4. Stressed importance of other specialties Surgical
Gastroenterology, Pathology, Microbiology Radiology
Dr Rangabashyam with Dr NMG
Dr Panda, Dr Thiagarajan
Dr Panchanadam,
Dr Sankaranarayanan
Dr Arcot Gajaraj
5. A Teacher par excellence &
STUDENT
Jotting down points at meetings
7. RESEARCH CONTRIBUTIONSâĻ.. DR NMG
ERA
īĸ Intestinal amoebiasis
īĸ HBV virus : Dr BN Tandon
Dr Panda, Dr. SPT
īĸ Hepatic venous outflow tract obstruction
īĸ Tropical Pancreatitis: Dr S. Chari
8.
9. AS A HUMAN BEINGâĻ..
īĸ Perfect, humble, and simple
īĸ Great concern for his extended family âĻ.risen in
career
īĸ Love for animals
īĸ Fond of trees & plants
10. Pre âGandhiâ Nagar Era
Govt General Hospital
MadrasâĻ.. 8 years
âGandhiâNagar EraâĻ. 4 years
DDHD, Govt. Peripheral Hospital
Anna Nagar, Madras
19. COMMON ERRORS IN CLINICAL
DIAGNOSISâĻ
īĸ Veno Occlusive Disease
īĸ Constrictive pericarditis
īĸ Nephrogenic ascites
īĸ Filarial lower extremities (Panchanadam N et al, 1986)
īĸ Varicose veins with repeated stripping of veins
īĸ APLS syndrome (Hypertension + IVC obstruction)
Ref: Joy V, Rajesh P et al Neth J Med 2008;66:175,180
53. ENDOVASCULAR TREATMENT âĻ
HVOTO
Joseph G, George OK, Pati PK, Eapen CE, Malathi S,
Sathyabhama C, Jayanthi V
Christian Medical College, Vellore, Precision
Diagnostics and Stanley Medical College, Chennai
Ref: Indian Heart Journal 2002; 54; 731-2
54. īĸ Period of study: 1994-2003
īĸ No. of patients: 64 patients
īĸ Mean age 32 īą 12 yrs, range 6 to 64 yrs
īĸ Sex ratio: 1.5 :1
īĸ Idiopathic : 49 (77%)
īĸ Prothrombotic state:15 (23%)
īĸ Mean duration of symptoms: 34 īą 6 mo
Patient Details
55. SITE OF OBSTRUCTION AT ANGIOGRAPHY
īĸ Suprahepatic inferior vena cava : 26 (41%)
īĸ Hepatic veins: 13 (20%)
īĸ Inferior vena cava+ Hepatic vein: 25 (39%)
īĸ Length of obstruction: 2 mm to 3 cm
īĸ Type of obstruction: partial or complete
59. RESULTS & FOLLOW-UPâĻ
īĸ Successful procedure
ī 42 of 45 patients (93%)
īĸ Antegrade flow
īĸ Pressure gradient
ī IVC-RA: 15.0+2.5 to 5.5+0.8 mm Hg (p<0.01)
Ref: Indian Heart Journal 2002; 54; 731-2
60. COMPLICATIONS
īĸ Bleed related : 4 patients
īĸ Cardiac tamponade : one patient â died
īĸ Right hemothorax : one patient
Settled with conservative management or aspiration
61. ALGORITHM âĻ.PRESENT DAYS
Treatment depends on
onset
site
extent of obstruction
Anticoagulation (acute)
Angioplasty + Stent deployment
Liver transplantation
* Surgical bypass âĻ not recommended
62. KEY POINTS
īĸ BCS: Rare but life threatening disorder
īĸ Only curable form of portal hypertension
īĸ Early recognition possible in patients with
ī Resistant ascites
ī Back veins
ī Venous congestion in lower limbs
īĸ US & Doppler of portal, HV and IVC: initial screening
procedure
66. LESSONS I LEARNT âĻ.. DR NMG & DR SV
īĸ Hard work and dedication paves way to success
īĸ Not to give up easily: hurdles can be circumvented
īĸ Step by step the art of writingâĻ
69. īĸ Jayanthi V, Chacko A, Karim G, Mathan VI. Intestinal
transit in healthy southern Indian subjects and in
patients with tropical sprue. Gut 1989; 30: 35-8âĻ..
