Publications by authors named "Kartar Singh"

178 Publications

Gastric secretion in patients with caustic ingestion: A prospective study.

Indian J Gastroenterol 2021 02 8;40(1):50-55. Epub 2021 Jan 8.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Background: Caustic ingestion can lead to structural changes in the upper gastrointestinal tract. However, there are limited data on the effect of caustic ingestion on gastric secretion. This study was planned to determine the changes in gastric acid output in patients with caustic ingestion.

Methods: It was a prospective study done at a tertiary care center in northern India. Twenty consecutive patients in chronic phase of caustic ingestion were evaluated for the study. The gastric secretory function was estimated in the basal state and following pentagastrin stimulation. These results were compared with normal values for our laboratory.

Results: The mean age of the included patients (n = 20) was 27.35 ± 2.96 years and 14 patients were male. Sixteen (80%) patients had a history of acid ingestion. Patients with caustic ingestion had significantly lower mean gastric acid secretion (0.8 ± 0.4 mEq/h vs. 4 ± 0.4 mEq/h; p < 0.001) compared to controls. After pentagastrin stimulation, the mean gastric juice volume (31.8 ± 6 mL/h vs. 62.3 ± 11.7 mL/h; p < 0.01) and acidity (15.3 ± 5.1 mEq/L vs. 39.6 ± 9.3 mEq/L; p < 0.001) increased in patients with caustic ingestion, but were lower than those in control subjects. Patients with a lower esophageal stricture (n = 6) had decreased maximum acid output (0.62 ± 0.32 mEq/h vs. 6.05 ± 0.55 mEq/h; p < 0.05) compared to patients with stricture in the upper or middle esophagus.

Conclusion: Caustic ingestion is associated with reduced gastric juice volume and acid output. Patients with stricture in the lower one third of the esophagus are at a higher risk of hypochlorhydria compared to patients with stricture in either the upper or middle esophagus.
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http://dx.doi.org/10.1007/s12664-020-01116-wDOI Listing
February 2021

Utility of narrow band imaging in predicting histology in celiac disease.

Indian J Gastroenterol 2020 08 23;39(4):370-376. Epub 2020 Jul 23.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Background: Narrow band imaging (NBI) with magnification better visualizes the duodenal microsurface and mucosal vascularity. NBI delineates villous atrophy better than conventional white light endoscopy.

Aims: This study was conducted to evaluate the diagnostic accuracy of narrow band imaging with magnification (NBI-ME) in celiac disease (CD).

Methods: In this prospective study, consecutive patients of suspected CD and controls were subjected to tissue transglutaminase antibody test and endoscopic evaluation initially with white light followed by NBI-ME, and biopsies were taken from duodenum. Duodenal villous patterns on NBI were interpreted as normal, blunted distorted, and absent. Severity of villous atrophy was reported according to the modified Marsh criteria.

Results: One hundred and twenty-two patients (mean age of 27.53 ± 13.37 years and a male to female ratio of 1:1.26) and 40 controls were studied. The sensitivity and specificity of NBI-ME in predicting villous atrophy were found to be 95.54% and 90%, respectively. The specificity and negative predictive value of NBI-ME in predicting villous atrophy amongst controls was 100% and 97.5%, respectively. Abnormal findings (blunted and absent villous patterns) combined with elevated transglutaminase antibody (> 5-fold) were found to have high accuracy in predicting villous atrophy.

Conclusion: NBI with magnification has high sensitivity and specificity in predicting villous atrophy in patients with celiac disease.
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http://dx.doi.org/10.1007/s12664-020-01030-1DOI Listing
August 2020

First Draft Genome Sequence of Wheat Spot Blotch Pathogen BS_112 from India, Obtained Using Hybrid Assembly.

Microbiol Resour Announc 2019 Sep 19;8(38). Epub 2019 Sep 19.

ICAR-National Research Centre on Plant Biotechnology, New Delhi, India.

is a devastating fungal pathogen causing spot blotch of wheat. We report here the first draft genome of strain BS_112 from India using sequence reads from the Ion Torrent, Illumina HiSeq, and Nanopore platforms. The genome size was estimated at 35.64 Mb with an average G+C content of 50.20%.
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http://dx.doi.org/10.1128/MRA.00308-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753261PMC
September 2019

Patterns of alcohol consumption and nutrition intake in patients with alcoholic liver disease and alcoholic pancreatitis in North Indian men.

JGH Open 2019 Aug 12;3(4):316-321. Epub 2019 Mar 12.

Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India.

Background And Aim: Chronic alcoholism and nutrition play an important role in liver and pancreatic diseases. To compare drinking habits and nutritional data in patients with alcoholic liver disease (ALD) and alcoholic pancreatitis (ALP).

