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Indian Society of Gastroenterology
Plenary Session
001
An open label trial to compare viral suppression with 0.5 and 1.0 mg doses of entecavir in treatment naive hepatitis B related decompensated cirrhosis
Amit Goel , Sumit Rungta, Prashant Verma, Abhai Verma, Ajay Verma, Prveer Rai, Rakesh Aggarwal
Correspondence- Rakesh Aggarwal-aggarwal.ra@gmail.com
King George Medical University, Lucknow, India, Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India, and Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Objectives For patients with hepatitis B virus (HBV) infection who have decompensated cirrhosis (DC), a higher dose (1.0 mg/day) of entecavir is recommended than that used for those with compensated disease (0.5 mg/day), though with very little supporting data. We therefore compared the viral suppression achieved with 0.5 mg/day and 1.0 mg/day of entecavir in patients with HBV-related DC (NCT03345498).
Methods Treatment-naïve patients with HBV-related DC and serum HBV DNA titer exceeding 100,000 IU/mL received either dose of entecavir for 24 weeks. HBV DNA concentration was measured in blood specimens collected at baseline, and after 2, 4, 8, 12 and 24 weeks of entecavir treatment.
Results Participants in the 0.5 mg (n=13) and 1.0 mg (n=16) groups had similar baseline HBeAg positivity rates (12/13 and 12/16; p=0.34) and median (range) log10 serum HBV DNA levels (6.81 [5.01-8.12] and 7.45 [5.24-8.65]; p=0.17). The two doses led to similar reductions in serum HBV DNA levels after 2, 4, 8, 12 and 24 weeks of entecavir administration. At 24 weeks, 3 of the 13 patients receiving 0.5 mg/day and one of the 16 patients receiving 1.0 mg/day of entecavir had undetectable serum HBV DNA. Serum albumin level showed significant and similar improvement at the end of 24 weeks in both the groups.
Conclusion Treatment-naïve patients with HBV-related DC can be treated with entecavir in a 0.5 mg/day dose instead of the higher 1.0 mg/day dose, without compromising the degree of virological suppression.
002
Bacterial spectrum and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients
Mohammad Talha Noor, Praveen Vasepalli
Correspondence- Mohammad Talha Noor-noorpgi@gmail.com
Department of Gastroenterology and Hepatobiliary Sciences, Sri Aurobindo Medical College, and PGI, SAIMS Campus, Indore-Ujjain State Highway, Near MR-10 Crossing, Sanwer Road, Indore 453 555, India
Introduction Temporal shifts have been known to occur in antibiotic sensitivity patterns of organisms causing cholangitis. This study was conducted to study the common microorganisms cultured from bile during endoscopic retrograde cholangiography and their local sensitivity pattern.
Methods This was a prospective study conducted between January 2016 and November 2017. Patients with extrahepatic biliary obstruction undergoing endoscopic retrograde cholangiography were included in the study. Bile was aspirated aseptically during endoscopic retrograde cholangiography and aspirated bile was transported to microbiology laboratory under all aseptic precautions. Bacteria were cultured, identified and antimicrobial susceptibility testing was performed by broth micro dilution method.
Results Hundred patients (48% males, mean age 53.53±14.65 years) were included. Sixty-six patients had growth in bile culture, out of which 9 patients had dual growth and thus a total of 75 microbial growths were obtained. The maximum growths amongst all micro-organisms were of Escherichia coli (40.9%) and pseudomonas aeruginosa (40.9%). With regard to bacterobilia, there was no significant difference between patients with cholangitis and without cholangitis (61.36% vs. 69.64%, p = 0.288), patients who had underwent previous endoscopic retrograde cholangiography with stenting and those who had not undergone the same previously (60% vs. 67%, p=0.301), patients who were empirically administered antibiotics before intervention and not administered (67.92% vs. 63.83%, p = 0.599). Growth rates were significantly higher in patients with non-malignant causes of biliary obstruction vs. those with malignant causes (70.76% vs. 57.14%, p=0.03). Polymixins had the highest sensitivity to cultured bacteria followed by aminoglycosides and Imipenem.
Conclusion Gram negative bacteria like Escherichia coli and Pseudomonas aeruginosa were the most common isolates from bile. Empirical antibiotic therapy in patients with cholangitis should be based on local sensitivity patterns.
003
Outcome of conservative therapy in COVID-19 patients presenting with gastrointestinal bleeding
Manas Vaishnav , Anshuman Elhence, Piyush Pathak, Soumya Mahapatra, Saurabh Kedia, Govind Makharia, Pramod Garg, Anoop Saraya, Shalimar
Correspondence- Shalimar-drshalimar@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with COVID-19 amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19.
Methods In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22nd April to 22nd July 2020, were included.
Results The mean age of patients was 45.8±12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5- day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay.
Conclusion Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy.
004
Exclusive enteral nutrition enhances the efficacy of intravenous steroids in acute severe ulcerative colitis: A randomized controlled trial
Pabitra Sahu , Sudheer Kumar, Aditya Bajaj, Manasvini Markandey, Namrata Singh, Mukesh Singh, Bhaskar Kante, Peeyush Kumar, Mukesh Ranjan, Peush Sahni, Raju Sharma, Prasenjit Das, Govind Makharia, Simon Travis, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Objective Intravenous (IV) steroids are main stay of therapy in acute severe ulcerative colitis (ASUC), but 30% to 40% patients fail to respond. This study investigates the effectiveness of exclusive enteral nutrition (EEN) as an adjunctive therapy to IV steroid in patients with ASUC.
Design This is an open label randomized controlled trial, in which patients with ASUC admitted between August 2018 to May 2020 were randomized in 1:1 ratio to EEN and standard of care (SOC) group. Patients in EEN arm received semi elemental EEN for 7days along with standard medical therapy including IV steroid. Primary outcome was rate of steroid failure defined by the need for rescue medical therapy or colectomy. In a subgroup of patients, day 1 and day 7 fecal microbial analysis was done by 16s ribosomal RNA sequencing.
Results The study was stopped because of COVID pandemic and significant results in interim analysis. Out of 62 patients (mean age:35.3±12.1 years and 59.7%: male), 32 were randomized to EEN arm and 30 in SOC arm. Steroid failure rate was significantly less in EEN arm compared to SOC arm (per protocol analysis; 18.5% vs. 43.3%; p=0.04), but no difference seen in colectomy rate (9.4% vs. 13.3%; p=0.4). Patients in EEN group had shorter hospital stay (10 [8-17] vs.13 [8-24] days; p=0.04), higher day7 albumin level (p<0.01), and greater reduction in serum CRP and fecal calprotectin (FCP) levels than SOC group (p=0.03). Although there was no significant difference in fecal microbial diversity between two groups on day 7 but patients in EEN group showed increased abundance of Erysipelotrichaceae with reduced Bifidobacterium and Veillonellaceae compared to SOC group.
Conclusion Short course of EEN is an effective and safe adjunctive therapy that augment steroid responsiveness in patients with ASUC.
005
Universal prophylactic per-rectal nonsteroidal anti-inflammatory drug with a discretionary policy of selective pancreatic duct stenting significantly reduces post-ERCP pancreatitis in unselected consecutive patients: A real world comparative study
Ashish Agarwal , Rahul Sethia, Soumya Jagannath Mahapatra, Deepak Gunjan, Pramod Garg
Correspondence- Pramod Garg-pgarg10@gmail.com
Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction and Aims Rectal NSAIDs have been shown to be effective for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. However, it is not clear if a strategy of routine rectal NSAID administration prior to ERCP is beneficial in non-high-risk patients. Our aim was to assess the benefit of prophylactic rectal NSAID in unselected consecutive patients to prevent post-ERCP pancreatitis (PEP).
Methods All patients undergoing index ERCP procedures from January 2018 till March 2020 in a tertiary care centre were included. All patients were given prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated wire cannulation of or contrast injection into the PD, at the discretion of the endoscopist. Trainee fellows were involved in performing ERCP. The outcome measure was frequency of PEP which was compared with that in historical controls from a previous randomized trial at our centre. Multivariable analysis was done to find out the predictors of PEP.
Results Of a total of 769 patients who underwent index ERCP, 34 (4.4%) developed PEP. PEP was mild in 29 (85.3%) patients, moderately severe in four and severe in one patient. Female gender, pre-cut sphincterotomy, inadvertent PD cannulation and procedural time (>30 minutes) were predictors of PEP in univariate analysis; and inadvertent PD cannulation [OR 4.6, 95% CI 1.8-11.7; p<0.001] and procedural time >30 minutes (OR 8.5, 95% CI 3.7-10.1; p<0.001) on multivariate analysis. When compared with historical controls, the odds of developing PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI 0.31-0.93, p=0.027). The number needed to treat was 22 to prevent one PEP with prophylactic rectal NSAID.
Keywords Rectal NSAIDs, Post ERCP pancreatitis, PD stenting
006
Development of a machine learning model to predict bleed in esophageal varices in compensated advanced chronic liver disease
Samagra Agarwal , Sanchit Sharma, Manoj Kumar * , Shanatan Venishetty * , Ankit Bhardwaj * , Kanav Kaushal, Abhinav Anand, Srikanth Gopi, Srikant Mohta, Deepak Gunjan, Anoop Saraya, Shiv Kumar Sarin *
Correspondence- Deepak Gunjan-drdg_01@rediffmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and *Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background and Aims Current endoscopic classification of esophageal varices does not stratify and predicts bleeding in all patients with compensated advanced chronic liver disease with varices. We aimed to supplement it with a novel machine learning (ML) model for prediction of hemorrhagic events in these patients.
Methods In a retrospective analysis from two centres, data from patients of cACLD who underwent esophagogastroduodenoscopy, laboratory investigations and transient elastography within 3 months were included. Extreme-gradient boosting (XGBoost) algorithm was used to generate a predictive model including these parameters to predict the risk of future bleed. Its performance characteristics were compared with the endoscopic classification alone and was validated in internal and external validation cohorts.
Results Eight hundred and twenty-eight patients of cACLD with esophageal varices, predominantly related to non-alcoholic fatty liver disease (28.6%), alcohol (23.7%) and hepatitis B (23.1%) were included, with 455 (55%) having the high-risk varices. Over a median follow-up of 24 months (interquartile range: 12-43 months), 163 patients suffered variceal-bleed, 139 (85.3%) in endoscopic high-risk group. Machine learning (ML) model had good performance characteristics with 85% to 99% accuracy in derivation (n=497), internal validation (n=149) and external validation cohorts (n=182), and was able to identify “true high-risk” group with 1-year and 3-year bleed rates of 31% to 43% and 64% to 85%, respectively. “True low-risk” varices identified by the model had significantly lower 1-year (0-1.6%) and 3-year (0-3.4%) bleed-rates. SHapley Additive exPlanations (SHAP) analysis showed endoscopic classification to be the most important determinant of the model prediction, followed by the liver stiffness measurement.
Conclusions Machine learning model allows a better risk stratification for the prediction of the incident variceal bleed in patients with cACLD with esophageal varices compared with endoscopic classification alone.
Young Investigator Award Session
007
Isolation and genome analysis of gluten-degrading bacteria from small intestinal of celiac disease patients
Sahabram Dewala , Yogesh Shouche
Correspondence- Yogesh Shouche-yogesh@nccs.res.in
Department of ICMR, National Centre for Cell Science, NCCS Complex, University of Pune Campus, Pune University Road, Ganeshkhind, Pune 411 007, India
Introduction Gluten intolerance or celiac disease is the most common genetically related food intolerance, worldwide. Celiac disease (CeD) is T-cell mediated small intestinal inflammation trigger by wheat gluten protein in genetically susceptible individual who carry HLA-DQ2/8 risk alleles. Lifelong elimination of gluten from diet is very challenging due to many reasons including availability of good quality gluten-free food items, cost, palatability. Thus, gluten and its’s immunogenic peptides degradation approach is considered to be a novel therapy for CeD. Researchers have made adequate efforts for isolation of gluten-degrading bacteria (GDB) from human body and other environment. Oral supplementation of GDB and gluten digesting enzyme is emerging therapeutic approach for the CeD.
Method Gluten agar plates assay for screening of gluten-degrading bacteria. Illumina Miseq was applied for whole genome sequencing of bacteria.
Results Aerobic and facultative anerobic bacteria were isolated from human small intestine with gluten-degrading activity. Indeed, 70 bacterial strains belonging to 35 bacterial species were isolated; 12 strains were able to show gluten-degrading activity on gluten plates. Moreover, proline-glutamine specific endopeptidase genes were confirmed in gluten-degrading bacteria by whole genome sequencing approach. Additionally, a docking model was proposed of representative gliadin substrate in active side of endopeptidase enzyme. We cultivated and sequenced new gluten-degrading microorganisms from the human small intestine.
Conclusion Study suggests that these bacteria or their gluten-degrading enzymes can be explored further for their application in treatment of celiac disease.
Keywords Celiac disease, Gluten-degrading bacteria, Endopeptidase, HLA-DQ 2/8
008
HSP70 modulates immune response in pancreatic cancer through dendritic cells
Bharti Garg , Bhuwan Giri, Prateek Sharma, Ashok Saluja, Vikas Dudeja, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, Jackson Memorial Hospital, University of Miami, USA, and Miller School of Medicine, University of Miami, USA
The role of heat shock protein 70 (HSP70), a protein chaperone, is largely unknown in the tumor micro-environment (TME). We evaluated if HSP70 in the TME modulated tumor growth.
Cancer cells were derived from various genetic models (KPC, MC-38, PKT) and were implanted in HSP70-/- or WT controls, thus simulating a TME with or without HSP70. Tumor size, metastases pattern, histology and immune infiltration were evaluated at endpoint. Splenocytes, CD8+ve T cells and dendritic cells (DCs) were isolated from HSP70-/- or WT mice to evaluate for specific absence of HSP70 in the immune cells. Splenocytes, CD8 cells and DCs were co-incubated with cancer cells to immune activation.
Tumors from HSP70-/- mice were smaller compared to tumors in WT mice. There was no difference in stromal markers and no effect on tumor growth when HSP70 was specifically depleted in the stromal compartment. HSP70-/- immune cells exhibited greater anti-tumor activity and HSP70/- dendritic cells showed greater expression of anti-tumor effectors against KPC cells both in vitro and in vivo. Thus, we show that absence of HSP70 in the TME results in inhibition of tumor through dendritic cells. HSP70 inhibition in DCs may emerge as novel therapeutic strategy against pancreatic cancer.
Keywords Pancreatic cancer, HSP70, Immunotherapy, Stroma, Dendritic cells
009
Platelet deactivation ameliorates hepatic fibrosis by modulating inflammation, intrahepatic microbiome and reduces hepatic stellate cell activation via ryanodine-receptor-2
Adil Bhat , Sudrishti Chaudhary, Gaurav Yadav, Anupama Kumari, Chhagan Bihari, Jaswinder Singh Maras, Shiv Kumar Sarin
Correspondence- Shiv Kumar Sarin-shivsarin@gmail.com
Department Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India
Introduction Platelet deactivation possibly help in the regression of liver fibrosis. However, the mechanism linked to the regression of fibrosis post antiplatelet treatment (APT) is elusive.
Methods To explore, aspirin (APT) was administered in the murine model of liver fibrosis and molecular signatures/signalling associated with fibrosis regression were validated in vivo (murine model and patients with liver fibrosis) and in vitro studies.
Results Increase in intrahepatic platelet number (CD42b) and activation (PDGFR-β) directly correlated with an increase in liver fibrosis (p<0.05, r2>0.3). APT reduced intrahepatic platelet number, platelet, and immune cell activation thereby reducing inflammation and fibrosis (p<0.05). APT in mice model increases autophagy, glutathione, energy metabolism, and decrease arachidonic acid and butanoate metabolism (p<0.05). APT modulated the liver microenvironment and showed a decrease in intrahepatic immune cell activation (blood transcription module) which correlated with histidine and tryptophan metabolism (r2>0.5, p<0.05). APT also modulate the liver microbiome by increasing the abundance of Firmicutes (Ruminococcaceae, Lachnospiraceae, and Clostridiaceae) and their functionality (p<0.05). Multi-omics of APT identified decreases in expression of Ryanodine-receptor-2 (RyR2), Arginase-1 and Kynurenine-3-monooxygenase correlate with the reduction in α-SMA and degree of hepatic fibrosis (r2>0.75; p<0.05). Expression of RyR2 was high in activated hepatic stellate cells (HSCs) and pan-specific blocking of RyR2 by carvedilol/flecainide markedly inhibits HSCs activation and proliferation (in vitro) via reducing Ca2+ overload, ER, and mitochondrial oxidative stress (p<0.05). Interestingly RyR2 blockade in HSCs reduced its activation by activated platelet secretome or TGFβ1 (p<0.05). This suggests that RyR2 induction is critical for fibrosis development and pharmacological inhibition of RyR2 could ameliorate liver fibrosis.
Conclusion Antiplatelet treatment modulates hepatic fibrosis by decreasing platelet activation, inflammation, and intrahepatic microbiome. Our findings demonstrate RyR2 suppression as a therapeutic approach for liver fibrosis regression.
Keywords Liver fibrosis, Hepatic proteome, Hepatic metabolome, Integrome, RyR2, ALOX5, ARG-1
010
Fluconazole reduces disease activity in active ulcerative colitis: A double-blind randomized placebo-controlled trial
Anuraag Jena , Usha Dutta, Jimil Shah, Vishal Sharma, Kaushal Kishor Prasad, M R Shivaprakash, Harshal S Mandavdhare, Jayanta Samanta, Pankaj Sharma, Priyanka Popli, A K Sharma, Saroj Kant Sinha, Arunaloke Chakrabarti, Rakesh Kochhar
Correspondence- Usha Dutta-ushadutta@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction There is an emerging role of fungal dysbiosis in the pathogenesis of inflammatory bowel disease (IBD). In such scenario, what is the prevalence of Candida in patients with active ulcerative colitis (UC) and can fluconazole therapy reduce disease activity?
Methods All patients with active UC defined as Mayo score ≥ 3 were evaluated for presence of Candida by stool culture. Patients with Candida positive in stool were randomized to receive oral fluconazole 200 mg daily or placebo for 3 weeks. Patients were assessed by clinical, sigmoidoscopy and laboratory parameters at baseline and at 4 weeks. The primary outcome variables were clinical and endoscopic response at 4 weeks. Secondary outcomes were reduction in fecal calprotectin, histological response and adverse events.
Results Of 242 patients with active UC, 68 (28%) patients had Candida in stool culture. Sixty-one patients were randomized to receive fluconazole (n=31) or placebo (n=30). Post intervention median Mayo score was lower in fluconazole than placebo group (4 [3, 5] vs. 5 [4, 6]; p=0.034). Patients in fluconazole group showed significant improvement in stool frequency (17 [54.8%] vs. 9 [30%]; p=0.07), lower median bleeding score (0 [0, 1] vs. 1 [0, 1]; p=0.018) and decrease in severity (21 [67.7%] vs. 10 [33.3%]; p=0.01) compared to placebo. Patients in fluconazole group had reduction in Mayo score (19 [61.2%] vs. 12 [40%]; p=0.12), three-point Mayo score (5 [16.1%] vs. 1 [3.33%]; p=0.19), fecal calprotectin (26 [83.9%] vs. 11 [36.7%]; p=0.001) and histological scores (23 [74.1%] vs. 10 [33.3%]; p=0.001) compared to placebo. All patients were compliant and did not report any serious adverse event. Independent predictors for presence of Candida were partial mayo score ≥3 and steroid exposure.
Conclusion Oral fluconazole therapy in patients with active UC was associated with reduction in disease activity and severity. Candida colonization was found in 28% of patients with UC. Steroid exposure and active disease were independent predictors for presence of Candida.
Keywords Ulcerative colitis, Candida, Fluconazole
011
Conventional versus oblique fibers sparing endoscopic myotomy for achalasia cardia: A randomized controlled trial
Vincy Chandran , Zaheer Nabi, Mohan Ramchandani, Rajesh Goud, Santosh Darisetty, Arun Karyampudi, Rama Kotla, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India
Background and Aim Gastroesophageal reflux disease (GERD) is common after per-oral endoscopic myotomy (POEM). Selective sparing of oblique fibers during POEM may reduce the incidence of reflux esophagitis after POEM. In this study, we aim to compare the incidence of GERD between conventional (CM) versus oblique fiber sparing (OFS) techniques of endoscopic myotomy in cases with type I and II idiopathic achalasia.
Methods Eligible patients with type I and II achalasia who underwent POEM from January 2020 to April 2020 were randomized into two groups (CM and OFS). Exclusion criteria were: type III achalasia, sigmoid esophagus and history of Heller’s myotomy with fundoplication. The primary outcome of the study was comparison of reflux esophagitis at two months in the two groups. The secondary aims included reflux symptoms, esophageal acid exposure, and clinical success.
Results Sixty patients were randomized in CM (30) and OFS (30) groups. Both the groups were similar with regards to the symptom scores, sub-types of achalasia and history of previous treatment. The mean operation time was similar in both the groups (CM 42.21±13.17 mins vs. OFS 48±29.12 mins). Mean length of total myotomies were comparable in the two groups (9.57±3.25 cm vs. 9.43 ±3.15 cm). Clinical success (Eckardt ≤3) was recorded in all the patients. Overall, reflux esophagitis was found in 30 (51.7%) patients. Grade B or higher esophagitis was similar in the two groups (34.6% vs. 41.4%, p=0.782). Symptoms of GERD were more frequent in the conventional group (35.7% vs. 16.7%, p=0.570). The mean number of reflux episodes (57.42±39.94 vs. 56.41±43.70), proportion of patients with increased esophageal acid exposure >6% (41.6% vs. 33.2%, p=0.574) and DeMeester scores (>14.7) (41.6% vs. 33.2%, p=0.574) were similar in both the groups.
Conclusion Sparing of sling fibers has no significant impact on the incidence of GERD after POEM. (NCT04229342).
012
Combination of intravenous antibiotics in acute severe ulcerative colitis: A placebo controlled randomized trial
Shubhra Mishra , Harshal Mandavdhare, Harjeet Singh, Arup Choudhury, Jimil Shah, Sant Ram * , Dimple Kalsi, Jayanta Smanta, Kaushal Prasad, Arun Sharma, Usha Dutta, Vishal Sharma
Correspondence- Vishal Sharma-docvishalsharma@gmail.com
Departments of *Biochemistry, and Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background Recent evidence suggest that targeted antibiotic combination could improve response in active ulcerative colitis (UC) but similar data is not available in acute severe UC (ASUC).
Methods Patients ASUC diagnosed as per modified Truelove and Witt’s classification were randomized to placebo infusions or combination antibiotics (intravenous ceftriaxone and metronidazole) groups. Primary outcome was response on day three (Oxford’s criteria). Also, we assessed the need for second line drug therapy, colectomy, length of hospital stays, mortality by day 28 and the changes in partial Mayo score, CRP levels and reduction in fecal calprotectin by day three.
Results Fifty patients were randomised: 25 in each arm (Median age: 33, IQR 25-45, 23 (46%) males). Twenty-two patients had extensive disease while the median disease duration was 24 months. Sixteen patients (64%) in antibiotic arm responded (complete and partial response) at day three while 18 (72%) in the placebo arm responded. Three patients from the antibiotic group underwent colectomy. Three patients in the antibiotic arm received intravenous cyclosporine whereas four patients in the placebo group received cyclosporine (p=0.725). There was no significant difference in change in CRP, Partial Mayo and fecal calprotectin between the two groups on day three.
Conclusion Combination of intravenous ceftriaxone and metronidazole in patients with ASUC neither improved the day 3 response nor reduced the need for second line therapy.
Presidential Posters
013
Feasibility of de-prescription of proton pump inhibitors in patients with typical reflux symptoms- A clinical experience
Mayank Jain
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre, 283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India
Background Proton pump inhibitors (PPI) are commonly used drugs in management of reflux symptoms. These drugs are frequently abused and have side effects on long term use.
Aim To determine the feasibility of de prescription of PPI in patients with typical reflux symptoms in Indian setting. Moreover, symptom resolution and PPI requirement were assessed in patients with erosive and nonerosive reflux disease (NERD).
Methods This retrospective study recruited all patients, >18 years, with heartburn and/or regurgitation. Severity of reflux was assessed white light endoscopy and graded as per Los Angeles classification. All patients were advised lifestyle changes, aerobic exercises for > 30 min/day and dietary interventions. Follow-up details, including symptom resolution and drug requirement, were noted at 3 months after initial visit.
Results A total of 106 patients formed the study cohort. Nearly three fifths of the cases were males and median age was 43 years. Reflux esophagitis was noted in 30% of cases. Of these patients, 25% had grade A esophagitis and the remaining had grade B or beyond. Three fourths of the patients were prescribed once a day dose of PPI. On follow-up at 3 months, PPI therapy could be stopped completely in 58 (54.7%) cases. Thirty-two (30.2%) and 16 (15.1%) patients were on on-demand PPI and continuous low dose therapy, respectively. Significantly higher proportion of patients with reflux esophagitis could stop PPI at the end of three months. The need for on demand PPI and continuous low dose therapy was higher in patients with NERD.
Conclusion De prescription of PPI is attained in nearly 85% of patients at 3 months. PPI are effective in symptom resolution, more so in patients with erosive esophagitis.
014
Nutritional assessment and factors affecting dietary intake in patients with cirrhosis: A single center observational study
Praveen Sharma , Charu Gupta, Ashish Kumar, Anil Arora, Naresh Bansal, Vikas Singla, Shivam Khare, Sakshi Jasrotia
Correspondence- Praveen Sharma-drpraveen_sharma@yahoo.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Objectives Malnutrition is predictor of morbidity and mortality in patients with cirrhosis. We investigated prevalence of malnutrition and factors affecting dietary intake in patient with cirrhosis.
Methods Two hundred and fifty-one patients with cirrhosis underwent dietary and nutritional assessment by subjective global assessment (SGA) and anthropometric measurement (dry body mass index [BMI], mid am circumference [MAC], mid arm muscle circumference [MAMC], tricep skin fold thickness [TSF] and handgrip strength [HGS]). Dietary intake assessed in terms of total calories and protein intake, percentage of recommended intake along with per kilogram body weight per day. Factors influencing dietary intake were also assessed.
Results Of 251 patients 199 (79%) were males and 52 (21%) were female (mean age 51±14 yrs, Child’s A: B: C:: 83:116:52). SGA analysis 87(35%) were well nourished (SGA-A), 106 (42%) moderately nourished (SGA-B) and 58 (23%) severely malnourished (SGA-C). Child’s C patients were severely malnourished compared to Child’s B and A. MAC, MAMC, TSF and HGS was significantly higher in SGA-A compared to SGA-B and SGA-C. Patients in SGA-A (1939±479 kcal/d) consumed significantly higher calories than SGA-B (1494±216kcal/d) and SGA-C (1321±213kcal/d). Percentage of recommended calories intake (SGA-A [76%], SGA-B [61%] and SGA-C [59%], p=0.001) and calories/kg/d is also higher in SGA-A compared to SGA-B and C. Similar were the results with protein intake (SGA-A [61±14 gm/d], SGA-B [56±7 gm/d] and SGA-C [51±9 gm/d], p=0.001). Sixty-one percent patients were vegetarian and 84% did not take evening snacks. Poor appetite (n=68, 27%), early satiety (n=75, 30%), abdominal fullness (n=62, 25%), low salt diet (n=52, 21%) and social myth about diet 43 (17%) were the common reason of poor intake. Distension of abdomen, social myth about diet and low sodium in diet were key factors affecting dietary intake in patients with cirrhosis and malnutrition.
Conclusion Malnutrition seen in 65% of patients. Distension of abdomen, social myth about diet and low sodium in diet were key factors affecting dietary intake in patients with cirrhosis.
015
Clinical, endoscopic and management profile of cytomegalovirus colitis in inflammatory bowel disease patients at tertiary centre in North India: A retrospective observational study
Sharad Dev , Dawesh Prakash Yadav, Vinod Kumar Dixit, Sunit Kumar Shukla
Correspondence- Dawesh Prakash Yadav-devesh.thedoc@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Aurobindo Colony, Banaras Hindu University Campus, Varanasi 221 005, India
Background Cytomegalovirus (CMV) colitis in immunocompetent patients generally manifests as benign, self-limiting disease whereas gastrointestinal tissue-invasive disease is frequently seen in immunocompromised and inflammatory bowel disease (IBD) patients.
Methods A retrospective study was conducted of all patients diagnosed as CMV colitis with IBD during a three-year period. From electronic database, patients’ clinical information, treatment regimens, endoscopic and pathologic findings and outcome were analyzed. CMV colitis was diagnosed by positive inclusion bodies on H&E staining or by immunohistochemistry (IHC) in colonic tissue biopsy.
Results Twenty-seven patients with CMV colitis were studied with median age of 32 (15-62) years and median IBD duration of 22 (2-36) months. There were 23 (85%) patients of UC and 4 (15%) patients of CD. Ten patients were on immunomodulators (steroid dependent or steroid refractory status). Predominant symptoms included bloody diarrhea (93%), abdominal pain (55%), low grade fever (20%) and anemia (70%). Endoscopic evaluation mainly noted deep punched out ulcerations (48%), longitudinal and geographic ulcerations (33%) and diffuse mucosal hemorrhage with superficial erosions (14%). Histopathology demonstrated inclusion bodies in 55% of patients and remaining were diagnosed by IHC. CMV DNA PCR was detected in 16/18 patients. Seven (25%) patients responded to intravenous steroids whereas intravenous ganciclovir followed by oral valganciclovir was required in 20/27 (75%) patients. Clinical response was noted in 14/20 (70%) patients whereas colectomy was required in 3/27 (11%) and 3/27 (11%) died due to complications.
Conclusion CMV colitis complicating IBD is independently associated with refractory disease, immunomodulator use and age over 30. Conventional H&E “owl eye” inclusions are specific but less sensitive (55% in this study) whereas IHC remain the gold standard for diagnosis. Deep punched out ulcerations (observed in 48% patients) may hint towards the diagnosis. Antiviral therapy significantly improves outcome. Few patients may develop life threatening complications carry high risk of mortality and necessitates surgical intervention.
016
FAT score: A novel predictive score to differentiate non-alcoholic steatohepatitis (NASH) from simple steatosis
Jijo Varghese , Krishnadas Devadas
Correspondence- Jijo Varghese-jairusjijo@gmail.com
Department of Medical Gastroenterology, Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Background Advanced fibrosis in NAFLD has got clinical and biochemical scoring like NAS score, APRI, FIB-4 score, ELF, Hepa score etc. as well as imaging system for diagnosis. The main problem is to distinguish NASH from simple steatosis. Liver biopsy is the Gold standard investigation to distinguish simple steatosis from NASH. Though there is a handful of scoring system to distinguish simple steatosis from NASH the deficits are.
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Most of the scoring system were done in patient with morbid obesity.
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The rest contains laboratory variables like cytokeratin 18, collagen etc which are costly and not easily available.
Aims and Objectives Aim of the study is to propose a simple predictive score to differentiate NASH from simple steatosis. NASH is defined as NAS score >5.
Methods Cross-sectional study. All patient’s who with liver biopsy proven NAFLD.
Results Sixty-four patients were taken up for the study. Among the variable's platelet count, ferritin and transaminase (ALT and AST) were independent predictors of NASH by logistic regression and cut off were found out. This lead to proposal of a new score, FAT score (Table 1) to differentiate NASH from simple steatosis (F stands for Ferritn, A for AST and ALT, T for t in Platelet) with AUROC of 0.95 (Fig. 1). Each component carry a score of 0 or 1 and a score of more than or equal to three can predict NASH from non-NASH NAFLD with sensitivity of 76.5%, specificity of 100%.
Conclusion FAT score is a simple predictive model to differentiate NASH from non-NASH NAFLD or simple steatosis (cut off of more than or equal to 3) without liver biopsy with high sensitivity, specificity and accuracy. FAT score less than 3 rules out the need for biopsy. It can be used as a screening tool instead of biopsy.
017
A comparative study on EUS-FNA and ERCP based brush cytology for tissue diagnosis in malignant biliary obstruction
Praveen Mathew, Jaseem Ansari , Prashant Kanni, Chandra Babu, Manoj Gowda, Achal Garg, Nithin Kumar, Raghuveer Balabhadra
Correspondence- Praveen Mathew-drpraveenmathew@yahoo.com
Department of Medical Gastroenterology, Vydehi Institute of Medical Sciences and Research Centre, 82, Near BMTC 18th Depot, Vijayanagar, Nallurhalli, Whitefield, Bengaluru 560 066, India
Introduction Patients with suspected malignant biliary strictures frequently undergo endoscopic retrograde cholangiopancreatography (ERCP) based brush cytology and endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) for establishing the diagnosis. The outcomes of these tests aid in further management of the patient. A comparison of these two modalities in establishing the diagnosis is seldom reported.
Aims To compare the diagnostic efficacy of ERCP based brush cytology and EUS FNA for tissue diagnosis in malignant biliary obstruction. It was obtained by performing a retrospective audit of all patients admitted in Vydehi Institute of Medical Sciences and Research Centre for EUS and ERCP from 2015–2019.
Method Data were collected from 1 January 2015 to 31 December 2019. Majority of the patients were in the 5th decade with a slight female predominance. Most common CT finding was periampullary mass with 59.7% of the having common bile duct stricture. EUS-FNA was more sensitive than ERCP based tissue sampling. The overall sensitivity was 90.63% for EUS-FNA and 65.63% for ERCP sampling. EUS-FNA was found to have diagnostic accuracy of 92.63% in comparison to 71.43% for brush cytology.
Conclusions EUS –FNA is found to be superior to ERCP based tissue sampling with excellent sensitivity and diagnostic accuracy. Performing EUS before ERCP in all the patients with suspected malignant biliary obstruction would definitely improve the diagnostic accuracy and thereby help in the management of such cases.
018
The prevalence and clinico-demographic profile of the histopathologically confirmed esophageal cancer patients at tertiary care center in South India: A retrospective study
Achal Garg , Praveen Mathew, Prashant Kanni
Correspondence- Praveen Mathew-drpraveenmathew@yahoo.com
Department of Medical Gastroenterology and Hepatology, Vydehi Institute of Medical Sciences, 82, Near BMTC 18th Depot, Vijayanagar, Nallurhalli, Whitefield, Bengaluru 560 066, India
Background and Aim Esophageal cancer is a disease of advanced age, peaking in the seventh and eighth decades of life. Most of the tumors of the esophagus are malignant and the pinpointing side effect, dysphagia, happens late. To assess the prevalence and clinico-demographic profile of the histopathologically confirmed esophageal cancer patients at a tertiary care center.
Methods The present retrospective observational study was carried out in the Department of Gastroenterology, among 210 patients, 196 patients were diagnosed with esophageal cancer (histologically proven) from January 2017 to December 2019. The demographic factors incorporate age; sex and the dependence normal for the patients were considered. The site of the ailment and the histopathology were likewise assessed.
Results The overall mean age of the study population diagnosed with esophageal cancer was 58.37±11.54. Of the 196 patients, 142 (72.4%) of them exhibited squamous cell carcinoma followed by adenocarcinoma 44 (22.4%) and dysplasia in 10 (5.2%) patients. Dysphagia was the most common presenting clinical symptom followed by vomiting and weight loss.
Conclusion Squamous cell carcinoma (SCC) is still the most common histological subtype and is way ahead of adenocarcinoma (AC). The mid esophagus is still the most common site.
019
Does inflammatory bowel disease behave differently at extremes of age?
Nikhil Bhangale , Devendra Desai, Philip Abraham, Tarun Gupta, Anand Joshi, Adesh Andhale
Correspondence- Devendra Desai-devendracdesai@gmail.com
Division of Gastroenterology, P D Hinduja Hospital, Mumbai 400016, India
Introduction Studies on characteristics of inflammatory bowel disease (IBD) with onset at extreme ages, which forms 10% to 25% of patients with IBD, have focused on either pediatric or elderly population, but not all age groups together.
Methods To compare the characteristics of IBD with onset in the pediatric (≤16 years) and elderly (≥60 years) age group with those with onset at age 17-59 years.
Results Of 266 patients (137 men), 47 had pediatric onset, 175 middle age and 44 elderly onset (ulcerative colitis [UC], median age 38 years [interquartile range 27], Crohn’s disease [CD], median age 35 years, interquartile range 30]). Among UC patients, pancolitis was more common in the pediatric group (p=0.018) and indolent behavior more common in the elderly group (p=0.005). Among CD patients, the pediatric group more often had colonic (p=0.02) and the elderly more often had ileal (p=0.04) involvement; perianal disease was least common in the elderly group (p=0.03). There was no treatment difference between the three groups in UC, while pediatric CD patients needed biologics more frequently (p=0.005) and elderly CD patients less frequently required steroids, biologics, immunosuppressants and surgery (p<0.05) than the middle age group.
Conclusion This study highlights the spectrum of IBD according to age at onset. Pediatric patients with UC more often had pancolitis while the elderly had milder disease, similar to earlier studies. Pediatric CD patients more often had colonic disease with more requirement for biologics as compared to western studies which showed ileo-colonic involvement and more of complicated disease behavior. Elderly CD patients more often had ileal disease, least common perianal disease, and less requirement for immune-suppressant drugs and surgery as compared to the middle age group in contrast to colonic involvement with commoner uncomplicated disease behavior (B1) in western studies.
020
Study of the role of non-invasive surrogate as predictor of esophageal varices in cirrhosis of liver
Jigar Patel , Ankur Jain, Kaushal Vyas, Sushil Narang
Correspondence- Jigar Patel-jskap1992@gmail.com
Department of Medical Gastroenterology, Sardar Vallabhbhai Patel Institute of Medical Sciences and Research (SVPIMSR), Riverfront Road, Ellis Bridge, Ahmedabad 380 006, India
Introduction Screening endoscopy for all, becomes difficult approach in developing countries where the burden of liver cirrhosis is high and use of endoscopy is limited by its cost. Moreover, it increases the burden that endoscopy units have to bear. Moreover, only about 30% of patients with cirrhosis are found to have varices on initial screening endoscopy and there is low prevalence of varices that require primary prophylaxis.
Methods The present study was a prospective analysis of 75 patients admitted at a tertiary care hospital in Gujarat. Our study included all consecutive patients with newly diagnosed liver cirrhosis. Platelet count (PC), bipolar splenic diameter (BSD), platelet count to spleen diameter (PC/SD), aspartate aminotransferase (AST) to platelet ratio index (APRI), fibrosis-4-index (FIB-4), model for end-stage liver disease (MELD), AST to alanine aminotransferase (ALT) ratio (AAR) were measured for all participants. All patients underwent endoscopic assessment for screening and grading of EV if present. The diagnostic performance of “predictors” for the presence of EV were assessed based on receiver operating characteristics curve.
Results On endoscopy, 25 patients (33.33%) had no EV and 75 (66.67%) had EV, of which 37 (74%) were medium-large varices and the rest (26%) small varices. On univariate analysis, the overall mean for presence of EV of MELD (17.88 vs. 20.34, p=0.17) and AAR (2.48 vs. 2.47, p=0.978) were not significant. However, the overall mean of PC (2.06 lakh vs. 1.1 lakh, p<0.0001), BSD (129.76 mm vs. 153.1 mm, p<0.0001), PC/SD (1604.41 vs. 759.28, p<0.0001), APRI (0.9737 vs. 2.2964, p<0.0001), FIB-4 (3.1621 vs. 6.9334, p=0.0001) significantly predicted the presence of EV. On multiple regression analysis only, PC (p<0.0001), APRI (p=0.0405), FIB-4 (p=0.0001) significantly predicted presence of EV. The optimal cut-off of these parameters for prediction of EV were, PC<1.57 lacs (sensitivity: 80%, specificity:80%, AUC:0.896), BSD >135 mm (sensitivity: 72%, specificity: 76%, AUC=0.775), PC/SD<1086.67 (sensitivity: 84%, specificity: 92%, AUC=0.924), APRI>0.87 (sensitivity: 82%, specificity:68%, AUC=0.788), FIB-4>3.0766 (sensitivity:80%, specificity:64%, AUC=0.766).
Conclusion PC, BSD, PC/SD, APRI, FIB-4 are reliable non-invasive surrogate for predicting EV.
021
Changes in liver and spleen stiffness following endoscopic variceal ligation predicts variceal eradication
Atul Hareendran , Krishnadas Devadas, Swetha Sattanathan
Correspondence- Atul Hareendran-atul354@gmail.com
Department of Medical Gastroenterology, Government Medical College, Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction Endoscopic variceal ligation (EVL) for high-grade varices (HGV) has reduced the morbidity and mortality of variceal bleed. Relook endoscopy is recommended after 2 weeks to confirm the eradication of varices. We tried to look at the changes in shear wave elastography (SWE) of spleen and liver following EVL and to identify the predictors for the eradication of varices at relook endoscopy.
Methods Prospective observational study conducted in a university hospital in south India over one year. Cirrhotic patients undergoing EVL for primary prophylaxis (PP) and secondary prophylaxis (SP) with multiband ligator were included. Spleen stiffness (SS) and liver stiffness (LS) were measured by 2dSWE using Supersonic Aixplorer, before and 1-hour post banding. Endoscopy was repeated along with SWE of spleen and liver at 2 weeks.
Results One hundred and fifty patients, 75 undergoing PP and 75 SP, were included. The Child status distribution was A: B: C = 40%: 44%: 16%. Splenic volume increased following variceal ligation in patients with CHILD C disease but difference was not significant. Mean increase in splenic volume in CHILD C was 177 cm3. Relook endoscopy showed HGV in 75 patients (42 - SP, 33 – PP). In the PP group, predictors of HGV were high baseline SS, increased serum creatinine and serial increase in LS at 2 weeks post EVL. ROC curve plotted for the new score (SLC score) devised using the above 3 parameters had an accuracy of 87% (p-value 0.001). In the SP subgroup, only ascites proved significant on regression analysis.
Conclusion Variceal banding causes an increase in splenic volume and liver stiffness in patients with severe liver disease. Relook endoscopy after EVL may be avoided in patients undergoing EVL for primary prophylaxis using SWE of liver and spleen, and serum creatinine before banding. Using this score, we would be able to avoid 53% of unwanted endoscopies.
022
Real-world re-treatment outcomes of direct-acting antiviral therapy failure in patients with chronic hepatitis C
Anshuman Elhence , Achintya Singh ** , Ramesh Kumar * , Anzar Ashraf, Sonu Kumar, Dibyabhaba Pradhan *** , Piyush Pathak, Manas Vaishnav, Mahendra Rajput, Vikas Banyal, Baibaswata Nayak, Shalimar
Correspondence- Shalimar-drshalimar@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, *All India Institute of Medical Sciences, Patna - Aurangabad Road, Phulwari Sharif, Patna 801 507, India, **Cleveland Clinic, Ohio, US, and ***Computational Genomics Centre, ICMR, New Delhi, India
Introduction Direct-acting antiviral (DAA) drugs are associated with high (>95%) sustained virological response at 12 weeks (SVR12) in chronic hepatitis C (CHC) patients. There is a paucity of data regarding the characteristics and re-treatment outcomes of DAA treatment failure patients.
Methods In a retrospective analysis of prospectively collected database, we assessed the outcomes of re-treatment among patients with previous DAA failure. Patients’ characteristics, viral characteristics including resistance associated substitutions (RAS) in a subgroup of patients, SVR12, and clinical outcomes were studied.
Results Of 40 patients with DAA failure, among whom 36 were retreated, mean age was 45.7 years, 63.9% (n=23) were male, 63.9% (n=23) had genotype-3 infection and 63.9% (n=23) were cirrhotic. The re-treatment regimens included combination of pan-genotypic DAA, mainly sofosbuvir and velpatasvir with or without ribavirin. Three patients who declined retreatment and one who was still on treatment was excluded. Patients who completed re-treatment, SVR12 was 100% irrespective of genotypes. SVR12 among genotype 3 was 75% (15/20) when lost to follow-up was considered treatment failure. Six patients died due to liver-related causes, including five (83.3%) with hepatocellular carcinoma. RAS analysis in 17 randomly selected patients did not reveal any dominant substitutions in NS5A or NS5B region affecting SVR12, though several novel mutations were observed.
Conclusion Re-treatment of CHC patients with prior DAA failure using pangenotypic DAA is associated with high SVR12 rates irrespective of genotype or presence of RAS.
023
Clinical and endoscopic picture of periampullary tumor at an Indian tertiary centre
Rithesh Gundam , Vijay Kumar T R, Nandeesh H P, Deepak Suvarna, Aradya H V
Correspondence- Vijay Kumar T R-drvijaytr@gmail.com
Department of Gastroenterology and Hepatology, J S S Medical College and Hospital, Bangalore - Mysore Road, Bannimantap A Layout, Bannimantap, Mysuru 570 015, India
Introduction Periampullary tumor is a clinical condition often encountered by gastroenterologist. There is limited data regarding clinical profile and endoscopic management of patients with periampullary tumor.
Methods We retrospectively analyzed the ERCP (endoscopic retrograde cholangiopancreatography) records of periampullary tumor patients who were referred to Department of Gastroenterology for ERCP over a period of three years from January 2015 to January 2018. Demographic profile, clinical findings and ERCP management were taken into consideration. Statistics used were mean and standard deviation for continuous variables, frequencies and percentages were calculated for categorical variables were determined.
Results We retrospectively analyzed 86 patients who had undergone ERCP for periampullary tumors from January 2015 to January 2018. Data interpretation revealed that majority of the cases were between 41 to 50 years (23.6%). There was a male preponderance (66.3%). Maximum number of cases were of ampullary growth (46.5%), followed by lower CBD stricture (32.6%). The predominant presenting symptom was jaundice (77.9%), followed by abdominal pain (54.6%). Twelve patients (14%) had cholangitis at presentation. Mean bilirubin in the current study ranged from 11.76 to 23.72. CBD cannulation was achieved in 98.8% cases (selective cannulation 65.1%, pre-cut sphincterotomy 33.7%). Biliary drainage was done using plastic biliary stent (PC) in 84.7% and SEMS (self-expandable metallic stent) in 15.2% cases. Ampullary growth biopsy and biliary brush cytology revealed malignancy in 55% and 35.7% cases respectively. At 3 months, 4 patients with PC stent developed block.
Conclusion In our study, ampullary growth was the most common type of periampullary tumour. Cholangitis was present in 14% cases at presentation. ERCP had good success for biliary drainage. Ampullary growth biopsy and biliary brush cytology has sensitivity rate of 50% and 35.7% respectively. Rate of PC stent block was low (< 5%).
024
Optimal utilization and efficacy of endoscopic therapy for acute gastrointestinal bleeding with low risk of cross-infection of SARS-CoV2: A multi-centre study of 638 patients during COVID-19 pandemic
Ashish Agarwal , Soumya Jagannath Mahapatra, Deepak Gunjan, Samir Mohindra, Vishal Sharma, Rajeeb Jaleel, Sudipta Dhar Chowdhury, Sanjeev Sachdeva, Rakesh Kochhar, Vivek Saraswat, Pramod Garg
Correspondence- Pramod Garg-pgarg10@gmail.com
Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110 029, India, Department of Gastroenterology, Christian Medical College, Vellore 634 004, India, Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, 1, J L N Marg, New Delhi 110 002, India, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India, and Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, India
Background and Study Aims Data on endoscopic management for gastrointestinal (GI) bleeding during the COVID-19 pandemic are limited. Our objective was to study the utilization and efficacy of endoscopic services for acute GI bleeding despite ergonomic challenges after wearing personal protective equipment (PPE) and limited resources.
Methods In an observational retrospective multicentre study across 5 academic tertiary-care centres in India, the utilization of endoscopic therapy, its efficacy and risk of cross-infection of SARS-CoV2 were assessed during April 1 to May 31, 2020, for an emergency endoscopic procedure such as GI bleeding. Outcome measures were primary hemostasis, rebleeding, mortality and risk of cross-infection.
Results Of a total of 1294 endoscopic procedures in an unselected patient population with no strict policy of pre-procedure testing for SARS COV-2, 638 were performed for GI bleeding: 500 for upper GI bleeding and 138 for lower GI bleeding. The primary hemostasis was achieved in 98% with 3.1% in-hospital rebleeding rate and 5.3% 28-day mortality which was similar to historical controls. The risk of a health care worker getting a COVID-19 infection with the use of adequate PPE was 0.49% per 100 endoscopic procedures performed with the use of adequate PPE. Median difficulty level faced by an endoscopist using level-2 PPE was 2 (2-3) on a Likert scale.
Conclusion Emergency endoscopic procedure for GI bleeding is safe during COVID-19 pandemic with adequate infection control measures and can be performed with outcomes similar to the usual setting despite ergonomic challenges.
Keywords COVID-19; Endoscopy; Gastrointestinal bleeding; SARS-CoV-2
025
Endoscopic submucosal dissection in duodenal neuroendocrine tumors using a novel traction technique
Zaheer Nabi, Mahiboob Sayyed , Mohan Ramchandani, Radhika Chavan, Shujaath Asif, Santhosh Darisetty, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India
Background and Aim The incidence of duodenal neuroendocrine tumors (DNETs) is increasing. Endoscopic resection has been recommended for small DNETs. However, there is limited data on the outcomes of endoscopic submucosal dissection (ESD) in DNETs. In this study, we aimed to evaluate the outcomes of ESD in DNETs.
Methods Data of consecutive patients who underwent ESD for DNETs from January 2018 to October 2019 were analyzed, retrospectively. All the cases of ESD were performed with or without traction using rubber band and two endoclips. En-bloc resection, complete endoscopic resection (C-ER), complete pathological resection (C-PR), adverse events and recurrence were evaluated.
Results Eighteen patients (17 males, 57.39 ± 9.72 years) underwent ESD for DNETs. The median size (IQR) of the DNETs was 1 (0.9-1.5) cm. ESD was performed with and without traction in 8 and 10 cases, respectively. Mean operating time was significantly lower in cases where traction was utilized (50.25 ± 14.98 vs. 69.6 ± 14.53 minutes; p=0.014). En-bloc resection, C-ER, C-PR were recorded in 88.9%, 100%, and 72.2% respectively. The histopathology revealed grade I DNET in 16 and grade II DNET in two patients. Vertical margins were positive in five patients. Adverse events (27.8%) included full thickness (3) and partial thickness (2) muscle injuries which could be closed endoscopically. Muscle injuries were less frequent in the traction group (12.5% vs. 40%). There was no recurrence at a 11.39±5.77 months (range 6-26).
Conclusion ESD is feasible and effective for the management of DNETs. The use of rubber band traction improves the visualization of submucosa, reduces operating duration and risk of muscle injuries in ESD for DNETs.
026
Management of walled-off necrosis: Comparison between nasocystic irrigation with hydrogen peroxide and biflanged metal stent - A randomized controlled trial
Sandeep Ratra , Sudhir Maharshi, Shyam Sunder Sharma, Bharat Sapra, Sandeep Nijhawan
Correspondence- Shyam Sunder Sharma-shyamsharma4@rediffmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India
Background and Aims Walled-off necrosis (WON) is a known complication of acute necrotizing pancreatitis (ANP). There is no study on comparison of nasocystic irrigation with hydrogen peroxide (H2O2) vs. biflanged metal stent (BMS) in the management of WON. The aim of the study was to compare the clinical efficacy of both the treatment strategies.
Methods This study conducted on patients with symptomatic WON who were randomized to nasocystic irrigation with H2O2 (group A) and BMS placement (group B). Primary outcomes were clinical and technical success while secondary outcomes were procedure time, adverse events, need for additional procedures, duration of hospitalization and mortality.
Results Fifty patients were randomized into two groups. Group A (n=25, age 37.8 and plusmn;17.6 years, 16 men) and group B (n=25, age 41.8 and plusmn;15.2 years, 17 men). There was no significant difference in baseline characteristics between the two groups. The most common etiology of pancreatitis was alcohol, observed in 27 (54%) patients. Technical success (100% vs. 96%, p=0.98) and clinical success (84% vs. 76%, p =0.76), requirement of additional procedures (16% vs. 24%, p=0.70) and adverse events (4 vs. 7, p=0.06) were comparable in both the groups. The duration to get clinical success (34.4 and plusmn;12 vs. 14.8 and plusmn;10.8 days, p=0.001) and procedure time (36 and plusmn; 15 vs. 18 and plusmn; 12 minutes, p=0.01) was longer in group A compared to group B.
Conclusions Biflanged metal stent and nasocystic irrigation with H2O2 are equally effective in the management of WON but duration to get clinical success and procedure time is longer with nasocystic irrigation.
027
Prospective validation of AIIMS' index as a predictor of steroid failure in patients with acute severe ulcerative colitis
Pabitra Sahu , Saransh Jain, Saurabh Kedia, Sudheer Vuyyuru, Peush Sahni, Raju Sharma, Rajesh Panwar, Prasenjit Das, Vipin Gupta, Govind Makharia, Simon Travis, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Optimal outcomes in acute severe ulcerative colitis (ASUC) are related to time-bound management based upon early prediction of response to intravenous (IV) steroids. In an earlier study we described the AIIMS' (All India Institute of Medical Sciences) index (baseline UCEIS >7 and day 3 fecal calprotectin (FCP) >1000 μg/g) for predicting failure of IV steroids. The current study designed to validate the index in a prospective cohort.
Methods Intravenous steroid naïve patients with ASUC, satisfying Truelove and Witts’ criteria, hospitalized from August 2018-July 2019 were included. Patients’ assessment included baseline sigmoidoscopy, day1 and 3 FCP, hemogram, biochemistry and day3 C-reactive protein. All patients received IV steroids and the primary outcome was steroid-failure, defined as need for colectomy or rescue therapy with cyclosporine/infliximab during admission.
Results Of 47 patients, 8 were excluded (4-received steroids outside, 2-directly taken for surgery/infliximab therapy, 1-toxic megacolon and 1-infectious colitis), and 39 patients included (mean age-36.1+/-12.6 years, male [31%]). Fifteen patients (38%) failed IV steroid and required rescue therapy (10-infliximab, 2-cyclosporine, 4-surgery). On univariate analysis, UCEIS >7 at baseline (p=0.006), Day 1 FCP (p=0.03), Day 3 FCP >1000 μg/g (p=0.001), Oxford criteria (p=0.04) and AIIMS' index (p<0.001) were significantly different between steroid-responders and -failures. On multivariate analysis, day 3 FCP >1000 μg/g (Odds ratio [OR]-10.1(95% CI:2.1-80.2]) and baseline UCEIS >7 (OR-6.4 [95% CI:2.2-196.1]) were independent predictors. AIIMS' index predicted steroid-failure with a better specificity (100% vs. 83%, p=0.04) and positive predictive value (100% vs. 64%, p=0.03) than Oxford criteria.
Conclusion AIIMS' index has been validated as an effective early predictor of steroid failure in patients with ASUC.
028
Clinical course of chronic pancreatitis during pregnancy and its effect on maternal and fetal outcomes
Soumya Jagannath Mahapatra, Shallu Midha , Gadella Varun Teja, Tanmay Vajpai, Nilanchali Singh, Sushree Monika Sahoo, Shivam Pandey, Anshuman Elhence, Rahul Sethia, Pramod Kumar Garg
Correspondence- Pramod Kumar Garg-pkgarg@aiims.ac.in
Departments of Gastroenterology, Obstetrics and Gynecology, Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction and Aims There are limited data on the effect of chronic pancreatitis (CP) on pregnancy outcomes and vice versa. Our aim was to evaluate the clinical trajectory of CP during pregnancy and its effect on pregnancy outcomes.
Methods All female patients of child-bearing age (≥15 years) diagnosed with CP were studied from January 2004 to July 2019. The change in frequency of painful episodes was assessed before, during and after pregnancy. Maternal and fetal outcomes were compared between pregnant women (early onset) and women presenting with CP after completion of all pregnancies (late onset).
Results Of 187 women with CP, pregnancy outcomes and clinical course were assessed in 99 patients. The frequency of painful exacerbations was significantly lower during pregnancy compared to pre-pregnancy and post-pregnancy period (p<0.001). The median pain score decreased significantly to 0 (0-2) during pregnancy from 3 (0-6) prior to conception and increased to 4 (0-8) after pregnancy (p=0.002). Women with early onset CP (n=57) had their first child later and had fewer pregnancies compared to those with late onset CP (n=42). There was no difference in maternal outcomes such as gestational diabetes, hypertension, preterm delivery and fetal outcomes such as abortion and still birth between the groups. There was no reported congenital anomaly.
