Chronic HBV infection is a dynamic disease when followed up over a period of
time. A person can change from one state to another over a period of time
more than once. Carrier state can turn into an active stage at anytime thus
it is recommended that the term carrier stage be dropped and replaced by
chronic hepatitis B virus infection .
Thus HBV disease be classified into two stages
1. Chronic HBV infection with no evidence of liver disease
  - HBsAg  + ve
-No signs of liver disease
-Normal AST/ALT
-Normal liver histology
2. Chronic HBV infection with  liver disease
-ALT> 40 IU/L
-signs of liver disease like PHT ( on USG/CECT/  Endoscopy), liver failure
-Abnormal liver histology

This is a better working classification .

Regards
Dr Sharat C. Misra MD,DM
Consultant Gastroenterologist
Moderator GIWorld
To join send blank email to
GIWorld-subscribe@onelist.com

Dear Cathy,
No need to panic . You wont get pneumonia or choke over one missed dose.
Drink plenty of fluids ( avoid milk) and less of solid food , give a  2 hr
gap between eating and sleeping and relax. Take Prilosec twice a day for
3 -4 days , then decrease to once daily.
  Increase in anxiety will also lead to increased GERD.

Regards
Dr Sharat C. Misra MD,DM

I need a quick response to this problem:

Over the weekend while out of town I overate and did not take my
prilosac until about 1am.  I went to bed and had my reflux problem about
30 minutes later.  I have never had it this bad, I took another
prilosac, drank a lot of milk, and found some tums to try and get the
irritation down.  My lungs seemed to have been effected by this recent
problem,  I have coughed a lot since it happened.  I am not coughing up
any food, just plegm, but is there something I should do, I know that I
could not get into my Dr. for sometime as he is very busy.  Does this
warrant my going to a emergency room, can I get pneumonia or what.  I
know that I was told that it can back up into your lungs and you can
choke to death, is this true.  I feel like what I think a smoker must
feel like with lots of need to cough it loose.  Thank you for any
input.

Pain Abdomen in Children



Children with gastrointestinal problems should be considered in the context
of their growth , development and diet. Children are often shy, vague or
inarticulate about their symptoms and it is important to ask the child to
give the history of his illness in his own words. Direct questions are best
combined with the  examination.

Abdominal pain is a common childhood complaint more often transitory and of
no identifiable  physical cause. Functional abdominal pain ( and other
gastrointestinal symptoms like nausea, vomiting, constipation) may be an
expression of anxieties , stresses and other difficulties in the child's
life. However pain should always be taken seriously since it is essential to
identify the acute abdomen as quickly as possible.

Common ailments that cause abdominal pain with / without  nausea, vomiting,
diarrhea include infectious gastroenteritis( usually viral), acute
appendicitis , helmenthiasis, mesenteric adenitis, intestinal obstruction or
food intolerance / allergy.

Only 5-10 % of children may require surgeryfor acute abdomen but full
investigations must be done to diagnose the cause as early as possible.
Observation in hospital allows the natural history of the disease to unfold.
Acute hepatitis in young children often presents with pain abdomen and
vomiting and a high index of suspicion and the relevant liver function tests
lead to early diagnosis. Peptic ulcer disease is rare in children and often
presents with a complication like persistent pain and rarely vomiting of
blood. Some  disorders like pancreatitis, diabetes , kidney infection and
pneumonia may also present with abdominal pain in children. Food intolerance
is more often perceived than real in childhood.  Lactose intolerance, milk
protein allergy and celiac disease affect young children but it is difficult
to perceive that abdominal pain alone can be caused by a food component.
These are usually associated with vomiting or diarrhea.

Reassurance, use of antispasmodics and deworming are commonly used in pain
management in children even when no definite cause is found.



Dr Sharat C Misra MD,DM

Consultant Gastroenterologist

"Steven Kirschbaum" wrote....

>I am a female age 51 who is in menopause.  I have been diagnosed with
GERD............>

Menopause may actually be beneficial in GERD however the effect may be
offset by use of estrogens

>I also have irratible bowel syndrome which manifests itself
basically in the form of constipation.  I have also been diagnosed with a
sluggish but working gall bladder.  It seems that most of my problems come
from poor motility>

Try prokinetic drugs like cisapride or domperideone and LES function will
improve.
Also try shifting to 15 mg /day of Lansoprazole for maintenace of GERD
symptoms.

Regards
Dr Sharat C. Misra MD,DM
Consultant Gastroenterologist
Moderater GIWorld

Hi all,
( esp to those on the hep B list, if they are on GIWorld as well)
There are several criteria on which decision to enter Ch hep B patients into
a certain protocol is taken. Newer drugs are becoming available but are
often reserved for patients with previous treatment failures.
Just being HbeAg positive alone does not merit treatment and on the contrary
even HbeAg negative people would be treated.
As Paul  said most people are nervous regarding taking treatment as they are
unaware of the outcome and prognosis.
Counseling about nature of Hep B infection is an important part of overall
therapy well illustrated by a  patient I saw just a few days back.
A civil engineer by profession ( no alcohol, no drugs, no casual sex  ) and
to be married in 3wk time he had a blood test , just a routine, and found
himself HBsAg positive. He came to me with no desire to live and wanted  to
reinforce his own feelings. He tested to be HBeAg negative , with a normal
liver on ultrasound and normal liver enzymes. He did  not want to go back
home  so he phoned his family that he was in hospital as he had met with a
road  accident and was unable to get married.
I spent some time with him to enable him to understand that nothing was lost
and he was not even a candidate for treatment. He would have to vaccinate
his bride and would have a normal life once she had protective antibodies.He
said a local GP had told him that nothing was possible once he had HepB and
was unaware that  curative treatment was possible.
He is now a changed person and vows to fight the disease......
We need these people to develop this attitude.
Anything is possible!

