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The association of apolipoprotein E (ApoE) gene polymorphism with Alzheimer's disease (AD) has been reported in several populations including one from a rural community in North India. However, the association of ApoE polymorphism with vascular dementia (VaD) is yet to be established in this population. In a case-control study involving 54 cases of dementia (29 AD and 25 VaD) and 76 age-matched healthy controls, the frequency of epsilon4 allele was significantly higher among cases of AD and VaD compared with controls (p < 0.001). The epsilon3epsilon3 (p < 0.05) and epsilon2epsilon3 (p < 0.001) genotypes were found to be protective. The odds of developing AD or VaD were 4.4 and 3.7 times higher, respectively, in the presence of even a single epsilon4 allele. Our results suggest that the increased risk of developing AD or VaD is similar among Asian Indians with ApoE epsilon4 compared with the Caucasian population., (Copyright 2004 S. Karger AG, Basel)

Essential thrombocythemia (ET) is a clonal disorder of unknown etiology involving multipotent hematopoietic progenitor cell and belongs to the spectrum of chronic myeloproliferative disorders (CMPD). It is rarest of the CMPD with no case reported from India. The case being presented was detected incidentally during routine investigations in an adult female who presented with mild abdominal discomfort.

Objectives: Several factors, including abdominal obesity, insulin resistance, diabetes mellitus and low levels of high-density lipoprotein cholesterol have been implicated in the high prevalence and early onset of coronary heart disease in Asian Indians. However, there are no reports regarding the role of apolipoprotein E (apo E) gene polymorphisms in premature myocardial infarction (MI) in this population. This study aimed to study the role of apo E gene polymorphisms in premature MI patients and their relation to serum lipid levels., Design and Methods: Apo E gene polymorphisms were analysed in 35 patients with MI aged <40 years and in 45 age- and sex-matched controls using polymerase chain reaction-restriction fragment length polymorphism. Levels of serum lipids were measured in addition to the evaluation of conventional risk factors., Results: Higher frequencies of the apo E4 allele (P<0.0001) and of genotypes E3/E4 (P<0.005) and E4/E4 (P<0.005) were recorded in the premature MI group compared with the controls. Multivariate regression analysis revealed that, after adjusting for other covariates, individuals with the E4 allele were at ~46 times higher odds to develop premature MI compared with individuals without the E4 allele [adjusted odds ratio, OR (95% confidence interval, CI): 45.7 (4.9-421.3)]. Among conventional risk factors, higher risk was observed in those having dyslipidaemia [OR (95% CI): 8.7 (0.9-86.6)] and those with a high waist : hip ratio [OR (95% CI): 5.6 (1.4-21.2)]., Conclusion: Based on the robust association, the apo E4 allele should be considered as an independent risk factor for premature MI in Asian Indians.

Objective: To investigate the relationships of sub-clinical inflammation and regional and generalized obesity and lipids in adolescent and young adult Asian Indians in north India., Methods: We determined serum levels of C-reactive protein (CRP), a marker for sub-clinical inflammation, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (W-HR), four skinfolds (biceps, triceps, subscapular and suprailiac), percentage of body fat (% BF) and lipid profile in 377 healthy adolescents and young adults (331 males and 46 females, age range: 14-25 years)., Results: Overweight subjects (BMI>85th percentile), and subjects with high values (>85th percentile) of WC and triceps skinfold thickness had significantly higher median CRP levels (P=0.04, P=0.001 and P=0.007, respectively) as compared with subjects with lower values of the variables. Elevated levels of CRP (>2.1 mg/l) were observed in 21.8% of the overweight subjects and 24.5% of the subjects with high (>85th percentile) % BF. After adjusting for age and gender, the odds ratios (95% CI) for elevated levels of CRP were 2.3 (1.1-4.7, P=0.02) for overweight subjects, 2.6 (1.2-5.4, P=0.01) for subjects with high % BF, and 3.7 (1.7-7.9, P=0.001) for subjects with high triceps skinfold thickness. Levels of CRP correlated significantly with % BF (r=0.13, P=0.009), W-HR (r=0.11, P=0.02), biceps skinfolds (r=0.13, P=0.01) and triceps skinfolds (r=0.13, P=0.01) for males only., Conclusions: The observations of substantial prevalence of elevated CRP levels in adolescents and young adults having increased generalized and abdominal adiposity may be important for the development of metabolic syndrome and atherosclerosis in Asian Indian adults.

One hundred and two liver biopsy specimens were stained for Argyrophilic nucleolar organizer regions and associated proteins to assess its utility in differentiating normal, cirrhotic and neoplastic liver tissue. A statistically significant (p < 0.001) difference was observed between mean AgNOR counts of normal (1.53 +/- 0.4), post-hepatitic cirrhosis (3.65 +/- 0.53) and hepatocellular carcinoma (7.94 +/- 1.18). In contrast the mean AgNOR count of biopsies with alcoholic cirrhosis (1.57 +/- 0.06) was significantly less (p < 0.001) than post-hepatitic cirrhosis and was similar to that of normal liver tissue. It is concluded that AgNORs can act as a good adjuvant to histology in diagnosing liver diseases especially in differentiating post-hepatitic and alcoholic cirrhosis.