Conclusion Younger patients with CP had later and fewer pregnancies but there was no increased risk of adverse maternal and fetal outcomes. The clinical course of CP was usually benign during pregnancy with decreased frequency and severity of pain.
029
Efficacy and tolerability of hyperbaric oxygen therapy in small bowel stricturing and fistulising Crohn’s disease
Kante Bhaskar , Pabitra Sahu, Sudheer Kumar Vuyyuru, Peeyush Kumar, Mukesh Ranjan, Kapil Soni, Saurabh Kedia, Raju Sharma, Govind Makharia, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Majority of patients with complicated CD including B2 and B3 require surgery and biologicals which have considerable morbidity and side effects. Hyperbaric oxygen therapy (HBOT) can alleviate the hypoxia driving chronic inflammation in CD. It has shown a beneficial effect in ASUC and perianal fistulising CD.
Aim To assess the efficacy and tolerability of HBOT in small bowel B2 and B3 CD.
Methods Selected patients of small bowel B2 and B3 active CD who were refractory to medical treatment were subjected to HBOT. Clinical disease activity was assessed using CDAI, patient-reported outcomes by SIBD questionnaire, baseline Hb, Alb and imaging findings (CTE or MRE) were noted. Patients were subjected to sessions of HBOT. Follow-up done at 2 months and 6 months by CDAI, SIBD questionnaire, MRE at 6 months.
Results Fourteen patients (mean age 42.9 ± 15.67 years, 7 [50% males]) were subjected to HBOT. Thirteen (92.7%) patients had B2 and 1 had B3 phenotype. Mean CDAI at baseline 252 (165-396). Median sessions of HBOT were 11(3-20), extended over an average of 4 weeks with duration of each session lasted for 60mins with a pressure of 1.5-2.5 atm. One patient had hemotympanum. At 2months of follow-up, 9 (64.2%) patients had a clinical response (reduction in CDAI >100), 7 (50%) had clinical remission, 8 (57.1%) had a steroid-free response. At 6 months of follow-up, 9 (64.2%) patients had clinical remission, 8 (57.1%) maintained steroid-free response. On MRE pre and post HBOT of patients having clinical response, 4 (50%) had no worsening, 2 (25%) had subtle improvement in enhancement scores and 2 (25%) had worsened. Significant improvement in SIBD scores at 2 months (p=0.03) and 6 months (p=0.07).
Conclusion HBOT is effective and well-tolerated therapy in patients of B2 CD. Long-term follow-up needed in these patients whether HBOT can maintain this response.
030
Efficacy of antioxidants in relieving pain in chronic pancreatitis in children: A prospective observational study
Amrit Gopan , Anshu Srivastava, Amrita Mathias, Surender Kumar Yachha, Sunil Jain, Prabhakar Mishra, Moinak Sen Sarma, Ujjal Poddar
Correspondence- Anshu Srivastava-avanianshu@yahoo.com
Departments of Biostatistics, Pediatric Gastroenterology, and Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Introduction Pain is the major problem in 90% of patients with CP. Although antioxidants are often used in children with CP but no study has objectively assessed its role in children. Adult data should not be directly extrapolated to children due to variation in etiology, severity and nutritional status.
Aims To study the efficacy of antioxidant supplementation in improving pain, markers of oxidative stress (OS) and antioxidant (AO) levels in children with chronic pancreatitis (CP).
Methods Children with CP were given antioxidants for 6 months. Pain assessment and measurement of OS (serum thiobarbituric acid reactive substances [TBARS], superoxide dismutase [S-SOD]), and AO levels (vitamin C, selenium, total antioxidant capacity-ferric reducing ability of plasma [FRAP]) were done at baseline and after 6 months. Good response was defined as ≥ 50% reduction in number of painful days per month.
Results Forty-eight CP children (25 males, median age 13 y, pain duration 24 months) and 14 healthy controls were enrolled. 38/48 cases completed 6 month follow-up on antioxidant supplements. Baseline OS marker (TBARS [7.8 vs. 5.20 nmol/mL; p<0.001]) was higher and AO markers (FRAP [231 vs. 381.3 μmol/L]; p= 0.003), vitamin C (0.646 vs. 0.780 mg/dL; p<0.001]) were lower in CP as compared to controls. Significant reduction in TBARS, S-SOD and increase in FRAP, vitamin C and Selenium occurred after 6 months of antioxidant therapy. Good response in pain was seen in 26 (68%) cases, with 9 (24%) becoming pain-free. Responders also had significant reduction in the requirement of analgesics and hospitalization. Baseline hemoglobin and selenium were significantly lower in non-responders than responders. Patients with Cambridge grade III responded in 100% as compared to 58% in grade IV-V (p=0.03). No predictor of response was identified on multivariate analysis.
Conclusion CP children have higher oxidative stress than controls. Nearly 2/3rd show response in pain after antioxidant therapy with improvement in markers of OS.
Keywords Children, Pancreatitis, Pain, Antioxidants, Oxidative stress
031
Post locoregional therapy changes in oncomiR for tumor response and targeting of microRNA modulating mTOR pathways in hepatocellular carcinoma
Neeti Nadda , Baibaswata Nayak
Correspondence- Baibaswata Nayak-baibaswat@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer mortality and mainly managed by locoregional therapy (LRT). Aberrantly expressed oncomiRs have diagnostic, prognostic and therapeutic implications which need to be evaluated in cancer. Post-LRT changes in OncomiR expression may predict tumor responses. In HCC, mTOR pathway activation leads malignant transition of hepatocytes and miRNAs modulating pathway can be targeted.
Aims Evaluation of oncomiRs as tumor response marker and therapeutics by targeting oncomiR modulating mTOR pathway.
Methods OncomiRs (miR-21, 221 and 16) change in circulation and AFP ratio at one-month post-LRT to baseline was estimated in viral HCC patients to differentiate tumor response as per mRECIST criteria. Activation of mTOR pathway was studied by real time PCR and western blot in miR-21, -221 overexpressing Huh7 stable cell lines. Target validation of these miRs were carried out by UTR assay and targeting by LNA anti-miR.
Result Significant increase of miRNA -21 and-221 expression was observed in PD (p=0.040, 0.047) and PR patients (miR-21, p=0.045). The AUROC of miR -21 fold change 0.718 (95% CI 0.54 -0.81) can differentiate in group 1 (CR+PR from PD) and the AUROC of 0.703 (95% CI, 0.572- 0.799) can differentiate in group 2 (CR from PR+PD). Luciferase reporter-3'UTR assay confirmed PTEN as miR target. Over expression of miR-21 and miR-221 had shown down-regulation of PTEN and upregulation of p70S6K in Huh-7 cell lines. This indicates mTOR pathway activation which confirmed by MTT assay for increase in cell proliferation. LNA anti-miR-21 reduced mTOR activation by reducing expression of AKT, mTOR and RPS6KB1.
Conclusion The miR-21-fold change correlates well with imaging in predicting tumor response and are also comparable to AFP ratio in AFP secreting HCC patients. LNA anti-miR-21 can prevent mTOR pathway activation in HCC and may have potential for miRNA based anti-cancer therapeutics.
Keywords OncomiR, HCC, Tumor response, Locoregional therapy
032
Efficacy of amitriptyline in pediatric functional abdominal pain disorders: A randomized placebo-controlled trial
Jayendra Seetharaman , Ujjal Poddar, Surender Kumar Yachha, Anshu Srivastava, Moinak Sen Sarma
Correspondence- Ujjal Poddar-ujjalpoddar@hotmail.com
Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Introduction Amitriptyline is useful in improving symptoms in functional abdominal pain disorders (FAPD) in adults with variable results in pediatric studies. The aim of this study was to evaluate the efficacy of amitriptyline in pediatric FAPD.
Methods In this randomized placebo-controlled trial children (≤18 years) diagnosed as FAPD based on ROME IV criteria were randomized to amitriptyline (10 mg for <35 kg and 25 mg for > 35 kg for 12 weeks) or placebo for 12 weeks. Post-treatment improvement of pain scores (intensity, duration, and frequency) and quality of life (QOL) from the baseline were compared between the two groups.
Results The mean age of 149 children (amitriptyline 75, placebo 74) was 11.3± 3.5 years (79 boys). There was significant difference in pain improvement in terms of percentage reduction of intensity (64.0% vs. 11.0%), frequency (61.5% vs. 5.3%), duration (64.3% vs. 7.7%) and percentage improvement in QOL (79.1% vs. 28.4%) between amitriptyline and placebo group (p<0.001 in all). Good improvement (>50% reduction) in pain was seen in 76% in amitriptyline compared to 14.9% in placebo group (p<0.001). On multivariate analysis, use of amitriptyline was the only factor predictive of response (OR 24.1, 95% CI: 9.1- 42.6, p<0.001). Minor adverse events were comparable between the groups (25.3% vs. 13.5% respectively, p=0.07).
Conclusions A three-month trial of amitriptyline is significantly more effective in reducing the pain in children with FAPD. The safety profile of the drug and its efficacy necessitate for more frequent use in clinical setting.
Keywords Functional abdominal pain, Amitriptyline, Children
033
Effects of enteral nutrition on intestinal permeability and expression of tight junction proteins in patients with acute pancreatitis
Shekhar Poudel , Deepak Gunjan, Pooja Goswami, Samagra Agarwal, Namrata Singh, Rajni Yadav, Prasenjit Das, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Tight junction proteins (TJP) maintain integrity of gut-barrier function and are disrupted in the early phase of acute pancreatitis (AP) leading to increased infectious complications, organ failure and mortality. We studied the effect of enteral nutrition (EN) on intestinal permeability (IP), endotoxinemia and duodenal TJP expression in patients with AP.
Methods Consecutive patients of AP (n=47) and patients with functional dyspepsia (n=21) as controls were prospectively included. Intestinal permeability was measured with lactulose/mannitol ratio (L/M) and serum anti-endotoxin was measured by ELISA. Expression of claudin-3 and zonula occludens-1(ZO-1) TJP was studied in duodenal biopsy by immunohistochemistry in all patients at baseline and in 22 patients with AP after two weeks of EN. Intensity and distribution of TJP were graded in scale of 0-3 and total score (0-6) was calculated by adding up the intensity and distribution grades.
Results In comparison to controls, patients with acute pancreatitis had significantly higher gut permeability (median L/M:16.76 [inter-quartile range: 6.48-34.87] vs. 2.039 [1.041-4.216]; p<0.001), significantly low serum IgM anti-endotoxin (72.0 [41.1-95.2] vs. 151.4 [62.3-245.8]; p=0.005), lower claudin-3 expression at both crypts (0 [0–1] vs. 6 [4-6]; p<0.001) and villi (0 [0-1] vs. 6 [5-6]; p<0.001) and lower ZO-1 expression at both crypts (2.5 [2-6] vs. 6 [6-6]; p=0.005) and villi (4 [2-6] vs. 6 [6-6]; p=0.017). There was a trend towards improvement in IP with EN (L/M:16.76 [6.48–34.87] at baseline vs. 6.76 [4.38–23.443] at 2 weeks; p=0.0646). Claudin-3 expression at villi also improved significantly after EN (0 [0-1] vs. 3 [1-4]; p=0.002). There was also improving trend in expression of both claudin-3 and ZO-1 at crypts.
Conclusions Acute pancreatitis is associated with significant derangement in IP possibly due to diminished TJP expression and enteral nutrition may have an important role in restoring it.
Keywords Intestinal permeability, Acute pancreattis, Enteral nutrition, Claudin, Zonulin
034
Early experience with endobiliary radiofrequency ablation (Endo-RFA) in patients with unresectable malignant hilar biliary obstruction
Arun Singh Bhadauria , Samir Mohindra, Gaurav Pandey, Vivek Saraswat
Correspondence- Vivek Saraswat-profviveksaraswat@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, India
Background Biliary obstruction is the most important determinant of survival and quality of life in patients with hilar malignancy. Radiofrequency ablation (RFA) induces coagulative necrosis within strictures, controls tumor growth and may prolong stent patency and patient survival.
Methods A pilot single-center, comparative prospective study to assess whether endobiliary-RFA (Endo-RFA) improves survival in patients with unresectable hilar obstruction. Patients with unresectable malignant hilar EHBO were included, and alternatively assigned into the study and control group. Patients with short expected survival, GOO, KPS<50 and severe comorbidities were excluded. After assessing the stricture by cholangiography, RF energy (8-10 watts x 120 seconds) was delivered using the HabibTM-Endo-RFA 8F probe (delivers RF-energy over a 2.5 cm length). The stricture was treated at one or two levels, followed by the placement of plastic stent(s). The stent exchange was done when stent blocked, with repeat endo-RFA, if stricture persisted.
Results Seventeen patients (GB carcinoma [GBC]) (7), Cholangiocarcinoma [CCA] (10)] in RFA-group, while 15 patients [GBC] (8), CCA (7)) in control-group were included. Median RFA-sessions were 1 and 1.5 (range 1-5) in RFA-GBC and RFA-CCA respectively. In patients with GBC, median survival was similar in RFA and control-group (6.7 mo [CI 95% 4.8-8.6] vs; 4 mo [CI 95% 1.4-6.6], p=0.378), while in patients with CCA survival was better in the RFA-group (15.8 mo [CI 95% 8.5-23.1] vs; 7.1 mo [CI 95% 2.5-11.7]; p=0.040, Breslow [Generalized-Wilcoxon] test). The most common adverse event was abdominal pain in both groups (more common in RFA group). Other adverse events-cholangitis (2) and minor hemobilia (1) in RFA-group, while cholangitis (4) in control-group were managed conservatively. The most common cause of death was metastasis (RFA-group), and cholangitis (control-group).
Conclusion Endo-RFA is safe, and may improve survival in patients with hilar malignant EHBO, particularly in those with cholangiocarcinoma.
Keywords: Radiofrequency ablation, Hilar block, Endobiliary stenting
035
Panel of serum miRNAs as potential non-invasive biomarkers for pancreatic ductal adenocarcinoma
Anoop Saraya, Imteyaz Khan , Safoora Rashid, Nidhi Singh, Sumaira Rashid, Vishwajeet Singh, Deepak Gunjan, Prasenjit Das, Nihar Dash, Ravindra Pandey, Shyam Chauhan, Surabhi Gupta
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Biochemistry, Biostatistics, Gastroenterology and Human Nutrition Unit, Gastrointestinal Surgery, Pathology, and Reproductive Biology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Early-stage diagnosis of pancreatic ductal adenocarcinoma (PDAC) is difficult due to non-specific symptoms. Circulating miRNAs in body fluids have been emerging as potential non-invasive biomarkers for diagnosis of many cancers. Thus, this study aimed to assess a panel of miRNAs for their ability to differentiate PDAC from chronic pancreatitis (CP), a benign inflammatory condition of the pancreas.
Methods Next-generation sequencing was performed to identify miRNAs present in 60 FFPE tissue samples (27 PDAC, 23 CP and 10 normal pancreatic tissues). Four up-regulated miRNAs (miR-215-5p, miR-122-5p, miR-192-5p, and miR-181a-2-3p) and four down-regulated miRNAs (miR-30b-5p, miR-216b-5p, miR-320b, and miR-214-5p) in PDAC compared to CP were selected based on next-generation sequencing results. The levels of these 8 differentially expressed miRNAs were measured by qRT-PCR in 125 serum samples (50 PDAC, 50 CP, and 25 healthy controls [HC]).
Results and Conclusion The results showed significant upregulation of miR-215-5p, miR-122-5p, and miR-192-5p in PDAC serum samples. In contrast, levels of miR-30b-5p and miR-320b were significantly lower in PDAC as compared to CP and HC. ROC analysis showed that these 5 miRNAs can distinguish PDAC from both CP and HC. Hence, this panel can serve as a non-invasive biomarker for the early detection of PDAC.
Keywords Pancreatic ductal adenocarcinoma, Chronic pancreatitis, Formalin-fixed paraffin-embedded tissue, Serum
036
Pediococcus pentosaceus I44, a novel beneficial bacteria from human gut
Lavanya Vasudevan , Jayanthi V, Srinivas M, T S Chandra
Correspondence- T S Chandra-lavanyavasudevan08@gmail.com
Department of Biotechnology, Gleneagles Global Health City, Chennai, India, Indian Institute of Technology, Madras, India, and Sri Ramachandra Institute of Higher Education and Research, Chennai, India
Background Gut bacteria are now known to influence metabolic processes, immunity, and mental health. Hence the study of gut microbiota is an emerging topic of research.
Aim Most research on human microbiota are done with molecular tools. Very few studies attempt to physically isolate gut bacteria due to various difficulties involved. Many studies use stool samples which provide only the transient passengers of the gut. Tissue samples (over stool samples) provide better expression of autochthonous gut bacterial population. This research focuses on challenges involved in isolation of "autochthonous" gut bacteria and how dietary constituents may influence their properties.
Methods and Results Biopsy samples were collected from ileum and cecum of healthy volunteers who underwent routine colonoscopy. Pediococcus pentosaceus I44, isolated from ileum, was studied for acid and bile tolerance and surface properties. It was unable to survive in acidic conditions (pH 2 and pH 3) but could grow well in pH 6.5-8.0. It could withstand high bile stress of 0.5% w/v and 1% w/v for 24h. The cell surface was hydrophilic and showed good aggregation of 87%. The effect of tween-80, oleic acid, olive oil and sesame oil on properties of P. pentosaceus I44 was analyzed. These factors did not improve the acid tolerance. Tween-80 and oleic acid facilitated the growth of organism under bile stress.
Conclusion P. pentosaceus I44 is a permanent inhabitant of gut and is deposited at National Centre for Microbial Resource, Pune. To our knowledge this is the first study on laboratory culturing of gut bacteria in Indian population. It is increasingly evident that dietary habits govern the gut microbiota, and hence what may benefit one ethnic human population may not be of use to another. Hence this study strives to provide the groundwork for the emerging concept of “personalized probiotics”.
Keywords Autochthonous, Biopsy, Pediococcus pentosaceus, Gut microbiota
Esophagus
037
A rare cause of dysphagia post living donor liver transplantation in a child
Shankar Bhanushali , Aabha Nagral, Deepakkumar Gupta, Amey Sonavane, Rahul Deotale, Abhijit Bagade, Puneet Jain, Darius Mirza, Pravin Mahajan 1
Correspondence- Shankar Bhanushali-shankru07@gmail.com
Department of Gastroenterology and Hepatology, Apollo Hospitals, Plot 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India, and 1S L Raheja Hospital, Raheja Rugnalaya Marg, Mahim West, Mahim, Mumbai 400 016, India
Introduction Post-transplant lymphoproliferative disorders (PTLD) is a life threatening disorder of the immunosuppressed state in transplanted patients. Common sites include lymph nodes, gastrointestinal tract and airways.
Case A 12-year-old boy underwent a living donor liver transplantation for Budd-Chiari syndrome. Eighteen months later, he presented with progressive dysphagia. He was on Tacrolimus and Azathioprine with normal counts and liver function and a trough tacrolimus level of 10 ng/mL. His EGD scopy revealed two deep ulcers with overhanging edges in mid esophagus. Histopathology showed atypical small to medium sized lymphoid infiltrate in the esophageal mucosa, expressing CD79a, CD138 and MUM-1, EBERsBY ISH. He was immunonegative for CD20, CD3 CD5, Pax-5, CD2, CD7, CD4, CD8, CD30 and ALK-1. No light chain restriction was seen. Mib-1 proliferation index was 60% suggestive of polymorphic PTLD. PET-CT was unremarkable. EBV viral load was 12,50,00 copies/mL. Azathioprine was omitted and tacrolimus was reduced to maintain a trough level of 2-3 ng/mL. There was complete resolution of dysphagia and an endoscopy after 3 months showed complete healing of ulcers with mild hypertrophied mucosa with no evidence of any residual PTLD on histology. Currently he is well with normal liver function and an undetectable EBV infection. EBV-infected B cells cannot be controlled by EBV-specific cytotoxic T cells. Restoring recipient immunity helps control of EBV driven lymphoproliferation. Ours being the only one in a post liver transplant setting. Ours is the first esophageal PTLD reported in a post liver transplant setting; other being a renal transplant recipient treated with rituximab.
Conclusion Esophageal PTLD should be considered in the DD of dysphagia in the post-transplant setting.
038
Esophageal stricture dilatation with Savary-Gilliard dilators- Etiological spectrum and response to treatment, a single centre experience from Central India
Mohd. Talha Noor, Praveen Vasepalli
Correspondence- Mohd. Talha Noor-noorpgi@gmail.com
Department of Gastroenterology, Sri Aurobindo Medical College, and PGI, SAIMS Campus, Indore-Ujjain State Highway, Near MR-10 Crossing, Sanwer Road, Indore 453 555, India
Introduction Esophageal stricture dilatation is a therapeutic procedure for the management of dysphagia secondary to structural or neuromuscular disorders of the esophagus that offers the benefits of temporary or permanent relief of dysphagia, with an improved quality of life and sometimes avoidance of surgery. Benign causes include peptic stricture, Schatzki’s ring, esophageal web, corrosive ingestion, post-radiotherapy or post-surgical strictures. Malignant causes include adenocarcinoma, squamous cell carcinoma, pseudo-achalasia and metastases. In this study, we aimed to investigate the effectiveness of dilatation with Savary-Gilliard dilators (SGD) with respect to etiology.
Methods We retrospectively analyzed the cases treated with esophageal dilatation with SGD in the Department of Gastroenterology at Sri Aurobindo Institute of Medical Sciences from January 2014 to August 2020. All the demographic and clinical data was recorded as well as endoscopic dilatation count and complications.
Results A total of 108 patients (52 [48.14%] males and 56 [51.85%] females) were included in the study with mean age of 52.4±14.7 (17-80) years. A total of 1025 dilatations of 108 patients were done in 225 sessions. The most commonly seen etiologies were post- radiotherapy strictures (n=46, 42.59%), peptic strictures (n=23, 21.29%), corrosive strictures (n=21, 19.44%) and esophageal web (n=11, 10.18%). Mean dilatation session count was 4.5 (1-10) in patients with post-radiotherapy strictures, 3.2 (1-8) in corrosive strictures, 2.1 (1-8) in peptic strictures, 1.3 (1-3) in esophageal web No major complications such as perforation, major bleeding were observed.
Conclusion SGD for the treatment of esophageal strictures is a relatively safe, cheap, easily performed method. While esophageal web is usually treated in a single session, repeated endoscopic dilation sessions are required for the strictures caused by radiotherapy and corrosive ingestion as majority of them are long and complex strictures.
039
Quality of life changes in patients of achalasia cardia undergoing pneumatic dilatation vs. laparoscopic Heller’s cardiomyotomy
Pratik Jha , Mumtaz Ansari, Vivek Srivastava
Correspondence- Mumtaz Ansari-mumtazbhu@gmail.com
Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
Introduction There are various treatment options available for achalasia cardia like botulinum toxin injection into the distal esophagus, balloon dilatation, calcium channel blockers or nitroglycerine, and open/laparoscopic Heller’s cardiomyotomy. However, the optimal approach is still a matter of debate.
Objectives To compare the clinical outcomes and overall quality of life in achalasia cardia patients undergoing pneumatic dilatation (PD) and laparoscopic Heller’s cardiomyotomy (LH).
Methods A total of 30 patients with achalasia cardia were divided into two groups using computer-generated randomization in this prospective study conducted from July 2017 to July 2019 at Institute of Medical Sciences, Banaras Hindu University. The diagnosis was confirmed by timed barium swallow study/esophagoscopy and high-resolution manometry. Pre-procedure data regarding demography, symptom duration and severity, and manometric pressure was collected. Group 1 and 2 underwent PD and LH respectively. The post-procedure evaluation was done on the basis of Eckardt score, manometric data and quality of life based on SF-36 questionnaire at 1 week and 3 months. Statistical analysis was done using SPSS 16.0 software.
Results Both the study groups were similar. The mean age was 40.70 ± 13.42 in the PD group and 39.70 ± 9.71 in the LH group. The symptom severity as evaluated by Eckardt score was less in the PD group initially but at 3 months LH group had fewer scores (p<0.01). The decrease in lower esophageal sphincter pressure (PD: 9.20 ± 3.75, LH: 1.79 ± 8.98), integrated relaxation pressure and distal contractile integral was more in the LH group (p<0.01). Role limitation due to physical functioning and emotional problems were comparable in both groups. However, physical function, energy, general health, mental health, emotional well-being and social functioning were better in the LH group at 3 months (p<0.01).
Conclusion Laparoscopic Heller’s cardiomyotomy is a better treatment option with comparable safety as pneumatic dilatation.
040
Efficacy of POEM for achalasia cardia in a tertiary care center of Odisha
Manas Kumar Behera , Manoj Kumar Sahu, Jimmy Narayan, Debakanta Mishra, Shobhit Agarwal
Correspondence- Manoj Kumar Sahu-manojsahu427@gmail.com
Department of Gastroenterology, Institute of Medical Sciences and SUM Hospital, (SOA deemed to be University), K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
Introduction Per oral endoscopic myotomy (POEM) is a highly effective and safe technique for treatment of achalasia cardia and has received worldwide acceptance for its promising results. The aim of this study is to evaluate the efficacy of POEM technique in patients with achalasia cardia.
Methods Patients of achalasia cardia treated by POEM between January 2018 to March 2019 were retrospectively analyzed. These patients were followed up for a period of 1 year. All the patients had undergone timed barium swallow and high-resolution esophageal manometry before and after procedure. The outcomes of POEM procedures including Eckardt score, and occurrence of gastroesophageal reflux disease (GERD) and periprocedural complications were compared.
Results A total 42 patients were performed POEM for achalasia cardia (Type I-9%, Type II-91%). POEM was successfully completed in all patients. Mean age was 37.12 ± 12.34 years, with males constitute 68% of all cases. Median duration of disease was 3 years. Dysphagia (81%), chest pain (62%), regurgitation (50%) were presenting symptoms, and mean pre-POEM Eckardt score was 8.51 ± 1.68 and mean post POEM Eckardt score was 1.63 ± 0.55 (p<0.001). The mean lower esophageal pressure before and after POEM procedure were 39.58 ± 7.82 and 15.86 ± 6.98 respectively (p<0.001). Technical success was 100 % and clinical success, defined as Eckardt score ≤?3 after POEM procedure, was achieved in 40 (95.2%) patients. Nine (21.4%) patients developed GERD, as documented by 24-hour pH-impedance study.
Conclusion POEM is a very effective, safe technique, and should be undertaken as a first treatment option in patients with achalasia cardia.
041
Esophageal stricture dilatation with Savary-Gilliard dilators- Etiological spectrum and response to treatment, a single centre experience from Central India
Mohd. Talha Noor, Praveen Vasepalli
Correspondence- Mohd. Talha Noor-noorpgi@gmail.com
Department of Gastroenterology, Sri Aurobindo Medical College, and PGI, SAIMS Campus, Indore-Ujjain State Highway, Near MR-10 Crossing, Sanwer Road, Indore 453 555, India
Introduction Esophageal stricture dilatation is a therapeutic procedure for the management of dysphagia secondary to structural or neuromuscular disorders of the esophagus that offers the benefits of temporary or permanent relief of dysphagia, with an improved quality of life and sometimes avoidance of surgery. Benign causes include peptic stricture, Schatzki’s ring, esophageal web, corrosive ingestion, post-radiotherapy or post-surgical strictures. Malignant causes include adenocarcinoma, squamous cell carcinoma, pseudoachalasia and metastases. In this study, we aimed to investigate the effectiveness of dilatation with Savary-Gilliard dilators (SGD) with respect to etiology.
Methods We retrospectively analyzed the cases treated with esophageal dilatation with SGD in the Department of Gastroenterology at Sri Aurobindo Institute of Medical Sciences from January 2014 to August 2020. All the demographic and clinical data was recorded as well as endoscopic dilatation count and complications.
Results A total of 108 patients (52 [48.14%] males and 56 [51.85%] females) were included in the study with mean age of 52.4±14.7 (17-80) years. A total of 1025 dilatations of 108 patients were done in 225 sessions. The most commonly seen etiologies were postradiotherapy strictures (n=46, 42.59%), peptic strictures (n=23, 21.29%), corrosive strictures (n=21, 19.44%) and esophageal web (n=11, 10.18%). Mean dilatation session count was 4.5 (1-10) in patients with postradiotherapy strictures, 3.2 (1-8) in corrosive strictures, 2.1 (1-8) in peptic strictures, 1.3 (1-3) in esophageal web No major complications such as perforation, major bleeding were observed.
Conclusion SGD for the treatment of esophageal strictures is a relatively safe, cheap, easily performed method. While esophageal web is usually treated in a single session, repeated endoscopic dilation sessions are required for the strictures caused by radiotherapy and corrosive ingestion as majority of them are long and complex strictures.
042
Fully covered stent in a case of endoleak for post aortic stenting in a case of primary aortoesphageal fistula
Deepakkumar Gupta, Amey Sonawane, Aabha Nagral, Rahul Deotale, Shanker Bhanushali
Correspondence- Deepakkumar Gupta-dkgt@rediffmail.com
Department of Gastroenterology, Apollo Hospital, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Introduction Endoleak post aortic stenting for primary aortoesophageal fistula is a rare complication requiring reintervention, however with high risk of mortality. We hereby used a fully covered self-expanding covered esophageal metal stent (SEMS) in one such case to control the rebleeding.
Case Seventy-eight-year-old gentleman with hypertension came with 2 episodes of hematemesis with hypotension, after resuscitation he underwent gastroscopy which showed a large non-occluding mass protruding from the posterior wall and occupying the esophageal lumen, biopsy taken which turned out to be inconclusive. CT scan thorax done showed a large aneurysm extending uptil the diaphragmatic opening and a large thrombus protruding into esophageal wall causing a large defect of 3.5 cm on the posteromedial wall in mid esophagus. Patient was immediately taken for aortic stenting which was successfully placed across the entire length of the aneurysm, patient was continued on ventilatory support overnight, however within 9 hours post-surgery patient had melena and a significant drop in hemoglobin. Patient underwent an urgent endoscopy which showed the clot at 20 cm insitu with active oozing of blood from the site, post-flushing the bleeding worsened and visibility reduced, hence initially a foleys balloon passed orally was inflated at 20 cm and a guidewire passed across into the gastric lumen and temporarily a rigiflex balloon placed along it, the bleeding was controlled for 24 hours, and patient underwent a CT scan which showed a type 2 endoleak. In view of high risk of surgery and no radiological intervention feasible we decided to use a covered esophageal stent for maintain hemostasis. Patient improved and was kept on RT feeds and was discharged after 7 days. Patient however readmitted and succumbed after 40 days due to persistent leak causing mediastinitis.
Conclusion Fully covered SEMS can be used in endoleak management to control hemostasis.
043
Esophageal tuberculosis in health care workers: A report of 2 cases
Swapnika Gadde , P Shravan Kumar, M Umadevi, K Saikrishna, Sriram S, Murali NSVM, Anirudh K, Abhinay P, Samad P
Correspondence- Swapnika Gadde-swapnikagadde@gmail.com
Department of Gastroenterology, Gandhi Medical College, Musheerabad, Secunderabad 500 003, India
Introduction Esophageal tuberculosis (ET) is rare in both immunocompetent and immunocompromised hosts with pulmonary tuberculosis, even in countries with high prevalence rates like India. Most reports of esophageal tuberculosis are secondary to direct extension from adjacent structures, such as mediastinal lymph nodes or pulmonary sites.
Case Presentation We present two cases of esophageal tuberculosis in patients with initial complaints of dysphagia and epigastric pain, emphasizing the diversity of endoscopic presentation of TB. Upper gastrointestinal endoscopy was used in the diagnosis of esophageal tuberculosis following the biopsy of lesions of ulcerated mucosa in one case; other was based on confirming tuberculosis in adjacent strucrues. Pulmonary tuberculosis was detected in one patient. Anti-tuberculosis treatment (ATT) was curative in both patients.
Conclusion Although rare ET has to be considered in the differential diagnosis of patients with dysphagia, especially in TB endemic areas, even in young immunocompetant patients. Detection of these cases by careful examination, biopsies and treatment with standard ATT appear effective.
Keywords Esophageal tuberculosis, Dysphagia, Endoscopy, Pulmonary tuberculosis
044
Cerebellar metastasis as first presentation from undiagnosed esophageal carcinoma: A case report
Dhaval Choksi 1 , Sanjay Vekhande 2 , Ketaki Choksi 3 , Vidya Kale 3
Correspondence- Dhaval Choksi-dhavalrchoksi@gmail.com
1Departments Medical Gastroenterology, 2Neurosurgery, and 3Pathology, Apollo Hospitals, Plot No. 1, Swaminarayan Nagar, New Adgaon Naka, Panchavati, Nashik 422 003, India
Introduction Brain metastasis from esophageal carcinoma is an uncommon event. Amongst these, cerebellar metastasis without cerebral metastasis is extremely rare.
Methods We report a case of a 74-years male presenting with headache and ataxia. Brain imaging was suggestive a cerebellar lesion which was operated upon. Biopsy was suggestive of metastatic squamous cell carcinoma. Patient had upper gastrointestinal bleeding on postoperative day 3 which was investigated with upper gastrointestinal endoscopy, biopsy and computed tomography scan of the chest. A diagnosis of metastatic esophageal carcinoma with cerebellar metastasis was made.
Result Patient succumbed to his illness after 2 months.
Conclusion Our case is an addition to this rare entity of cerebellar metastasis from esophageal carcinoma presenting with neurological features.
Keywords Esophageal carcinoma, brain metastasis, cerebellar metastasis
045
Clinical profile, etiology and outcome of esophageal strictures in a tertiary care centre in Kerala
Gouri S , Sunilkumar Kandiyil, T M Ramachandran
Correspondence- Gouri S-mailme2gouri@gmail.com
Department of Gastroenterology, Government Medical College, Calicut 673 008, India
Introduction Esophageal strictures are a commonly encountered problem in daily practice and can occur from a variety of benign and malignant etiologies, which varies in developed and developing countries. This study was intended to describe the clinical profile of esophageal strictures and assess the outcome and complications associated with endoscopic dilatation.
Methods A prospective study was conducted among 96 patients with esophageal stricture, attending Department of Gastroenterology in a tertiary care centre in Kerala from July 2019 to June 2020. The outcomes were to assess clinical and technical response to dilatation, procedure related complications and the factors predicting refractoriness to dilatation.
Results Among the 96 patients studied, (M:F–1.46:1), mean age–54 years), corrosive and radiation induced strictures were the commonest contributing 20.8% each. Malignant, post-anastomotic, peptic, web and inflammatory strictures were 16.7%, 12.5%, 9.4%, 9.4% and 4.2% respectively. Esophageal dilatations were performed with bougie (91.5%), balloon or both with a clinical and technical success rates of 73% and 65%, and 22.9% remained refractory. Severe grades of dysphagia on presentation, poor nutritional status and long segment strictures involving multiple sites in corrosive induced and malignant strictures were found to predict refractoriness. A complication rate of 4.16% was noted during the periprocedural period.
Conclusion Ingestion of corrosives and radiation therapy appear to be the most common causes of esophageal strictures. Endoscopic dilatation is usually successful and safe in achieving luminal patency, but corrosive and malignant strictures are mostly refractory, and the former tend to recur even after successful dilatation.
Keywords Esophageal stricture, Etiology, Dilatation success, Complications
046
Role of high-resolution manometry and 24 hours ambulatory pH impedance study in patients with PPI refractory non erosive gastroesophageal reflux disease
Charu Gupta , Piyush Ranjan, Shrihari Anikhindi, Munish Sachdeva, Mandhir Kumar
Correspondence- Piyush Ranjan-piyushranjan70@gmail.com
Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Introduction Refractory gastroesophageal reflux disease (GERD) is a common problem faced by a gastroenterologist. Understanding the cause of treatment refractory GERD helps in guiding the further course of treatment. We aim to study the physiological basis of patients with nonerosive refractory gastroesophageal reflux disease and classify these patients based on findings of high-resolution manometry (HRM) and 24-hour ambulatory pH impedance monitoring.
Methods This is a single centre prospective study from March 2019 to August 2020 in which clinical profile and data of HRM and pH impedance studies was analyzed in patients on PPI with refractory non erosive GERD. Refractory GERD was defined as persistence of heartburn or regurgitation at least once a week after receiving standard dose of PPI for at least 8 weeks. Patients on NSAIDs, pregnant females, patients with organic disease of the upper digestive tract or previous upper digestive tract surgery, significant comorbidities like decompensated chronic liver disease, chronic kidney disease, poorly controlled diabetes mellitus or any malignancy were excluded.
Results One hundred and fifty-one patients with refractory GERD were analyzed of which, 48 had abnormal esophagogastroduodenoscopy and 103 were nonerosive GERD. Amongst, nonerosive disease, acid reflux disease was found in 29.1%, non-acidic reflux disease in 21.4%, 30.1% patients had reflux hypersensitivity whereas, 19.4% patients had functional heartburn. On HRM, 8.74% had esophageal motility disorders, most commonly being IEM in 5.82% patients followed by esophagogastric junction (EGJ) obstruction in 1.94% and absent contractility in 0.97%. 25.2% had hiatus hernia; 20.4% patients had type II EGJ morphology, 2.9% had type IIIa and 1.9% had type IIIb EGJ morphology.
Conclusion True acid reflux disease was found in less than 1/3rd refractory non erosive GERD patients only and around 50% patients had functional esophageal disorder as found on pH impedance studies. Majority patients have normal esophageal motility but 1/4th have abnormal EGJ morphology.
Keywords Refractory NERD, pH impedance studies, High resolution
047
An unusual cause of hematemesis: Managed by endoscopic and radiological interventions
Mahesh Kumar Gupta 1 , Rinkesh Kumar Bansal 2 , Rajesh Puri 3
Correspondence- Mahesh Kumar Gupta-guptamahesh1982@gmail.com
1,2Department of Gastroenterology and Hepatobiliary Science, Fortis Memorial Research Institute, 44, Opp. HUDA City Centre, Gurugram 122 002 India, Department of Gastroenterology, Medanta -The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram 122 001, India
Background Perforation of esophagus secondary to bursting of tubercular mediastinal lymph nodes, presenting with hematemesis rare. Commonest site is mid-esophagus, due to proximity to mediastinal lymph nodes.
Case A 50-year-old male, diagnosed case of sputum positive pulmonary tuberculosis, on first line ATT x 2 months, presented with multiple episode of massive hematemesis X 2 days. Clinical examination revealed mild-grade fever, tachycardia and tachypnoea. His hemoglobin was 5 gm%, managed by multiple units of blood transfusion. Patient shifted to ICU for close monitoring and intensive care. After stabilization endoscopy done which showed lymph node eroding in the esophagus at 30 cm from incisors with suspected bronchoesophageal fistula without active bleeding at eroded site. CECT chest showed enlarged subcarinal nodes with bronchoesophageal fistula. Bronchoscopy conformed bronchoesophageal fistula. He had another episode of hematemesis on next day so repeat endoscopy was done which showed there was active oozing through eroded site on which OTSC applied. He responded well to endotherapy and was discharged in stable condition on ATT. After one month, he again had hematemesis, endoscopy showed a small bleeding vessel at previously clipped site, another clip tried but not succussed. His CT angiography chest showed right bronchial artery pseudoaneurysm measuring 1.1 cm x 0.7 cm. Urgent interventional radiology team called and he underwent angiographic embolization of pseudo aneurysm. He responded well to the given treatment. Follow-up endoscopy showed no bleeding and clip in position. He was discharged in stable condition on ATT. He is doing well on 4 months follow-up without any further bleed.
Conclusion It is important to consider esophageal perforation due to mediastinal lymph nodes in endemic areas of tuberculosis; the patient can be managed by simple clipping with anti-tubercular drug therapy and without removing the esophagus.
Keywords Hematemesis, Tubercular lymphadenopathy, Perforation, OTSC clipping, Embolization
048
Ten-year study on management of corrosive esophageal stricture
Neeraj Nagaich 1 , Radha Sharma 2
Correspondence- Neeraj Nagaich-drneerajn@gmail.com
1Department of Gastroenterology, Fortis Hospital, Jawahar Lal Nehru Marg, Malviya Nagar, Jaipur 302 017, India, and 2RUHS College of Medical Sciences, Kumbha Marg, Sector 11 Road, Pratap Nagar, Jaipur 302 033, India
Objective Analysis of outcome and safety of esophageal dilatation in caustic esophageal strictures.
Methods This prospective and retrospective study was conducted to evaluate the safety and efficacy of endoscopic dilatation in corrosive esophageal stricture. All eligible patients with caustic esophageal strictures presenting between 2010 to 2020 and above 03 years of age were included. Patient with caustic stricture and fistulae or diverticulae, peptic stricture and malignant stricture were excluded. Barium swallow and meal was done if required Savary-Gilliard plastic dilators of increasing sizing were employed. Repeated sessions were performed fortnightly till a 15 mm (45 Fr) lumen size was achieved. Follow-up session were arranged whenever dysphagia developed after completing initial session of adequate dilatation. In patients with refractory stricture injection triamcinolone or topical mitomycin C application was done during dilatation session.
Results Out of 320 patients, 192 patients (60%) were more than 12 years of age. Mean age is 20.25 ranging from 5 years to 64 years. There were 185 males (58%) and 135 females (42%). Total dilatations were 4822. Successful dilatation up to a lumen size of 15 mm could be achieved in 211 patients (66%). In 48 patients (15%) with refractory stricture application of triamcinolone or mitomycin c lead to success. In 108 patients (34%) satisfactory dilatation could not be achieved and were referred for surgery. Nine patients (2.8%) had perforation with an incidence rate of 0.30%.
Conclusion Caustic stricture is more common in adolescent and adults in our population. Endoscopic dilatation of esophageal strictures is a relatively safe procedure with good results and low rate of complications. Resection with esophagogastric anastomosis or colonic interposition is required in severe cases. Injection Triamcinolone and topical Mitomycin are safe and effective adjuvants in refractory stricture.
Keywords Corrosive, Stricture
Stomach
049
Incidence, prevalence of H. pylori and eradication following treatment in general population
Syed Ibrahim Hassan
Correspondence- Syed Hassan-doctorhassanibrahim@yahoo.co.in
Department of Medical Gastroenterology, Deccan College of Medical Sciences, Princess Esra Hospital, Kanchanbagh, Hyderabad 500 058, India
Introduction H. pylori is world’s most common bacterial infection affecting majority of population. Its incidence ranges between 7% to 97% in developed vs. less developed areas. Since incidence in our country is high eradication of the bacteria is necessary to prevent health disability due to its complications. The present study was undertaken to know the incidence and response to treatment.
Methods Patients of different age groups and of either sexes presenting with symptoms of epigastric pain related to food of variable duration, from 2 weeks and above with no co morbidity were included in the study. All patients underwent UGIE, RUT, US abdomen and CBP, stool for occult blood. Those patients positive for H. pylori were given triple drug regimen of amoxycillin (750 mg BD), clarithromycin (500 mg BD) with esomeprazole 40 mg BD for 10 days with food precautions. After 10 days of treatment UGIE was repeated with RUT to know the clearance of H. pylori. Patients still positive were given tinidazole (500 mg 2 tablets OD), azithromycin (1 tablet OD) and rabeprazole 40 mg BD for a period of 10 days and subsequently underwent UGIE with RUT to know the response.
Results Fifty patients of age groups 11-70 years were included in the study. Seventy-six percent of patients responded to the first line of treatment. Non responders were given second line of treatment who responded completely (100%). After treatment all were asymptomatic.
Discussion H. pylori infection which is a worldwide problem can be corrected by good food habits, good sanitation, avoiding specific uncooked, unhygienic preserved food and water.
Conclusion Screening of patients of APD is the first step followed by eradication with specific drug regimen to clear the infection and bringing good health in the community.
050
Is use of proton pump inhibitors associated with renal dysfunction? A prospective cohort study
Adeshkumar Andhale , Philip Abraham, Devendra Desai, Anand Joshi, Tarun Gupta, Jatin Kothari, Pavan Dhoble, Nikhil Bhangale
Correspondence- Philip Abraham-dr_pabraham@hindujahospital.com
Department of Gastroenterology, P D Hinduja Hospital and MRC, Mahim, Mumbai 400 016, India
Introduction Long-term use of proton pump inhibitors (PPI) has been linked with infrequent but serious adverse events, including acute kidney injury (AKI), chronic kidney disease (CKD), and progression of CKD.
Objective To determine whether use of PPI is associated with any short- or long-term renal dysfunction.
Methods Patients taking PPI for 6 weeks had serum creatinine tested pre and post treatment; those with baseline eGFR <90 mL/min/1.73m2 were excluded. Patients taking PPI for at least 90 days in the next 6 months, and at least another 90 days in further 6 months, had serum creatinine tested at such follow-up. Renal dysfunction was classified as per the KDIGO criteria for AKI.
Results At baseline, a majority of patients were aged 21-40 y (median 39; IQR 31-47); 98 (49%) had history of previous PPI use (median 6 mo; IQR 3–24). Serum creatinine was tested at baseline, 6 weeks, 6 mo and 1 y in 200, 180, 77 and 50 patients, respectively. Corresponding creatinine mean (SD) values were: 0.76 (0.14), 0.69 (0.16), 0.71 (0.15) and 0.76 (0.16) mg/dL. Although there was statistically significant difference (p<0.05) in creatinine at 6 weeks and 6 mo as compared to baseline, the difference was not clinically significant. Increase in creatinine was noted in 20 (11.1%), 11 (14.3%) and 6 (12%) patients at 6 weeks, 6 mo and 1 y, respectively; 14, 8 and 4 of these had less than Stage 1 dysfunction (i.e. less than 0.3 mg/dL increase), and 10, 5 and 5 had other risk factors for renal dysfunction. No patient developed CKD during the study period.
Conclusion Increase in serum creatinine occurred in 10% to 15% of patients on PPI but was mild (KDIGO Stage 1 or less) in a majority and not progressive. A majority of them had other risk factors for renal dysfunction.
051
Gastric cancer in young patients with no alarm symptoms: Focus on delay in diagnosis
Rathod Vivek , A Anand
Correspondence- Rathod Vivek-rathodrockzz@gmail.com
Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai 600 010, India
Introduction There has been a tendency in recent years to delay endoscopy in dyspeptic patients younger than 45 years with no so-called "alarm symptoms." This study was conducted to test whether this policy might lead to an increased rate of delayed diagnosis of gastric cancer.
Method A prospective study was carried out on dyspeptic patients < or = 45 years of age in our hospital from October 2019 to July 2020. Characteristics analyzed included duration and features of dyspeptic symptoms, presence of alarm symptoms, time interval from the onset of symptoms to diagnosis and pathological characteristics.
Results In the study group we found 30 patients had gastric cancer (17 females, 13 males). Six patients (20%) presented with uncomplicated dyspepsia and 24 patients with (80%) alarm symptoms (persistent vomiting, anemia, weight loss, dysphagia). None had positive family history. In those with uncomplicated dyspepsia epigastric pain was the most common complaint (64.1%) followed by vomiting (30.4%). Weight loss was the most common alarm symptom (53.3%), followed by anemia (46.6%). Of the 6 patients without alarm features 3 were having adenocarcinoma, 2 lymphoma, 1 signetring cell carcinoma.
Conclusion Significant proportion of young (<=45 yrs) gastric cancer patients present without alarm symptoms. We need to review the existing standard age criteria (>45 yrs) for endoscopy in dyspepsia without alarm features particularly in high gastric cancer prevalence areas.
052
High prevalence of APD in general population and its approach
Syed Ibrahim Hassan , Syed Hassan
Correspondence- Syed Hassan-doctorhassanibrahim@yahoo.co.in
Department of Medical Gastroenterology, Deccan College of Medical Sciences, Princess Esra hospital, Kanchanbagh, Hyderabad 500 058, India
Introduction H. pylori is the world’s most common bacterial infection in humans effecting more than half population of the world and seems to be increasing in less developed countries vs. developed countries. The factors responsible for infection and increasing transmission include low socioeconomic status, poor sanitation, overcrowding, contaminated water ingestion, and consumption of raw and uncooked vegetables, person to person transmission. Hence it is imperative to clear the infection in individual patient and explain risk factors to them.
Aim To study the incidence of gastritis, reflux esophagitis, peptic ulcer disease in patients presenting with epigastric discomfort, related to food intake and lasting for few hours more than 1 week and work up with UGIE, RUT to know the changes and presence of H. pylori.
Methods We are presenting the one year data from April, 2019 to March, 2020 in which patients have presented with dyspepsia of more than 10 days and underwent the UGIE with RUT, US abdomen, CBP and stool for occult blood comorbiditis were also recorded. Pediatric, pregnant female were excluded from the study.
Results Total number of UGIE for year was 2274. 1996 patients underwent procedures for dyspepsia (88%) 5.1% had prepyloric and duodenal ulcers and 94.9% had evidence of gastritis and 10% also had reflux esophagitis. The 90.1% of patients were H. pylori positive and advice anti H. pylori treatment.
Discussion The present study shows high incidence of H. pylori dyspepsia which needs specific treatment and correction of risk factors which have to be taken up by the family sanitary agencies.
Conclusion H. pylori infection is a major problem for all developing countries which requires good sanitation and good eating habits to prevent its further spread which is 2% in advance countries and 12% in developing countries.
053
NK cell enteropathy with extraintestinal involvement: Presenting as symptomatic anemia
Chandan Kumar , Manas Panigrahi, Hemanta Kumar Nayak, Subash Chandra Samal
Correspondence- Manas Panigrahi-medgast_manas@aiimsbhubaneswar.edu.in
Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar 751 003, India
Introduction NK cell enteropathy is a newly described disease of unknown etiology withh indolent clinical course characterized by atypical proliferation of NK cells throughout gastrointestinal tract while term lymphomatous gastropathy defines disease localized too stomach only.
Case history A 26-year-old male presented with recurrent oro-genital ulceration for 8-yearr with significant weight loss, postprandial fullness and intermittent vomiting. He required blood transfusion for low hemoglobin. No history of NSAID intake. He has BMI=17.5 kg/m2. Unlike in Behcet’s disease (being closest differential) ulcers were painless, non-scarring and located on glans penis. Laboratory values: Hb: 7g/dL (microcytic hypochromic), low B12 level, low normal serum ferritin and normal serum folate level and negative IgA negative IgA tTG. Stool for occult blood was positive. Esophagogastroduodenoscopy revealed pangastricc nodular mucosa with multiple superficial ulcers and occasional discrete ulcers in first and second part of duodenum. Ileocolonoscopy showed multiple small aphthae throughout colonn and ileum.
Gastric biopsy was mimicking MALT lymphoma with mixed infiltrates of lymphocytes, histiocytes, eosinophils, and neutrophils expanding the glands. Overlying epithelium were ulcerated. Atypical cells were strongly positive for CD3, CD7, CD56 and granzyme with low proliferative index. CD30 and CD20 (Pan-B) markers and immune stain for EBV weree negative. CD4 and CD8 were variably positive in different sites. Similar findings noted inn colonic and penile ulcer biopsy. Bone marrow examination revealed megaloblastic maturation without any NK cell infiltration. He already received 2 courses for H. pylori.
Management He is started with budesonide (9 mg OD) followed by azathioprine (50 mg) therapy. Response included dramatic weight gain with improvement of hemoglobin level till 6 months of therapy with no effect on gastric lesions.
Conclusion Over-investigation and aggressive therapy described in the literature (chemotherapy/gastrectomy). Symptomatic response to budesonide therapy points towards low-grade autoimmune process.
054
Metastatic involvement of stomach- A rare complication of Ca breast
Hozefa Runderawala , Nutan Desai, Hardik Shah, Boman Dhabhar
Correspondence- Hozefa Runderawala-hozaaee@gmail.com
Department of Gastroenterology, Fortis Hospital Mumbai, India
Introduction Breast cancer accounts for 29% of newly diagnosed cancer in women and frequently, it metastasizes to liver, lungs, bones or brain and rarely is reported to metastasize to stomach. We report a rare case of Ca breast metastasizing to the stomach 12 years after the first diagnosis.
Case Report Seventy-six-year-old female presented with pain in left hypochondriac region and backache which was continuous and dull aching without any radiation or aggravating or relieving factor and with no history of fever, vomiting or cough. Twelve years back, she was diagnosed with right side breast invasive ductal carcinoma grade 3, underwent surgery and subsequently chemo and hormonal therapy. For her persistent abdominal pain, upper gastrointestinal endoscopy was done which was s/o diffuse thickening of gastric folds with poor distensibility with multiple ulcers extending beyond pylorus, biopsies s/o poorly differentiated tumor and IHC was consistent with metastasis from primary breast invasive ductal carcinoma.
Discussion A high index of suspicion is required for metastatic breast cancer when patient develops gastric symptoms with prior history of breast cancer. Due to non-specific symptoms of anorexia, dyspepsia, dysphagia, nausea, vomiting, early satiety, abdominal pain and bleeding, it is difficult to distinguish between primary gastric cancer and gastric metastases from breast cancer. Moreover, gastric metastases may develop after many years following the first diagnosis of breast cancer as seen in our patient. Combinations of endoscopic, radiological, histological and IHC examination is the only reliable method to distinguish between metastatic and primary gastric cancer and the optimal treatment is chemotherapy or hormonal therapy.
Conclusion Gastric metastasis from breast cancer is rare and it requires complete diagnosis by endoscopic, radiological and histological examination with IHC to differentiate from primary gastric cancer and hormonal or chemotherapy is the mainstay treatment modality.
055
Spectrum of gastric outlet obstruction in north west India
Rishabh Gupta , Deepak Sharma, Sudhir Maharshi, Bharat Sapra, Sandeep Nijhawan, S S Sharma, Rupesh Pokharna
Correspondence- Rishabh Gupta-rishabh1313@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College And Attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Gastric outlet obstruction (GOO) is a partial or complete mechanical obstruction at antrum-pyloric region or first and second segment of duodenum. Earlier benign causes of GOO were more common than malignant causes. Now, recent studies suggests that 50% to 80% of cases are attributable to an underlying malignancy, in developed and developing countries.
Methods This prospective study was conducted at Gastroenterology Department of SMS Hospital, Jaipur, India between June 2017 to June 2020. Consecutive patients having symptoms, and endoscopic or radiological evidence of gastric outlet obstruction were included in this study.
Results A total of 451(288 male/163 female) patients with GOO were included. 248/451 (54.9 %) patients had malignant etiology and 203/451 (45.1 %) had benign etiology. In females, malignant etiology was present in 74.8 % and benign etiology in 25.2 % patients. In males, malignant etiology was present in 43.7 % and benign etiology in 56.3% patients. In malignant GOO, common causes were gallbladder carcinoma in 95 (37.5%); gastric carcinoma in 48 (31.8%) and carcinoma head of pancreas (HOP) in 49 (19.6%). Other causes were periampullary carcinoma in 9 (3.5%); cholangiocarcinoma in 10 (4%); Duodenal carcinoma in 4(1.6%); gastrointestinal lymphoma in 3 (1.2%) and neuroendocrine tumor and retroperitoneal sarcoma in 1 patient each. In benign GOO, common causes were opioid abuse in 59 (29%); peptic ulcer disease in 44 (21.6%) corrosive ingestion in 41 (20.2%) and chronic pancreatitis in 25 (12.3%). Other causes were acute pancreatitis in 15 (7.3%); NSAID abuse in 9 (4.4%); tuberculosis in 6 (2.9%); celiac disease in 3(1.5%) and Crohn’s disease in one patient.
Conclusion Overall, malignant causes are responsible for more than half of the cases of GOO in North West India. In males and females, most common causes are benign and malignant respectively.
056
To study the performance of prognostic scores in acute non variceal upper gastrointestinal bleeding
A Balakrishna , T M Ramachandran, K Srijith
Correspondence- A Balakrishna-dr.balu.bk@gmail.com
Department of Gastroenterology, Government Medical College, Medical College Road, Kozhikode 673 008, India
Background Acute upper gastrointestinal bleeding is a common medical emergency that has a 10% hospital mortality rate. Different scoring systems and risk factors have been used and implemented to assess the risk of rebleeding and mortality in patients with uppegastrointestinal bleeding. The primary objective of this study is to assess the performance of these prognostic scores (clinical Rockall score, complete Rockall score and Glasgow-Blatchford score) in patients with acute non variceal UGI bleeding. Secondary objective is to assess the risk factors of re-bleeding and mortality rates.
Methods Sixty patients were assessed with respect to their clinical parameters, organ dysfunction, laboratory parameters and three risk assessment scores i.e. clinical Rockall score (cRS), Complete Rockall score (CRS) and Glasgow-Blatchford score (GBS) were calculated. The scores were correlated with outcome. The sensitivity and specificity of scores in predicting the outcomes were calculated using AUROC.
