India’s gastrointestinal disease profile is changing. Alongside long-standing infections such as Helicobacter pylori and intestinal worm infestation, doctors are increasingly dealing with fatty liver disease, colorectal cancer, inflammatory bowel disease (IBD) and coeliac disease.
The concern is not merely the number of people affected but the fact that several of these conditions can remain unnoticed until complications develop.
This changing landscape will be discussed threadbare at the 20th World Congress of Gastroenterology (WCOG), which India will host for the first time from September 30 to October 3 at Yashobhoomi in the national capital.
Top gastroenterologists from AIIMS Delhi said the emphasis needs to move beyond treating advanced disease to preventing it, identifying people at risk and encouraging patients to seek medical attention when symptoms persist.
The scale of some of the problems is striking. An AIIMS-led systematic review and meta-analysis estimated that fatty liver disease affects 38.6% of Indian adults and 35.4% of children. The condition is closely associated with obesity, diabetes, hypertension and abnormal blood lipid levels. It can remain silent while liver damage progresses towards fibrosis and, in severe cases, cirrhosis and liver failure.
Dr Pramod Garg, Professor and Head of Gastroenterology and Human Nutrition at AIIMS, Delhi, said the country was undergoing an epidemiological transition, with metabolic diseases emerging on a scale that needs a different public-health response.
“India is facing an epidemiological shift at this time. We have made significant strides in controlling preventable disease through awareness, vaccinations and improving quality of life; however, alongside these, we are now seeing metabolic disease on a scale we have never handled before. Fatty liver is the clearest example. The disease is easy to find if we look for it, and we become aware only after the patient falls ill. This is a greater challenge than before – we must move away from only treating diseases – we must now actively promote good health,” he said.
Dr Shalimar, Professor of Gastroenterology and Human Nutrition at AIIMS, Delhi, concurred as he pointed out that fatty liver was closely intertwined with the wider burden of metabolic disease.
“With fatty liver disease affecting around one in three adults and children in India, understanding its links with diabetes, hypertension, obesity and dyslipidaemia is increasingly important,” he said.
But newer metabolic problems have not replaced older gastrointestinal infections. H. pylori remains an important cause of gastritis and peptic ulcers and is a recognised risk factor for stomach cancer. The discovery of the bacterium transformed the treatment of ulcers by establishing that an infection could be responsible for a disease once largely attributed to other causes, said Dr Govind Makharia, Professor of Gastroenterology and Human Nutrition at AIIMS.
Intestinal worm infestation, meanwhile, continues to be widespread, particularly among children. Experts at the meeting are expected to discuss its less visible consequences. While not every worm infection causes illness, significant infections can contribute to anaemia and undernutrition and may affect children's physical and cognitive development and their ability to perform at school, Dr Shalimar said.
The cancer burden presents another challenge.
India recorded an estimated 40,430 new colorectal cancer cases among men and 24,433 among women in 2022, according to figures cited by the experts. Doctors are also concerned about the disease being recognised at younger ages.
An important opportunity for prevention lies in detecting colorectal polyps. Some polyps can develop into cancer over time, although not all do. Identifying and removing those with malignant potential can therefore prevent cancer from developing, added Dr Garg.
Studies are now examining the prevalence of such polyps among apparently healthy Indians around the age of 50, including research in Punjab and a larger countrywide study. Their findings could help determine how screening for colorectal cancer should evolve in India.
The need for early detection is equally important for oesophageal cancer. Difficulty in swallowing, or dysphagia, can occur temporarily during a fever or throat infection and generally settles as the infection improves. Persistent difficulty, however, warrants medical attention.
“If someone continues to have difficulty eating or swallowing, they should see a doctor. There should be no doubt about that,” the expert said.
This distinction matters because food-pipe cancers are often detected late, by which time the tumour may have narrowed the oesophagus. Patients may have experienced difficulty swallowing for weeks or months before seeking help.
Blood in the stool is another symptom that is commonly dismissed as piles. Although haemorrhoids are a frequent cause of bleeding, their presence does not exclude colorectal or rectal cancer. Persistent or unexplained bleeding therefore needs evaluation rather than automatic attribution to piles.
Other diseases are also becoming more visible. Coeliac disease, for instance, was once considered relatively uncommon in India but is now regularly encountered in clinical practice, noted Dr Makharia, who has been doing extensive research in coeliac disease. An AIIMS-led community study has estimated its prevalence at around one in 96 people in northern India. IBD, too, is increasingly being diagnosed.
Dr Vineet Ahuja, Professor of Gastroenterology and Human Nutrition at AIIMS Delhi, said IBD and coeliac disease were once rarely encountered during medical training but are now seen regularly. Advances in endoscopy, imaging, molecular diagnostics, artificial intelligence and microbiome research are opening new avenues for diagnosis and treatment.
For doctors, however, technology alone cannot solve the problem if patients continue to ignore warning signs.
“India has never been short of gastroenterologists or technology. What we have lacked is the habit of taking early symptoms seriously and neglecting our health. We often misattribute our symptoms to stress or simply overlook them. Some even take over-the-counter medications for months before they reach a doctor. We must realise that every time we fail to identify a disease early, we lose the opportunity to potentially modify its natural history. Any symptom that persists beyond two to three weeks should be evaluated,” said Dr Makharia.
The preventive approach is particularly relevant for conditions such as fatty liver and colorectal cancer. In the former, healthier diets, regular physical activity, weight management and control of diabetes and other metabolic risk factors can reduce the likelihood of progression. In colorectal cancer, identifying precancerous lesions can potentially prevent disease altogether.
The WCOG, being jointly hosted by the Indian Society of Gastroenterology, the Indian National Association for the Study of the Liver, the Crohn's and Colitis Foundation of India, the Indian Pancreas Club and the Indian Neurogastroenterology and Motility Association, in partnership with the World Gastroenterology Organisation, will bring together specialists and researchers from India and abroad.
For India, the larger challenge is to make digestive health part of routine preventive care given that the burden ranges from infections and nutritional problems to metabolic liver disease and cancers.
The doctors said that persistent gastrointestinal symptoms like blood in the stool, unexplained weight loss or sustained changes in bowel habits should not be ignored.
