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Gastroenterology: Advanced diagnostic tools and endoscopic interventions improve treatment outcome
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A new beginning: Vinay, 12, with his father, who donated part of his liver. Photo by Aayush Goel
A new beginning: Vinay, 12, with his father, who donated part of his liver. Photo by Aayush Goel

Thirty years ago, what was only left to our imagination is now a refined reality in gastroenterology. Today, you just need to swallow a capsule with a camera fitted in it to detect bleeding in your small intestines. You can effortlessly shed kilos of ugly fat through the belly button via a minimally invasive spider surgical system. Also coming soon to India is the latest spy glass system that provides direct visual access to a patient's biliary duct, in full colour and real time. The list goes on.
Gastroenterology, the branch of medicine that focuses on the digestive system and its disorders, is becoming a preferred field to specialise and practise in India, thanks to such advanced diagnostic tools and endoscopic interventions. “It is as much in demand as cardiology among postgraduate students,” observes Dr Philip Abraham, consultant gastroenterologist at Hinduja Hospitals, Mumbai. “Among the top 10 students, at least six readily take up gastroenterology.”
Traditionally considered a sub-speciality of gastroenterology, hepatology that deals with disorders of the liver, gall bladder, biliary duct and pancreas is another branch which is gaining prominence.
Indications for liver transplantation are now expanding to include acute or chronic liver failure, liver carcinoma and other metabolic conditions where liver replacement prevents further complications. In the last 30 months, 571 liver transplants have been done at Indraprastha Apollo Hospitals in Delhi. According to Dr Anupam Sibal, group medical director of Apollo Hospitals, the outcome of the transplants has considerably improved because of increasing number of surgeries, with more than 90 per cent survival rate for the last three years.
Despite technological advancements and an increasing number of centres specialising in liver transplantation, live transplants have remained a challenge across India, thanks to an acute shortage of organ donors.
In August, Union minister Vilasrao Deshmukh, who was diagnosed with liver cancer, died at Chennai's Global Hospitals, where he was flown down from Mumbai for a transplant. He had a 12-hour window of opportunity to be treated with a dual organ transplant (liver and kidney), which may have improved his chances of survival. But the organs came late, although it was categorised as a ‘super ultra-emergency case', a condition that put him ahead of over 200 patients who had registered before him. The only potential donor, a 31-year-old brain-dead patient, had died of cardiac arrest before the organs could be removed.
There is at least one such potential case awaiting transplant almost every week. “An average institute in the US or any developed country performs 100 to 200 transplants a year. But here in Mumbai, we have done less than 50 transplants overall till date. Some hospitals in Delhi claim to have completed 600 transplants,” says Abraham.
There are, however, cases of successful transplants, too. Like that of 12-year-old Vinay. A month after a critical liver transplant, he is finally back in action and waiting to get back to school in his village Jalandhar in Gujarat. Recurrent episodes of jaundice and severe pain in his abdomen over the last four years had almost crippled him, forcing him to drop out of school.
His was a case of primary sclerosing cholangitis—swelling, scarring and destruction of the bile ducts inside and outside the liver. Stent placement by ERCP (endoscopic retrograde cholangiopancreatography), in which a plastic drainage tube is placed in the bile duct to allow it to drain, had failed in his case. The cholecystostomy tube (for drainage of his bile) had not helped him much either.
He was then referred to Indraprastha Apollo Hospitals for a liver transplant. Luckily, he didn't have to wait much as his father donated a part of his liver. Vinay was discharged within 15 days of the transplant.
Many people played a role in Vinay's success story. The village panchayat raised funds from philanthropists across Delhi and Gujarat. Kamala, his mother, gets rather emotional talking about the ones who first touched their lives—the kabaddi players of the village. “When we got to know of his condition, we had no money for any treatment,” she says. “These players helped us by touring places to play benefit matches only to support our boy. Most of them did not even have a proper income to support their own family back home. How many people can think like that?''

Doc talk

Wearable artificial kidneys are going to be a game changer for patients suffering from end-stage kidney disease. In the field of kidney transplantation, there is now a better understanding to optimise the use of immunosuppressive drugs to minimise undesirable side effects. Unlike a few years ago, it is now possible to do kidney transplantation among different blood groups, too. Autologous mesenchymal stem cells in related kidney transplantation is also another hope for not just improved graft survival but also minimal use of expensive immunosuppressive drugs.
Dr D.S. Rana, chairman, board of management and department of nephrology, 
Sir Ganga Ram Hospital, Delhi

Whats New

Capsule endoscopy
A non-invasive method to detect small bowel ulcers and growths. A small capsule with a camera, when swallowed, takes images of the small bowel for eight hours.
Endoscopic ultrasound (EUS)
This method combines the advantages of endoscopy and ultrasound. Apart from taking pictures, it also takes samples or biopsies of abnormalities in the pancreas or stomach wall. Bile duct stones can be diagnosed without the risk of radiation.
Impedance and high resolution manometry
Manometry is the study of pressure in the oesophagus and impedance shows boluses of air or liquid passing in the oesophagus. A combination of the two can diagnose gastro-oesophagal reflux or abnormal pressure that causes difficulty in swallowing.
This machine measures the stiffness of the liver, and thus determines 
various stages of liver damage 
without invasive biopsy.
With inputs from Dr Naresh Bansal, consultant gastroenterologist and transplant hepatologist, Sir Ganga Ram Hospital, and Dr Anupam Sibal, Dr Subhash Gupta and Dr Manav Wadhavan of Apollo Hospitals

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