Regards
Dr Sharat C. Misra MD,DM

Approach to Dyspepsia

After a clinical impression of Dyspepsia further management depends on
performing an endoscopy

Endoscopy is a must in the following

Age > 45 yrs
New dyspepsia
Alarm symptoms
Highly anxious patient
Patients on NSAIDs

Endoscopy may be  deferred in the following

Young patient with symptoms < 4 wks
economic burden
H pylori serology testing available and inexpensive

Endoscopy is fast becoming the investigation of choice in dyspepsia unless
the facility is expensive or not easily available . It  is not necessary if
a duodenal ulcer has been
unequivocally diagnosed by radiology. If symptoms persist after an
unrevealing radiographic examination, however, endoscopy must be performed.
A major advantage of endoscopy is its capacity to detect mucosal lesions,
such as gastritis and duodenitis. The opportunity to diagnose Helicobacter
pylori infection by rapid urease  test, culture, or histologic examination
is becoming more important in determining management of various upper
gastrointestinal conditions especially in curing duodenal ulcer.

Management of Duodenal Ulcer (DU)
(uncomplicated)

Diagnosis confirmed by endoscopy
Rapid urease test for Hp (95% are +ve)
H pylori eradication therapy for 1 week
Follow up with PPI for 3 weeks
Stop smoking and use of NSAID
Ulcer heals in 2-4 wk in 95% people
Relapse rate is less than 5% / year
Diet- high in  fiber and  essential fatty acids

Gastric ulcer

Biopsy from ulcer edge for dysplasia ( early changes of cancer) is a must
Test for H pylori (70 % +ve)
If Hp + ve : eradicate Hp , continue PPI till healing confirmed by endoscopy
after 6-8wks
If Hp -ve : PPI till ulcer heals, maintenance therapy if no dysplasia
Once established as benign, however, gastric ulcers rarely become malignant;
thus long-term follow-up is not required. Ulceration of gastric cancers
often shows a tendency to heal with      ulcer treatment, which can lead to
a false sense of security.

Non ulcer dyspepsia

Only 50 % are Hp + ve
Hp infection is not the cause of dyspepsia
Hp eradication does not alter natural history
Hp - ve patients :
H2RA( ranitidine) / PP( omeprazole)/prokinetics( domperidone,cisapride)
Hp +ve patients:
  no consensus for eradication therapy.
This is the commonest form of dyspepsia and the most difficult to manage.

Regards
Dr Sharat C. Misra MD,DM

Greetings List friends, and especially Dr. Sharat C. Misra MD,DM,

This post is a cross post, with the permission of Paul, from our Hepatitis B
Information and Support List. From time to time a list subscriber there
makes a point which is of interest to the GI world, and I hope you don't
mind sharing these ideas with you on this list.

In short, Paul highlights the difficulties HBV patients face in obtaining
new, experimental treatment that we know about from published abstracts and
other internet documents. I wonder if anyone here has any ideas on how to
improve access to trial drugs or any other thoughts on this topic?


^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
John & Matti Kirk, Blackpool, United Kingdom
mailto:jskirk@...
http://www.users.globalnet.co.uk/~jskirk/
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Information about the Hepatitis B Information and Support List
Visit -  http://hbv.web-page.net
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

-----Original Message-----
From: Paul Boyd [mailto:boydp@...]
Sent: 25 May 1999 08:18
To: hepatitis-b@...
Subject: [HB] e-antigen positive candidates


Good Morning..
	 Can't sleep so I'm reading and writing...lol.. that will get me
back to the pillow...  The following is a quote form the Hep B
Foundations flyer titled "Tell me about Clinical Trials"

Dr. Vinod Rustgi, Director of GI Research at the Northern Virginia
Clinical and Research Center in Fairfax Va, currently conducts
several HBV clinical trials.. He speaks to the increasing difficulty of
finding people who meet the profile for enrollment..  "Part of the
problem in the US is there are not enough e-antigen positive
candidates to enroll in the trials.  Of the 1 million people in the US
with chronic hepatitis B, only about 15 percent have the e-antigen.
Of those many have already been treated with other HBV drug
treatments, or do not know there are any options.  It is really
difficult to find more than four or five eligible people in any one
area," he explains.

Is there anyone else out here on this list that is e-antigen positive
and hasn't had any form of treatment?  and like me didn't know?

Seems to me Our doctors need alittle enlightment on the subject of
Clinical Trials ans who's eligible to participate in them.. Its sad to
think there are people out here that know nothing of the trails
available to them and whats required to get into them..

What can we do to expand upon this and increase the numbers
available..  I to am nervous about participating in one of them from
the stand point of possibly doing myself more harm then good,, but
if in the long run it helps me,, or in the future my having tried the
trials helps someone else,, even just one person,, then its not all
for nothing.. and when my day comes to leave this world and go on
to whatevers next.. I want to go knowing I've tried whatevers there
and possibly helped in the process..

Now I'm tired again,, Night!!!


Paul Boyd :) Do, or do not. There is no "try."
A work in Progress   http://boozers.fortunecity.com/bridge/422/index.html
Hepatitis B Foundation:  http://www2.hepb.org/hepb
The Hepatitis Info Net:  http://www.hepnet.com/hepb.html
ICQ# 37993692
The Hepatitis Neighboorhood,
http://www.hepatitisneighborhood.com

__________________________________________________________________________
A blank message to these addresses performs the following -
   hepatitis-b-on@... gets you on the list.
   hepatitis-b-off@... gets you off the list.
   hepatitis-b-switch@... toggles you to/from the fancy digest
version.
   hepatitis-b-vacation@... toggles you to/from the vacation list.

   hepatitis-b@... posts your message to the list.