Results The mean age of the group was 44.14years (±14.9). The average duration of hospital stay in the study population was 5.72 days. The incidence of re-bleed in this study was found to increase with increasing age. The incidence of rebleeding highest for the patients with GI malignancy and those patients with Mallory-Weiss tear. For prediction of outcomes, GBS was superior to the others (AUROC of 0.839) followed by the complete Rockall score (AUROC of 0.819), followed by clinical Rockall score (AUROC 0.80) all values being statistically significant.
Conclusions The CRS score is best in predicting the mortality in patients with upper GI bleed. The optimum cut off being >3. Though GBS may be better in predicting the need for intervention, it is inferior in predicting the mortality.
Keywords CRS-Complete Rockall Score, cRS-Clinical Rockall Score, GBS-Glasgow Blatchford Score
057
Spectrum of primary gastric lymphoma in northern India: A series of thirty patients
Akash Mathur , Uday C Ghoshal, Sushil Kumar, Neeraj Kumari
Correspondence- Uday C Ghoshal-udayghoshal@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Background Primary gastric lymphoma (PGL) is less commonly reported in India. Since gastric cancer is a relatively less common malignancy in northern India, the possibility of PGL being less common in this region can’t be excluded. However, another possibility could be under-reporting due to lack of adequate diagnostic workup and awareness.
Methods During a 12-y period (2000-2012), data of gastric neoplasm in a teaching institute were retrospectively analyzed with the aim to know (i) the frequency of PGL among patients with gastric neoplasm, (ii) their demographic and clinical profile, and (iii) the diagnostic procedures needed for the diagnosis.
Results 30/324 (9.2%) patients (median age 56, range 25-72, 73.3% male) with gastric neoplasm had PGL. 40% of them had H. pylori infection (2/3 tests positive). Most presented with dyspepsia with or without weight loss (9, 30%); others presented with gastric outlet obstruction (n=7, 23.3%), upper gastrointestinal bleeding (n=5, 16.7%), dysphagia (n=4, 13.3%), malignant ascites (n=3, 10%) and other (n=2, 6.7%). In most (60%) diagnosis could be established on endoscopic biopsy while in 40%, surgical resection was required. The endoscopic and surgical diagnosis groups were comparable in age (53.4 vs. 52.7 years), sex (male 77.8% vs. 66.7%), H. pylori (38.9 vs. 16.7%), presentation with dyspepsia with or without weight loss (38.9 vs. 16.7%), presentation with organic symptoms (61.1 vs. 83.3%) and need for repeated endoscopic biopsies before conclusive diagnosis was established (12.5 vs. 33.3%).
Conclusion The study demonstrates the comparatively high frequency of PGL in this population (9.2%) and confirms the intimate association of H. pylori infection (40%). PGL should always be considered in the differential diagnosis of gastric malignancy.
Keywords Lymphoma, Gastric, Primary Gastric Lymphoma
Small Intestine
058
Seroprevalence of celiac disease in high altitude area in India
Brij Sharma, Alka Singh , Neetu Sharma, Rajesh Sharma, Vishal Bodh, Anmol Gupta, Anam Ahmed, Ashish Chauhan, Vikas Jinda 2 , Govind K Makharia
Correspondence- Govind K Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and Departments of Gastroenterology, Community Medicine, and Physiology, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India
Introduction While celiac disease (CeD) is known to occur in many regions on the plane, there is a lack of data on its prevalence in high altitude area of India.
Methods We screened serum samples of 332 participants of another population-based study in Lahaul and Spiti districts of (mean altitude >4000 meter) Himachal Pradesh, for estimation of prevalence of CeD in high altitude area. The screening of CeD was done using commercially available IgA human anti-tissue transglutaminase antibody (anti-tTG Ab).
Results Of 332 samples (mean age 31.5±15.9) screened, two were found to have a positive anti-tTG Ab at low titre, suggesting a seroprevalence of 0.6%.
Conclusions The seroprevalence of CeD in high altitude area is 0.6%, almost equal to the rest of the country. The physicians working in high altitude areas to be aware about CeD in their communities.
Keywords Celiac disease, High altitude, Prevalence, Anti-tissue transglutaminase
059
Single balloon enteroscopy for small bowel evaluation in pediatric patients- A tertiary care experience
Sachin Kasle , Manohar Reddy, Sujay Kulkarni, Zaheer Nabi, Radhika Chavan, Mahiboob Sayyed, Partha Pal, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India
Background and Aim Balloon enteroscopy is the cornerstone for small bowel evaluation in adult patients. However, the data are limited in pediatric patients. In this study, we aim to evaluate the safety and diagnostic utility of single balloon enteroscopy (SBE) in children with suspected small bowel diseases.
Methods The data of all the children (≤ 18-years) who underwent SBE from November 2010 to July 2020, was analyzed retrospectively. The safety and diagnostic yield of SBE were assessed.
Results One hundred and eighty-nine SBE procedures (males 117, mean age 15.1±2.76, range 3-18 years) were performed in 174 children. The most common indication for SBE was abdominal pain with or without additional symptoms in 119 (68.4%), followed by gastrointestinal bleed 17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%). Antegrade and retrograde enteroscopy procedures were performed in 98 (51.8%) and 77 (40.7%), respectively. Both (antegrade and retrograde) were performed in 7 (3.7%) cases. The mean length of small bowel intubation in antegrade and retrograde SBE groups were 168.9±58.6 cm and 120.7±52.1 cm, respectively. Overall, a positive finding was seen in 117 (67.2%) cases. The most common findings were ileal and jejunal ulcers with or without strictures found in 76 (64.9%). A final diagnosis could be established in 63.8% children. The diagnostic yield was higher in cases with additional symptoms besides pain abdomen as compared to pain abdomen alone (85.1% vs. 50%, p=0.001). A total of 17 therapeutic enteroscopic procedures were performed in 11 children including polypectomy in 7 children with Peutz-Jeghers syndrome and argon plasma coagulation therapy in 4 cases with vascular lesions. There were no major adverse events. Self-limiting bleeding not requiring blood transfusion was noticed in one patient after polypectomy.
Conclusion SBE is a safe procedure for the evaluation of small bowel diseases in children and adolescents. SBE establishes a diagnosis in nearly two-thirds of the children.
060
Retrospective study of tissue transglutaminase antibody (ttgA) levels in celiac disease suspected patients at tertiary care hospital in Uttarakhand
Swati Rajput , Rohit Gupta, Itish Patnaik, Yogesh Arvind Bahurupi, Prashant Kumar, Kiran Meena, Nowneet Kumar Bhat, Satyavati Rana
Correspondence- Satyavati Rana-svrana25@hotmail.com
Department of Biochemistry, All India Institute of Medical Science, Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Background and Objective Celiac disease (CeD) is a chronic gastrointestinal disorder arising due to gluten sensitivity in susceptible individuals. In India, one person per 100 is suffering from this disease. CeD has been reported more in high wheat consuming areas like northern India. But the incidence of CeD in patients attending tertiary care hospital of Uttarakhand has not yet been reported. Therefore, this study was planned.
Methods A retrospective study with 603 patients was done at AIIMS, Rishikesh in Biochemistry Department. These patients were screened for CeD by tissue transglutaminase antibodies (ttgA) levels using ELISA method. Percentage of levels of ttgA <4 U/mL (normal value) and >4 U/mL in male, female adults and children was calculated. Chi-square test was applied to compare results.
Results Out of 603 patients, 23 (3.81%) had abnormally raised ttgA levels (>4 U/mL). Percentage (15.18%) of ttgA levels in male children was significantly (p=0.01) higher than 2.56 % in female children. Mean + SD of normal and abnormal ttgA levels in patients was 1.17 + 0.45 vs. 66.81+34.80 U/mL respectively. Mean+SD of abnormal ttgA levels in children and adults was 72.84+41.91 vs. 32.38+24.75 U/mL respectively. There was significant difference in abnormal ttgA levels among children and adults with children predominantly being higher (p value= 0.0235).
Conclusion This study shows that the levels of ttgA suggestive of CeD in children is higher as compared to adults and more in males than females attending the tertiary care hospital of Uttarakhand.
061
Seronegative celiac disease - Frequently encountered yet undiagnosed clinical entity
Kapil Dhingra , Sudhir Maharshi, Bharat Sapra, Sandeep Ratra, Shyam Sunder Sharma, Sandeep Nijhawan
Correspondence- Kapil Dhingra-kapil7029@yahoo.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India
Background There are limited studies on seronegative celiac disease from Indian subcontinent. The aim of the study is to assess the prevalence, pathological, genetic and clinical profile of patients with seronegative celiac disease.
Methods This prospective observational study was conducted in the Department of Gastroenterology, SMS Hospital, Jaipur between October 2017 to March 2019. Consecutive patients of seronegative celiac disease with age ≥3 years were enrolled for the assessment of demography, clinical features, histological findings, celiac serology, genetic analysis, and response to gluten-free diet.
Results Out of total 312 celiac disease patients, 13 (4.16 %) patients (median age 25 years [range 5-46 years], 10 female) were diagnosed as seronegative celiac disease. Presenting symptoms were chronic diarrhea in 9 (69.23%), pain abdomen in 6 (46.15 %), weight loss in 5 (38.46%) and short stature in 2 (15.38 %) patients. On histological analysis, Marsh stage 2 seen in 5 (38.46%), Marsh 3c in 2 (15.38%), Marsh 3a in 3 (23.07%), and Marsh 3b in 3 (23.07%) patients. On HLA analysis, HLA- DQ2.5 seen in 6 (46.15%) patients, HLA-DQ2.2 in 5 (38.46%) and HLA-DQ8 in 2 (15.38%) patients.
Conclusions The prevalence of SNCD in our study is 4.16%. Most common symptoms were chronic diarrhea and pain abdomen and histological grade was Marsh stage 2.
062
Castleman disease variant of POEMS syndrome: A case report of a patient with diarrhea
Manas Kumar Panigrahi, Mohd Imran Chouhan , Hemanta Kumar Nayak, Subash Chandra Samal, Shivam Sethi
Correspondence- Manas Kumar Panigrahi-medgast_manas@aiimsbhubaneswar.edu.in
Department of Gastroenterology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Castleman disease, a variant of POEMS syndrome is a multisystem disorder of monoclonal plasma cell disorder. To reduce mortality and morbidity associated with POEMS syndrome proper diagnose and early treatment should be started. We report a case of POEMS syndrome who presented with diarrhea, skin hyperpigmentation, and edema and weight loss.
Clinical presentation A 40-year-old male presented with chronic small bowel diarrhea, weight loss, swelling of feet, hyperpigmentation, and tingling sensation of both lower limbs. Examination revealed BMI of 15 kg/m2, pallor, papilledema, generalized lymphadenopathy, hyperpigmentation clubbing, hepatosplenomegaly, edema, decreased pain and temperature. Investigation showed anemia (Hb 10 gm%), thrombocytosis (6.5 lakh), raised ESR (42 mm in 1st hour), raised TSH (14 ng/mL). CECT revealed multiple sclerotic lesions, hepatosplenomegaly, and multiple subcentimetric lymphnodes. Lymph node biopsy showed reactive lymphadenitis with plasmacytosis and vascular proliferation. Gastric biopsy- pangastrtis with activity and lymphoid follicle formation and increased IEL. Bone marrow aspirate showed 7% plasma cells. NCV-asymmetrical sensory motor demyelating polyneuropathy. Serum immunoelectrophoresis did not reveal monoclonal gammopathy. Patient met the diagnostic criteria for Castleman disease variant of POEMS syndrome. He had polyneuropathy, sclerotic bone lesions, Castleman’s disease, organomegaly (splenomegaly, hepatomegaly, and lymphadenopathy), endocrinopathy (hypothyroidism), skin changes (hyperpigmentation, white nails), papilledema, thrombocytosis, extravascular volume overload (edema), clubbing, weight loss and diarrhea. Polyneuropathy is one of the most common presentation; however in our case diarrhea was the predominant symptom which may mislead in reaching the diagnosis. Though gastrointestinal (GI) involvement is not a predominant part of the syndrome but GI symptoms may be an accompanying clinical feature and may occasionally be the predominant symptom like this case.
Conclusion In this rare disorder diagnosis can be challenging but a high level of suspicion, good history and general physical examination followed by appropriate investigation can help to diagnose and start early treatment.
063
Clinical profile of patients with acute mesenteric ischemia in Northern India
Jatin Agrawal , Ashish Kumar, Anil Arora, Shrihari Anikhindi, Vikas Singla, Praveen Sharma, Naresh Bansal
Correspondence- Jatin Agrawal-jatinagrawal1989@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Introduction and Aims Acute mesentric ischemia (AMI) is a rare medical emergency and constitutes around 0.09% to 0.2% of all cases of acute abdomen. According to Western literature, AMI most commonly occurs in 7th-8th decade, with 50% mortality, and arterial occlusion being the most common cause. The clinical profile of patients of AMI in India may be different from Western patients, however, the data is lacking. We aimed to study clinical profile of patients of AMI at a tertiary care centre in northern India.
Methods We retrospectively collected data of consecutive patients of AMI admitted our department from March 2015 to January 2019. Data regarding epidemiology, clinical presentation, etiology, imaging, treatment and outcome were studied.
Results Our study included 59 patients (78% males, median age 47 years). The most common presentation was pain abdomen in 88%, obstipation 43%, gastrointestinal bleeding 17%, and peritonitis 0.5%. Mesenteric venous thrombosis was seen in 68% and mesenteric artery thrombosis in 32%. On imaging wall necrosis seen in 45 (65.2%) while additional 3 (4.34%) found during laparotomy. Most (68%) patients required surgical resection. The overall in-hospital mortality was 14%.
Conclusions Unlike the Western literature, the AMI in North India is most commonly due to venous thrombosis, presenting in fifth decade, and has a lower mortality rate than West. Large prospective studies will be required to elucidate the cause of these differences from Western data.
064
Clinical outcomes in Crohn’s patients newly initiated on azathioprine – A large single center cohort
Alok Bansal , A J Joseph, Ebby George Simon, Amit Kumar Dutta, Sudipta Dhar Chowdhury, Reuben Thomas Kurien, Ratnaprabha Gupta
Correspondence- A J Joseph-ajjoseph@cmcvellore.ac.in
Department of Gastroenterology and Hepatology, Christian Medical College Hospital, Vellore 632 004, India
Background Azathioprine remain the first choice for maintenance therapy in Crohn’s disease (CD) as biologicals are expensive. Response to treatment is commonly assessed by clinical and laboratory parameters rather than by endoscopy. The recent literature is limited regarding clinical outcomes and variables predicting response to thiopurines.
Methods Crohn's disease patients started on azathioprine in the IBD clinic, Christian Medical College (CMC), Vellore between January 2016 to December 2019 were retrospectively reviewed. Outcomes were assessed using the Harvey-Bradshaw score (HBS). Patients were grouped as (i) remission = HBS < 5, (ii) response = reduction of 3 points and (iii) non-response.
Results Among 318 patients who received azathioprine (AZA) for CD, 155 (48.7%) received higher doses (>1.5 mg/kg) and 163 (51.7%) received lower doses (<1.5 mg/kg). Among those who followed up at least once, 3 months from drug initiation, 188 (76%) patients had remission/response on AZA, while 60 (24%) did not. A greater proportion of patients who had remission/response (116 [61.7%]) received higher doses (>1.5 mg/kg) of AZA compared to non-responders 26 (43.3%) (p<0.001). Among patients who initially achieved remission or response, 26 relapsed on follow-up. Nineteen (73%) of these patients were on a higher dose (>1.5 mg/kg) of AZA. The mean weight gain was significantly higher in the remission (5.3 kg) and response (6.8 kg) groups as compared to non-responders (1.3 kg) with p<0.001. Mean CRP improvement was significantly higher in remission (11 mg/L) and response (27.7 mg/L) groups as compared to non-responders (-1.3 mg/L). The drug was discontinued in 52 (16%) patients because of cytopenia, anemia, hepatitis, pancreatitis, tuberculosis and perianal abscess.
Conclusion Patients on higher doses (>1.5 mg/kg/day) of AZA were more likely to achieve remission or response as compared to those on lower doses (<1.5 mg/kg/day). However, patients who required higher doses for disease control were more likely to relapse. Weight improvement was a useful parameter reflecting the response to AZA in CD patients.
Keywords AZA azathioprine, HBS Harvey Bradshaw Score, CRP C-reactive protein
065
Timely management of a case of obscure upper gastrointestinal bleed: A team approach saves the
Nikhil Thomas , L Venkatakrishnan, Mukundan S, Prudhvi Krishna Chandolu, R K Karthikeyan, Ravindra Kantamneni, Elango S, Balu K
Correspondence- Nikhil Thomas-nikhilkennythomas@gmail.com
Department of Medical Gastroenterology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore 641 004, India
Background Gastrointestinal stromal tumor (GIST) comprises 1% to 3 % of all malignant GI tumors with up to 40% with acute hemorrhage following tumor rupture. Our patient presented with acute upper GI bleed with severe hypotension. A prompt and early diagnosis and multidisciplinary teamwork saved the patient.
Case Presentation A 57-year-old male, engineer with no prior comorbidities presented to the ER at 5 pm with h/o 3 - 4 episodes of hematemesis and melena since 1 day. Cinical examination revealed alert patient with pallor and severe hypotension (60 systolic) digital rectal examination revealed melena. He was admitted to the MICU and resuscitation done. He has severe anemia with relative neutrophilia and hypoalbuminemia. Urgent UGI scopy was done which showed only grade A GERD with erosive gastritis. However, there was altered blood in D2 with no active bleeding point. A possibility of small bowel bleed was considered. Emergency CT angiography revealed lobulated exophytic heterogeneously enhancing soft tissue lesion with coarse calcifications and small non enhancing areas in the proximal jejunum supplied by jejunal branches of superior mesenteric artery. We considered the possibility of jejunal GIST and angioembolization was done the same night by the interventional radiologist. With supportive care patient made a remarkable recovery.
Once stabilised he underwent laparoscopic excision of proximal jejunum with GIST and side to side duodenojejunostomy.
Discussion Most of GIST arise in the stomach (60% to 70%), 20% to 30% originate in the small intestine and less than 10% in the esophagus, colon, and rectum. The most important element in diagnostic evaluation is a high index of suspicion for any mass lesion noted throughout the length of the GI tract. Our case highlights the need for a team approach in successful management of GI bleed in these cases.
066
Celiac disease - Atypical is the new typical !
Shraddha Sharma , Rahul Kakkar, Naveen Kumar, Sabir Hussain, Sewaram Chaudhary, Sunil Dadhich, Narendra Bhargava
Dr S N Medical College, India
Introduction Classically recognized for its gastrointestinal manifestations, celiac disease (CD) is now increasingly identified in patients with non-specific manifestations like iron deficiency anemia (IDA), short stature, infertility, osteoporosis, asymptomatic transaminitis and cryptogenic cirrhosis. The aim of this study was to explore the spectrum of atypical presentation in CD patients and to highlight the differences in modes of presentation in adult and pediatric population.
Methods Case records of 42 diagnosed CD patients presenting to Gastroenterology OPD between January to June 2020 were retrospectively reviewed for their chief manifestation. The diagnosis of CD was made on the basis of serology and/or histology.
Results The median age of the study group was 12 years (range 1-52 years). Majority of them (55%) belonged to pediatric population. Out of 42 patients, 38% were male and 62% were female. Our study showed typical gastrointestinal symptoms in 29% patients while 71% patients had atypical presentation. In adult group, chronic diarrhea (31.5%), IDA (31.5%) and cryptogenic cirrhosis (36.8%) were common modes of presentation. Pediatric group had short stature (43.5%), IDA (34.7%) and chronic diarrhea (17%) as dominant presentations. Transaminitis was present in 23.8% patients. The typical symptoms of diarrhea and vomiting were more frequent in adult as compared to paediatric patients.
Conclusion Atypical Presentation is becoming dominant and typical for CD. More than half of the CD patients present with atypical manifestations and create a diagnostic dilemma. Paediatric patients tend to have a wider spectrum of presentation than adult patients. More awareness and a high index of suspicion is required for timely management.
067
Glasgow-Blatchford score and risk stratifications in acute upper gastrointestinal bleed: Our experience in tertiary care centre for extending this to 3 for urgent outpatient management
Vinod Kumar Dixit, Indresh Dixit , Sunit Kumar Shukla, Dawesh Yadav
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Banaras Hindu University Campus, Varanasi 221 005, India
Background Upper gastrointestinal bleeds are a common presentation to emergency departments. The Glasgow-Blatchford score (GBS) predicts the outcome of patients at presentation. NICE and ESGE recommend outpatient management for a GBS of 0.
Aim Our aim was to assess whether extending the GBS allows for early discharge while maintaining patient safety. We also analyzed whether pathologies could be missed by discharging patients too early.
Methods Data were prospectively collected and analyzed on patients admitted with upper GI bleed between 1 October 2019 and 31 December 2019. GBS calculated and gastroscopy reports were obtained for each patient. Patients were assessed for need for blood transfusion, endoscopic intervention during admission and for rebleeding, repeated endoscopic intervention, surgery or radiological intervention and mortality in 1-month follow-up.
Results Eighty patients were included in study between 16 and 85 years of age, 72.5% were male and 27.5% female. Most common endoscopic findings were duodenal ulcer in 27.5% patients followed by gastric ulcer in 22.5%. GBS score was between 1 to 3 in 58 patients, none of them needed blood transfusion or endoscopic intervention during admission, none had upper GI bleeding related events or mortality during 1 month. Six patients having GBS between 4 to 6, 2 out of 6 (33%) needed endoscopic intervention and blood transfusion, None reported any upper GI bleed related adverse event or mortality during 1 month. Sixteen had GBS more than 6. Twelve (75%) required blood transfusion, endoscopic intervention done in 10 (62.5%), during 1 month period, 8 patients (50%) had rebleeding, 4 managed by endoscopic management successfully, 2 required surgical intervention and 2 out of these 16 (12.5%) expired due to rebleed.
Conclusion Study concluded, GBS may be extended to 3 for safe outpatient management, reducing the number of bed days in centres with high volume patient load with limited health care resources for better patient management.
068
A rare case of isolated jejunal tuberculosis
Nithin K R , Umashankar U S, Akhilandeshwari, Anand A, Arun N, Vaishnavi Priya, Kani Sheikh, Aravind
Correspondence- Nithin K R-Nith.kr@gmail.com
Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai 600 010, India
Introduction Abdominal TB accounts for 11% of extrapulmonary tuberculosis. Intestinal TB accounts for 1% to 3% of TB worldwide. Any part of bowel may be involved and usually presents as multiple lesions. Most commonly distal ileum/ileocecal region is involved. Jejunal involvement is seen in terminal stages of extensive tuberculosis of bowel. It's rare, however, to find isolated tuberculosis of jejunum without tuberculosis elsewhere in bowel. Here, we present a rare case of isolated Jejunal tuberculosis.
Case Sixty-year-old lady presented with complaints of upper abdominal pain, intermittent, colicky pain since 2 months, increasing with food intake and partly relieved by non-induced vomiting, associated with ball rolling movements with history of significant weight loss and loss of appetite. No history of loose stools, obstipation, constitutional symptoms, fever and cough.
On examination Pallor present, no lymphadenopathy/edema. Per abdominal examination and per rectum examination- normal.
Investigations Anemia+. Total count, platelets, RBS, RFT, LFT, amylase- normal. Viral markers-negative. Chest X-ray, erect abdomen X-ray-normal. USG abdomen- normal. UGI endoscopy- normal. Colonoscopy-normal.
CT abdomen and CT enterography showed proximal jejunal thickening of 6 cm with sub-centimetric para aortic lymph nodes. Tumor marker CEA-normal.
On day 4 of admission patient developed severe abdominal pain, abdominal distension with sluggish bowel sounds. X-ray erect abdomen showed features suggestive of small bowel obstruction. Surgical gastroenterology opinion was taken. Diagnostic laparoscopy was done, showed an obstructive jejunal mass and resection anastomosis was done. Surgical biopsy-suggestive of tuberculosis, no evidence of malignancy or inflammatory bowel disease. Postoperative period was uneventful. Patient was started on ATT and is on follow-up.
Conclusion Involvement of jejunum as part of abdominal tuberculosis is not uncommon. Isolated tuberculosis of jejunum can occur, though very rare. Hence abdominal TB should be considered in patients presenting with isolated jejunal mass lesions.
069
Prevalence of SIBO in IBS-D patients and role of rifaximin in the management
Nirdesh Chauhan , B Shankar Sharma
Correspondence- Nirdesh Chauhan-drnirdesh@live.com
Department of Gastroenterology, Kurnool Medical College, Bharath Petroleum, Near, Bhudawarapet, Kisan Ghat Road, Kurnool 518 002, India
Irritable bowel syndrome (IBS) is characterized by the presence of abdominal pain associated with disturbed defecation. Because of non-uniformity in the definition, the prevalence of IBS is varied from 1% to 45% worldwide and in India; prevalence is about 11% to14%.
The pathogenesis of IBS is multifactorial. There is a paradigm shift from brain-gut axis disorder, as previously thought, to gut-brain axis disorder, which has shown increased importance to gut dysbiosis, including small intestinal bacterial overgrowth (SIBO).
The gold standard to diagnose SIBO is the quantitative culture of a jejunal aspirate, but being invasive and costly as it generally requires endoscopy for sample collection, glucose hydrogen breath test (GHBT) is a reliable test to diagnose SIBO with about 80% to 100% specificity and sensitivity of about 40%.
This study was done in the tertiary hospital to find the prevalence of SIBO in IBS-D patients by using the GHBT (LactoFAN2*) and response of rifaximin (400 mg TID for 14 days) in treating these patients. Eighty diagnosed cases of IBS-D (using ROME IV criteria) were subjected to GHBT using 100 g of glucose in 250 mL water and breath samples were taken at baseline and 20 min interval for 2 hours. An increase >12 ppm from baseline was considered to be positive for SIBO. Out of 80, only 18 patients came out positive and were treated with rifaximin. After 14 days, out 18, only 15 patients showed improvement in symptoms clinically, and there repeat GHBT was also negative.
According to this study, we conclude that the prevalence of SIBO in IBS-D patients is 22.5% using GHBT and the use of broad-spectrum non-absorbable antibiotics, rifaximin 400 mg TID dose for14 days is associated with good clinical response in treating SIBO in IBS-D patients.
Keywords IBS-D, SIBO, GHBT.
070
Celiac disease – Atypical is the new typical!
Shraddha Sharma , Rahul Kakkar, Naveen Kumar, Sabir Hussain, Sewaram Chaudhary, Sunil Dadhich, Narendra Bhargava
Correspondence- Shraddha Sharma-shraddhasharma.udr@gail.com
Department of Gastroenterology, Dr. S N Medical College, Residency Road, Sector-D, Shastri Nagar, Jodhpur 342 003, India
Introduction Classically recognized for its gastrointestinal manifestations, celiac disease (CeD) is now increasingly identified in patients with non-specific manifestations like iron deficiency anemia (IDA), short stature, infertility, osteoporosis, asymptomatic transaminitis and cryptogenic cirrhosis. The aim of this study was to explore the spectrum of atypical presentation in CeD patients and to highlight the differences in modes of presentation in adult and pediatric population.
Methods Case records of 42 diagnosed CeD patients presenting to Gastroenterology OPD were retrospectively reviewed for their chief manifestation. The diagnosis of CeD was made on the basis of serology and/or histology.
Results The median age of the study group was 12 years (range 1-52 years). Majority of them (55%) belonged to pediatric population. Out of 42 patients, 38% were male and 62% were female. Our study showed typical gastrointestinal symptoms in 29% patients while 71% patients had atypical presentation. In adult group, chronic diarrhea (31.5%), IDA (31.5%) and cryptogenic cirrhosis (36.8%) were common modes of presentation. Pediatric group had short stature (43.5%), IDA (34.7%) and chronic diarrhea (17%) as dominant presentations. Transaminitis was present in 23.8% patients. The typical symptoms of diarrhea and vomiting were more frequent in adult as compared to paediatric patients.
Conclusion Atypical presentation is becoming dominant and typical for CeD. More than half of the CeD patients present with atypical manifestations and create a diagnostic dilemma. Pediatric patients tend to have a wider spectrum of presentation than adult patients. More awareness and a high index of suspicion is required for timely management.
071
HLA haplotypes in patients with celiac disease in India: High frequency of non-DQ2/8 haplotypes
Balakrishnan Ramakrishna 5 , Giriprasad Venugopal 1 , Alka Singh 2 , Srinivasan Pugazhendhi 4 , Sangitanjan Dutta 3 , Vineet Ahuja 2 , Govind Makharia 2
Correspondence- Balakrishnan Ramakrishna-wurama@hotmail.com
1All India Institute of Medical Sciences, AIIMS Road, Sijua, Patrapada, Bhubaneswar 751 019, India, 2Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, 3Guwahati Medical College, India, 4Kansas University Medical Center, US, and 5Department of Gastroenterology, SRM Institutes for Medical Science, India
Objectives HLA-DQ2 and/or DQ8 are believed to be essential for development of celiac disease (CeD). We conducted a case control study to determine HLA DQ haplotypes in patients with CeD and healthy adults using next generation sequencing.
Methods HLA-DQA1 and DQB1 loci were amplified using long range PCR, from DNA of 400 patients with CeD (259 symptomatic, 45 asymptomatic, 96 potential) and 300 healthy adults. Amplicons were Illumina sequenced and HLA-DQ genotypes and haplotypes were assigned by matching against the HLA-IMGT database, while DQ serotypes were assigned on the basis of DQB1 genotype.
Results Of 300 healthy controls, 80 expressed DQ2, and 33 expressed DQ8. DQ6 (170) and DQ7 (120) were the most common serotypes. Haplotypes DQ2.2, DQ2.5 and DQ8.1 were noted in 61, 32 and 33, respectively. Among 400 CeD patients, 221 had DQ2 serotype, 37 had DQ8 while 24 could express both. DQ6 and DQ7 serotypes were found in 53 and 29, respectively. DQ2.2, DQ2.5, and DQ8 haplotypes were found in 52, 147, and 36, respectively, while double heterozygote haplotypes were noted in 47. DQ2.5 haplotype was strongly associated with CeD (odds ratio 10.31, 95%CI 6.80-15.30), with a gradient in the strength of association between symptomatic, asymptomatic, and potential CeD phenotypes. In an overall analysis, DQ5.1 and 5.3 haplotypes showed protective associations with CeD.
Conclusion Thirty three percent of healthy individuals expressed HLA DQ2 and/or DQ8, while thirty percent of CeD patients expressed neither.
072
Duodenoduodenal intussusception with invagination of the pancreatic head into the duodenum secondary to tubulovillous adenoma in the setting of duodenal malrotation: A case report
Sara Jessica Pizarras , Maria Raisa Katrina Fontanilla, Maria Joanne Paula Rubio, Roehl Salvador, Nelson Cabaluna
Correspondence- Sara Jessica Pizarras-sarajessicapizarras@gmail.com
Department of Internal Medicine - Section of Gastroenterology and Digestive Endoscopy, Manila Doctors Hospital, Philippines
Introduction Duodenoduodenal intussusception (DDI) is a rare entity due to the fixed position of the duodenum in the retroperitoneum. We report a rare case of documented DDI with invagination of the pancreatic head into the duodenum in a patient with a lead point (a tubulovillous adenoma) and duodenal malrotation with spontaneous resolution of the pancreatic invagination as noted intraoperatively.
Methods/Presentation Our patient is a 31-year-old male presenting with a 2-month history of vague epigastric pain, melena, anemia and weight loss.
Results Esophagogastroduodenoscopy revealed a duodenal mass with adenomatous features. A triple contrast abdominal CT scan initially showed a duodenojejunal intussusception with invagination of the pancreatic head into the duodenum, causing dilatation of the pancreatic duct and the biliary tree. A follow-up MRI was then done which showed a duodenoduodenal intussusception, still with invagination of the pancreatic head. Patient underwent exploratory laparotomy where duodenal malrotation and intussusception at the second segment of the duodenum where the mass was also located with resolution of the pancreatic invagination were noted. Reduction of the intussusception and wedge resection of the mass was done. Patient was discharged with no complications.
Conclusion Adult DDI is a rare entity that is challenging to diagnose due to its nonspecific symptoms and is possible in cases of malrotation and duodenal lesion which can act as lead point, such as in our patient. Hence, DDI should be considered in patients presenting with abdominal pain, bowel obstruction or bleeding.
Keywords Case report, Duodenoduodenal intussusception, Intussusception
073
Abdominal cocoon – An enigmatic entity
Gongati Venu , Ramesh Kumar B, Ramanna M
Correspondence- Gongati Venu-venu.gongati@gmail.com
Department of Medical Gastroenterology, Osmania General Hospital, Afzalgunj Road, Afzal Gunj, Hyderabad 500 001, India
Introduction Encapsulating peritoneal sclerosis (EPS) is a rare benign cause of acute or subacute small bowel obstruction. It is also called as "abdominal cocoon" to describe total or partial encasement of the small bowel within a thick fibrocollagenous membrane. It is called as "icing gut" due to the intestinal surface appearing white from the membrane covering. EPS is classified as primary (idiopathic) or secondary based on the etiological factors. We report a case of EPS secondary to tuberculosis.
Case report A 40-year-old male patient presented with abdominal pain, distension, altered bowel habits and significant weight loss since 3 months. No prior history of tuberculosis, dialysis, and abdominal surgery. On examination per abdomen is firm, tender, a fixed mass was felt extending from 2-3 cms above the umbilicus to the suprapubic area. CT abdomen showed clustering of small bowel loops encased in a sac like structure, diffuse omental thickening, mesenteric lymphadenopathy. Colonoscopy was normal up to the terminal ileum. USG guided FNAC from omentum revealed fibroblasts with epitheloid histiocytes suggestive of tuberculosis. Patient denied laparoscopy. He was started on ATT. On follow-up he improved symptomatically and clinically with decreased abdominal pain, distension and weight gain.
Conclusion EPS is a rare clinical entity causing intestinal obstruction. The primary form is of unknown origin and has been classically described in young adolescent females. Secondary EPS has been reported in association with abdominal tuberculosis, peritoneal dialysis, sarcoidosis, systemic lupus erythematosus and prior abdominal surgeries. Peritoneal tuberculosis in the form of sclerosing variant is an unusual entity. Early recognition and initiation of ATT may prevent the need for operative intervention or bowel resection in these patients.
Keywords Encapsulating Peritoneal Sclerosis,Tuberculosis, Intestinal obstruction
074
Enteroscopic management of life threatening obscure gastrointestinal bleeding due to jejunal leiomyoma
Dhaval Choksi , Ketaki Choksi, Vidya Kale * , Milind Shah **
Correspondence- Dhaval Choksi-dhavalrchoksi@gmail.com
Department of Medical Gastroenterology, *Pathology, and **Surgery, Plot No. 1, Swaminarayan Nagar, New Adgaon Naka, Panchavati, Nashik 422 003, India
Introduction Obscure gastrointestinal bleeding is a difficult medical emergency to manage. Benign small bowel tumors are rare cause of obscure gastrointestinal bleeding.
Methods A 64-year-old male presented with massive gastrointestinal bleeding with hemorrhagic shock. The patient had severe comorbid conditions like diabetes mellitus, hypertension, ischemic heart disease with cardiomyopathy (Ejection Fraction-30%) and chronic kidney disease. After a non-conclusive upper GI scopy, colonoscopy and a plain CT scan, capsule endoscopy was done which showed proximal jejunal bleeding. Push enteroscopy was the done which showed a jejunal polyp measuring 3 x 2 cms.
Result The polyp was successfully removed en-bloc by endoscopic mucosal resection (EMR) technique without any complications like bleeding or perforation. Histopathology examination and immunohistochemistry confirmed the polyp to be a leiomyoma. Patient was asymptomatic on follow-up at 6 months.
Conclusion With adequate surgical back up, endoscopic resection of benign small bowel tumors can be done in selected high risk group of patients in whom surgery may be associated with increased morbidity and mortality.
Keywords Gastrointestinal bleeding, Jejunal leiomyoma, Endoscopic mucosal resection, Capsule endoscopy, Push
075
Dental enamel defects and oral cavity manifestations in Asian patients with celiac disease
Anam Ahmed , Alka Singh, Smile Kajal, Ashish Chauhan, Vikas Jindal, Mahendra Singh Rajput, Vikas Banyal, Vineet Ahuja, Govind K Makharia
Correspondence- Govind K Makharia-govindmakharia@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Small intestine is the main site of celiac disease (CeD), affecting other organs also. Dental enamel defects are common indicators of CeD, in absence of other classical symptoms. Aims was to study dental and oral manifestations in Asian patients with CeD.
Methods We recruited 118 patients with biopsy-confirmed CeD (36 treatment naïve and 82 follow-ups on at least one year of gluten-free diet) and 40 controls. Diagnosis was made as per standard criteria. Oral and dental manifestations were evaluated by a dental surgeon. The dental enamel defects (DED) were evaluated according to Aine’s criteria.
Results Overall higher number of patients with CeD (66.9%); both treatment naïve (69.4%) and those on GFD (65.8%) had DED in comparison to controls (20%) (Odds ratio, 8.1, 95% CI 3.4-19.2; p<0.001). Specific/bilaterally symmetrical DED were present in significantly higher number of patients with CeD than controls. Recurrent aphthous ulcers were significantly higher in patients with CeD. Approximately 80.6% and 63.4% treatment naïve patients and those on GFD, respectively reported dry mouth sensation which was significantly higher than that in controls.
Conclusions Almost two third of patients with CeD have DED. Physicians and dietitians caring for patients with CeD should train in identification of DED and other oral manifestations of CeD.
Keywords Gluten; Teeth; Recurrent aphthous ulcers; Dry mouth
076
The proteome of the human small intestinal mucosa by SWATH-MS analysis
Govind K Makharia, Atreyi Pramanik * , Praveen Singh ** , Alka Singh, Prasenjit Das6, Vineet Ahuja5, Pragyan Acharya * , Shantanu Sengupta **
Correspondence- Govind K Makharia-govindmakharia@gmail.com
Department of Gastroenterology, *Biochemistry,***Pathology, and ****Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, **CSIR-Institute of Genomics and Integrative Biology, New Delhi, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201 002, India
Introduction Small intestinal mucosa, maintain and control a number of structural, functional, and regenerative activities in the human body. Understanding of diseases that damage small intestinal mucosae such as celiac disease or Crohn’s disease necessitates understanding the normal human small intestinal mucosa proteome. However, an in-depth characterization of the normal small intestinal mucosal proteome is lacking. Therefore, we have carried out proteomics analysis of the small intestinal mucosa by obtaining small intestinal biopsies from twelve subjects with gastrointestinal reflux disease undergoing the routine endoscopic examination and having normal small intestinal morphology.
Methods A spectral ion library representing the total proteome of small intestinal mucosa from 45 biopsies was generated in data-dependent acquisition mode. Small mucosal biopsies from 12 participants having GERD were included as representatives of normal human small intestinal tissue. Proteins extracted from the biopsies were subjected to tryptic digestion and SWATH-MS analysis.
Results A total of 3369 proteins were identified with high confidence. Amino acid metabolism, endoplasmic reticulum-secretory pathway, spliceosome complex, and glycolysis were among the most prominent pathways as represented by the proteome. Proteins from various parts of the small intestinal mucosal structure mapping to enterocytes, goblet cells, Paneth cells, intestinal crypts were found in the dataset.
Conclusions Cataloging the proteome in a healthy intestinal mucosa provides baseline characterization data that will help to better understand the alteration in the small intestinal proteome during various stress conditions and diseases associated with the small intestinal mucosa.
Keywords Proteome, Small intestine, Gene ontology, Enteropathy, Celiac disease
077
Acute mesentric ischemia- A series of 8 cases
Raghuveer Balabhadra , Praveen Mathew
Correspondence- Praveen Mathew-drpraveenmathew@yahoo.com
Department of Gastroenterology, Vydehi Institute of Medical Sciences, 82, Near BMTC 18th Depot, Vijayanagar, Nallurhalli, Whitefield, Bengaluru 560 066, India
Introduction Acute mesenteric ischemia (AMI) refers to sudden onset of intestinal hypoperfusion. Incidence of acute mesenteric ischemia appears to be rising- partly due to increased awareness among clinicians, ageing population with cardiovascular disease. Intestinal ischemia can be classified as acute or chronic and of venous or arterial origin. In young patients without cardiovascular disease, mesenteric venous thrombosis is the common cause of intestinal ischemia.
Aims To evaluate and study the clinical profile of cases of AMI in our tertiary care centre. It was obtained by performing a audit of all patients presenting with Acute abdomen in Vydehi Institute of Medical Sciences and Research Centre from 2019-2020.
Method Data were collected from 1 September 2019 to 31 August 2020. All relevant investigations including CECT abdomen- Mesenteric ischemia protocol, Procoagulant work up was done where indicated.
Observations A total of 8 cases were enrolled in the study. Mean age of patients was 43.2 years (Range: 21-60 years). Majority of the patients were in the 4th and 5th decade. Male preponderance was noted. All patients presented with abdominal pain. Four patients (50%) had arterial thrombosis. Four patients (50%) had venous thrombosis. Seven cases were involving superior mesenteric territory. One case was involving inferior mesenteric artery territory. CECT abdomen was diagnostic in all cases. One patient had arterial thrombosis secondary to atrial fibrillation. Venous thrombosis was secondary to APLA in 2 cases, Protein S deficiency in 1 case. Evaluation for thrombosis could not be done in 4 cases.
Keywords Mesenteric ischemia. Superior mesenteric vein thrombosis, Superior mesenteric artery thrombosis
078
Celiac disease: Western Indian perspective
Khwaja Aminodddin Siddiqui , Vaibhav Somani
Correspondence- Vaibhav Somani-drvaibhavsomani@gmail.com
Department of Gastroenterology, Bombay Hospital and Medical Research Centre, Mumbi 400 020, India
Introduction Celiac disease (CeD) is an autoimmune disorder diagnosed predominantly in pediatric population in western countries. With the advent of better awareness, CeD is being increasingly diagnosed in India across all regions. The aim of this study was to evaluate the clinical profile of CeD in western Indian population.
Methods We retrospectively analyzed prospectively maintained data. Total 111 consecutive patients who were diagnosed with CeD as per the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria in a tertiary care center in Western India. Their clinical profile was studied.
Result Of total 111 patients, 71 (63.96%) cases were females and 40 (36.03%) cases were males. Median age of presentation was 37 years. Diarrhea was the commonest symptom. Many patients presented with atypical symptoms like nausea, vomiting and bloating of abdomen. Extraintestinal symptoms are common in CeD and include weight loss, anemia, osteopenia, neurological abnormality and gynecological abnormality. CeD can present in adult as well as elderly age groups.
Conclusion CeD is not an uncommon disease is Western India. High index of suspicion is required in patients with atypical presentation.
Keywords Diarrhea, extraintestinal manifestations, hypertransaminasemia
079
Gluten content in labelled and unlabelled gluten-free food products used by patients with celiac disease
Wajiha Mehtab , Vikas Sachdev, Alka Singh, Samagra Agarwal, Namrata Singh, Rohan Malik * , Anita Malhotra ** , Vineet Ahuja, Govind K Makharia
Correspondence- Govind K. Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition Unit, and *Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, **Department of Home Science, University of Delhi, New Delhi, India, ***Department of Food Technology, Lakshmibai College, University of Delhi, New Delhi, India,
Objective Gluten-free (GF) diet is the only reliable treatment for patients with celiac disease (CeD), but data on the extent of gluten contamination in GF-food available in India is scanty. We evaluated gluten content in labeled, imported and non-labeled GF-food products currently available in the Indian market.
Methods Seven hundred and ninety-four processed and commercially available packaged GF products (labelled GF [n=360], imported GF [n=80] and non-labelled/naturally GF [n=354]) were collected from supermarkets of National Capital Region of India. Those unavailable in stores, were purchased from e-commerce sites or directly from the manufacturers. Gluten level in them was determined by Ridascreen Gliadin sandwich R5-enzyme-linked immunosorbent assay (R-Biopharm AG, Germany). As per Codex Alimentarius and Food Safety and Standard Authority of India, “gluten-free” labelled products must not contain >20 mg/kg of gluten.
Results Overall, 10.1% of 794 GF products including 38 (10.8%) of 360 labelled and 42 (11.8%) of 354 non-labelled/naturally GF-food products had gluten content >20 mg/kg (range: 24.43–355 and 23.2–463.8 mg/kg, respectively). None of the imported GF products had gluten more than the recommended limits. The level of contamination was more in the labelled GF-food products manufactured using oats, amaranth, buckwheat and pearl millet than others which used Bengal gram dal, rice, maize, sorghum and multi-grains as ingredients. Contaminated products most commonly belonged to cereal and their products (flours, coarse grains, pasta/macaroni, snack foods) pulse flours, spices and bakery items.
Conclusions A substantial proportion (10.1%) of GF-food products (both labelled and non-labelled) available in India have gluten content greater than the prescribed limits of <20 mg/kg. Physicians, dietitians, support group and patients with CeD should be made aware of this fact and regulatory bodies should ensure quality assurance.
Keywords Labelled gluten-free, Naturally gluten-free, Contamination, Quality assurance, India
080
Falsely elevated anti-tissue transglutaminase antibodies in patients with immunoproliferative small intestinal diseases: A case series
Srikant Mohta , Ashish Chauhan, Mahendra Rajput, Alka Singh, Prasenjit Das * , Soumita Bagchi**, Vineet Ahuja, Govind Makharia
Correspondence- Govind Makharia-govindmakharia@gmail.com
Departments of Gastroenterology and Human Nutrition, *Pathology and **Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction There is an overlap between clinical symptoms of celiac disease many other diseases including tropical sprue, parasitosis and immunoproliferative small intestine disease (IPSID). They are distinguished by presence of celiac specific antibodies and certain histological characteristics. We present a case series of 11 patients with IPSID, 8 of which were found to have falsely elevated anti-anti-tissue transglutaminase (anti-tTG Ab) in them.
Methods We reviewed all patients who were diagnosed to have IPSID between 2016 and 2019. As part of evaluation, all patients had undergone complete work up including anti-tTG Ab, intestinal mucosal biopsies. Wherever feasible, anti-endomysial Ab, HLA haplotype, and serum IgA levels were estimated. A trial of gluten-free diet was also done in 4 patients before committing a diagnosis of IPSID.
Results While diagnosis of IPSID was confirmed in all 11 patients, eight of them had persistent rise in IgA anti-tTG Ab; 6 of them had anti-tTG Ab more than 2 times upper limit of normal (ULN), 4 had values >5 times ULN and only one patient had a value 10 times ULN. EMA could be done in seven patients and it was negative in all of them. Haplotyping of HLA-DQ2 and -DQ8 could be done in five of them and only one of them had HLA-DQ2 haplotype. A gluten-free trial was given to 4 patients with a significantly raised anti-tTG Ab (>5x ULN), none demonstrated significant reduction symptoms and IgA-tTG Ab titre.
Conclusion Patients with IPSID can have a false positive anti-tTG Ab. By making a diagnosis of celiac disease based only on anti-tTG Ab may lead to a false diagnosis of celiac disease.
Keywords Anti tTG, IPSID, celiac disease
081
Spectrum of height in patients with celiac disease
Nishant Aggarwal , Vignesh Dwarakanathan, Alka Singh, Ashish Agarwal, Akhilesh Khuttan, Anam Ahmad, Mahendra Singh Rajput, Ashish Chouhan, Vikas Banyal, Anil Verma, Vipin Gupta, Rakesh Lodha, Vineet Ahuja, Govind Makharia
Correspondence- Govind Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Growth retardation and growth failure are important features of celiac disease (CeD) that lead to failure of attainment of full potential of adult height. Although there is data on the proportion of patients having short stature in CeD, there is a lack of data on the spectrum of height, with normal expected height at one end and short stature being the other end.
Methods We performed a retrospective analysis of a prospectively maintained database at our center, including a total of 419 adults (183 [43.7%] males) and 164 adolescents (12-18 years) (72 [43.9%] males). The data from the National Family Health Survey 2015-16 (NFHS-4) from India was used as control group. Height and BMI Z-scores were defined according to the Indian Academy of Pediatrics (IAP) growth charts and compared with the control group.
Results Overall, 19.6% of adult and 57.9% of adolescent patients with CeD had short stature. Mean height of male patients with CeD was similar whereas women were taller than the population controls. Higher proportion of men with CeD had short stature, as compared to population controls (32.2% vs. 20%, p<0.0001). In contrast, a lower proportion of women with CeD had short stature as compared to the controls (9.7% vs. 18.9%, p=0.0003). Higher proportion of adolescents with CeD had short stature compared to adults (57.9% vs. 19.6%, p<0.001). On multivariate analysis, adulthood was found to be independently associated with a lower prevalence of short stature.
Conclusions The mean height of men with CeD was not significantly different from that of population controls, whereas females were taller than the population controls. Adolescent boys and girls with CeD are significantly shorter than their peers from the general population.
Keywords Short stature, Enteropathy, Small intestine, Growth failure
082
Neuroendocrine tumor in ulcerative colitis- ? Coincidence OR association
Binila Jose , George Thomas, Ramesh M, Satheesh A V
Correspondence- Binila Jose-binilajose@gmail.com
Department of Gastroenterology, Pushpagiri Institute of Medical Sciences, Near Pvt Bus Stand, Thiruvalla 689 101, India
Introduction Association between inflammatory bowel disease (IBD) and neuroendocrine tumor (NET) is not well established till now. NETs are seen rarely in IBD patients but some new reports shows increased prevalence of NET in IBD patients compared to general population. Increased number of neuroendocrine cells along with other cells present in colonic mucosa which inflamed for long period in setting of IBD may be the triggering factor for NET along with IBD. NET is rare among colonic or small bowel neoplasms and its infrequently described along with IBD. Here we report a case of distal ileal carcinoid arising in a UC patient.
Case report A 47-year-old man with 9 years history of ulcerative colitis and diabetes mellitus was admitted due to intermittent bleeding per rectum and constipation. He was well maintained with mesalamine 1.2g/day and symptomatic treatment. Previous colonoscopy showed features of remission. Colonoscopy showed thickening in rectosigmoid region and exophytic intraluminal polypoidal lesion (12.7 x 10.5 mm) in distal ileum. Biopsy from rectal and sigmoid region showed features suggestive of mild colitis. Biopsy specimen from distal ileal polyp showed features suggestive of carcinoid. Laparoscopic resection was done, biopsy showed features consistent with carcinoid.
Discussion Previous literature showed NET predominantly carcinoid tumors associated with IBD, most of them were clinically indolent and incidentally reported in surgical specimens of IBD patients. Siegel et al. suggested multipotential cells in dysplastic epithelium in IBD might be the prerunner for neuroendocrine differentiation leads to NET. Concept of cellular dysplasia involving neuroendocrine cells in inflamed mucosa of IBD patient leading to NET including carcinoids needs further validation.
Keywords Carcinoid, Ulcerative colitis
083
Genetic polymorphisms in prediction of thiopurine related cytopenia in inflammatory bowel disease: A prospective study
Narinder Grover , Prateek Bhatia, Antriksh Kumar, Minu Singh ** , Deepesh Lad * , Harshal Mandavdhare, Kaushal Prasad, J Samanta, Usha Dutta, Vishal Sharma
Correspondence- Vishal Sharma-docvishalsharma@gmail.com
Departments of Gastroenterology, *Internal Medicine, and **Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background Genetic polymorphisms in TPMT and NUDT enzymes are implicated in thiopurine related cytopenia. The contribution of these polymorphisms in Indian population with inflammatory bowel disease (IBD) is uncertain.
Methods Consecutive patients with the diagnosis of ulcerative colitis or Crohn disease initiated on thiopurines (azathioprine or 6-mercaptopurine) were included in the study. Only those patients who developed an adverse event resulting in discontinuation or had at least three months of follow-up were included. Polymorphisms for TPMT and NUDT were detected. The patients with the genetic polymorphisms were compared to those without any detectable polymorphisms for frequency of cytopenia, maximal tolerated thiopurine dosage and occurrence of idiosyncratic reactions.
Results Of the 119 patients (mean age was 36.8 ± 13.5 years) included, 61 (51.3%) were males. One hundred and five had ulcerative colitis while 14 had Crohn’s disease. Of these 119, cytopenia were noted amongst 33 (27.7%), gastrointestinal tolerance in 5 (4.2%) and pancreatitis in 2 (1.6%). TPMT polymorphisms were noted amongst five patients while NUDT polymorphism was noted in 13 patients. One of these had both TPMT and NUDT polymorphism. The occurrence of cytopenia was more frequent in those with NUDT polymorphism than those with wild phenotype (53.8% vs. 24.5%) but was similar in those with TPMT polymorphism as compared to wild type (20% vs. 24.5%).
Conclusion In Indian population with IBD, NUDT polymorphisms are more frequent than TPMT and are predictive of development of cytopenia.
Keywords Ulcerative colitis, Crohn's disease, Azathioprine
084
A rare case of multiple jejunal diverticulosis with perforation
T Ashokkumar , A Amudhan, R Kamalakannan, J Saravanan, M Thiruvarul, Satish Devakumar, S Jeswanth, T Selvaraj
Correspondence- Ashok Kumar-asasupernova@gmail.com
Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, Chennai 600 003, India
Background Small bowel diverticular disease occurs in in 0.3 % to 20% of the population less common than large bowel diverticular disease .of these only 4% will develop symptoms. Three types of small bowel diverticula the duodenal, jejunoileal and Meckel diverticula, of these most frequently encountered diverticula are the duodenal 45%, jejunoileal 25% and Meckel diverticula 25%.
Case report An 80-year-old women admitted in medical ward with complaints of abdominal pain vomiting and diarrhea patient underwent imaging after atypical presentations found to have small bowel thickening with mesenteric haziness patient underwent laparotomy for peritonitis and was discovered to have multiple jejunal diverticula with perforation and enterolith patient underwent resection anastomosis and her postoperative period was uneventful.
Conclusions Jejunal diverticula are the least common 60% to 70% patients are symptomatic peaks around 6th for 7th decade, these diverticula usually in the mesentric side of the bowel acquired diverticula result of smooth muscle dysfunction or defect in the myentric plexus resulting in irregular bowel contraction and increased intraluminal pressure these diverticula can present with or without perforation hemorrhage and after auction obstruction. Asymptomatic cases are left alone if there are signs of hemodynamic instability sepsis or peritonitis surgical resection is recommended.
Keywords Small bowel diverticula, jejunal diverticula, perforation, enterolith
085
Hemangio-lymphangioma of small bowel - A rare cause of recurrent gastrointestinal bleed and chronic anemia
Govind Purushothaman , Jeswanth S
Correspondence- Govind Purushothaman-govindmmc@gmail.com
Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, 1, Old Jail Road, Chennai, 600 001, India
Introduction Benign vascular lesions occur rarely in the gastrointestinal (GI) tract and are diagnosed by endoscopy or angiography. Rarely, these present with refractory bleed and a surgical resection is required to arrest the hemorrhage.
Case Capsule Forty-eight-year-old female, presented with melaena and anemia for 2 years. She had undergone hemorrhoidectomy elsewhere 1 year back. Colonoscopy and upper GI scopy were normal. Abdominal CECT scan showed mesenteric lymph node enlargement. She had undergone diagnostic laparoscopy elsewhere and intraoperative enteroscopy was done. Intraoperatively she had mesenteric lymph node enlargement, nodular mucosa of the small bowel and Meckel’s diverticulum. Meckel’s diverticulum along with a segment of adjoining bowel was resected. Postoperatively she had recurrent melaena. CECT scan abdomen showed hemoperitoneum. She underwent exploratory laparotomy. Intraoperative enteroscopy showed highly vascular nodular lesion of the jejunum. Resection of 80 cm of small bowel was done. Histopathology report was suggestive of Hemangiolymphangioma. At follow-up, patient was symptom free.
Discussion Hemangiolymphangioma is a benign disease, mainly found on the skin. Rarely, it is found in small bowel, spleen, colon, rectum and thorax. The incidence of hemangio-lymphangiomas varies between 1.2 and 2.8 per 1000 live births. Most are asymptomatic, or show painless GI hemorrhage. Eighty percent of patients show intraluminal GI bleeding symptoms, and 50 % have chronic anaemia. Most effective treatment is surgical resection, but other treatment modalities include sclerotherapy and angioembolisation.