Methods: Clinical, anthropometric, dietary intake, laboratory, and imaging data were recorded in consecutive patients of ALD and ALP.

Results: In 150 patients of ALP ( = 76) and ALD ( = 74), the age of starting alcohol consumption (19.03 ± 3.78 18.0 ± 2.59 years) and the mean amount of alcohol consumed per day (165.63 ± 87.99 185.50 ± 113.54 g;  = 0.230) were similar. Patients with ALD consumed alcohol on a daily basis more frequently (90.5 72.3%;  = 0.003) and had a longer duration of alcohol intake (21.6 + 0.2 14.5 + 6.9 years;  < 0.0001) than patients in the ALP group. Binge drinking was more common in patients with ALP compared to patients with ALD (60.5 20.3%);  < 0.0001). Patients with ALP had a lower body mass index (19.9 ± 3.49 22.64 ± 4.88 kg/m;  = 0.001) and more frequent decrease in mid arm circumference (57.9 44.6%;  = 0.042) and triceps skin fold thickness (67.1 52.7%;  = 0.072) compared to patients with ALD.

Conclusion: There was no difference in the age of starting alcohol consumption and mean amount of alcohol consumption per day between the groups. Patients with ALD were more likely to be daily drinkers with a longer duration of alcohol intake. However, binge drinking and malnourishment was more common in the ALP group.
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http://dx.doi.org/10.1002/jgh3.12165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684506PMC
August 2019

Vitamin D deficiency in adult patients with ulcerative colitis: Prevalence and relationship with disease severity, extent, and duration.

Indian J Gastroenterol 2019 Feb 13;38(1):6-14. Epub 2019 Mar 13.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.

Background: Vitamin D plays a key role in gut immunity and maintenance of the mucosal barrier. Vitamin D deficiency (VDD) worsens ulcerative colitis (UC) and its supplementation ameliorates the disease in mouse models. The prevalence and predictors of VDD in UC are not known.

Methods: Consecutive patients with UC (n = 80) underwent clinical, endoscopic, and histological evaluation to assess the extent, severity using UC disease activity index (UCDAI) score, and duration of illness. An equal number of age and gender-matched healthy adults without any features of inflammatory bowel disease (IBD) living in the same latitude were identified as controls. The serum 25-hydroxy vitamin D level was estimated. The subjects were classified as deficient (< 20 ng/mL), insufficient (20-32 ng/mL), sufficient (32-80 ng/mL), and optimal (> 80 ng/mL) based on vitamin D levels. Chi-square test and Mann-Whitney U test were done to identify factors associated with vitamin D deficiency.

Results: The patients and controls were similar in age and gender (40 ± 11.4 years, 51% male vs. 40 ± 12 years, 51% male; p = 1.000). Median vitamin D levels among patients were lower than the controls (18.1 ng/mL [IQR 14] vs. 32.5 ng/mL [IQR 36]; p < 0.001). Patients were more often VDD (56% vs. 40%) or insufficient (34% vs. 9%) and less often sufficient (9% vs. 40%) or optimal (1% vs. 11%), in contrast to controls (p < 0.001). Median vitamin D levels were lower in those with UCDAI > 6 (15 vs. 21 ng/mL; p = 0.01), having pancolitis (13 vs. 21 ng/mL, p = 0.01), and longer duration of illness > 2 years (13.8 vs. 20.8; p = 0.025). Vitamin D levels showed a negative correlation with frequency of stools (rho = - 0.244, p = 0.05), disease duration (rho = - 0.244, p = 0.007) and UCDAI score (r = - 0.348, p = 0.002).

Conclusion: VDD is highly prevalent among patients with UC. Patients with longer disease duration, more severe symptoms, and pancolitis are likely to have lower vitamin D levels.
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http://dx.doi.org/10.1007/s12664-019-00932-zDOI Listing
February 2019

Glutathione-redox status on hydro alcoholic root bark extract of Premna integrifolia Linn in high fat diet induced atherosclerosis model.

J Ayurveda Integr Med 2020 Oct-Dec;11(4):376-382. Epub 2019 Feb 6.

Ayurveda, Central Council for Research in Ayurvedic Sciences, M/o AYUSH, Govt. of India, New Delhi, 110058, India.

Background: Premna integrifolia Linn. is a medicinal plant of an Ayurvedic importance and proved to have an anti-inflammatory, anti-diabetic, anti-microbial and hypo-lipidemic activity. Glutathione (GSH) redox status is an important parameter to assess the antioxidant activity of any neutraceuticals.

Objective: In order to assess the anti-oxidant potential of hydro alcoholic extract (HAE) of P. integrifolia, this study was aimed to evaluate the GSH redox status in high fat diet induced experimental atherosclerosis.

