Oration under the auspices of TN Chapter of ISG

PROF N MADANAGOPALAN MD FRCP

PROF NMG….....

Had a dream and a visi

on for

Gastroente

rology

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

A Teacher par excellence & STUDENT

Jotting down points at meetings

A KEEN RESEARCHER… MAJOR CONTRIBUTIONS

RESEARCH CONTRIBUTIONS….. DR NMG ERA

Intestinal amoebiasis

HBV virus : Dr BN TandonDr Panda, Dr. SPT

Hepatic venous outflow tract obstruction

Tropical Pancreatitis: Dr S. Chari

AS A HUMAN BEING…..

Perfect, humble, and simple

Great concern for his extended family ….risen in career

Love for animals

Fond of trees & plants

Pre “Gandhi” Nagar EraGovt General HospitalMadras….. 8 years

“Gandhi”Nagar Era…. 4 yearsDDHD, Govt. Peripheral HospitalAnna Nagar, Madras

MADRAS MEDICAL COLLEGE & GOVT. GENERAL HOSPITAL

1978 …..MD PG

Cirrhosis with ascites……. Some unusual features

Dr NMG & Dr Solomon Victor

Cirrhosis with Portal

hypertension

Resistant to tre

atment !!!!

CLINICAL PRESENTATION

Pot belly Spider man

Hepatic Vein OcclusionLarge tender liver, tense ascites Absent HJR, Spleen (small)

Scrotal varicocoele

Lower extremity congestive findings

Prominent neck veins

Suprahepatic IVC occlusion

Suprahepatic IVC occlusion

Note: back vns

Madanagopalan N, Jayanthi V, Victor S et al. J Gastroenterol and Hepatol 1986; 1: 359-69

CLINICAL PROFILE (IN %)…HVOTO

HV IVC CombinedAbd. Pain 60 70 64Ascites 75 62 36Jaundice 50 20 4

Pedal edema 40 90 29Veins abd/trunk 70 93 79Varicose veins, stasis ulcers leg

0 22 18

Fever 10 29 11

Madanagopalan N, et al. J Gastroenterol Hepatol 1986;1:359-69.

COMMON ERRORS IN CLINICAL DIAGNOSIS…

Veno Occlusive Disease

Constrictive pericarditis

Nephrogenic ascites

Filarial lower extremities (Panchanadam N et al, 1986)

Varicose veins with repeated stripping of veins

APLS syndrome (Hypertension + IVC obstruction) Ref: Joy V, Rajesh P et al Neth J Med 2008;66:175,180

AETIOLOGY… CONGENITAL OR ACQUIRED

Extension of obliteration of ductus venosus into LHV BCS in situs inversus totalis

‘Coarctation of IVC’ akin to coarctation of aorta

Filariasis & BCS

Victor S, Jayanthi V, Panchanadam M et al. Budd Chiari syndrome and pericaval filariasis. Tropical Gastroenterology 1994; 15: 161-8

Coarctation of inferior vena cava

The Birth…

REVIEWING THE LITERATURE

PREVALENCE

High prevalence of Coarctation of IVC Africa China IndiaJapanNepalUSA (few)

PREVALENCE OF PHT (%)

Centre Cirrhosis NCPF

EHPVO

HVOTO (BCS)

Lucknow 70 10 20 -

Chandigarh

42 15 36 7 %

Jaipur 33 40 27 -N Delhi(GB) 53 20 20 6 %N. Delhi(AIIMS 26 19 55 -

Calcutta 52 47 1 -

Chennai 88 - 12 3 %

HVOTO… DIFFERENCES United

KingdomIndia

(regional distribution)Japan, China

HV (%) 79 Jaipur, Mumbai (42%-59%)

7

IVC (%) 17 Delhi, Calcutta, Chennai (54%-82%)

93

Combined (%)

5 Chandigarh, Mumbai Vellore, Lucknow (54%-64%)

EAST VS WEST….1980’S-1990’S

Western Countries HV thrombosis: 80%

Haematological disorders

30-55%

Oral Contraceptives

Afro-Asian Countries HV thrombosis 0-32%

Hypercoagulable states rare…(no prothrombotic work up)