I am a female age 51 who is in menopause.  I have been diagnosed with GERD
six years ago.  I have been on Prevacid for the last 6 yrs.  I still
experience lapses in which I have burning in my mouth and throat as well as
upper abdominal area.  I had a motility test which showed that the LES was
sluggish.  I also have irratible bowel syndrome which manifests itself
basically in the form of constipation.  I have also been diagnosed with a
sluggish but working gall bladder.  It seems that most of my problems come
from poor motility.  I would appreciate any suggestions as to what role
menopause may have in making my GERD worse.  I am having problems with my
insurance company continuing to pay for the quite expensive Previcid,
however I cannot imagine myself without it.
-----Original Message-----
From: Doc <liver@...>
To: Undisclosed-Recipient:@delcluster1.vsnl.net.in;
<Undisclosed-Recipient:@delcluster1.vsnl.net.in;>
Date: Tuesday, May 25, 1999 4:38 PM
Subject: [GIWorld] Estrogen and GIT


>From: "Doc" <liver@...>
>
>Effects on the gastrointestinal tract of estrogen and progesterone are well
>established.. Motility changes occur throughout the gastrointestinal tract,
>including a reduction in lower esophageal sphincter pressure and its
>physiologic function with resulting gastroesophageal reflux.  Further there
>are alterations in gastric motor function associated with nausea and
>vomiting; and a decrease in the rate of small-bowel and colonic transit
>manifested primarily as abdominal bloating and constipation. These effects
>are mediated by progesterone,
>with estrogen probably acting as a primer.
>These changes are observed  during normal menstrual cycle , pregnancy, use
>of oral contraceptives and when estrogens are being  used .
>
>For further information email me.
>
>
>Regards
>Dr Sharat C. Misra MD,DM
>Consultant Gastroenterologist
>List Moderater  GIWorld
>
>
>
>
>------------------------------------------------------------------------
>ONElist:  where real people with real interests get connected.
>http://www.onelist.com
>Join a new list today!
>------------------------------------------------------------------------
>Welcome to GI World on line community

Effects on the gastrointestinal tract of estrogen and progesterone are well
established.. Motility changes occur throughout the gastrointestinal tract,
including a reduction in lower esophageal sphincter pressure and its
physiologic function with resulting gastroesophageal reflux.  Further there
are alterations in gastric motor function associated with nausea and
vomiting; and a decrease in the rate of small-bowel and colonic transit
manifested primarily as abdominal bloating and constipation. These effects
are mediated by progesterone,
with estrogen probably acting as a primer.
These changes are observed  during normal menstrual cycle , pregnancy, use
of oral contraceptives and when estrogens are being  used .

For further information email me.


Regards
Dr Sharat C. Misra MD,DM
Consultant Gastroenterologist
List Moderater  GIWorld

Dyspepsia ( bad digestion)

This is defined as presence of one or more of these :

Upper abdominal symptoms - epigastric pain or discomfort , bloating , gas
Heartburn , nausea , eructations , regurgitation
Mixed symptoms (most common)
Alarm symptoms- weight loss , anorexia , vomiting , dysphagia

Causes  of Dyspepsia

Duodenal ulcer
Gastric ulcer
Gastric cancer
Gastroesophageal reflux
Non ulcer dyspepsia , dur >=4wks ( mainly due to motility disturbance)
Rule out biliary disease, worms

Duodenal ulcer disease is associated with the following

Cigarette smoking
high parietal cell mass in stomach
duodenal metaplasia
H pylori - toxic strain
heridity
male sex
blood group O
Diet- cola/coffee, rice, no alcohol
greater immune response to H pylori
H pylori acquisition at older age
NSAIDS

Gastric ulcer (benign,chronic)  is associated with following

Extensive gastric atrophy
Diet low in antioxidants, high in salts
H pylori acquired at young age
Blood group A
Toxigenic strains of H pylori
Humoral immunodeficiency
Cigarette smoking , NSAID use

Gastroesophageal reflux disease (GERD)

Presents with heartburn, regurgitation
30% have overlap of symptoms like epigastric pain, nausea,bloating
endoscopy, pH monitoring diagnostic
endoscopy negative patients should be given a therapeutic trial

Non ulcer dyspepsia ( NUD)

Symptoms referable to the UGIT > 1 month in the absence of endoscopic or
systemic disease
It may be of following types:
1. ulcer like : no PU on endoscopy
2. dysmotility : gastroparesis, dysrhythmias
3. reflux like: reflux like symptoms  in absence of GERD
4. essential


Dyspepsia Part II -  Diagnosis     (will follow)

Regards
Dr Sharat C. Misra MD,DM

Greetings, Dr. Misra,

Thanks for approving the subscription (if indeed you had to make any manual
efforts!)

I am writing off list to introduce myself and to say why I have joined in. I
am an HBV sufferer who found little support or patient participation
specific to HBV on the internet. Almost exactly a year ago I jointly with
another formed a paid-for mailing list. (See below) Being primarily a
patient participation list, we have recruited quite a few professionals. In
the near future I shall be opening a moderated announcement list entitled
HBV_Research which will be intended for the professionals and some of the
patient subscribers who wish only to receive the informational posts.

I look forward to reading your list's mail for a time, and will in the
fullness of time post to your list. I will always sign my mail, and wanted
to make sure you know I am not advertising or anything like that by doing
so. Our mailing lists may well complement each other, yours with the wider
GI interests, and ours with our specifics on HBV issues. Where I think there
may be good cross over is where HBV issues are discussed on the GI list - if
ever. On that point, I will ALWAYS ask permission before forwarding or cross
posting. I never forward anyone's mail without their express permission.

I wish you every success with the GI list, and will tell my own specialist
about it.

So thanks for letting me on, and I hope that we can help each other.

Cheers, John.

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
John & Matti Kirk, Blackpool, United Kingdom
mailto:jskirk@...
http://www.users.globalnet.co.uk/~jskirk/
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Information about the Hepatitis B Information and Support List
Visit -  http://hbv.web-page.net
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

> -----Original Message-----
> From: GIWorld-owner@onelist.com [mailto:GIWorld-owner@onelist.com]
> Sent: 24 May 1999 12:34
> To: jskirk@...
> Subject: [GIWorld] Welcome to GIWorld@onelist.com
>
>
>
> Welcome to the GIWorld.
> Please take a moment to review this message and save it for
> future reference.
>
> GI World is an online discussion list relating to Gastrointestinal and
> Hepato-biliary-pancreatic diseases.
> From time to time the list moderator or other experts will post medical
> information regarding  latest developments in this field.
> It is imporatant to emphasize that this list is unmoderated in order to
> facilitate active participation among list members.Thus restraint must be
> exercised in list postings which should be pertaining to the theme of this
> discussion list. No spam, advertising or personal contents are
> permitted. List
> moderator reserves the right to unsubscribe an offending member.
> Join in the discussion and we can follow all related threads.
> Please do  not send any  "exe" or "dll "  attachments.
> Thanks
>
> Posting Information
> ------------------------------
> Post all listings to GIWorld@onelist.com
>
> Subscribe information
> --------------------------------------
> send blank email to GIWorld-subscribe@onelist.com
>
> Unsubscribe information
> ------------------------------------
> To unsubscribe from this list, go to the ONElist web site, at
> www.onelist.com, and select the User Center link from the menu bar
> on the left. This menu will also let you change your subscription
> between digest and normal mode.
> Or
> send a blank email to GIWorld-unsubscribe@onelist.com
>
> For digest mode
> -----------------------------------
> send blank email to GIWorld-digest@onelist.com
>
> For stopping mail temporarily
> -------------------------------------------
> Go to www.onelist.com and against the list  name  check no mail
>
> Thanks,
>
> Dr SHARAT C . MISRA MD, DM
> Consultant Gastroenterologist
> List Moderator GIWorld
> Email liver@...
> List Address GIWorld@onelist.com
>