Keywords Small bowel hemangiolymphangioma, Upper gastrointestinal bleed
086
An interesting case of intestinal obstruction
Pavan Kumar , A Aravind, Caroline Selvi, Kani Shaikh Mohamed, Jayakumar Jayakrishnan, A R Akilandeshwari, Vaishnavi Priyaa, S Kavitha, A Anand, N Arun
Correspondence- Pavan Kumar-drpavankumar19@gmail.com
Department of Medical Gastroenterology, Kilpauk Medical College, Chennai 600 010, India
Introduction Gallstone ileus is a rare complication of cholelithiasis and is one of the rarest forms of all mechanical bowel obstructions.
• It is caused by impaction of a gallstone in the gastrointestinal (GI) tract after passing through a biliary-enteric fistula.
Case 57-year-old female presented with days h/o abdominal pain, vomiting, constipation. No h/o jaundice, fever, distension of abdomen. h/o caesarean section 35 years back h/o incisional hernia repair 10 years back k/c/o DM. O/E: Patient conscious, oriented pulse:92/min BP:110/80 mm of hg.
•P/A: soft tenderness present in the epigastric and right hypochondrium no VIP/VGP ,BS+
•Other systems: normal
•P/R : fecal matter+
Investigations: HB 13.7, TLC 12900, PLT 5 lakhs, blood urea 53, S creatinine 1.1, amylase 31, LFT normal, CXR - normal,
Erect Abdomen X-ray - normal, CT abdomen F/S/O chronic cholecystitis with cholecysto duodenal fistula subacute small bowel obstruction? gallstone ileus.
•Emergency laparotomy was done, impacted stone in jejunum measuring 4*4 cm seen with ?sealed perforation, removel of stone and resection anastamosis of bowel small bowel done post op period was uneventful.
Conclusion Gallstone ileus occurs in 0.3% to 0.5% of all patients with gallstones. It is one of the rarest causes of gallstone ileus, occurring in about less than 0.1% of all mechanical obstruction cases and 1% to 4% of non-strangulating mechanical small bowel obstructions. Mortality remains high, ranging from 12% to 27%, because of non-specific symptoms, unremarkable biochemical investigations, high misdiagnosis rate, and delayed discovery. So gallstone ileus should be kept as differential diagnosis in evaluating a patient with subacute intestinal obstruction.
Keywords Gallstones, Ileus
087
Jejunal gastrointestinal stromal tumor in a case of duodenal perforation in a COVID-19 positive patient
Venkatesh G, Arun Babu C, Sofia J
Correspondence- Arun Babu C-arun_dr@yahoo.com
Department of General Surgery, Government Stanley Medical College and Hospital, Chennai 600 001, India
Introduction Gastrointestinal stromal tumors are rare. GISTs comprise 0.2% of gastrointestinal tumours and only 0.04% of small intestinal tumors. Jejunal GISTs are the rarest subtype. Only 10% to 30% progress to malignancy.
Case capsule A 65-year-old male was admitted with abdominal pain for 6 hours. He was diagnosed to have hollow viscous perforation and on further evaluation found to be COVID-19 positive. Intra-operatively, he was found to have D1 perforation which was repaired by using Graham’s patch repair. During exploratory laparotomy, the patient was found to have well circumscribed growth of size 3X3X2 cm which was 10 cm distal to duodenojejunal flexure. No mesenteric lymph nodes were found, no ascites was present, and liver was normal. Resection and anastomosis of the bowel was done with 2 cm margins on both ends. Histopathological examination revealed gastrointestinal stromal tumor which is of spindle cell type. Immunohistochemical analysis showed that the tumor is CD117 positive and S100 negative. During follow up, patient was asymptomatic.
Discussion GISTs are uncommon mesenchymal neoplasms of the alimentary tract. The incidence of GIST is very low (i.e. 2 in 1,00,000). Most common site of presentation is stomach, but it can crop up anywhere in the digestive tract. Two-thirds of GISTs occur in the stomach while about one-fourth develop in the small intestine, usually in the duodenum. while jejunal GIST is extremely rare accounting for 0.1% to 3% of all gastrointestinal (GI) tumors. Usually they are asymptomatic but can present as abdominal pain, bleeding, or mechanical obstruction. Surgery is the primary treatment of choice and imatinib mesylate is the first and only effective drug for the treatment of gastrointestinal stromal tumor at present.
Keywords GIST, Jejunal, CD117, Imatinib, Perforation
088
Extraintestinal gastrointestinal tract involvement in patients with celiac disease: An early proof
Ashish Chauhan , Mahender Singh Rajpoot, Alka Singh, Vikas Sachdev, Vikas Banyal, Ashish Upadhyay, Wajiha Mehtab, Asif Iqbal, Anam Ahmed, Ashish Aggarwal, Rimlee Dutta, Madhu Rajeshwari, Prasenjit Das, Vineet Ahuja, Govind Makharia
Correspondence- Govind Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction While celiac disease (CeD) is considered to affect mainly small intestine, a few of them also have lymphocytic infiltration of other parts of gastrointestinal tract. Whether these changes are due to CeD is not well-established. Deposits of IgA anti-tissue transglutaminase antibody (anti-tTG Ab) in the small intestinal mucosa has been used as an evidence of CeD.
Methods Forty-two treatment naive patients with CeD (as cases) and 45 patients with irritable bowel syndrome (as controls) were recruited. They underwent esophagogastroduodenoscopy and sigmoidoscopy and multiple mucosal biopsies were collected from the esophagus (lower, mid and upper), stomach (multiple sites as per Sydney protocol), duodenum (bulb and post ampullary) and rectosigmoid, both at baseline and at 6-month post gluten-free diet (GFD). All biopsies were evaluated for histological characteristics and immunostaining, for co-localization of IgA anti-tTG deposits, using dual-colour immunohistochemistry, as an evidence of CeD at these sites.
Results Significantly higher number of patients with CeD had evidence of lymphocytic esophagitis (9.7% vs. 0%, p<0.05), lymphocytic gastritis (35% vs. 8.8%, p<0.01), duodenal intraepithelial lymphocytosis (100% vs. 0%, p <0.001) and lymphocytic colitis (17.4% vs. 0%, p<0.05) than that in controls. Significantly higher number in patients with CeD had anti-tTG Ab deposits in esophagus (30.9% vs. 6%, p<0.001), stomach (62.2% vs. 9.3%, p<0.01), duodenum (88.5% vs. 0%, p<0.001) and rectum (17.4% vs. 0%, p<0.05) in comparison of controls. On follow-up on GFD, there was a decline not only in severity of intra-epithelial lymphocytosis but also in the intensity of anti-tTG deposits at all sites.
Conclusion A significantly higher number of patients with CeD having intraepithelial lymphocytosis and anti-tTG Ab deposits in the esophagus, stomach and rectum in addition to small intestine suggests that other organs are also affected in CeD.
Keywords Celiac disease, Immunohistochemistry, IgA tTG mucosal deposits
089
Colonic mucormycosis in fistulizing Crohn’s disease: A case report
Akash Mathur , Piyush Mishra, Neha Nigam, Uday C Ghoshal
Correspondence- Uday C Ghoshal-udayghoshal@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Background Gastrointestinal mucormycosis, a rare fatal fungal infection in an immunocompromised host, commonly affects the stomach.
Case Report A 46-year-old female with long-standing diabetes mellitus, hypothyroidism, and hypertension, presented with a 3-month history of fecal discharge per vagina. She reported having intermittent loose stools, mixed with blood and mucus for 1.5 years. Based on the evaluation and unsuccessful treatment with anti-tubercular drugs elsewhere, Crohn’s disease was diagnosed, and adalimumab biosimilar started; however, the response was partial. Examination revealed: pallor and large perianal tags. Investigations: Hb 9.4 g/dL, total serum protein, and albumin 5.5 and 2.8 g/dL, respectively. A computerized tomography (CT) scan with rectal contrast showed inflammatory involvement of the rectum and sigmoid along with a rectovaginal fistula. A magnetic resonance (MR) enterography showed a loss of haustrations in the transverse colon with a prominent vasa recta in the sigmoid colon. Colonoscopy showed loss of vascular pattern with pseudopolyps in the terminal ileum, IC valve, cecum, ascending, transverse, descending, sigmoid colon, and rectum; a fistulous opening was seen in the rectum (Fig. 2A, B and C). Descending and sigmoid colon biopsies revealed crypt distortion, mononuclear cell infiltrates in lamina propria, exudate with broad aseptate fungal hyphae suggesting mucormycosis (Fig. 1A, B and C). The serology for the human immunodeficiency virus was negative. With a diagnosis of colonic mucormycosis with fistulising Crohn’s disease, liposomal amphotericin B was started, but the patient succumbed.
Conclusion This rare patient highlights the need for increasing awareness about fungal infestations as a cause of disease flare in patients with inflammatory bowel disease.
Keywords IBD, Crohn's disease, Fistulizing Crohn's disease, Mucormycosis
Large Intestine
090
Mimics of inflammatory bowel disease in clinical practice
Mayank Jain
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre, 283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India
Introduction There are several conditions that mimic inflammatory bowel disease (IBD) because of location, symptoms, or appearance on endoscopy, imaging and histology. Consideration of alternative diagnosis is important when conventional therapy does not work or worsens the symptoms. The present study is a retrospective analysis of cases where IBD mimics were diagnosed.
Methods Over a nine-year period, 104 cases with suspected IBD were seen by the author. Of these, 88 were suspected as ulcerative colitis (UC) and the remaining as Crohn’s disease (CD). Diagnosis of IBD was suspected if 2 or more of the following symptoms were present- fever, weight loss, abdominal pain, chronic mucoid or bloody diarrhea, subacute intestinal obstruction with or without right iliac fossa mass. The diagnosis was confirmed using radiological investigations (ultrasound, computed tomography), colonoscopy evaluation and histopathology. Based on histology, and re–evaluation in cases with non-response, the eventual diagnosis was changed in 11 cases.
Results Infections were commonest mimics and were noted in 6 cases (54.5%). Tuberculosis and amebic colitis were detected in 3 and 2 cases respectively. Five other cases (45.5%) were diagnosed with rarer diseases based on the clinical profile, histology and response to treatment. These included segmental colitis with diverticulosis (SCAD), solitary rectal ulcer syndrome, eosinophilic enteritis, Behcet’s disease and NSAID enteropathy are rarer IBD mimics seen in India and reported mainly as case series.
Conclusion IBD mimics are detected in nearly 10% of cases of suspected IBD. They are commoner in CD than UC. Infections are the commonest IBD mimics in Indian scenario.
091
Clinical and endoscopic profile of inflammatory bowel disease in a tertiary care hospital in South India
Rithesh Gundam , Deepak Suvarna, Aradya H V, Nandeesh H P, Vijay Kumar T R
Correspondence- Deepak Suvarna-drdeepaksuvarna@gmail.com
Department of Gastroenterology and Hepatology, JSS Medical College and Hospital, Mysore Road, Bannimantap A Layout, Bannimantap, Mysuru 570 015, India
Introduction We aim to study the clinical profile of inflammatory bowel disease (IBD) patients in a tertiary care hospital of Karnataka.
Methods We retrospectively analyzed the clinical profiles of IBD patients who had presented to Department of Gastroenterology over a period of four years from January 2015 to January 2019. Demographic profile, clinical and endoscopic findings along with management and complications were taken into consideration.
Results Of the 143 patients, there were 126 (88.1%) patients with ulcerative colitis (UC), 6 (4.2%) with Crohn’s disease (CD) and 11 (7.7%) with inflammatory bowel disease unclassified (IBDU). Chronic diarrhea (77.8%) and blood in stools (75.4%) were common in UC, whereas abdominal pain (50%) was common in CD. E2 (57.1%) was more common in UC, there were equal number of L2 (50%) and L3 (50%) in CD. Left sided colon involvement (81.8%) was common in IBDU. Extraintestinal manifestations were noted in CD (66.6%), IBDU (54.5%) and UC (53.3%). Most of the patients had moderate disease activity and responded well to pharmacotherapy.
Conclusion In our study, we found that IBD was common in rural population of India and UC was more common than CD.
092
Profile of colonic polyps in north Indian population
Anurag Mishra , Arpan Jain, Manish Tomar
Correspondence- Anurag Mishra-dr.anuragmishrakgmc@gmail.com
Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER),1, Jawaharlal Nehru Marg, 64 Khamba, Raj Ghat, New Delhi, Delhi 110002
Introduction Data on the prevalence and distribution of colonic polyps in Indian/Asians is limited. To study this we conducted a retrospective study on 202 polyps out of 7936 colonoscopies.
Method The objective was to analyse demographic, clinical, endoscopic and histopathological characteristics of polyps in patients undergoing colonoscopy from 2016 to 2019 at GIPMER, New Delhi. All polyps were removed colonoscopically by polypectomy and specimen were sent for histopathological examination. Parameters like age, gender, symptoms, site, gross morphology and histological subtypes of polyps were assessed.
Result Total 7936 colonoscopies were performed in this period. Polyps were seen in 202 patients. Mean age was 23 years. Seventy-two percent were males. Eighty-two percent were below 40 years and 18% were above 40 years of age. 69% polyps were found in rectum. Sixty-three percent polyps were juvenile, 10% Peutz-Jegher, 17% adenomatous, 3% inflammatory and 7% others. Mean age of adenomatous polyp was 48 year. Sixty-six percent polyps were pedunculated. Fifty-one percent polyps were less than 1 cm. Eighty-one percent patients presented with bleeding P/R. Seventy-eight percent of adenomatous polyps were dysplastic. Out of adenomatous polyp 44% were tubular, 34% tubulo-villous and 22% villous.
Conclusion Frequency of polyps on colonoscopy at our centre was 2.5%. Most common type was juvenile polyp. Polyps were more common in younger age group. Adenomatous polyps were common in middle to old age group. Most polyps were small, pedunculated and located in rectum. Tubular was most common type of adenomatous polyp. Dysplasia was more common in villous type.
093
Solitary rectal ulcer syndrome and its relation to specific food
Padmanabhan Purushottam, Mohammed Syed, Syed Mohd Akbar Hassan
Correspondence- Mohammed Syed-drakhassan@gmail.com
Department of Gastroenterology, Meenakshi Medical College, Enathur, Karrapettai Post, Kanchipuram 631 552, India
Introduction Solitary rectal ulcer syndrome (SRUS) was first identified as clinical identity in 1969. But the etiology is not known. Anal fissure, inflammatory bowel disease (IBD), proctagia fugax and malignancy, rectal polyps, hemorrhoids, and infections. Rarely ischemia, trauma and cystic profunda colitis and stercoral ulcers have to be excluded. Hence a careful history is important.
Methods Patients presenting with C/O constipation or straining at stools with difficulty in passing motion with associated minimal bleeding per rectum on and off period less than a month were included in the study. All patients were investigated for stool for occult blood, US abdomen, BMFT, CBP and flexible sigmoidoscopy
Results 1. Patients presenting with constipation and bleeding PR were investigated. Flexible sigmoidoscopy showed multiple pinpoint superficial ulcers on the anterior rectal wall without involvement of sigmoid colon. The incidence age group wise was seen very high between 20 to 60 years. M: F ratio 47:53. All were positive for stool for occult blood, negative for IBD and malignancy by biopsy. They responded to dietary changes i. e. veg, non-spicy, non-fried diet with antibiotic, mesalamine (400 mg BD) and lactulose 15 mL at bed time. Ten days after the test follow-up sigmoidoscopy was found normal and patient asymptomatic even after 3 months.
Discussion The incidence of SRUS has become common irrespective of age and sex. The type of food used by all these patients was found to be more or less similar with majority of them using fast food, fried food, and spicy food. Stoppage of the above-mentioned food with specific treatment for 10 days resulted in recovery with normal sigmoidoscopy.
Conclusion SRUS incidence is high in general population due to specific food type and evacuation behavior.
094
Management of inflammatory bowel disease in active phase for induction of remission - Steroid vs. tacrolimus
Padmanabhan Purushottam, Mohammed Syed, Syed Mohd Akbar Hassan
Correspondence- Mohammed Syed-drakhassan@gmail.com
Department of Gastroenterology, Meenakshi Medical College, Enathur, Karrapettai Post, Kanchipuram 631 552, India
Introduction Steroids along with amino salicylates are classically used for induction of remission but the side effects of steroids are many and cause multiple problems to patients receiving it. A result many non-inflammatory bowel disease (IBD) immune suppressants are being tried for induction of remission and include methotrexate, cyclosporine, infliximab, azathioprine, 6-mercaptopurine, adalimumab, vadalizumab, tafacitimabb, golimumab, and tacrolimus. The major problem in its use is development of adverse side effects, increase hospital stay and high cost.
Aim To compare and evaluate the efficacy and safely of tacrolimus with aminosalicylates vs. use of aminosalicylates with corticosteroid therapy in active phase of inflammatory bowel disease (IBD).
Methods Fifty patients of acute IBD were evolved in this study based on inclusion and exclusion criteria. Group –I:(25 patients) received corticosteroid (prednisolone 10 mg BD) along with aminosalicylates 1.3 gms/day Group –II: (25 patients) received tacrolimus in a dose of 0.1 mg/kg body weight per day (2 tablets of 1 mg twice daily) along with aminosalicylates 1.3 gms/day along with maintenance drugs required for patients for a period of 10 days. Colonoscopic evaluation was done before starting the drugs and after 10 days of completion of treatment and the efficacy assessed using Mao endoscopic scoring system. Follow-up of these patients was done at the end of 2 months with repeat colonoscopy to assess the effectiveness of the treatment.
Results After initial therapy of 10 days clinical remission was observed in both groups of patients. Follow-up at 2 months no patient of group –II was admitted for exacerbation whereas in group –I 5/25 patients were re hospitalized following exacerbation (20%).
Conclusion Tacrolimus has prolonged period of remission compared to corticosteroid with better efficacy, safety profile and cost effective which was well tolerated by patients.
095
Microbiological spectrum, endoscopic and histological characteristics and outcomes of enteric infection associated flare of ulcerative colitis - A retrospective analysis
Senthamizhselvan Kuppusamy , Pazhanivel Mohan, Abdoul Hamide
Correspondence- Senthamizhselvan Kuppusamy-senthamizh2909@gmail.com
Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Gorimedu, Puducherry 605 006, India
Introduction Enteric infections in ulcerative colitis (UC) can cause adverse outcomes in terms of increased severity, failure to attain remission, refractoriness to medical treatment and increased colectomy rates. Hence, this study was conducted to find the frequency, microbiological spectrum, endoscopic and histological characteristics, and outcomes of enteric infection associated flare of UC.
Methods This retrospective study included patients hospitalized for moderate or severe UC between January 2019 and June 2020. The baseline characteristics, laboratory values, clinical severity, endoscopic and histological grading of disease severity, stool culture and sensitivity, stool microscopy, Cytomegalovirus (CMV) cytopathic changes in colonic biopsy, were collected.
Results A total of 17 (n=75, cases 22.7%) enteric infection associated moderate or severe flare of UC was seen during the study period. Their median age was 36 years (22-48 years), with a male preponderance (M:F=12:5). Stool culture was positive in 12 patients (70.6%), Salmonella species was the commonest organism isolated in 5 patients (41.7%), followed by Aeromonas punctate, Aeromonas caviae, Vibrio cholera, Vibrio vulnificus, Edwardsiella tarda, Pleisomonas shigelloides, and Shigella dysenteriae, in each of the remaining 7 patients (each 5.9%). Stool microscopy for parasites was positive in 3 patients (17.6%). The parasites include Ankylostoma duodenale, Blastocystis hominis, and Entameba histolytica. Cytopathic changes of CMV were seen in histology in 2 patients (11.8%). Mayo Endoscopic score was 1, in 4 patients (23.5%) and Geboes histological activity score was less than 3, in 10 patients (58.8%). All patients showed significant clinical improvement with appropriate dose and duration of antimicrobial treatment. None of them required colectomy or change in their maintenance therapy during this period.
Conclusions In conclusion, clinically severe enteric infection associated flare of UC may have milder histological disease activity. Their symptoms and endoscopic findings improve with antimicrobial treatment and rarely warrant newer or change in immunosuppression or immunomodulation.
096
Thrombotic thrombocytopenic purpura as extraintestinal manifestation of ulcerative colitis
Ronak Ajmera , Ashish Garg, Anant Kumar Chauhan, Sushil Kumar Sharma, Subhasish Mazumder
Correspondence- Subhasish Mazumder-subhasish.dr@gmail.com
Department of Gastroenterology, Max Super Speciality Hospital, W-3, near Radisson Blu Hotel, Sector-1, Vaishali, Ghaziabad 201 012, India
Ulcerative colitis (UC) is autoimmune disease with varied extraintestinal manifestation. Acquired TTP is associated with autoimmune diseases but very rare with ulcerative colitis (only 4 cases reported in literature). We had a case of 31-year-old male who was a known case of UC since 5 years but not on regular treatment. Patient presented with history of index episode of focal seizures with secondary generalization with altered sensorium. Patient was having persistent seizures and altered sensorium after admission in spite adding of multiple antiepileptics and supportive care. No cause was found after blood investigations and brain imaging for seizures. His bowel habits were normal and there were no features of sepsis. His investigations revealed high serum creatinine, falling hemoglobin (8.3 gm%) and thrombocytopenia. Peripheral smear showed evidence of Schistocytes, high serum LDH, low serum haptoglobulin and negative coombs test suggestive of micorangiopathic hemolytic anemia (MAHA). In view of MAHA, thrombocytopenia, seizures and renal dysfunction diagnosis of acquired TTP was made and he was initiated immediately to plasmapheresis. After multiple sessions of plasmapheresis, patient improved clinically, his sensorium improved and also there was normalization of serum creatinine, steady Hb and platelet count. Hence, we concluded that acquired TTP can be an extra intestinal manifestation of UC which clinicians should keep in mind and initiate prompt management in the form of plasma exchange.
097
Incidence and anatomical distribution of colorectal cancer - A single centre retrospective study
Aswin Jacob , A Aravind, J Jayakumar, C Vaishnavi Priya, S Kavitha, A Anand, Kani Shaikh Mohamed, Caroline Selvi
Correspondence- A Aravind-aswingeorgejacob@gmail.com
Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai 600 010, India
Background Colorectal cancer (CRC) is one of the major cancers in the developed world causing significant morbidity and mortality. Most colorectal cancers are due to old age and lifestyle factors, with only a small number of cases due to underlying genetic disorders. A recent study had shown a rising incidence of CRC in patients younger than 50 years of age. The incidence of CRC is low in India due to high dietary fiber intake.
Aim of the study To determine the incidence and anatomical distribution of colorectal colorectal cancer at a tertiary care centre in south India.
Methods Retrospective descriptive analysis of anatomical distribution, age at diagnosis and demography of 238 cases (149 [57.1%] men) of adenocarcinoma of the colon or rectum diagnosed by colonoscopy and biopsy over a period of five years (June 2014- May 2019) at Government Kilpauk Medical College, Chennai.
Results Total numbers of patients presented with colorectal cancer were 238, with M: F 1.3:1. The mean age at diagnosis was 54.55 years (SD 14.12; range 19–89 years). Thirty-five (14.7%) cases were below the age of 40 years. The majority (45.3%) cases were aged between 41–60 years. Most of the tumors (n=178, 78.5%) were located distal to the splenic flexure.
Conclusion Almost half of the colorectal cancers in this series occurred in the fifth and sixth decades of life and most of them were located distal to the splenic flexure.
098
Frequency and characteristics of colonic polyps in Indian patients
Ajith C Kuriakose , Rajeeb Jaleel 2 , Anoop John, Rajesh S, Ajith Thomas, Lalji Patel, Sudipta Dhar Chowdhury, Ebby G Simon, A J Joseph, Amit Kumar Dutta
Correspondence- Amit Kumar Dutta-akdutta1995@gmail.com
Department of Gastroenterology, Christian Medical College, Vellore 632 004, India
Introduction Data on the frequency and characteristics of colonic polyps from our country are limited. We aimed to study the frequency and profile of colonic polyps among our patients.
Methods We conducted a retrospective study of patients who underwent colonoscopy from November 2019-June 2020. Clinical records including colonoscopic findings were evaluated. Patients with polyposis syndrome or incomplete colonoscopy were excluded. The demographic profile and indications for colonoscopy were assessed. The morphological and histological characteristics of polyps were recorded. In addition, the risk factors of adenomatous polyps were assessed.
Results Among the consecutive 2000 patients who underwent colonoscopy during the study period, 135 (6.75%) had sporadic colonic polyps. These 135 patients had a total of 251 colonic polyps and histology report was available for 222 of them. Mean age of patients was 52+18.1 years and 71.1% were males. Majority (88,62.8%) of the patients had single polyp. Common indications for colonoscopy were altered bowel habits (25.2%), lower GI bleeding (21.5%) and surveillance in patients with prior polyps (20%). Most of the polyps were sessile (60.2%) and located in the left colon (60.2%). Majority were <1cm in size 189 (75.3%) and were adenomatous (56.3%) or inflammatory (25.7%). Other types included hyperplastic (9.9%), juvenile (4.1%), Peutz-Jeghers (0.9%), serrated (0.9%) and lipomatous polyps (0.9%). In adenomatous, tubular variety was more common (80.8%) and 12% showed features of high-grade dysplasia. Synchronous cancer was found in 8 patients. Risk factors for adenomatous polyps are shown in Table1.
Table 1
Features | Adenomatous (n=69) | Non adenomatous (n=54) | P value* |
Age (mean+SD) years | 57.3+14.4 | 43+20.1 | 0.013 |
Sex (male) | 74% | 64.8% | 0.28 |
Size (>1cm) | 30.3% | 33.3% | 0.61 |
Location (left colon) | 65.2% | 79.6% | 0.08 |
Hemoglobin (mean+SD) gm/dL | 11.9+2.3 | 11.8+2.3 | 0.77 |
*Categorical variables by Chi Square Test and continuous variables by Student-t test
Conclusion Among our patients, adenomatous and inflammatory polyps are the commonest histological subtype and most polyps are located in the left colon. Patients with older age have higher risk of having adenomatous polyps.
099
Clinicopathological profile of colorectal polyps : A retrospective study at a tertiary care center in South India
Hitesh Ramesh , Deepak Suvarna
Correspondence- Deepak Suvarna-drdeepaksuvarna@gmail.com
Department of Medical Gastroenterology, J S S Medical College, Mysore Road, Bannimantap A Layout, Bannimantap, Mysuru 570 015, India
Introduction A gastrointestinal polyp is a discrete mass of tissue that protrudes into the lumen of the bowel wall. It is postulated that certain varieties of colonic polyps turn malignant over a period of time. The most common precursor of colorectal cancer is adenoma. The biggest concern is their ability to progress into carcinoma, through the adenoma-carcinoma sequence. In this retrospective study we analyzed clinical features, location, pattern of distribution, histopathological types of polyps and its association with severity of dysplasia.
Methods We retrospectively analyzed data of patients diagnosed to have polyps who had undergone colonoscopy between January 2016 to December 2019 in our hospital. We analyzed the association between age, sex, location of polyps, histopathological types and correlated size of polyps with degree of dysplasia.
Results Among the 2595 complete colonoscopies 140 (5.39%) patients were found to have colonic polyps. Mean age of the study population was 53.97 years and majority were men (69.2%). 48.69% polyps were located in rectum and 34.78% were seen in sigmoid colon. Commonest histopathological type was Adenomatous polyps in 64 (45.7%) followed by inflammatory in 41 (29.2%), hyperplastic in 23 (16.4%), juvenile in 10 (7.14%), hamartomatous and Peutz-Jeghers polyp in 1 each (0.71./.). 83% of polyps with size (>2 cms) and 57.1% of polyps with villous histology were associated with severe dysplasia.
Conclusion Adenomatous polyps were the predominant histologic type similar to the west. Among the adenomatous polyps larger polyps (>2 cm) were more commonly associated with severe dysplasia. Polyps with villous histopathological variant were associated with severe dysplasia.
100
Demographic, etiological and histopathological profile of ileo-colonic ulcers from a tertiary care centre in North India
Arpan Jain , Anurag Mishra, Manish Kumar, Ujjwal Sonika, Ajay Kumar, Siddharth Shrivastava, Sanjeev Sachdeva, Barjesh Chander Sharma, Puja Sakhuja * , Ashok Dalal
Correspondence- Arpan Jain-drjain.arpan@gmail.com
Departments of Gastroenterology, and *Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER),1, Jawaharlal Nehru Marg, 64 Khamba, Raj Ghat, New Delhi 110 002, India
Background Data on ileocolonic ulcers due to inflammatory bowel diseases (IBD) is extensive. We retrospectively studied demographic profile and etiology of non IBD related ileocolonic ulcers over 6 months in patients undergoing colonoscopy for various reasons.
Methods All patients undergoing colonoscopy from July 2019 to December 2019 and diagnosed as non IBD ulcers were included. The demographic, clinical, radiological data was extracted from patient case files. The endoscopic location of ulcers and their histopathological diagnosis were assessed. The data entry and analysis was done using SPSS version 23.
Results A total of 101 patients of ileocolonic ulcers were included with median age of 38 (range 6-75) yrs. There were 61 males and 40 females. Abdominal pain (n=73) was the most common symptom followed by diarrhea (n=33), bleeding PR (n=28) and fever (n=17). Drug intake history was present in (n=22) patients. Ileocecal thickening with lymphadenopathy on computed tomography was the common radiological finding requiring colonoscopy. Cecum (n=29) was the most common location of ulcers followed by ileum and rectum (n=25) each. Ulcers were present at more than one location (n=13), with most common being combined ileocecal involvement (n=4).
Histopathological examination revealed non-specific colitis/ileitis (n=60, 59.4%) as the most common cause followed by amebic as well as solitary rectal ulcer syndrome (SRUS) (n=12, 11.9%) each. Tubercular ulcers were present in 9 patients (8.8%). Infectious colitis and drug induced ulcers in 5 and 1 patient (NSAID related) respectively. Benign appearing ulcers were reported as malignant in 2 patients.
Conclusion Abdominal pain, diarrhea and bleeding PR were the common symptoms. Most common non IBD related ileocolonic ulcers were non-specific/idiopathic. Amebic and SRUS were the next common cause followed by tuberculosis. In 2 cases we had benign appearing ulcers which were histopathologically malignant.
101
Efficacy of hepatitis B vaccination in patients with ulcerative colitis: A prospective cohort study
Anurag Mishra , Arpan Jain, Manish Tomar
Correspondence- Anurag Mishra-dr.anuragmishrakgmc@gmail.com
Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER),1, Jawaharlal Nehru Marg, 64 Khamba, Raj Ghat, New Delhi 110 002, India
Introduction Response to vaccine in Patients with inflammatory bowel disease (IBD) seems to be considerably lower than in general population, probably because of nature of disease and immunosuppressive regimens used.
Aim Aim of this study was to evaluate the efficacy of hepatitis B (HBV) vaccination in patients with ulcerative colitis (UC) vs. controls.
Method This is a prospective cohort study. One hundred IBD-UC cases and 100 healthy controls were taken. UC patients with no prior history of HBV vaccination between 18 to 60 years of age were included. HBV vaccination was given to all the cases and controls at 0/1/6 months. Anti-HBs titres were done 4 weeks after 1st and 3rd dose vaccination. Adequate immune response (AIR) was considered if anti-HBs titre was >10 IU/mL and effective immune response (EIR) if anti-HBs titre was >100 IU/mL.
Result Total of 100 (59 male, 41 female) patients with IBD-UC and 100 (54 male, 46 female) healthy controls were included (p=0.47). Mean age for cases and controls was 33 ± 11 and 36 ± 10 respectively (p<0.05). AIR was significantly lower in cases than in controls (82% vs. 96%, p=0.003). EIR was also significantly lower in cases than in controls (41% vs. 66%, p=0.0007). Sixty-four percent IBD patients were on immunosuppressive therapy before vaccination. Among the IBD patients who were taking immunosuppressant AIR was 72% and EIR was 23%. Among the IBD patients who were not taking immunosuppressant AIR was 100% and EIR was 72%.
Conclusion Response rate of IBD patients receiving HBV vaccinations were significantly lower compared to controls. Response rate of those receiving immunosuppressive therapy was also low.
102
Etiological spectrum of intestinal obstruction In North India in gastroenterology practice
Dilip Singh Mudgal , Shyam Sunder Sharma, Sudhir Maharshi, Bharat Sapra, Mayank Ameta
Correspondence- Shyam Sunder Sharma-shyamsharma4@rediff.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India
Background and Aims Dynamic intestinal obstruction is a common and potentially dangerous surgical emergency with high morbidity and mortality. Early diagnosis and timely treatment in order to improve the chance of survival are of paramount importance. Regional as well as worldwide variations in the pattern of intestinal obstruction from time to time are well documented. Periodic studies are needed to evaluate the etiological factors for prevention. In India regarding regional changes in etiological spectrum of acute intestinal obstruction the literature are not much. The aim of this study was to study the clinical profile and to find out the underlying cause of acute intestinal obstruction in patients under study .
Methods This prospective descriptive study of 224 patients, presenting with dynamic acute intestinal obstruction was conducted in Department of Gastroenterology, SMS Medical College and Hospitals, a tertiary care center at Jaipur from August 2017 to July 2019. All patients with clinical and radiological evidence of acute intestinal obstruction were included. Details of individual patients regarding age, sex distribution, presentation duration, symptomatology and workup related to etiology was carried out according to proforma sheet and data analyzed statistically on SPSS version-22.
Results A total of 224 patients with dynamic acute intestinal obstruction were admitted and treated conservatively for 48 hours, if patient not improved or sign and symptoms progressed patients were further managed in surgery department. Mean age of study population was 43.74 years and male were 57.14% and female were 42.86%. Neoplasia was most common cause (33.92%) with large intestinal colorectal cancer causing 28.64% of intestinal obstruction (mean age- 54.58 years) followed by intestinal tuberculosis and benign stricture with nonspecific histology each with 20.54%.
Conclusion Colorectal cancer, tuberculosis and benign strictures with nonspecific histology were the common cause of dynamic intestinal obstruction.
103
A retrospective single blinded study comparing efficacy of six months versus nine months antitubercular treatment in intestinal tuberculosis
Saiprasad Lad , Gaurav Kumar Singh, Pratik Sethiya, Mayur Gattani, Kailash Kolhe, Shamshersingh Chauhan, Deepti Vishwanathan, Akash Shukla*, Meghraj Ingle, Vikas Pandey
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai 400 022, India, and *Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai 400 012, India
Introduction The duration of treatment in intestinal tuberculosis, whether six months or more than six months, remains a dilemma. We conducted this study to assess efficacy of six months vs. nine months antitubercular treatment (ATT).
Methods Retrospective, single blinded, single center study was done in out patient department to evaluate efficacy of 6 months vs. 9 months of daily administered directly observed ATT. One hundred patients with intestinal tuberculosis who received ATT either for 6 months (n=55; 55%) or 9 months (n=45; 45%) were included and both pre-treatment as well as post-treatment details of clinical features, radiologic evaluation, endoscopic examination, histopathologic findings and special investigations like Gene Xpert and MGIT were noted. Patients from both the groups were observed for adverse drug events (nausea, vomiting, abdominal pain, ATT hepatotoxicity).
Results One hundred patients were included in study (mean age - 32.2 years, females- 44; 44%). There was statistically significant difference between pre-treatment tenderness (higher in 9 months group 6 [13.3%] vs. 0 [0%]) when compared to 6 month group. Rest all the symptoms, signs and pre-treatment investigation findings were similar in both the groups. There was no statistically significant difference between clinical response (53 [96.4%] vs. 45 [100%]; p=0.196), radiologic resolution (52 [94.5%] vs. 43 [95.6%]; p=0.818) and endoscopic healing (49 [89.1%] vs. 43 [95.6%]; p= 0.236), also in adverse drug events like vomiting (22 [40%] vs. 21 [46.7%]; p=0.503), abdominal pain (12 [21.8%] vs. 6 [13.3%]; p=0.272), hepatotoxicity (2 [3.6%] vs. 2 [4.4%]; p=0.837) in 6 months and 9 months group respectively.
Conclusions For intestinal tuberculosis 6 months therapy is equally efficacious as that of 9 months.
104
An interesting case of bilateral lower limbs swelling in a patient of chronic diarrhea: A case report
Amit Agarwal , Amit Soni,
Correspondence- Amit Agarwal-amitbijnor2010@gmail.com
Department of Gastroenterology, MMIMSR, MMU Campus, Mullana University Road, MMIMSR, Mullana 133 207, India
Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE is a serious complication of IBD that carry significant cost, morbidity and mortality. Certain risk factors such as active disease, immobilization and drugs increases the risk. Thromboembolism in IBD is either overlooked or delayed as patients new symptoms are attributed to their disease severity or side effects of drugs. We present a case of 22 years old male patient presented in OPD with complains of chronic diarrhea and bilateral lower limbs swelling and breathlessness. On workup patient was diagnosed as a case of active Crohn’s disease. Bilateral lower limb swelling is common in IBD patients due to malnutrition (anemia and hypoalbuminemia), in our case it was found to be due to extensive bilateral lower limb deep vein thrombosis also and breathlessness was due to pulmonary embolism. Bilateral deep vein thrombosis extending up to inferior vena cava (IVC) with pulmonary embolism is a rare finding which was seen in our patient. Balloon angioplasty of IVC was done with placement of a self expandable stent and IVC filter. In conclusion VTE has substantial morbidity and mortality and when IBD patients presents with a new symptom complex thromboembolic phemonenon needs to be considered.
105
Are all colonic thickening on CT worrisome - A tertiary care experience
Sourav Kr Chhajer , Vinod Kumar Dixit, Sunit K Shukla, Dawesh Yadav, Anurag Tiwari
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
Background and Aim Increasing use of abdomino-pelvic CT for various indications has greatly increased the diagnosis of bowel wall thickenings. We aim to find out the correlation between bowel thickening with subsequent colonoscopic and histopathological findings.
Methods Data of patients referred for colonoscopy on basis of Colonic thickening on CT were collected retrospectively between January 2019 and April 2020 and their histopathology reports were traced. Patients undergoing CT for known GI disease or known malignancy were excluded.
Results A total of 320 patients were identified. Mean age of patients was 37.8 years (15-80) with male to female ratio of 0.7:1. The most common location of thickening was ileocecal (62.5%, n=200), followed by ascending colon (13%, n=42) and rectosigmoid (10.9%, n=35). Colonoscopy was normal in 29% cases. More than 75% patients under age group <40 yrs had ileocecal thickening and 42% of them had normal colonoscopy. The most common colonoscopic abnormality found was presence of ulcers and erosions (n=82, 25.6%), followed by stricture (n=67, 20.9%) and growth (n=52, 16.25%). Other less common findings included diverticulosis, telangiectasia, pseudomelanosis coli. Non-specific colitis was most commonly reported in patients with ulcers (57.8%). Tuberculosis was diagnosed in 17.5% (n=56) mostly in pts with strictures (63%). The diagnosis of IBD was made in 23 patients (7.18%). Malignancy was found in 16.56% patients. Adenocarcinoma was most common (> 95%) followed by lymphoma, metastatic and NET in remainder Two patients had eosinophilic colitis. The diagnosis of malignancy was significantly more present in age group >40 yrs with only 5.3% cases less than 40 yrs had malignancy, most common site in them being rectosigmoid.
Conclusion Ileocecal thickening remain the most common reported site of thickening in CT. However, a significant proportion of patients may have normal colonoscopy and many have non-specific colitis on histopathology especially in younger age group patients.
106
Fecal calprotectin levels in patients with diarrhea at the tertiary care hospital of Uttarakhand
Swati Rajput , Rohit Gupta, Itish Patnaik, Prashant Chauhan, Satyavati Rana
Correspondence- Satyavati Rana-svrana25@hotmail.com
Department of Biochemistry, All India Institute of Medical Sciences, Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Aim To find out the incidence of raised fecal calprotectin levels in patients with diarrhea at tertiary care hospital of Uttarakhand.
Methods For this study, 193 adult patients with diarrhea attending Gastroenterology OPD at tertiary care hospital of Uttarakhand were enrolled. The study period was from July 2019 to February 2020. Levels of fecal calprotectin were measured using ELISA method. Patients with fecal Calprotectin levels >43 μg/g was suggestive of IBD and <43 μg/g of IBS. On the basis of fecal calprotectin levels, percentage of IBD and IBS patients was calculated.
Results Out of 193 adult patients with age range 18 to 85 years, 138 (71.5%) were males and 55 (28.5%) females. Mean + SD of age of these patients was 34.89 + 15.69 years while of males 34.08 + 14.45 years and of females 36.9 + 18.44 years. 124 out of 193 (64.2%) patients had fecal calprotectin levels <43 μg/g suggestive of IBS and 69 out of 193 (35.8%) patients had fecal calprotectin levels >43 μg/g suggestive of IBD. Out of 69 patients, 53 had fecal calprotectin levels between 43-500 with Mean + SD of 138.73 +105.48 μg/g, 8 between 500-1000 with Mean + SD of 769.38 + 187.36 μg/g and 8 between 1000- 2000 with Mean + SD of 1600.67 + 268.36 μg/g.
Conclusion 64.2% patients had fecal calprotectin levels <43 μg/g suggestive of IBS and 35.8% patients had fecal calprotectin levels >43 μg/g suggestive of IBD at tertiary care hospital of Uttarakhand during a period of 8 months.
107
An unusual cause for sudden massive hematochezia in ICU-A case report
Manmohan U S , Arun R S, Prashanth B Gandhi
Correspondence- Manmohan U S-manmohanus@gmail.com
Department of Medical Gastroenterology, Madras Medical Mission Hospital, 4A, Dr, CLRI Staff Quarters, Mogappair, Chennai 600 037, India
Introduction The incidence of gastrointestinal bleed varies from 15% to 50% in the first 24 hrs of ICU stay. Severe painless hematochezia results from foregut source in 15% of non-cirrhotics. The common colonic causes of severe hematochezia are diverticulosis, hemorrhoids, ischemic colitis, colon cancers and rectal ulcers.
Case presentation We reported a 64-year-old female who is known case of diabetes and hypertension, underwent emergency cardiac bypass surgery for coronary artery disease with ventricular tachycardia (VT). She had on table VT with cardiogenic shock and was revived. On 7th post OP day, she developed fresh bleeding per rectum with significant drop in hemoglobin. On examination she was anemic and mild left iliac region tenderness. Initially upper GI scopy done which showed clean based duodenal ulcer. But as she continued to bleed and was on inotropic support, bedside colonoscopy was done which revealed large irregular ulcer ~3 cm overlaid with exudates in rectum and multiple clean based ulcers in cecum. The distribution was unlikely to be ischemic in origin. Histopathological examination of colonic ulcers biopsies revealed invasive intestinal mucormycosis. Patient showed full clinical resolution after course of parenteral Amphotericin B followed by oral posaconazole. She had an uneventful recovery and on follow-up after 2 months, she was in good health. Mucormycosis is life threatening opportunistic invasive fungal infection caused by mucorales of class Zygomycetes. It’s commonly seen in immunosuppressed cases like diabetes, organ transplantation, Human immunodeficiency virus infection and those on immunosuppressive medications. Gastrointestinal mucormycosis has high mortality rate.
Conclusion Invasive Intestinal Mucormycosis is a rare cause of hematochezia in immunocompromised individuals. Timely diagnosis and treatment with antifungals plays a major role in reducing mortality. A good histopathological examination including IHC markers (if needed) for all colonic ulcers and to have high index of suspicion plays a crucial role for diagnosis
108
Clinical profile and outcome of patients presenting with acute flare of ulcerative colitis: A tertiary care experience
Sourav Kr Chhajer , Vinod Kumar Dixit, Sunit K Shukla, Dawesh Yadav, Anurag Tiwari, Piyush Thakur
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
Introduction Acute flare of ulcerative colitis is a life-threatening condition carrying high morbidity and mortality. We aim to find out the profile of patients presenting with ASUC and assess response to treatment.
Methods A prospective study was conducted between January 2019 and May 2020. All patients admitted with acute flare of ulcerative colitis as defined by the truelove and Witts criteria were included in our study. Patients were investigated and treated according to standard guidelines and were followed for 4 weeks.
Results A total of 66 patients were evaluated. Baseline characteristics are listed in Table1. The average duration of disease was 4.6 years (2 months -18 yrs). Fifteen patients (22.7%) had recent onset disease symptoms with mean duration of 2.5±0.4 months. The most common cause of flare was treatment default in 30.3% (n=20) followed by Cl. difficle infection (15.15%, n=10) and CMV infection in 10.6% (n=7). Two patients had recent h/o NSAID intake and one patient had amoebiasis. In remaining cases no obvious cause was identified. About 50 patients (75.7%) achieved clinical remission with IV steroids. In remaining 16 patients rescue therapy was initiated of which 12 patients (75%) responded. Three patients required surgery and there was one mortality. Rescue therapy was needed more frequently in patients who had E3 disease, became steroid dependant early in their disease course with no obvious cause of flare (60%). Albumin < 2.4 g/dL and CRP level >77 mg/dL at D3 of steroids had significant association with steroid non responsiveness (p<0.05).
Conclusion The most common cause of flare in our cohort of patients was treatment default followed by Clostridium difficle infection. Low albumin and high CRP at day 3 along with prior steroid dependence had significant association with failure to steroid response.
Table 1
Age (yrs) | 30.8 (15-54) |
Male:Female | 1.3:1 |
Hemoglobin (g/dL) | 8.2±1.8 |
Albumin | 2.8±0.8 |
CRP (mg/dL) | 68±26 |
CMS | 7 (5-9) |
UCEIS | 6 (5-8) |
109
Clinical response to anti tubercular therapy given as a diagnostic strategy does not affect long-term outcomes in patients with Crohn’s disease
Srikant Mohta , V Pratap Mouli, Akshita Gupta, Kalaivani Mani * , Saurabh Kedia, Govind Makharia, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Departments of Gastroenterology and Human Nutrition, and *Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Intestinal tuberculosis and Crohn’s disease (CD) are often indistinguishable even with imaging and endoscopy. To tackle the dilemma, a therapeutic trial of antitubercular therapy (ATT) is often given to which patients show variable response. ATT has been shown to modify the disease course in CD especially in the long-term.
Methods We conducted a retrospective study to compare long-term course and outcomes among CD patients who received a trial with ATT based on the symptomatic response to ATT.
Results 29.1% (n=221) of the 760 patients received ATT and clinical response was seen in 42.8%. The baseline disease characters were similar in both groups. The median duration of ATT trial (9 [IQR=6-12] vs. 6 [6-9] months; p=<0.01) and median time to make a diagnosis of CD after starting ATT (15 [9-30] months vs. 10 [6-14] months, p<0.01]) were longer in the ATT responders group. More non responders were given steroids (93.7% vs. 72.9%, p<0.01) but long-term outcomes including disease behavior, extent, need for immunomodulators, biological or surgery did not differ among both groups. No baseline parameter could predict response to ATT.
Conclusion Symptomatic response to a therapeutic ATT trial in CD patients did not affect long-term clinical course and it should not affect long-term treatment strategy. Reassessment by endoscopy and/or imaging for mucosal response should be early in indeterminate cases.
110
Systematic review and network meta-analysis: Comparative efficacy and safety of faecal microbial transplantation and targeted therapies for induction in active ulcerative colitis
Sudheer K. Vuyyuru, Saurabh Kedia, Mani Kalaivani, Pabitra Sahu, Bhaskar Kante, Peeyush Kumar, Mukesh Kumar Ranjan, Govind Makharia, Ashwin Ananthakrishnan * , Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and *Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
Background/Aims To compare the efficacy and safety of FMT with targeted therapies for induction of remission in active UC.
Methods We analyzed data from randomized controlled trials (RCTs) evaluating induction of remission in adults with UC treated with anti-TNF (infliximab and adalimumab), anti-integrin (vedolizumab), anti-IL23 (ustekinumab), Janus kinase (JAK) inhibitors (tofacitinib), and FMT, compared with placebo or another active agent.
Results Overall nineteen studies were included, among which there was only one head to head RCT (adalimumab vs. vedolizumab). All interventions including FMT were superior to placebo in inducing clinical remission (except adalimumab-OR 1.66; 95%CI, 0.97-2.85), clinical response and endoscopic remission. FMT was comparable with other agents for all efficacy outcomes including clinical remission and response, and endoscopic remission. Infliximab was ranked highest in inducing clinical remission (SUCRA, 0.8), vedolizumab in clinical response (SUCRA, 0.9) and tofacitinib in endoscopic remission (SUCRA, 0.9). There was no difference in safety outcomes between FMT and other targeted therapies, among which ustekinumab ranked the safest.
Conclusions FMT is effective than placebo in inducing remission and appears to be as effective and safe as targeted therapies in inducing remission in patients with active ulcerative colitis. Further studies needed for definitive conclusion and the cost effectiveness of FMT with targeted therapies needs to be analyzed.
111
Utility of noninvasive markers in predicting mucosal healing in ulcerative colitis - A longitudnal follow-up study
Deepak C , Senthamizh Selvan, Pazhanivel Mohan, Abdoul Hamide
Correspondence- Deepak C-drdeepakcjipmer@gmail.com
Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Gorimedu, JIPMER Campus, Puducherry 605 006, India
Introduction ‘Treat to target approach’ is the current approach to management of ulcerative colitis (UC). Mucosal healing and histological remission are the targets associated with better long-term outcome but their assessment requires invasive tests. Hence, this study was conducted to determine the utility of noninvasive biomarkers in predicting mucosal healing in UC.
Methods It was a longitudinal follow-up study conducted on newly diagnosed acute UC or a relapse of pre-existing UC between September 2018 and February 2020. The disease activity was assessed using clinical, Mayo endoscopic sub-score (MES) and histological scores at baseline and at remission. Biomarkers such as ESR, CRP, fecal calprotectin, serum NGAL and 24-hour urinary potassium were estimated at baseline and at clinical remission. The correlation of biomarkers with mucosal healing (MES of 0 or 1) was analyzed using Chi-square or Fisher’s exact test.
Results During the study period, 40 patients were recruited with a total of 43 episodes of flare. The mean age (SD) of study population was 35 (10) years. At baseline, majority had moderate or severe disease activity by clinical score (88%) as well as by MES (93%). At clinical remission, there was a significant reduction in fecal calprotectin (p=0.036), serum NGAL (p=0.002), ESR (p= < 0.001), and CRP (p= 0.002) and a significant increase in 24-hour urinary potassium (p=0.001) from baseline. The change in levels of all the biomarkers were also significantly associated with mucosal healing at clinical remission. Fecal calprotectin was the only biomarker that significantly correlated with mucosal healing (p=0.03). Delta calprotectin with cut off of 77μg/g had a significant AUC (0.738) for predicting mucosal healing with a sensitivity of 0.77 and specificity of 0.72.
Conclusion Our study confirmed that changes in the level of biomarkers after treatment could predict remission in UC. Fecal calprotectin correlated well with mucosal healing.
112
A rare case of gastrointestinal polyposis, where steroids work
Hemant Nayak, Sunil Jee Bhat , Manas Kumar Panigrahi, Subash Chandra Samal
Correspondence- Hemant Nayak-drhemantnayak@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Cronkhite-Canada syndrome (CCS) is a rare cause of gastrointestinal (GI) polyposis syndrome presenting with protein losing enteropathy and diarrhea. Here we report one such case.
Case presentation A 42-year-old female presented with abdominal pain, vomiting, frequent loose watery stools for the last six months and generalized body swelling, excessive fatigue, and decreased appetite for one month. She also noticed increasing hair fall, decreased taste sensation, nail changes and patchy skin darkening all over the body. Physical examination revealed anasarca, frontal alopecia, finger and toenails dystrophy, and diffuse hyperpigmentation of the skin. Laboratory investigations showed anemia with hemoglobin 9.5 g/dL (12-14 g/dL), hypoproteinemia with serum protein 3.4 g/dL (6–8 g/dL), hypoalbuminemia with serum albumin 1.2 g/dL (3.5 - 4.5 g/dL) and hypokalemia with serum potassium 2.8 mg/dL (3.5-4.5 mg/dL). Ultrasound revealed mild ascites and mild bilateral pleural effusion. Esophagogastroduodenoscopy showed numerous nodular and polypoid lesions in stomach, first and second part of duodenum. Ileocolonoscopy also revealed numerous polyps throughout the colon and terminal ileum. Segmental biopsies from stomach, duodenum, ileum and colon were taken. Evaluating her for protein losing enteropathy, the characteristic ectodermal and endoscopic findings made us to think of a rare GI polyposis syndrome known as CCS. Our diagnosis was further confirmed on histopathology of GI polyps which revealed hamartomatous polyps with intervening mucosal biopsies remarkable for marked edema, mild lymphoplasmacytic infiltrates, and cystically dilated glands with inspissated mucin. She showed dramatic response to steroids (prednisone 40 mg daily for 1 month) followed by tapering over 2 months with overlap of azathioprine 50 mg. She is asymptomatic for last 18 months on azathioprine 50 mg.
Conclusions To the best of our knowledge, CCS is the only gastrointestinal polyposis syndrome which responds to steroids.
113
A case of noacardia empyema in Crohn’s disease on Adalimumab: Suspect unexpected opportunistic infection on immunosuppression
Chandan Kumar 5 , Hemant Nayak 2 , Manas Kumar Panigrahi 3 , Subash Chandra Samal 4 , Srujana Mohanty 1
Departments of Microbiology, and Gastroenterology, All India Institute of Medical Sciences, AIIMS Road, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Nocardia is an emerging infection in the era of biological therapy with a fatal outcome without treatment. Risk of dissemination and multisystem involvement demands an early diagnosis from the treating physician. To the best of our knowledge, nine cases have been described in immunosuppressed inflammatory bowel disease (IBD).
Case Description We are sharing our experience with such opportunistic infection (pulmonary nocardiosis) in a 23-year-old male with Crohn’s disease on Inj. Adalimumab. He received anti tubercular therapy for six months without improvement before presenting to our center. For ileo-colonic Crohn’s disease, he initially received prednisolone (60 mg/day) and azathioprine (100 mg) for symptoms control. During tapering of steroid, relapse of the disease occurred so injection Adalimumab was initiated. There was overlapping period of two weeks when he was on inj. Adalimumab, steroid and azathioprine. After receiving two doses of inj. Adalimumab (160 mg, 80 mg), he again presented with fever for 2 days with dry cough. CECT revealed multiple loculated pleural space collections with well-defined abscess formation along mediastinal pleura in 9, 10 and 11th intercostal spaces invading muscles. Pleural fluid aspiration was purulent in infra-axillary pocket. Gram staining suggested bacilli with filamentous elements and on modified acid-fast staining branching bacilli were seen. MRI brain was normal.
Management Patient was managed with Inj. Meropenem and Inj Linezolid followed by Tab. Cotrimoxazole for 6 months. Inj. Adalimumab was reinitiated as he developed perianal disease with continued Cotrimoxazole prophylaxis without recurrence.
Conclusion Human nocardiosis is a rare opportunistic bacterial infection. The optimum duration of antibiotic therapy is uncertain but 1-year therapy seems to be advisable. The safety and timing of re-initiation of biological therapy remains unsettled.
114
Study of profile of hepatic disorders in patients with inflammatory bowel disease: Our experience in tertiary care hospital
Vinod Kumar Dixit, Indresh Dixit, Sunit Kumar Shukla, Dawesh Yadav
Correspondence- Vinod Kumar Dixit-drindreshdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Aurobindo Colony, Banaras Hindu University Campus, Varanasi 221 005, India
Background Ulcerative colitis (UC) and Crohn’s disease (CD) are inflammatory bowel diseases (IBD) that have different clinical presentations and are responsible for chronic idiopathic inflammation of the intestine. Several extraintestinal manifestations may be associated with IBD, and the disease may have a profound impact on patients’ quality of life. Hepatobiliary extraintestinal manifestations are sometimes underdiagnosed in IBD patients, and their presence may impair the patients’ prognosis.
Aim Our study is to evaluate the prevalence of hepatobiliary extraintestinal manifestations of IBD and to compare frequency of different hepatobiliary extraintestinal manifestations in ulcerative colitis and Crohn disease.
Methods It is a Cross-sectional study in our hospital, with interviews and review of medical charts between 1 January 2019 and 31 December 2019.