Background and Aims: To do a histomorphometric study of vascular changes in colonic mucosa of patients with portal hypertension (PHT) and to find their association with clinical and upper and lower gastrointestinal endoscopic observations., Methods: Full length colonoscopy was carried out in 55 patients with portal hypertension and 25 controls. Hemorrhoids, anorectal varices and colopathy were carefully looked for and recorded. Two biopsies each were taken from the caecum, ascending colon, transverse colon, descending colon and rectum. Sections from all the five sites were examined for histopathological changes with special reference to changes in mucosal capillaries. Morphometric assessment of the diameter of the capillary and thickness of the capillary wall was performed. These histomorphometric changes were correlated with clinical parameters and findings of upper and lower gastrointestinal endoscopic findings., Results: Dilated and congested capillaries as well as capillaries with irregular thickening of the wall were seen in a significantly higher number of sections from patients than controls in biopsies from all the five sites from caecum to rectum. On morphometry, the diameter of the capillaries and the thickness of the capillary wall in biopsies from all the five sites in patients was significantly higher than that in the control group. Apart from vascular changes, edema and inflammatory infiltrate in lamina propria were the other significant histological features noted. No significant association between clinical and endoscopic features and histomorphometric assessment was found., Conclusion: Dilated tortuous mucosal capillaries with irregular thickening of wall, edema of lamina propria and mild chronic inflammatory infiltrate are the major histopathological changes seen in colonic biopsies of patients with PHT, showing that PHT produces changes in the colonic mucosa similar to those seen in the mucosa of upper GI tract. However, the histological changes had no correlation with the clinical or endoscopic findings except that the thickness of the capillary wall was higher in patients who had undergone endoscopic sclerotherapy as opposed to those who had not received sclerotherapy.

The association between apolipoprotein E (apo E) polymorphism and stroke has been controversial. So far there are no studies reported on the polymorphism of apolipoprotein E in cerebrovascular diseases in the Asian Indians. A blinded case-control study was therefore undertaken and the apo E genotypes and lipid profile of a total of 120 subjects (63 stroke patients and 57 healthy controls) were done. The frequency distribution of apo E alleles and genotypes were assessed and their relation with the occurrence of stroke in Asian Indian subjects was determined. A significantly high frequency of apo epsilon4 allele (30%) was observed in the stroke patients than the controls (11%) (p < 0.005), and patients with epsilon4 allele had a fourfold higher odds to develop stroke OR (95%CI) 4.2 (1.8-10.1) (p < 0.005). On multivariate analysis, after adjusting for age, triglycerides and hypertension, the association of epsilon4 allele with stroke was found to be no longer statistically significant, OR (95%CI) 1.2 (0.4-4.5) (p = NS). On multiple logistic regression analysis age, OR (95%CI) 1.1 (1.1-1.2) (p < 0.001), and hypertension OR (95%CI) 15.1 (2.6-89.1) (p < 0.005) were found to be independent risk factors for development of stroke. This is the first report to have examined the association of apo E gene polymorphism with stroke in the Asian Indians. This study suggests that apo epsilon4 allele, triglycerides, age and hypertension are the predictors for stroke development.

Background: Due to improvements in imaging techniques and immunodiagnostic methods there has been a spurt of cases of hepatic hydatidosis. Till now surgical management in the form of marsupialization and tube drainage, omentoplasty or hepatectomy was the mainstay of treatment. Recently treatment options have improved considerably after introduction of the PAIR (precutaneous aspiration, injection of scolicidal agent and reaspiration) procedure. In this study we report the results of ultrasound guided PAIR procedure in 39 hepatic hydatid cysts., Method: All patients with hepatic hydatid cysts underwent the PAIR procedure under ultrasound guidance. The scolicidal agent used was 20% hypertonic saline. Type I and II (n=24) cysts were managed by precutaneous aspiration while type III and IV showing a multiloculated or pseudotumour appearance (n=15) cysts were managed by the percutaneous placement of a Malecot's catheter which was removed after 3-7 days., Results: All patients responded to the PAIR procedure. The commonest ultrasonographic appearance in hepatic hydatid cyst patients was a solitary uniloculated cyst with prominent back wall echoes in the right lobe of the liver. The complications encountered were in the form of mild hypotension (two cases), urticaria in one patient and severe hypotension leading to shock in one case., Conclusions: The PAIR procedure was found to be effective, cheap and safe in the non-surgical management of hepatic hydatid cysts.

