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Gastroenterology in the Tropics
Rakesh Tandon,M.D Ph.DNew Delhi, India
Special features of the Tropics:Special features of the Tropics:• Poverty, poor sanitation,
water scarcity, over-crowding, malnutrition, hot climate and limited resources
• High fiber, low calorie intake, physically active life style, better family support, younger population.
Tropical diseasesTropical diseases
• Acute gastroenteritis, Ascariasis, Amebiasis, Ecchinococosis
• Abdominal TB, Enteric fever, Malaria, Dengue, Hepatitis
• Tropical Sprue, Tropical Pancreatitis, Portal biliopathy, HepatolithiasisGall Bladder cancer
Malnutrition Infection DiarrheaMalnutrition Infection Diarrhea
Amoebic liver abscess and colonic ulcers
Biliary Biliary helminthshelminths: : AscariasisAscariasis
1.47PD
1.68GB
840HD
34.2171CBD
54.8274Duo
%NoSite
Khuroo et al Lancet 1990
BiliaryBiliary Helminths:LiverHelminths:Liver flukefluke
Helminths cause – biliary obstruction , suppurativecholangitis and lead to Intrahepatic & CBD stones
Appropriate antihelminthics and endoscopic biliary decompression
HepatoHepato--BiliaryBiliary HydatosisHydatosis
BiliaryBiliary hydatosishydatosis
• 25% cysts >5cm in size leak into CBD
• Endoscopicremoval of cyst contents treatment of choice
• Irrigation of CBD and cyst with saline
Dadaukis J et al World J Surg1984;8:786Rodriguez AN et al GIE 1998;48:593
Lower GI bleedLower GI bleed
• Causes of LGI bleed different• Younger patients• 20% - 35% bleed from infective causes
– Amoebic colitis 12% - 25%– Typhoid ulcers 3% - 8%– Ileo-colonic tuberculosis 4.2% - 8.7%
• Diverticulosis coli and angiomas infrequent
Anand AC et al Tropical Gastro2001;22:131-4Goenaka MK et al1993;12:129-31
LGI bleed LGI bleed –– InfectionsInfections
Amoebic colonic ulcers – Endotherapy
Typhoid ulcers (terminal ileum)
Typhoid ulcers (terminal ileum)Typhoid ulcers (terminal ileum)
No published data on efficacy of endotherapy of bleeding infective ulcers
3/14 patients operated due to rebleed
World Expert Panel 1997 :World Expert Panel 1997 :TB still rampantTB still rampant
• 83 experts from > 40 countries• 1997: new cases – 7.96 m; existing 16.2 m
died 1.87 m• Global prevalence: 32%; 1.86 billion – 80%
from 22 countries, [> half from 5 SE Asian countries]
• 9/10 highest prevalences from AfricaTB/HIV 0.18% ie 640,000 cases
Site of involvement: CDSite of involvement: Site of involvement: CDCD
50-60%50-60%
50-60%
50-60%
Corrosive stricture of esophagusCorrosive stricture of esophagus
•Acid more often than lye
•Strictures long, tortuous and multiple
•Mean sessions needed per patient -14*
•Good response -63.6%
•High recurrence rate -66%
•Intralesional steroids useful**
*Broor SL et al J Gastroent hepat.1989;4:55-61
**Kochhar R Makharia GK. GIE 2002;56:829-34
Hepatitis E: Global distributionHepatitis E: Global distribution
• Commonest cause of acute viral hepatitis in India and other tropical countries
• In endemic regions, two forms– Large outbreaks affecting hundreds to thousands
– 30%-70% of sporadic acute hepatitis
• Feco-oral transmission (contaminated water)
• Insignificant person-to-person spread
• Vertical transmission possible from infected pregnant mothers
Hepatitis EHepatitis E
• Incubation period = 2-9 wk• High attack rate among young adults• Self-limited course, mortality low (0.07-0.6%)• No chronic infection • High disease attack rate and mortality rate
(15-20%) among pregnant women• Animal HEV known, appears to cause disease
in non-endemic region but not in endemic countries
Hepatitis EHepatitis E
Tropical diseasesTropical diseases
• Acute gastroenteritis, Ascariasis, Amebiasis, Ecchinococosis
• Abdominal TB, Enteric fever, Malaria, Dengue, Hepatitis
• Tropical Sprue, Tropical Pancreatitis, Portal Biliopathy, Hepatolithiasis, GB cancer
Tropical Pancreatitis
Tropical pancreatitisTropical pancreatitis
• Nonalcoholic young patients• Population prevalence-1:800*• 26% therapeutic ERCP procedures**• Pancreatic calculi
– ESWL pancreatic papillotomy and PD clearance– Intraductal lithotripsy
• PD strictures – Dilatation and stenting
*Balaji LN et al Intl J.Pancreatol.1994;15:29**Reddy DN AIG Hyderabad (personal communication)
Tropical pancreatitisTropical pancreatitis
Portal Portal biliopathybiliopathy
• EHPVO common cause of portal Ht.*• Pericholedochal varices cause changes in CBD
– largely asymptomatic• Symptoms of biliary obstruction in 2- 7%**
– Biliary strictures and stones need endotherapy– High risk of hemobilia***– P-S Shunt needed before biliary therapy****
*Chaudhary A et al BJS1998;85:326-329**Webb LJ, Sherlock S. Q J Med 1979;48:627-39
*** Mutignani M et al Dig. Liver Dis.2002;34:587-9**** Khare R et al J Gastro.& Hepatol2005;20:56(A)
Portal Portal biliopathybiliopathy
IntrahepaticIntrahepatic stonesstones
Difficult therapeutic problem
Wire guided baskets & balloons useful
Multiple endoscopic/ percut. attempts
Surgery when isolated segments involved
Carcinoma gall bladderCarcinoma gall bladder
Poor performance status of pts
94.3% have stage III/ IV disease
54% have gall stones
Median survival 3 monthsBatra Y et al. J Gastro Hepatol 2005;20
Ca GB Ca GB -- EndotherapyEndotherapy resultsresults
• Vij et al Gastrointest Endosc. 1996 Feb;43:121-3
Bismuth I -14 Bismuth II-8 Bismuth III-10Technical success 27/32 (84%)Relief in symptoms 25/32(76%)Complications 4/32 (13%)Double stent in only 3 patients
Changing life style causing Changing life style causing dual burden of diseasesdual burden of diseases
While diseases due to infection and malnutrition continue to thrive egDiarrhea (Globally 1.8 million deaths /yr (India: 1,000 children die every day)Changing life style is causing emergence of modern diseases like UC,Crohn’s dis, NASH - Dual burden
WHO Report, 2005WHO Report, 2005
India: 60 million Indians will die by 2015 from chronic diseases like CAD,
DM and obesity (loss of US $237 billion in national income).