Materials And Methods: The present study comprises sixty Wistar rats and they were divided into six groups: the first group served as control, the second group was fed with high fat diet and the third, fourth and fifth groups were fed with high fat diet along with various concentrations of HAE of 200, 400 and 500 g/kg.b.wt respectively and the sixth group was administered high fat diet along with 10 mg/kg b.wt of atorvastatin for 30 days. GSH-dependent enzymes like GSH-peroxidase (GPx), GSH-reductase (GR) and glucose 6-phosphate dehydrogenase (G6PD) were estimated in hemolysate, kidney, heart and liver of experimental rats.

Results: Analysis of GSH levels showed a significant decrease in hemolysate, heart and kidney (p < 0.05) and liver (p < 0.01) in high fat-fed rats when compared to control. Activities of GPx, GR and G6PD in hemolysate and heart (p < 0.001), liver and kidney (p < 0.05) in high fat-fed rats when compared to control. Dose-dependent increase was observed in rats treated with various concentrations of HAE.

Conclusion: The HAE of root bark of P. integrifolia is proved to have a protective role on antioxidant defense in high fat diet induced atherosclerosis model. As a whole P. integrifolia increases the GSH content in a dose-dependent manner and in turn altered the redox cycle.
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http://dx.doi.org/10.1016/j.jaim.2018.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772499PMC
February 2019

Rapid detection of Puccinia triticina causing leaf rust of wheat by PCR and loop mediated isothermal amplification.

PLoS One 2018 26;13(4):e0196409. Epub 2018 Apr 26.

Fungal Molecular Biology Laboratory, Division of Plant Pathology, ICAR-Indian Agricultural Research Institute, New Delhi, India.

Leaf rust of wheat caused by Puccinia triticina has significant impact on wheat production worldwide. Effective and quick detection methodologies are required to mitigate yield loss and time constraints associated with monitoring and management of leaf rust of wheat. In the present study, detection of P. triticina has been simplified by developing a rapid, reliable, efficient and visual colorimetric method i.e., loop mediated isothermal amplification of DNA (LAMP). Based on in silico analysis of P. triticina genome, PTS68, a simple sequence repeat was found highly specific to leaf rust fungus. A marker (PtRA68) was developed and its specificity was validated through PCR technique which gave a unique and sharp band of 919 bp in P. triticina pathotypes only. A novel gene amplification method LAMP which enables visual detection of pathogen by naked eye was developed for leaf rust pathogen. A set of six primers was designed from specific region of P. triticina and conditions were optimised to complete the observation process in 60 minutes at 65o C. The assay developed in the study could detect presence of P. triticina on wheat at 24 hpi (pre-symptomatic stage) which was much earlier than PCR without requiring thermal cycler. Sensitivity of LAMP assay developed in the study was 100 fg which was more sensitive than conventional PCR (50 pg) and equivalent to qPCR (100 fg). The protocol developed in the study was utilized for detection of leaf rust infected samples collected from different wheat fields. LAMP based colorimetric detection assay showed sky blue color in positive reaction and violet color in negative reaction after addition of 120 μM hydroxyl napthol blue (HNB) solution to reaction mixture. Similarly, 0.6 mg Ethidium bromide/ml was added to LAMP products, placed on transilluminator to witness full brightness in positive reaction and no such brightness could be seen in negative reaction mixture. Further, LAMP products spread in a ladder like banding pattern in gel electrophoresis. Our assay is significantly faster than the conventional methods used in the identification of P. triticina. The assay developed in the study shall be very much useful in the development of diagnostic kit for monitoring disease, creation of prediction model and efficient management of disease.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196409PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5919678PMC
August 2018

Anti-atherosclerotic activity of root bark of Linn. in high fat diet induced atherosclerosis model rats.

J Pharm Anal 2017 Apr 30;7(2):123-128. Epub 2016 Dec 30.

Ayurveda, Captain Srinivasa Murthy Regional Ayurveda Drug Development Institute, Central Council for Research in Ayurvedic Sciences, M/o AYUSH, Govt. of India, A.A. Hospital Campus, Arumbakkam, Chennai 600106, India.

Linn. is a medicinal plant used in "Dhasamula" drug preparation of Ayurvedic systems of medicine in the treatment of various ailments like bronchitis, dyspepsia, liver disorders, piles, constipation, hyperlipidemia and fever. The anti-atherosclerotic activity of hydroalcoholic extract (HAE) of root bark of was evaluated in high fat diet induced atherosclerosis rats. Sixty Wistar rats were divided into six groups: the first group served as control, the second group was fed with high fat diet and the other three groups were fed with high fat diet along with various concentrations of HAE and the last group was treated with atorvastatin for 30 days. Lipid and lipoprotein profile, atherogenic index, and cardiac markers and histopathological evaluation of aorta were determined in high fat diet induced atherosclerosis rats. HAE of produced a significant and dose-dependent anti-atherosclerotic activity in terms of reduction in lipids and lipoprotein profile, atherogenic index, HMG-CoA reductase activity, marker enzymes such as lactate dehydrogenase (LDH), creatine phosphokinase (CPK), aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP), alteration in collagen and calcium contents, mild mineralization and focal rupture of intima and media of aorta was noticed in treated groups as compared to the control. The results suggested that anti-atherosclerotic activity of HAE of Linn. was due to its modulatory activity on metabolic pathway of lipid. The results contribute to the validation of the traditional use of Agnimantha in high fat diet induced atherosclerosis rats.
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http://dx.doi.org/10.1016/j.jpha.2016.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686870PMC
April 2017

Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of 10 cases.

