in six patients.

Severe ulcerative colitis is conventionally treated with parenteral corticosteroids followed by oral corticosteroids. Regular use of corticosteroids is associated with side effects. Corticosteroid pulse therapy, i.e., use of supraphysiologic dose followed by complete withdrawal, which is likely to have fewer side effects, was tried in the current study.Dexamethasone pulse therapy, i.e., 100-mg/d infusion in 5% dextrose, was used for 3 consecutive days in 14 patients with severe ulcerative colitis. Ulcerative colitis disease activity was assessed on days 7, 15, 30, and 60. The primary end point was defined as the number of patients who achieved clinical remission and an activity index less than 150 at day 15. The second end point was the number of patients who remained in remission and had an activity index less than 150 at 30 and 60 days. None of the patients enrolled got subsequent oral corticosteroids after their 3 days of megadose corticosteroid infusion.Clinical remission was achieved in 93% patients (13 of 14 patients) by day 15. Two of these 13 patients suffered relapse during follow-up, and hence, the clinical remission was sustained in 79% patients at 30 and 60 days.Dexamethasone pulse therapy is highly effective in inducing remission in patients with ulcerative colitis, but randomized controlled trials are needed to compare dexamethasone pulse therapy with standard oral continuous corticosteroid regimens.

The search is on to find more effective drug regimens for patients with severe ulcerative colitis, as conventional drugs such as sulfasalazine and its congeners fail to prevent relapse in a significant number of patients. Azathioprine has also been reported to be useful as a steroid-sparing drug in patients who suffer from frequent relapses. As these drugs when used individually fail to sustain remission in a significant number of patients, we evaluated the combination of these two drugs. Methods. Thirty-five newly diagnosed patients with severe ulcerative colitis were randomized into two groups; group A (combination therapy) received sulfasalazine and azathioprine, while group B (sulfasalazine monotherapy) received sulfasalazine and placebo. In addition, all the patients received steroids initially to achieve clinical remission. The patients were followed-up for a period of 1 year. The therapeutic outcome was measured by the number of patients who suffered relapse in each group. Results. All the patients completed the 1-year study period. While 4 patients (23.5%) in group A suffered relapse of disease, 10 (55.6%) in group B suffered relapse, the difference being statistically significant. The relapse-free period was also significantly longer in group A. Conclusions. Combination therapy (sulfasalazine and azathioprine) is more effective than sulfasalazine and placebo in the maintenance of remission in patients with severe ulcerative colitis.

Hemobilia following liver biopsy is rare and acute pancreatitis associated with hemobilia in such a situation is rarer. We report a 55-year-old man with ulcerative colitis and hepatitis C-positive liver disease who developed acute pancreatitis following liver biopsy. Surgical removal of blood clots from the biliary tree led to recovery.

their content of “ gluten,”cause celiac disease, which is the best recognized form of gluten allergy. The yearly increase in the number of patients diagnosed with celiac disease appears alarming. Projections of this trend from our hospital data to the years 2010 and 2020 indicate an enormous increase in its incidence. These results are alarming, though it must be kept in mind that ours is a hospital-based study. Nevertheless, serious thought should be given to identifing the possible reasons for the increasing prevalence of disease in India. Is it just an increased awareness of the disease? Is it that the wheat of today differs appreciably in composition or characteristics from the wheats of times past? Is it that the enormous potential benefits from the genetically improved crops are causing people to ignore such unforeseen effects? Is it that the alteration of just one or two genes with known traits through biotechnology to increase yield or quality in the already popular crop variety leads to this menace? Or is it that conventional plant breeding methods leading to the introduction of unknown genes (wild variety) whose traits have not been studied are causing an increase in incidence? Most of these concerns are technical issues that need to be addressed through appropriate research. First and foremost, the specific peptide sequence of the gliadin responsible for triggering intestinal in flammation needs to be identified. Gene-altered wheat and its products have found their way into the Indian markets. The alarming increase in the incidence of celiac disease invokes fears about the type and quality of wheat being used. The hypothetical risks posed by its use need to be scientifically evaluated. Animal model trials with the various transgenic crops of wheat over the years need to be carried out.

TO THE EDITOR: Alcohol is known to cause nontraumatic rhabdomyolysis and its associated complications such as renal failure. The known causes of renal failure in alcoholic liver disease patients are nephrotoxic drugs, infections, gastrointestinal bleed, hypotension, and hepatorenal syndrome. Besides these, prerenal azotemia is known to occur because of repeated vomitings or poor intake. This report highlights the fact that myoglobinuric renal failure can occur in patients of alcoholic hepatitis and that this is a treatable cause.