China: similarly projected to lose US $ 558 billion over the same period.
Diseases of Modern Lifestyle: Diseases of Modern Lifestyle: AlcoholismAlcoholism
SteatohepatitisSteatohepatitis(NASH)(NASH)
Ballooning degeneration
Lobular Inflammation
NASH / NAFLDNASH / NAFLD•Asymptomatic•Right hypochondrial pain•Malaise•ALT(SGPT) > AST(SGOT)•Mild elevation of GGT or alkphosphatase•Uncommonly, s/o hepatic failure: ascites, low albumin, variceal bleeding
Incidence of IBD in Songpa-Gangdongdistrict, Korea
0
0.5
1.0
1.5
2.0
2.5
3.0
86 88 90 92 94 96 98 00 01
CDUC
Inci
denc
e(/1
05)
Yang et al. J Gastroenterol Hepatol 2000Yang et al. DDW 2003
Normal sigmoid
Grade IIIchanges
Distinguishing ASLC from IBDDistinguishing ASLC from IBD
• Bacillary dysentry (infectious colitis)
Endoscopic findings are nondiagnostic and diagnosismade by integrating data from multiple sources :HistoryStool cultureBiopsy
Distinguishing ASLC from UCDistinguishing ASLC from UC
ASLC• Faecal leucocytes
are insensitive as seen in both
• Stool cultures may help
Features predicting UC
• Faecal blood• Anaemia• Leucocytosis• Thrombocytosis• Hypoalbuminaemia
Most useful :Platelet count >450,000 seen in 59%of UC andonly 1.6% of ASLC
Laboratory evaluation
Comparing CD Comparing CD vsvs ITIT
10%50%Blood
++(60-90%)++Abd pain
70-80%50%Fever
Rare50-80%Anal canal
20-30%50%Diarrhea
ITCDFeatures
• Crohn’s disease
Colonoscopic Appearance – Crohn’s disease
Ulceronodular lesions in Tuberculosis
AFB caseation
Characteristic Histological Features
IT CD
Hard Points to Differentiate CD Hard Points to Differentiate CD and Intestinal Tuberculosisand Intestinal Tuberculosis• Relapsing and remitting course• Extra intestinal manifestations• Aphthous ulcers & long vs trans• Cobblestoning of mucosa• Characteristic of granuloma• Presence of AFB• Caseating lymph nodes
ASCA and ANCA in CD and ITASCA and ANCA in CD and IT
AIIMS, Dig Dis Sci, In press
Emergence of Celiac disease in Asia
• Sood et al– Rising incidence of Celiac disease in hospitalized patients
over 10 yrs.Am J Gastroenterol 2001
• Lal S etal– Sero-prevalence study in healthy school children in
Chandigarh– Prevalence- 1:120
Indian J Gastroenterol 2003
Why is there a rise in celiac disease?Why is there a rise in celiac disease?
• Increased awareness
• Availability of new accurate serological tests
• “Changes in gluten”
?Change in type of wheat we produce and
consume
Celiac disease incidence also rising in the
West• United states- Earlier estimated prevalence- 1 per 3000
• Gastroenterology 2005- Systemic review– 1% in general population
– 3%–6% in type 1 diabetics
– 20% in 1° relatives
– 10%–15% in symptomatic IDA
Incidence of celiac disease, Minnesota
Special Problems in AsiaSpecial Problems in Asia
• Herbal medicines: Toxic effects on liver, kidneys and so on Delay or modify disease presentation
• Sociocultural factors: eg problems with liver transplant program
• Cost containment: A major issue
Reuse of accessories necessary to Reuse of accessories necessary to make make TherapTherap EE’’scopyscopy cost effectivecost effective
CBD stone extraction• Hospital Cost Rs 3000• Professional Cost Rs 3000• Disposable Cost Rs 30,000-34,000• Total Cost in India Rs 36,000-40,000
• Cost in India with reuse Rs 6,000-10,000of accessories US $130 - $220(Cost of surgery Rs 20,000 – 30,000)
Gastroenterology in the Tropics: Gastroenterology in the Tropics: SummarySummary
• Wider spectrum of diseases: infections and malnutrition
• Modern life-style diseases
• Dual disease burden + Limited resources pose a major health problem
• Cost containment / innovative approaches
• Large scale preventive measures: WHO & Natl Health Authorities
Thank you
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