key: cord-1012273-i35sfsi6
authors: Limdi, Jimmy K.
title: Editorial commentary on Indian Journal of Gastroenterology—September–October 2021
date: 2021-10-19
journal: Indian J Gastroenterol
DOI: 10.1007/s12664-021-01219-y
sha: 36bedf081e66bb48e8ea0bb95bff6de79bb9a049
doc_id: 1012273
cord_uid: i35sfsi6

nan

Hepatitis A virus (HAV) infections are seen around the globe but are hyperendemic in developing countries; HAV is transmitted feco-orally and from close contact [3] . Adult infections are characterized by jaundice, diarrhea, and hyperbilirubinemia, peaking 7-10 days after the onset of jaundice. Pediatric infections are often asymptomatic or have very few symptoms. Atypical manifestations including hepatitis A-associated prolonged cholestasis, acute liver failure, rash, kidney injury, myocarditis, and Guillain-Barre syndrome have also been reported rarely [3] .

Alam et al. from Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, report on their experience of 200 consecutive children with acute HAV (mean age 8.3 ± 3.5 years) [4] . "Atypical" features were present in 15% of these children including prolonged cholestasis (8.5%), ascites (6%), pleural effusion (2%), thrombocytopenia 2 (1%), and hemolysis in 1 child. Pruritus, higher serum total and direct bilirubin, and lower serum albumin levels were statistically significant in children with atypical manifestations. Moreover, this group had a prolonged mean duration of jaundice and hospital course. The authors discuss their findings and the implications in this manuscript.

Inflammatory bowel disease (IBD) can have multidimensional manifestations including rheumatological, dermatological, and other multi-systemic effects, with often negative effects on patients' personal, psychological, professional, and social well-being [5] . Data on the prevalence of extraintestinal manifestations (EIMs) of IBD from India are limited.

Rawal and colleagues from Prime Institute of Digestive Sciences, Rajkot, India, report a large prospective series of 227 patients with ulcerative colitis (UC) and the presence of EIMs as recorded by the supervising gastroenterologist and confirmed by relevant specialists [6] . EIMs were noted in 7.9% in this cohort. Mucocutaneous (4.84%) manifestations were most common, followed by musculoskeletal (1.32%), ocular (0.88%), hepatobiliary (0.44%), and vascular (0.44) manifestations. These findings draw our attention to the myriad ramifications of IBD, which are not limited to systemic effects alone, as is emerging in other studies [7] . Clinicians should carefully assess EIMs at diagnosis and through the course of the patient's journey to ensure optimal outcomes.

Acute pancreatitis is a recognized but feared complication of endoscopic retrograde cholangiopancreatography (ERCP). A number of pharmacological agents have been used to prevent post-ERCP pancreatitis (PEP) but with variable success [8] . Dar and colleagues from the Government Medical College, Baramulla, Srinagar, India, report on a double-blind randomized trial of 882 patients with naive papilla undergoing ERCP [9] . All patients received a single dose of rectal diclofenac 100 mg within 30 min before ERCP and were randomized to receive either 20 mL of diluted epinephrine 0.02% or saline sprayed on the duodenal papilla at the end of ERCP. The primary outcome was incidence of PEP in two groups. PEP developed in 28 patients in the epinephrine group A (6.4%) and 35 patients in the saline spray group B (7.9%) demonstrating a numerical (but not statistically significant) reduction in PEP. Technical and operator-dependent risk factors notwithstanding, more prospective studies addressing confounders and different doses of pharmacological agents are needed to address this important issue.