ī Normal transit time of a healthy south Indian 22 hrs
74. THE FIVE FâSâĻ
īĸ Gall bladder stone diseases
ī Fat
ī Fertile
ī Fair
ī Female
ī Forty
īĸ UDCA as an agent for dissolving GS
75. WHY THE RESEARCH INTEREST??
Why white GS in N India?? Why black GS in S. India??
76. PATTERN OF GS
DISEASEâĻCHENNAI
īĸ Retrospective study: 1986-1992
īĸ No. of patients : 346 patients
īĸ Mean age
ī Men: 51.1. yrs
ī Female: 46.2 yrs
īĸ M:F ratio: 1.3:1
īĸ Macroscopic appearance
ī Black pigment GS: 77%
ī Mixed GS: 17%
ī Cholesterol : 6%
Jayanthi V. JAPI 1996;44:461-4
77. GALLSTONESâĻ.SOUTH INDIA
īĸCase - controlled study
īĸ Equally common in either sex
īĸRisk factors
ī Women
īĸObesity
īĸDiabetes
ī Men
īĸSedentary
īĸRetired life style
īĸAbstinence from smoking
Ref: Jayanthi V et al: Bombay Hospital Journal 1999;41:494-502
78.
79. GALL STONESâĻ. S. INDIA
īĸ Analysis of 105 gallstones
ī Pigment GS: 67 (68.%)
īĸ Black : 55%
īĸ Amorphous: 63%
ī Intermediate/mixed type : 36 (34.8%)
īĸ Variegated color: yellow to ivory white : 61%;
īĸ Hard in 50%
ī Cholesterol stones: 2
īĸ Multiple
īĸ Hard and brown
Jayanthi V et al. IJ G 1998; 17: 134-5
82. PRINCIPLEâĻ..
īĸ Identifies and Quantitates
ī Components organic or inorganicâĻ solids, liquids, & gas
īĸ Strength of absorption is proportional to
concentration
ī Range from few ppm up to the percent level
84. 0 200 400 600 800 1000
1
10
100
1000
K
ZnZn
Cu
Fe
Fe
Mn
Ca
Ca
Counts/Channel
Channel Number
0 200 400 600 800 1000
10
100
1000
PbPb
Zn
Zn
Cu
Cu
Fe
Fe
MnCa
Ca
K
Counts/Channel
Channel Number
Cholesterol gallstone
0 200 400 600 800 1000
1
10
100
1000
PbZn
Zn
Cu
Fe
Fe
Mn
Ca
Ca
K
Counts/Channel
Channel Number
Mixed gallstonePigment gallstone
EDXRF
spectra
Energy Dispersive X-ray
Fluorescence
Ref: Ashok et al.International Journal of PIXE. 2002; 12,137-144
87. īĸ Study centre :
ī Regional Sophisticated Instrumentation Centre, IIT, Chennai
īĸ Analysis: 213 GS
īĸ Centres
ī Tamil Nadu 125
ī Kerala 21
ī Karnataka 22
ī Hyderabad 45
Ref: Ashok et al. Tropical Gastroenterology 2005;26:73-5
88. Cholesterol (īg/g) Mixed (īg/g) Pigment (īg/g)
K 3.9 13.0 92.1
Calcium 171.2 1792.4 7861.7
Ti 44.4 65.5 39.9
V 7.8 9.5 5.8
Cr 29.6 3.6 None--
Mn 4.1 17.0 75.8
Iron 85.9 51.2 205.8
Co 2.8 2.4 4.2
Ni 65.4 1.4 26.2
Copper 10.2 51.1 3050.0