Endosc Ultrasound 2014 Jan;3(1):54-7

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Background: Duodenal varices (DV) although an uncommon cause, are an important cause due to the severe nature of the bleed and associated adverse outcome.

Materials And Methods: We retrospectively evaluated patients with DV seen at our institution over past 4 years.

Results: A total of 10 patients (nine males; mean age was 35.8 ± 7.68 years) with DV were studied. Five patients had underlying cirrhosis and five had DV because of non-cirrhotic portal hypertension (four patients had extra-hepatic portal venous obstruction and one patient had non-cirrhotic portal fibrosis). Five patients presented with upper gastrointestinal (GI) bleed, whereas in the remaining five patients DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient an initial endoscopic diagnosis of Dieulafoy's lesion was made. However endoscopic ultrasound (EUS) could clearly identify DV in all patients. Of five patients presenting with upper GI bleed, three had the esophageal varices eradicated and two presented 1(st) time with bleed form DV and did not have esophagogastric varices. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients and there has been no recurrence of bleed in these four patients over a follow-up period of 4-46 months. The five non-bleeding DV were already on beta- blockers and the same were continued. Two of these five patients succumbed to progressive liver failure with none of these five patients having GI bleed on follow-up.

Conclusion: EUS is a useful investigational modality for evaluating patients with DV and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.
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http://dx.doi.org/10.4103/2303-9027.121243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063264PMC
January 2014

Portal hypertensive biliopathy developing after acute severe pancreatitis.

Endosc Ultrasound 2013 Oct;2(4):228-9

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.4103/2303-9027.121244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062273PMC
October 2013

Esophageal duplication cyst in an adult masquerading as submucosal tumor.

Endosc Ultrasound 2013 Jul;2(3):165-7

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Gastrointestinal duplications usually manifest in children and may involve the esophagus in 20% cases. Esophageal duplication cysts are a rare cause of dysphagia in adults. We report the case of a 35-year-old male who presented to us with progressive dysphagia of 6 months duration. Contrast enhanced computed tomography showed a soft-tissue lesion in right lateral wall of distal thoracic esophagus. On endoscopic ultrasound, a heterogeneously echotextured lesion with anechoic component present at intramural location in the lower esophagus was noted. The patient underwent surgical excision of the lesion and histopathology confirmed the diagnosis of esophageal duplication cyst.
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http://dx.doi.org/10.7178/eus.06.0011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062263PMC
July 2013

Endoscopic ultrasound assisted etiological localization in acute pancreatitis.

Endosc Ultrasound 2013 Jul;2(3):162-4

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Hyperparathyroidism is an uncommon cause of pancreatitis and one should look for its telltale evidence on history (renal stone disease) and investigations (hypercalcemia). Endosonography has an upcoming role in the management of acute pancreatitis, especially in the presence of fluid collection. We report a case of parathyroid adenoma related acute pancreatitis complicated with pseudocyst, which was managed with percutaneous drainage and endosonographic localization of the adenoma to the left parathyroid gland. This patient underwent sestamibi scanning, which confirmed its presence and underwent surgical excision of the adenoma. Endosonography should be included in the work up of patients with unclear etiology and thyroids should be routinely scanned for parathyroid adenomas. One should always look outside the box to get clues for diseases inside the box.
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http://dx.doi.org/10.7178/eus.06.0010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062260PMC
July 2013

Hypotension in the first week of acute pancreatitis and APACHE II score predict development of infected pancreatic necrosis.

Dig Dis Sci 2015 Feb 13;60(2):537-42. Epub 2014 Mar 13.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

Background: Hypotension and intestinal mucosal ischemia lead to bacterial translocation from the gut lumen into systemic circulation.

Aim: The purpose of this study was to determine the strength of association between different types of organ failure (OF): hypotension (cardiovascular system failure), renal failure, respiratory failure, CNS failure and coagulopathy in the first week of acute pancreatitis (AP) and the subsequent development of infected pancreatic necrosis (IN).