Results We interviewed 198 patients, out of which 140 (70.7%) had UC and 58 (29.3%) had Crohn's disease. Proportion of females is 64.6% and males were 35.4%. Hepatobiliary manifestations were observed in 40 (20.2%) patients with IBD of which 27(19.3%) were UC patients. Among 27 UC patients, the hepatobiliary disorders identified were 15 (10.7%) non-alcoholic fatty liver disease, 8 (5.7%) cholelithiasis, 1 (0.7%) primary sclerosing cholangitis (PSC), 1 (0.7%) hepatotoxicity associated with azathioprine, 1 (0.7%) hepatitis B, and 1 (0.7%) hepatic fibrosis. Thirteen (22.4%) out of 40 patients having hepatobiliary manifestations had Crohn's disease of which 4 (6.9%) had cholelithiasis, 4 (6.9%) non-alcoholic fatty liver disease,1 (1.7%) hepatotoxicity, 1 (1.7%) hepatitis B, (1.7%) hepatitis C, 1 (1.7%) alcoholic liver disease, and 1 (1.7%) autoimmune hepatitis (AIH).
Conclusion Hepatobiliary disorders are frequent extraintestinal manifestations of IBD and abnormal liver biochemical tests are present in significantly high proportion of patients with IBD. They are varied and range from limited mild diseases to serious progressive life-threatening diseases. Therefore, patients with IBD should be periodically monitored by liver function tests and a full diagnostic workup is required when elevated liver enzymes are found.
115
Identification of colorectal carcinoma in symptomatic young adult: A preliminary study from tertiary care centre in south India
Sai Harish , Ganesh P, Shanmuganathan Subramanyam, Anand T K, Kaushik A K
Correspondence- Sai Harish-harishreddy87@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Medical College, Chennai 600 116, India
Introduction Sporadic colorectal cancer is traditionally diagnosed after the sixth decade of life, and current recommendations for surveillance include only patients older than 50 years. Increasing incidence of colorectal cancer in young adults has been reported. This study looks into the epidemiology of colorectal cancer in population under screening age group.
Aims To study the age, gender, site of primary tumor, histopathological type of colorectal cancer with special reference to adults 45 years or younger.
Study design Retrospective observational Study conducted at Department of MGE, Chennai between January 2017 and February 2020.
Methods The study retrospectively analyzed the case records of all cases of colorectal cancer diagnosed between January 2017 and February 2020. The records were analyzed in detail for age, gender, site of primary tumor and histopathological type and presence of metastasis.
Results A total of 241 cases were studied. 58.9% of the patients were males and 41.1% were females. Significant 26.1% cases were reported in young adults less than 45 yrs. 71.4% of patients had bleeding PR as primary complaint in age group <45 yrs., 85% patients had left sided lesion and rectum as the most common site of primary lesion in age group <45 yrs, adenocarcinoma was most common accounting for 95.4%, 79% presented in advance stage in age group < 45 yrs.
Conclusions An increased incidence of colorectal carcinoma was seen amongst younger individuals in our study group. It is possible that CRC in our study is of a different phenotype as compared to the West. Moreover, in light of a significant number of young patients presenting with advanced CRC in our study, it is advisable to recommend for an early screening protocol for CRC in our population.
116
Objective assessment of the rectal effluent before colonoscopy gives fairly good idea about the quality of bowel preparation
Ajay Patwa , Sandeep Verma * , Guddoo Kumar, Virendra Atam
Correspondence- Ajay Patwa-drajaymd12345@gmail.com
Departments of Medicine, and *Surgery, King George Medical University, Shah Mina Road, Chowk, Lucknow 226 003, India
Multiple factors including color and consistency of the rectal effluent determine the quality of bowel preparation during colonoscopy. Patients verbal statement regarding color and consistency of the rectal effluent always does not give the idea of real picture. Our aim was to correlate the objective assessment of the color and consistency of rectal effluent with the quality of bowel preparation along with other factors such as preprocedural diagnosis, comorbid illnesses, amount of bowel preparatory agent consumed and runway time. 10 mL of the last rectal effluent was collected in plastic specican for visual inspection and grading for the color and consistency. Ottawa bowel preparation scale was used to assess the adequacy of bowel preparation. A pilot study involving 11 patients showed that objective assessment of color and consistency of the rectal effluent were good predictors of bowel preparation. This observation may help in improving the quality of bowel preparation and avoid hustle in colonoscopy room.
117
An unusual etiology of a left colon “tumor”
Rahul Deotale , Deepakkumar Gupta, Amey Sonavane, Aabha Nagral, Shankar Bhanushali
Correspondence- Rahul Deotale-rahuldeotale23@gmail.com
Department of Gastroenterology, Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Ameboma is a tumor-like mass involving whole thickness of the bowel wall and a rare manifestation of intestinal amoebiasis. We report an ameboma of left colon masquerading as an intra-abdominal mass.
A 72-year-old man presented with loose motions a month prior to presentation: 2-3 episodes/day, not associated with blood per rectum and lasted for 7 days, followed by fever with chills, breathlessness and pain in epigastric and left hypochondriac region. Physical examination of the abdomen revealed a 10 x 6 cm firm, tender, immobile lump in the left upper quadrant. Blood investigations showed Hb 9.4 g/dL, WBC of 29,450/μL, N 88%, platelet count of 551 x 103/μL. CECT of the abdomen showed circumferential wall thickening causing moderate luminal narrowing of colon (12-13 cm length) near splenic flexure with no leakage of contrast and no evidence of proximal dilatation, few subcentimetric sized enhancing lymph nodes in paracolic region. A possibility of neoplastic etiology was raised. Colonoscopy showed ulceroproliferative lumen occluding lesion suspicious of malignancy. Histopathology of the biopsy from the involved area revealed necrotic mass, fibrinous and granulation tissue. The patient was treated with left hemicolectomy with ileostomy and parenteral metronidazole. Colonic specimen showed necrotic mass, fibrinous and granulation tissue with multiple trophozoites of Entamoeba histolytica with small eccentric nucleus and cytoplasmic vacuole containing red blood cells. Patient is well on follow- up for 7 months.
Amebomas are most commonly found in cecum and ascending colon. They are usually solitary with variable size and may measure up to 15 cm in diameter. Men, between 20 and 60 years of age, are most commonly affected. The exact incidence of ameboma is unknown with only isolated case reports.
Conclusion “Ameboma” should be considered in the differential diagnosis of colonic tumors presenting with fever and diarrhea, especially in countries with high prevalence of amebiasis.
118
Correlation of fecal calprotectin level with disease activity in active idiopathic inflammatory bowel disease
Smitkumar Vaghasia , Sudeep Khanna, Milan Kumar Vaghasia *
Correspondence- Smitkumar Vaghasia-vaghasiasmit@gmail.com
Departments of Gastroenterology and *General Surgery, Indraprastha Apollo Hospital, Mathura Road, New Delhi 110 076, India
Introduction Inflammatory bowel disease (IBD) is caused by immune dysregulation of the digestive tract that results in chronic inflammation. Ulcerative colitis and Crohn’s disease are the two major forms of idiopathic IBD. Endoscopy (and histology) remains the gold standard method for detecting and assessing bowel inflammation. Nevertheless, it has the disadvantage of being invasive, time consuming and not well tolerated by patients. Within the last years various laboratory markers have been investigated in search to provide non-invasive, cheap and rapid methods able to help in assessment of IBD activity. The most widely used laboratory parameters of inflammation, such as ESR and CRP resulted not sufficiently specific or sensitive and poorly correlated with symptoms and disease activity index. On the other hand, a series of studies indicate fecal calprotectin as the most useful marker able to quantify bowel acute inflammation. We propose to undertake a study to find out the correlation of fecal calprotectin levels with clinical, endoscopic and histological indices currently in use to classify the severity of IBD.
Methods Total number of 60 patients with IBD were studied to find out correlation of fecal calprotectin levels with endoscopic index, clinical index, histological index currently in use to classify the severity of IBD.
Results Among total number of 60 patients of IBD 40 patients were of UC (57.5% patients were male) and 20 patients were of CD (65% patients were male).
Conclusions Fecal calprotectin levels correlate well with disease activity scores in ulcerative colitis and Crohn’s disease.
119
Misdiagnosed case of anal canal malignant melanoma: A case report
Nikhileswar Yandamuri , Ramesh Kumar B, Ramanna M
Correspondence- Nikhileswar Yandamuri-itsnikhil.rio@gmail.com
Department of Medical Gastroenterology, Osmania Medical College and General Hospital, 5-1-876, Turrebaz Khan Road, Troop Bazaar, Koti, Hyderabad 500 095, India
Introduction Anorectal malignant melanoma (ARMM) is an uncommon and aggressive disease. It accounts for only 0.4% to 1.6% of all melanomas and less than 1% of anal canal tumors. They tend to occur more often in women than men with peak incidence in the sixth and seventh decade. We report a much rarer scenario of a young male presenting with bleeding per rectum treated as hemorrhoids found to have anal melanoma on further evaluation.
Case report A 32-year-old male patient presented with blood in stools and anal mass of one month duration. DRE -mass protruding from anus. Colonoscopy revealed polypoidal lesion in the anal canal just above the dentate line suggestive of hemorrhoid for which he underwent hemorrhoidectomy. The specimen sent for HPE revealed nests of epitheloid and spindle like cells with brisk mitosis -10% of cells showing melanin pigmentation. IHC with HMB45 and S100 found to be positive diagnostic of ARMM. MRI revealed circumferential wall thickening in anal canal with no evidence of nodal spread (AJCC stage 1). He further underwent Wide local excision and under follow-up.
Discussion Anorectum is the third most common location of malignant melanoma after skin and retina. The common initial symptoms are bleeding PR, anal mass, tenesmus, change in the bowel habits. ARMM most often misdiagnosed as hemorrhoids, polyp or adenocarcinoma. Confirmed by IHC panels S-100, Melan A, HMB-45. It is staged as stage I (local disease), stage II (local disease with regional lymph nodes), stage III (with distant metastasis) by CT, MRI, PET. Surgical approaches include Wide local excision and abdomino perineal resection.
Conclusion Anorectal malignant melanoma though uncommon and described in elderly females, this case report suggests it can present in young males. Due to its polypoid appearance and lack of obvious pigmentation in majority of cases misdiagnosed as hemorrhoids/polyps. High index of suspicion is warranted in this innocuous looking lesion as it is an aggressive neoplasm with local invasion and distant metastasis.
Keywords Anorectal malignant melanoma, Misdiagnosed hemorrhoids, HMB45, S100.
120
Surgical technique to prevent redundancy after colon interposition for corrosive stricture of the esophagus
Vasur Ladumor , Praveen Sharma, Mukesh Pancholi, Rajan Jagad *
Correspondence- Vasur Ladumor-vasurladumor@gmail.com
Department of General Surgery, Government Medical Collage and New Civil Hospital, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India and *Synergy Hospital, Synergy Circle, Near Gokulmathura Apartment, Ayodhya Chowk, BRTS Stand, 150 Feet Ring Road, Rajkot 360 005, India
Background In 1911, Vuillet and Kelling independently described the anatomical and surgical bases for the use of the colon for esophageal replacement and currently retrosternal coloplasty is the gold standard for post corrosive esophageal replacement. An important complication, in particular in later follow-up, is redundancy of the interposed colon, seen more after retrosternal interposition. The objective of this study is to share our experience of colon interposition for corrosive stricture of the esophagus in 150 patients within duration of 09 years and use of two-point fixation technique in 25 patients to prevent redundancy of colon conduit.
Methods This was a retrospective study of colon interposition for corrosive stricture of esophagus in 150 patients from March 2011 to March 2020.
Results There were 112 female and 38 male (3:1) patients; the mean age was 30.6 years (ranges from 21 to 47 years); 130 patients had suicidal and 20 patients had accidental ingestion; mean hospital stay was 14.5 days (range 10 to 25 days) and mean operative duration was 4.5 hours (range 2.5 to 7 hours). In our study, out of 150 patients with 10 deaths and 01 patient lost in follow-up, more than 80% patients (n=114) had ‘good’ result, 09 patients had ‘fair’ and 01 patient had ‘poor’ result. After using two-point fixation technique in 25 patients, we did not encounter any subjective or objective (barium swallow) evidence of redundancy in any patients during follow-up period of 2.5 years.
Conclusion Colon redundancy is the most common late morbidity and second most common complication that required surgical correction with inherent morbidity and mortality of revision surgeries. Our two-point fixation technique is refinement of already performed and tried fixation techniques to prevent redundancy of colon conduit considering kinetics, anatomical alignment and pathology .
Keywords Redundancy, Colon interposition, Corrosive stricture, Two-point fixation technique
121
Uncommon presentation of a common disease
Ramya Mamidipalli , Arun R S, Prashanth Gandhi
Correspondence- Ramya Mamidipalli-RAMYA.MAMIDIPALLI27@GMAIL.COM
Department of Gastroenterology and Liver Diseases, Madras medical mission Hospital, 4A, Dr, CLRI Staff Quarters, Mogappair, Chennai 600 037, India
Introduction Enteric fever is a systemic infection caused by gram negative bacillus salmonella typhi or paratyphi. It’s a feco-orally transmissible disease endemic in southeast Asia. The most serious complications are intestinal ulceration, bleeding and perforation seen in 3rd week. We report a rare case of typhoid fever with atypical distribution of ulcers on colonoscopy.
Case report A 52-year-old man presented to us with high grade fever and loose stools since 10 days. On admission he was febrile and had relative bradycardia. Abdominal examination revealed mild periumbilical tenderness. Routine blood investigations showed a leukocytosis (11,900 cells/cumm) with lymphopenia (12.5%), elevated alanine transaminase (79 IU/L) and C-reactive protein (62.5 mg/L). Colonoscopy revealed variable sized ulcers with punched out margins throughout the colon including rectum and an ulcer with everted erythematous margins noted in terminal ileum extending up to ileocecal valve raising the possibility of Crohn’s disease or intestinal tuberculosis. TB PCR was negative. Histological examination revealed features of active colitis with cryptitis and crypt abscess suggestive of infective etiology. Blood and stool cultures revealed growth of Salmonella typhi. He became asymptomatic after treatment with IV ceftriaxone 2 grams for 10 days and Tab. azithromycin 1 gram for a week.
Discussion The classical colonoscopic findings in Typhoid are multiple round and oval punched-out ulcers along the long axis of bowel with elevated margins. The most common site for typhoid ulcers is the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%) with sparing of left colon. Our patient had involvement of left colon along with rectum.
Conclusion This case highlights the importance of considering Typhoid fever as a differential for diffuse colonic ulcers.
Keywords Typhoid fever, Colonic ulcers, Rectum
122
Non-invasive assessment of cardiovascular risk using carotid intima-media thickness in patients with inflammatory bowel disease: Does non-alcoholic fatty liver disease add on to the risk?
Anju Krishna , Krishnadas Devadas, Nidhin R, Sandesh K
Correspondence- Nidhin R-nidhinraveendranputhoor@gmail.com
Department of Gastroenterology, Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction We compared the carotid intima-media thickness test (CIMT) of patients with IBD and controls without IBD to know the association between subclinical atherosclerosis in IBD and the cardiovascular risk. We also looked at whether NAFLD is an important factor affecting CIMT in IBD.
Methods Descriptive study on 80 patients with IBD and 80 subjects without IBD conducted in a tertiary care hospital. Subjects aged more than 55-years, obese individuals, patients already diagnosed with cardio/cerebrovascular disease and those with other chronic inflammatory conditions were excluded. CIMT was measured using B mode Doppler imaging. Presence of fatty liver and shear wave elastography of the liver were assessed. The quantitative data were compared using students t test and the qualitative data by Chi-square test. Pearson and Spearman correlation was done to find out the factors correlating with CIMT.
Results Age, sex distribution and traditional cardiovascular risks (hypertension, diabetes and dyslipidemia) were comparable in both groups. The CIMT was higher in patients with IBD as compared to controls (0.532±0.091 vs. 0.476±0.038, p=000). On analyzing the factors affecting CIMT in patients with IBD, those with NAFLD as an extra intestinal manifestation had increased CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP and ultrasound grades of fatty liver had positive correlations with CIMT. There was no change in CIMT with disease type (UC/CD), extent of disease, disease activity or severity of disease. Multivariate regression analysis showed that age and ultrasound grading of fatty liver (R2=0.576, p=000) were independent predictors of CIMT.
Conclusion We found that CIMT was increased in patients with IBD as compared to controls. Age and NAFLD were independently associated with increased CIMT in IBD. Patients with IBD especially those with NAFLD may require enhanced monitoring for cardiovascular events.
Keywords Inflammatory bowel disease; Ulcerative colitis; Crohn’s disease; Carotid intima media
123
Lower gastrointestinal bleed: Experience from a tertiary care hospital in coastal Odisha
Reshu Khandelwal , Haribhakti Seba Das, Chittaranjan Panda, Rakesh Kumar Barik, Subhasis Pradhan, Saroj Kanta Sahu, Pankaj Bharali, Mrinal Gogoi, Prajna Anirvan
Correspondence- Haribhakti Seba Das-reshu_rocks@yahoo.co.in
Department of Gastroenterology, Sriram Chandra Bhanj Medical College and Hospital, Cuttack 753 007, India
Introduction Lower gastrointestinal bleeding (LGIB) is a frequently encountered medical emergency with marked geographic variation in the frequency of its different etiologies. Colonoscopy is considered as first-line diagnostic procedure for LGIB. We analyzed the etiological spectrum of LGIB in coastal Odisha by colonoscopic examination.
Methods Retrospective analysis of patients with overt LGIB presenting to Gastroenterology Department of SCB Medical College, Odisha from August 2017 to August 2020 and undergoing colonoscopy, was done. The data, including patient’s age, sex, etiology of bleed and treatment given was recorded.
Results During the study period 1109 patients who had presented with LGIB, underwent colonoscopy. Of these, colonic source of bleed could be identified in 1040 (93.77%) patients. Patients were sub-grouped according to their ages into paediatric (<18 yrs, n=79 [7.59%]), adult (18-60 yrs, n=767 [73.75%]) and elderly ([>60 yrs], n=194 [,18.65%]). Male preponderance was noted across all age groups and overall M:F ratio was 1.4:1. The common causes of LGIB in paediatric group were solitary pedunculated polyps 38 (48.10%), inflammatory bowel disease 15 (18.98%) and colonic TB 7 (8.86%). Other etiologies were hemorrhoids, infective ulcers, sessile polyps, polyposis syndromes, SRUS and colonic malignancy. However, in adults and elderly, colorectal malignancy was the commonest etiology found in 224 (29.20%) and 82 (42.2%) patients respectively. Other common etiologies in the 2 groups were IBD seen in 154 (20.07%) and 23 (11.85%) patients, hemorrhoids in 150 (19.55%) and 42 (21.64%) patients and colonic TB in 32 (4.17%) and 5 (2.57%) patients respectively. Etiologies like infective/non-specific ulcers, polyps and polyposis syndromes, rectal varices, diverticulosis, rectal prolapse, radiation proctitis, diversion colitis, SRUS, angioectasia and benign strictures constituted less than 1/4th of the total cases.
Conclusion Although causes of LGIB in pediatric population in our study match the data from the West, common causes seen in adults and elderly, including colorectal malignancies, IBD and hemorrhoids, are in stark contrast with causes, namely diverticulosis and angioectasia, that are mentioned in Western literature.
Keywords Lower gastrointestinal bleeding
124
Efficacy of fecal microbiota transplantation for induction of remission in patients with active ulcerative colitis: Results from a series of 192 patients
Arshdeep Singh , Vandana Midha, Ramit Mahajan, Dharmatma Singh, Kirandeep Kaur, Ajit Sood
Correspondence- Ajit Sood-ajitsood10@gmail.com
Departments of Gastroenterology,*Medicine, and **Pharmacology, Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India
Background Fecal microbiota transplantation (FMT) targeting gut microbiome dysbiosis is an emerging therapy for ulcerative colitis (UC). We report our experience with FMT used for induction of remission in 192 patients with active UC.
Methods This is a single-center retrospective analysis of patients with active UC (total Mayo score≥3 and Mayo endoscopic sub-score of>1) treated with FMT between September 2015 and December 2019 at Dayanand Medical College and Hospital, India. Fecal samples from random unrelated donors were administered through colonoscopy at weeks 0, 2, 6, 10, 14, 18, and 22. The primary outcome was achievement of steroid-free clinical remission (Mayo score ≤2, with each sub-score ≤1) at week 24. Secondary end points were clinical response (reduction of Mayo score ≥30% and ≥3 points compared to baseline), and endoscopic remission (Mayo score 0 or 1).
Results During the study period, 192 adult patients (mean age 34.54±11.68 years; 123 [64.06%] males) with active UC (mean mayo score 7.46±2.22) were treated with FMT. The main indications for FMT were steroid dependent UC (n=121 [63.02%]) followed by chronic active and acute severe UC (n=39 [20.31%] and 32 [16.66%] respectively). Majority of the patients had moderately-severe disease. Ninety-six (50%) patients completed 7 FMT sessions as per protocol. On intention to treat analysis, steroid-free clinical remission was achieved in 94 (48.95%) patients (mean FMT sessions needed to induce remission 4.08±1.69), whereas clinical response and endoscopic remission were achieved in 135 (70.31%) and 95 (49.47%) patients, respectively (Table 1). The proportion of patients in remission increased with number of FMT sessions (Fig. 1). Twenty-six (13.54%) patients dropped out (non-response, n=10; persistent worsening of diarrhea, n=5; bleeding per rectum, n=4; perianal pain, n=4 and fever, n=3). No serious adverse events were noted.
Conclusions Multisession FMT via colonoscopic route is a promising therapeutic option for patients with active UC to induce clinical remission.
Keywords: Ulcerative colitis, FMT, Fecal microbiota transplantation
125
Expression of NDRG4 in neurons of myenteric plexus of colonic tissue of colorectal carcinoma patients
Esha Singh
Correspondence- Esha Singh-esha.singh.rmch@gmail.com
Department of Anatomy, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Colorectal cancer (CRC), the third major cause of mortality among various cancer types in United States, has been increasing in developing countries due to changing lifestyle and dietary habits. Colorectal cancer is largely asymptomatic until alarming features develop to advanced stages. The implementation of the screening program is very much essential to reduce cancer incidence and mortality rates. N- Myc downstream-regulated gene 4 (NDRG4) is a novel candidate tumor suppressor and related to carcinogenesis.
Aim To study the NDRG4 protein expression in neurons of myenteric plexus of colorectal tissues.
Methods Samples collected from 22 patients undergoing surgery for colorectal adenocarcinoma in department of gastrointestinal surgery and 8 normal colon tissues from the department of forensic medicine, All India Institute of Medical Sciences, New Delhi, after obtaining ethical clearance. Tumor grading determined by pathologist and tissues were processed. Colonic tissues from the cancer site and normal specimens processed for paraffin blocks and 3μm thick sections used for H&E and immunohistochemistry (antibody used anti-NDRG4 antibody).
Results H&E stained sections showed infiltration of tumor cells in submucosa, inner circular muscle and in vicinity of myenteric plexus. Increase in the number of inflammatory cells in myenteric ganglia appeared with increasing grades of colorectal adenocarcinoma. Immunohistochemistry results showed the decreasing pattern of expression of anti-NDRG4 antibody in neurons with increasing grades of colorectal adenocarcinoma as compared to normal human colonic tissue.
Conclusion These results proved that NDRG4 could be a potential tumor suppressor and prognostic marker for colorectal cancer.
Acknowledgement The work reported is part of postgraduate dissertation in department of Anatomy, AIIMS, New Delhi
Conflict of interest No
Keywords Colorectal carcinoma, NDRG4, Neurons
126
Early fecal microbiota transplantation after donor stool defecation predicts response for patients with active ulcerative colitis
Arshdeep Singh , Vandana Midha * , Ramit Mahajan, Dharmatma Singh, Kirandeep Kaur ** , Ajit Sood
Correspondence- Ajit Sood-ajitsood10@gmail.com
Departments of Gastroenterology,*Medicine, and **Pharmacology, Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India
Background Fecal microbiota transplantation (FMT) targeting gut microbiome dysbiosis is an emerging therapy for ulcerative colitis (UC). FMT infusions prepared from fresh or frozen (80 degree C) stool have demonstrated comparable efficacy in recurrent Clostridium difficile infection (rCDI). There is however no consensus on protocols for FMT in UC.
Methods This is a single-center retrospective analysis of patients with active UC (total Mayo score ≥3 and Mayo endoscopic sub-score of >1) treated with FMT between January 2017 and December 2019 at Dayanand Medical College and Hospital, India. Fresh fecal samples from unrelated voluntary donors were administered through colonoscopy at weeks 0, 2, 6, 10, 14, 18, and 22. Time interval between donor stool defecation and FMT procedure (t) was recorded for each FMT session. Impact of (t) on achievement of steroid-free clinical remission (Mayo score ≤2, with each sub-score ≤1) and clinical response (Mayo score declined by ≥3) was evaluated.
Results During the study period, 123 adult patients (mean age 33.74±11.96 years; 77 [62.6%] males) with active UC (mean mayo score 7.17±2.03) were treated with FMT. Mean (t) was 2.29±0.75 hours (median 2.2 hours). With increase in (t), clinical remission and response rates decreased (Fig.1). Sixty-five (52.84%) patients achieved clinical remission. Patients achieving clinical remission had shorter interval between donor stool defecation and FMT procedure (2.18±0.76 hours) as compared to patients not achieving clinical remission (2.50±0.74 hours; p=0.02). On comparing patients who received FMT within 2 hours (n=41) of donor stool defecation with those who received after an interval of ≥2 hours (n=82), a greater proportion of patients were in clinical remission in the former group (63.41% vs. 47.56%; p=0.09).
Conclusions Early FMT after donor stool defecation favorably impacts the clinical remission rates in patients with active UC. More data evaluating the ‘ideal window period’ after donor stool defecation is needed.
Keywords Ulcerative colitis, Timing of FMT, Fecal microbiota transplantation
127
Expression of nerve growth factor (NGF) in myenteric ganglia of colorectal carcinoma tissues in human
Asha Gupta
Correspondence- Asha Gupta-gasha5207@gmail.com
Department of Anatomy, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Colorectal carcinoma (CRC) is one of the most common carcinoma of gastrointestinal tract in the. CRC develops from the epithelium of the colon or rectum and are mainly adenocarcinoma (≥ 90%). Nerve growth factor (NGF) is an essential neurotropic factor for the survival and maintenance of neurons. There is an important role for NGF in maintenance of gut integrity. The role of NGF in cancer development and progression has been reported in gastric mucosa and pancreatic cancers but in colorectal cancer is unknown.
Aim To study expression of nerve growth factor (NGF) in myenteric ganglia of the colorectal carcinoma in human.
Objectives To evaluate the expression of NGF in colorectal carcinoma tissue by haematoxylin and Eosin (H & E) and immunohistochemistry by anti-NGF antibody.
Methods Samples collected from 22 patients undergoing surgery for colorectal adenocarcinoma in department of gastrointestinal surgery, All India Institute of Medical Sciences, New Delhi. Tumor grading determined by pathologist and tissues were processed. Sections processed for paraffin blocks and 3 μm thick sections used for H&E and immunohistochemistry (antibody used anti-NGF antibody: neuronal markar).
Results H&E stained sections showed myenteric plexus containing myenteric ganglia (MG) located between the inner circular muscle (CM) and outer longitudinal muscle (LM) layers of the muscularis externa in all grades of adenocarcinoma tissue sections and invasion of tumor cells and increase in the number of inflammatory cells in the myenteric ganglion appeared to increase with different grades of colorectal adenocarcinoma. Immunohistochemistry results showed the increase expression of anti-NGF antibody with in poorly differentiated adenocarcinoma.
Conclusion It is concluded that loss of neuron and neurodegeneration takes place in colorectal adenocarcinoma which is of supreme importance in understanding the problems of CRC patients who suffer from many GI symptoms. Expression of NGF in myenteric ganglion in different grades of adenocarcinoma.
Keywords NGF CRC
Liver
128
Hepatitis C treatment in the era of directly acting antivirals- An encouraging scenario!
Mayank Jain
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre, 283-A, Gumasta Nagar, Scheme 71, Indore 452 009, India
Introduction The availability of directly acting antivirals (DAA) has revolutionised the management of hepatitis C in developing countries like India.
Aim of the study To determine the spectrum of hepatitis C related liver disease and response to treatment using generic DAAs.
Methods The study is a retrospective analysis of prospectively collected data from a cohort of adult (>18 years) patients with hepatitis C infection. Patients with hepatocellular carcinoma, co infections with hepatitis B, HIV and those with incomplete data were excluded. The data analyzed included the severity of liver disease, treatment offered and response rates.
Results A total of 106 patients (84 males, median age 55 [22-80 years]) formed the study cohort. Eleven cases (10.4%) had received prior treatment with interferon based regimens but did not attain SVR. Twelve patients (11.3%) were on maintenance hemodialysis. Eight cases (7.5%) were patients with thalassemia major on regular blood transfusions. Genotype 3 (53.7%) and 1 (37.7%) were commonly noted. Sustained virological response was documented in 101 cases (95.3%)
Conclusion DAA drugs are highly effective in management of hepatitis C infection across a wide spectrum of clinical presentations.
129
Acute HBV or chronic HBV with acute flare: Distinguishing clinical, biochemical, immunonological and virological parameters
Ravi Kant Thakur , Sunit Kumar Shukla, Vinod Kumar Dixit, Dawesh Prakash Yadav, Tuhin Mitra, Piyush Thakur
Correspondence- Sunit Kumar Shukla-sunitshuklabhu@gmail.com
Introduction The availability of directly acting antivirals (DAA) has revolutionised the management of hepatitis C in developing countries like India.
Aim of the study To determine the spectrum of hepatitis C related liver disease and response to treatment using generic DAAs.
Methods The study is a retrospective analysis of prospectively collected data from a cohort of adult (>18 years) patients with hepatitis C infection. Patients with hepatocellular carcinoma, co infections with hepatitis B, HIV and those with incomplete data were excluded. The data analyzed included the severity of liver disease, treatment offered and response rates.
Results A total of 106 patients (84 males, median age 55 [22-80 years]) formed the study cohort. Eleven cases (10.4%) had received prior treatment with interferon based regimens but did not attain SVR. Twelve patients (11.3%) were on maintenance hemodialysis. Eight cases (7.5%) were patients with thalassemia major on regular blood transfusions. Genotype 3 (53.7%) and 1 (37.7%) were commonly noted. Sustained virological response was documented in 101 cases (95.3%)
Conclusion DAA drugs are highly effective in management of hepatitis C infection across a wide spectrum of clinical presentations.
130
Evaluation of pro-inflammatory markers IL-6 and TNF-a and their correlation with non-alcoholic fatty liver disease
Pratap Singh , Jayanti Khura
Correspondence- Pratap Singh-drpratapsingh@yahoo.co.in
Department of Medicine and Gastroenterplogy, Ram Manohar Lohia Hospital, Type III, President's Estate, New Delhi 110 001, India,
Background Non-alcoholic fatty liver disease (NAFLD) is a condition in which excess fat accumulates in the liver of a patient with no history of alcohol abuse or other causes for secondary hepatic steatosis. The pathogenesis of NAFLD and non-alcoholic steatohepatitis (NASH) has not been fully elucidated. NAFLD consists of a complex spectrum of diseases, ranging from asymptomatic steatosis with possible aminotransferase alterations to NASH, cirrhosis, and also hepatocellular carcinoma. Pro inflammatory cytokines like IL-1, IL-6 and TNF-α play a major role in the pathogenesis of NAFLD. These cytokines also play a crucial role in the development of insulin resistance, which is a key factor in the pathogenesis of NAFLD. There is limited data on the association of IL-6 and TNF-α with NAFLD from India. Hence, we aim to assess the correlation of IL-6 and TNF-α with NAFLD.
Methods It was a cross sectional observational study which was conducted on 40 cases of NAFLD and 40 healthy controls. All relevant investigations and serum levels of IL-6 and TNF-α were measured. Statistical analysis was done using Pearson Chi-square/fisher exact test, student t-test (un-paired). Pearson correlation test was used to see the relationship between the variables.
Result The serum levels of IL-6 and TNF-α correlated significantly with NAFLD with a p-value of <0.001. The serum levels of IL-6 showed a significant correlation with the severity of NAFLD (p<0.001), but the same was not seen with TNF-α.
Conclusion Our study showed significant correlation of TNF-α and IL-6 with NAFLD, which suggested a proven role of these pro-inflammatory markers in the pathogenesis of this disease as shown in past studies. In future target-based therapy is new field of research.
131
Acute liver failure due to viral hepatitis E and thyroid storm: A case report
Vivek Sharma , Amit Mathur, Kandarp Saxena, Arun Singh
Correspondence- Vivek Sharma-vivekmohansharma@gmail.com
Department of Gastroenterology, National Institute of Medical Science and Research (NIMS), NH-11C, Delhi - Jaipur Expy, Shobha Nagar, Jaipur 303 121, India
Introduction Thyroid storm and acute liver failure are both independently associated with high mortality. Hepatic dysfunction in a patient with thyroid storm presents a diagnostic and therapeutic challenge.
Case A young male presented with symptoms suggestive of acute liver failure. Examination revealed bilaterally enlarged thyroid gland. Initial laboratory investigations showed suppressed thyroid stimulating hormone (0.0009 μIU/mL), high triiodothyronine (1.7 ng/mL), tetraiodothyronine (24 μg/dL), and positive anti–thyroid peroxidase. Liver function tests revealed total bilirubin (15.6 mg/dL), direct bilirubin (14.24 mg/dL), AST 1327 U/L, ALT 1186 U/L, ALP 1023 U/L, and serum ammonia (> 400 μmol/L). Furthermore, the patient was found to be IgM anti-hepatitis E virus (HEV) positive. Other viral, metabolic and autoimmune profile was negative. USG abdomen was normal. Working diagnosis of acute liver failure due to HEV and thyroid storm was made. In view of hepatic dysfunction methimazole and propylthiouracil were avoided and the patient was stabilized with Lugol’s iodine and lithium, after which the patient underwent total thyroidectomy. Post-surgery patient had significant clinical improvement and he was put on oral thyroxine. Histopathology of the removed thyroid gland showed congested blood vessels with colloid filled spaces suggestive of adenomatous goitre. He achieved normal liver function on subsequent follow ups.
Conclusion Though uncommon, uncontrolled thyrotoxicosis can result in severe hepatic dysfunction. Patient’s remarkable recovery following total thyroidectomy indicates that thyroid storm was the probable cause of acute liver failure, although HEV leading to acute liver failure could not be completely ruled out. Early recognition of thyroid storm and total thyroidectomy may have played a major role in clinical recovery of liver failure.
132
Prevalence of bacterial infection at admission in patients with acute on chronic liver failure: A single centre experience
Chitta Ranjan Khatua, Ansuman Mishra, Putul Bara, Kamalakhya Samantaraya, Ajaya Kumar Biswal, Saroj Kanta Sahu, Rina Mohanty, Shivaram Prasad Singh
Correspondence- Chitta Ranjan Khatua-chittamedicine@yahoo.co.in
Department of Medicine, MKCG Medical College and Hospital, Medical College Campus, NH59, Brahmapur, Odisha 760 004, India, Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Introduction Acute on chronic liver failure (ACLF) is a life-threatening condition in patients of chronic liver disease (CLD). However, the prevalence and impact of bacterial infection in ACLF patients has not been assessed in this region of Asia. Hence, we performed a prospective study to evaluate the spectrum of ACLF patients and the impact of bacterial infection on outcome.
Method This study was conducted in consecutive ACLF patients (as per EASL-CLIF consortium criteria), hospitalized in Gastroenterology Department, SCB Medical College, India between October 2016 and December 2018. Demographic, clinical, laboratory and microbiological parameters were recorded, and survival was compared between patients with and without infection during hospitalization, and also at 28 days and 90 days.
Results Two hundred and thirty-two (40.3%) out of 576 CLD patients had ACLF, of which 67.2% (n=126) had infection. 50.9% (n=118) had urinary tract infection (UTI), 15.5% (n=36) had spontaneous bacterial peritonitis (SBP), 13.8% (n=32) had respiratory infection, and 6% (n=4) had infection of skin and soft tissue. 20.7% (n=48) patients had more than one type of infection. 55.8% (n=67) of grade 1 ACLF patients, 77.6% (n=52) of grade 2 ACLF patients, and 82.2% (n=37); (p=0.001) of grade 3 ACLF patients had infection. Patients with infection had higher serum creatinine, serum urea, and higher MELD UNOS, MELD Na+, CTP score (p<0.01), and decreased serum albumin level (p=0.024). Further, ACLF patients with infection had a trend of prolonged hospitalization, increased hospital death, and decreased 28 days and 90 days survival.
Conclusion In our institution, over two thirds of ACLF patients had infection during hospitalization and higher grade ACLF patients were increasingly associated with infection. UTI was the commonest infection and about one fifth of patients had multiple infections. There was a trend towards decreased survival of ACLF patients with bacterial infection.
133
A case report- A rare case of carbimazole induced liver injury
Nirdesh Chauhan
Correspondence- Nirdesh Chauhan-drnirdesh@live.com
Department of Gastroenterology, Kurnool Medical College and Government General Hospital, Kurnool Medical College, Budhwarpet Road, Budhawarapeta, Kurnool 518 002, India
The anti-thyroid drugs methimazole (MMZ) and its prodrug – carbimazole (CBZ) and propylthiouracil (PTU) are often used as first-line treatment for hyperthyroidism. Because of a higher risk of causing severe liver injury by PTU, as highlighted in the U S Food and Drug Administration's boxed warning, CBZ is more preferred except during the first trimester of pregnancy (can cause birth defects) and in patients with an adverse reaction to methimazole.
The following case report of 60-year-old female, known case of hyperthyroidism, admitted for urgent evaluation of new-onset jaundice, pruritus, nausea, fatigue, and clay-colored stool for 15 days. As per the patient history and investigations, a probable diagnosis of a cholestatic pattern of drug-induced liver injury was made. CBZ was stopped and with the advice of the endocrinology department, lithium carbonate and propranolol were started.
Clinicians should be aware that hepatotoxicity though rare, can occur with CBZ and should swiftly consider an alternative treatment strategy. Patients who take anti-thyroid drugs should be informed about the risk of liver injury and be advised to avoid other possible susceptibility factors such as alcohol consumption, which might hasten liver damage induced by their anti-thyroid medications.
134
Psoas muscle index: A simple and reliable method of sarcopenia assessment on CT scan in chronic liver disease
Gajanan Rodge , Usha Goenka, Rachit Agarwal, Shivaraj Afzalpurkar, Bhavik Shah, Surabhi Jajodia, Mahesh Goenka
Correspondence- Gajanan Rodge-grodge3@gmail.com
Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata 700 054, India
Background L3-Skeletal Muscle Index (SMI) is a CT based conventional method for sarcopenia assessment. However, recently psoas muscle parameters have been proposed as a simple and quick method without need of a special software. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle quantification on CT scan.
Methods One hundred and fifty patients were assessed for the psoas muscle on CT scan and psoas muscle index (PMI) was calculated: PMI = total psoas muscle area (mm)/(height) 2 (m). The cut off values for diagnosis of sarcopenia were derived from the local control group (n=75) who did not have CLD/other causes of sarcopenia. The case group included consecutive CLD patients (n=75) who underwent CT scan of abdomen. Hand Grip (HG) dynamometer was used to assess the HG strength.
Results Sarcopenia assessed by PMI was seen in 36% (n=27) of CLD patients. Ascites, hepatic encephalopathy (HE) and gastrointestinal bleed was seen in 48%, 18.7% and 24% respectively, among the cases. The association of sarcopenia was statistically significant with ascites and HE (p value < 0.05). Sarcopenia was significantly higher in patients with CHILD C. HG weakness was seen in 41.3% (n=31) and mid-arm muscle circumference was low in 25.3% (n=19) of CLD patients. Fifty-three out of 75 patients completed the follow-up period of 1 year. Out of patients with sarcopenia, 77.8% (n=7) succumbed to liver related illness, while 22.2% (n=2) without sarcopenia expired during follow-up. The association of 1-year mortality and sarcopenia was statistically significant (p value = 0.01). The Kappa measure of agreement between HG and sarcopenia assessment was 0.608 (good strength of agreement).
Conclusions In conclusion, PMI sarcopenia proved to be a reliable predictor of mortality and HG dynamometer seems to be a good alternative for sarcopenia assessment.
135
Comparison of efficacy of rifaximin and norfloxacin in prevention of spontaneous bacterial peritonitis
Mukesh Kumar , Ankur Jain
Correspondence- Mukesh Kumar-mukesh98153@gmail.com
Department of Medical Gastroenterology, Sardar Vallabhbhai Patel Institute of Medical Sciences and Research (SVPIMSR), Riverfront Road, Ellisbridge, Ahmedabad 3800 061, India
Background Norfloxacin is the most commonly used agent for the prophylaxis against spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. Rifaximin, another broad-spectrum antibiotic, is used for the treatment of traveller’s diarrhea and hepatic encephalopathy.
Objective We aimed to test the efficacy of rifaximin versus norfloxacin for prevention of SBP in patients with hepatitis C virus (HCV)-related liver cirrhosis.
Methods One hundred patients with HCV-related liver cirrhosis and ascites were included in study and divided into two groups of matching age, sex and Child–Pugh class. Group I patients were given norfloxacin 400 mg/day and group II patients were given total dose of rifaximin 1200 mg/day in three divided doses. The follow-up time was one year.
Results Patients on rifaximin developed fewer episodes of SBP than those on norfloxacin (8% vs. 16% respectively) although it was statistically insignificant (p=0.265). Also, the duration before developing a new attack of SBP was longer in patients treated with rifaximin as compared to those taking norfloxacin (9.0 vs. 5.5 months, respectively). Additionally, rifaximin significantly reduced the rate of new compared to past episodes of SBP by 24% (p while the rate reduction with norfloxacin was only by 18% and not statistically significant (p= 0.45). Overall survival was equal in both groups.
Conclusion Rifaximin is – at least – as good as norfloxacin. It seems to be an appropriate alternative for long-term primary and secondary prophylaxis of SBP in cirrhotic patients with ascites.
136
Daclatasvir and half-dose sofosbuvir is an effective and pangenotypic treatment for hepatitis C virus infection in patients with estimated glomerular filtration rate
Harshita Katiyar , Amit Goel, Dharmendra Singh Bhadauria, Anupma Kaul, Prachi Tiwari, Abhai Verma, Narayan Prasad, Amit Gupta, Praveer Rai
Correspondence- Amit Goel-agoel.ag@gmail.com
Departments of Gastroenterology, and Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Aim Sofosbuvir, the backbone of hepatitis C virus (HCV) treatment, use is controversial in patients with estimated glomerular filtration rate (eGFR) <30 mL/min. We report here off label treatment with daclatasvir and half daily dose of sofosbuvir in patients with eGFR <30 mL/min on real life experience with increase in sample size and data in continuation with previous data reported.
Methods Adult patient with eGFR <30 mL/min and detectable HCV RNA were screened. We included those who (i) started treatment with direct acting antiviral drugs (DAAs) between July 2013 and January 2020 (ii) had taken DAAs at least for four weeks and (iii) had reached one of the end points either during HCV treatment or up to 12 weeks after stopping the treatment (death; lost to follow-up; quantitative HCV RNA assay at 12 weeks after stopping the treatment, SVR12; relapse). All the patients, regardless of HCV genotypes, were treated with daily doses of daclatasvir 60 mg and sofosbuvir 200 mg. Patients with or without cirrhosis were treated for 24 weeks or 12 weeks respectively.
Results Eighty-seven participants (age mean±SD 44 ± 12.9 years; male 63 [72%]) were included in final analysis. Two had compensated cirrhosis. The genotypes were tested for 67 (77%) participants. The HCV genotype 1, 3, and 4 were identified in 31 (36%), 34 (39%), and 2 (2%) respectively. Serum HCV RNA (log10) was 5.73±1.24 IU/mL. Seventy-seven (89%) achieved SVR12, 6 (7%) lost to follow-up, 2 (2%) died during treatment and 2 (2%) relapsed.
Conclusion Daclatasvir and half-dose of sofosbuvir is effective against all the HCV genotypes in ESRD patients.
137
A clinical study of spontaneous bacterial peritonitis in cirrhosis of liver
Arnab Dey , Krishnasamy Narayanasamy
Correspondence- Arnab Dey-arnie303@gmail.com
Department of Hepatology, Institute of Hepatobiliary Sciences, Madras Medical College, Chennai 600 003, India
Introduction Spontaneous bacterial peritonitis (SBP) is one of leading cause of death in cirrhosis. The studies have shown that causative bacteriological agent and empirical therapy guidelines are different in different parts of world and even different in same region on different time periods. This study was undertaken with an idea to evaluate bacteriological profile and preciseness of preformed guidelines for treatment, monitoring of therapy and prognostic factors in SBP in patients catering to Madras Medical College, Chennai.
Method A hospital based prospective observational study between June 2019 to April 2020 conducted in the Department of Hepatology, MMC Chennai, Tamil Nadu.
Result Total 50 patients of age group >12 years, diagnosed as SBP. Cirrhosis and SBP was seen predominantly in older age group, 72% of patients >40 yrs. Predominantly in male population i.e. 34 cases (68%) and only 16 (32%) females. Majority (72%) alcoholics. Sixty-two percent had fever and 58% had abdominal pain at the time of presentation, while 40% were brought with h/o altered sensorium. Mean ascitic fluid PMN cell count at the time of diagnosis was 492 in patients who survived, while it was 1721 in patients who died. An ascitic fluid PMN count of >450 at 48 hours predicted poor prognosis with sensitivity of 87.5% and 94.15%. Achievement of ascitic fluid PMN cell count of < 450/or >28% reduction at 48 hours of treatment was associated with good outcome. Ascitic fluid culture did not show any growth in 56% of cases while 38% showed E. coli. Mean serum creatinine levels was 1.5 in patients who expired.
Conclusions Increased TLC, low serum albumin, increased creatinine levels and low ascitic fluid protein are associated with poor prognosis. Once SBP is diagnosed, serial ascitic fluid cell count is helpful in predicting prognosis and should be used to monitor treatment.
138
Study of cytopenias and neutrophil lymphocyte ratio in rodenticidal hepatotoxicity patients
C E Eapen, Ajith C Kuriakose , B Vijayalekshmi, Lalji Patel, Uday Zachariah, Sukesh Nair
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Department of Gastroenterology, Hepatology, Transfusion Medicine and Immunohematology, and Wellcome Trust Laboratory, Christian Medical College, Vellore 632 004, India
Introduction As clinical significance of cytopenias in rodenticidal hepatotoxicity patients is unclear, we aimed to analyse incidence of cytopenias, any complications due to cytopenias and prognostic role of cytopenias and neutrophil lymphocyte ratio (NLR) in these patients.
Methods We retrospectively analyzed prospectively collected data on rodenticidal hepatotoxicity patients managed in our department from December 2017 to June 2020. Adverse outcome of hospital stay was defined as death/discharged against medical advice (DAMA). We looked for complications due to cytopenias (bacteremia in leucopenic patients, bleeding in thrombocytopenic patients).
Results Of 80 rodenticidal hepatotoxicity patients (age: 24 [7-45] years, median [range], female: male – 1.2:1, MELD score: 31.5 14-49]) studied, 15 patients (19%) had adverse outcome (died:13, DAMA:2). 10 patients had bacteremia. During hospital stay, 54 patients (67%) had leucopenia (WBC count 4000-2000/mm3 in 32 patients, WBC count <2000/mm3 in 22 patients) and 56 patients (70%) had thrombocytopenia (platelet count 1,50,000-50,000/mm3 in 40 patients, platelet count <50,000/mm3 in 16 patients). Time from alleged ingestion of rodenticide to maximum cytopenia was 5 (1-9) days for leucopenia, 7 (2-16) days for thrombocytopenia and to onset of hepatotoxicity was 4.5 (2-8) days. Time to onset of hepatotoxicity correlated with time to maximum leucopenia (correlation coefficient =0.485, p<0.01). Leucopenia normalized by 7 (4-10) days and thrombocytopenia by 10 (6-26) days. Presence of leucopenia did not affect occurrence of bacteremia or outcome. However, 44% of patients with severe thrombocytopenia had adverse outcome (p=0.02). One patient (platelet count-43,000) had minor bleed (from erosive gastritis). NLR > 3 was seen in 40 (50%) patients, 27.5% of patients with NLR >3 had adverse outcome (p =0.04).
Conclusion Cytopenias were common in rodenticidal hepatotoxicity patients and maximum leucopenia correlated with onset of hepatotoxicity. Severe thrombocytopenia and NLR > 3 were associated with adverse outcome, however, clinically significant bleeding was uncommon.
139
Low volume plasma exchange and low dose steroid to treat idiosyncratic drug induced liver failure - Our experience in 34 patients
Kunwar Ashish Singh , Santosh Kumar, Uday Zachariah, Vinoi David, Dolly Daniels, Subramani Kandasamy, Kishore Pichamuthu, Ashish Goel, C E Eapen
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Department of Hepatology, Christian Medical College, Vellore 632 004, India
Introduction Acute liver failure (ALF) and acute on chronic liver failure (ACLF) due to idiosyncratic drug-induced liver injury (I-DILI) carry high short-term mortality without liver transplantation. We present our experience of plasma exchange to treat I-DILI patients.
Methods We retrospectively analyzed prospectively collected data on I-DILI patients treated with low volume plasma exchange (PLEX) and low dose steroid in our department from October 2016 to May 2020. Patients who met listing criteria were advised urgent liver transplantation, those not opting for transplantation were treated with PLEX. The disease severity parameters were measured at admission. Primary outcome was survival at 30 days from the date of admission.
Results Thirty-four I-DILI patients (17 males, age 35.8 (15-36) years, median (range) underwent plasma exchange for ALF (12 patients), sub-acute liver failure SAHF (9) and ACLF (13). Causative agents are native medication (44%), antimicrobial (21%), antiepileptics (11%), antitubercular drugs (9%), hormonal pills (5%) and others (10%). By RUCAM score, 29 patients had probable DILI and 5 had possible DILI. Twenty-two patients had hepatic encephalopathy. The 34 patients underwent 2 (1-7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma were exchanged per session. Twenty-one patients received prednisolone up to 20 mg per day for a duration of 32 (4-160) days median (range). The survival at day 30 from date of admission was 64.2% in 34 patients, 42% in ALF patients,78% in SAHF patients and 76% in ACLF patients. Of 19 ALF/SAHF patients who fulfilled Kings College Criteria for liver transplantation,11 patients (58%) survived with plasma exchange.
Conclusion Plasma exchange appears a promising treatment option in I-DILI patients not opting for liver transplantation.
Changes in parameters before and after PLEX
Parameters Median, IQR | Baseline values (at admission) | Post PLEX values (at discharge) | p-value |
Bilirubin (mg/dL) | 21.6 (14.7-26.7) | 15.7 (10.4-16.1) | 0.033 |
INR | 2.45 (1.73-3.9) | 1.99 (1.2-2.45) | 0.002 |
Creatinine (mg/dL) | 0.8 (0.6-1.2) | 0.7 (0.6-1.1) | 0.5731 |
MELD | 30 (27.2-34.7) | 27 (19.5-29) | <0.001 |
VWF Antigen % | 480.7 (348.5-709) | 297.9 (229.8-501) | 0.0001 |
SOFA | 8 (7-9) | 7 (6-8) | 0.116 |
Ferritin (ng/mL) | 727 (407.5-1427.9) | 348.8 (218-788.9) | 0.009 |
All parameters in 34 patients except Ferritin (23 patients)
140
Analysis of liver function tests in rodenticidal hepatotoxicity patients
Gadadhar Panda , B Vijayalekshmi, Uday Zachariah, Ashish Goel, C E Eapen
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Department of Gastroenterology, Christian Medical College, Vellore 632 004, India
Introduction Hyperferritinemia is a macrophage activation marker. We aimed to study the pattern of liver injury and of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and to correlate these with hyperferritinemia and with the outcome.
Methods We retrospectively analyzed LFTs in rodenticidal hepatotoxicity patients managed in our department from December 2017 to June 2020. R values (i.e. [ALT/ALT upper normal limit (ULN)]/ [alkaline phosphatase (ALP)/ALP ULN]) of ≥ 5, ≤ 2 and 2– 5 were taken to indicate hepatocellular, cholestatic and mixed hepatocellular-cholestatic liver injury respectively.
Results Of 80 consecutive rodenticidal hepatotoxicity patients (age: 24 [7-45] years, median [range], female : male: 1.2:1,MELD: 31.5 [14-49]), 64 patients were discharged alive, 14 died and 2 discharged against medical advice. Time from rodenticidal ingestion to first abnormal LFT was 4 (1-18) days. Initial liver injury was hepatocellular in 72 patients (90%), cholestatic (2 patients) and mixed (6 patients); 62 patients (78%) had AST 941 (25-4994) U/L > ALT 539 (16-2893) U/L and 18 patients had ALT 463 (111-1361) U/L > AST 280 (95-1153) U/L. Concomitant ferritin levels were 4447 (161-72001) ng/mL in 39 patients with AST>ALT and 758 (59-3787) ng/mL in 13 patients with ALT>AST (p <0.001). Of 62 patients with initial AST>ALT, 51 patients (82%) had ALT>AST 2 (1-6) days later.14 /62 patients (22.5%) with AST>ALT had poor outcome compared to 2/18 patients (11.1%) with ALT>AST (p=0.24). AST levels were higher in patients with poor outcome (1022 [361-4134] U/L) compared to those with good outcome (668 [25-4994] U/L) (p=0.02). Ferritin levels were higher in those with poor outcome (4520 [562-72001]) ng/mL compared to those with good outcome (2029 [59-30344] ng/m) (p=0.07).
Conclusion Rodenticidal hepatotoxicity causes hepatocellular liver injury with AST>ALT in most patients. AST>ALT was associated with higher ferritin, this may indicate macrophage activation. Patients with poor outcome had higher initial AST and ferritin levels.
141
Effect of dapaglifozine in Type 2 DM with non-alcoholic fatty liver disease – ‘A single centre experience’
Navin Sudhakaran , Girish Kumar Pati, Chandan Das, Abhay Sahoo
Correspondence- Girish Kumar Pati-pati.drgirishkumar@gmail.com
Department of Gastroenterology, IMS and SUM Hospital, Bhubaneswar 751 003, India, and Sum Ultimate Medicare Hospital, K8 Kalinga Nagar, Ghatikia, Bhubaneswar 751 003, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting around one third of global population. As there is paucity of reports on effects of dapaglifozine (SGLT2 inhibitor) in NAFLD cases with diabetes mellitus (DM) from this part, we aimed to evaluate the same.
Method Consecutive cases with Type 2 DM and NAFLD were included in the study and subjected to dapaglifozine 10 mg therapy for 3 months. Biochemical parameters, ultrasonographic fatty liver grading, fibroscan scoring, and non-invasive scoring for hepatic fibrosis (FIB4 and NAFLD fibrosis scores) of all the cases were evaluated at baseline and again after 3 months of completion of therapy and compared with each other.
Result In our study, amongst total of 100 cases, males outnumbered females (Male: Female – 4.27: 1). Mean age of presentation was 44.11±8.24 years. Mean body mass index (BMI) of cases decreased from 27.31±1.87 to 26.21±1.51 Kg/ m2 (p–0.0001) following therapy. Seventy percent cases presented with dyspeptic symptoms, whereas 29% cases had no symptoms and only 1% case had occasional upper abdominal pain. Significant decrease (p-0.0001) in transaminitis (SGOT: 55.88±20.92 vs. 49.52±16.61 IU/L and SGPT: 64.69±22.73 vs. 58.69±17.98 IU/L) and blood sugar level (FBS: 137±18.91 vs. 125.54±15.87 mg% and 2 hour PPBS: 188.38±34.49 vs. 169.13±29.49 mg %) occurred following therapy. Significant decrease (p< 0.05) in hepatic steatosis occurred following therapy. Although significant decrease (p - 0.001) in fibroscan value: 6.95±1.42 to 6±1.44 kPa occurred following therapy but significant decrement in FIB4 score: 1.66±0.91 vs. 1.54±0.76 and NAFLD Fibrosis score: - 0.58±0.92 vs. - 0.64±0.91 (p>0.05) did not occur. Hepatic fibrosis did not decrease significantly following therapy (p>0.05).
Conclusion Although dapaglifozin improved transaminitis, glycaemic status and hepatic steatosis but had minimal effect on hepatic fibrosis.
142
Clinical characteristics and management of liver abscess: A tertiary care centre experience
Adarsh C K, Puneeth B S , Bhuvan Shetty, Jairaj V Bomman
Correspondence- Adarsh C K-adarshck@gmail.com
Department of Medical Gastroenterology, BGS Global Hospital, Bangalore, India
Introduction Liver abscess is a space-occupying lesion in liver associated with high morbidity and mortality. Our objective was to study the clinical characteristics and management outcomes in patients with liver abscess.