Peptic Ulcer


Nearly 25 % of people in our community suffer from dyspepsia , which means
symptoms of bad digestion like abdominal pain or burning, fullness and gas.
These symptoms are commonly referred to as those of  "acidity " and most
people resort to self medication . It  is important to remember that any new
dyspepsia  of more than one month duration should be investigated. Further ,
at age above 45 years and the presence of "alarm" symptoms  like loss of
appetite , weight loss  and difficulty in swallowing  investigations are
mandatory.

Peptic ulcer is responsible for about 10 % of these symptoms . It is
important  for patients suffering from dyspepsia to be evaluated by their
physician as apart from ulcers , cancer of stomach may also present in the
same way.

Peptic ulcer implies the development of  a breach in the lining of stomach
or upper small intestine called duodenum and to the naked eye it  looks like
a wound . This illness effects nearly 10% of people in our country. It  is
commonly found in young people at the prime of their age and has been said
to be associated with  " hurry, worry and curry". The factors responsible
for causing ulcers include  cigarette smoking, use of pain killer drugs,
physical and mental stress and a diet rich in chilies, coffee, colas and
rice. However  recent research has shown that the most important factor is
the presence of a spiral shaped bacteria in the stomach called Helicobacter
pylori. This bacteria enters the stomach by the oral route and is usually
acquired at a young age. The organism may be present in about 40 % of
healthy people but  transformation into disease like peptic ulcer and
stomach cancer occurs  only in few.

Peptic ulcer and stomach cancer are easily diagnosed by an endoscopic
procedure. Flexible fibreoptic endoscope is  easily and safely introduced
through the mouth  to directly examine the food pipe, stomach and upper
intestines. This does not require any anaesthesia and takes only 5 minutes.
The chemical test for the bacteria can also be carried out at the same time.

  Once diagnosis is reached it is half the battle won. Treatment of duodenal
(small intestine) ulcer is simple and includes anti bacterial and ulcer
healing medicines. it is important to realize that strict diet restrictions
are no longer necessary  with modern medicines. However  all analgesic
medication and cigarette smoking must be stopped . Once treatment is
complete only 5 % people will have a recurrence, rest  of them will be
cured. Stomach ulcers must be biopsied at the time of endosopy to rule out
cancer which presents in a similar way. These ulcers take at least 6 weeks
to heal  and healing must be confirmed by a repeat endoscopy. Non healing
stomach ulcer may require surgery. Duodenal ulcers heal by medicines only
and surgery is required only for complications like bleeding , intestinal
obstruction or perforation.Once an ulcer always an ulcer " an old dictum is
no longer true and if early  diagnosis is made they can  be cured.





Dr Sharat C Misra

MD,DM (Gastroenterology)

Consultant in Gastroenterology & Liver Diseases

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
¤¤¤¤¤
The Cornish Search Engine one of the UK's premier web promotion sites on the
Net!
visit us at http://digitalchaos.hypermart.net/?004 or
join our newsletter for FREE promotional advice and Quality articles
mailto:subscribe@...?subject=SUBSCRIBE
And as a FREE GIFT download WebPad v1.0 direct from
http://digitalchaos.hypermart.net/webpad.zip
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
¤¤¤¤¤

Gastroesophageal Reflux Disease (GERD)

      The spectrum of problems caused by gastroesophageal reflux disease
(GERD) has expanded in the last decade far beyond the traditional heartburn
and hiatus hernia concept of a generation ago. Accompanying our increased
knowledge of the manner in which GERD may produce problems is new
understanding of the physiological factors  which contribute to this problem
and a host of diagnostic methods by which the diagnosis may be confirmed and
the progress of treatment monitored. Finally, advances in therapy have
carried us beyond the choice of antacid or surgery which were the primary
options only two decades ago.

Many Faces of GERD
Introduction of ambulatory pH monitoring of the lower esophagus in which the
patient goes about his
      usual affairs while wearing a small recording device (similar to the
familiar Holter cardiac monitor) has shown us  that GERD may manifest itself
as other syndromes. These include intrinsic asthma, nocturnal cough,
recurrent  pneumonia, persistent hoarseness, non-cardiac anginal-type chest
pain, and episodic hypersalivation (ptyalism). It should be remembered of
course that GERD may also present initially with evidence of chronic damage
such as a stricture with or without Barrett s metaplastic columnar
epithelium. Acute dysphagia, i.e., meat impaction or  chronic difficulty in
swallowing of solids may therefore be the first indication of GERD in an
individual patient.

Diagnosis of GERD
      The proliferation of tests to diagnose reflux disease requires that the
physician decide what question(s) are to be answered in order to pick the
most efficient tests and to determine whether tests be done at all. The
presence or absence of reflux can be investigated utilizing a barium
esophagram with a request to the
      radiologist to attempt to demonstrate reflux (Valsalva, abdominal
pressure, positional change, etc.). Alternatively, scintiscanning using
isotopic material instilled into the stomach in association with abdominal
pressure may be used  to demonstrate reflux. Finally, if available in your
area, ambulatory or stationary 24-hour pH monitoring can be done with an
intraesophageal pH electrode and recorder.  If one is attempting to
correlate symptoms with reflux (chest pain, bronchospasm, etc.), one can
utilize either acid  perfusion of the lower esophagus (Bernstein test) or
the use of a pH monitor which allows the patient to record the time of
specific symptoms (such as chest pain or wheezing) while intraesophageal pH
is being continuously
      monitored. High correlation suggests causality but the system is
imperfect.  If one wishes to assess the degree of esophagitis, stricture
formation, or the presence of metaplastic epithelium,  fiberoptic endoscopy
and mucosal biopsy can be performed by consultants trained in this
technique. Alternatively,  barium study with air contrast, although somewhat
less sensitive, is usually reliable in diagnosing erosive esophagitis,
ulceration or stricture.