Methods: Consecutive patients with AP were evaluated for OF and its severity in the first week of hospital admission. Modified multiple organ failure score (MOFS) was used to identify and grade severity of OF. MOFS of ≥2, lasting for more than 48 h was defined as OF. Occurrence of IN (isolation of bacteria in necrosectomy specimen or image guided fine needle aspiration of pancreatic necrosis) was compared between groups with and without OF.

Results: Of the 81 patients, mean age was 40.1 ± 14.4 years and 55 were males; 60 (74 %) patients had OF and 13 (16 %) patients had IN. Occurrence of IN was not significantly different between patients with OF (18.3 %) and without OF (14.3 %), p = 0.48. However IN occurred in 10 % of patients without and 33.7 % patients with hypotension, p = 0.01. The rest of the organ systems analyzed did not show any significant difference in occurrence of infected necrosis. On multivariate analysis independent predictors of occurrence of IN were hypotension (odds ratio, OR 2.5, p < 0.001) and APACHE II score at 24 h of hospital admission (OR 4.77, p < 0.001).

Conclusion: Hypotension in the first week of AP and APACHE II score predict development of IN.
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http://dx.doi.org/10.1007/s10620-014-3081-yDOI Listing
February 2015

Pancreatic trauma: a concise review.

World J Gastroenterol 2013 Dec;19(47):9003-11

Uma Debi, Division of GE Radiology, Department of Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities, and these injuries are often overlooked in cases with extensive multiorgan trauma. The most evident findings of pancreatic injury are post-traumatic pancreatitis with blood, edema, and soft tissue infiltration of the anterior pararenal space. The alterations of post-traumatic pancreatitis may not be visualized within several hours following trauma as they are time dependent. Delayed diagnoses of traumatic pancreatic injuries are associated with high morbidity and mortality. Imaging plays an important role in diagnosis of pancreatic injuries because early recognition of the disruption of the main pancreatic duct is important. We reviewed our experience with the use of various imaging modalities for diagnosis of blunt pancreatic trauma.
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http://dx.doi.org/10.3748/wjg.v19.i47.9003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3870553PMC
December 2013

Implementation of the Asia-Pacific guidelines of obesity classification on the APACHE-O scoring system and its role in the prediction of outcomes of acute pancreatitis: a study from India.

Dig Dis Sci 2014 Jun 28;59(6):1316-21. Epub 2013 Dec 28.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Aims: We studied the role of obesity and the Acute Physiology and Chronic Health Evaluation (APACHE) O score in predicting the outcome in patients with acute pancreatitis (AP) using the Asia-Pacific obesity classification.

Methods: Two hundred eighty AP patients were classified into three different groups, normal weight [body mass index (BMI) = 18.5-22.9 kg/m(2)], overweight (BMI = 23-24.9 kg/m(2)) and obese (BMI > 25 kg/m(2)), according to the Asia-Pacific obesity classification. For all patients APACHE II scores and modified APACHE O (i.e., APACHE Oap) scores that included a factor for obesity were calculated. The patients were managed using a standard protocol, and the outcome measures were compared for different obesity groups.

Results: Of the 280 patients (mean age 40.7 years), 46.8% were normal weight, 29.6% overweight and 23.6% obese. Forty-six (16.4%) patients underwent surgery, and 61 (21.8%) patients died. Patients with higher BMI had worse radiological indices of severity, more infected necrosis (p < 0.001), more persistent organ failure (p < 0.001) and higher requirement for percutaneous drain insertion (p = 0.04), surgery (p = 0.008) and mortality (p < 0.001). The area under the curve for predicting mortality was 0.879 for APACHE II and 0.886 for APACHE Oap; at a cutoff of 8.5, the APACHE II score had a sensitivity of 88.2% and specificity of 68.7%, and APACHE Oap 90.2 and 64.0%, respectively.

Conclusions: BMI ≥ 23 kg/m(2) was an important predictor of a severe disease course and fatal outcome in patients with AP. However, the predictive accuracy of APACHE Oap for mortality was similar to APACHE II.
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http://dx.doi.org/10.1007/s10620-013-3000-7DOI Listing
June 2014

Dynamic nature of organ failure in severe acute pancreatitis: the impact of persistent and deteriorating organ failure.

HPB (Oxford) 2013 Jul 5;15(7):523-8. Epub 2012 Dec 5.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background And Aims: In acute pancreatitis (AP), patients with persistent organ failure [POF, duration of organ failure (OF) ≥48 h] and transient organ failure (TOF, duration of OF <48 h) have different outcomes. We have compared the clinical course and outcome of patients with severe AP (SAP) with TOF and POF in the first week of hospitalization as well as the impact of change in the OF score in the first week on patient outcome.

Methods: Consecutive patients with SAP were evaluated for OF and its dynamics during the first week of hospitalization. The modified multiple organ failure score (MOFS) was used to identify OF, grade its severity and monitor its progression. The clinical course and outcome of patients were studied.

