EVOLUTION OF PEDIATRIC GASTROENTEROLOGY IN INDIA
It gives me great pleasure to present to you the history and evolution of pediatric gastroenterology in India. I hope this will inspire all of us to work together to propel this specialty to even greater heights.
Dr Ujjal Poddar MD DNB DM, Associate Professor, Department of Pediatric Gastroenterology, SGPGIMS Raebareli Road, Lucknow-226014, India firstname.lastname@example.org
Acknowledgements – I am grateful to Prof Saroj Mehta, Prof SK Mittal, Dr VS Sankaranarayanan and Prof SK Yachha for providing historical details.
- A quarter century ago, in the year 1984, Pediatric Gastroenterology was born in India at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh as a separate division in the Department of Superspecialty of Gastroenterology. Professor Saroj Mehta had conceived this innovative idea and she emerged as the architect of this subspecialty in India. Pediatric Gastroenterology at PGIMER was supported by other faculty members Dr BR Thapa and Dr Ujjal Poddar. In the year 1985, Dr SK Mittal, after receiving formal training in pediatric Gastroenterology from UK, established the division of Pediatric Gastroenterology at Maulana Azad Medical College, New Delhi. In eighties another Pediatric Gastroenterology center came up at the Institute of Child Health, Chennai headed by Dr VS Sankaranarayanan and subsequently joined by Dr Bhaskar Raju and Dr Malathi Sathiyasekharan.
- Dr Saroj Mehta was the president of Indian Society of Gastroenterology in 1984 and a study group of Pediatric Gastroenterology was then created in the society. This reflected a great encouragement given to pediatric gastroenterology by our adult gastroenterology colleagues.
- In the year 1987, the three eminent pediatric gastroenterologists Prof Saroj Mehta, Prof VS Sankaranarayanan and Prof SK Mittal launched the National Pediatric Gastroenterology Forum (NPGF) at Chennai with Prof Saroj Mehta as its first president and Prof Sankaranarayanan as secretary. Later in 1989 NPGF was converted into Pediatric Gastroenterology subspecialty chapter of Indian Academy of Pediatrics.
- Professor Saroj Mehta, Prof Sankaranarayanan, Prof SK Mittal, Dr SK Yachha, Dr BR Thapa and currently Dr John Mathai led the specialty as chairpersons. Enrollment of life members of the specialty has grown from just 27 to almost 500.
- In November, 1991 Dr SK Yachha moved from PGIMER, Chandigarh to Sanjay Gandhi Postgraduate Institute of Medical Sciences – SGPGIMS, Lucknow to establish Pediatric Gastroenterology as a unit in the Department of Gastroenterology.
- Following retirement of Professor Saroj Mehta in the year 1991 reins at PGIMER were taken up by Dr BR Thapa.
- Dr MK Bhan had initiated his path breaking research in diarrheal disease and went on to establish internationally acclaimed ‘diarrheal disease research center’ at All India Institute of Medical Sciences – AIIMS, New Delhi. Later Dr NK Arora established clinical and research services in pediatric liver diseases at AIIMS.
- The other center was at KEM, Pune which was established by Dr Anand Pandit and Dr.Sheila Bhave. Their pioneering research in Indian Childhood Cirrhosis (ICC) established copper toxicity as the cause of ICC. Now Dr Ashish Bavdekar continues to work there on Wilson disease and other metabolic liver diseases.
- In the 1990’s another Pediatric Gastroenterology center came up at Lady Harding Medical College, New Delhi under the stewardship of Dr AK Patwari.