Background and Aim: An adverse coronary risk profile has been reported amongst rural-to-urban migrant population living in urban slums undergoing stressful socio-economic transition. These individuals are likely to have low intakes of folic acid and vitamin B12, which may have an adverse impact on serum levels of homocysteine (Hcy). To test this hypothesis, we studied serum levels of Hcy in subjects living in an urban slum of North India and healthy subjects from urban nonslum area., Methods: Group I consisted of 46 subjects (22 males and 24 females) living in an urban slum, while group II consisted of healthy subjects (n = 26, 13 males and 13 females) living in the adjacent non-slum area. Anthropometric measurements, biochemical profile (fasting blood glucose, total cholesterol, serum triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol) and fasting serum levels of Hcy were measured. Dietary intakes of folic acid, vitamin B12, vitamin B1, and iron were calculated by the 24-hour dietary recall method. Serum levels of Hcy were correlated with dietary intakes of nutrients, anthropometry, and metabolic variables., Results: Sex-adjusted serum levels of Hcy in micromol/L (Mean +/- SD) were high, though statistically comparable, in both the groups (group I: 20.8 +/- 5.9 and group II: 23.2 +/- 5.9). Overall, higher than normal serum levels of Hcy (> 15 micromol/L) were recorded in 84% of the subjects. A substantial proportion of subjects in both groups had daily nutrient intakes below that recommended for the Asian Indian population (folic acid: 93.4% in group I and 96.7% in group II, vitamin B12: 76.1 % in group I and 88.4% in group II). However, between the two groups, average daily dietary intakes of both the nutrients were statistically comparable. As compared to non-vegetarians, vegetarians showed lower intakes of folic acid (p < 0.01) and vitamin B12 (p < 0.01) in both groups. On multivariate linear regression analysis with serum Hcy as the response variable and vegetarian/non-vegetarian status and sex (male/female) as predictor variables, higher serum levels of Hcy were observed in vegetarians vs non-vegetarians (1 = 4.6, p < 0.05) and males vs females (beta = 5.3, p < 0.01)., Conclusions: Low intakes of folic acid and vitamin B12, and hyperhomocysteinemia, in both the healthy population living in urban slums and adjacent urban non-slum areas, are important observations for the prevention of nutritional and cardiovascular diseases in the Indian subcontinent.

Background and Study Aims: Although it is known that obliteration of esophageal varices following endoscopic variceal band ligation results in an increase in the incidence of portal hypertensive gastropathy, the effect of variceal ligation on hemorrhoids, anorectal/colonic varices and portal hypertensive colopathy is not known. The aim of this study was to investigate the effect of endoscopic variceal band ligation on hemorrhoids, anorectal/colonic varices and portal hypertensive colopathy., Patients and Methods: A total of 60 consecutive patients with cirrhosis of the liver and portal hypertension were prospectively studied. Upper gastrointestinal endoscopy and full-length colonoscopy were carried out before the patients underwent endoscopic variceal band ligation for esophageal varices and after obliteration of the varices following band ligation., Results: Obliteration of esophageal varices by endoscopic variceal band ligation did not affect the incidence of hemorrhoids (37 % before and after), anorectal varices (40 % before and after), and portal hypertensive colopathy (57 % before and after)., Conclusions: It is concluded that esophageal variceal band ligation does not affect the incidence of hemorrhoids, anorectal varices or portal hypertensive colopathy in patients with cirrhosis of the liver.

Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy are carried out for a variety of billo-pancreatic diseases. These procedures were earlier performed at only a handful of tertiary centres in India. However, of late, they are being performed at several centres and even smaller clinics. Although, endoscopic sphincterotomy is one of the most commonly performed endoscopic procedure, there are no data on the number of procedures performed each year in India. It is estimated that in the USA alone more than 200,000 procedures are performed each year. The procedure has the dubious distinction of being considered as one of the most hazardous of all endoscopic procedures and is associated with a small but significant morbidity and mortality. The immediate complications of endoscopic sphincterotomy include pancreatitis, haemorrhage, perforation and cholangitis in addition to those associated with the use of sedation and anaesthesia. There are also reports of the long term adverse effects of the destruction of the sphincter of Oddi. There is also controversy as to what should be the minimum requirements for training and who should be allowed to perform these procedures.

Background: High prevalence of diabetes, obesity, and dyslipidemias in people belonging to poor socio-economic strata in urban slums of northern India has been recorded recently. To assess whether this population has high levels of soluble intercellular adhesion molecule-1 (sICAM-1), a cytokine involved in the pathogenesis of atherosclerosis, we investigated subjects belonging to poor socio-economic strata in urban slums and compared them to healthy control subjects from non-slum urban areas of New Delhi., Design: Cross-sectional study., Methods: Subjects from a previously carried out cross-sectional study, Delhi Urban Slum Project (DUSP) were divided into two groups: Group-1 (n = 56) included subjects dwelling in slum area, having at least one risk factor (hypertension, hyperglycemia, hypertriglyceridemia and hypercholesterolemia), while group-2 (n = 60) consisted of subjects without any risk factor dwelling in the slum area. A third group (n = 29) of non-obese subjects without any risk factor living in non-slum urban area was included for comparison. Measurements included; body mass index (BMI), waist-hip ratio (W-HR), four skinfolds, percentage body fat, fasting plasma glucose (FPG), serum lipids, and serum levels of sICAM-1., Results: Though statistically not significant, mean level of sICAM-1 was higher in group-1 (718.5 +/- 232.8 ng/ml) as compared to the other groups. Of note, 35% of subjects in group-1 (p < 0.05 as compared to other two groups), and 25.3% of all subjects had levels of sICAM-1 in uppermost quartile (> 850 ng/ml). Partial correlation coefficients (R) of sICAM-1 levels with various parameters adjusted for age were statistically significant for BMI (R = 0.27, p < 0.05) in group-1; W-HR (R = 0.26, p < 0.05) and BMI (R = 0.19, p < 0.05) for group-2; and FPG (R = 0.17, p < 0.05) for all the subjects considered together. For females, the levels of sICAM-1 were significantly higher in the following: BMI > OR = 25 kg/m2 (p = 0.04) and FPG > 7 mmol/l (p < 0.05). Multiple linear regression analysis suggests that an increment in BMI by one kg/m2 would correspond to an increase in the levels of sICAM-1 by 8.5 units controlling for the influence of age and W-HR in the pooled data of all subjects., Conclusions: High percentage of subjects had levels of sICAM-1 in the upper quartile in the study, particularly those dwelling in the slum area and having coronary risk factor (s). The levels of sICAM-1 strongly correlated to the anthropometric and metabolic parameters, particularly in females. These observations are of potential importance for the pathogenesis of atherosclerosis in this population, though further studies are needed to predict those prone to the complications of atherosclerosis, based on sICAM-1 levels, as has been observed in other ethnic groups.