Results: Of 114 patients, mean age 39.2 ± 13.7 years, 37 (32.5%) patients had no OF, 34 (29.8%) had TOF and 43(37.7%) had POF. Patients with POF had the higher infected necrosis, increased requirement for percutaneous drain placement, surgery and higher mortality as compared with those with TOF. The odds ratio for mortality with persistent and deteriorating OF was 26.2 [confidence interval (CI) 5.1-134.9] compared with only persistent OF.

Conclusion: The dynamics of OF in the first week of SAP predicts the clinical course and outcome. Persistent and deteriorating OF indicates a poor outcome.
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http://dx.doi.org/10.1111/j.1477-2574.2012.00613.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3692022PMC
July 2013

Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm.

Pancreatology 2013 May-Jun;13(3):250-3. Epub 2013 Mar 14.

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Background: Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment.

Aim: To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts.

Methods: Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21-38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts.

Results: All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients.

Conclusions: Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.
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http://dx.doi.org/10.1016/j.pan.2013.02.011DOI Listing
January 2014

Tuberculosis presenting as Dysphagia: clinical, endoscopic, radiological and endosonographic features.

Endosc Ultrasound 2013 Apr;2(2):92-5

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.

Objective: Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years.

Methods: We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years.

Results: Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol-ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients.

Conclusion: Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.
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http://dx.doi.org/10.4103/2303-9027.117693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062249PMC
April 2013

Prospective validation of 4-category classification of acute pancreatitis severity.

Pancreas 2013 Apr;42(3):392-6

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objective: Atlanta classification divides patients with acute pancreatitis (AP) into mild and severe disease. A 4-category severity classification has been proposed based on the presence or absence of local and systemic determinants, giving rise to mild, moderate, severe, or critical AP. The aim of this study was to validate this new 4-category system of severity classification by examining markers of severity and outcome.

Methods: Data from 151 consecutive patients with AP from January 2009 to December 2010 [mean age (SD), 41.1 (3.5) years; 101 men] were collected. Management was standardized. Patients were classified as mild [no necrosis or organ failure (OF)], moderate (sterile necrosis or transient OF), severe [infected necrosis (IN) or persistent OF], or critical (IN and persistent OF) AP. Data were compared between groups for severity and outcome.

Results: There were 21 (13.9%) patients with mild, 63 (41.7%) moderate, 59 (39.1%) severe, and 8 (5.3%) critical AP. There was a significant difference between these categories for length of hospital stay, computed tomographic severity index scores, occurrence of bloodstream infections, incidence of IN, requirements for percutaneous catheter drain, numbers of operations, and mortality.

Conclusions: This prospective case series clinically validated the 4-category classification of AP severity.
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http://dx.doi.org/10.1097/MPA.0b013e3182730d19DOI Listing
April 2013

Implications of culture positivity in acute pancreatitis: does the source matter?

J Gastroenterol Hepatol 2013 May;28(5):887-92

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background And Aims: Sepsis is an important complication and cause of morbidity and mortality in acute pancreatitis (AP). The source of sepsis may be infected pancreatic and peripancreatic collections and/or necrosis or extrapancreatic including infections in the bloodstream or respiratory and urinary tracts. We studied the implications of the source of sepsis on various outcome parameters in AP like persistent organ failure (POF), length of hospital (LOH) stay, and mortality.

Methods: A retrospective analysis of culture reports of AP patients was done, and the outcome parameters were recorded.

Results: Three hundred fifty-seven patients (229 M; age: 40.3 ± 14.04 years) of AP who had detailed culture reports were included. Eighty-four (23.5%) patients had pancreatic (or peripancreatic) source (group 1), 52 (14.6%) patients had other (extrapancreatic) sources (group 2), 20 (5.6%) patients were noted to have positive cultures from sources, which were both pancreatic and extrapancreatic (combined) sources (group 3), while 201 patients had sterile cultures. POF was seen in 147 (48%) patients (group 1: 67.8%; group 2: 65%; group 3: 90%; group 4: 34% [P < 0.001]). The mean LOH stay was 22.1 ± 20.26 days (group 1: 30.2 ± 20.64 days; group 2: 26.4 ± 26.82 days; group 3: 47.3 ± 32.60 days; group 4: 15.2 ± 11.34 days [P < 0.001]). Seventy (19.7%) patients succumbed to their illness (group 1 [22.9%]; group 2 [36.5%]; group 3 [40%]; group 4 [12%] [P < 0.001]).

Conclusions: POF and LOH stay were more common in patients with combined pancreatic and extrapancreatic sources of sepsis. Mortality was significantly higher in patients with sepsis (groups 1, 2, 3) compared with sterile groups.
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http://dx.doi.org/10.1111/jgh.12161DOI Listing
May 2013

Clinical presentation and outcome of endoscopic therapy in patients with symptomatic chronic pancreatitis associated with pancreas divisum.