Regards
Dr Sharat C. Misra MD,DM
Consultant Gastroenterologist

This site is being reviewed by The Hersh Web Site Observer which has these
links
http://CyberJournalist.com/
http://CyberJournalist.com/reviewed.gif

Effect of NSAIDS on the Upper Gastrointestinal Tract

Joint disease is a common reason for seeking medical advice and since
NSAIDs offer  excellent symptomatic relief, they are commonly prescribed.
Add to this the over-the-counter sales of aspirin (20 million pounds per
year) and other NSAIDs (Ibuprofen) and an extraordinary number of
people are exposed to possible side effects from these drugs.
NSAIDs are well-known to cause gastrointestinal mucosal damage. Of
particular concern are patients with arthritic conditions. More than 14
million such patients consume NSAIDs regularly. Up to 60% will have
  gastrointestinal side effects related to these drugs and more than 10%
will cease recommended medications  because of obnoxious gastrointestinal
symptoms. NSAIDs increase the risk of ulcer formation and complications
(bleeding, perforation, and mortality). Data from a variety of studies show
a three- to tenfold increased risk for these events.In clinical
studies,ulcer complications related to NSAIDs generally are
dose-dependent, and the likelihood of complications is greatest during
  the first month of treatment.
However, even low dose aspirin (325mg per day)   increased the risk for
bleeding. Antral gastritis and Helicobacter pylori infection accompany most
non-NSAID ulcers. NSAIDs do not usually generate gastritis, but are
considered a cause for gastric or duodenal ulcers independent of other
factors such as Helicobacter pylori, smoking, or a history of previous ulcer
disease. Although logic would suggest that a prior history of  ulcer would
increase the risk of NSAID complications, data addressing this specific
issue is sparse. An "ulcer history" predicted the development of ulcers
  seen endoscopically  during a two-month NSAID trial. A history of prior
  NSAID intolerance for rheumatoid arthritispatients predicted
  future hospitalizations for NSAID ulcers. Age is
another predisposing factor to consider because the elderly often  have more
advanced disease processes (often multisystem), and tend to use more NSAIDs.
While some data support the notion that elderly patients requiring NSAIDs
have increased mortality and are more likely to require  hospitalization,
this belief is not universal. Of 114 patients admitted with gastrointestinal
bleeding, those taking  NSAIDs were older and had more complicated disease
processes, but required fewer surgeries and transfusions. Moreover, their
mortality was less.

Treatment
Most NSAID ulcers heal easily if the NSAIDs are stopped. If the medication
cannot be stopped, the dose should  be reduced. However, even with continued
administration of NSAIDs, healing will still occur. Conventional doses   of
cimetidine have healed gastric lesions < 5mm diameter. Another study reports
decreased gastric ulcer healing  (63% vs 95%) and duodenal ulcer healing
(84% vs 100%) with ranitidine 150mg bid if NSAIDs are continued.PPI like
omeprazole are also very effective in healing ulcers.

Prevention
Prostaglandin administration prevented ulcers in the stomach during NSAID
treatment. A similar effect has been shown for duodenal ulcer. H2-blockers
and sucralfate also prevent NSAID-induced duodenal ulcer. However  there is
no data to support the efficacy of sucralfate or antacids in preventing
gastric ulceration. Although  H2-blockers are not considered prophylactic
for gastric ulcer, some recent data disputes this claim.  Omeprazole is
definitely more useful, but data supporting this is still accumulating.
In view of the large amount of NSAIDs consumed, and because only a distinct
minority of NSAID users develop complications, universal prophylaxis is
impractical. Consider prophylaxis for 1) patients with prior history of
ulcer complications, 2) patients requiring concomitant steroids, and
3) patients with other medical conditions that are at   risk for serious
morbidity/mortality  from ulcer complications.

Dr Sharat C. Misra MD,DM

CHICAGO, IL -- May 18, 1999 -- Parents of children facing organ transplants
received good news at the American Society of Transplantation annual scientific
meeting about new treatments that could increase the supply of organs and
improve chances that children will survive and lead a normal life.
Jorge Reyes, MD, Children's Hospital of Pittsburgh, and Stephen Dunn ,M.D., St.
Christopher's Hospital for Children, discussed studies which that show that
splitting livers from donors -- making it possible for one liver to be
transplanted into two recipients -- can be an effective way to meet the need for
donated organs.
The studies, from Europe and the United Network for Network Sharing, show that
split liver transplants have results equivalent to transplants of whole livers.
While a split liver transplant is somewhat more complicated than a whole liver
transplant, Reyes and Dunn said that learning the procedure is very manageable
and the results make it worthwhile.
"About half of pediatric transplant patients are age five or less," Dunn
explained. "Almost every single one of them would be a candidate for a split
liver transplant. We could shrink, if not eliminate, the waiting list for
pediatric liver transplants every year."
Sue McDiarmid, MDCC, of the UCLA Medical Center, reported on a study which shows
that children who receive liver transplants from donors who are children have a
better graft survival rate than children who receive transplants from adult
donors. The study, by McDiarmid and her colleagues, found that the probability
of graft failure for children who get transplants from pediatric donors is 8.8
percent at one year. If children get livers from adult donors, however, the
probability of graft failure almost doubles, to 16.3 percent.
"This is important because about 2/3 of pediatric donors are now transplanted
into adult patients," McDiarmid said. "Children could benefit from having access
to these organs."
Since transplantation began, most children who receive donated hearts have been
treated with steroids to help them prevent their bodies from rejecting the new
organ. But steroids have particularly dangerous side effects for children,
including reduced growth, loss of calcium, cataracts, amongst others.
Mark Boucek, MD, Children's Hospital Denver, will report that he and his
colleagues have had excellent results treating pediatric heart recipients using
only standard medications and no steroids. Children's Hospital's survival curves
are as good as or better than the national average and the Children's patients
live a more normal life. The results indicate that it is safer to do transplants
without ever using steroids than it is to start patients with steroids and then
try to wean them off.
"It appears steroids are being so widely used for historical reasons -- we use
them because we've always used them -- than for strong medical reasons," Boucek
said.
Cliona Rooney, Ph.D, of the Center for Cell and Gene Therapy at Baylor College
of Medicine will describe a new study that will test whether killer T cells
designed to eliminate Epstein-Barr virus-transformed cells can help fight a form
of lymphoma particularly common in children who have received organ transplants.
The EBV-related malignancies are fatal in about half of solid organ recipients
who develop them. Killer T-cells have proven to be effective as prevention and
treatment for bone marrow recipients, whose immune systems are suppressed
drastically and who are also at risk for EBV-associated lymphomas.
"Solid organ recipients must have their immune systems suppressed for a much
longer time, so we want to test how well they respond to treatments with
EBV-specific cells," Rooney said.

