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