Zn 7.5 11.9 129.0
As -- -- 9.3
Se 1.4 -- 3.6
Br 4.3 2.7 11.5
Sr 1.3 3.6 32.3
Y 3.1 3.1 9.2
Zr 8.0 16.6 17.0
Mo 3.8 3.1 5.1
Hg 2.0 1.9 17.5
Pb -- 1.3 68.5
I -- -- --
89. Regional differences in elemental constituents
TN, Kerala, Karnataka Andhra Pradesh
Cholesterol
GS
Low concentration V, Ni, Ca, Ti, Cr, K, Fe, Cu, Zn Sr, Zr, Hg K, Ca,
Fe, Cu, Zn
High concentration Ni, Cr
Pigment
GS
Low concentration V, Ni, Cr, As, Sr, Ba Ni, V
Absent Cr
High concentration K, Ca, Mn, Fe, Cu, Zn,
Br, Pb, Cu
K, Ca, Mn, Fe, Cu,
Zn, Br, Pb, Sr, Hg
Mixed
GS
Low concentration V, Ni Cr
High concentration Ti, Cr, Ca, K, Fe, Cu, Zn Ti, K, Ca, Fe, Cu,
Zn
Ashok M et al Tropical Gastroenterology 2005;26:73-5
90. Method North India
Cholesterol Pigment Mixed
South India
Cholesterol Pigment Mixed
Visual 10 - - 5 30 15
FTIR 10 - - 5 30 15
PIXE 10 - - 5 30 15
Comparison of North & South Indian CHOLESTEROL GS
91. 4000 3500 3000 2500 2000 1500 1000 500
South Indian Cholesterol
%Transmittance
cm
-1
FTIR- Cholesterol gallstone
North India
South India
Ref:Ashok M et al. J Med Sci & Res 2012;3:3-5
92. 0 100 200 300 400 500
10
0
10
1
10
2
10
3
0 100 200 300 400 500
10
0
10
1
10
2
10
3
10
4
10
5
South India
Ti
Mn
Pb
Pb
Br
Zn
Zn
Cu
Fe
Fe
Ca
Counts(Log)
P
North India
Pb
Br
Pb
Zn
Zn
Fe
Mn
Fe
Ca
Ca
Channel Number
PIXE analysis of cholesterol gallstones from South and North India
93. Element North India South India
K 183 4
Ca 2283 171
Cr - 9
Mn 2 4
Fe 66 86
Cu 21 10
Zn 2 8
Br 1 4
Sr - 2
Pb 0.1 0.3
Concentration in ppm
Ref:Ashok M et al. J Med Sci & Res 2012;3:3-5.
CHOLESTEROL GALLSTONES
94. QUESTION ???
īĸ The cause of high copper and iron content in the
pigment stone not clear
īĸ Could it be dietary in origin ?
95. IS A DIETARY FACTOR RESPONSIBLE
..?
īĸ Positive association
īĸ Tamarind (OR 27.6; 95 % CI 9.5 to 84.4)
īĸ Spicy foods (OR 6; 95%CI 2.8 to 16.3)
īĸ Fried foods (OR 9.1; 95%CI 2.8 to 33.2) (âĨ4 times per week)
īĸ Cooking oil âĨ300 mL per month (OR 62.0; p<0.0000)
īĸ Negative association
ī Vegetables : âĨ2 times per week (OR 0.09; 95 % CI 0.04-0.21)
ī Fruits: > 3 times / week (OR 0.45; 95 % CI 0.20 to 0.99)
ī Sugar: (OR 0.27; 95 % CI 0.07 to 0.95)
ī Tea and coffee : less frequently by cases (2.5 vs. 2.9 cups/day; ANOVA
p<0.01).
Ref: Alexander, Vijaya S, Srinvas M, Jayanthi et al.