Congenital membrane IVC

Infection

INVESTIGATIONS…

Hemogram

R/O Hypercoagulable states

Radiological Investigations Invasive and noninvasive

INFERIOR VENA CAVOGRAM & FUNCTIONAL HEPATOGRAMBERNARD INSTITUTE OF RADIOLOGY

(Late) Prof Arcot Gajaraj MD

(Late) Dr I Kandasamy MD

1978-1980

BIDIRECTIONAL VENACAVOGRAM

Bird’s beak Shrimp-like Dolphins’ nose Giraffe’s neck

X-mas tree

Carrot Cucumber Drumstick

Dome shaped Wine glass

Penguin

IDENTIFYING THE HEPATIC VEIN/S

Trans femoral Hepatic vein cannulation

Simultaneous Transfemoral, Transatrial and Functional hepatogram

Functional hepatogram

Central Intermediate Portal Superficial

Intrahepatic&Perihepatic collaterals

Note the intrahepatic interlacing collaterals

Note: Thoracic duct

Note:intrahepatic collaterals

Thrombus within IVC & Vertebral collaterals

CENTRAL AND RETROPERITONEAL COLLATERALS

ULTRASOUND AND DOPPLER

1985-1990Dr Bharathi Dhala, Dr Sathyabhama

Ultrasonogram

Jayanthi V et al Clin Radiol 1988; 39: 154-8

Doppler in BCS

Ref: Satyabhama C, Jayanthi V et alAnn Gastroenterol 2007, 20:218-222

MRI showing venae commitantesIVC gm showing identical findings

EVALUATION OF BCSHigh index of clinical suspicion

US with Doppler : HV, IVC & Portal Vein

HVOTO confirmed HVOTO not confirmedStrong clinical suspicion

Therapeutic IVC & Hepatic venography

Thrombophilic & Cardiac evaluation

CT angio/MR angio

HVOTO not confirmed

Liver biopsy : laparoscopy

Ref: Jayanthi V, Udhaykumar N. BCS: Changing epidemiology. Minerva Gastroenterologica E Dietologica 2009;55:85-89

MANAGEMENT

SURGERY…1980’S

SURGICAL SHUNTS…

Principle decompress the liver by

Cavoatrial shunt, mesoatrial shunt etc….

Indications (with a patent portal vein) non-fulminant presentation chronic without significant hepatic fibrosis

Ref: Victor S, Jayanthi V, Raghuram K, Madanagopalan N. J Thorac Cardiovasc Surg 1986; 91: 99-105

•Victor S, Jayanthi V, Madanagopalan N.Bull ATCVS of India 1979, 1:29•Victor S, Jayanthi V. Indian J Thorac Cardiovasc Surg 1983; 2: 55-8

Pre and Post – operative graft patency

PRE POST PREPOST

NOT TOO FAR BEHIND….

ENDOVASCULAR TREATMENT … 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

Period of study: 1994-2003 No. of patients: 64 patients Mean age 32 12 yrs, range 6 to 64 yrs Sex ratio: 1.5 :1

Idiopathic : 49 (77%) Prothrombotic state:15 (23%)

Mean duration of symptoms: 34 6 mo

Patient Details

SITE OF OBSTRUCTION AT ANGIOGRAPHY

Suprahepatic inferior vena cava : 26 (41%)

Hepatic veins: 13 (20%)

Inferior vena cava+ Hepatic vein: 25 (39%)

Length of obstruction: 2 mm to 3 cm Type of obstruction: partial or complete

RECANALISATION PROCEDURES

Suprahepatic IVC (47)• Balloon angioplasty: 24 • Additional stenting : 23

Pre Post Pre Post

Pre Post

HEPATIC VEIN ANGIOPLASTY

Terminal HV obstruction (28)

• Recanalisation : 28• Additional stenting: 26

RESULTS & FOLLOW-UP… Successful procedure

42 of 45 patients (93%)