Interferon therapy for hepatitis C can result in renal complica-tions as interstitial nephritis, minimal change disease andimmune complex glomerulonephritis [1]. We present the caseof a 42-year old man infected with chronic hepatitis C whodeveloped focal and segmental glomerulosclerosis (FSGS)after treatment with pegylated interferon alfa 2a and ribavirin.A 42-year-old man reported with incidental detection ofhepatitis C virus infection (anti-HCV positive) at the time ofdonation. His risk factors included surgery for fracture tibia,bloodtransfusionsandfrequentuseofinjectionspossiblywithreusable needles and syringes for joint pains. His physicalexamination was unremarkable. His baseline laboratoryinvestigationsshowedhemoglobin13g/dL,meancorpuscularvolume (MCV) 87 fl, white blood cell count 4000/cumm,platelet count 3,00,000/mm

Background/Aim: Ulcerative colitis is a chronic inflammatory disease of unknown etiology characterized by periods of remission and relapses. This study has been carried out in a group of North Indian patients, where the disease has shown an increasing prevalence and frequent relapses. Hence, there is a need to predict relapse for better management and to reduce morbidity. To assess the importance of biological and histological parameters in predicting relapse when the disease is in quiescent phase. Materials and Methods: A prospective study of twenty-six patients with quiescent ulcerative colitis was carried out in Dayanand Medical College and Hospital, Punjab. Only patients with clinical and endoscopic remission at the time of screening visit were included. Hemoglobin, erythrocyte sedimentation rate (ESR), C- reactive protein (CRP) and serum Interleukin-6 (IL-6) levels were measured. The baseline colonoscopic mucosal biopsies were retrieved and studied. Follow-up was conducted for one year at monthly interval or earlier if relapse occurred. Results: Fifteen out of twenty-six patients (57.69%) had evidence of clinical relapse during the follow-up. Hemoglobin, ESR, CRP and IL-6 levels were not found to be significant predictors of relapse. Increased number of eosinophils and neutrophils in the lamina propria were observed to be associated with significantly higher relapse rate. Conclusion: A higher risk of relapse in patients with quiescent colitis can be predicted by the presence of increased number of eosinophils and neutrophils in the lamina propria.

AIM: To evaluate the role of azathioprine (AZA) in Indian patients with ulcerative colitis over longer duration of time. METHODS: One hundred fifty six patients with ulcerative colitis who were treated with AZA from January 1995 to December 2003 were reviewed. The indications for its use were as follows: (1) steroid dependent and steroid refractory disease; (2) Azathioprine monotherapy for naive patients with severe disease; and (3) combination therapy (AZA + sulfasalazine or 5-aminosalicylates) for naive patients with severe disease. The data included patient and disease demographics, efficacy and toxicity profile of AZA. Patients with a minimum duration of 6 mo use of AZA were included in this report. RESULTS: Of a total of 156 patients treated with AZA, 45 were excluded from analysis for the following reasons- (follow up less than 6 mo, n = 9; poor follow up, n = 18; adverse affects, n = 18). In steroid refractory/dependent group the mean number of relapses prior to and post initiation of AZA therapy were 3.28 (± 0.81) and 0.94 (± 0.29) respectively. Discontinuation of steroids could be accomplished in 12 of the 15 steroid dependent patients. The proportion of patients with sustained remission of 1, 2, 3, 4 and 5 years duration were calculated. Eighteen patients experienced adverse effects necessitating withdrawal of AZA (pancreatitis, n = 7; hepatitis, n = 3; gastrointestinal intolerance, n = 2; alopecia, n = 2; and hematological, n = 4) while 13 patients needed dose reduction or temporary withdrawal of the drug. CONCLUSION: Azathioprine is well tolerated and has therapeutic benefits lasting as long as 4 years. Adverse effects such as pancreatitis, hepatitis, cytopenias and gastrointestinal symptoms do occur but are controlled by drug withdrawal only.

Obstructive jaundice due to common bile duct stone in a patient with langerhans’ cell histiocytosis

Background Based on age of presentation, celiac disease (CD) is categorised as pediatric CD and adult CD. It however remains unclear if these are genetically and/or phenotypically distinct disorders or just different spectrum of the same disease. We therefore explored the common genetic components underlying pediatric and adult CD in a well characterized north Indian cohort. Methods A retrospective analysis of children (n = 531) and adult (n = 871) patients with CD between January 2001 and December 2010 was done. The database included basic demographic characteristics, clinical presentations, associated diseases and complications, if any. The genotype dataset was acquired for children (n = 217) and adult CD patients (n = 340) and controls (n = 736) using Immunochip. Association analysis was performed using logistic regression model to identify susceptibility genetic variants. Results The predominant form of CD was classical CD in both pediatric and adult CD groups. There was remarkable similarity between pediatric and adult CD except for quantitative differences between the two groups such as female preponderance, non-classical presentation, co-occurrence of other autoimmune diseases being more common amongst adult CD. Notably, same HLA-DQ2 and –DQ8 haplotypes were established as the major risk factors in both types of CD. In addition, a few suggestively associated (p