Indian J Gastroenterol 2005 & 2014
96. TAMARINDâĻCAUSE FOR GS
īĸ ICPMS ( Elan 6100 Perkin Elmer SCIEX )
īĸ Elemental concentration
ī Chromium: 1.2 ppm
ī Iron: 12.99 ppm
ī Copper : 4.75 ppm
ī Zinc: 11.93 ppm
īĸ Zn and Fe are in high concentration
Ashok M (NIT, Trichy), Jayanthi V (personal observation)
98. īĸ Retrospective data : 2001 to 2010
ī Gallbladder cancer
ī Cholecystectomy for GS disease
īĸ Data retrieved : age, gender, clinical presentation,
findings on imaging, histology and details of management
Ref: Sachidananda et al. Indian J Surg Oncol 2012;3:228â230
99. RESULTSâĻCHOLECYSTECTOMY: 758
PATIENTS
īĸ GB Ca cases : 38 men; 23 women
īĸ Male female ratio: 1.6:1
īĸ Stage I: 6 patients (9.8 %).
īĸ Stage IV disease : 40 patients (50 %)
īĸ Co-existing GS: 12 patients (19.6%)
īĸ Conclusion : GB CA uncommon in S. India; association with
GS is low.
100. SYMPTOMATIC GALL STONES VERSUS GB
CARCINOMA
0
20
40
60
80
100
120
140
2007 2008 2009 2010
GS
GB CA
Noofcases
101. NORTH VS SOUTH INDIAâĻ.
NorthIndia
īĸ More in women
īĸ Cholesterol GS:80-90%
īĸ Pigment GS: 9.4%
īĸ GS: hard, faceted
īĸ Obesity, high cholesterol
īĸ High incidence of GB cancer
SouthIndia
īĸ M:F: 1.3:1
īĸ Cholesterol GS: 6%
īĸ Pigment GS: 77%
īĸ Soft and amorphous
īĸ No hemolysis
īĸ Non infective bile
īĸ GB cancer rare
103. ONGOING RESEARCH WORK
īĸ Composition of bileâĻ.is south Indian bile non lithogenic?.....
Personal information: low cholesterol
īĸ Crystallisation of GS based on bile composition
īĸ Dissolution of synthesized GS by chemical agents
105. SUMMARYâĻ
īĸ Gallstones from south India are distinctive
ī Morphology
ī Chemical composition
īĸ Majority are pigment or mixed
īĸ Bile is non lithogenic (Ms Ramya, personal communication)
īĸ GB cancer incidence is low
108. Adult and Pediatric Gastroenterologists
Stanley Medical College & Hospital
The New GenerationâĻâĻâĻâĻâĻâĻâĻâĻ
109. īĸ Krishnaveni: excels in EUS at PSG
īĸ Randhir (Cleveland): Liver indices in PHT
īĸ Sumathi, Hema & Nirmala (HOD, ICH)âĻ.. Epidemiology of
carcinoma stomachâĻNow Crohnâs disease in children
īĸ Rajesh (Salem)âĻ.several case reports
īĸ Rajesh (Madurai)âĻ.H pylori and long term PPI
īĸ Jijo CherianâĻ.epidemiology of ca stomach and esophagus
īĸ Joy Verghese âĻ..cirrhosis liver, liver transplant related (12
publications as a DM student)
īĸ ArvindâĻ.Leptospirosis, HCV management
īĸ Arul selvam and SivaâĻ. Hepatitis B, Alcohol:liver and pancreas
DM PGs
110. MD & MS STUDENTSâĻMMC, SMC
īĸ Uday NavneethamâĻ.a MD PG, MMC, today a
leading Gastroenterologist at Florida Hospital,
Orlando started his journey with a publication in
Am J Gastroenterology on Hepatic encephalopathy
âĻ..
īĸ PrabhuâĻAcute corrosive injury
īĸ Mala: waist and hip circumference in GERD
ī Indian J Gastroenterol 2015 (in press)