Antegrade flow

Pressure gradient IVC-RA: 15.0+2.5 to 5.5+0.8 mm Hg (p<0.01)

Ref: Indian Heart Journal 2002; 54; 731-2

COMPLICATIONS

Bleed related : 4 patients

Cardiac tamponade : one patient – died

Right hemothorax : one patientSettled with conservative management or aspiration

ALGORITHM ….PRESENT DAYS

Treatment depends ononsetsite

extent of obstruction

Anticoagulation (acute)

Angioplasty + Stent deployment

Liver transplantation

* Surgical bypass … not recommended

KEY POINTS BCS: Rare but life threatening disorder Only curable form of portal hypertension

Early recognition possible in patients with Resistant ascites Back veins Venous congestion in lower limbs

US & Doppler of portal, HV and IVC: initial screening procedure

WORK ON CIVC ….1978 TO 1996..

7-LONG YEARS

Hunterian Award…1996

LESSONS I LEARNT ….. DR NMG & DR SV

Hard work and dedication paves way to success

Not to give up easily: hurdles can be circumvented

Step by step the art of writing…

SECOND INNINGS…MOVED on…..DM (GE)

CMC, Vellore 1982-84

Jayanthi V, Chacko A, Karim G, Mathan VI. Intestinal transit in healthy southern Indian subjects and in patients with tropical sprue. Gut 1989; 30: 35-8….. Normal transit time of a healthy south Indian 22 hrs

GANDHI NAGAR….ERA

Dept of Digestive Health & DiseaseGovt. Peripheral Hospital,

KMCH, Chennai

6 AUGUST, 1986….OCT 1990

GALLSTONE DISEASE

THE FIVE F’S… Gall bladder stone diseases

Fat Fertile Fair Female Forty

UDCA as an agent for dissolving GS

WHY THE RESEARCH INTEREST??

Why white GS in N India?? Why black GS in S. India??

PATTERN OF GS DISEASE…CHENNAI Retrospective study: 1986-1992 No. of patients : 346 patients Mean age

Men: 51.1. yrsFemale: 46.2 yrs

M:F ratio: 1.3:1 Macroscopic appearance

Black pigment GS: 77%Mixed GS: 17%Cholesterol : 6%

Jayanthi V. JAPI 1996;44:461-4

GALLSTONES….SOUTH INDIA

Case - controlled study Equally common in either sexRisk factors

WomenObesityDiabetes

MenSedentaryRetired life styleAbstinence from smoking

Ref: Jayanthi V et al: Bombay Hospital Journal 1999;41:494-502

GALL STONES…. S. INDIA

Analysis of 105 gallstones

Pigment GS: 67 (68.%) Black : 55% Amorphous: 63%

Intermediate/mixed type : 36 (34.8%) Variegated color: yellow to ivory white : 61%; Hard in 50%

Cholesterol stones: 2 Multiple Hard and brown

Jayanthi V et al. IJ G 1998; 17: 134-5

BIOCHEMICAL COMPOSITION….GS

Pigment

Mixed

Cholesterol

7.1% 30.2%

Bilirubin 26.1% 18.4%

Calcium 7.8% 6.3%Jayanthi V et al. IJ G 1998; 17: 134-

5

PRINCIPLE…..

Identifies and Quantitates Components organic or inorganic… solids, liquids,

& gas

Strength of absorption is proportional to concentrationRange from few ppm up to the percent level