Which patients should be tested for Helicobacter
pylori infection?



Testing should be restricted to patients with clinical manifestations
compatible with H
pylori infection for whom treatment is being planned. Only symptoms of the
upper
gastrointestinal (GI) tract (eg, dyspepsia, bleeding) qualify as possible
manifestations
of H pylori infection. Vague constitutional symptoms (eg, fever, headache,
anemia,
weight loss) do not. The 1994 National Institutes of Health's Consensus
Development Conference report on treatment of H pylori infection indicated
that
only patients with peptic ulcer disease and H pylori infection required
antimicrobial
treatment. This report has recently been updated, and now also recommends
treatment in selected patients with dyspepsia but no ulcers.

These recommendations stem from the following premises: (1) the tests have
been
validated for populations with specific symptoms, and their performance
under
different circumstances is unpredictable; and (2) because most infected
subjects are
asymptomatic, the clinician must be cautious when ascribing the patient's
symptoms
to a concomitant recovery of H pylori.

Regards
Dr Sharat C. Misra MD,DM

Cirrhosis is a term that refers to a group of chronic liver diseases in
which normal liver cells are damaged and replaced by scar tissue, decreasing
the amount of normal liver tissue. The distortion of the normal liver
structure by the scar tissue interferes with the flow of blood through the
liver. It also handicaps the function of the liver which, with the loss of
normal liver tissue, leads to failure of the liver to perform some of its
critically important functions. Cirrhosis and other liver diseases take the
lives of over  thousands of people each year and rank eighth as a cause of
death.

------------------------------------------------------------------------
Cirrhosis is caused by:
Alcohol consumption > 60 gm /day ( 180 ml of 40% proof
whiskey,rum,gin,vodka) for at least 10 yrs

Hepatitis B and C

Inherited disorders like Haemochromatosis, Wilson's Disease, Alpha 1
antirypsin deficiency, Metabolic storage disorders

Biliary obstruction like in Congenital biliary atresia, primary biliary
cirrhosis, sclerosing cholangitis

----------------------------------------------------------------------------
Cirrhosis is an asymptomatic disease till complications set in or it may be
detected on certain blood tests.

It may present as ......jaundice, swelling over feet, distension abdomen,
vomiting of blood, alteration in conscious level .

Once diagnosed treatment is aimed at limiting the complications and survival
becomes shortened.

The onset of cirrhosis is often 'silent' with few specific
symptoms........thus it is important to prevent this disease.



Regards
Dr Sharat C. Misra MD,DM

>Mdmssmile@...
>wrote
>What does it mean to have recurrent cysts on the liver?  They seem to go
away
>and then recur.

Liver cysts are fluid collections inside the liver.
1.They may be congenital ( since birth) in which case they are harmless and
usually stay as they are.
2.They may be due to parasitic infections- common being hydatid, amoebic.
These require treatment or they will continue to grow larger.
3.They may be part of a cystic disease elsewhere like in kidneys and lungs -
polycystic disease. These are the ones which keep appearing and are mulitple
in number.
4. Sometimes there may be  a simple cyst which again is harmless, these may
appear and disappear on their own .

I suspect the recurrent cysts which you are referring to may be in the last
two categories.However detailed investigations are required to confirm the
underlying cause.

Regards
Dr Sharat C. Misra MD,DM

What does it mean to have recurrent cysts on the liver?  They seem to go away
and then recur.

Know your Liver

Liver is  the largest organ in your body and  weighs about 1.25 kg. It lies
in the upper right side of your abdomen situated mostly under the lower
ribs. The normal liver is soft and smooth and is connected to the small
intestine by the bile duct which carries bile formed in the liver to the
intestines. Nearly all of the blood that leaves the stomach and intestines
must pass through the liver. Acting as the body's largest chemical factory
it performs a number of vital metabolic functions including detoxification.
It is no wonder that liver disease can cause widespread  disruption of body
function.

Liver may get diseased from viruses , five different viruses termed A,B,C,D,
and E cause viral hepatitis . Nearly 40 million people in our country suffer
from hepatitis and some  eventually develop  chronic damage to the liver
causing a serious disease called cirrhosis.Viral hepatitis  causes
  "jaundice" along with fever, loss of appetite and fatigue  and usually
lasts 2 to 6 wk.Virus A and E usually spread from contaminated drinking
water  and  cause no chronic liver damage.However, Virus B and C spread from
infected blood or other body fluids , unprotected sex  or intravenous drug
abuse . Treatment in acute stage is mainly rest  and  intake of nutritious
diet while looking out for complications by means  of clinical findings and
blood tests. However,  5-10% of those people who are infected with B virus
and  nearly 80% of those infected with C virus will become carriers and may
progress to chronic liver disease, cirrhosis and possibly liver
cancer.Hepatitis B is more dangerous than AIDS and   thus you  should
protect yourself against it  with a vaccine. The vaccine  can be taken at
any age , it is safe and effective.No vaccine is available for virus C and
E but recently a vaccine for virus A has become available for use in young
adults who are more prone to this illness.