Two antral biopsies each from 104 patients of leprosy and 100 controls were studied to find out the prevalence of H. pylori and associated histopathological changes. Sections were stained with hematoxylene and eosin, AB/PAS (Ph 2.5) and Loeffler's methylene blue stains. Infection by H. pylori, inflammation and atrophy were found to be significantly more in leprosy patients as compared to controls (p < 0.01, < 0.005 and < 0.02 respectively). On comparing the histopathological changes in various subgroups of leprosy, H. pylori, inflammation and activity showed a statistically decreasing trend from tuberculoid to lepromatous subgroups (p < 0.05, < 0.001, < 0.01 respectively). Atrophy showed a significant increasing trend from tuberculoid to lepromatous group (< 0.001), it is concluded that despite a low prevalence of H. pylori and associated gastritis in patients with lepromatous leprosy, gastric epithelial damage is more marked due to altered immune response.

Background and Aims: The topographic distribution and density of Helicobacter pylori and associated gastritis in the stomach were studied in order to determine which biopsy sites are likely to provide the maximum yield so as to reduce the fallacious results due to sampling error., Methods: Fifty patients with upper gastrointestinal symptoms were studied. Eleven gastric biopsies from predetermined sites were obtained and subjected to ultra-rapid urease test, imprint cytology and histology. Haematoxylin and eosin stain was used for defining gastritis and other associated histopathological details. Loeffler's methylene blue stain was used to confirm the presence of H. pylori in imprint smears and histological sections., Results: All 50 patients had H. pylori infection and evidence of chronic gastritis at one or more of the 11 biopsy sites. Maximum and minimum percentage positivity were observed at A3 (antral lesser curvature) and B4 (corpus greater curvature), respectively. Various sites in decreasing order of percentage positivity were A3 > A2 > A1 > A4 > B3 > B1 > A5 > B6 > B5 > B2 > B4. Among the biopsies obtained from the corpus, B3 (corpus lesser curvature) was the site with maximum positivity. A3 and B4 had a statistically significant difference in percentage positivity (P < 0.0001) for H. pylori and gastritis. The maximum and minimum density scores of H. pylori and gastritis were found in A3 and the B4, respectively. A3 had a significantly higher (P < 0.0001) mean density score than any other site in the stomach. The difference in the grading of H. pylori between A3 and B3 (sites of maximum positivity in antrum and corpus) was statistically significant (P < 0.0001). A statistically significant (P < 0.001) positive correlation between increasing grades of H. pylori and gastritis was observed at the site of maximum density. Eighty per cent of the patients had antral predominant gastritis and in 82%, H. pylori was predominantly observed in antral biopsies., Conclusion: It is concluded that two biopsies taken from A3 are sufficient for confirmation of presence of H. pylori and associated gastritis for initiation of treatment. However, additional biopsies from B3 will help in deciding the topographic pattern of gastritis.

Three hundred and fifty biopsies from patients undergoing upper gastrointestinal endoscopy were studied for histopathological changes, H. pylori infection and argyrophilic nucleolar organizer region (AgNOR) counts. Histopathological examination revealed normal gastric mucosa in 10 (2.85%), gastritis in 254 (72.56%), intestinal metaplasia in 12 (4.0%), dysplasia in 13 (3.7%) and adenocarcinoma in 61 (17.4%). The mean (SD) AgNOR count was 1.66 (0.20) in normal, 2.43 (0.64) in gastritis, 3.09 (0.52) in intestinal metaplasia, 4.17 (0.31) in dysplasia, and 6.57 (0.98) in carcinoma. A statistically significant difference was observed between the AgNOR count of normal gastric mucosa and gastritis (p<0.001), gastritis and dysplasia (p<0.001), and dysplasia and adenocarcinoma (p<0.001). A statistically significant increase in mean AgNOR count was found with increase in H. pylori density in gastric biopsies (p<0.001) with gastritis. No significant difference was observed between mean AgNOR count of intestinal and diffuse type carcinomas. The AgNOR count in gastric biopsies with adenocarcinoma and H. pylori infection was 7.03 (0.85) as compared to 6.89 (0.73) in gastric biopsies with evidence of adenocarcinoma but without H. pylori infection. The difference was not statistically significant. The findings support the role of H. pylori as a promoting agent in gastric carcinogenesis by stimulating gastric epithelial cell proliferation at the stage of chronic inflammation, thereby making the cells more susceptible to endogenous or exogenous carcinogenic agents.

