Indian Journal of Gastroenterology最新文献

Background and aims: Dyssynergic defecation (DD) is a disorder of anorectal function characterized by impaired relaxation or inappropriate contraction of pelvic floor muscles on attempted defecation. Based on previous Indian studies, we devised a symptom score (bleeding per rectum, excessive straining for stools, digitation, sense of incomplete evacuation/blockage-BEDS) and tried to determine if it can identify which patients with chronic constipation are more likely to have DD.

Methods: This is a prospective observational cohort study in which consecutive adult patients (> 18 years) with chronic constipation who were referred to our centre for anorectal manometry (ARM) between 2019 and 2023 were included. Prior to tests, patients were asked in detail regarding their symptoms and scoring was done. ARM was done by a single observer. Diagnosis of DD was based on standard criteria. Statistical tests used were median, range and percentages, Chi-square test and Mann-Whitney U-test. The data was analyzed for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Agreement of symptom-based scoring and DD diagnosis as per criteria was calculated using Cohen's κ coefficient. A p value of < 0.05 was considered statistically significant.

Results: As many as 244 patients (males 140, median age 42 years) formed the study cohort. Of these, 104 (42.6%) have DD. Sense of incomplete evacuation/sense of blockage (72.1% vs. 40%, p < 0.0001), excessive straining (73.1% vs. 22.1%, p < 0.0001) and digitation (28.8% vs. 13.5%, p 0.003) were more commonly reported in patients with DD. Taking a cut-off score of > / = 2, sensitivity of 69.2%, specificity 81.4% and positive likelihood ratio of 3.73 were noted. Similarly, if the score of > / = 3 was considered, the likelihood ratio increased to 4.71 with an increase in specificity (94.29%) and fall in sensitivity (26.92%).

Conclusion: Symptom-based BEDS score of > / = 2 is useful in identifying patients with DD.

Background: Patients and primary care providers alike benefit greatly from the expertise of gastroenterologists when it comes to managing Helicobacter pylori (H. pylori) infection. However, information on gastroenterologists' practices in the management of H. pylori infection is scarce in this part of the world. This study aimed at evaluating the practice patterns of gastroenterologists and gastroenterology fellows in India.

Method: This was a cross-sectional questionnaire-based survey of gastroenterologists and gastroenterology fellows working in India.

Results: Total 207 gastroenterologists and 53 fellows filled out the questionnaire. Responses were received from all around India. Approximately 70% of respondents perceive H. pylori to be a gastric pathogen, while 20% regard it as a commensal bacterium. While the proportion of respondents who chose a test and treat method (34.6%) for uninvestigated dyspepsia without alarm symptoms was comparable to empirical proton pump inhibitor (PPI) therapy (38.8%), about one-fifth chose a scope and treat strategy in this setting. Even in the absence of alarm signs, more than half of respondents (61.5%) preferred endoscopic biopsy to detect H. pylori. While rapid urease testing (RUT) was the preferred modality (80%) for detecting H. pylori, about one-third preferred single-site RUT (from the antrum). Only 40% followed the Updated Sydney protocol, while performing biopsies and a majority (78.8%) are unable to discontinue PPIs before testing for H. pylori. PPI-clarithromycin-based triple treatment was the preferred regimen (67%) for first-line eradication, while nearly a quarter of respondents did not utilize bismuth due to concerns about adverse effects.

Conclusion: The survey reveals a lack of adherence to the current H. pylori guidelines for diagnosis, testing and treatment among gastroenterologists and gastroenterology fellows in India. It is vital that scientific societies simplify guidelines, investigate challenges to their effective implementation and execute targeted interventions to increase adherence.

Introduction: There is sparse data from India on indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) using standard adult duodenoscope in the pediatric population.

Methods: Retrospective analysis of prospectively maintained electronic endoscopy and clinical database was performed to identify pediatric patients (age ≤ 18 years) who underwent ERCP between January 2017 and December 2022. Demographics and procedural details including indications, cholangio-pancreatogram findings, endotherapy type performed, technical and clinical success and complications were noted.

Results: As many as 150 pediatric patients were included of whom 88 had pancreatic (mean age-13.7 years) and 62 had biliary disease (mean age- 14.9 years). Common pancreatic ERCP indications were chronic pancreatitis (n = 45 [51.1%]), pancreatic duct disruption fistula (n = 21 [23.9%]) and recurrent acute pancreatitis (n = 16 [18.2%]). Among biliary indications were choledocholithiasis (n = 29 [46.8%]), benign bile duct strictures (n = 13 [21%]), bile duct injury/leak and biliary stent removal (n = 7 [11.3%]) , choledochal cyst (n = 5  [8.1%]) and pancreatic mass causing biliary compression (n = 1 [1.6%]). Technical success in pancreatic and biliary ERCP was 94.3% and 95.2%, respectively, and clinical success was 84.1% and 93.5%, respectively. Most common complications following pancreatic ERCPs were acute pancreatitis (n = 9 [10.2%]) (mild = 5, moderate = 4) patients and post sphincterotomy bleed in one (1.1%). Among biliary ERCPs, post ERCP pancreatitis was seen in (n = 3 [4.8%]) (mild = 2, moderate = 1).

Conclusion: ERCP can be safely and effectively performed in children using standard duodenoscope. Chronic pancreatitis, choledocholithiasis and pancreatic divisum are common pediatric ERCP indications.

Screening colonoscopy and polypectomy are the cornerstone in decreasing the incidence and mortality of colorectal cancer. Despite the low incidence of colorectal cancer in India, there has been a rising trend in the incidence of colonic polyps and cancer over the last decade. It is, hence, imperative that we are well equipped in the management of colonic polyps. Adequate training in the detection and characterization of polyps to aid in their management is necessary. Detection of polyps can be increased by adhering to the standards of colonoscopy, including good bowel preparation, cecal intubation rate, adequate withdrawal time and use of distal attachment devices. A detected polyp needs optimal characterization to predict histology in real time and decide on the management strategies. Characterization of the polyps requires high-definition-white light endoscopy and/or image-enhanced endoscopy (dye based or digital). Various factors that help in predicting histology include size, location and morphology of the polyp and the pit pattern, vascular and surface pattern of the polyp. Polyps can be differentiated as neoplastic or non-neoplastic with reasonable accuracy with the above features. Prediction of advanced pathology including high-grade dysplasia and deep sub-mucosal invasion is essential, as it helps in deciding if the lesion is amenable to endotherapy and the technique of endoscopic resection. Adequate training in image-enhanced endoscopy is necessary to assess advanced pathology in polyps. Technology pertaining to image-enhanced endoscopy includes narrow banding imaging and blue laser imaging; newer variations are being introduced every few years making it necessary to be abreast with growing information. The recent advances in gastrointestinal (GI) endoscopy with the advent of endocytoscopy and artificial intelligence seem promising and are predicted to be the future of GI endoscopy.