- The wave although slow spread with motivation from their predecessors that culminated in to second generation pediatric gastroenterologists. Dr Ujjal Poddar at Chandigarh first and then at Lucknow, Dr Anupam Sibal at Delhi, Dr Neelam Mohan at Delhi, Dr Shinjini Bhatnagar at AIIMS, Dr Sutapa Ganguly at Kolkata, Dr John Mathai at Coimbatore, Dr Seema Alam at Aligarh, Dr Anshu Srivastava at Lucknow, Dr Riyaz at Calicut, Dr Sarath Gopalan at Delhi, Dr Pankaj Vohra at Delhi, Dr Praveen Kumar at Delhi, Dr Ramesh Kancharla at Hyderabad, Dr Kannan Ramaswami at Bangalore gave further boost to the development of Pediatric Gastroenterology in India.
- As Gastroenterology in India is celebrating its ‘golden jubilee’ year, the year 2009 is the ‘silver jubilee’ year for pediatric gastroenterology. In 25 years, from a mere unit in a department it has almost become a full-fledged specialty in India with independent departments, trained manpower and dedicated training program. With continued patronage from the elder brother (adult gastroenterology) the younger brother (pediatric gastroenterology) is definitely going to be a matured one in the near future.
Formal Training in Pediatric Gastroenterology
- Professor Saroj Mehta was the first one to create a model of inducting pediatricians into DM Gastroenterology training program so that a blend of Pediatrics and Gastroenterology would emerge in to development of Pediatric Gastroenterology. This trend of training pediatricians in DM Gastroenterology was adopted at Chennai and later in the year 1992 by SGPGIMS, Lucknow. These three centers offering DM in Gastroenterology had additional components of Pediatric Gastroenterology that would provide a reasonable base to fulfill the objectives of training. In late nineties it was observed that pediatricians who successfully completed DM in Gastroenterology would prefer mostly practicing adult Gastroenterology rather than sticking to Pediatric Gastroenterology. Only a couple of trained super-specialists following MD pediatrics and DM Gastroenterology trainings held the ground of exclusive pediatric gastroenterology choice namely Dr SK Yachha, Dr Sudipta Misra, Dr Ujjal Poddar and Dr Anshu Srivastava. Most of the other trained Pediatricians in Gastroenterology (DM) had its own limitations and thus the need for a separate training program in Pediatric Gastroenterology was realized.
- Taking the lead from above limitations in training, another important mile stone in India took place in the year, 2002. Dr Yachha with the help of (Late) Prof SR Naik started one year post-doctoral certificate course (PDCC) for pediatricians in Pediatric Gastroenterology at SGPGI, Lucknow that continues till this date. In fact on popular demand SGPGIMS increased intake of PDCC candidates from two to four / year.
- A joint committee was setup in late nineties by the subspecialty under the leadership of Dr Saroj Mehta along with Dr SK Mittal, Dr NK Arora and Dr SK Yachha as members to formulate a proposal for starting DM Pediatric Gastroenterology training program in India. The documents were submitted to Medical Council of India. Persistent efforts of Dr SK Mittal and later by Dr Yachha led to recognition of DM in Pediatric Gastroenterology by Medical Council of India that is effective from September, 2009.
- A major breakthrough in Pediatric Gastroenterology took place in October, 2005 (fully functional March, 2008), when an independent pediatric gastroenterology department at SGPGI, Lucknow was created. This was possible by consistent efforts of Dr Yachha and Dr Poddar. Professor Kartar Singh then the Director SGPGIMS, Lucknow and Professor G Choudhuri HOD Gastroenterology facilitated emergence of the specialty. The department has full complements including four faculty members and dedicated manpower/ equipment. This marks the beginning of a new era. It is expected that from the next academic session three-year DM training program in pediatric gastroenterology will start at SGPGIMS, Lucknow thus fulfilling a long standing need.
- In the recent past establishment of separate training program at SGPGI, Lucknow and others having received training fellowships from abroad led to generation of more pediatric gastroenterology services in various parts of the country. The new generation pediatric gastroenterologists are Dr Lalit Bharadia at Jaipur, Dr S Srinivas, Dr Sumathi and Dr Nirmala at Chennai, Dr Rakesh Mishra at Bhopal, Dr Harshdeep Sahni at Bareilly, and Dr Shrish Bhatnagar at Lucknow.