Objective: To determine the clinical and ultrasound appearances of carcinoma gallbladder in Indian patients., Methods: The study included all patients suspected to have gallbladder malignancy, attending the gastroenterology department from January 1989 to February 1997. These patients underwent ultrasonographic examination with a grey scale sector scanner (Aloka SSD-630) with a 3.5 MHz transducer after an overnight fast. Histological confirmation was done at surgery, by US guided fine needle aspiration cytology or by direct biopsy/aspiration of the palpable mass., Results: There were a total of 92 cases of cytologically and histologically proven carcinoma of gallbladder. A distinct female preponderance was seen with a male:female ratio of 1:3.6. The mean +/- SD age was 47.9 +/- 19.6 years (range 25-75 years). The histological confirmation was done at surgery in 10% of patients, by US guided fine needle aspiration cytology in 50 cases (54%) or by direct biopsy/aspiration of the palpable mass in 33 (36%) of cases. Pain in the right hypochondrium was the commonest presenting symptom (91%) followed by anorexia (88%) and weight loss (67%). Surgical obstructive jaundice was observed in 54% cases while 10.9% presented with biliary sepsis. A mass of mixed echogenicity protruding in the lumen of the gallbladder was seen in the majority of cases (52.8%). Less commonly infiltration of the gallbladder wall (33.7%) or a mass replacing the gallbladder (14.1%) was encountered. Gallstones were associated in 57% of patients with gallbladder malignancy. The elevated stone sign and peripancreatic nodal spread were important clues for gallbladder malignancy., Conclusion: A high index of suspicion of gallbladder malignancy in elderly Indian female patients presenting with features of choletithiasis, and awareness of the ultrasound findings may lead to early diagnosis and radical resection of this highly lethal malignancy.

Biliary ascariasis is common in certain geographical areas of the world. In India, it is common in the Kashmir valley and only stray cases have been reported from other parts of the country. Between January 1995 and May 1997, 14 patients with biliary ascariasis were seen at our centre, which is more than 1000 km from the Kashmir valley. The mean (+/- SD) age of the patients was 31.7 (+/- 6.1) years and all were females. None of them had been to a place known to be endemic for biliary ascariasis. Four patients presented with acute cholangitis, eight with acute abdominal pain and vomiting, and the remaining two were diagnosed incidentally during surgery for gallstone disease. Barring these two patients, ultrasound examination of the abdomen diagnosed the condition accurately. In 10 patients, a part of the worm was visible outside the papilla of Vater. The roundworm was caught in a Dormia basket and could be extracted in nine patients. In one patient the worm migrated inside the bile duct while it was being caught in a Dormia basket. In this and two other patients, in whom the worm had migrated completely inside the bile duct, worms were removed with the help of a Dormia basket after endoscopic sphincterotomy. There were no complications of endoscopic therapy. In the two patients in whom biliary ascariasis was detected during surgery, the worms were removed after choledocholithotomy. On a mean follow-up of 13.8 months, only one patient had a recurrence of biliary ascariasis. It is concluded that biliary ascariasis is not an uncommon disease and must be considered as a possibility in patients presenting with acute cholangitis and biliary pain even in a non-endemic area. Ultrasonography is an excellent diagnostic tool and endoscopic management is very effective and safe in the treatment of these patients.

Background and Study Aims: Endoscopic sclerotherapy (EST) results in an increase in the prevalence of portal hypertensive gastropathy (PHG). However, the effects of sclerotherapy on hemorrhoids, anorectal or colonic varices and portal hypertensive colopathy are not known. The aim of this study was to investigate these effects., Patients and Methods: A total of 39 patients with portal hypertension were studied. Upper gastrointestinal endoscopy and full-length colonoscopy were carried out before the patients underwent EST for esophageal varices, and after obliteration of the varices following sclerotherapy., Results: The obliteration of esophageal varices by EST did not significantly affect the prevalence of hemorrhoids (32 % before and after), anorectal varices (45% before and after) or portal hypertensive colopathy (60.5 % before and 66 % after, P > 0.05)., Conclusion: Obliteration of esophageal varices does not affect the prevalence of hemorrhoids, anorectal varices, or portal hypertensive colopathy.

Background: Although rare in the West, colonic tuberculosis is not an uncommon disease in developing countries. However, the clinical manifestations and radiological appearance of the disease are non-specific. In recent years, colonoscopy has been found to be very useful in diagnosing patients with colonic tuberculosis., Methods: Clinical features, colonoscopic findings, histology and response to treatment were recorded in 50 patients with colonic tuberculosis., Results: Abdominal pain, fever, anorexia, weight loss and diarrhoea were the common symptoms. The colonoscopic features consisted of ulcers (92%), nodules (88%), deformed caecum and ileocecal valve (42%), strictures (25%), multiple fibrous bands (8%) and polypoid lesions (6%). Segmental tuberculosis and lesions simulating carcinoma were seen in 22 and 16% of patients, respectively. Histological examination of the colonic biopsy specimens showed well-formed, non-caseating granulomas in 18%, collection of loosely arranged epithelioid cells in 40% and chronic non-specific inflammatory changes in 42% of the patients. Six patients needed surgical intervention. The other 44 patients responded well to anti-tuberculous therapy and became asymptomatic., Conclusions: It is concluded that colonoscopy is a useful method for diagnosing colonic tuberculosis. It is suggested that if the clinical picture and colonoscopic appearance are suggestive of tuberculosis and target biopsies reveal non-caseating granulomas, a collection of loosely arranged epithelioid cells, or even non-specific changes, then a therapeutic trial of anti-tuberculous drugs should be given and continued if there is clinical improvement.