Cholesterol

Calcium bilirubinate

Calcium carbonate

Mixed stoneRef: Gokul et al Trop Gastroenterol2001; 22:87-9

0 200 400 600 800 1000

1

10

100

1000

K

ZnZnCu

Fe

Fe

MnCa

Ca

Co

un

ts/

Ch

an

ne

l

Channel Number

0 200 400 600 800 1000

10

100

1000

PbPb

Zn

Zn

Cu

Cu

Fe

Fe

MnCa

Ca

K

Counts

/ C

hannel

Channel Number

Cholesterol gallstone

0 200 400 600 800 10001

10

100

1000

PbZnZn

Cu

Fe

Fe

MnCa

Ca

K

Co

unts

/Ch

ann

el

Channel Number

Mixed gallstonePigment gallstone

EDXRF spectra

Energy Dispersive X-ray Fluorescence

Ref: Ashok et al.International Journal of PIXE. 2002; 12,137-144

Elemental concentration of gallstones in ppm

ElementCholesterol Mixed Pigment

K 840.069 800.974 206.858 3810.694 825.016

Ca 1233.671 1240.936 1.479 1.481 %w 1.313 1.315 %w

Mn 0.078 0.325 0.326 0.649 0.651

Fe 519.700 31.752 419.070 22.796 1522.025 84.364

Cu 19.938 4.535 20.035 4.261 2770.790 583.674

Zn 12.650 14.115 3.586 337.268 82.455

Br 5.249 2.567 0.435 7.147 1.425

Rb 1.626 1.775 0.486 4.176 1.166

Sr 0.837 5.251 5.259 2.961 2.973

Pb 0.268 0.471 0.472 7.227 7.237

COLLABORATIVE STUDY…SOUTHERN STATES

Study centre : Regional Sophisticated Instrumentation Centre, IIT, Chennai

Analysis: 213 GS

Centres Tamil Nadu 125 Kerala 21 Karnataka 22 Hyderabad 45

Ref: Ashok et al. Tropical Gastroenterology 2005;26:73-5

Cholesterol (g/g) Mixed (g/g) Pigment (g/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 -- 3.6Br 4.3 2.7 11.5Sr 1.3 3.6 32.3Y 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 -- -- --

Regional differences in elemental constituentsTN, Kerala, Karnataka Andhra Pradesh

CholesterolGS

Low concentration V, Ni, Ca, Ti, Cr, K, Fe, Cu, Zn Sr, Zr, Hg K, Ca, Fe, Cu, Zn

High concentration Ni, Cr

PigmentGS

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

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

4000 3500 3000 2500 2000 1500 1000 500

South Indian Cholesterol

% T

ran

smit

tan

ce

cm-1

FTIR- Cholesterol gallstone

0.0

20.0

40.0

60.0

80.0

100.0

%T

500.01000.01500.02000.03000.04000.01/cmgbs113

North India

South India

Ref:Ashok M et al. J Med Sci & Res 2012;3:3-5

0 100 200 300 400 500

100

101

102

103

0 100 200 300 400 500

100

101

102

103

104

105 South India

Ti

Mn

PbPb

Br

Zn

ZnCu

Fe

Fe

Ca

Co

un

ts (

Lo

g)

P

North India

Pb

Br

Pb

ZnZn

Fe

MnFe

Ca

Ca

Channel Number

PIXE analysis of cholesterol gallstones from South and North India

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

QUESTION ???

The cause of high copper and iron content in the pigment stone not clear

Could it be dietary in origin ?

IS A DIETARY FACTOR RESPONSIBLE ..?

Positive association Tamarind (OR 27.6; 95 % CI 9.5 to 84.4) Spicy foods (OR 6; 95%CI 2.8 to 16.3) Fried foods (OR 9.1; 95%CI 2.8 to 33.2) (≥4 times per week) Cooking oil ≥300 mL per month (OR 62.0; p<0.0000)

Negative association Vegetables : ≥2 times per week (OR 0.09; 95 % CI 0.04-0.21) Fruits: > 3 times / week (OR 0.45; 95 % CI 0.20 to 0.99) Sugar: (OR 0.27; 95 % CI 0.07 to 0.95) 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

TAMARIND…CAUSE FOR GS ICPMS ( Elan 6100 Perkin Elmer SCIEX ) Elemental concentration

Chromium:  1.2 ppm Iron:     12.99 ppm Copper : 4.75 ppm Zinc: 11.93 ppm

Zn and Fe are in high concentration

Ashok M (NIT, Trichy), Jayanthi V (personal observation)