Methods Prospective study was done from August 2019 to July 2020 on 52 patients with liver abscess at BGS Global Hospital, Bangalore. History, examination, laboratory investigations, imaging findings were recorded. Ultrasound guided aspiration was done and samples were investigated.
Results Out of 52 patients, 31 were male and 21 were female patients. Twelve of them were diabetic and 16 were alcoholics. Pain abdomen (96%) was predominant symptom. Hepatomegaly was found in 88%, jaundice in 23%. Elevated ESR was found in 65%, TLC was elevated in 88%, Total bilirubin was elevated in 28%, AST was elevated in 38%, ALT was elevated in 27% and serum albumin was reduced in 76%. On imaging liver abscess was found in right lobe in 65%, left lobe in 25%, bilateral in 10%; solitary in 79% and multiple in 21%. Segment VIII (46%) was predominantly involved. Pus culture was positive in 31% out of which K. Pneumonia was seen in 50%, E. coli in 31% and pseudomonas in 19%. Amebic serology was seen in 27%, AFB was positive in only 1 patient. Percutaneous abscess drainage was needed in 63% of patients and rest 37% were managed medically. No mortality was seen.
Conclusion Early diagnosis and treatment is necessary in management of liver abscess since the presentation may be subtle and nonspecific. Combined antibiotic therapy and percutaneous drainage will improve the patients prognosis.
143
A study on role of Lille’s score in predicting response to granulocyte colony-stimulating factor therapy in patients with severe alcoholic hepatitis
Sagar Dembla , Harsha M, Srinivas M G
Correspondence- Srinivas MG-demblasagar@gmail.com
Department of Medical Gastroenterology, Narayana Medical College Hospital, Chinthareddipalem, Nellore 524 002, India
Introduction Alcohol-related liver disease is a broad spectrum of disease. Severe alcoholic hepatitis has high short-term mortality up to 50%. The therapeutic options are limited. Glucocorticoids are recommended but have various limitation. A liver transplant is limited therapeutic option. G-CSF stimulates pluripotent stem cells which contribute to regeneration and repair of hepatocyte. In few RCTs, G-CSF therapy has improved liver function and survival. However, these studies lacked a prognostic guide for G-CSF. Thus, we hypothesized that G-CSF has better outcomes and Lille’s score may be used in predicting response to G-CSF.
Result We enrolled total 67 patients, all were male. 26 were excluded as per exclusion criteria. Thus, 41 enrolled for therapy. Out of which 37 received first 5 doses and 25 patients completed 12doses. Overall mortality at 90days was 31.7% (13/41). Lille’s score on day 6 had significant correlation (p-value <0.005) with survival at 90 days. AUC was 0.925 (CI 95%, 0.838 to 1.000). The cut-off value of 0.195 (sensitivity-81.8% and specificity-86.7%). Kaplan-Miere plot showed that the two groups as ≤0.195 and >0.195, showed at survival at 90days was 90% and 26.7% respectively. Lille’s score also independently predicted mortality with cut-off 0.195 (p-value 0.009) and Odds ratio is 16.3. In survival group there was a significant improvement in CTPS, DF, bilirubin and transaminases on day 6 and day 30. MELD score improved on day6 and day 30, but was significant on day 30. Creatinine and serum albumin showed no significant change at day 6 and day 30. In non-survival group, no significant improvement in liver disease clinical score and biochemical parameters. G-CSF therapy was well tolerated in patients.
Conclusion G-CSF is appearing as a promising therapy in alcoholic hepatitis and Lille’s score may be used as prognostic marker for survival. But, we need larger data and more similar studies to validate it as tool in G-CSF therapy.
144
Study of association of serum homocysteine levels with non-alcoholic fatty liver disease
Aditya Srivastava , B K Tripathi
Correspondence- Aditya Srivastava-adityasrivastava2301@gmail.com
Department of General Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, Mahatma Gandhi Marg, Safdarjung Campus, Ansari Nagar West, New Delhi 110 029, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is an emerging public health problem ultimately progressing to fibrosis, cirrhosis and hepatocellular carcinoma. The absence of specific symptom or sign warrants the need for identifying non-invasive tools for early identification of the disease and it's progression. Homocysteine is a sulfhydryl containing amino acid which can alter intracellular lipid metabolism thereby promoting hepatic fat accumulation. Thus, it is plausible that high homocysteine levels could be a marker for early identification, and an effective target for preventing the progression to NAFLD and it's related complications.
Aim To determine if there is any association of serum homocysteine levels with NAFLD.
Methods Forty NAFLD patients along with 40 healthy volunteers underwent serum homocysteine level measurement along with a gamut of baseline investigations from August 1, 2019 to January 31, 2020 in this observational case control study conducted on an out-patient basis in the Gastroenterology Unit, Department of General Medicine, Safdarjung Hospital. USG and Fibroscan were done in 40 NAFLD patients.
Results 57.5% (23) of case cohort were males and rest were females. Mean age of case cohort was 43.08 years. 40% of patients were diabetic. Mean homocysteine levels were 44.87 micromoles/L in cases as compared to 27.57 micromoles/L in controls. 47.50% of cases had Grade I fatty liver. Mean liver stiffness was 6.44 kPa on fibroscan. All cases with homocysteine levels in first quartile (<17.9) had Fibrosis score of F0-F1. On the other hand, only 33.3% cases with Homocysteine levels in fourth quartile (>51.5) had Fibrosis score of F0-F1.
Conclusion Higher serum homocysteine levels were significantly associated (p value<0.0001) with progressive grades of hepatic fibrosis, as assessed by fibroscan, in NAFLD patients and holds the potential to be used as a tool for early identification of hepatic fibrosis in NAFLD.
145
Melioidosis: A rare cause of liver abscess
Manas Panigrahi, Mohd Imran Chouhan , Hemanta Kumar Nayak, Subash Chandra Samal, Srujana Mohanty*, Shivam Sethi
Correspondence- Manas Panigrahi-medgast_manas@aiimsbhubaneswar.edu.in
Departments of *Microbiology, and Gastroenterology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Melioidosis, caused by the gram-negative bacillus, Burkholderia pseudomallei is clinically indistinguishable to other causes of pyogenic liver abscess. A high index of suspicion is needs to diagnose early as it is poorly responsive to usual empiric antibiotics and is associated with significant mortality. Isolated liver abscess however is extremely rare. Here we report two cases of hepatic meliodiosis who were previouly treated as liver abscess elsewhere and were not responsive to the treatment.
Clinical presentation Case 1: A 39-years-old female with no known co-morbid illness presented with history of pain right upper quadrant and fever of 3 months. On examination liver and spleen were enlarged. Patient was diagnosed elsewhere as liver abscess and had received multiple antibiotics (oral and intravenous) over last 2 to 3 months without any improvement in her symptoms. ultrasonography and CECT showed liver and splenic abscesses. USG guided aspiration was done and on culture Burkholderia pseudomallei was grown. She was started on IV meropenam for 2 weeks followed by oral trimethoprim and sulfamethoxazole for six months. She improved symptomatically after 48 hours of IV Meropenam.
Case 2: A 42-years-male, diabetic with uncontrolled blood glucose presented with high grade fever and pain right upper quadrant. On examination there was rigidity and gaurding in the right hypochondrium. USG and CT showed multiple liver abscess in both the lobes. USG guided aspiration was done and on culture Burkholderia pseudomallei was grown. He was started on I.V Meropenam (as per sensitivity) and responded to the treatment.
Conclusion In clinical practice liver abscess is a commonly encountered problem and majority of which responds to standard antibiotic therapy. These reports highlights the specific problem of non-responsive to antibiotic therapy and stresses the need to be aware of Burkholderia pseudomallei as a potential cause of liver abscess.
146
A prospective study on profile of hepatic Wilson disease at a tertiary care centre
Sharad Dev , Vinod Kumar Dixit, Sunit Kumar Shukla, Dawesh Prakash Yadav, Anurag Tiwari
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
Introduction Wilson disease is a rare inherited disorder characterized by excess deposition of copper in liver, brain and other tissues. In this study we assess the clinical profile of Wilson disease in patients with hepatic involvement.
Methods A total of 45 patients (M:F-2.5:1) of Wilson disease; diagnosed by low serum ceruloplasmin, high 24 hr urinary copper and D-penicillamine challenge test were enrolled in the prospective study conducted between August 2018 and July 2020.
Results Mean age of patients was 24.7±12.6 years. Twenty-eight (62%) patients presented with decompensated CLD (ascites–82%, jaundice–75%, hepatic encephalopathy–28%, variceal bleeding–18%) with mean baseline CTP 8.9±2.4 and MELD 22.5±5.4 values. Clinical presentation was acute hepatitis in 12/45 (27%) patients (2 mimicking autoimmune hepatitis), asymptomatic transaminitis with hepatomegaly in 3/45 (7%) patients and fulminant hepatic failure in 2/45 (4%) patients. KF ring on slit lamp examination was present in 20/45 (44%) patients. Upon diagnostic evaluation, mean 24 hr urinary Cu was 392.62± 206.08 mg/day and mean serum ceruloplasmin was 18.40±6.34 mg. On liver function tests, mean value of total bilirubin was 19.64±11.84 mg/dL, AST was 227±131 U/L, ALT was 161±125 U/L and ALP was 194±55 U/L whereas other parameters were normal. On hemogram, anemia was found in 23/45 patients with mean of 9.85±3.15 g/dL and evidence of hemolysis in 4 of them. Thirty-five patients (78%) responded to treatment with D-penicillamine and/or zinc therapy, three underwent liver transplant, two died of complications and five were lost to follow-up.
Conclusion In this study, most patients of Wilson disease presented as decompensated CLD, followed by acute hepatitis like presentation. Early institution of pharmacotherapy is usually very effective but meticulous follow-up to monitor clinical wellbeing, adherence and long- term adverse effects is mandatory for better outcome.
147
Outcome of wait-listed recipients without the option for living donor liver transplantation at a newly established tertiary care liver transplant centre in Western India
Amey Sonavane , Deepak Gupta, Aabha Nagral, Ameet Mandot, Vikram Raut, Ketul Shah, Amruthraj C, Ashok Thorat, Ambreen Sawant, Harshit Chaksota, Suresh Vasanth, Darius Mirza
Correspondence- Amey Sonavane-amey_max@yahoo.com
Department of Gastroenterology, Hepatology and Liver Transplantation, Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Background The scenario of cadaveric organ donation is rapidly evolving in Western India. However, living donor liver transplantation (LDLT) still forms the backbone of most transplant programs in this region. The aim of our study was to analyse the outcome of wait-listed recipients who did not have the option for LDLT.
Methods All patients listed for the cadaveric transplant program since inception at a newly established tertiary care liver transplant centre in Western India were included. We studied the outcome of recipients who did not have a living related liver donor; or whose donor(s) were rejected during evaluation and thus were listed for cadaveric transplant.
Results We performed 102 liver transplants (75 LDLTs and 27 deceased donor liver transplants [DDLT]) over 56 months since inception. All of the 32 pediatric transplants performed were LDLT. Total 286 potential recipients were listed for the cadaveric program. 220/286 (76.92%) did not have a related living donor whereas 66/286 (23%) patients had living related donor(s) who were rejected during donor evaluation. Non-alcoholic steatohepatitis (64%), low graft-recipient weight ratio (13%), alcoholic steatohepatitis (7%), unsuitable anatomy (7%) and withdrawal of consent (5%) were common reasons for donor rejection. After a waiting period of 15±8 months, the overall wait-list mortality was 13.63% (39/286). 57.69% of the recipients experienced at least one episode of decompensation post listing for DDLT. Amongst the cohort having an unsuitable donor, the wait-list mortality was 21.21% (14/66). 2/66 patients with an unsuitable donor and 25/220 without a living liver donor underwent DDLT.
Conclusion Wait-list mortality is high amongst patients listed for DDLT. LDLT significantly contributes to the available organ pool and fulfils the void of organ deficit. This assumes importance especially in countries with an evolving cadaveric transplant program, thus reducing waitlist morbidity and mortality.
148
Atypical presentation of hepatic tuberculosis: a case series
Manas Kumar Panigrahi, Madhav Sameer Makashir , Hemanta Kumar Nayak, Subash Chandra Samal, Srujana Mohanty *
Correspondence- Manas Panigrahi-medgast_manas@aiimsbhubaneswar.edu.in
Departments of *Microbiology and Gastroenterology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Since the description of tuberculosis in literature, it has been always a challenge for the clinicians. Though endemic in developing nations, its atypical presentation makes it an enigmatic entity. Tuberculosis can mimic malignancy, exposing the patient to unnecessary investigations and sometimes even surgery. The hepatic involvement of tuberculosis is a rare entity with paucity of literature on the presentation. We are reporting our experience with four such cases seen over last 2 years.
Case presentation Case 1, a 38-year-old male, presented with pyrexia of unknown origin (PUO) with jaundice which later turned to be granulomatous liver disease of tubercular origin with mediastinal lymphadenopathy.
Case 2 is a 40 year old male, in whom portal vein thrombosis secondary to hepatic tuberculosis was the etiology of portal hypertension causing esophaegeal varices and long-term sequelae, including formation of portal cavernoma leading to portal cholangiopathy, who also had tubercular ascites and active pulmonary tuberculosis.
Case 3 is a case of 59-year-old male with tuberculoma of the liver mimicking malignancy (hepatocellular carcinoma) on imaging, who responded to anti-tubercular therapy.
Case 4 is a 65-year-female, an interesting case of paradoxical response to anti-tubercular therapy forming tubercular liver abscess which extended to involve the gallbladder fossa, leading to spontaneous perforation of the gallbladder.
Conclusion Even in modern era, tuberculosis still poses a great diagnostic challenge for gastroenterologists. Deviation from normal clinical presentation keeps the treating physician in diagnostic dilemma. Sometimes, response to anti-tubercular therapy is the only option left in endemic countries like India.
149
CHIBA score, A novel model for predicting 3 month mortality in decompensated liver disease
Bony George , Krishnadas Devadas, Jijo Vargheese, Anoop Vaeghese
Correspondence- Bony George-bonygeorge88@gmail.com
Department of Medical Gastroenterology, Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction Decompensated Liver Disease (DCLD) has got a high mortality rate and prediction of mortality is important to prognosticate the patient and to channel high risk patients for liver transplantation.
Objectives To propose a new prognostic model for DCLD which is better than the existing scores.
Methods Retrospective study. Clinical and biochemical variables were assessed on the date of admission from the medical records and patient/patient relatives were telephonically contacted regarding the date of death and mortality at 3 months from the date of admission. Logistic regression was done, coefficient of beta of independent variables were found out and a new score was proposed (New score/CHIBA score = Creatinine *0.6 + HE*0.4+ INR *0.8 + bilirubin *0.125 + INR *0.8 + ascites* 1.2) C stands for creatinine, H for hepatic encephalopathy, I for INR, B for bilirubin and A for ascites. Ascites was further divided into absent or mild with score of 0, moderate -1 and tense 2. Hepatic encephalopathy absent with score of 0, Grade I west heaven score of 1, Grade II score of 2 and Grade III and IV a score of 3.
Results CHIBA score has AUROC of 0.793 (at a cut off of >5.5 it has sensitivity of 66% and specificity of 76%) compared to MELD-Na of 0.735 (0.735, cut off >25 sensitivity 65% and specificity 72%), MELD of 0.727 (cut off >17 sensitivity of 80.37% and specificity of 55.14 %), i-MELD of 0.7223, MESO index of 0.727 and UKELD of 0.686.
Conclusion CHIBA score is superior to MELD and MELD variants in predicting 3 month mortality. In short CHIBA score is better than all existing prognostic models for DCLD. CHIBA score needs to be validated in a different cohort to find out it’s prognostic performance.
150
Analysis of effect of blood group on plasma von Willebrand factor levels, liver disease severity and survival in rodenticidal hepatotoxicity patients
Rutwik Loya , B Vijayalekshmi, Uday Zachariah, Jess Rasalam, Joy Mammen, Dolly Daniel, Sukesh Nair, Ashish Goel, C E Eapen
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Departments of Gastroenterology, Hepatology, Transfusion Medicine and Immunohematology, and Wellcome Trust Research Laboratory, Divison of GI Sciences, Christian Medical College, Vellore 632 004, India
Introduction In health, plasma von Willebrand factor (VWF) levels are significantly lower levels in group O compared to non – O group individuals. We have previously reported raised VWF levels correlate with liver disease severity and predict in-hospital survival in rodenticidal hepatotoxicity patients. The aim of this study was to analyse VWF levels, liver disease severity, and outcomes in rodenticidal hepatotoxicity patients as per their blood group.
Methods We retrospectively analyzed prospectively collected data on rodenticidal hepatotoxicity patients managed in our department from January 2016 to June 2020, in whom blood grouping data was available. Normal plasma VWF antigen level is 50% to 150%.
Results Fifty rodenticidal hepatotoxicity patients 40% males, age 22 (7-44) years, acute liver injury (78%), acute liver failure (22%) had blood group O (21 patients), A (12 patients), B (13, patients), AB (4 patients). 28 patients underwent plasma exchange. Baseline parameters were serum bilirubin 5.52 (1.7-19.5) mg/dL, INR 5 (1-10), creatinine 0.8 (0.48-2.8) mg/dL, MELD 31.5 (14-49) and VWF 430.6 (121-1106.8)%. VWF levels were 408 (121-1106.8)%, 415.5 (263.9-646)%, 506.3 (186.8-890)%, and 588 (376.3-990)% in O, A, B and AB blood group patients respectively (p value =0.10). MELD scores were 33 (14-49), 31.5 (18-44), 30 (14-45) and 38 (28-40) in O, A, B and AB blood group patients respectively (p value =0.61). At 30 days, 38 patients were alive and 12 died. Survival at day 30 in O group vs. non – O blood group patients was 76.2 % and 75.9 % respectively (p=0.97).
Conclusion VWF levels tended to be higher in non – O blood group compared to O blood group in rat killer hepatotoxicity patients, however, 30 day survival was not different in these blood groups.
151
The triglyceride and glucose index (TyG) as screening biomarker to identify non-alcoholic fatty liver disease
Hozefa Runderawala, Nutan DesaiCorrespondence - Hozefa Runderawala-hozaaee@gmail.com
Fortis Hospital, Mumbai, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is associated with insulin resistance through an accumulation of fat in the liver. The triglyceride and glucose index (TyG), which is defined as the product of an individual’s serum levels of triglycerides (TG) and fasting plasma glucose (FPG), has been recommended as a reliable and simple surrogate index for insulin resistance. We compare the ability of triglyceride and glucose index (TyG), as compared with the predictive value of alanine aminotransferase (ALT), to identify individuals at risk for NAFLD.
Methods People attending our institution health check-up OPD as per inclusion and exclusion criteria are selected between December 2019- March 2020. People of age >18 years were included and those with significant alcohol intake, known case of diabetes mellitus, hypertension, dyslipidemia or any known liver disease were excluded. Routine blood parameters were noted, and fatty liver assessed as the presence or absence of hepatic steatosis by abdominal USG. The TyG is calculated with established formula: TyG= Ln (Tg [mg/dL] X FBS [mg/dL]/2).
Results A total of 95 people were enrolled, among which 53 were (56%) found to have fatty liver by abdominal USG. TyG index was calculated by using above mentioned formula and taking cut off value of 8.6, and that for ALT of 40 IU/L, Sensitivity of TyG index is 72% and for ALT is 27.08%, also negative predictive value (NPV) for TyG index is 82.35% and for ALT is 54.5%. By using McNemar Chi-square test, p value is found to be significant with p <0.01.
Conclusion TyG index is found to have higher sensitivity in comparison with ALT for an effective screening biomarker to identify NAFLD.
152
Clinical profile and outcome of chronic hepatitis C patients in a tertiary care centre in North India
Chandan Kumar , Itish Patnaik, Ashok Kumar, Anand Sharma, Rohit Gupta
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Introduction Hepatitis C virus (HCV) infection is known to cause cirrhosis. Advent of direct antiviral agents (DAA) have significantly altered the disease course of these patients. We describe our experience with HCV patients.
Methods A prospective observational study was done over a one-year period (1st February 2019 to 31st January 2020) in patients of our department. Patients were evaluated and treated as per standard of care and followed up for 12 weeks after completion of DAA for sustained virological response (SVR12).
Results During the study period 189 patients (Median [Range] Age 37.5 [17-69] years; 57% were males, family history of HCV in 7%; high risk behavior in 39%) were diagnosed to have HCV infection. Cirrhosis was present in 30 (15.8%) patients (MELD 10, [6- 18]), of which 18 patients were decompensated (ascites in 12, jaundice in 8, hepatic encephalopathy in 1, variceal bleed in 2). One patient presented with acute hepatitis. One hundred and seventy-three patients were asymptomatic. None were co-infected with hepatitis B or human immunodeficiency virus. Among genotypes, 3a was the most common (65.75%). All patients were treated with DAA (sofosbuvir/daclatasvir given to 146 cases for 12 weeks, sofosbuvir/velpatasvir given to 24 cases for 12 weeks and 18 cases for 24 weeks and sofosbuvir/ledipasvir to 02 cases for 12 weeks). End of treatment response (ETR) was achieved in 188/189 (99.5%) patients and SVR12 was achieved in 188/189 (99.5%) patients.
Conclusion Most of the patients with chronic HCV in our centre were asymptomatic. Genotype 3a was the most common. It responded well to current DAA regimens with excellent rates of SVR12.
153
Clinical profile of autoimmune liver disease in north India: Tertiary care experience
Vishnu Agarwal, Rishabh Gupta , Anubhav Jain, Girish Dhakad, Sandeep Nijhawan
Correspondence- Rishabh Gupta-rishabh1313@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College and attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Autoimmune hepatitis (AIH) is a disease of unknown etiology, characterized by chronic hepatocellular inflammation, serum autoantibodies, and hypergammaglobulinemia, which in most cases respond to immunosuppression. AIH is considered to be rare in Asia-Pacific region.
Aim of the study To determine the clinical, biochemical, serological and histopathological profile of autoimmune hepatitis.
Method It was a prospective observational study conducted in the department of gastroenterology, SMS Medical College, Jaipur. Study period was from May 2018 to June 2020. Inclusion criteria were consecutive patients of chronic or acute liver disease who were newly diagnosed as AIH, PSC, PBC or Overlap syndrome.
Results Total 83 patients were included and 67 (80.7%) were females. The mean age was 33 years. Seventy-nine had AIH, 3 had PBC with AIH overlap and 1 had PSC with AIH overlap. Modes of presentation was chronic hepatitis (n=24) and decompensated cirrhosis (n=40), 7 had ACLF like presentation, while 8 were asymptomatic. Liver biopsy was done in 34 patients. The presentations were jaundice in 45 (56.9%), abdominal distention in 40 (50.6%), pruritis in 15 (18.9 %), amenorrhea in 10 (12.6%), abortion in 5 (6.3%). Hepatomegaly was present in 30 (37.9%), splenomegaly in 35 (44.3%), encephalopathy in 15 (18.9%), and fever in 7 (8.8%) patients. Nineteen had esophageal varices (24%) and 2 had variceal bleed. The autoimmune markers were ANA (n=58), ASMA (n=30), both SMA and ANA (n=25), AMA (n=3), rheumatoid factor (n=2), p-ANCA (n=1), and anti-LKM (n=6). 25 patients (31.6%) had definite AIH. Associated diseases were seen in 20/79 (25.3%) patients.
Conclusion Autoimmune liver disease is not an uncommon entity and high index of suspicion may lead to a timely diagnosis and improved prognosis.
154
Hepatic angiosarcoma presenting as a hemorrhagic cyst
Sujit James , Benoy Sebastian, Sunil Mathai, Anil Jose, Mary George, Santhosh R, Cyril Alex, Swaran Kumar, Sunil T ** , Varun Rajan *
Correspondence- Sujit James-jamessujit@gmail.com
Department of Medical Gastroenterology, *Medical Oncology, and **Surgical Gastroenterology, Medical Trust Hospital, Ernakulam 682 016, India
We report a very rare presentation of angiosarcoma of liver as a simple hemorrhagic cyst. The patient is a 68-year-old male, who came with non-specific right hypochondriac pain since 3 months. Contrast CT done showed a 10 X 10 cm cystic lesion in the right lobe of liver and MRI abdomen done showed T1 hyperintensities giving us a differentials of a hemorrhagic/ hydatid cyst. He then underwent laproscopic deroofing of the liver cyst and cyst fluid which was hemorrhagic was sent for analysis and tissure for histopathology. Cyst fluid analysis was negative for tumor markers and bilirubin levels. Histopathology showed clusters of atypical cells and pleomorphic nuclei and eosinophilic cytoplasm. However, IHC done was suggestive of angiosarcoma. Hepatic angiosarcoma presenting as a simple hemorrhagic cyst is a very rare presentation. The importance of keeping an open mind to the differentials even in a simple cyst is the highlight of this case report.
155
Profile of hepatocellular carcinoma in a tertiary care centre in South India with etiologic association and treatment outcome
Mohamed Fawas , Krishnasamy Narayanasamy
Correspondence- Mohamed Fawas-ncfawaz@gmail.com
Department of Hepatology, Institute of Hepatobiliary Sciences, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India
Introduction Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Risk factors involved in development of HCC include underlying cirrhosis, hepatitis B, hepatitis C, non-alcoholic fatty liver disease etc. This study aims to describe clinical profile, underlying risk factors, tumor characteristics and outcomes of therapy.
Methods One year prospective study on patients coming to our OPD with either imaging or biopsy proven HCC cases. Detailed history, examination and laboratory tests were performed. The statistical analysis of the data was performed.
Results The mean age was 56.8 yrs. Presenting complaints included loss of appetite in 83%, abdominal distension in 71%, weight loss in 61%, abdominal pain in 60%, hemetemesis in 10%, jaundice in 18% and hepatic encephalopathy in 6% cases. The risk factors were hepatitis B virus (HBV) in 43.6%, hepatitis C virus (HCV) in 24.6%, non-alcoholic steatohepatitis (NASH) in 20.4%, alcohol in 13.6%, hepatitis B and alcohol in 35.5%, hepatitis C and alcohol in 13%. 86% of patients had underlying cirrhosis while 14% were non-cirrhotics. Most of the patients were in advanced stage BCLC-C 43.3%, followed by BCLC-D 28.3%, BCLC-B 26.6%, BCLC-A 28.3%. Most of the patients were CTP B 68.3%. Patients having ascites had significant greater mortality at 1 year (p=0.025). Portal vein thrombosis (PVT) increased the mortality at 1 month (p=0.002) and 1 year (p=0.001) follow up. Higher mortality was found with higher BCLC class,1 month (0.05) and at 1 year (p=0.001).
Conclusion Most patients diagnosed HCC belonged to 6th decade. Hepatitis B was the commonest etiology. Decreased appetite was the commonest complaint. Most patients were diagnosed at an advanced stage which narrows down the therapeutic options and this study further emphasizes the importance of periodic screening in patients with risk factors.
156
Hepatic hydrothorax: Clinical profile and initial management of symptomatic patients not responding to medical therapy - Case series from a tertiary care centre
Swaran Kumar S , Sunil K Mathai, Benoy Sebastian, Anil Jose Kokkat, Mary George, George Mothi Justin, Vivian Wilson, Varghese Louis, Cyril Alex, Santhosh R, Sujit Jacob James
Correspondence- Swaran Kumar S-swarankumar29@gmail.com
Department of Gastroenterology, Medical Trust Hospital, Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
Background Hepatic hydrothorax is known to occur in 5% to 15% of patients with cirrhosis and can lead to respiratory failure and also aggravate the clinical course of cirrhosis. The development of spontaneous bacterial empyema is also associated with significant mortality. We outline the clinical profile and initial management of 7 patients who were admitted to our centre over a duration of 14 months. (03/2019 – 07/2020).
Methods and Results Mean age was 60 yrs and 6 out of 7 patients were male and one was female. Five of the 7 patients had CHILD C Cirrhosis (CTP score > 10) and 2 patients belonged to CHILD Class B. All patients had MELD Na score of 15 or more with 4 patients having a Score > 21. All patients had ascites clinically. All patients had transudative effusion. 5 patients had right sided effusion, one had bilateral effusion and one had left sided effusion. All patients were treated with dietary sodium restriction, diuretics and albumin. All patients required thoracocentesis. 5/7 patients had recurrence of effusion during the initial follow-up within 2-4 weeks. All patients required a minimum of two pleural fluid aspirations during the initial admission. Indwelling Pleural Catheter (IPC)/Pigtail was inserted in 6/7 patients including the two patients who did not have recurrence of Effusion on follow-up. One patient developed Empyema and died.
Conclusion Hepatic hydrothorax is a relatively uncommon complication of cirrhosis. Temporary usage of an IPC/Pigtail for intermittent pleural aspiration obviated the need for repeated thoracocentesis. In our small case series, one patient developed empyema and succumbed and others did not have any procedure related complications. IPC/Pigtail catheter may be a good option to optimise the patient before transplant.
157
Transfusion associated lung injury is uncommon in liver failure patients treated with low volume plasma exchange and low dose steroid
Vijay Alexander , Jess Rasalam, Dolly Daniel, Joy Mammen, Lalji Patel, Uday Zachariah, Ashish Goel, Chundamannil Eapen
Correspondence- Chundamannil Eapen-eapen@cmcvellore.ac.in
Department of Hepatology, Christian Medical College, Vellore 634 004, India
Introduction Transfusion of plasma containing blood products is associated with a small risk of breathing difficulty that can be broadly classified as TRALI and TACO. This study aimed to analyze the incidence of TRALI and TACO in patients undergoing plasma exchange (PLEX) to treat liver diseases.
Methods We retrospectively analyzed prospectively collected data in consecutive patients undergoing PLEX to treat liver failure in our department who did not require respiratory support prior to initiation of PLEX. Cases who had onset of dyspnoea within 12 hours of a PLEX session were identified. TRALI and TACO were diagnosed as per Consensus Panel recommendations. The cases were categorized as TRALI, TACO, or any other cause using a predefined algorithm. The patients were treated with low volume PLEX (50% of plasma volume exchanged with equal volume of fresh frozen plasma) and low dose steroid.
Results From October 2016 to April 2020, 180 liver disease patients underwent 563 PLEX sessions. Twenty-eight patients who were intubated prior to initiation of PLEX were excluded. A total of 152 patients (age – 35.42 +/- 15.15), (M – 100, 65.7% and F – 52, 34.2%) were identified who underwent 492 PLEX sessions and were transfused 4598 units of different blood products. Five patients who had new-onset dyspnoea within 12 hours of transfusion were identified. Among the 5 patients, 2 had TACO, and 3 had pneumonia (2 of these were aspiration pneumonitis). No patient fulfilled the diagnostic criteria for TRALI. The incidence of TRALI was 0%, and that of TACO was 1 in 2299 units of product transfusion in these patients.
Conclusion We did not find TRALI in liver failure patients treated with low volume PLEX and low dose steroids. However, TACO seems a potential and life-threatening problem that needs careful monitoring, especially in those at risk of fluid overload.
158
Dengue fever in liver transplant recipients: report of 2 cases
Sachin Jain , Nihar Ranjan Dash
Correspondence- Nihar Ranjan Dash-nagranjan@gmail.com
Department of GI Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Dengue fever is a common mosquito borne disease in India. Dengue fever in liver transplant recipient has rarely been described. We report here 2 cases of dengue fever in our liver transplant patients.
Case Presentation We report 2 cases of dengue fever in our liver transplant patients.
Case 1- presented 3 months after transplantation with history of febrile illness with myalgia, arthralgia, thrombocytopenia, leukopenia. His low platelet and WBC counts were initially attributed to hypersplenism. Dengue was diagnosed using NS1antigen test and he was managed conservatively as for dengue fever. He recovered well and his graft is functioning well till last follow- up.
Case 2: Presented 2 years after transplantation with a history of fever, thrombocytopenia, mildly elevated liver enzymes. He had history of biliary stenting for post op anastomotic stricture. Initial diagnosis was suspected to be stent block cholangitis. Dengue IgM antibody test was negative but NS1 antigen test was positive. Final diagnosis of dengue fever was made. He improved well with conservative management. He is also doing well till last follow-up.
Conclusion Reports of dengue fever in liver transplant recipients are limited. The presentation may be atypical. It should be suspected when patient present with febrile illness with thrombocytopenia, along with other possible causes. NS1 antigen has better sensitivity than IgM Elisa. Both should be included in diagnostic work up. Dengue fever usually follows a mild course in primary infection and most patients recover well. Dengue fever does not affect graft function in long-term.
159
Assessment of visceral fat volume and its correlation with the severity of hepatic fibrosis in patients with non-alcoholic fatty liver disease
David Thomas , Krishnadas Devadas, Jijo Varghese
Correspondence- David Thomas-davidmathew186@gmail.com
Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram 695 005, India
Introduction Non-alcoholic fatty liver disease (NAFLD) has progressively surpassed other etiologies in leading to the development of chronic liver disease. The clinical spectrum of NAFLD includes simple steatosis, non-alcoholic steatohepatitis (NASH) and fibrosis. Knowledge of the stage of NAFLD would greatly influence treatment and outcome. Numerous studies have outlined the association between visceral fat and fibrosis in NAFLD1. This study aimed at calculating visceral fat volume at the L3-L4 vertebral level which was then correlated with hepatic fibrosis as assessed by transient elastography.
Methods All patients above 18 years undergoing CT abdomen who were incidentally detected to have NAFLD were included. Transient elastography was performed to assess hepatic fibrosis. Patients were categorized into advanced fibrosis (>10 kpa) and those without (<10 kpa). AUROC was plotted to determine the cut off for visceral fat volume in predicting advanced fibrosis. Pearson correlation was used to calculate the variables that correlated with visceral fat volume.
Results Sixty-four patients which comprised 36 males and 28 females. Thirty-one (46%) were having advanced fibrosis (TE>10 kpA) and 34 (54%) patients without advanced fibrosis. Age, weight, BMI, visceral fat volume, ALP, HbA1c, FBS and ferritin were all found to be statistically significant between the 2 patient groups. AUROC curve for visceral fat in predicting advanced fibrosis was 0.733 and at a cut off of 167. 5cm3. Visceral fat had a sensitivity of 77.4% and a specificity of 51.5% in predicting advanced fibrosis. Subgroup analysis revealed visceral fat to be a predictor of advanced fibrosis in males with a BMI >25.
Conclusion Visceral fat measured at L3-L4 level with a cut off of 167.5 cm3 had a sensitivity of 77.4% and specificity of 51.5% in predicting development of advanced fibrosis in NAFLD. In male patients with a BMI >25 kg/m2 visceral fat was a predictor of advanced fibrosis.
160
Efficacy and outcome of endoscopic cyanoacrylate injection for gastric variceal bleed - A prospective observational study
Dharanesh Daneti , Senthamizh Selvan, Pazhanivel Mohan, Vikram Kate * , Abdoul Hamide
Correspondence- Senthamizh Selvan-senthamizh2909@gmail.com
Departments of Medical Gastroenterology, and *Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Gorimedu, JIPMER Campus, Puducherry 605 006, India
Introduction Gastric variceal bleeding (GVB) compared to esophageal varices is rare but often massive and associated with a high mortality. Endoscopic cyanoacrylate glue injection is the first line treatment for GVB. Hence, we conducted this study to assess the efficacy and short-term outcome of cyanoacrylate for gastric variceal bleed.
Methods This was a prospective observational study of patients with endoscopic cyanoacrylate treatment for GVB between June 2019 to July 2020. Demographic characteristics, details regarding etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate and survival at three months were collected.
Results A total of 39 patients underwent endoscopic cyanoacrylate injection for GVB. Their mean age was 48.2+-13.8 years with a male preponderance (n=23). 26 patients (66.7%) had cirrhosis, and half of them (n=13) were due to alcoholic liver disease. Gastric varices were GOV2 in 29 (74.4%), IGV1 in six (15.4%) and GOV1 in four (10.6%) patients. Varices were tortuous and medium sized in 21 (53.8%) and 16 (41%) patients respectively. Successful obliteration of gastric varices was achieved in 31 patients (79.5%). Median sessions required were 1 (1-4) and median volume of cyanoacrylate per session was 2 (1-6) mL. The procedure was associated with minor complications like transient abdominal pain in three (7.7%) and fever in one patient (2.6%). Rebleeding was observed in six (15.4%) patients, five of whom had a high MELD score. Cyanoacrylate failed in one patient (2.6%) who under-went emergency devascularization. Two patients (5.1%) died during follow-up due to advanced cirrhosis.
Conclusion In conclusion, our study demonstrated endoscopic injection of cyanoacrylate to be very effective and safe for gastric variceal bleed. The technical success was high and can be achieved in fewer sessions and smaller volume of cyanoacrylate during each session.
161
Change in muscle mass with nutritional therapy in cirrhotic patient- A randomized controlled trial
Gireesh Dhaked , Sudhir Maharshi, Sandeep Nijhawan
Correspondence- Gireesh Dhaked-dr.gireeshdhaked2210@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India
Introduction Sarcopenia has been associated with poorer survival in patients with cirrhosis. Nutrition may very well have a direct influence on sarcopenia and functional status. There is no study on the nutritional management of patients with sarcopenia. We performed a randomized controlled trial to assess the effects of nutritional therapy on sarcopenia in patients of cirrhosis.
Methods In a tertiary care setting in Jaipur, India, patients with cirrhosis with sarcopenia were randomly assigned to groups given nutritional therapy (30–35 kcal/kg/day, 1.0–1.5 g vegetable protein/kg/day; (n=49) or no nutritional therapy (patients continued on their same diet; (n=47) for 6 months. Sarcopenia was diagnosed based on computerized tomography psoas muscle index (PMI), handgrip strength, gait velocity. Primary endpoints were an improvement or worsening in sarcopenia at a 6month follow-up.
Result To date total 97 patients were enrolled. Thirty-eight patients were analyzed in each group. Alcohol (65.8%) was the most common etiology. Baseline characteristics like age, body mass index (BMI), hemoglobin, MELD score, mid-arm circumference (MAC), handgrip, gait velocity, and PMI were comparable in both groups. On 6 month follow-up, there was a significant improvement in MAC (22.80±1.63 vs. 21.18± 2.41, p-value- 0.003), handgrip strength (31.57±5.4 vs. 22.61±7.96, p-value- 0.03), gait velocity (0.96±0.20 vs. 0.73± 0.33, p-value < 0.05), PMI, (7.29±2.26 vs. 4.70 ±2.17, p-value- 0.001) in nutrition group compare to no nutrition group.
Conclusion Nutritional therapy is effective in the improvement of sarcopenia in cirrhotic patients.
162
Hepatic sinusoidal obstruction syndrome by oxaliplatin based chemotherapy in relapsed refractory case of diffuse large B cell lymphoma
Maitrey Patel , Apurva Shah, Shravan Bohra
Correspondence- Apurva Shah-apurvashah411@gmail.com
Department of Gastroenterology, Apollo Hospitals International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Bhat, Ahmedabad, Gujarat 382428
Introduction Hepatic sinusoidal obstruction syndrome (SOS) is commonly recognized vascular pattern of drug-induced liver injury and has been frequently associated with oxaliplatin-based chemotherapy.
Methods and Results In this case report, we describe a case of 70-years-old male who was diagnosed case of relapsed refractory diffuse large B cell lymphoma and received 3rd line chemotherapy R-GEMOX (Rituximab, Gemcitabine, Oxaliplatin, Ifosfamide. After receiving seven cycles of R-GEMOX, patient developed jaundice, abdominal distension, vomiting and 5 kg weight gain in one week duration. On examination he had tender right upper quadrant, icterus, pedal edema and gross ascites. Investigations revealed raised total bilirubin (13.1 mg/dL), elevated liver enzymes (SGOT 131U/L, SGPT 67U/L, ALP 114U/L, GGT 162U/L), total protein 4.8 gm/dL, albumin 2.6 gm/dL albumin: globulin 1.1, INR 1.45. Viral markers showed HBsAg positive, HBeAg and anti-Hbc IgM negative, HBV DNA viral load 69,56,53,574 IU/mL with HEV IgM positive. Ascitic fluid analysis showed high SAAG and low protein with fluid negative for malignant cells. CECT abdomen was showing multiple cystic lesions in liver in segment III, IVa, VI with moderate ascites. No splenomegaly, venous collaterals or changes of cirrhosis seen. Patient refused for liver biopsy. Repeat investigations revealed rising bilirubin (30.2 mg/dL) and SGPT-57 U/L so diagnosis of oxaliplatin induced HSOS, reactivation of hepatitis B, acute viral hepatitis E was made and treated with entecavir, therapeutic ascitic paracentesis, albumin and diuretics. He got better in initial two weeks but unfortunately after one-month patient expired due to advanced lymphoma.
Conclusion The incidence of oxaliplatin induced HSOS was 77.4%. Hepatic SOS should be included in the differential diagnosis of patients with rapid onset ascites, weight gain and jaundice following the administration of oxaliplatin based chemotherapy regimens.
163
Hepatic sarcoidosis with acute hepatitis E presenting as cholestatic jaundice in a young male
Apurva Shah , Shravan Bohra, Maitrey Patel
Correspondence- Apurva Shah-apurvashah411@gmail.com
Department of Gastroenterology, Apollo Hospitals International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Bhat, Ahmedabad 382 428, India
Introduction Hepatic sarcoidosis covers a broad spectrum from asymptomatic and slightly deranged liver function tests to clinically evident cholestasis or, in advanced cases, cirrhosis, portal hypertension.
Methods and Result We report a case of 30-year-old male without comorbidity presented with painless progressive jaundice without itching followed by abdominal distension, pedal edema and weight loss of 20 kilograms since three months. No history of hepatotoxic/alternative medicine present. On examination, pallor, icterus, pedal oedema, moderate ascites and right axillary lymphadenopathy. Investigations showed pancytopenia, cholestatic liver pattern with raised total bilirubin (13.5 mg/dL) with direct 12 mg/dL, albumin: globulin ratio 0.9, PT-INR 1.3, raised ACE level 97 U/L (Reference range 8-53U/L), IgM hepatitis E virus (HEV) positive with negative HBsAg and HCV antibody. anti-mitochondrial antibody was negative. Diagnostic ascitic fluid analysis showed high SAAG, low protein, ADA 29 U/L and fluid negative for malignant cell. Contrast enhanced CT abdomen showed mild hepatosplenomegaly with poorly enhancing ill-defined hypodense lesions in liver and spleen of granulomatous etiology with moderate ascites. HRCT thorax showed mild bilateral pleural effusion with normal lungs, axillary lymphadenopathy largest measuring 3.9*1.6 cm, no hilar lymphadenopathy. Axillary lymph node excision biopsy was inconclusive, so USG guided percutaneous liver biopsy was done and it showed non caseating epithelioid granulomatous disease likely sarcoidosis. Gene Xpert for M. tuberculosis was negative on both liver, axillary lymph node biopsy. Patient treated with oral steroid, got better symptomatically and biochemically at one week but lost to follow-up. This patent had hepatic sarcoidosis with cholestasis as a primary disease complicated by acute viral hepatitis E. He responded to oral steroids.
Conclusion Sarcoidosis should be kept in differential diagnosis of patient presenting with cholestatic liver pattern with lymphadenopathy and significant weight loss.
164
Terlipressin induced hyponatremia in patients with hepatocellular carcinoma presenting with acute variceal bleed in a cancer center
Utkarsh Chhanchure , Aditya Kale, Shaesta Mehta, Prachi Patil
Correspondence- Prachi Patil-prachipatil@gmail.com
Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Parel, Mumbai 400 012, India
Introduction Terlipressin is used in treatment of acute variceal bleeding due to its selective splanchnic and extrarenal vasoconstrictor effect by stimulation of V1 receptors. Due to its partial agonist effect on V2 receptors, it can also increase water reabsorption in the renal collecting ducts and cause hyponatremia. We planned a retrospective study to evaluate Terlipressin induced hyponatremia in patients with hepatocellular carcinoma (HCC).
Methods From August 2017 till August 2020, 32 patients with HCC presenting to our centre with variceal bleeding who were treated with Terlipressin were analyzed.
Results Among 32 patients, there were 29 males. Mean age was 53 years (range 27-75 years). Most patients had advanced BCLC stage (B-1, C-25 and D-6). All patient underwent endoscopic variceal ligation (EVL) at admission and were started on Terlipressin 1 mg 6 hourly for 3-5 days. Serum sodium decreased from a mean of 132.8 ± 3.6 mEq/L (126-139 mEq/L) to 128.2 ± 6.0 mEq/L (113-138 mEq/L) (p< 0.001) in 29 patients over 3 days. It decreased by ≤ 5 mEq/L in 16 patients (50%), by 5-10 mEq/L in 8 patients (25%) and >10 mEq/L in 5 patients (16%). In this latter group, serum sodium decreased from mean of 130.2 ± 2.1 to 117.2 ± 2.7 mEq/L and 2/5 patients developed neurological manifestations in the form of nausea, headache and mental confusion. Risk of hyponatremia decreased with increasing MELD score (p=0.037). Serum sodium returned to baseline values in most patients after stopping therapy. Four patients (all BCLC D with poor performance status) died during hospitalization due to other complications.
Conclusion Terlipressin can cause an acute reduction in serum sodium concentration in most patients with HCC during treatment for portal-hypertensive bleeding. It develops rapidly after starting therapy, may be severe in some patients where it can cause neurological manifestations, but is usually reversible.
165
Comparison of visceral and subcutaneous adipose tissue in lean and obese non-alcoholic fatty liver disease patients: An observational study
Manoj Kolhe, Anil Arora, Ashish Kumar, Praveen Sharma
Correspondence- Manoj Kolhe-manojck008@gmail.com
Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Non-alcoholic fatty liver disease (NAFLD) is major cause of cirrhosis in India and around the world. Asians are more predisposed to NAFLD at lower BMI rates as compared to west. Although lean NAFLD population has been shown to share metabolic features and hepatic pathology as the classical obese NAFLD, there is lack of linear correlation with adiposity. As per Framingham heart study the distribution of adipose tissue in the body has more relevance in the pathogenesis of lean NAFLD. Abdominal fat is compartmentalized into two parts, visceral and subcutaneous adiposity. Lean NAFLD patients also have visceral adiposity as obese populations. Visceral fat is a driving factor for insulin resistance, activation of innate immunity, hepatic inflammation and finally fibrosis. So it is a necessity of time to quantify subcutaneous and visceral adipose tissue in patients. It will help to understand the pathogenesis of lean NAFLD. We studied 52 patients, 25 were lean (BMI =< 23 kg/m2) and 27 were obese (BMI >23 kg/m2). We evaluated biochemical and imaging profile in both groups. We quantified the visceral and subcutaneous adipose tissue at 5th lumbar vertebra by non-contrast computed tomography scan. Thirty-six out of 52 patients had insulin resistance (HBA1c ≥5.7 gm%). This study showed that obese NAFLD group has higher visceral fat, subcutaneous fat and lower visceral to subcutaneous fat ratio (VSR). On subgroup analysis, non-diabetic lean NAFLD group had lower subcutaneous fat and VSR as compared to obese NAFLD group. In conclusion, lean NAFLD group had lower visceral and subcutaneous fat and higher VSR. Subcutaneous fat is more in obese NAFLD group. Visceral fat may be more associated with NAFLD than subcutaneous fat.
166
Clinical profile and factors influencing mortality of patients diagnosed with acute hepatitis E in a tertiary center in South India
Damodar Krishnan , Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Gastroenterology, Sri Ramachandra Institute of Higher Education and Research, No.1, Ramachandra Nagar, Porur, Chennai 600 116, India
Introduction In this study, we aimed to explore the clinical and epidemiological profile of all patients with hepatitis E virus (HEV) who were admitted to a tertiary care hospital in Chennai, India and to further assess various factors that influence the prognosis of these patients.
Methods Hospital records of patients who presented with features of acute hepatitis taking into consideration inclusion and exclusion criteria were taken from medical records from 2018-2020. History and clinical examination including the presence of signs of organ failure were obtained. Investigations collected included routine parameters with viral markers for HBV, HAV, HCV, HEV. Outcomes are recorded in the form of discharge or death.
Results Based on the inclusion and exclusion criteria, 43 patients were analyzed. Males had a higher (81.39% n=35) incidence of HEV infection. Yellowish discoloration of urine was the most common symptom (n=19, 44.19%) followed by fever (n=16, 37.21%), and icterus was the most common sign at presentation (n=28, 65.11%). Hepatomegaly was the most common finding on abdominal examination (n=10, 22.72%). Overall, mortality observed was 13.90% (n=6), including 2 patients presented as ACLF and 3 patients developed sepsis. Higher mean prothrombin time-international normalised ratio (PT-INR) (2.08 vs 1.41), total bilirubin (11.94 vs. 11.01 mg/dL), and direct bilirubin (7.35 vs. 6.43mg/dL) was associated with higher mortality, whereas lower mean serum albumin (2.86 vs. 3.06 gm/dL) was associated with higher mortality. Increase in renal parameters (i.e, BUN [44.17 vs. 14.46 mg/dL] and creatinine (1.98 vs. [1.08 mg/dL]) and electrolyte imbalances (i.e. hyponatremia [128.5 vs. 132 mmol/L]) were associated with higher mortality.
Conclusions Higher mean age, duration of hospital stay, PT-INR, total bilirubin, direct bilirubin, blood urea, serum creatinine, lower mean serum albumin, and sodium values were associated with higher mortality along with co-morbidities especially chronic liver disease which can result in ACLF and cause higher mortality.
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Circulating tumor cells assessment in patients with hepatocellular carcinoma by imaging flowcytometry and it`s relationship with staging - An interim analysis
Partha Debnath , Kruti Dalal * , Shreyasi Athalye * , Bhavik Dalal * , Saurabh Bansal, Prasanta Debnath, Sujit Nair, Siddhesh Rane, Shubham Jain, Sanjay Chandnani, Aruna Shankarkumar * , Pravin Rathi
Correspondence- Partha Debnath-partha628@gmail.com
*Department of Transfusion Transmitted Disease, National Institute of Immunohaematology (ICMR), Mumbai, India, and Department of Gastroenterology, Topiwala National Medical College, B Y L Nair Hospital, Mumbai 400 008, India
Introduction Circulating tumor cells are considered as potential biomarkers for the detection of hepatocellular carcinoma. It is expected to play an important role in early diagnosis and dynamic monitoring. This study aimed to evaluate the relationship of circulating tumor cells with hepatocellular carcinoma Barcelona clinic liver cancer (BCLC) staging.
Methods An imaging flow cytometry method, using immunofluorescence of cytokeratin, EpCAM, AFP together with the analysis of size, morphology and DNA content for detection of circulating tumor cells was developed and applied to 20 hepatocellular carcinoma patients and 10 patients with cirrhosis of liver without any evidence of hepatic or extrahepatic malignancy.
Results Among 20 hepatocellular carcinoma patients 17 (85%) were male. Two patients were BCLC stage A, 5 were BCLC stage B and 13 were BCLC stage C. Out of 10 cirrhotic patients 7 were CTP B and 3 were CTP C. Circulating tumor cells were detected in 20 of 20 patients of HCC and none among cirrhosis of liver patients. The mean number of circulating tumor cells was 9.9 (range 1- 20). Circulating tumor cells positive for EpCAM were detected in 18 patients with a mean value of 4.6. Circulating tumor cells positive for cytokeratin were detected in 16 patients with a mean value of 1.8. Circulating tumor cells positive for AFP were detected in all patients with a mean value of 3.5. The number of circulating tumor cells was significantly associated with BCLC stage (p<0.0005) and portal vein thrombosis (p=0.025).
Conclusion This study shows the potential role of circulating tumor cells as a biomarker of hepatocellular carcinoma and also a significant association between the number of circulating tumor cells with BCLC staging and portal vein thrombosis.
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Predictors of response to therapy with terlipressin and albumin in patients with cirrhosis and hepatorenal-acute kidney injury according to new International club of ascites criteria
Jatin Agrawal , Ashish Kumar, Anil Arora, Praveen Sharma, Naresh Bansal, Vikas Singla
Correspondence- Ashish Kumar-jatinagrawal1989@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Introduction Hepatorenal syndrome-acute kidney injury (HRS-AKI) or HRS -1 carries high short-term mortality in patients with advanced cirrhosis. Recently International club of ascites (ICA) has proposed new definition criteria for HRS and at present we lack literature on the predictors of response of terlipressin according to this new definition. So, we aimed to evaluate the response rate of terlipressin and factors affecting the response rate according to this new HRS-AKI definition.
Methods We performed a prospective study on 114 cirrhotic patients with HRS-AKI diagnosed according to ICA definition 2015 from August 2018 to April 2020 using terlipressin and albumin. Baseline clinical and biochemical details were noted. Response was defined as improvement in serum creatinine within 0.3 mg/dL of baseline (if baseline s. cr <1.5 mg/dL) or < 1.5 mg/dL (if baseline s. cr >1.5 mg/dL). Further responder and non-responder were followed up to 90 days or death.
Results Among 114 HRS-AKI patients the median age was 52.5 years and 83.3% were male. Response to terlipressin was seen in 70 (61.4%) patients. On subgroup analysis, response rate in acute decompensation (AD) was seen in 37 (78.7%) patients and in acute on chronic failure (ACLF) was seen in 32 (47.7%) patients. Independent predictive factors of response to therapy were serum creatinine before start of terlipressin and baseline Child-Pugh score (CTP). Response to therapy was associated with improved 90 days survival compare to patients with non-response (69.56 % vs. 10%, p<0.00001). The best cut off for serum creatinine that best predicted response to treatment was 2.3 mg/dL (AUROC, 0.79; p<0.0001; sensitivity, 87%; specificity, 64%). and for CTP was 12 (AUROC, 0.72; p<0.0001; sensitivity, 84%; specificity, 58%).
Conclusions Serum creatinine before start of terlipressin and CTP predicts response to terlipressin in HRS-AKI. Early transplantation should be considered in patients of HRS low likelihood of response.
169
HCC mimickers: Unusual presentation
Abhishek Mahajan , Shiran Shetty, Ganesh Bhat, Ananth Pai
Correspondence- Abhishek Mahajan-abhi141191@yahoo.co.in
Department of Gastroenterology, Kasturba Medical College, Manipal 576 104, India
Carcinoid tumors are neuroendocrine origin neoplasms producing serotonin and other functional peptide hormones. 74% carcinoid tumors arise from GI tract of which 75% metastasize to liver. We present 2 patients with features of HCC on CT abdomen but were later diagnosed with NET after histology analysis.
1st case: 43-year-old female presented with low grade fever and loss of appetite since 1 month. Ultrasound abdomen showed multiple hyperechoic lesions in liver. CECT abdomen suggested multifocal hepatocellular carcinoma involving both lobes, largest lesion measuring 10.8 x 9.2 x 14.2 cm. Biopsy revealed neuroendocrine tumor grade-1, IHC positive for synaptophysin and Ki 67 index 2%. Ga-68 DOTANOC PET CT showed multiple somatostatin receptors avid retroperitoneal lymph node and liver metastasis.
Arterial phase Portovenous phase Delayed phase
2nd case: 60-year-old female presented with loss of appetite and mild right hypochondriac pain since 1 month. CECT abdomen showed few lesions in liver suggesting multifocal HCC. Biopsy revealed NET – grade 1 with IHC positive for synaptophysin and chromogranin. Ga-68 DOTANOC PETCT showed multiple somatostatin receptor avid hepatic nodules and para aortic lymphadenopathy.
Arterial phase Porto venous phase Delayed phase
Hence, it’s important to know conditions mimicking imaging appearance of HCC to avoid false-positive diagnosis of HCC and subsequent management. A multimodality imaging approach along with a careful review of clinical and laboratory findings can be helpful when in doubt for these potential tumor mimicking lesions.
170
Atherosclerotic cardiovascular disease (ASCVD) risk assessment in non-alcoholic steatohepatitis (NASH), alcoholic steatohepatitis (ASH), and both alcoholic and non-alcoholic steatohepatitis (BASH)
Dinesh Meher , Debakanta Mishra, Chitta Ranjan Khatua, Subhendu Panigrahi, Rakesh Barik, Saroj Kanta Sahu, Subhasish Pradhan, Gautam Nath, Reshu Khandelwal, Prajna Anirvan, Mrinal Gogoi, Pankaj Bharali, Shivaram Prasad Singh
Correspondence- Shivaram Prasad Singh-scb_gastro_dept@hotmail.com
Department of Gastroenterology, S C B Medical College and Hospital, Cuttack 753 007, India
Introduction Alcoholic steatohepatitis (ASH) and non-alcoholic steatohepatitis (NASH) are known to possess increased atherosclerotic cardiovascular disease (ASCVD) risk. Although, there are studies correlating severity of liver injury with future cardiovascular risks in ASH and NASH, in cases of BASH there is very little data on future ASCVD risks.