Dyspepsia is a symptom complex referable to the gastroduodenal region and includes epigastric pain or burning, postprandial fullness, or early satiety. Approximately 80% of individuals with dyspepsia have no structural explanation for their symptoms and have functional dyspepsia (FD). Among likely etiological factors or associations, H. pylori is implicated [10] . Padole and colleagues from Sir Ganga Ram Hospital, New Delhi, India, studied the effect of H. pylori eradication in consecutive adult patients with FD compared with "standard medical therapy" (SMT) [11] . Treatment success was defined as symptom relief (Global Overall Score -[GOS]) score ≤ 2 and reduction by at least 2 points at 6 months, and H. pylori eradication was defined as stool antigen negative at 4 weeks. Of 202 patients randomized, 32/101 patients in group 1 (H. pylori eradication) and 31/101 in group 2 had treatment success (31.7% vs. 30.7%, p = 1.000). The efficacy of H. pylori eradication therapy was 74.46% (70/94). H. pylori eradication therapy did not provide additional benefit with symptom relief in patients with FD as compared with SMT.

Although a predominantly respiratory disease with multisystemic ramifications, gastrointestinal (GI) symptoms such as diarrhea, vomiting, abdominal pain, and hepatic abnormalities have been reported in up to 20% of patients with corona virus disease-19 (COVID-19), including those with minimal symptoms [12] . Rogers and colleagues report their experience of treating patients with COVID-19 at the George Washington University Hospital, Washington, DC, USA [13] .

In line with previous reports, GI symptoms were seen in 25.9% of patients. The most common GI symptom was diarrhea (12.8%) followed by nausea or vomiting (10.5%), reduced appetite (9.3%), and abdominal pain (3.8%). Patients with diarrhea were more likely to die (OR 2.750; p = 0.006; CI 1.329-5.688), be admitted to the intensive care unit (ICU) (OR 2.242; p = 0.019; CI 1.139-4.413), and be intubated (OR 3.155; p = 0.002; CI 1.535-6.487). Diarrhea was more likely in patients requiring vasopressors, those with shock and acute kidney injury. Further data and mechanistic insights will inform clinicians and researchers in managing this new and complex disease.

The opportunistic parasite Cystoisospora (previously Isospora) belli is frequently responsible for severe diarrhea in immunocompromised (e.g. human immunodeficiency virus [HIV]-infected) people in tropical and subtropical regions. The species develop in enterocytes, and are excreted via feces and transmitted through the fecal-oral route via ingestion of contaminated water or food, or direct contact with infected animals or humans [14] . Acute diarrhea is usually self-limiting in immunocompetent individuals, but in severely immunocompromised patients, it can cause severe chronic diarrhea, which may result in a wasting syndrome, or even the death of acquired immunodeficiency syndrome (AIDS) patients [14] . The diagnosis by microscopy is less sensitive due to intermittent shedding of oocysts. In this issue, Katiyar et al. from Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, report on a new single run polymerase chain reaction (PCR)-based diagnostic assay for C. belli [15] . In a cross-sectional study of 331 immunocompromised patients with diarrhea, 354 stool samples were tested for the presence of oocysts and a new PCR assay for C. belli. Microscopy detected C. belli in 11/354 (3.1%) of stool samples and PCR detected C. belli in 16/354 (4.5%). The PCR-based assay detected C. belli in all the stool samples, which tested positive by microscopy and additionally detected C. belli in five stool samples. Robustness and reproducibility of the PCR test notwithstanding, further studies will be needed to provide additional evidence.

Gastrointestinal (GI) bleeding is a dreaded and potentially fatal sequela of portal hypertension [16] . Successful management hinges on a multidisciplinary approach potentially involving medical interventions and/or percutaneous or surgical portosystemic shunting for portal hypertension reduction. Recognizing the significant and practice changing advances in recent years, as also the need for a specific national guidance document, the Indian Society of Gastroenterology (ISG) Taskforce on Upper Gastrointestinal bleeding commissioned an expert multidisciplinary panel, tasked with producing an expert consensus document (using a modified Delphi consensus) to guide clinicians managing portal hypertensive bleeding. The final report of the Coorg Consensus Workshop, published in this issue of the Indian Journal of Gastroenterology [17] , is a comprehensive evidence-based document and constitutes essential reading.

Disclaimer The author is solely responsible for the data and the contents of the paper. In no way, the Honorary Editor-in-Chief, Editorial Board Members, the Indian Society of Gastroenterology or the printer/ publishers are responsible for the results/findings and content of this article.

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