- Advances in endoscopic techniques and equipment, laboratory development and pediatric liver transplantation have further boosted the development and consolidation of this specialty.
The researchers in the field of pediatric gastroenterology have brought India to the world map in various diseases like Indian childhood cirrhosis (ICC), Wilson disease, neonatal cholestasis syndrome (NCS), Celiac disease, extrahepatic portal venous obstruction, oral rehydration solution (ORS) and its modification, zinc in the management of acute diarrhea, endotherapy in portal hypertension, liver transplantation etc.
Major diseases where Indian pediatric gastroenterologists contributed a lot in the advancement of our knowledge are discussed here.
Till 1966 celiac disease was thought to be the disease of the Europe and Europeans. Prof BNS Walia in 1966 first time reported a series of celiac disease cases in children in BMJ1. Even after that medical fraternity in India was not in a mode to accept the idea that celiac disease does occur in India especially in north India. The tireless efforts of Prof Saroj Mehta and her team from Chandigarh and Prof MK Bhan and his team from Delhi helped to spread the message across and awareness among pediatrician of north India improved. However, the real boost came in the last one decade with plethora of publications from various centers from north India. Yachha et al from SGPGI, Lucknow2 and Bhan et al from AIIMS3, Delhi have established the fact that genetically our celiac disease patients are same as that in the Europe (majority are HLA DQ2/DQ8 positive). Subsequently Poddar et al4 from Chandigarh and Yachha et al5 from Lucknow showed the utility of various serological tests in the diagnosis of celiac disease in India. The futility of using modified ESPGHAN criteria to diagnose celiac disease in India was first established by Bhan et al from Delhi.6 In a seminal paper they showed that severe villous atrophy was seen in various non-celiac conditions in India. This fact was further substantiated by Poddar et al from Chandigarh.7 Because of these publications now it has been established that we need to add serology in addition to modified ESPGHAN criteria to diagnose celiac disease in developing countries like in India. Clinical presentation of celiac disease is changing over the years. Celiac disease is no longer synonymous with malabsorption syndrome. Now non-diarrheal or atypical form of celiac disease is much more common than typical or classical form of celiac disease. In India too this fact has been established by Poddar et al from Lucknow.8
Extrahepatic portal venous obstruction (EHPVO):
Mittal et al from Delhi, 9 Yachha et al10 from Lucknow and Arora et al from Delhi11 have shown that the commonest cause of upper gastrointestinal bleeding in children in India is EHPVO. Poddar et al12 from Chandigarh has shown that the commonest cause of portal hypertension in children in India is EHPVO. The majority of children (90%) with EHPVO present with variceal bleeding and the primary management of this condition is targeted towards the management of variceal bleeding. The role of sclerotherapy (EST) in the management of this condition was established by Thapa et al,13 Yachha et al14 and Poddar et al.15 Subsequently band ligation (EVL) followed by sclerotherapy has shown to be a better modality in children as it eradicates varices faster with fewer complications and with lower recurrence rate.16 First time from India it has been shown that the prevalence of gastropathy and fundal varices in EHPVO was almost same as in cirrhosis and following sclerotherapy there was a significant increase in the prevalence of severe PHG and isolated gastric varices.17, 18
Neonatal cholestasis syndrome
Almost one third of all cases of liver disease in children are due to neonatal cholestasis syndrome. It is important to differentiate biliary atresia (EHBA) from neonatal hepatitis early as the outcome of Kasai portoenterostomy depends on the age of the patient at the time of surgery. To pick up biliary atresia early ‘yellow alert’ was established in UK in 1980s and since then the age of diagnosis of BA has decreased significantly. In India most of the cases of BA are diagnosed late and as a result of which surgery could be offered in only a few cases. Dr Yachha from Lucknow has started an ‘yellow alert’ among the pediatricians of UP and over the next five years the mean age at diagnosis of BA has decreased significantly in his center.19 Time has come to spread the ‘yellow alert’ all over the country.