Aim To assess and compare future ASCVD risks for ASH, BASH, and NASH patients.
Methods We studied 934 patients with fatty liver during 2010-2019. They were classified into 3 groups: ASH, BASH, and NASH on the basis of obesity (BMI ≥25) and alcohol intake. After appropriate matching, 551 included for statistical analysis. Future cardiovascular risk was assessed using American College of Cardiology (ACC)/American Heart Association (AHA) guideline of 2013.
Results Of 551 patients, 73 had ASH, 185 had BASH and 253 had NASH. Using calculator provided by ACC/AHA, median 10-years ASCVD risk for ASH, BASH and NASH was 4.2%, 2.5% and 1.8% whereas for control groups (similar characteristics and optimal risk factors), the median values were 1.7%, 1.3% and 1.2% respectively with significant differences among them (p<0.0001, 0.0001 and 0.004 respectively). Similarly, the median lifetime ASCVD risk for each groups was 36%, whereas for control groups (50 year-old persons with optimal risk factors), it was 5% (p<0.0001) in each. When inter group comparison was made among the three groups, median 10 years ASCVD risk was higher in ASH group while median lifetime risk was same across all 3 groups.
Conclusion Our study shows that in ASH, BASH and NASH, the 10-year and lifetime ASCVD risk are higher compared to normal healthy individuals of same age and optimal risk factors. Among the three groups, 10-year median ASCVD risk was highest in ASH although the median lifetime risk was same across all three groups.
171
Transjugular intrahepatic portosystemic shunt for refractory ascites in Gaucher’s disease: First case report in literature
Kunal Adhyaru , Pratik Jaydeokar, Aabha Nagral, Shaji Marar *
Correspondence- Kunal Adhyaru-getkunal12@yahoo.com
Departments of Gastroenterology and Hepatology, and *Interventional Radiology, Jaslok Hospital and Research Centre, 15, Pedder Road, Mumbai 400 026, India
Gaucher’s disease is a rare disease, but the most common amongst the lysosomal storage disorders in India. Patients present with cytopenias and massive splenohepatomegaly arising from deficiency of beta glucosidase enzyme. Splenectomised patients may develop portal hypertension and its complications. The main stay of treatment is enzyme replacement therapy (ERT).
We report a case of 30-year-old man diagnosed at the age of 8 years with Gaucher’s disease (L444P variation) when he was splenectomised for a massive splenomegaly. He also had recurrent bone crisis and underwent bilateral hip joint replacement for avascular necrosis of the femoral head. He had variceal bleeding two years back followed by development of ascites which had become refractory in the past 6 months. He was referred to us for liver transplantation. On examination, he was sarcopenic, had tense ascites, with hugely dilated veins on the abdominal wall. Investigations revealed pancytopenia and liver function tests revealed mildly elevated transaminases and an albumin of 1.5g/dL. He had a high SAAG ascites. He underwent a transjugular study and was found to have an HVPG of 22 mm Hg. Transjugular intrahepatic portosystemic shunt (TIPS) was performed with post TIPS pressures fell to 2 mmHg. The ascites and the dilated abdominal veins resolved significantly after the TIPS procedure over a period of 2months. He also been started on ERT (imiglucerase).
Few cases of Gaucher disease needing liver transplantation for end-stage liver disease have been reported in literature with one of these patients needing TIPS for variceal bleeding. However, ours is the first Gaucher disease patient in literature to have received a TIPS for management for refractory ascites
Conclusion TIPS can be used to successfully treat refractory ascites secondary to severe Gaucher related liver disease.
172
Profile of liver abscess patients in a tertiary care hospital
Ashutosh Gupta , Vinod Kumar Dixit, S K Shukla, D P Yadav, Anurag Tiwary
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
Introduction Liver abscess is a common disease entity and early diagnosis and prompt intervention improve the survival and outcome of the disease. The objective of the study is to assess the clinical profile and management of liver abscess in the patients attending tertiary care hospital.
Methods This is a retrospective cross-sectional study carried out from January 2019 to February 2020. A total of 138 patients presenting with signs and symptoms of liver abscess were accessed. Confirmation of diagnosis was made by abdominal ultrasound and examination of aspirates.
Results The mean age of patients was 43.54 years and majority of them (86.7 %) were males. There was a strong correlation of the occurrence of liver abscess with addiction to alcohol and history of diabetes mellitus. Most common presenting complaint was pain abdomen (91.3%) followed by fever (85.5%), vomiting (27.5%) and abdominal distension (10.1%). Clinical examination revealed tender hepatomegaly in (70.5%) of cases while ascites, pleural effusion and icterus were present in (23.6%), (26.8%) and (13.04%) cases respectively. On evaluation, mean TLC was 15860/cumm, serum albumin was (2.78 gm/dL) while serum creatinine was raised in (8.69%) of patients. The abscess were predominantly in right lobe (73.9%) and solitary (53.62%) with mean volume of 363.8 mL. Left lobe abscess were present in (10.1%) while both lobes were involved in (17.39%) of patients. Etiological analysis revealed that 79% were amebic, 18% pyogenic and 1.4% were tubercular in origin. Percutaneous needle aspiration was done in 73.9%, pigtail drainage in 23.1% and surgical intervention for rupture in 2.8% patients. Mortality rate was 1.4%.
Conclusion The commonest presentation was in the middle aged males with history of alcohol intake having right lobe solitary amebic liver abscess. Minimally invasive drainage techniques reduced mortality.
173
Neutrophil lymphocyte ratio and platelet lymphocyte ratio are excellent markers for predicting survival and severity of hepatocellular carcinoma
Sagar Walinjkar, Ashish Kumar, Praveen Sharma, Naresh Bansal, Vikas Singla
Correspondence- Anil Arora-dranilarora50@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Background and Aims Hepatocellular carcinoma (HCC) is the 5th most common malignancy worldwide. Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are the markers which have been proven useful in prognostication of many malignancies. We aimed to evaluate the predictive value of NLR and PLR in prognosticating patients with HCC and to study its association with severity of HCC.
Methods Patients with newly diagnosed HCC getting admitted at our centre were included in the study. The imaging features, ECOG status and liver functional status were analyzed and BCLC staging was done. Patients were given treatment according to the BCLC stage. Pre-treatment NLR and PLR were calculated from differential leukocyte count. Repeat imaging was done at 1- and 3-months post treatment. Patients were followed up for 6 months for survival. Optimum cut off values of NLR and PLR were calculated by ROC curve analysis. The OS at 6 months was compared on Kaplan-Meier curve using high and low NLR, PLR values. Association between NLR and PLR was also tested with BCLC stages.
Results The optimum cut off for high NLR and PLR were >= 3 and >= 102 respectively. OS rates at 6 months in patients with NLR >= 3 and < 3 were 41% and 93.5% (p< 0.01) and with PLR >= 102 and < 102 were 34% and 88% respectively (p< 0.00). 90.47 % and 96% of BCLC stage C and D had NLR >= 3 (p 0.000) whereas 71.42% and 84% of BCLC Stage C and D had PLR >= 102 (p 0.000).
Conclusion NLR and PLR are strong markers for predicting survival and severity in patients with HCC.
174
Evaluation of fibrosis by transient elastography (Fibroscan) and acoustic radiation force impuse elastography in Type II DM individuals without overt liver disease
Manjit Kanungo , A Satya Sahi, L R S Girinath
Correspondence- Manjit Kanungo-drmanjitkanungo@gmail.com
Department of Gatroenterology, Andhra Medical College, Jagadamba Junction, Visakhapatnam 530 002, India
Introduction Patients with non-alcoholic fatty liver disease (NAFLD) and T2DM have up to 20% advanced fibrosis. Clinicians treating the diabetic population are underestimating the covert hepatic injury which account for future complications. This study was conceived to assess the fibrosis in Type 2 DM without overt liver disease by comparison of various non-invasive fibrosis scores with Fibroscan and acoustic radiation force impuse (ARFI) and risk factor determination for advanced fibrosis.
Methods This was a cross-sectional study including Type 2 DM patients attending Endocrinology OPD of AMC between March 2019 to April 2020 with steatosis on ultrasound. BMI >35 kg/m2, alcohol intake (men >20 g/d and women >10 g/d), drugs causing steatosis, hepatitis viral markers were excluded.
Results Among total 100 patients, mean age was 57.80 years. Mean BMI was 28±2.09 kg/m2. No subject had ALT or AST ≥ 2 x ULN. The mean value of APRI, NFS, FIB4, ARFI and LSM were 0.41±0.24, -0.58±1.37, 1.56±0.91, 1.44±0.39 and 8.94±2.71 respectively. 0%, 17%, 15%, 47% and 47% were categorized advanced fibrosis (F3/F4) by APRI, NFS, FIB 4, ARFI and LSM respectively. There was an increasing trend of HbA1c with fibrosis stage (mean HbA1c=10.54 in F4 group). 28%, 3% and 12% subjects having advanced fibrosis by LSM values were categorised under low group of APRI, NFS and FIB 4 respectively. Majority of advanced fibrosis subjects who were missed by the non-invasive scores had values in the intermediate groups. APRI, NFS, FIB 4 and ARFI correlated significantly with Fibroscan (r=0.374, r=0.594, r=0.411, r=0.963, p< 0.001). The AUROC of APRI, NFS, FIB 4 and ARFI for advanced fibrosis were 0.683, 0.676,0.703 and 0.886 respectively. On multivariate analysis, duration of T2DM, platelet count and albumin levels were significantly associated with LSM.
Conclusions ARFI had significant correlation with Fibroscan for predicting advanced fibrosis. Fibroscan and ARFI are useful in assessing the subjects in the intermédiate zones of the various non-invasie scores.
175
Sarcoidosis presenting as acute liver failure-the first case report
Smitkumar Vaghasia , Yogesh Batra, Milan Kumar Vaghasia
Correspondence- Smitkumar Vaghasia-vaghasiasmit@gmail.com
Department of Gastroenterology, Indraprastha Apollo Hospital, Mathura Road, New Delhi 110 076, India
Introduction Sarcoidosis is a chronic multisystem disease with different clinical presentations. Asymptomatic presentation (75%) is the commonest, but others include jaundice with chronic cholestasis, cirrhosis, portal hypertension, hepatic venous outflow tract obstruction and extrahepatic biliary obstruction. Cirrhosis and portal hypertension are the rarest manifestation of hepatic sarcoid and represent less than 1% of all cases. Acute liver failure as a presentation of sarcoidosis has never been reported before. Here we present a patient of sarcoidosis presenting with acute liver failure.
Case A 60-year-old man was admitted to the Indraprastha Apollo Hospital, New Delhi with complaints of fever, jaundice, altered mental status for 2 days. He had history of pulmonary sarcoidosis 20 years back for which he took medication for around 10 years after that he stopped medication. Based on history, clinical and investigational analysis, the patient was diagnosed as a case of acute liver failure (ALF) with acute insult being probable sarcoid flare secondary to pulmonary sarcoidosis.
Management He was started on weight based corticosteroid therapy, with other anti-hepatic coma measures. The patient did not recover clinically and manifestations of hepatic encephalopathy, worsened substantially. He was kept on ventilatory, inotropic, CRRT and other supportive treatment. Patient’s relatives were explained for liver biopsy (transjugular approach) and liver transplant repeatedly but they refused for the same due to some financial constraints and we lost the patient.
Conclusion The patient of sarcoidosis may present as acute liver failure. Conservative management of acute liver failure in sarcoidosis associated with an increased risk of mortality.
176
Association of lifestyle and metabolic risk factors with grades of fatty liver
Swapna Chaturvedi *, Neena Bhatia*, Naval K Vikram, Kumble S Madhusudan, Ravindra Mohan
Correspondence- Swapna Chaturvedi-swapnaaiims@gmail.com
Department of Dietetics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and *Department of Dietetics, Lady Irwin College, University of Delhi, India
Background and Aim Non-alcoholic fatty liver (NAFL) is a public health problem in India. We aimed to study association of lifestyle and metabolic risk factors with grades of fatty liver (FL).
Methodology NAFL (n=160) cases constituted the study group, FL was diagnosed by ultrasound of abdomen. Anthropometric and biochemical parameters were recorded. Lifestyle risk factors (physical activity, diet, nutrient, snacks and alcohol intake) and metabolic risk factors as per standard cut-offs were compared in different grades of FL.
Results Grade 1 FL was present in 69% and grade 2 in 31% of subjects. The prevalence of lifestyle risk factors were higher in grade 2 FL vs. grade 1 FL but were non-significant: Low physical activity (57.1% vs. 55.8%), snack intake (87.7% vs. 81.0%), saturated fatty acid >8% of total calories (18.3% vs. 16.2%), edible oil >25 g for males and >20 g for females (93.8% vs. 90.9%) alcohol intake (81.6% vs. 78.3%). The prevalence of metabolic risk factors were significantly higher in grade 2 FL versus grade 1 FL: BMI > 25 (87.7% vs. 61.2%), waist circumference (75.5% vs. 45.0%), WHR (91.8% vs. 76.5%), IGT (24.4% vs. 6.3%), triglycerides (53.0% vs. 28.8%), metabolic syndrome (MetS) (46.9/% vs. 22.5%). On univariate regression analysis, grade 2 FL showed positive association with metabolic factors (OR [95% CI]) for BMI > 25 (11.38 [1.46- 18.37]), waist circumference (3.7 [1.77-7.97]), WHR (3.4 [1.13-4.47]), IGT (4.8 [1.76-13.16]), triglycerides (2.7 [1.39-5.59]), MetS (3.0 [1.48-6.22]).
Conclusions The worsening grades of fatty liver are associated with metabolic risk factors and should initiate workup of patients to avoid progression of NAFL to severe forms.
177
The triglyceride and glucose index (TyG) as screening biomarker to identify non-alcoholic fatty liver disease
Hozefa Runderawala, Nutan Desai
Correspondence- Hozefa Runderawala-hozaaee@gmail.com
Department of Gastroenterology, Fortis Hospital Mumbai, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is associated with insulin resistance. The triglyceride and glucose index (TyG), which is defined as the product of an individual’s serum levels of triglycerides (TG) and fasting plasma glucose (FPG), has been recommended as a reliable and simple surrogate index for insulin resistance. NASH is diagnosed on basis of ultrasound and biochemical tests and exclusion of other etiologies for liver disease. We compare the ability of triglyceride and glucose index (TyG), compared with alanine aminotransferase (ALT), to identify individuals at risk for NAFLD.
Methods Patients more than 18 yrs of age attending our institution health check-up OPD were screened as per inclusion and exclusion criteria between December 2019- March 2020. Pregnant women and those with significant alcohol intake, history of diabetes mellitus, hypertension, dyslipidemia, viral hepatitis or any known liver disease were excluded. Routine blood parameters were noted and fatty liver assessed as the presence or absence of hepatic steatosis by abdominal USG. The TyG is calculated with established formula: TyG= Ln (Tg [mg/dL] X FBS [mg/dL]/2).
Results A total of 95 people were enrolled, among which 53 were (56%) found to have fatty liver by abdominal USG. TyG index was calculated by using above mentioned formula and taking cut off value of 8.6, and that for ALT of 40 IU/L, Sensitivity of TyG index is 72% and for ALT is 27.08%, also negative predictive value (NPV) for TyG index is 82.35% and for ALT is 54.5%. By using McNemar Chi-square Test, p value is found to be significant with p <0.01.
Conclusion TyG index is found to have higher sensitivity in comparison with ALT for an effective screening biomarker to identify NAFLD.
178
Non-alcoholic fatty liver disease as independent risk factor for coronary artery disease
Simna L , Krishnadas Devadas, Anjukrishna K, Nibin Nahaz, Jijo Varghese, Tharun Tom Oommen, Athul Hareendran
Correspondence- Simna L-shyamsasi04@gmail.com
Department of Medical Gastroenterology, Government Medical College, Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Background Non-alcoholic fatty liver disease (NAFLD) is currently the most common cause of chronic liver disease. The leading cause of mortality in NAFLD patients is coronary artery disease (CAD). Our study attempts to evaluate whether NAFLD is an independent risk factor for CAD and to study the correlation between hepatic steatosis and fibrosis with subclinical atherosclerosis.
Methods Case control study.125 cases with angiographic proven CAD and 125 controls with normal angiogram were enrolled after informed consent and subjected to sonography and blood investigations. Carotid intima media thickness (CIMT) measurement was also done to assess subclinical atherosclerosis. Hepatic steatosis was measured by sonographic grading of fatty liver. Liver stiffness measurement was done to assess fibrosis.
Results 65.6% (82/125) of cases were found to have NAFLD and it was found to be an independent risk factor for CAD (adjusted OR= 2.6955, p=0.0079). On multivariate analysis, the other independent risk factors for CAD were male gender (adjusted OR=52.8314 (17.6521 - 158.1206), p=0.001), waist to hip ratio (adjusted OR=59.7407 (1.6755 - 2130.0431), p=0.0249), Type 2 diabetes mellitus (adjusted OR=2.3453 (1.1574-4.7526), p=0.018), systemic hypertension (adjusted OR=2.9748 (1.4559-6.0785, p=0.0028) and smoking (adjusted OR=2.087 [1.2333 - 3.5316], p=0.0079). Mean CIMT did not differ between the two groups. Subgroup analysis of NAFLD patients showed that mean CIMT differ significantly between NAFLD with and without CAD patients. A mean CIMT value of 0.55 mm had a sensitivity of 81% and specificity of 68% (AUROC=0.696, p=0.0001) in predicting CAD in NAFLD patients. Hepatic steatosis measured by sonographic grading of fatty liver correlated with CIMT (r=0.423, p<0.001). Liver fibrosis measured by liver stiffness measurement did not correlate with CIMT (r=0.09, p=0.117).
Conclusions NAFLD is a risk factor for CAD independent of other traditional risk factors. In NAFLD patients hepatic steatosis not fibrosis correlated with subclinical atherosclerosis.
179
Clinico-biochemical risk factors for non-alcoholic steatohepatitis and significant fibrosis in patients with non-alcoholic fatty liver disease
Saroj Kanta Sahu , Rakesh Kumar Barik, Subhasis Pradhan, Dinesh Meher, Reshu Khandelwal, Gautam Nath, Prajna Anirvan, Pankaj Bharali, Mrinal Gogoi, Prasant Kumar Parida, Sambit Kumar Behera, Kaibalya Ranjan Dash, Shivaram Prasad Singh, Kaumudi Pattnaik, Pallavi Bhuyan
Correspondence- Shivaram Prasad Singh-scb_gastro_dept@hotmail.com
Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Introduction and Aim In patients with non-alcoholic fatty liver disease (NAFLD) presence of non-alcoholic steatohepatitis (NASH) and/or significant fibrosis (stage 2 to 4) is a key driver of liver disease-related morbidity and mortality. Our aim is to identify the clinical and biochemical risk factors associated with the presence of NASH and significant fibrosis.
Methods Two hundred and forty-three consecutive biopsy-proven NAFLD patients with clinical, anthropometric, biochemical, and liver biopsy data (from 2013 to 2020) were included in the study. Appropriate statistical analysis was done. P-value <0.05 was considered significant.
Results The mean age of patients was 40.14 ± 9.36 years (range: 17 to 64 years) with a male to female ratio of 5.5:1. On liver biopsy 75 (37.28%) patients had definite NASH and among them, 11 (15.1%) had significant liver fibrosis (stage 2 or 3). Patients with concomitant NASH and significant fibrosis had significantly higher BMI, waist circumference, fasting blood sugar, and serum aspartate aminotransferase levels. On univariate analysis high AST/ALT ratio, TC/HDL ratio >3.5, insulin resistance (IR) (HOMA IR >2) were the risk factors for concomitant NASH and significant fibrosis. On multivariate logistic regression analysis, the only risk factors significantly associated with concomitant NASH and significant fibrosis were high TC/HDL ratio (OR= 1.524, 95% CI= 0.591-2.821, p=0.001) and IR (OR=1.224, 95% CI= 0.360-2.684, p=0.047).
Conclusion Insulin resistance and TC/HDL ratio >3.5 were the independent risk factors for the presence of concomitant NASH and significant fibrosis. Patients with fibrotic NASH are at higher risk of disease progression. So a high TC/HDL ratio >3.5 and insulin resistance could identify the cohort of patients who are at risk of progression of NAFLD and need timely intervention with lifestyle modification and drugs.
180
A comparative study of non-A-E hepatitis with acute viral hepatitis and autoimmune hepatitis - An interim analysis
Siddhesh Rane , Rahul Deshmukh, Shubham Jain, Sujit Nair, Saurabh Bansal, Sameet Patel, Qais Contractor, Pravin Rathi
Correspondence- Siddhesh Rane-sid.6173@gmail.com
Department of Gastroenterology, Topiwala National Medical College, B Y L Nair Charitable Hospital, Mumbai 400 008, India
Introduction The objective was to compare clinical/laboratory features (and histopathology as needed) of non-A-E hepatitis with acute viral and autoimmune hepatitis (AIH) and determine whether etiology is likely to be viral or autoimmune.
Methods Cases of acute hepatitis were evaluated to segregate acute viral, autoimmune and non-A-E hepatitis. Viral hepatitis was diagnosed by viral serology. All the patients with negative viral serology and revised AIH score between 10-14 (probable AIH) underwent liver biopsy. Patients with negative conventional serology for AIH were tested for other liver-defined autoantibodies. Those with post-biopsy revised AIH score > 15 were diagnosed as AIH and rest were considered as non-A-E hepatitis. Patients were followed up for 3 months.
Results Of 107 patients presenting with acute hepatitis, 8 (7%) had non-A-E hepatitis, 10 (10%) AIH (acute presentations), 13 (12%) acute viral hepatitis (hepatitis A, B, E). Jaundice, anorexia and nausea were the most common presentations (100%) of non-A-E hepatitis followed by fatigue (87.5%). Three out of 8 (37.5%) patients with non-A-E hepatitis were males. Median age was 44 years (range 15-55). Total bilirubin was 11 mg/dL (range 4.5-16.1), aspartate and alanine aminotransferases were 575 and 717 U/L (range 273-1665 and 445-2245 U/L, respectively). Two (25%) patients had anti-nuclear antibody and 1 (12.5%) had anti-smooth muscle antibody positive. Three (37.5%) had raised immunoglobulin G (median 14.6 gm/L, range 11.1-28.2 gm/L). No patient developed liver failure or recurrent hepatitis. Bilirubin, aspartate and alanine aminotransferases were not significantly different between all the groups. Non-A-E hepatitis is more likely to have albumin >3.5 gm/dL compared to AIH (p=0.006) but no difference in INR seen. Patients with AIH are more likely to have anti-nuclear and anti-smooth muscle antibodies (p=0.01), raised immunoglobulin G (p=0.006), interface hepatitis/lymphoplasmacytic infiltration/rosette formation on histopathology (p=0.0001) as compared to non-A-E hepatitis.
Conclusion Non-A-E hepatitis can present as a self-limiting illness. Etiology is less likely to be autoimmune.
181
Change in frailty status with nutritional therapy in cirrhotic patient: A randomized controlled trial
Surendra Khunte , Sudhir Maharshi
Correspondence- Sudhir Maharshi-sudhir.maharshi@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College and attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Frailty is characterized by low physiologic reserve and decreased functional status. Whether frailty status in patient with cirrhosis reduces with nutritional intervention is not well studied. Aim was to assess the effects of nutritional therapy on change in frailty status in cirrhotic patients.
Methods In a tertiary care centre in Jaipur, India, patients with cirrhosis were randomly assigned to groups received nutritional therapy (30–35 kcal/kg/day, 1.0–1.5 g vegetable protein/kg/day; (n= 47) or no nutritional therapy (patients continued on their same diet (n = 47) for 6 months. Frailty status was assessed by liver frailty index (LFI) and gait velocity. Primary endpoints were improvement or worsening in frailty status at the end of 6 months.
Results Till date total 104 patients were enrolled. Forty patients were analyzed in each group. Alcohol (70%) was most common etiology. Baseline characteristics like age, body mass index (BMI), hemoglobin, MELD score, mid arm circumference (MAC), hand grip, gait velocity and LFI were comparable in both the groups. At the end of 6 months there were significant improvement in hand grip strength (30.02 ± 3.01 vs. 26.17 ± 3.14, p= <0.001), MAC (24.59 ± 2.5 vs. 21.16 ± 2.27, p= < 0.001), gait velocity (0.91 ± 0.25 vs. 0.69 ± 0.32, p= <0.002) and LFI (3.84± 0.34 vs, 4.14 ± 0.32, p= <0.001) in nutritional therapy group compare to no nutritional therapy group.
Conclusion Based on a randomized controlled trial performed, nutritional therapy is effective in the improving the frailty status.
182
Small intestinal bacterial overgrowth in patients with non-alcoholic fatty liver disease- A tertiary care centre experience
Gursimran Kaur , Rinkesh Kumar Bansal, Avnish K Seth, Varun Gupta, Gourdas Choudhuri
Correspondence- Gourdas Choudhuri-choudhuri.gour@gmail.com
Department of Gastroenterology and Hepatobiliary Sciences. Fortis Memorial Research Institute, Sector - 44, Opposite HUDA City Centre, Gurugram 122 002, India
Background The pathogenesis of non-alcoholic fatty liver disease (NAFLD) is multifactorial. The gut microbiota has been suspected to contribute to the pathogenesis of NAFLD through several mechanisms. We evaluated the prevalence of small intestinal bacterial overgrowth (SIBO) in NAFLD and its association with various lab parameters and anthropometric measurements.
Methods One hundred patients with NAFLD (63 males)- diagnosed by imaging, were enrolled. They were subjected to glucose hydrogen breath test (GHBT). Anthropometric parameters and lab parameters (liver function tests, lipid profile, platelet count) were noted.
Results Of 100 NAFLD patients, 43/100 (43%) had SIBO. A significantly higher number of patients with SIBO had elevations in transaminases: AST (55.56% vs. 44.44%, p=0.029), ALT (60.61% vs. 39.39%, p<0.006). There was also a significant relative risk of increase in transaminases with SIBO –positive status: AST - 1.657 (95% CI, IQ range 0.985-2.788), and ALT- 2.039 (95% CI, IQ range 1.165-3.568). Both these findings were more pronounced in females. The mean AST (38.58 ± 16.66 IU/L vs. 32.28 ± 15 IU/L, p = 0.025) and mean ALT (41.12 ± 21.28 IU/L vs. 33.96 ± 19.65, p= 0.043) values were also higher in patients with SIBO. Majority of patients enrolled in our study had high BMI (32.05 + 3.07 kg/m2), increased waist circumference (36.29 + 4.88 inches) and high mean cholesterol (167.4 ±30.22 mg/dL). There was no significant relation of SIBO with grade of obesity, increased waist circumference, lipid profile (including serum triglyceride levels) or aspartate aminotransferase to platelet ratio index (APRI) score in our patients.
Conclusion SIBO is prevalent in NAFLD patients and is associated with significant derangement in aminotransferases. Patients with SIBO may benefit from aggressive control of risk factors for NAFLD.
Keywords SIBO, NAFLD, Dysbiosis, Hydrogen breath test
183
Small intestinal bacterial overgrowth is more prevalent in non-alcoholic fatty liver disease
Gursimran Kaur , Rinkesh Kumar Bansal, Avnish K Seth, Mahesh Kumar Gupta, Gourdas Choudhuri
Correspondence- Gourdas Choudhuri-choudhuri.gour@gmail.com
Department of Gastroenterology and Hepatobiliary Sciences. Fortis Memorial Research Institute, Sector - 44, Opposite HUDA City Centre, Gurugram 122 002, India
Background The underlying mechanism for the development and progression of non- alcoholic fatty liver disease (NAFLD) is complex and multifactorial. Studies have suggested the role of gut microbiota and, association of small intestinal bacterial overgrowth (SIBO) with NAFLD. We investigated the frequency of a SIBO in NAFLD.
Methods One hundred patients with NAFLD-diagnosed by imaging, and 20 healthy volunteers were enrolled. They were subjected to glucose hydrogen breath test (GHBT) for detection of SIBO. Anthropometric parameters were noted and compared in both groups. Lab parameters were noted in NAFLD patients.
Results Of 100 patients of NAFLD 43/100 (43%) tested positive for SIBO, and 6/20 (30%) tested positive in control group. This was not a statistically significant difference (p=0.140). Obesity parameter remained associated with NAFLD-healthy volunteers had a significantly lower BMI (27.09 + 4.03 kg/m2 vs. 32.05 + 3.07 kg/m2, p=<0.001), waist circumference (32.05 + 3.07 inches vs 36.29 + 4.88 inches , p=<0.001) than NAFLD patients. In NAFLD patients-elevation in transaminases was significantly more prevalent in patients with SIBO: AST (increased in 55.56% vs. 44.44%, p=0.029), ALT (increased in 60.61% vs. 39.39%, p< 0.006). Also, among those testing positive for SIBO in NAFLD- the relative risk of increase in transaminases was significant: AST - 1.657 (95% CI, IQ range 0.985-2.788), and ALT- 2.039 (95% CI, IQ range 1.165-3.568).
Conclusion SIBO is more prevalent in NAFLD, than healthy population. Obesity parameters remain associated with NAFLD. SIBO may contribute to progression of liver disease.
SIBO, Hydrogen Breath Test, Gut microbiota, NAFLD
184
Langerhans cell histiocytosis - a rare and unusual case of obstructive jaundice in a child
Harsha Vardhan Ganta , Ramesh Kumar B, Ramanna M
Correspondence- Harsha Vardhan Ganta-drharsha.rocks@gmail.com
Department of Medical Gastroenterology, Osmania General Hospital, Afzalgunj Road, Afzal Gunj, Hyderabad 500 001, India
Background Langerhans cell histiocytosis (LCH) is an abnormal accumulation of Langerhans cells in various organs that sometimes induces organ dysfunction. LCH can affect the liver, resulting in sclerosing cholangitis and biliary cirrhosis. However, liver and bile duct involvement is usually observed in the disseminated form of LCH. We here in report a rare case of LCH presented to us with cholestatic jaundice with skin manifestations.
Case Presentation A 1-year-old girl with elevated liver enzymes, obstructive jaundice with crusted lesions on scalp and pruritic skin lesions on hands and feet presented to our OPD TORCH panel was negative. CECT abdomen and MRCP where normal except for borderline hepatomegaly. Sections of liver biopsy showed histiocytic cell proliferation with sclerosing fibrosis of portal tracts and IHC revealed histiocytoses that were positive for Langerin, S-100 protein, and CD1a. histiocytic cell proliferation was noted in the liver tissue and correlated with skin biopsy findings. The definitive diagnosis was LCH with skin and hepatic involvement. The patient was initiated on prednisolone and vinblastine as bridge therapy prior to liver transplantation with good response under follow-up.
Conclusions LCH can affect the liver rarely. LCH should be considered as a differential diagnosis if pediatric patients show the presence of cholestatic jaundice with skin lesions. sclerosing cholangitis is unusual complication and eventually progress to cause cirrhosis and may require liver transplantation.
Keywords Langerhans cell histiocytosis, Sclerosing cholangitis, Biliary cirrhosis, Liver transplantation
185
A study of acute kidney injury in cirrhosis of liver with special reference to precipitating factors and outcome
Saket Agrawal , Asokananda Konar, Bhaskar Bikash Pal
Correspondence- Asokananda Konar-asoke.konar@gmail.com
Department of Medical Gastroenterology, Peerless Hospital and B K Roy Research Institute, 360, Pancha Sayar Road, Sahid Smirity Colony, Pancha Sayar, Kolkata 700 094, India
Introduction Cirrhosis is frequent cause of death mostly as a result of complication predominantly including sepsis and/or renal failure. Acute kidney injury (AKI) is a common complication in cirrhotic estimated as 19% of hospitalization and mortality of 55% to 91%.
Methods A total 94 patient (74 (M) and 23 (F)) with either newly diagnosed or known case of cirrhosis of liver, admitted with AKI or developed AKI during hospital stay with no documented renal parenchymal disease were studied with AKI diagnosed by International club of ascites criteria followed by history, medical evacuation and testing including creatinine, LFT, lactate, uNGAL and then classified into types, stages of AKI and followed till either death or discharge from hospital.
Results Mean age (56.79 +11.74 yrs) CTP score (10.41 + 1.75) and MELD score of (24.84 + 7.97). NASH (41.5%) and alcoholism (28.7%) were cause of cirrhosis. Cause and stage of AKI were prerenal AKI (52.1%), HRS (28.7%) and ATN (19.1%) with Stage 1 (38.3%), Stage 3 (31.9%) and Stage 2 (29.8%) AKI respectively. Majority of prerenal AKI shows complete response with minority of ATN shows response. 25.53% expired (predominantly male) with death classified seen in ATN (37.5%), HRS (33.33%) and prerenal (29.1%), 41.66% (Stage3) 37.5% (stage 2) and 21% (Stage1). Hemodialysis is required in 27.7% as modality of treatment majority in ATN and Stage3 AKI with 38.5 % of these patients didn’t recovered from HD. Urinary NGAL was tested in 43 patients with 60.5% patients having level > 121 ng/mL with level 1340.91 (ATN) and 727.49 (death). uNGAL is 84.2% sensitive and 54.2% specific for predicting mortality (cut-off 111.7ng/mL) and 100% sensitive and specific for detecting ATN (cut-off value 771.9 ng/mL).
Conclusion Prerenal AKI is most common cause of AKI but having better prognosis with ATN having highest mortality and mostly requiring HD. uNGAL is sensitive method to detect ATN leading to early diagnosis, improve prognosis and henceforth predicting mortality.
Keywords uNGAL -neutrophil gelatinase associated lipocalin, AKI, ATN, HRS
186
Normal reference range of liver stiffness measurement (LSM) by transient elastography (TE) in healthy Indian children
Krishnadas Devadas, Nibin Nahaz, Avisek Chakravorty
Correspondence- Avisek Chakravorty-avisek.doc@gmail.com
Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram 695 011, India
Introduction The use of liver transient elastography (TE) to assess liver fibrosis is attractive for its non-invasiveness, but reference values in Indian paediatric population has not been established.
Objectives We aimed to determine the liver stiffness (LS) and controlled attenuation parameter (CAP) for healthy children in the age group 5-12 years, and to determine whether liver fibrosis is age dependent in children.
Methodology We conducted a school based cross-sectional study in Kerala, India for healthy children of age 5-12 years. Fatty liver screening was done with ultrasound. TE and CAP were measured using Fibroscan 502 Touch using M probe. Children were grouped in to 2 groups, 5-8 years and 9-12 years. Student t test was used to compare the mean for TE and CAP.
Results Total 110 children were screened. 60.9% (67) were male and 39.1% (43) female. 47.2% (52) belonged to 5-8 years age group and 52.8% (58) in 9-12 years group. 3.6% (4) children had fatty liver by ultrasound. Pooled mean TE was 4.496±0.29 KPa (95%CI). For 5-8 years group mean was 4.19±0.43 and for 9-12 years group 4.77±0.38 KPa. Mean difference of TE was statistically significant (p value=0.027). Mean difference was significant (4.19 vs. 4.73 KPa, p=0.036) even after excluding children with fatty liver. Pooled mean for CAP was 180.01±2.99dB. Mean difference between the 2 groups (5-8 years 178.1±3.8dB vs. 9-12 years 181.7±4.4dB) was not statistically significant. In the 4 children with fatty liver, the mean CAP was 198.5dB. None of the children with fatty liver had steatosis according to CAP adult standards of 241dB.
Conclusion TE values in children increases with age. However, values in children may be much less than in adults. CAP is age independent. However, CAP value standards of 24dB to diagnose fatty liver may not be applicable to Indian children.
Keywords Pediatric NAFLD, Transient elastography, Liver stiffness measurement, Controlled attenuation parameter
187
Hepatitis B and C viral infections in chronic liver disease: Experience from a resource constrained region of Asia
Chitta Ranjan Khatua, Saroj Kanta Sahu, Shivaram Prasad Singh
Correspondence- Chitta Ranjan Khatua-chittamedicine@yahoo.co.in
Department of Medicine, MKCG Medical College and Hospital, Medical College Campus, NH59, Brahmapur 760 004, India and Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Introduction Chronic liver disease (CLD) is associated with serious complications and increased mortality, and is caused by different etiologies like alcohol use, chronic viral hepatitis B (CHB), chronic viral hepatitis C, and other etiologies. However, the prevalence of chronic hepatitis B, hepatitis C infection in CLD patients has not been assessed in this region of Asia. Hence, we performed this prospective study to evaluate the prevalence and spectrum of hepatitis B, and hepatitis C related CLD and its outcome.
Method A prospective study was carried out in consecutive CLD patients hospitalized in the Gastroenterology Department, SCB Medical College between December 2016 and October 2018. On admission all CLD patients were screened to identify the underlying etiologies. Further the demographic, clinical, and laboratory parameters were recorded and survival during hospitalization was recorded.
Results Out of 708 CLD patients, alcohol was the underlying etiology in 59.7% (n=423) patients, CHB in 16.4% (n=116) patients, both alcohol and CHB in 2.4% (n=17) patients, chronic viral hepatitis C in 0.8% (n=6) patients and other etiologies in in 20.6% (n=164) patients. Among the patients with chronic viral hepatitis B and C, 78.4% (n=109) were male, mean age was 53.39±12.42, BMI was 20.85±3.09, MELD UNOS score was 18.39±10.84, MELD Na+ score was 20.09±2.50, and CTP score was 10.01±3.33. More no of patients were admitted with severe liver disease (5% [n=7]) had Child A, 37.4% (n=52) had Child B, and 57.6% (n=80) had Child cirrhosis], and more importantly 5% of patients died during hospitalization.
Conclusion In our institution chronic viral hepatitis B or C were found to be the underlying etiologies of CLD in one fifth of patients. 95% of the patients were hospitalized with either Child B or Child C cirrhosis and were associated with mortality during hospitalization.
Keywords Chronic liver disease, Hepatitis B, Hepatitis C
188
Skin and soft tissue infections (SSTI) in cirrhotics: Bacteriology, clinical profile and outcome
Gautam Vinay Kumar Budumuri , Itish Patnaik, Anand Sharma, Rohit Gupta
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Background Skin and soft tissue infections (SSTI) are among the common bacterial infections noted in patients with cirrhosis and are related to hypoalbuminemia and edema.
Aims This study aimed to determine the clinical profile, bacteriology and in-hospital mortality in patients with cirrhosis with SSTI.
Methods In this retrospective study, we analyzed patients with cirrhosis presenting to our department with soft tissue infections (SSTI) between March 2019 and June 2020. Clinical and laboratory data were retrieved from hospital records. Data retrieved included demographics, aetiology, comorbidity, cirrhosis related complications, site of Cellulitis, baseline investigations, wound culture, blood, urine, and ascitic fluid culture and clinical outcome.
Results During the study period, 387 patients with cirrhosis were admitted, of whom 29 (7.5%) had skin and soft tissue infections (median [IQR]) age 44.5 [16) years; 75.9% w]ere males, model for end-stage liver disease score (MELD) score 27 (14), Child-Pugh (CTP) score 12 (3). Etiology of cirrhosis was alcohol in 45%, hepatitis C virus in 27.6 %. 20.7% (6/29) had diabetes mellitus. Lower limbs were most commonly involved. Of the 29 patients, cellulitis was noted in 15 (52%), ulcers in 10 (34.5%). Cultures were positive in 58.6% (17/29) patients. The majority of cultures showed monomicrobial growth with predominant gram-negative bacteria 64.7% (11/17). E coli 35.2% (6/17) was the commonest isolate, followed by Klebsiella 10.3% (3/17). 11 (34.4%) patients died during the hospital stay. Compared to non-survivors, survivors had higher CTP score (13 [2] vs. 12 [4], p < 0.05).
Conclusion SSTI was noted in 7.5% of patients with cirrhosis. Alcohol was the most common etiology of cirrhosis in these patients. Gram-negative bacteria (E. coli and Klebsiella) were the most common bacterial isolates. In-hospital mortality was noted in 34.3% of patients and was higher in patients with higher CTP and MELD score.
Keywords Liver cirrhosis, Soft tissue infections, Bacteriology
189
Diffusion MRI in focal liver lesions and role of apparent diffusion coefficient (ADC) in Barcelona clinic liver cancer (BCLC) staging of hepatocellular carcinoma
Sujit Nair , Prasanta Debnath, Parmeshwar Junare, Siddhesh Rane, Partha Debnath, Sanjay Chandnani, Ravi Thanage, Shubham Jain, Pravin Rathi
Correspondence- Sujit Nair-sujitnair12345@gmail.com
Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai Central, Mumbai 400 008, India
Introduction Diffusion weighted imaging has resulted in enhanced disease detection and characterization with easy implementation techniques. The quantitative apparent diffusion coefficient derived shows good measurement reproducibility, which can be applied for tissue characterization, assessment of tumor response and disease prognostication. We compared the diagnostic utility of diffusion weighted imaging with conventional MRI in benign and malignant focal liver lesions and compared the apparent diffusion coefficients with Barcelona clinic liver cancer (BCLC) stage of hepatocellular carcinomas.
Methods Fifty patients of focal liver lesions were prospectively evaluated by Diffusion Weighted-MRI and conventional MRI after approval of Ethics Committee. ADC values of each benign and malignant lesion were calculated. Ten patients of HCC were staged as per the BCLC staging. The liver imaging in HCC patients was standardized with LI-RADS (Liver imaging Reporting and Data system).
Results Of 210 focal liver lesions in 50 patients, 84 were benign lesions and 126 were malignant lesions. Most common lesion was metastasis (52.8%). There is significant difference between T2WI and DWI for detection of malignant lesions. There was no difference between the use of T2 weighted imaging and DWI for the detection of benign hepatic lesions in our study. The mean ADC values of malignant lesions were significantly lower than those of benign lesions (0.90 x 10-3 mm2/s vs. 2.52 x 10-3 mm2/s) (p<0.001). There was significant difference between the mean ADC values of HCC and metastasis (p-value<0.001). Lower the ADC values of the lesions, patients had a poorer outcome as per the BCLC staging.
Conclusion DWI can be used as the imaging modality to differentiate malignant from benign liver lesions, thus avoiding unnecessary biopsies. Its utility in the assessment of diffuse hepatic parenchymal diseases is still at a research level. Further investigations are needed to increase the reliability of the technique for these indications.
Keywords Diffusion MRI, Apparent diffusion coefficient (ADC), Hepatocellular carcinoma
190
Age and gender variations of FIB 4 score in fatty liver
Bhargav V Y , Mayank Jain, Alen Tom, Preetam Arthur, Shweta D, Karthikeyan M U, Chandan Kumar Kedarisetty, Thamarai Selvan S, Jayanthi Venkataraman
Correspondence- Bhargav V Y-varanasi.b4@gmail.com
Arihant Hospital and Research Centre, 283-A, Gumasta Nagar, Scheme 71, Indore 452 009, India, and Department of Hepatology, Sri Ramachandra Medical College and Research Institute, Chennai 600 116, India
Background FIB 4 score is known to have a significant negative and positive predictive value in predicting lower and higher grades of liver fibrosis.
Aim Correlate FIB-4 score with grades of fatty liver (FL) amongst men and women greater and less than 45 years.
Methods Prospective data on hemogram, liver biochemistry, and ultrasound (USG) was collected in master health check. USG findings were classified as normal, Gr 1, 2, and 3 FL, FIB-4 was calculated. Patients with known liver disease were excluded. Cut-off of 45 years was taken for comparison between men and women.
Statistical Analysis Appropriate non-parametric tests were used. AUROC was obtained for the FIB-4 cut-off. SPSS version 23.0 version was used.
Results There were 741 subjects (474 men; 64%). 418 (56.4%) were > 45 years. Liver was normal in 297 (40.1%); grade 1, 2 and 3 FL in 293 (39.5%), 114 (15.4%) and 37 (5%) subjects respectively. The overall mean FIB-4 score was high in males (1.37 ± 1.06 vs 1.15±0.83, p value 0.009) and remained so, for > 45 years (1.69+ 1.09 vs. 1.33+ 0.88, p value 0.000) and < 45 years (1.01±0.90 vs. 0.87±0.66; p NS). Mean FIB-4 scores increased with grades of FL (p 0.126). AUROC was 0.538, 0.516 and 0.602 respectively for Gr 1, 2 and 3 respectively.
Conclusion FIB-4 score in our study is lower than that reported in the west with a poor prediction for any grade of FL.
Keywords FIB 4, Fatty liver
191
Perspectives in hepatocellular carcinoma management in a tertiary care centre in South India
Nithin Kumar, Praveen Mathew, Prashant Kanni, Chandra Babu, Manoj Gowda, Achal Garg, Jaseem Ansari, Raghuveer Balabadra
Correspondence- Nithin Kumar-nithinnagraj08@gmail.com
Department of Gastroenterology, Vydehi Institute of Medical Science and Research Centre, 82, Near BMTC 18th Depot, Vijayanagar, Nallurhalli, Whitefield, Bengaluru 560 066, India
Background and Aims Hepatocellular carcinoma (HCC) is a primary cause of liver cancer leading to death worldwide. Meanwhile, in a country like India where because of financial constraints for patients, liver transplantation is not popular in spite of being offered to patients. Thus, HCC is managed with the best available treatment options.
Methods Prospective study was conducted in which a total of 21 diagnosed cases of HCC patients were managed and treatment strategy was planned according to Barcelona Clinic Liver Cancer staging over a period of 3 years.
Results Study showed male predominance (85%). Mean age was 65+/- 5 years. The etiology was mainly hepatitis B (70%), followed by hepatitis C (25%). 60 % patients were asymptomatic. Serum alpha fetoprotein was raised in 45% of patients. Unresectable cases underwent loco regional therapy. Trans arterial chemoembolization (TACE) was done in 9 patients, radiofrequency ablation (RFA) in 3 patients, TACE+RFA in 6 patients, TACE + ethanol ablation in 1 patient , TACE followed by curative partial hepatectomy in 1 patient and only sorafenib in 1 patient.
Median survival of patients is 2 years after TACE + RFA with no recurrence; TACE patients had a median survival of 6-8 months in which 44% had recurrence. RFA patient’s survival is around 1 year, after which the patient developed recurrence. TACE + ethanol and TACE + surgery patients are on follow-up with no recurrence.
Conclusion HCC is potentially curable if discovered in its initial stages. Strategies for early diagnosis and treatment of HCC is a way to decrease mortality.
Keywords Hepatocellular carcinoma, Radiofrequency ablation, Trans arterial chemoembolization
192
Giant cavernous hemangioma of left lobe of liver with epigastric herniation: A rare presentation in postmenopausal woman
Nikhileswar Yandamuri , Ramesh Kumar B, Ramanna M
Correspondence- Nikhileswar Yandamuri-itsnikhil.rio@gmail.com
Department of Medical Gastroenterology, Osmania Medical College And General Hospital, 5-1-876, Turrebz Khan Road, Troop Bazaar, Koti, Hyderabad 500 095, India
Introduction Cavernous hemangioma is the most common benign tumor of the liver and is found in as many as 7% of autopsies. Women are predominantly affected (6:1) and often present at a younger age. Majority are small (<2cm), predominantly in right lobe of liver and are discovered incidentally during imaging of the liver for another reason. Those larger than 5 cm are called giant cavernous hemangiomas. Upper abdominal pain is the most common complaint. We report a case of elderly female with giant hemangioma occupying entire left lobe presenting as epigastric hernia.
Case Report Sixty-two year-old female patient presented with pain abdomen and distension since 3 months. She had prior history of abdominal surgery 10 yrs back (no records). On examination she had swelling in midline in epigastric region becoming prominent while coughing. USG abdomen-midline defect noted at epigastric region with herniation of abdominal fat. To our surprise large heterogenous lesion noted in left lobe of liver. AFP-normal, viral markers-negative, LFT and CBP within normal range. CECT triphasic done revealed 15*12*17 cm hypodense lesion occupying entire left lobe showing intense enhancement in arterial phase with progressive centripetal enhancement in delayed phase suggestive of giant hemangioma. She is referred for surgical resection and hernia repair.
Discussion Giant hemangiomas are more likely to cause abdominal discomfort or pain, vomiting. Infarction, bleeding or necrosis may occur. Rare complications include compression of bile ducts, portal vein, gastric outlet obstruction. Management include surgical resection, arterial ligation, embolization or systemic glucocorticoids.
Conclusion Though small hemangiomas are frequent finding, Giant hemangioma of 17 cm in left lobe of liver with epigastric herniation in a 62-year-old post-menopausal woman not on estrogen supplements is an unusual presentation. Early diagnosis and prompt resection are indicated to avoid rupture which is a catastrophic complication of giant hemangioma.
Keywords Giant cavernous hemangioma, Left lobe of liver, Postmenopausal woman, Epigastric hernia
193
Neutrophil to lymphocyte ratio as a prognostic marker in patients with alcoholic hepatitis
Bharat Sapra, Jagatjot Gill
Correspondence- Bharat Sapra-sudhir.maharshi@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India
Background Alcoholic liver disease is one of the commonest causes of advanced liver diseases. The prognosis of patients with alcoholic hepatitis (AH) can be established by different scoring systems. The prognostic role of neutrophil to lymphocyte ratio (NLR) has been documented in multiple diseases but the overall evidence of prognostic role of NLR in AH is relatively scarce. The aim of the study was to assess NLR as a prognostic marker in patients with AH and compare it with other prognostic scores.
Methods Patients of AH both admitted and from OPD were included. Along with baseline investigations, various scores like MELD (model for end-stage liver disease), DF (discriminant function), GAHS (Glasgow alcoholic hepatitis score), CTP (Child Turcot-Pugh score) and NLR were calculated. Patients were followed up at 1 and 3 months. Correlation of NLR with other scores was done by appropriate statistical analysis.
Results Till date 58 patients have been included in the study. Mean age was 36.8±8.7 years. All patients were males. The lab parameters were hemoglobin 8.9±1.4 gm%, bilirubin 7.6±3.8 mg/dL, serum creatinine 1.1±0.5 mg/dL, serum albumin 2.9±0.4 g/dL. Various prognostic scores were NLR 4.8±1.7, CTP 9.4±1.3, MELD 24.1±4.8, GAHS 8.1±1.3, DF 42.2±19.8. Correlation coefficient (r value) of NLR with CTP was 0.5, with MELD-0.6, with GAHS-0.6 and with DF-0.7.
Conclusion NLR correlates positively with CTP score, MELD score, DF and GAHS and can be used as a prognostic marker in patients of alcoholic hepatitis.
Keywords Alcoholic hepatitis, scoring
194
A rare cause of portal hypertension in a 7-year-old child
Viswanath Kamisetty , Ramesh Kumar B, Ramanna M, Sindhu K * , Sahitya L
Correspondence- Viswanath Kamisetty-vissu.ksp@gmail.com
Department of Medical Gastroenterology, Osmania Medical College and General Hospital, Hyderabad 500 012 India, and *Department of Pathology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India
Introduction Extrahepatic portal venous obstruction or cirrhosis is the cause of portal hypertension (PHT) in majority of Indian children (92%). Nodular regenerative hyperplasia (NRH) is a rare entity especially in children which is clinically dominated by PHT with splenomegaly. This condition is often associated with systemic diseases or drugs and is characterized by a widespread benign transformation of liver parenchyma into small regenerative nodules. We report a rare case of NRH with portal hypertension with a normal spleen in a girl child, as an isolated occurrence.
Case Report A 7-year-old girl, pre-morbidly well, presented with multiple episodes of hematemesis. Clinically she had severe pallor without icterus and hepatosplenomegaly. Labs showed severe anemia (Hb-6.8 g/dL) and normal platelet count. Liver function tests were normal apart from mild transaminitis. Ultrasonography abdomen revealed heterogeneous liver echotexture without nodularity, portal vein measuring 4.2 mm at porta, with normal spleen and minimal ascites. Grade III esophageal varices were detected on gastroduodenoscopy. Liver biopsy showed early nodular regenerative hyperplasia with few porta showing obliterated portal vein. Endoscopic variceal banding was done as a secondary prophylaxis. Our patient had no drug exposure and further investigations did not reveal any autoimmune, metabolic, myeloproliferative or neoplastic disorders.
Discussion NRH has rarely been described in children. It is important to consider NRH in the differential diagnosis of unexplained PHT owing to its relatively favorable prognosis. Though the largest pediatric series (16 cases) by Moran et al. emphasized the association of NRH with other diseases, we did not find any association, suggesting the possibility as an isolated occurrence. To the best of our knowledge this is the first case report of NRH with clinically significant portal hypertension with a normal spleen which is inconsistent with the previous case reports.
Keywords Nodular regenerative hyperplasia, Portal hypertension, Spleen
195
Clinico-epidemiological profile of hepatic hydatid cyst patients presenting to a tertiary care hospital
Mayank Bhushan Pateriya , V K Dixit, S K Shukla, D P Yadav, Anurag Tiwari
Correspondence- V K Dixit-vkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
Introduction Hydatid cyst is endemic zoonotic diseases in India. Due to its different morphological presentation it has multiple treatment options like PAIR, surgical enucleation and antihelmintics.
Methods This is retrospective cross-sectional observational study carried out in consecutive 48 patients of hepatic hydatid cyst presented to Department of Gastroenterology, SSH/BHU between January 2016 to December 2019.
Observation Mean age of our patient group was 37.6 years (7 to 68 years). Most of the patients were female (70.8%). Most common presenting symptom was right hypochondrium pain (62.5%) followed by abdominal lump (25%). Fifty-two percent of hydatid cysts were of Gharbi I , 31% of Gharbi III. Mean cyst volume was 7.5*6.2*8.1cm. Hydatid serology was positive in 47% cases and protoscolex of echinococcus granulosus in aspirated fluid was present in 72% of the cases. Successful PAIR was done in 66% 0f cases (out of which in 20% cases repeated PAIR was required). PAIR was failed in 22% cases for which surgical referral was taken and in remaining 12% of cases only albendazole was sufficient.
Conclusion For management of hepatic hydatid cysts of favourable morphology PAIR is still a conservative treatment option.
196
Ischemic hepatitis: Easily identifiable but frequently overlooked
Anant Gupta , Jayant Sharma, Khushbu Jain *** , Alok Gupta * , Sandeep Nijhawan **
Correspondence- Jayant Sharma-dranantg@gmail.com
Department of Medical Gastroenterology, Fortis Escorts Hospital, Jawahar Lal Nehru Marg, Sector 5, Malviya Nagar, Jaipur 302 017, India, *PSC, Jaipur, India, **Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India, and ***Suryam Diagnostics,
Introduction Ischemic hepatitis (IH) presents as significantly raised liver enzymes in ICU patients, who are more prone in view of co-existing illness. This study aimed to evaluate the profile of IH.
Methods Patients admitted to ICU with cardiac/respiratory failure, hypotension, sepsis, or those resuscitated after cardiac-arrest were screened. LFT, INR, creatinine were measured on day 1. ALT, bilirubin (T), LDH were measured on day 3, 7 and 14. ABG (in hypoxia) and cultures (in sepsis) were done. Echocardiography and USG abdomen were done for all. Patients with ALT >800 IU/L, negative IgM antibodies (HAV and HEV) and with no history of drug-induced toxicity were followed.
Results Of 3794 patients screened over a year, 75 had IH. Mean age was 67 years and 46 were male. 60% had ≥2 predisposing causes. Predisposing causes were bi-ventricular dysfunction (56%), left-ventricular dysfunction (43%), hypotension (40%), sepsis (25%), cardiac-arrest and resuscitated (20%), respiratory failure (17%). 3 (6%) were cirrhotic, but none developed ACLF. Mortality was 46% but none were primary liver related. Mean ALT (IU/L) level on day 1 (54 IU/L), day 3 (4305 IU/L), day 7 (1915 IU/L), day 14 (523) and the ALT levels reduced by >50% (day 7) and >80% (day 14). Mean T. bilirubin (mg/dL) was 1.49 (day1), 3.2 (day7) and 2.6 (day 14). Mean AST (3711 IU/L) was higher than ALT (3683 IU/L), ALT/LDH ratio was 1.15 and ALT were higher in those who died (4305.17 ± 2465.0 and 3683.74 ± 2618.43 respectively). Peak ALT were on day 3 (non-cirrhotics) and on day 7 (in cirrhotics). Cirrhotics had higher mean bilirubin on day 7 and day 14.