ARE PIGMENT GS AT RISK FOR GB CANCER

Retrospective data : 2001 to 2010 Gallbladder cancer Cholecystectomy for GS disease

Data retrieved : age, gender, clinical presentation, findings on imaging, histology and details of management

Ref: Sachidananda et al. Indian J Surg Oncol 2012;3:228–230

RESULTS…CHOLECYSTECTOMY: 758 PATIENTS

GB Ca cases : 38 men; 23 women Male female ratio: 1.6:1

Stage I: 6 patients (9.8 %). Stage IV disease : 40 patients (50 %)

Co-existing GS: 12 patients (19.6%)

Conclusion : GB CA uncommon in S. India; association with GS is low.

SYMPTOMATIC GALL STONES VERSUS GB CARCINOMA

2007 2008 2009 20100

20

40

60

80

100

120

140

GSGB CAN

o o

f ca

ses

NORTH VS SOUTH INDIA….

North India More in women Cholesterol GS:80-90% Pigment GS: 9.4% GS: hard, faceted

Obesity, high cholesterol High incidence of GB

cancer

South India M:F: 1.3:1 Cholesterol GS: 6% Pigment GS: 77% Soft and amorphous

No hemolysis Non infective bile GB cancer rare

HYPOTHETICAL THOUGHTS…SOUTH INDIAN… BLACK PIGMENT GS

Black pigment Complex compounds of Cu and Fe with bilirubin

(derived from Hb or its derivatives)

Nidus

Growth of cholesterol, calcium carbonate, apatite

ONGOING RESEARCH WORK Composition of bile….is south Indian bile non

lithogenic?..... Personal information: low cholesterol

Crystallisation of GS based on bile composition

Dissolution of synthesized GS by chemical agents

SUMMARISING…. GS

SUMMARY… Gallstones from south India are distinctive

Morphology Chemical composition

Majority are pigment or mixed

Bile is non lithogenic (Ms Ramya, personal communication)

GB cancer incidence is low

SHIFT TO ADMINISTRATION, TEACHING…

PASSING ON THE BATON….

Adult and Pediatric Gastroenterologists

Stanley Medical College & Hospital

The New Generation……………………

Krishnaveni: excels in EUS at PSG Randhir (Cleveland): Liver indices in PHT Sumathi, Hema & Nirmala (HOD, ICH)….. Epidemiology

of carcinoma stomach…Now Crohn’s disease in children Rajesh (Salem)….several case reports Rajesh (Madurai)….H pylori and long term PPI Jijo Cherian….epidemiology of ca stomach and

esophagus Joy Verghese …..cirrhosis liver, liver transplant related

(12 publications as a DM student) Arvind….Leptospirosis, HCV management Arul selvam and Siva…. Hepatitis B, Alcohol:liver and

pancreas

DM PGs

MD & MS STUDENTS…MMC, SMC

Uday Navneetham….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 …..

Prabhu…Acute corrosive injury

Mala: waist and hip circumference in GERD Indian J Gastroenterol 2015 (in press)

……. Many more

MEDICAL STUDENTS…..FINAL YEARS… MMC, KMC & SMC

Dr Saurav (3 rd year): plenary paper, ISG, Jaipur, Mind and Liver test

Guru Vythi, Guru, KMCH……publications on Dyspepsia and GERD among hospital personnel

Alexander and Ramya (6 publications): epidemiology of gallstones, GER in pregnancy, long term effects of PPI on gastric mucosa

Arun Kumar: at least 20 publications, co-authored GE text book, now in New York

Anand and Ashok: Gall stone dietary factors

PROUD OF YOU ALL….

BUT…… FOR MANY FLIGHT STOPS HERE...

80%

70%

10%

< 1 %

Future of Research & Academics

DM PG…..

3

It is a difficult Task

To be a rising star

But

ONE NEEDS TO PUBLISH OR ELSE YOU PERISH

PROFESSIONAL HURDLES….