Cirrhosis is a chronic disease in which normal liver cells are damaged and
replaced by scar tissue. It is  commonly caused by excess consumption of
alcohol  and types B and C hepatitis. The onset of cirrhosis is often
'silent' with few specific symptoms but when it is diagnosed it  is often
too late as liver failure has set in. The treatment is mainly aimed at
stopping progression of disease and preventing complications. The only
curative therapy is liver transplantation which is prohibitively expensive
and not yet successful in our country.

Prevention of liver disease is  possible if simple guidelines as mentioned
above are followed . This will prevent many from contracting chronic  liver
disease which has high morbidity and mortality.





Dr Sharat C Misra  MD,DM

Consultant Gastroenterologist

Hepatitis C virus (HCV) is known to account for the great majority of what
was previously referred to as non-A, non-B hepatitis. The hepatitis C virus
was identified and described in 1989, and in 1990 a hepatitis C antibody
test (anti-HCV) became commercially available to help identify individuals
exposed to HCV.
In general, individuals infected with HCV are often identified because they
are found to have elevated liver enzymes on a routine blood test or because
a hepatitis C antibody is found to be positive at the time of blood
donation.
Nearly 80% of people infected with this virus will develop chronic hepatitis
and cirrhosis. Like hepatitis B it is also known to progress to liver
cancer. It is thus important to diagnose and treat this illness early. .
HCV  can be transmitted through blood transfusions and operations. However,
all blood is now tested for the presence of this virus by the antibody test.
It is estimated that the risk of post-transfusion hepatitis C has been
reduced from the 8-10% frequency of infection several years ago to less than
0.5%. Other individuals who may come in contact with infected blood,
instruments, or needles, such as I.V. drug users, health care workers or
laboratory technicians are also at risk of acquiring hepatitis C.
Currently, there is no vaccine available to immunize people against this
virus.

Here are a few more insights into therapy of GERD
In patients with endoscopically demonstrable lesions PPI ( proton pump
inhibitors like omeprazole,lansoprazole , pantoprazole) and prokinetics
  cisapride/metoclorpramide) are very effective in controlling symptoms and
healing esophagitis in 4-6 wk.
Those with gr 4 disease will require maintenance therapy while in gr2-3
disease the cost effective option is to delay maintenance therapy until, but
not beyond , the first relapse /symptomatic recurrence.
In face of poor esophageal motility or absent peristalsis ( as per motility
studies)  laparoscopic surgery is a viable option for long term remission.
It must be remembered that aim of therapy in GERD is control of symptoms. It
is surprising that many clinicians do not aggressively treat endoscopically
negative GERD. These subset of patients have significant motility
disturbances and benefit from fundoplication.
Here is a recent abstract which gives more information on this aspect of
therapy of GERD.

EFFICACY OF MEDICAL THERAPY IN GASTROESOPHAGEAL REFLUX DISEASE DEPENDS ON
THE FUNCTION OF THE LOWER ESOPHAGEAL SPHINCTER AND ESOPHAGEAL PERISTALSIS



Background: The mechanically defective lower esophageal sphincter (LES) is
the main cause of gastroesophageal reflux disease (GERD). Impairment of
esophageal peristalsis may worsen GERD. Medical treatment of GERD is not
causative, thus long-term results may be poor in the presence of a defective
LES. The aim of this study was to evaluate the efficacy of medical treatment
in GERD depending on the function of the LES and esophageal peristalsis.

Methods: We studied 128 consecutive GERD patients with mild esophagitis, no
Barrett's metaplasia, no dysphagia, and no respiratory symptoms. Based on
manometric evaluation patients were divided in 3 groups. Group 1 (n = 26)
consisted of patients with a normal LES (resting pressure >8 mmHg and
intra-abdominal sphincter length >1.2 cm) and normal esophageal peristalsis
(defective contraction waves <20%). Group 2 (n = 63) comprised patients with
a defective LES but normal esophageal peristalsis. Patients of group 3 (n =
39) had a defective LES with impaired esophageal peristalsis. The patients
were treated with omeprazole 20 mg/day for 1 year. Heartburn and esophagitis
responded in all patients after 3 months of treatment. 17 further patients
were excluded from the study since they did not respond to 20 mg of
omeprazole per day initially. Clinical evaluation and endoscopy were
repeated after 1 year. Recurrence of GERD was diagnosed if there was relapse
of heartburn and/or esophagitis.

Results: The recurrence rate was 7.7% in group 1 versus 34.8% in group 2 (p
< 0.05) versus 79.5% in group 3 (p < 0.05 compared with group 2). The
overall recurrence rate was 44.5%.

Conclusions: The results of medical treatment in GERD depend on the function
of the LES and esophageal peristalsis. In patients with a mechanically
defective LES and especially in those with deteriorated esophageal
peristalsis antireflux surgery should be considered.


Regards
Dr Sharat C. Misra MD,DM

Here are a few more insights into therapy of GERD
In patients with endoscopically demonstrable lesions PPI ( proton pump
inhibitors like omeprazole,lansoprazole , pantoprazole) and prokinetics
  cisapride/metoclorpramide) are very effective in controlling symptoms and
healing esophagitis in 4-6 wk.
Those with gr 4 disease will require maintenance therapy while in gr2-3
disease the cost effective option is to delay maintenance therapy until, but
not beyond , the first relapse /symptomatic recurrence.
In face of poor esophageal motility or absent peristalsis ( as per motility
studies)  laparoscopic surgery is a viable option for long term remission.
It must be remembered that aim of therapy in GERD is control of symptoms. It
is surprising that many clinicians do not aggressively treat endoscopically
negative GERD. These subset of patients have significant motility
disturbances and benefit from fundoplication.
Here is a recent abstract which gives more information on this aspect of
therapy of GERD.