JOP 2013 Jan 10;14(1):50-6. Epub 2013 Jan 10.

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Context: The results of endoscopic drainage in pancreas divisum with chronic pancreatitis have been debatable.

Objective: To evaluate clinical presentation and long term results of endoscopic therapy in patients of calcific and non-calcific chronic pancreatitis with pancreas divisum.

Patients And Methods: Between 1996 and 2011, 48 patients (32 males and 16 females) with chronic pancreatitis and pancreas divisum were treated endoscopically. Patients were considered to have clinical success if they had resolution of symptoms and did not require surgery.

Results: All patients presented with abdominal pain and symptoms were present for 36.6 ± 40.5 months. Pseudocyst, diabetes, pancreatic ascites, pancreatic pleural effusion, segmental portal hypertension and steatorrhea were seen in 13 (27.1%), 6 (12.5%), 3 (6.3%), 2 (4.2%), 2 (4.2%) and 1 (2.1%) patients, respectively. Ductal calculi and strictures were noted in 3 (6.3%) and 2 (4.2%) patients, respectively. In 47 patients, an endoprosthesis (5 or 7 Fr) was successfully placed in the dorsal duct. Following pancreatic endotherapy, 45/47 (95.7%) patients had successful outcome. The mean number of stenting sessions required to have clinical success was 2.6 ± 0.9. One patient each had mild post ERCP pancreatitis, inward migration of stent and precipitation of diabetic ketoacidosis. Over a follow up of 2-174 months (median: 67 months), 12 out of 31 patients with pain only and no local complications (38.7%) required restenting for recurrence of pain and none of these patients required surgery.

Conclusion: Intensive pancreatic endotherapy is safe and effective both in patients with chronic calcific, as well as non-calcific, pancreatitis associated with pancreas divisum. It gives good long term response in patients having abdominal pain and/or dorsal ductal disruptions.
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http://dx.doi.org/10.6092/1590-8577/1218DOI Listing
January 2013

Non-fluoroscopic endoscopic ultrasound-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis.

Dig Endosc 2013 Jan 26;25(1):47-52. Epub 2012 Apr 26.

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background And Aim: Endoscopic treatment of pancreatic necrosis is less invasive than surgery but is a technically demanding procedure. The aim of the present study was to retrospectively evaluate the safety and efficacy of endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis (WOPN) without the use of fluoroscopy.

Methods: Over the last 24 months, 20 patients (16 men) with symptomatic non-bulging WOPN were treated endoscopically at Department of Gastroenterology, PGIMER, Chandigarh, India.The WOPN was transmurally approached using a linear echoendoscope and the tract dilated over the wire and multiple stents and a nasocystic drain were placed.

Results: All 20 patients had acute severe pancreatitis and the etiology of pancreatitis was alcohol in 12, gallstones in six and idiopathic in two patients. All patients were symptomatic with pain and six patients had fever and presented 5 to 16 weeks after an acute episode.The size of WOPN ranged from 5 to 16 cm.All 20 patients had marked improvement with radiological resolution noted in 19 patients and only one patient required direct endoscopic necrosectomy. One patient with multiple WOPN had a large peripherally located WOPN that did not resolve after transmural drainage and required an additional percutaneous drainage. One to seven endoscopic sessions were required and all these patients had complete resolution within 6 weeks.There were no complications of the procedure.There has been no recurrence of symptoms in these patients over a median follow up of 14 months.

Conclusion: EUS-guided transmural drainage of non-bulging WOPN without the use of fluoroscopy appears to be safe and effective.
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http://dx.doi.org/10.1111/j.1443-1661.2012.01318.xDOI Listing
January 2013

Role of endoscopic ultrasound in the diagnosis of pancreas divisum.

Endosc Ultrasound 2013 Jan;2(1):7-10

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.

Objective: The published data on the accuracy of the detection of pancreas divisum by endoscopic ultrasound (EUS) is limited. In this study, we evaluate the accuracy of detection of pancreas divisum by radial EUS in patients with chronic pancreatitis.

Methods: We retrospectively evaluated patients with chronic pancreatitis who underwent EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) in the last four years to identify patients with complete pancreas divisum.

Results: One hundred and forty six patients with chronic pancreatitis underwent EUS examination and 20 patients (13.6%) had pancreas divisum. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of absence of stack sign on EUS for the diagnosis of pancreas divisum were 50%, 97%, 73%, 93% and 91%, respectively and for the inability to trace pancreatic duct from the head to the body were 100%, 96%, 80%, 100% and 96%, respectively.