īĸ âĻâĻ. Many more
111. MEDICAL STUDENTSâĻ..FINAL YEARSâĻ MMC,
KMC & SMC
īĸ Dr Saurav (3 rd year): plenary paper, ISG, Jaipur, Mind
and Liver test
īĸ Guru Vythi, Guru, KMCHâĻâĻpublications on Dyspepsia
and GERD among hospital personnel
īĸ Alexander and Ramya (6 publications): epidemiology of
gallstones, GER in pregnancy, long term effects of PPI
on gastric mucosa
īĸ Arun Kumar: at least 20 publications, co-authored GE
text book, now in New York
īĸ Anand and Ashok: Gall stone dietary factors
116. PROFESSIONAL HURDLESâĻ.
īĸ Every day is filled with small steps
Every step is a learning hurdle
Every hurdle can be overcome
Every hurdle that is overcome makes you a
stronger person
īĸ As hard as the journey may be
Never regret climbing those small steps
Never regret crossing the hurdles
In the end, that is what will bring you success
117. CORPORATE SECTORâĻ..WORK CONTINUES âĻ DR
M RELA
īĸ Dr Joy VergheseâĻ.transplant related
īĸ Dr DineshâĻacute liver failure
īĸ Dr DeeptiâĻ.transfusion medicine
īĸ Dr PalaniappanâĻ EUS, therapeutic endoscopy
īĸ Dr R RaviâĻtherapeutic endoscopy
īĸ Dr SrinivasâĻ..motility study
123. âĻâĻ..NON GOVERNMENTAL SECTOR
īĸ CMC HospitalâĻ..Prof VI Mathan, Dr Ashok Chacko, Dr BS
Ramakrishna
īĸ United Kingdom : Dr Mayberry, Leicester General Hospital
ī Inflammatory Bowel Disease
īĸ Dr Vijaya Srinivasan MD, MSc (Epid)
ī Director, Research, Global Hospital
124. For South India to remain in forefrontâĻ time to wake
up in the research frontâĻ. Represent in full strength
in the National Forum of Indian Society of
Gastroenterology
Great researchersâĻâPublish or Perishâ
129. A person with academic brilliance
A person with a vision
130.
131. FOR THE FUTUREâĻ..
īĸ What is the nidus of the GSâĻ.?
īĸ Is there a role for bacteriaâĻ.?
ī Our study showed E coli was present in 20%
īĸ Are there other dietary factorsâĻ?
īĸ Is GS disease a genetic disorderâĻ?
132. FURTHER READINGâĻ
īĸ Ashok M et al. International J PIXE, 2002
īĸ Ashok M et al. Radiol Nuclear Chem 2002
īĸ Gokulakrishnan S et al. Gastoenterology Today,
2002
īĸ Gokulakrishnan S et al. Tropical Gastroenterol
2001;22:87-9
133. ACKNOWLEDGEMENTSâĻ
īĸ Dr. Naryana Kalkura PhD,
Crystal Growth Centre
īĸ Dr. Devaraj PhD, Glycotechnology Centre
īĸ Dr. Ashok M PhD
īĸ Dr. Gokulakrishnan S, PhD, Germany
īĸ Dr. Meenakshi
īĸ Dr. V. Vijayan PhD, Institute of Biophysics,
Bhubaneswar
īĸ My colleagues at Stanley Medical College
134. QUALITATIVE ANALYSIS..
īĸ Wavelength of light absorbed is characteristic of the chemical bond i.e.
(functional groups)
īĸ FTIR spectra of pure compounds are unique : like a molecular
"fingerprint".
īĸ Organic compounds have very rich, detailed spectra, inorganic
compounds are usually much simpler
īĸ Spectrum of an unknown can be identified by comparison to a library of
known compounds
īĸ Can be combined with NMR, mass spectrometry, emission spectroscopy,
X-ray diffraction
135. RECOMMENDED READINGâĻ
īĸ Datta et al: Gut 1972; 13:372-378
īĸ Madanagopalan et al: J Gastroentrol Hepatol 1986; 1:359-
369
īĸ Victor et al: Coarctation of Inferior vena cava. Tropical
Gastroenterology 1987;8:127-142
īĸ Monograph: Victor et al. Coarctation of Inferior Vena Cava,
1996
īĸ Eapen CE et al. Changing profile of BCS in India. Indian J
Gastroenterol 2007;26(2):77-81
īĸ Amarapurkar DN et al. Changing spectrum of Budd-Chiari
syndrome in India with special reference to non-surgical
treatment. World J Gastroenterol 2008;14:278-85