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The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

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BACKGROUND: Tropical chronic pancreatitis frequently presents with intractable abdominal pain. Surgical treatment has its own morbidity and mortality, and long-term results may not be satisfactory. OBJECTIVE: To analyze the results of endoscopic pancreatic-stent placement and sphincterotomy for the pain of tropical pancreatitis. DESIGN: Retrospective review. SETTING: Tertiary-referral hospital. PATIENTS: Twenty-four patients with tropical pancreatitis with severe, persistent pain not responding to standard medical therapy over a period of 30 months beginning January 1998. INTERVENTIONS: Stent placement of the pancreatic duct, along with sphincterotomy. MAIN OUTCOME MEASUREMENTS: At least 80% global improvement in pain as reported by the patient during follow-up after the procedure. RESULTS: In the 19 evaluable patients, the intended procedure, pancreatic stent placement along with sphincterotomy, was successful in 14 (73.7%); 3 others had sphincterotomy alone. Over a follow-up period of 6 to 38 months, 12 of the 14 patients (85.7%) who underwent stent placement plus sphincterotomy and 2 of the 3 patients who had sphincterotomy alone responded. Twelve of these were completely free of pain, and the remaining 2 patients had mild infrequent pain that occurred once in 2 to 4 months, lasting a few hours at a time and never needing hospitalization. The only major complication was the development of pancreatic sepsis, which required stent removal in 1 patient. Eight patients were stent free at the end of 6 months, and, over a further follow-up of 6 to 20 months, the pattern of pain relief persisted in them. LIMITATIONS: The retrospective nature of the study, the limited numbers studied, and the lack of assessment of pain on a standard visual analog scale. CONCLUSIONS: Stent placement of the pancreatic duct with pancreatic sphincterotomy constitutes an important nonsurgical therapeutic option for the intractable pain of tropical pancreatitis.

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Enterocutaneous fistulas are potentially life-threatening complications of gastrointestinal surgery. Nutritional support is the mainstay of management. We report a 32-year-old man who developed an enterocutaneous fistula following surgery for ulcerative colitis. Enteral feeding was attempted by introducing a Foley's catheter through the midjejunal fistula.

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OBJECTIVE: To identify clinical and laboratory features of patients with malarial hepatitis simulating fulminant hepatic failure (MHsFHF) and distinguish it from viral FHF. PATIENTS AND METHODS: At a tertiary care unit in Bangalore, India, we compared clinical and laboratory characteristics of 25 patients with MHsFHF with those of 25 patients with viral FHF from November 1996 to January 2000. RESULTS: No statistically significant differences were seen in duration of jaundice, altered consciousness, and the interval between onset of jaundice and altered consciousness between the 2 groups. Hepatomegaly and splenomegaly were present in 72% and 48% of patients with MHsFHF and in 12% and 0% of patients with viral FHF (P<.001), respectively. The MHsFHF group had a significantly lower hemoglobin level (9.3 g/dL vs 12.9 g/dL), total leukocyte count (9.1 x 10(9)/L vs 18 x 10(9)/L), platelet count (44.8 x 10(9)/L vs 218.6 x 10(9)/L), and transaminases (alanine aminotransferase, 86.2 U/L vs 1230.0 U/L; aspartate aminotransferase, 131.9 U/L vs 720.0 U/L) (P<.001). Thrombocytopenia and elevated serum urea nitrogen were universal in patients with MHsFHF. Prothrombin time was abnormal in all patients with viral FHF and in only 1 patient with MHsFHF. Of patients with MHsFHF, 24% died; of patients with viral FHF, 76% died (P=.02). CONCLUSIONS: In endemic areas, severe malaria should be considered in the differential diagnosis of FHF. Hepatomegaly and normal prothrombin time in the setting of FHF are suggestive of malaria, and a peripheral blood smear should be obtained for diagnostic confirmation.

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We report a 45-year-old woman who presented with hematemesis. Endoscopy showed nodular lesions and ulcers in the gastric antrum; histology of the lesions showed amyloidosis. The patient had received melphalan and prednisolone for multiple myeloma 5 years earlier.

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BACKGROUND: Esophageal tuberculosis is rare but appears to be increasing, especially in endemic areas and in immunosuppressed individuals. The esophagus is involved by spread from adjacent structures. The natural history, complications, and treatment of this condition are unclear. METHODS: Experience with 10 cases of esophageal tuberculosis encountered from 1995 to 2000 is described. OBSERVATIONS: Esophageal tuberculosis was always associated with spread from adjacent structures such as mediastinal or cervical lymph nodes and the spine. Dysphagia or coughing on eating were the predominant symptoms. Esophageal ulcers with undermined edges were the most common finding, followed by esophageal sinuses or fistulous openings. One patient died of disseminated disease; the remaining 9, including 4 with esophagotracheal or esophagomediastinal fistulas, recovered by treatment with antituberculous drugs alone. CONCLUSION: Esophageal tuberculosis almost always is associated with mediastinal lymphadenopathy. In half of the cases, it is associated with an esophagotracheal fistula or an esophagomediastinal sinus. Despite these complications, patients can be treated safely with antituberculous drugs alone.

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