Conclusion: EUS can diagnose pancreas divisum in a majority of patients. Pancreas divisum can be reliably excluded if pancreatic duct could be tracked backwards from the head to the body around the genu.
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http://dx.doi.org/10.7178/eus.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062234PMC
January 2013

Role of endoscopic ultrasound in evaluation of unexplained common bile duct dilatation on magnetic resonance cholangiopancreatography.

Ann Gastroenterol 2013 ;26(1):66-70

Department of Gastroenterology (Surinder Singh Rana, Deepak Kumar Bhasin, Vishal Sharma, Chalapathi Rao, Kartar Singh.

Background: Dilated common bile duct (CBD) without obvious cause is a not uncommon finding on magnetic resonance cholangiopancreatography (MRCP). The aim of this study was to evaluate the diagnostic performance of endoscopic ultrasound (EUS) in patients with unexplained dilated CBD on MRCP.

Methods: Patients referred for EUS evaluation of a dilated CBD were retrospectively analyzed with respect to serum alkaline phosphatase prior to EUS and subsequent outcome after EUS.

Results: Over a 3-year period, 40 patients (24 males; mean age 38.9±9.9 years) with dilated CBD were retrospectively identified. Ten patients had elevated serum alkaline phosphatase. The diagnosis reached after EUS examination was: CBD stones in 15 (37.5%) with largest size of CBD stone being 9 mm, mass in CBD in 2 (5%), benign biliary stricture in 2 (5%), biliary stricture with underlying chronic pancreatitis in 1 (2.5%) patient respectively. EUS examination revealed normal CBD in 20 (50%) patients and two of these patients had periampullary diverticulum. All the patients with abnormal liver function tests had a detectable CBD pathology whereas 20/30 (66.6%) patients with normal liver biochemistry had normal EUS findings. There was no significant difference in the mean CBD diameter between the groups with demonstrable pathology compared with those without (P=0.64).

Conclusion: EUS is a useful investigational modality for patients with unexplained dilated CBD on MRCP. The mean CBD diameter and the presence of normal liver function tests are not predictive of underlying pathology.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959517PMC
January 2013

Tubercular Crohn's ileal strictures: role of endoscopic balloon dilatation without fluoroscopy.

Ann Gastroenterol 2013 ;26(2):141-145

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background: Benign ileal strictures can cause considerable morbidity and they have been conventionally treated with surgery. The aim of this study was to report our experience of endoscopic balloon dilatation (EBD) in patients with terminal ileal strictures because of Crohn's disease and tuberculosis.

Methods: Over the last 8 years, 9 patients (6 males; mean age 39.7±13.2 years) with benign terminal ileal strictures were treated by EBD using a colonoscope and through-the-scope controlled radial expansion balloon dilators.

Results: The etiology of benign ileal stricture was Crohn's disease in 5 and tuberculosis in 4 patients. All the patients with Crohn's disease had no or partial response to 4 weeks of steroid therapy and there were no mucosal ulcerations on ileoscopy. Three patients with ileal strictures due to tuberculosis underwent dilatation after completion of the antitubercular therapy (ATT) while one patient required dilatation 3 months after starting ATT. All patients had single ileal stricture with length of stricture ranging from 0.6-1.8 cm. EBD was successful in all 9 patients with a median number of dilating sessions required of 2 (range: 1-5 sessions). Patients with Crohn's disease required more endoscopic sessions as compared to patients with tuberculosis but this difference was not statistically significant (mean number of session being 3.0±1.58 vs. 1.75±0.5 sessions respectively; P=0.1). One patient with ileal tuberculosis had enterolith proximal to the stricture that could be removed with dormia. There were no complications of the endoscopic procedure.

Conclusions: EBD is an effective, safe, and minimally invasive treatment modality for benign ileal strictures.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959941PMC
January 2013

Gastric outlet obstruction caused by duodenal intramural pseudocyst.

Ann Gastroenterol 2013 ;26(1):71

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), India.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959512PMC
January 2013

Achalasia cardia associated with esophageal varices: a therapeutic dilemma.

Ann Gastroenterol 2013 ;26(3):258-260

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research -PGIMER (Surinder Singh Rana, Deepak Kumar Bhasin, Chalapathi Rao, Kartar Singh), Chandigarh, India.

A 63-year-old male, chronic alcohol consumer, presented with progressively increasing dysphagia of 6 months duration. Upper gastrointestinal endoscopy revealed dilated esophagus with residue along with esophageal varices. Esophageal manometry revealed findings suggestive of classic achalasia cardia. Endoscopic ultrasound (EUS) examination revealed peri-esophageal collaterals as well as prominent perforators at lower end of esophagus. The co-existence of varices with achalasia is very rare and this case posed a difficult therapeutic dilemma as risk of bleeding from the varices limited the treatment options available. This case was successfully treated with EUS-guided botulinum toxin injection.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959450PMC
January 2013
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