EFFICACY OF MEDICAL THERAPY IN GASTROESOPHAGEAL REFLUX DISEASE DEPENDS ON
THE FUNCTION OF THE LOWER ESOPHAGEAL SPHINCTER AND ESOPHAGEAL PERISTALSIS



Background: The mechanically defective lower esophageal sphincter (LES) is
the main cause of gastroesophageal reflux disease (GERD). Impairment of
esophageal peristalsis may worsen GERD. Medical treatment of GERD is not
causative, thus long-term results may be poor in the presence of a defective
LES. The aim of this study was to evaluate the efficacy of medical treatment
in GERD depending on the function of the LES and esophageal peristalsis.

Methods: We studied 128 consecutive GERD patients with mild esophagitis, no
Barrett's metaplasia, no dysphagia, and no respiratory symptoms. Based on
manometric evaluation patients were divided in 3 groups. Group 1 (n = 26)
consisted of patients with a normal LES (resting pressure >8 mmHg and
intra-abdominal sphincter length >1.2 cm) and normal esophageal peristalsis
(defective contraction waves <20%). Group 2 (n = 63) comprised patients with
a defective LES but normal esophageal peristalsis. Patients of group 3 (n =
39) had a defective LES with impaired esophageal peristalsis. The patients
were treated with omeprazole 20 mg/day for 1 year. Heartburn and esophagitis
responded in all patients after 3 months of treatment. 17 further patients
were excluded from the study since they did not respond to 20 mg of
omeprazole per day initially. Clinical evaluation and endoscopy were
repeated after 1 year. Recurrence of GERD was diagnosed if there was relapse
of heartburn and/or esophagitis.

Results: The recurrence rate was 7.7% in group 1 versus 34.8% in group 2 (p
< 0.05) versus 79.5% in group 3 (p < 0.05 compared with group 2). The
overall recurrence rate was 44.5%.

Conclusions: The results of medical treatment in GERD depend on the function
of the LES and esophageal peristalsis. In patients with a mechanically
defective LES and especially in those with deteriorated esophageal
peristalsis antireflux surgery should be considered.


Regards
Dr Sharat C. Misra MD,DM

Hi Judy,
Librax is not good for people with  established GERD .
Consider stopping it and substitute it with a prokinetic drug like cisapride
or metoclorpramide.
Regards
Dr Sharat C. Misra MD,DM

I am a 51 yr. old female who was diagnosed with GERD 6 yrs. ago.  I have been on
a regimen of Previcid and Librax for the past six yrs.  I am never really
without symptoms which include burning in the chest and throat and a constant
cough.  I have had several endoscopies which proved to be negative and showed no
signs of H Pylori bacteria.  I have also had a motility test which showed that
the LES was quite sluggish and that 7 out of 10 swallows were not functioning
properly.  I am very concerned that I will probably be on the medication for the
rest of my life and still I have the discomfort.  Right now I am on 60 mg. of
Previcid because I am experiencing a severe attack.  Any insight would be
greatly appreciated.

Thank you
Judy

Hepatitis B is a global disease with nearly 2000 million people infected
with the virus and 1 million die each year of this disease. It is spread by
acutely infected people and by an estimated 300-500 million people who are
"healthy" carriers. This disease is more infectious than AIDS and is
transmitted through infected blood and other body fluids (seminal fluid,
vaginal secretions, breast milk, tears, saliva and open sores). However, in
approximately 30-40% of cases the method of transmission is unknown.
People who are exposed to blood or body fluids of an infected person are at
risk.
You may also be at risk if
      you are exposed to blood on the job - first aid or emergency
worker,funeral
      director, police personnel, dentist or dental assistant,
medicalpersonnel
      live in the same household with an infected person
      have sex with a carrier or chronically infected person
      use intravenous drugs
      have more than one sex partner
      received a blood transfusion prior to 1975 (when a test to screen blood
was developed)
      have hemophilia
      work or are a patient in a health or long term care facility
      work or are incarcerated in a prison
      travel to countries with a high incidence of hepatitis B. (Africa,South
America,South East Asia, parts of China)

Well tolerated and effective genetically engineered vaccine has been
available  globally and everyone should be protected against this deadly
virus.

Regards
Dr Sharat C. Misra MD,DM

Welcome to GI World community.

This is  a list for discussion related to gastroenterology and
related subjects.

Please send posts to list address: GIWorld@onelist.com
No attachments please.
To unsubscribe send blank email to GIWorld-unsubscribe@onelist.com

Regards
Dr Sharat C. Misra MD,DM
Consultant Gastroenterologist
List Master

I think this type of thing is very important in so many ways, but for me,
more so because I suffer from a mysterious condition. I do not want overwhelm so
if someone is interested in knowing more, just post a reply and I will e-mail
you. I've suffered from fatigue, lower back pain, horrible gas pain and
constipation since I can remember and I am a 35 year old male. I could not
afford a doctor and I didn't realize that the symptoms were abnormal while
growing up. I thought everyone used a half a roll of toilet paper in the
bathroom. I was taught, by my "old school" father, that if you're not bleeding,
you're not hurt and adjusted in such a way that I told myself that working hard
labor like both of my parents was for the birds and I was going to use my brain.
I got sick and tired of being sick and tried three years ago and I went with the
only money I could gather and begged a doctor to help. He told me that I would
have to go to a GI clinic for the gas but he could help me with the lower back
pain. He sold me on this new medicine called Ultram, "It's the effects of a
narcotic with the damage to your body of a Tylenol". It changed my life! My
bowel movements became normal and my pain was gone. I was still tired all the
time but I felt so much better. Well, if it's not broke, don't fix it, I was
told and I spent the next 2 1/2 years ruling out every know digestive disorder
with even a time with mental health to see if I was nut's, (sorry, mentally
challenged?). I have done everything in the book to rule out the more known
problems. I was told I have IBS and I am not satisfied with that diagnosis. No
matter what I eat I go little slivers of defecation without Ultram. I have been
in real good shape during some of my life so spare me the, "just get exercise",
consult, (sorry, I just hurt about it). I am tired all the time and now I see
signs of this in my 1 year old and 9 year old boys. I will travel anywhere I
need to to see anyone that can help. I don't know what else to say but....HELP!
Thank you for your time.

Welcome to all members,
This is an unmoderated list for discussion related to gastroenterology and
related subjects.
Please no attachments....and lets begin.
Regards
Dr Sharat C. Misra MD,DM
List Master