Objective: To assess the role of fine needle aspiration biopsy (FNAB) in patients with palpable colonic masses., Study Design: FNAB was performed on 32 patients with palpable colonic masses before subjecting them to colonoscopic examination. Smears prepared from the material obtained by aspiration biopsy were examined. The results of aspiration biopsy were confirmed by histopathologic examination of the tissue obtained on colonoscopy or surgery or by a salutory response to antituberculous therapy in patients with tuberculosis of the colon., Results: Twenty-nine patients had carcinoma of the colon, and three had ileocecal tuberculosis. Aspiration biopsy could correctly diagnose all the cases with malignancy and two of the three cases with colonic tuberculosis. Colonoscopy could not be performed on two patients with cancer of the colon. However, a barium enema examination revealed evidence of cecal malignancy in both patients. In the two patients diagnosed as having colonic tuberculosis by FNAB, colonoscopic biopsies revealed only nonspecific changes. There were no false positive results or complications of the procedure., Conclusion: FNAB is a simple, rapid and accurate method of diagnosing palpable colonic masses.

Objective: To report the clinical features, endoscopic appearance, management and outcome of patients with upper gastrointestinal bleeding due to Mallory-Weiss tear seen at our institution during the last seven years., Methods: A retrospective study of all patients with upper gastrointestinal bleeding seen during the last seven years was performed. Patients who were bleeding from longitudinal non-perforating tear(s) of the gastro-oesophageal mucosa were included in the study and their clinical features, endoscopic appearance management and outcome were recorded., Results: During the study period 426 patients with upper gastrointestinal bleeding were seen. Sixty-six (15.5%) of these were found to have bled or were bleeding from Mallory-Weiss tear(s). Twenty-seven (41%) patients with Mallory-Weiss tear had no antecedent nausea, retching, abdominal pain or vomiting. Two patients had portal hypertension and a solitary case bled from an iatrogenic tear induced during routine upper gastrointestinal endoscopy. Multiple bleeding episodes were seen in 12% of cases. Twenty (30%) patients needed endoscopic sclerotherapy. Haemostasis was achieved in all. Except retrosternal pain, no procedure related complications were seen., Conclusions: Mallory-Weiss tear is a common cause of upper gastrointestinal bleeding. Nearly half of the patients have no antecedent symptoms and presented for the first time with upper gastrointestinal bleeding. Endoscopic therapy is very effective and safe in producing haemostasis in these patients.

To determine the diagnostic accuracy of the one-minute ultra-rapid urease test for diagnosing Helicobacter pylori infection, two biopsies were taken from both the gastric corpus and antrum from 1000 patients undergoing upper gastrointestinal endoscopy. All the biopsies were subjected to the one-minute ultra-rapid urease test before imprint smears were prepared from them. Thereafter, the biopsies were fixed in 10% formalin and histological sections were examined for the presence of H pylori by a pathologist who was not aware of the clinical details or the results of the urease test. The prevalence of H pylori in the gastric antrum and corpus was 86.7% and 53.3%, respectively. The sensitivity, specificity, positive and negative predictive value and the overall diagnostic accuracy of the ultra-rapid urease test to diagnose H pylori infection in the gastric antrum were 92%, 100%, 100%, 66%, and 93%, respectively. The corresponding figures for the gastric corpus were 83%, 100%, 100%, 85%, and 91%, respectively. It is concluded that the one-minute ultra-rapid urease test has a high sensitivity and specificity and may be used as a rapid and cheap method to diagnose H pylori infection.

Fifty patients with chronic renal failure and 50 asymptomatic healthy volunteers were studied to determine the prevalence of Helicobacter pylori in the two groups and to compare the results of ultrarapid urease test (URUT) and gastric histology for detecting H. pylori infection. Four gastric antral biopsy specimens were taken. Two specimens were used for the URUT and two were processed routinely. Sections were stained with H&E and Loeffler's methylene blue. Histological examination showed presence of H. pylori in 56% of patients with chronic renal failure (CRF) and in 78% of the controls. The difference was statistically significant (p < 0.05). The URUT was positive in only 16% of patients with CRF compared to 74% in the controls (p < 0.0001). The sensitivity and overall diagnostic accuracy of the URUT to diagnose H. pylori infection were 94.8 and 96%, respectively, in controls but were only 29 and 60%, respectively, in patients with CRF. It is concluded that the prevalence of H. pylori is significantly less in patients with CRF and that the URUT is less sensitive than gastric histology for diagnosing H. pylori infection in these patients.

Acute appendicitis caused by Ascaris lumbricoides is an uncommon variant of a common disease. We describe a case in which sonography was used for preoperative diagnosis of ascaris appendicitis.