Indian Childhood Cirrhosis (ICC)
In seventies and eighties ICC used to be the commonest cause of chronic liver disease in children. Dr Anand Pandit and his team in collaboration with Dr Tanner from UK have established the fact that ICC is associated with gross hepatic copper overload and this copper overload is attributable to dietary copper excess.20 They also showed the reversal of changes with d-penicillamine therapy when started in the early stage of the disease.21 A large intervention study in the Pune district of Maharashtra was conducted by Dr Bhave et al and it was shown that through intensive program of health education against the use of brass utensils for preparing infant feeds, there was a drastic decline in the incidence of ICC with reduction in the use of brass utensils.22 It provided further evidence to the hypothesis that excess ingestion of copper was responsible for the development of ICC.
Modified ORS and zinc in acute diarrhea
Dr Bhan and his team from the diarrheal disease research center at AIIMS, Delhi has done many pioneering research in the field of diarrheal disease. In randomized control trials they have shown that by modifying standard ORS by adding amino acids like alanine23 or glycine24 does not improve its efficacy. In nineties they have shown that hypo-osmolar ORS is superior to standard WHO- ORS25 and now WHO has accepted hypo-osmolar ORS as the sole ORS to be used in acute diarrhea. Again Dr Bhan’s team from Delhi has shown that zinc therapy as an adjunct to ORS decreases the severity and duration of diarrhea.26, 27 and zinc as an adjunct to ORS has been added to the national diarrheal disease control program.
In the endeavor of development of Pediatric Gastroenterology in India immense contribution has come from Adult Gastroenterologists, Indian Society of Gastroenterology, Indian Association of Study of Liver and the Indian Academy of Pediatrics.
1. Walia BNS, Sidhu JK, Tandon BN, Ghai OP, Bhargava S. Celiac disease in North Indian children. Br Med J 1966; 2: 1233-34.
2. Kaur G, Sarkar N, Bhatnagar S, et al. Pediatric celiac disease in India is associated with multiple DR3-DQ2 haplotypes. Hum Immunol 2002; 63: 677-82
3. Agarwal S, Gupta A, Yachha SK, et al. Association of human leucocyte – DR and DQ antigens in celiac disease: a family study. J Gastroenterol Hepatol 2000; 15:771-4.
4. Poddar U, Thapa BR, Nain CK, Singh K. Is tissue transglutaminase autoantibody the best for diagnosing celiac disease in children of developing countries? J Clin Gastroenterol 2008; 42 (2): 147-51
5. Yachha SK, Agagrwal R, Srinivas S, Srivastava A, Somani SK, Itha S . Antibody testing in Indian children with celiac disease. Indian J Gastroenterol 2006; 25: 132-5.
6. Khoshoo V, Bhan MK, Puri S, et al. Serum anti-gliadin antibody profile in childhood protracted diarrhea due to celiac disease and other causes in a developing country. Scand J Gastroenterol 1989; 24: 1212-16.
7. Poddar U, Thapa BR, Nain CK, et al. Celiac disease in India: are they true ca ses of celiac disease? J Pediatr Gastroenterol Nutr 2002; 35: 508-12.
8. Sharma A, Poddar U, Yachha SK. Time to recognize atypical celiac disease in India. Indian J Gastroenterol 2007; 26: 269-73
9. Mittal SK, Kalra KK, Aggarwal V. Diagnostic upper GI endoscopy for hematemesis in children: experience from a pediatric gastroenterology centre in north India. Indian J Pediatrics 1994;61:651-4
10. Yachha SK, Khanduri A, Sharma BC, Kumar M. Gastrointestinal bleeding in children. J Gastroenterol Hepatol 1996; 11: 903-7.