Every day is filled with small stepsEvery step is a learning hurdleEvery hurdle can be overcomeEvery hurdle that is overcome makes you a stronger person

As hard as the journey may beNever regret climbing those small stepsNever regret crossing the hurdlesIn the end, that is what will bring you success

CORPORATE SECTOR…..WORK CONTINUES … DR M RELA

Dr Joy Verghese….transplant related Dr Dinesh…acute liver failure Dr Deepti….transfusion medicine

Dr Palaniappan… EUS, therapeutic endoscopy

Dr R Ravi…therapeutic endoscopy Dr Srinivas…..motility study

DR NMG’S MOTTO

A KICK IN THE ….. WAS BETTER THAN A PAT IN THE BACK

TODAY, WE ARE LIKELY TO BE KICKED BACK….

KEEP SAFE AND PAT

BEWARE….!!!!

CONCLUDING ….

THANKS TO …..

…….GOVERNMENT

Prof Raghuram, Prof Rajasambandam, Prof Subash, Prof V Balasubramanian

Prof Ramathilakam

Prof Surendran

AC Tech: Prof Devaraj, Prof Kalkura

……..NON GOVERNMENTAL SECTOR

CMC Hospital…..Prof VI Mathan, Dr Ashok Chacko, Dr BS Ramakrishna

United Kingdom : Dr Mayberry, Leicester General Hospital Inflammatory Bowel Disease

Dr Vijaya Srinivasan MD, MSc (Epid) Director, Research, Global Hospital

For South India to remain in forefront… time to wake up in the research front…. Represent in full strength in the National Forum of Indian Society of Gastroenterology

Great researchers…”Publish or Perish”

PROF. N. MADANAGOPALANTEACHER, PHILOSOPHER, & RESEARCHER

Thank YouTNISG!!!

A person with academic brilliance

A person with a vision

LOVED BY ONE AND ALL

PROF N. MADANAGOPALAN

FOR THE FUTURE…..

What is the nidus of the GS….?

Is there a role for bacteria….?Our study showed E coli was present in 20%

Are there other dietary factors…?

Is GS disease a genetic disorder…?

FURTHER READING…

Ashok M et al. International J PIXE, 2002

Ashok M et al. Radiol Nuclear Chem 2002

Gokulakrishnan S et al. Gastoenterology Today, 2002

Gokulakrishnan S et al. Tropical Gastroenterol 2001;22:87-9

ACKNOWLEDGEMENTS… Dr. Naryana Kalkura PhD,

Crystal Growth Centre Dr. Devaraj PhD, Glycotechnology

Centre Dr. Ashok M PhD Dr. Gokulakrishnan S, PhD, Germany Dr. Meenakshi Dr. V. Vijayan PhD, Institute of

Biophysics, Bhubaneswar My colleagues at Stanley Medical

College

QUALITATIVE ANALYSIS..

Wavelength of light absorbed is characteristic of the chemical bond i.e. (functional groups)

FTIR spectra of pure compounds are unique : like a molecular "fingerprint".

Organic compounds have very rich, detailed spectra, inorganic compounds are usually much simpler

Spectrum of an unknown can be identified by comparison to a library of known compounds

Can be combined with NMR, mass spectrometry, emission spectroscopy, X-ray diffraction

RECOMMENDED READING… Datta et al: Gut 1972; 13:372-378

Madanagopalan et al: J Gastroentrol Hepatol 1986; 1:359-369

Victor et al: Coarctation of Inferior vena cava. Tropical Gastroenterology 1987;8:127-142

Monograph: Victor et al. Coarctation of Inferior Vena Cava, 1996

Eapen CE et al. Changing profile of BCS in India. Indian J Gastroenterol 2007;26(2):77-81

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

Cholesterol GS

Mixed GS

A PLEA…TO YOUNGSTERS

Only way south can get represented in national front

is by publications

Attended conferences clinical meetings, jotting down points, and discuss

A LEADER …..

Hard working, simple down to earth person Caring for the poor Credence to junior's

Respected them for their input

PREVALENCE - INDIA

ChandigarhNew DelhiCalcuttaMumbaiChennai – 1:10 PHT

BCSVellore