A 30-year-old female was seen with symptoms and radiological evidence of gastric outlet obstruction. Endoscopic examination revealed findings suggestive of gastric outlet obstruction with nodularity of the antral mucosa leading to deformity of the pylorus. Endoscopic biopsies from the nodular antral mucosa showed presence of Helicobacter pylori-induced lymphonodular hyperplasia without evidence of mucosa-associated lymphoid tissue lymphoma. Anti-H. pylori therapy resulted in eradication of the H. pylori infection and the signs and symptoms of gastric outlet obstruction. The case demonstrates that H. pylori-induced lymphonodular hyperplasia can also cause gastric outlet obstruction. We believe this is the first such case to be reported.

Fifty-five patients with oral submucosal fibrosis and an equal number of patients with no evidence of the disease were studied. All patients underwent upper gastrointestinal endoscopy and any abnormality was noted. Multiple oesophageal biopsies were obtained from the upper end of the oesophagus and from any endoscopically observed abnormality. The histological changes in the two groups were assessed blindly by an experienced histopathologist. Histological abnormalities were noted in the oesophageal mucosa in 2% of controls and 66% of patients with oral submucosal fibrosis (p < 0.0001). In the control group, acanthosis was seen in one patient, while in the patient group atrophy of the squamous epithelium was evident in 52%, hyperkeratosis in 52%, parakeratosis in 30%, dyskeratosis in 14%, acanthosis in 14%, and papillomatosis and mild dysplasia in 2% patients. Subepithelial collagenization was seen in 32 (64%) patients. The oesophageal abnormalities were seen more frequently in patients who had consumed Pan masala, Gutka, betel nut, tobacco or a combination of some or all of these, with or without betel leaf, for > or = 5 years compared to those consuming them for a shorter period of time (91% vs 46%, p < 0.001). It is concluded that oral submucosal fibrosis is not a disease confined to the oral cavity; the oesophagus may also be involved in about two-thirds of patients.

Since it was first described in 1974, endoscopic sphincterotomy has been the procedure of choice for management of choledocholithiasis, especially for retained common bile duct stones. However, it has the dubious distinction of being the most hazardous of all endoscopic retrograde cholangiopancreatographic procedures and carries an immediate complication rate of 8-10%. Concern has also been voiced about the long-term complications of sphincterotomy, as the sphincter of Oddi is cut during the procedure. To prevent, or at least lessen, the short- and long-term complications of endoscopic sphincterotomy, an alternative in the form of balloon dilatation of the papilla, has been advocated. However, the procedure of balloon dilatation is cumbersome, time consuming and, more importantly, a recent multi-centre study from the US comparing endoscopic sphincterotomy with balloon dilatation observed higher complications with balloon dilatation. The use of nitrites to relax the papilla is another novel method used for removal of common bile duct calculi. So how should a therapeutic endoscopist decide which method is to be used? The advantage of endoscopic sphincterotomy is that it has been around for more than two decades and most endoscopists are familiar with the technique as well as its complications. It can be accomplished quickly and with the advent of wire-guided and balloon-mounted sphincterotomes, the time taken for the procedure to be completed has been reduced further. The complications of the procedure are less when it is employed for removal of common bile duct stones and when used by experts. It, therefore, still appears to be the procedure of choice for endoscopic management of choledocholithiasis. The other two methods may, however, be useful in patients with coagulopathy.

Between 1989 and 1996, fine-needle aspiration biopsy was performed in 22 patients with palpable colonic masses. In all of these patients colonoscopic examination was either not possible or could not be carried out successfully. The results of aspiration biopsy were confirmed by surgery and histopathological examination of the tissue. Aspiration biopsy correctly diagnosed all except one case. It identified all cases of colonic cancer. One patient with colonic tuberculosis was also diagnosed correctly. However, in another patient with colonic tuberculosis, aspiration biopsy showed only nonspecific changes in the form of inflammatory and epithelial cells. There were no false-positive results or complications from the procedure. It is concluded that fine-needle aspiration biopsy is a simple, rapid, and accurate method of diagnosing palpable colonic masses in patients in whom a colonoscopy is not possible or cannot be performed satisfactorily.

To determine the prevalence of spider angiomata in patients with cirrhosis, the factors influencing them and whether or not they are present in the retina of patients with cirrhosis, 93 cirrhotics were studied. Cutaneous spider angioma were seen in 19 (20%) patients. All patients with spiders had at least one episode of variceal bleeding and had grade III or IV oesophageal varices. Spiders were seen more commonly in patients with alcoholic cirrhosis than in those with non-alcoholic cirrhosis (53.5% vs 6%, p < 0.001), in patients with Child's C cirrhosis than those with Child's A and B cirrhosis (67% vs 4%, p < 0.001). However, although spiders were seen more often in patients undergoing sclerotherapy than those not, the difference was statistically not significant (23% vs 19%, p = NS). Spiders had no association with presence or absence of portal hypertensive gastropathy or gastric varices. None of the patients showed any abnormality or presence of spiders in the retina. It is concluded that spider angiomas are seen more commonly in patients with alcoholic cirrhosis, those with more severe liver disease and patients having large oesophageal varices and they are not seen in the retina of patients with cirrhosis.