11. Arora NK, Lodha R, Gulati S, et al. Portal hypertension in North Indian Children. Indian J Pediatr 1998; 65: 585-91.
12. Poddar U, Thapa BR, Narashima Rao KL, Sing K. Etiological spectrum of esophageal varices due to portal hypertension in children in India: is it different from the West? J Gastroenterol Hepatol 2008; 23 (9): 1354-7 (e-pub August 6, 2007)
13. Thapa BR, Mehta S. Endoscopic sclerotheapy of esophageal varices in infants and children. J Pediatr Gastroenterol Nutr 1990; 10: 430-4.
14. Yachha SK, Sharma BC, Kumar M, Khanduri A. Endoscopic sclerotherapy for esophageal varices in children with extrahepatic portal venous obstruction: A follow – up study. J Pediatr Gastroenterol Nutr 1997; 24: 49-52.
15. Poddar U, Thapa BR, Singh K. Endoscopic sclerotherapy in children: experience in 257 cases of extrahepatic portal venous obstruction. Gastrointest Endosc 2003; 57: 683-6.
16. Poddar U, Thapa BR, Singh K. Band ligation plus sclerotherapy versus sclerotherapy alone in children with extrahepatic portal venous obstruction. J Clin Gastroenterol 2005; 39: 626-9.
17. Yachha SK, Ghoshal UC, Gupta R et al. Portal hypertensive gastropathy in children with extrahepatic portal venous obstruction: role of variceal obliteration by endoscopic sclerotherpay and Helicobacter pylori infection. J Pediatr Gastroenterol Nutr 1996; 23: 20-3.
18. Poddar U, Thapa BR, Singh K. Frequency of gastric varices and gastropathy in children with extrahepatic portal venous obstruction treated with sclerotherapy. J Gastroenterol Hepatol
2004; 19: 1253-6.
19. Yachha SK, Sharma A. Neonatal cholestasis in India. Indian Pediatrics 2005; 42: 491-492.
20. Bhave SA, Pandit AN, Tanner MS. Comparison of feeding history of children with Indian childhood cirrhosis and paired controls. J Pediatr Gastroenterol Nutr 1987; 6: 562-7.
21. Bavdekar AR, Bhave SA, Pradhan AM, Pandit AN, Tanner MS. Long term survival in Indian childhood cirrhosis treated with D-penicillamine. Arch Dis Child 1996;74: 32-5.
22. Bhave SA, Pandit AN, Singh S, Walia BNS, Tanner MS. The prevention of Indian childhood cirrhosis. Ann Trop Paediatr 1992; 12; 23-30.
23. Sazawal S, Bhatnagar S, Bhan MK, Saxena SK, Arora NK, Aggarwal SK, Kashyap DK. Alanine-based oral rehydration solution: assessment of efficacy in acute non-cholera diarrhea among children. J Pediatr Gastroenterol Nutr 1991; 12: 461-8.
24. Bhan MK, Sazawal S, Bhatnagar S, Bhandari N, Guha DK, Aggarwal SK. Glycine, glycil- glycine and maltodextrin based oral rehydration solution: assessment of efficacy and safety in comparison to standard ORS. Acta Paediatr Scand 1990; 79: 518-26.
25. Valentiner-Branth P, Steinsland H, Gjessing HK, Santos G, Bhan MK, Dias F, et al. Community-based randomized controlled trial of reduced osmolality oral rehydration solution in acute childhood diarrhea. Pediatr Infect Dis J 1999;18:789-95
26. Sazawal S, Black RE, Bhan MK, Bhandari N, Singh A, Jalla S. Zinc supplementation in young children with acute diarrhea in India. New Engl J Med 1995; 333: 839-844.
27. Bhatnagar S, Bahl R, Sharma PK, Kumar GT, Saxena SK, Bhan MK. Zinc with oral rehydration therapy reduces stool output and duration of diarrhea in hospitalized children: a randomized controlled trial. J Pediatr Gastroenterol Nutr 2004; 38: 34-40.