Background and Study Aims: It has recently been reported that in developed countries gastric outlet obstruction now predicts gastric malignancy. The aim of this study was to find out if this is the case in a developing country like India., Patients and Methods: Seventy-four patients with gastric outlet obstruction underwent upper gastrointestinal endoscopy and biopsy specimens were obtained from any suspicious looking lesions or from the most distal point at which the endoscope could be positioned., Results: In 56 patients (76%) the cause of the gastric outlet obstruction was malignant. On clinical and endoscopic appearance three patients were wrongly diagnosed as having malignancy when the cause, on endoscopic biopsy, was benign (tuberculosis n = 2, and immunoproliferative small intestinal disease n = 1). Twelve of the 18 patients with benign gastric outlet obstruction were managed conservatively with drugs and endoscopic balloon dilatation., Conclusion: Even in a developing country like India, malignancy is the commonest cause of gastric outlet obstruction and endoscopic biopsy specimens should be obtained in all patients with gastric outlet obstruction because the occasional benign lesions can be managed conservatively.

Imprint cytology of the gastric mucosa has been found to be very simple, inexpensive, and rapid for diagnosing Helicobacter pylori infection. However, there is a fear that preparing imprint smears may damage the biopsy specimen for subsequent histologic examination. This study was planned to investigate whether this damage happens. Four antral biopsy specimens were obtained from each of the 100 patients undergoing upper gastrointestinal endoscopy. Imprint smears were made from two biopsy specimens, which were then fixed in 10% formal saline and sent for histologic study. The third and fourth biopsy specimens were directed fixed in 10% formal saline for histologic examination. Two pathologists examined the imprint smears. Agreement between the two observers was observed in 97% of cases. Beyond-chance agreement was good with a kappa index of 0.90. H. pylori organisms were seen in 82% of biopsy specimens from which imprint smears were prepared and in the same percentage of biopsy specimens that were processed directly. The pathologists could not identify the histologic sections form which imprints were made. It is concluded that imprint cytology is an excellent method of diagnosing H. pylori infection and that preparing imprint smears does not alter the quality of the tissue. The same biopsy specimen can be used for histologic studies.

To evaluate whether the diameter or thickness of the wall of mucosal capillaries in the stomach could be a useful histological marker of portal hypertension, gastric mucosal biopsies were taken from the fundus and antrum of 73 patients with cirrhosis of the liver and 64 healthy volunteers. The mean +/- SD diameter of mucosal capillaries in the fundus of patients was not significantly different from that in the control group (59.4 +/- 16.8 microns vs 53.5 +/- 16.5 microns, respectively; P = NS). However, the mean +/- SD diameter of the antral mucosal capillaries was significantly greater in patients compared to controls (61.3 +/- 18.1 microns vs 47.6 +/- 12.7 microns, respectively; P < 0.001). The mean +/- SD thickness of the fundal and antral capillary wall in the patients group (6.8 +/- 2.4 microns and 7.2 +/- 2.4 microns, respectively) was significantly greater than that in the control group (3.5 +/- 1.5 microns and 3.3 +/- 1.5 microns, respectively) (P < 0.001 for each). The overall diagnostic accuracy of antral mucosal capillary diameter to diagnose portal hypertension was 50%, while that of thickened fundal and antral mucosal capillary wall was 84% and 85%, respectively. It is concluded that the gastric mucosal capillary walls are thicker in patients with portal hypertension and that this is a more reliable histological marker of portal hypertension than dilated gastric mucosal capillaries.

The injection of sclerosants and adrenaline in a bleeding peptic ulcer is known to arrest bleeding in the majority of patients. However, there are very few studies from India on this subject. Injection therapy was carried out using absolute alcohol in 21 patients with bleeding gastric ulcer and 55 with bleeding duodenal ulcer. Injection therapy successfully controlled bleeding in all 76 patients. Bleeding recurred in two patients who were successfully managed with a second injection of absolute alcohol. Post-injection blood transfusion was required in 16 (76%) patients with gastric ulcer compared with only 12 (22%) of those with a duodenal ulcer. The difference was statistically significant (P < 0.001). No complication of injection therapy was noted. It is concluded that injection therapy using absolute alcohol is a safe and effective therapy for managing patients with bleeding peptic ulcer.

Histopathologic features of duodenal and jejunal mucosal biopsy specimens obtained from 58 patients with portal hypertension and 30 healthy volunteers were studied. Dilated mucosal vessels with thickened walls were seen in duodenal and jejunal biopsy specimens from 39 (67%) and 41 (71%) of the patients, respectively, compared with corresponding biopsy specimens from 8 (27%) and 6 (2%) of the control subjects. The difference between the two groups was statistically significant. Other important histologic features in the patient group included edema of the lamina propria, fibromuscular proliferation, a decreased villous/crypt ratio, and thickened muscularis mucosae. The mean +/- SD thickness of capillary wall and diameter were significantly more in the patient group compared with those in the control subjects. We conclude that thick-walled dilated vessels along with edema of the lamina propria, fibromuscular proliferation, a decreased villous/crypt ratio, and thickened muscularis mucosae form a characteristic picture of portal hypertensive enteropathy. These changes seem to be a part of the changes seen in the gastrointestinal tract of patients with portal hypertension without any meaningful clinical implication except the increased chance of occult gastrointestinal blood loss.