Conclusions Incidence of IH was 1.98% of ICU admissions. Their presentation closely mimics acute viral/toxin-induced hepatitis. It has no specific symptoms, is easily missed, unless looked for. Careful monitoring of LFTs in critical-care patients would identify IH. Early aggressive management of precipitating cause, avoiding the use of hepatotoxic drugs may help in preventing ALF.
Keywords Ischemic Hepatitis, Hypoxic Hepatitis, ICU
197
Prospective observational study comparing sepsis-1, qSOFA and sepsis-3 in predicting 90-days mortality in patients of cirrhosis with infection
Ajay Kumar Jain, Abhilash Surela , Shohini Sircar, Amit Joshi, Arun Singh, Sumit Singh, Vikas Raikwar
Correspondence- Abhilash Surela-surelaabhilash@gmail.com
Department of Gastroenterology, Choithram Hospital and Reasearch Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction Patients with cirrhosis of liver are more prone to sepsis and sepsis related complication with poor prognosis. Recently the international task force proposed new criteria to define sepsis and septic shock which has been named as sepsis -3 criteria. The group also proposed qSOFA criteria for screening of sepsis. It is believed that based on these new criteria prognostication of patients of cirrhosis with sepsis will be more accurate, therefore we aimed this study “to compare sepsis -3 with sepsis -1 (old criteria for screening of sepsis) and qSOFA to predict 90-days mortality in patients with cirrhosis of liver and infection”.
Method All patients with cirrhosis and proven infection were prospectively included in our study. Demographic, clinical, laboratory and microbiological data were collected at time of admission. Base line qSOFA score was obtained from previous record. Sepsis 1, sepsis 3 and q SOFA were calculated at the time of admission. The primary outcome was 90-days survival.
Result A total of 108 patients of cirrhosis with proven infection were recruited. Out of 108 patients, 60 patients (55.6%) fulfilled sepsis-1 criteria, 63 patients (58.3%) fulfilled sepsis -3 criteria and only 32 (29.6%) fulfilled positive qSOFA criteria. Overall 90-days mortality was observed in 21 (19.4%) patients, out of these 21 patients who died within 90 days, 13 patients (61.9%) fulfilled sepsis-1 criteria, 11 patients (52.4%) fulfilled q-SOFA criteria and all 21 patients (100%) fulfilled sepsis-3 criteria. Sepsis-3 showed good accuracy for 90-days mortality area under the receiver operating characteristic (AUROC)=0.838, 95% CI, 0.755-0.902 than qSOFA (AUROC=0.760, 95% CI, 0.669-0.837) and sepsis-1 (AUROC=0.658, 95% CI, 0.560-0.7) (Fig.1).
Conclusion Present study shows that sepsis-3 criteria are more accurate than qSOFA and sepsis-1 in predicting 90-days mortality in patients of cirrhosis with infection.
Keywords: Liver, Cirrhosis, Sepsis-3, qSOFA, Sepsis
198
Systemic amyloidosis - Hepatic presentation
Rushil Solanki , Krishnadas Devadas
Department of Gastroenterology, Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Fifty-six-year old lady, Asha worker was referred to MGE, OPD with complaints of bloating, belching and nausea with findings of hepatomegaly on USG abdomen done outside. She gave additional h/o DM and suspected CAD, on antiplatelets. LFTs done revealed an cholestatic pattern with elevated ALP, GGT and borderline raised OT/PT and hepatomegaly was confirmed with repeat USG abdomen. Subsequent serological and imaging investigation (CT scan abdomen), done to determine the etiology yielded no definitive results. A liver biopsy was planned to give a definitive diagnosis. A liver biopsy was planned to give a definitive diagnosis. Liver biopsy showed congophilic material with apple green birefringence which s/o hepatic amyloidosis. Once confirmed, SPE was performed as part of determining the type of amyloid. SPE showed band in gammaglobulin region and subsequent bone marrow showed biopsy confirmed multiple myeloma. Screening for other organ involvement showed involvement of heart (2Decho with bulls eye appearance on strain imaging and cardiac MRI confirming cardiac amyloidosis) and peripheral; nerves showing length dependent axonal polyneuropathy. MRI spine also showed multiple levels of degenerative vertebral bodies.
199
Clinicoepidemiological profile of liver abscess patients admitted in a tertiary center in south India
Bontha Vineesha, Ganesh Panchapakesan, Shanmuganathan Subramanyam
Correspondence- Bontha Vineesha-bontha.vineesha@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research, No: 1, Sri Ramachandra Nagar, Porur, Chennai 600 116. India
Background India has the 2nd highest incidence of liver abscess in the world due to overcrowding, poor sanitation and inadequate nutrition and continue to be an important cause of morbidity and mortality. So identification of risk factors and early diagnosis are key issues for effective interventions. Most of the Indian data are from north and north east with sparse data from the south. The aim of this study is to evaluate the changing trends in clinical profile, microbiological aetiology of patients diagnosed with liver abscess.
Methods A retrospective data of the 108 patients who admitted with a liver abscess in a tertiary care center in south India from January 2018 to January 2020 was collected including presenting complaints, lab parameters including cultures and serology along with necessary imaging.
Results Pyogenic liver abscess PLA (86.1%) is predominant over amebic liver abscess ALA (13.8%). The mean age of the patients with PLA is 52.5 vs. 44.8 years for amebic with male preponderance (94.4%). There was no significant difference in lab values between pyogenic and amebic liver abscess. Alcoholism (23.1%) and diabetes (43.5%) are main predisposing factors. Pain abdomen and fever was present in 91.7% and jaundice in 19.4% patients. The ALA were predominantly solitary and in right lobe. The most common pathogen in pyogenic was klebsiella pneumonia (36.8%) followed by E. coli (21%). More than 5 cm abscess required a pigtail insertion. Forty-nine patients (45.3%) underwent pigtail insertion. Mortality was 1.8% and was due to sepsis and multi organ dysfunction.
Conclusion The commonest type of liver abscess was pyogenic in contrast to studies from north India. Liver abscess was predominant in males. Obstructive type of jaundice was more common in pyogenic abscess compared to amoebic. Most of the patients can be effectively managed with antibiotics covering gram negative spectrum and with proper selection of patients for drainage.
Keywords Liver abscess, Pyogenic liver abscess, Amebic liver abscess
200
Clinical profile and outcome of acute liver failure in north west India: A tertiary care centre experience
Rishabh Gupta , Gaurav Gupta, Sandeep Nijhawan
Correspondence- Rishabh Gupta-rishabh1313@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College and Attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Acute liver failure (ALF) is a rapidly progressive syndrome having high mortality rate with varied etiology. It is characterized by development of coagulopathy (INR >1.5), and encephalopathy within 4 weeks of the onset of symptoms in a patient without pre-existing cirrhosis. Geographical differences are seen in terms of etiology and outcome. Viral hepatitis is the commonest cause in India unlike drugs and toxins in the West. Thus, careful evaluation for the cause of ALF is important for the management and prognosis of the patient.
Aim of the study To evaluate the etiology, clinical profile and outcome in patients with acute liver failure.
Method It was a prospective observational study conducted in the Department of Gastroenterology, SMS medical college, Jaipur, India. All patients with the diagnosis of ALF as per IASL criteria were included between September 2018 to July 2020.
Results Total 124 patients were included out of which 66 were males and 58 females. Mean age was 36.68+/-18.44 years. Overall mortality in our study was 65/124 (52.4%), with highest being viral hepatitis 26/124 (20.96%), followed by indeterminate group 18/124 (14.5%). Viral hepatitis 63/124 (50.8%) was the most common cause of ALF, of which HEV being the commonest with 35 patients, followed by drug or toxin induced 30 (20.2%) and indeterminate group 18 (14.5%). Among drug induced acute liver failure, 25 had ATT induced ALF. Out of 58 females, 6 were pregnant. Predictors of outcome were age, etiology, hepatic encephalopathy grade, coagulopathy, deranged renal function, bilirubin, intracranial pressure and other complications.
Conclusion ALF is a disease having mortality of 52.4%. Viral hepatitis is the commonest cause in north west India, like the rest of India. ATT is also an important cause of ALF. Prompt diagnosis and timely management of complications is required.
Keywords Acute liver failure, Cirrhosis, Viral hepatitis
201
Cell free DNA integrity index differentiating hepatocellular carcinoma from chronic liver disease patients
Sonu Kumar , Neeti Nadda, Shashi Paul, Anoop Saraya, Shivanand Gammanagatti, Shalimar, Baibaswata Nayak
Correspondence- Baibaswata Nayak-baibaswat@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Hepatocellular carcinoma (HCC) is fourth most deadly cancer. Majority of HCC patients have underlying chronic liver disease (CLD) that leads delayed HCC diagnosis. Surveillance of high risk CLD patients can led to early HCC diagnosis. Delay in diagnosis results in progression of HCC and metastasis. Routine screening for HCC is not cost effective. Liquid biopsy holds great promise for early detection, prognosis, and response to cancer treatment. The cell free DNA (cfDNA) concentration and its integrity index changes early during carcinogenesis. The DNA integrity index by real time PCR of repetitive genomic sequences (Alu, LINE1) and beta actin and GAPDH may predict early hepatocarcinogenesis for which propose study was undertaken.
Objectives Cell free DII determination by real time PCR for the early prediction of hepatocarcinogenesis in CLD patients.
Methods Consecutive HCC (n=100), CLD (n=55) and healthy (n=10) controls were included. CfDNA was isolated from serum using Qiagen kit. Genomic DNA from Huh7 cell line was used as control. Cf DNA concentration and purity was checked by scan-iT software. The primer pairs for large (>200 bp) and small (<200 bp) amplicon against Alu, LINE1, beta- Actin and GAPDH gene were designed. Real time PCR using SYBR was carried for both fragment. The DII by comparative Ct method was used for differential ability CLD vs HCC.
Results More fragmentation was observed in DNA in cancer. Normalization was done with genomic DNA. Increased DII indicates lower integrity in HCC vs. CLD vs. healthy. ROC curve in CLD vs. HCC subjects are significant for ALU and GAPDH gene having AUC value 0.67 and 0.69 respectively. LINE1 elements and b-actin genes more fragmented in but ROC curve is not significant for them.
Conclusions Both Alu and GAPDH holds great promise for prediction of early hepatocarcinogenesis.
Keywords HCC, CLD, Cf DNA, RT PCR, DII,LB
202
Non-alcoholic steatohepatitis as an emerging cause of hepatocellular carcinoma in India
Apurva Shah , Shravan Bohra, Maitrey Patel
Correspondence- Apurva Shah-apurvashah411@gmail.com
Department of Gastroenterology, Apollo Hospitals International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Ahmedabad 382 428, India
Introduction Hepatocellular carcinoma (HCC) is the third leading cause of cancer related death worldwide. Although hepatitis B (HBV) and hepatitis C (HCV) have been the main drivers of HCC, non-alcoholic steatohepatitis (NASH) is emerging as a leading cause of HCC. The aim of this study was to assess NASH as cause of HCC.
Methods This retrospective observational study was carried out on diagnosed patients of HCC during last one year at tertiary care center in western India. Data included were clinical presentation, comorbid conditions, biochemical parameters with alfa fetoprotein levels, imaging (ultrasound/ computed tomography of abdomen). Data regarding etiology of cirrhosis and HCC were collected. Barcelona clinic liver cancer (BCLC) staging was used to stage and guide HCC therapy.
Results Total 13 patients of HCC were included in analysis. Mean age of patients was 64.53 ± 8.43 years with male predilection (93.30%). Most common presentation was abdominal pain (61.53%) followed by ascites (46.15%) and constitutional symptoms like anorexia and weight loss (46.15%). Eleven patients had underlying cirrhosis and two patients were noncirrhotic. 69.23% patients of HCC had diabetes mellitus as co morbidity. NASH was the commonest etiology in cirrhotics with HCC (72.72%) followed by HBV (18.18%) and alcohol (9.1%). HBV and NASH was the etiology respectively in two noncirrhotics. Alfa fetoprotein was normal, between 40-400 ng/mL and >400 ng/mL in 54%, 23% and 23% respectively. Majority of patients had higher stages of HCC (BCLC- C and D) at diagnosis even on surveillance (62%) and received targeted therapy of sorafenib.
Conclusion NASH is the most rapidly emerging cause of HCC paralleled with epidemic of metabolic syndrome components in India. Screening of HCC should be considered in all patients of NASH cirrhosis and advanced fibrosis.
Keywords Non-alcoholic steatohepatitis, Hepatocellular carcinoma, Diabetes mellitus, Alfa fetoprotein
203
A rare cause of sepsis in chronic liver disease
Binila Jose , George Thomas, Ramesh M, Satheesh A V
Correspondence- Binila Jose-binilajose@gmail.com
Department of Gastroenterology, Pushpagiri Institute of Medical Sciences, Municipal Stadium Road, Pushpagiri Medical College Campus, Thiruvalla 689 101, India
Introduction Pasteurella multocida is pleiomorphic, facultatively anaerobic, a Gram-negative coccobacillus commonly isolated as commensals in the oral flora of a variety of animals. In dog and cat bite wounds, Pasteurella multocida, are isolated in 50% to 70% of the cases. Although direct inoculation of the skin through animal bite or scratch is the most common route of human disease, infection has been documented even in the absence of direct animal contact. Pasteurella multocida serves as an opportunistic pathogen in humans, especially in patients with depressed immune system. Few cases in the literature identify Pasteurella multocida as the causative agent of septic shock, especially in cirrhotic patients. Here, we present a rare case of Pasteurella multocida septic shock in an elderly woman with chronic liver disease.
Case Report A 74-year-old female was admitted with abdominal distension, breathlessness and edema without any fever or gastrointestinal bleed. She also gives history of close contact with pet dog, but no history of any dog bite. She had past history of chronic obstructive pulmonary disease, hypertension and recently detected chronic liver disease. Physical examination showed drowsy, pallor, icterus, edema, cellulitis both legs, hypotension, tachycardia and ascites. Evaluation showed features of sepsis with probable source as cellulitis and blood cultures grew P. multocida which was managed with piperacillin/tazobactam with clinical improvement.
Discussion Although cases of bacteremic P. multocida infections has been infrequently reported in the literature, clinicians should consider this organism as an important and potentially lethal pathogen in humans, where it can cause life-threatening infections. It should be included in the microbiologic differential diagnosis in patients with underlying chronic liver diseases who presents with possible infection, with history of exposure to domestic animals. Septic shock is an uncommon complication of P. multocida infection with a mortality rate of 15% to 30%.
Keywords Pasteurella, Septicshock, CLD
204
Elevated serum ferritin and CRP levels as prognostic markers in decompensated cirrhosis: A prospective cohort study
Mithun Harold Thomas , Sunilkumar Kandiyil, T M Ramachandran
Correspondence- Mithun Thomas-drmithunharold@gmail.com
Department of Gastroenterology, Government Medical College, Medical College Road, Kozhikode 673 008, India
Introduction Serum ferritin, a marker of hepatic necroinflammation has been studied to predict early mortality in patients with decompensated cirrhosis. But its significance when compared with serum CRP levels has not been studied. The aim of the study was to analyze serum ferritin and CRP levels as prognostic markers in patients with decompensated cirrhosis and compare it with MELD and CTP scores.
Methods Two hundred and twenty consecutive patients with decompensated cirrhosis were included. Serum ferrtin and CRP levels at presentation and factors predicting mortality at 3 months were assessed.
Results Patients with decompensated cirrhosis (n=220) (M:F 168:52, mean age 55.7 yrs +/- 11 ) were followed up for a period of 3 months. At presentation, median serum ferritin level was 321.45 (7.4-750) ng/mL in survivors and 725 (275-3000) ng/mL in non-survivors, and median serum CRP level was 9 (2-60) mg/L in survivors and 18.5 (6-64) mg/L in non-survivors. Serum ferritin levels were significantly different between survivors and non-survivors (p<0.05) and showed significant correlation with CRP levels (p<0.01). Serum ferritin, CRP, total leukocyte count, MELD score, CTP score, presence of hepatorenal syndrome, spontaneous bacterial peritonitis, hepatic encephalopathy and ACLF were significant predictors of mortality on univariate analysis. Ferritin, MELD and presence of hepatorenal syndrome were significant predictors of mortality on multivariate analysis. Serum ferritin (AUROC 0.91, 95% CI 0.87-0.95) was comparable to MELD score (AUROC 0.92, 95% CI 0.891-0.961) and better than CRP (AUROC 0.74, 95% CI 0.67-0.80) and CTP score (AUROC 0.847, 95% CI 0.79-0.89), in predicting death at 3 months.
Conclusion Elevated serum ferritin level is as an independent prognostic marker in decompensated cirrhosis. Elevated serum CRP levels did not show association with mortality at three months in decompensated cirrhosis.
205
Prevalence of sarcopenia in patients with cirrhosis: A large observational study
Indu Grover , Namrata Singh, Deepak Gunjan, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Sarcopenia is common and camouflaged complication which adversely affects quality of life and outcomes in the patients with cirrhosis. The aim of this study is to describe the prevalence of sarcopenia and its relationship with nutritional status, disease severity and disease duration in patients with cirrhosis.
Methods The appendicular skeletal muscle mass index (ASMI) was assessed by dual energy X-absorptiometry (DEXA). Cut off given by Asian working group for sarcopenia (AWGS) was used to define sarcopenia; for male (<7 kg/m2) and female (<5.4 kg/m2). Subjective global assessment (SGA) modified for liver disease was used to assess nutritional status. Patients were categorized in compensated and decompensated group and MELD score was calculated.
Results A total 341 patients with cirrhosis (271 male, mean age 44.0±12.0 years) were included in this study. The prevalence of sarcopenia was 36.7% (male: 36.9% vs. female: 35.7%). The value of ASMI (kg/m2) was for male (7.36±1.16), female (5.86±0.99), compensated (7.01±1.25) and decompensated cirrhosis (7.01±1.32), respectively. More results are shown below:
Table: Comparison of patients with cirrhosis (n=341)
Variables | No sarcopenia (n=216) | Sarcopenia (n=125) | P value |
ASMI (kg/m2) | 7.71 ±1.03 | 5.91 ± 0.76 | <0.001 |
Weight (kg) | 66.4 ± 11.8 | 51.6 ± 8.6 | <0.001 |
BMI (kg/m2) | 24.6 ±3.5 | 19.3 ± 2.5 | <0.001 |
Duration of disease (months) | 25 (0-312) | 38 (1-219) | <0.001 |
MELD score | 10.89 ± 4.5 | 10.5 ± 4.13 | 0.484 |
Disease severity, n (%) | |||
Compensated | 134 (62.1) | 69 (55.2) | 0.215 |
Decompensated | 82 (37.9) | 56 (44.8) | |
SGA, n (%) | |||
Well nourished | 100 (46.3) | 39 (31.2) | <0.001 |
Moderately malnourished | 106 (49.1) | 64 (51.2) | |
Severely malnourished | 10 (4.6) | 22 (17.6) | |
*Expressed in Mean±SD and Median (min-max)
Conclusion Around one third patients with cirrhosis had sarcopenia, and they had longer duration of disease and lower BMI. As nutritional status worsens frequency of sarcopenia increases in patients with cirrhosis.
Keywords Cirrhosis, Sarcopenia, Dual energy X-ray absorptiometry, Nutritional status
206
LFT profile in intensive care unit patients: A prospective observational study
Krishna Kartik Reddy B , Anand A, Aravind A, Kani Sheik Mohammed, Akhilandeswari A R, Vaishnavi Priya, Arun N, Krishna Reddy B
Correspondence- Krishna Reddy B-bhumanakkr@gmail.com
Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai 600 010, India
Background and study aim Deranged LFT, commonly noted along with other abnormal blood parameters in ICU patients is both a consequence as well as a significant cause of patient’s morbidity. In this observational study we aim to analyse the pattern of liver injury noted in patients being treated in ICU and suggest various precocious therapeutic measures for better clinical outcomes.
Method We conducted a prospective observational study in ICU patients irrespective of age and gender from October 2019 to July 2020. We analyzed the pattern of liver injury (hepatocellular/cholestatic) and also noted the derangement observed in specific liver parameters secondary to hepatic dysfunction.
Results Of the 184 patients in study group, 132 (72%) found to have abnormal LFT. Among them majority are found to have hepatocellular pattern, 103 of 132 (78%). Cholestatic pattern is noted in 12 patients (9%) and mixed pattern in 17 (13%) patients. The major causes for hepatocellular injury are hypoxic hepatitis (shock/congestion/respiratory failure) noted in 69 patients (77%) and ethanol related liver injury noted in 34 patients (33%). The major cause for cholestatic pattern and mixed pattern noted is sepsis related.
Conclusion Liver dysfunction is a major contributor for significant morbidity and mortality in ICU patients. Deranged LFT is seen in almost 2/3rd patients of our study group. Precocious therapeutic measures like early and aggressive treatment of sepsis, hemodynamic abnormalities and metabolic derangements can prevent or reduce the severity of liver dysfunction there by leading to improved clinical outcomes in measures of morbidity and mortality.
Keywords LFT profile in intensive care unit patients: Prospective observational study
207
Study of clinico-radiological profile of hepatocellular carcinoma: Comparing viral with non-viral etiology
Manne Gowtam , Ganesh P
Correspondence- Manne Gowtam-gowtam.manne@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Medical College and Research Institute, Chennai 600 116, India
Introduction Hepatocellular carcinoma (HCC) is the 5th common cause of cancers affecting humans. In recent times non-viral causes of HCC have been rising at an alarming rate. There are few studies comparing HCC patients with non-viral liver diseases with HCC patients due to viral diseases.
Aim To study the clinical radiological profile of HCC patients and to highlight the differences between viral HCC and non-viral HCC patients.
Methods In this retrospective study total of 61 case records of patients diagnosed with HCC of all causes in our hospital from 2018 to 2020 were studied. Clinical and radiological profile of HCC patients with viral etiologies were compared with non-viral etiologies.
Results Of the 61 patients of HCC, 39 patients had non-viral etiologies and 22 had viral etiologies. Non-alcoholic fatty liver disease (48.7%) is the leading cause of non-viral etiology and hepatitis B virus (77.27%) in viral etiology. Similar proportions of both groups were male (92.3% and 95.5%). A similar percentage of patients were cirrhotic at the time of diagnosis of HCC (non-viral 71.8% and viral 77.3%). The most common clinical presentation in both groups was abdominal pain. Viral HCC patients were younger (52.59% vs. 65.23%) with tumor characteristics on imaging similar to non-viral patients (arterial enhancement with delayed washout). The mean tumor size is 6.44 cm in the non-viral group comparable to 6.76 cm in the viral group. Barcelona clinic liver cancer (BCLC) stage C disease was more common at presentation among the viral HCC group compared with the non-viral HCC group (50% vs. 35.89). BCLC stage D is seen in 33.33% in non-viral and 36.4% in the viral group.
Conclusion Patients with viral etiology of HCC are younger and present with an advanced stage of HCC compared with non-viral causes of HCC.
Keywords Hepatocellular carcinoma
208
A novel predictor for fibrosis in pediatric non-alcoholic fatty liver disease
Nibin Nahaz , Krishnadas Devadas, Arun P, Sandesh Kolassery
Correspondence- Arun P-arunarathy88@gmail.com
Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram 695 005, India
Introduction Pediatric non-alcoholic fatty liver disease (NAFLD) poses a risk for significant fibrosis and eventual cirrhosis. Vibration controlled transient elastography (TE) noninvasively assesses the level of fibrosis. We tried to predict the risk factors for fibrosis in pediatric NAFLD.
Methods Liver stiffness was assessed using TE and shear wave elastography (SWE) in children with ultrasonologically diagnosed fatty liver. Hepatic steatosis was quantified with hepatorenal index (HRI)/B mode ratio and continuous attenuation parameter (CAP).
Results One hundred and fifty children were enrolled. Mean age was 11.5+3.7 years. 28% had normal weight, 22.7% were overweight and 47.3% obese. Any fibrosis (>F1) was present in 56.7%, significant fibrosis in 17.3% and advanced fibrosis in 5.3%. Waist circumference (WC) (r=0.45), mid arm circumference (MAC) (r=0.437) and hip circumference (HC) (r=0.391) correlated well with fibrosis. Controlled attenuation parameter (CAP) (r=0.559), screen-time (r=0.331), HOMA-IR (r=0.345) and triglycerides (TG) (r=0.307) had moderate correlation. Age, WC, aspartate aminotransferase (AST), alanine aminotransferase (ALT), triglycerides (TG), gamma-glutamyl transferase (GGT), albumin (Alb) and HOMA-IR were significantly different between no fibrosis (F0), any fibrosis (F1-F4) and significant fibrosis (>F2-F4). A Pediatric NAFLD fibrosis predictor (PNFP) score was developed. PNFP = 2.564+ (0.049*WC) + (0.005*TG)+(0.016*AST)-(0.578*ALB). PNFP score had an AUROC for any fibrosis, significant fibrosis and advanced fibrosis of 0.747, 0.864 and 0.909 respectively when compared to pediatric NAFLD index (PNFI) (0.604, 0.778 and 0.925). A PNFP score of 5.05 had a sensitivity of 71% and specificity of 53% for any fibrosis. A score of 5.94 had a sensitivity of 80% and specificity of 88.7% for significant fibrosis.
Conclusion Significant fibrosis occurs in 15% to 20% of pediatric NAFLD. Age, obesity, insulin resistance, and dyslipidemia increase fibrosis. Inactivity in the form of increased screen time accelerates fibrosis. PNFP score, a simple score incorporating AST, Alb, WC, and TG can predict significant fibrosis with better accuracy than existing models in children.
Keywords Transient elastography, Fibrosis, Pediatric non-alcoholic fatty liver disease fibrosis predictor (PNFP)
209
Does undetected non-alcoholic fatty liver disease lead to poorer treatment outcomes in patients undergoing surgery for gastrointestinal malignancy?
Sagar Narayan , C Kapil Tejaswy, Jacob Mathew, V P Gangadharan, H Ramesh
Correspondence- Sagar Narayan-nsagar2591@gmail.com
Department of Gastrointestinal Surgery, VPS Lakeshore Hospital and Research Centre, NH 47 Byepass, Nettoor, Maradu, Ernakulam 682 040, India
Introduction Patients with undetected liver disease seem to have poorer outcomes after treatment for gastrointestinal malignancies. Liver disease may not be picked up on routine preoperative screening and may be incidentally detected intraoperatively. Suitable modifications in the treatment plan could be made if liver disease is detected preoperatively. The aim was to determine the prevalence of undetected non-alcoholic fatty liver disease (NAFLD) in patients undergoing surgery for gastrointestinal malignancy; to assess correlation between MRI, MR elastography and liver biopsy and determine if morbidity is increased in patients with undetected pre-existing liver disease.
Methods Patients undergoing surgery for primary gastrointestinal malignancy without known liver disease between July 2018 and December 2019 were included. All patients underwent baseline LFT, MRI and MR elastography in the preoperative period. Intraoperative liver biopsy was done. Change in surgical or chemotherapeutic plan was noted. Any morbidity in the postoperative period was noted and patients were followed up during chemotherapy period to look for worsening in the liver function.
Results Sixty-two patients were included in our study. NAFLD was more common in elderly males (n-46). Twenty-four of 62 patients (38.7%) had NAFLD. Seven of 15 (44.6%) patients who were overweight and obese had NAFLD. The sensitivity and specificity of MRI in detecting steatosis was 62.5%, 94.7% respectively. The sensitivity and specificity of MR elastography in detecting fibrosis was 29.2%, 100% respectively. Treatment plan was modified in 7 patients due to pre-existing liver disease. On multivariate analysis presence of sinusoidal dilatation was associated with statistically increased morbidity. There was an increased trend of complications in patients with NAFLD, but the increase did not reach statistical significance (p-0.070).
Conclusion The prevalence of NAFLD in our population was less than Delhi and more than Eastern India. There was an increased incidence of complications among patients with NAFLD though it did not reach statistical significance.
Keywords Non-alcoholic fatty liver disease (NAFLD), Magnetic resonance imaging (MRI), Magnetic resonance elastography (MR elastography)
210
Variations in CD14 gene and severity of alcoholic liver disease
Neelanjana Roy , Hem Kumar * , Hem Pandey, Yatan Pal Singh Balhara ** , Anoop Saraya * , Shalimar * , Baibaswata Nayak *
Correspondence- Neelanjana Roy-neelanjanam@gmail.com
Departments of Blood Transfusion Medicine, *Gastroenterology and Human Nutrition, and ** Psychiatry, National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Alcohol accounts for 60% of all injuries registered in emergency rooms in India. Alcohol consumption in excess resulting in leaky gut is attributed to liver injury due to portal translocation of bacterial endotoxin ultimately leading to alcoholic liver disease (ALD). Variations in genes for alcohol metabolism and inflammation also contribute to development of ALD. The gene CD14 is a key player of endotoxin-mediated inflammation and vulnerability to ALD. Association of CD14 polymorphisms and the mechanisms relevant to alter inflammatory responses leading to ALD was assessed in this study.
Aims Associations of CD14 gene polymorphisms and mechanisms relevant to alcoholic liver disease.
Methods Alcoholics with (ALD, n=128) and without (ALCon, n=184) liver disease and controls without alcohol habit (HLC, n=152) from North India were enrolled. The CD14 SNP rs2569190 of all individuals (n=464) were genotyping by RFLP and confirmed bysequencing. Secretory CD14 (sCD14), LBP, TLR4, MD2, TNFa, IL1b, IFNg, IL6, IL10 and IL4 levels in serum were measured by ELISA. And circulatory bacterial DNA level was estimated by realtime PCR.
Results Sequencing of promoter and exonic regions for reported SNPs of CD14 gene was done and majority found to be monomorphic except rs2569190 in Indian population. The SNP rs2569190 (C/T) was genotyped and TT genotype showed significant association with risk of ALD (ALD vs. ALCon [p=0.014] or vs. HLC [p=0.043]). Significant increased sCD14 level was detected in ALD and ALCon as compared to HLC (p=0.010, 0.013). Enhanced levels pro-inflammatory cytokines, like LBP, TLR4, TNFa, IL1b, IFNg and IL6 and reduced levels of anti-inflammatory cytokines, as MD2, IL10 and IL4 was observed among the ALD patients (especially, in TT genotype) than the other two groups.
Conclusion Enhanced CD14 expression associated with inflammatory responses increases susceptibility of ALD in risk TT genotype individual.
Keywords Alcoholic liver disease, CD14 gene, Polymorphism
211
Alterations in autophagy and mTOR pathways mediate sarcopenia in patients with cirrhosis
Abhinav Anand ** , Aruna Nambirajan, Vikas Kumar, Samagra Agarwal, Sanchit Sharma, Srikant Mohta, Srikanth Gopi, Deepak Gunjan, Namrata Singh * , Kumble Madhusudhan, Shyam Chauhan, Mehar Chand Sharma, Virinder Kumar Bansal, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Gastroenterology and Human Nutrition, *Dietetics, and **Hepatology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction The pathophysiology of sarcopenia in cirrhosis is poorly understood. We aimed to evaluate the histological alterations in the muscle tissue of cirrhotic patients with sarcopenia and identify the regulators of muscle homeostasis.
Methods Computed tomography images at the third lumbar vertebral level were used to assess the skeletal muscle index (SMI) in 180 patients. Sarcopenia was diagnosed based on the SMI cut-offs from a population of similar ethnicity. Muscle biopsy was obtained from the vastus lateralis in 10 sarcopenic cirrhotics, and the external oblique in 5 controls (voluntary kidney donors during nephrectomy). The histological changes were assessed by hematoxylin and eosin staining and immunohistochemistry for phospho-FOXO3, phospho-AKT, phospho-mTOR, annexin V, and caspase 3. The mRNA expressions for MSTN, FoxO3, markers of ubiquitin-proteasome pathway (FBXO32, TRIM63), markers of autophagy (Beclin-1 and LC3-II) were also quantified.
Results The prevalence of sarcopenia was 14.4%. Muscle histology in sarcopenics showed abundant atrophic angulated fibers (p=0.002). Immunohistochemistry showed a significant loss of expression of phospho-mTOR (p=0.026) and a trend towards loss of phospho-AKT (p=0.089) in sarcopenic patients. There were no differences in the immunostaining for annexin-V, caspase-3, and phospho-FoxO3 between the two groups. The mRNA expressions of MSTN and Beclin-1 were higher in sarcopenics (p=0.04 and p=0.04, respectively). The two groups did not differ in the mRNA levels for TRIM63, FBXO32, and LC3-II.
Conclusions Significant muscle atrophy, an increase in autophagy markers, MSTN gene expression and an impaired mTOR signalling were seen in cirrhotic patients with sarcopenia.
Keywords Sarcopenia, AKT-mTOR, Beclin-1
212
Bacteriological profile and outcome of chronic liver disease patients admitted with sepsis in a teritary care center in southern India
Ravindra Kantamaneni , Rathi Bhaskaran, Venkatakrishnan L, Mukundan S, Joseph Jhon B, Thirumal Perumal, Prudhvi Chandolu, Kartikayan K, Nikhil Kenny Thomas
Correspondence- Ravindra Kantamaneni-navyateja2803@gmail.com
Department of Medical Gastroenterology, PSG Institute of Medical Sciences and Research Center, Off Avanashi Road, Peelamedu, Coimbatore 641 004, India
Background and Aims Bacterial infections are one of the most important clinical problems commonly encountered in cirrhotic patients due to underlying immunocompromised status. The most common infection in cirrhotic patients are spontaneous bacterial peritonitis (SBP), urinary tract infection (UTI), pneumonia and soft tissue infections.
Aim Aim of this study was to evaluate the most frequent infections in patients with cirrhosis and bacteriological profile, complications and prognosis.
Method This is retrospective analysis of two years from March 2017 to March 2019 which included 316 patients. Demographic characteristics were evaluated, including age, gender, sex, site of infection, CHILD, bacterial resistance profile, antibiotic use and mortality rate.
Results Ethanol is the major (58.4%) cause of the liver disease, followed by NAFLD (14.6%). Community acquired infections (78%) were more common than the hospital acquired infections. Seventy-two percent of the patients in this study was CHILD C. 27% of the patients had hepatic encephalopathy. 32% patients had acute kidney injury. 17% of the patients had acute on chronic liver cell failure. Most common site of infection is ascitic fluid followed by urinary tract infections. Most common organism isolated was E. coli ESBL (gram negative organism) and most common gram positive organism isolated was Enterococcuss Faecalis. Most common antibiotic used was third generation cephalosporins. Mortality in this study was less than 1%.
Conclusion Our study showed high prevalence of gram negative bacterial infections in patients with cirrhosis. Early identification and appropriate antibiotic therapy will decrease the mortality.
Keywords Bacteriological profile, Cirrhosis, Gram positive, Gram Negative
213
The masquerader: An interesesting tale of cystic SOL liver
Ashok Kumar , Kamalakannan R, Jeswanth Sathyanesan
Correspondence- Ashok Kumar-asasupernova@gmail.com
Department of Surgical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, Chennai 600 003, India
Background Etiology and clinical presentation of space occupying lesion SOL of liver are varied it can be solid cystic for heterogeneous and it can be very difficult for hepato-biliary-pancreatic surgeons to diagnose preoperatively.
Case report An 27-year-old lady came with complaints of abdominal pain for one month and fever of 1 episode. she was investigated outside, her vitals was stable and abdominal findings was insignificant. Sonogram showed a well-defined lesion in the left lobe of liver with no internal vascularity possibly abscess, tumor markers where within normal limits, CE CT suggested recurrent pyogenic cholangitis with abscess while MRI suggested intrahepatic duplication of gallbladder. initial diagnosis of SOL segment 4b of liver. patient underwent laparoscopic cholecystectomy with enucleation of the lesion postoperative period was uneventful and final histopathology came back as Caroli disease.
Conclusions Caroli disease has been broadly applied to describe any patient with intrahepatic bile duct cyst regardless of the presence of extrahepatic bile duct cyst or the shape of the intrahepatic cyst. This disease occur in less than 1% of all the patients with biliary cystic disease and isolated version is even more rare in medical literature. Routine diagnostic armamentarium can not always achieve an accurate preoperative diagnosis. Caroli disease in adults main present in a localized form limited to 1 hepatic lobe or segment or a diffuse form most often the left side.
Keywords liver SOL, Cystic, Caroli disease
214
FibroScan-aspartate aminotransferase score in an Asian cohort of non-alcoholic fatty liver disease and its utility in predicting histological resolution with bariatric surgery
Abhinav Anand * , Anshuman Elhence, Manas Vaishnav, Amit Anurag Singh, Mahendra Singh Rajput, Vikas Banyal, Vikas Jindal, Piyush Pathak, Peeyush Kumar, Baibaswata Nayak, Rajni Yadav, Prasenjit Das, Harshit Garg, Lokesh Agarwal, Sandeep Aggarwal, Ramesh Kumar, Shalimar
Correspondence- Shalimar-drshalimar@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, and *Hepatology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background and Aim The FibroScan-aspartate aminotransferase (FAST) score was developed for identifying patients with non-alcoholic steatohepatitis (NASH), who also have an elevated non-alcoholic fatty liver disease (NAFLD) activity score (NAS) ≥4 and significant fibrosis (F≥2). We aimed to validate it in our NAFLD cohort and assess if it correlates with the histological changes post-bariatric surgery.
Methods Patients with NAFLD, including those undergoing bariatric surgery, were included. The FAST score was calculated using liver stiffness measure, controlled attenuation parameter, and AST. Calibration and discrimination of the model were assessed by calibration plots and area under the receiver operating curve (AUROC), respectively. Sensitivity and specificity were assessed at the rule-out and rule-in cut-offs (≤0.35 and ≥0.67), respectively. Changes in the NAS and FAST scores were compared in the bariatric cohort one-year after surgery.
Results The cohort comprised of 309 patients, of which 48 patients underwent repeat liver biopsy at 1-year. The model showed good discrimination with AUROC of 0.79 (0.74-0.84); however, it wasn’t satisfactorily calibrated (Hosmer Lemeshow test p=0.008). The sensitivity and specificity at the rule-out and rule-in cut-offs were 0.90 and 0.84, respectively. A significant correlation was seen between the 1-year reduction in the NAS and FAST scores (r=0.38, p=0.009). A significant reduction in the median FAST score was seen in patients who had ≥2-point reduction in NAS post-bariatric surgery.
Conclusion FAST score demonstrated good discrimination for fibrotic NASH in our cohort. However, a miscalibration resulted in over prediction. The score correlated well with the histological response to interventions for NAFLD.
Keywords NASH, NAFLD, AST
215
HAM score-A MELD-sodium variant for predicting 3 month mortality in decompensated liver disease
Jijo Varghese , Krishnadas Devadas, Asif N Iqbal, Srijaya Sreesh
Correspondence- Asif Iqbal-asif.nn.iqbal@gmail.com
Department of Medical Gastroenterology, Trivandrum Medical College, Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction Decompensated liver disease (DCLD) has got a high mortality rate. Prediction of mortality is important to prognosticate the patient and to channel high risk patients for liver transplantation. Objective of the study was to propose a new prognostic model for DCLD which is better than the existing scores.
Methods It was a retrospective and prospective observational study. Clinical and biochemical variables were assessed on the date of admission from the medical records and patient relatives were telephonically contacted regarding the date of death and mortality at 3 months from the date of admission. Logistic regression was done, coefficient of beta of independent variables were found out and a new score (HAM score) was proposed. HAM score=MELD-Na x 0.1 + (2 if moderate/severe ascites present; 0 if absent) + (1 if overt hepatic encephalopathy present; 0 if absent). H-hepatic encephalopathy, A-ascites, M-MELD-Na (HAM score).
Results In predicting 3 month mortality in DCLD, the New score (HAM score) has an AUROC of 0.772 (cut off >=5; sensitivity of 71%, specificity of 72.9%, positive predictive value 56.7%, negative predictive value 83.4% and accuracy 72.3%) (Fig. 1) compared to CTP score of 0.769 (cut off >11; sensitivity 71% and specificity 73.8%) (Fig. 2), MELD-Na of 0.735 (cut off >25; sensitivity 65% and specificity 72%) (Fig. 3), MELD of 0.727 (cut off >17; sensitivity of 80.37% and specificity of 55.14 %),i-MELD of 0.7223, MESO index of 0.727 and UKELD of 0.686.
Conclusion HAM Score (New score) is superior to MELD and MELD variants in predicting 3-month mortality. HAM Score is better than most of the existing prognostic models for DCLD. HAM Score needs to be validated in a different cohort to find out its prognostic performance.
Keywords New MELD-sodium variant, HAM Score, 3 month mortality
216
Patients with coronary disease have high prevalence but mild non-alcoholic fatty liver disease
Kannan Murugesan ** , Ajay Duseja * , Ajay Bah, Ankur Gupta, Prashant Panda, Sunil Taneja * , Radha Krishan Dhiman *
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
Department of Cardiology, *Hepatology, and **Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction Even though enough literature exists regarding the prevalence of CAD in patients with NAFLD, the literature on the prevalence and severity of NAFLD in patients with CAD is sparse. Objective of the present study was to assess the prevalence of NAFLD and its severity in patients with CAD.
Methods In a prospective study, consecutive adult patients with CAD were screened for the presence and severity of NAFLD after an informed consent. The study had the approval of Institute’s Ethics Committee. CAD was diagnosed on coronary angiography and severity assessed by number of vessels involved and SYNTAX score. Prevalence and severity of NAFLD was assessed on ultrasound (abdomen), transient elastography [measuring liver stiffness measurement (LSM) and controlled attenuation parameter (CAP)] and other non-invasive assessment.
Results Of 256 patients screened over one and half years, 100 patients (males 71, mean age 56.7 ± 9.6 yrs) meeting the criteria were included. Prevalence of NAFLD on USG and CAP was 48% and 42% respectively and 38 patients (38%) had evidence of steatosis on both modalities. Severity of hepatic steatosis as assessed on CAP (n=42) was S1 (248 to ≤ 268 dB/m) in 26%, S2 (268 to 288 dB/m) in 31% and S3 (>288 dB/m) in 43% patients respectively. Seven (18.4%) patients had abnormal ALT (>40 IU/L); significant hepatic fibrosis (LSM≥8 kPa) was observed in 6 (15.8%) among 38 patients with hepatic steatosis on both USG and CAP with none of the patients having evidence of cirrhosis (LSM ≥12.5 kPa). Severity of CAD did not affect the prevalence or severity of NAFLD; severity of NAFLD did not affect the severity of CAD.
Conclusion NAFLD is common in patients with CAD; majority of them have mild disease without significant necro-inflammation and hepatic fibrosis.
Keywords Fatty liver, Steatosis, NAFLD, NASH, Cardiovascular disease, Metabolic syndrome
217
Therapeutic plasma exchange is safe and effective in the treatment of acute-on-chronic liver failure- A case-control, pilot study
Sharanya Ramakrishnan , Rekha Hans, Ajay Duseja * , Rati Ram Sharma
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
Departments of Transfusion Medicine, and *Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background Acute-on-chronic liver failure (ACLF) is associated with high in-hospital mortality. Efficacy of therapeutic plasma exchange (TPE) in treating patients with ACLF is not yet established. The aim of the present study was to assess the efficacy and tolerability of TPE in patients with alcohol related ACLF.
Methods Twenty-eight patients (27 males [96.4%], mean age 39.8 ± 7.9 years) with alcohol related Asian Pacific Association for the Study of the Liver (APASL)-ACLF with grade II AARC score without liver transplant prospects were enrolled in this prospective, case-control, pilot study. Fourteen cases received standard volume TPE in addition to standard medical treatment (SMT) while 14 matched controls were managed with SMT alone. In addition to tolerability and safety of TPE, biochemical parameters, cytokines, clinical scores (AARC, MDF, MELD, CTP, SOFC at day 10) and 30-day and 90-day mortality rates were compared between cases and controls.
Results Total of 51 TPE procedures were performed in 14 cases (average-3.62 procedures/patient). In comparison to controls, cases had higher reduction in mean serum bilirubin (-10.4 [14.75] vs. 1.55 [2.9], p=0.000), ammonia (-32 [36] vs. 8.5 [24], p=0.0001), prothrombin time (-7 [11.6] vs. 4 [5.3], p=0.0002) and INR (-0.45 [0.88] vs. 0.26 [0.1], p=0.0022]. The difference in reduction of serum IL-6, IL-10 and TNF-a concentrations among cases and controls was not significant. However, in comparison to controls, cases had higher reduction in AARC score (-2 ±1.10 vs. 0.36 ±0.84, p=0.000), MDF (-39.7 [34.2] vs. 4.7 [21.4], p=0.0001) and MELD (-6 [7] vs. 2 [2], p=0.0005) at day 10. There was no difference in 30-day (21.43% vs. 21.43%, p= 1.000) and 90-day mortality (35.7% vs. 50, p=0.4450) rates and no difference in total and serious adverse events (p= 0.663) among cases and controls.
Conclusion TPE is safe and effective in the treatment of alcohol related patients with APASL ACLF.
Keywords Cirrhosis, Alcohol, AARC, MELD, Liver transplantation
218
Point shear wave elastography is helpful in prognosticating patients with alcohol related patients with acute-on-chronic liver failure defined by APASL definition
Vamsidhar Reddy , Ajay Duseja, Prajina Pradhan * , Radha Krishan Dhiman, Sunil Taneja, Naveen Kalra *
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
Departments of Hepatology, and *Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background and Aim Various prognostic scores are available for acute-on-chronic liver failure (ACLF). The aim of the present study was to evaluate the utility of point shear-wave elastography (pSWE) in predicting severity, organ failure andday-28 and day-90 mortality in patients with alcohol related ACLF.
Methods In a prospective study (January 2019 to February 2020), pSWE was done at presentation in 102 patients with alcohol related ACLF defined as per APASL, CANONIC and combined (APASL+CANONIC) definitions to predict the baseline severity, organ failure and 28-day and 90-day mortality.
Results In the APASL ACLF group (n=46, males=45, mean age= 42.65±8.92), baseline pSWE correlated with AARC score (r=0.371, p=0.01) but not with the presence and number of organ failures. pSWE at the baseline in the APASL ACLF group also predicted the 28-day (cut off of 31.35 kPa, AUROC-0.983, p<0.001, diagnostic accuracy of 95.65%) and 90-day mortality (cut off 26.5 kPa, AUROC-0.983, p<0.001, diagnostic accuracy 82.61%). In the CANONIC group (n=26, males=26, mean age=44.27±10.09), baseline pSWE neither correlated with baseline severity nor with organ failures. Also, baseline pSWE in the CANONIC group did not predict the 28 day (AUROC-0.670, p=0.179) and 90-day mortality (AUROC-0.705, p=0.101). Similar to CANONIC group, in the combined ACLF group as well (n=30, males=30, mean age=40.57±9.5), baseline pSWE neither correlated with baseline severity nor with organ failures and did not predict the 28-day (AUROC-0.531, p=0.179) and 90-day mortality (AUROC-0.562, p=0.101).
Conclusion Baseline pSWE is helpful in predicting the severity, 28-day and 90-day mortality in patients with alcohol related ACLF as defined by the APASL definition but not in those having ACLF as per CANONIC and combined (APASL+CANONIC) definitions.
Keywords Cirrhosis, Liver failure, ACLF, APASL, Elastography
219
A comparison study of steroid and pentoxifylline in alcoholic hepatitis
Dharmendra Tyagi , B Shankar Sharma
Correspondence- Dharmendra Tyagi-drdtyagi89@gmail.com
Department of Gastroenterology, Kurnool Medical College, Bharath Petroleum, Near, Bhudawarapet, Kisan Ghat Road, Kurnool 518 002, India
Introduction Alcoholic hepatitis is the most florid presentation of alcohol-related liver disease. In its severe form, defined by a Maddrey’s discriminant function (DF) ≥32, the 28-day mortality rate is approximately 35%. Several potential treatments have been subjected to clinical trials, of which two, corticosteroids and pentoxifylline, may have therapeutic benefits.
Method This study was conducted in the dept of Medical Gastroenterology in Govt. General Hospital, Kurnool in which 60 patients were taken. Patients were randomized in 2 groups:
Group A: 30 patients on steroid
Group B: 30 patients on pentoxifylline
The primary endpoint of mortality was 28 days
Result Treatment with steroid reduced the 28 days mortality to 13.3% (4 patient died out of 30) and treatment with pentoxifylline associated with 33.3% mortality (10 patient died out of 30 patient).
Conclusion Pentoxifylline did not improve survival in patients with alcoholic hepatitis as compared to steroids. Prednisolone was associated with a reduction in 28-day mortality.
Keywords Alcoholic hepatitis, Steroids, Pentoxifylline
220
Analysis of correlation of clinicopathological profile, prognostic indicators, and survival outcomes in patients of hepatocellular carcinoma with baseline alfa-fetoprotein levels: Bruised but not broken biomarker
Vaneet Jearth 2 , Prachi Patil 3 , Vishal Seth 3 , Sridhar Sundaram 1 , Vidya Rao 2 , Shaesta Mehta 3
Correspondence- Vaneet Jearth-vaneet.jearth@gmail.com
1Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai 400 012, India, and 2Departments of Surgical Pathology, and 3Digestive Diseases and Clinical Nutrition, Tata Memorial Center, Dr. E Borges Road, Parel, Mumbai 400 012, India
Introduction Almost 60 years after its discovery, role of alfa fetoprotein (AFP) in management of HCC is still matter of debate with disagreements between different international guidelines. The purpose of this study was to analyze relationship between clinicopathological profile, prognostic indicators, and survival outcomes with respect to serum AFP levels.
Methods Retrospective analysis of a prospectively accrued dataset of consecutive HCC patients registered in the hepatology clinic at the Tata Memorial Hospital, Mumbai between June 2017 and September 2019 was done.
Results Five hundred and eight treatment naïve HCC patients were included in analysis, of whom 92 (18.1%) had normal AFP levels (<10 ng/mL). One hundred and forty-six patients (28.7%) had AFP levels of 10-400 ng/ml and 270 (53.2 %) patients had AFP greater than 400 ng/mL. Patients with AFP > 400 ng/mL had poor hepatic reserves (higher mean serum bilirubin, AST, ALT, INR, and lower mean albumin) and advanced disease at presentation (higher incidence of portal vein tumor thrombosis [PVTT], extrahepatic metastasis, advanced Barcelona clinic liver cancer [BCLC] stage and significantly less proportion of patients with well differentiated tumors). On multivariate logistic regression, AFP >400 ng/mL was independent predictor for presence of PVTT (OR, 4.08; 95% CI, 2.34–7.12; p< 0.001), higher tumor size (OR, 2.19; 95% CI, 1.36-3.54, p=0.001) and more advanced BCLC stage (OR, 4.19; 95% CI, 2.51–7.03; p < 0.001) at presentation. No statistically significant relationship was seen between survival and baseline AFP levels in patients who underwent surgery (p=0.113) but survival was significantly different in patients who underwent non-surgical therapies (p=0.003) (Fig. 1). AFP levels >400 ng/mL was independent predictor of survival in patients receiving any form of therapy (HR=2.23; 95% CI=1.19-4.18, p=0.012).
Conclusion AFP as a biomarker have significant influence on management in HCC patients and is here to stay till the search for ideal biomarker in HCC is over.
Keywords Alfa fetoprotein, Portal vein tumor thrombosis, Barcelona clinic liver cancer staging
221
DAA therapy is associated with improvement in state of MELD purgatory in decompensated hepatitis C virus cirrhosis
Prasanta Debnath , Parmeshwar Junare, Sujit Nair, Pravin Rathi
Correspondence- Prasanta Debnath-prasantad89@gmail.com
Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai Central, Mumbai 400 008, India
Introduction Decompensated HCV cirrhosis is a difficult-to-treat cohort, with an SVR rate of over 80%. DAAs are also associated with an improvement in overall liver function. MELD purgatory is used to describe patients, who experience viral eradication, have an improvement in the biochemical parameters-MELD score, yet remain decompensated, post-treatment. We conducted this study to look for improvement in MELD purgatory state post-treatment in decompensated HCV cirrhosis.
Methods A prospective analysis of data from decompensated HCV cirrhotics was done. MELD score was calculated for each patient and patients were stratified into Child-Pugh class B and C. clinical and biochemical parameters were noted at baseline and factors predicting persistent MELD purgatory state post-treatment were evaluated.
Results A total of 62 patients were recruited. Median age 52 (42-80) years; male 36 (58.1%). Patients with Child class B 55 (88.7%%) and Child class C 7 (11.3%). Median HCV RNA 2,24,000 with HCV genotype 3 in 80.7%. The number of patients with MELD purgatory state pre-treatment was 48 (77.4%). Post-treatment follow-up period (36 weeks), only 12 (19.3%) remained in the state. On multivariate analysis CTP score (OR 0.34) and serum bilirubin (OR 0.28) and on univariate analysis serum bilirubin (OR 0.41), albumin (OR 3.64), and eGFR (OR 1.03) were significantly associated with MELD purgatory state post-treatment.
Conclusion DAA therapy is associated with improvement in MELD purgatory status. The natural history of such patients is lacking in the long run. A long-term follow-up study in a large population is advisable.
Keywords Hepatitis C, MELD purgatory, Decompensated cirrhosis
222
Prevalence of bacterial infections in acute-on-chronic liver failure: Bacteriology, patient profile and clinical outcome
Beeram K Prasanna Kumar , Rohit Gupta, Anand Sharma, Itish Patnaik, Ashok Kumar, Sahaj Rathi
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Biochemistry, All India Institute of Medical Sciences, Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Background Bacterial infections are common triggers for acute-on-chronic liver failure (ACLF). We aimed to study the prevalence of bacterial infections in ACLF patients.
Methods In an ongoing prospective study, consecutive hospitalized patients diagnosed with ACLF according to EASL criteria between January 2019 and July 2020 were recruited and followed up for one-month post discharge.
Results During the study period, 100 consecutive patients with ACLF (age 44.67±11.5 years; 90% were male; baseline CTP 13.72±1.06, MELD-Na 34.4±5.87, CLIF SOFA 11.4±1.73, CLIF C ACLF 52.07±9.18) were included in the study. Alcohol was the most common etiology of acute insult (alcoholic hepatitis 49%; hepatitis B reactivation 17%; sepsis 16%; acute hepatitis A 2%; acute hepatitis E 4%;) as well as cirrhosis (alcohol 59%; hepatitis B 18%; hepatitis C 5%). Previous decompensation was present in 20%. 64 % of patients had evidence of bacterial infections (blood 8%; ascitic fluid 36 %; urine 13 %; cellulitis 6%) at admission. Gram negative bacteria were the most common isolates (Escherichia coli 44%, Klebsiella sp 23%. Acinetobacter 11%). Compared to patients without bacterial infection, those with evidence of infection had higher CLIF C ACLF score (48.63±7.79 vs. 54±9.39; p=0.004) Procalcitonin (2.13±2.64 ng/mL vs. 4.81±4.85 ng/mL; p=0.002); blood leucocyte count (14.02 ±7.49 x 109 cells/L vs. 18.13±9.81 x 109 cells/L; p= 0.03) and mortality (41 vs. 15; p= 0.03). Forty-two of 100 (42%) patients died during hospital stay (duration of hospitalization 12 ±8 days). Fourteen of remaining 58 (24%) patients died within one month of discharge.
Conclusion Bacterial infections were noted in 64% patients with ACLF and was associated with significantly higher mortality.
Keywords ACLF, Bacterial infections, Mortality
223
“Bilioenteric anastomosis: Use the normal route”: A retrospective analysis of hepaticoduodenostomy versus hepaticojejunostomy in living donor liver transplantation
Jaya Agarwal , Binoj S T, Shweta Malick, Krishnanunni Nair, Johns Shaji Mathew, Christi Varghese, Biju Chandran, Ramachandran Menon, Dinesh B, Unnikrishnan G, Sudhindaran S
Correspondence- Sudhindaran S-sudhi@aims.amrita.edu
Department of GI Surgery and Liver transplantation, Amrita Institute of Medical Sciences, Kochi 682 041, India
Introduction In living donor liver transplantation (LDLT) when donor bile duct to recipient bile duct anastomosis is not feasible, usually in the case of multiple ducts, hepaticojejunostomy (HJ) is often performed. Recently in non-transplant biliary surgery hepaticoduodenostomy (HD) has shown equivalent results to HJ. This study is our experience of outcomes of HD in adult LDLT.
Method A retrospective case control study of 58 adult patients undergoing right lobe LDLT with bilioenteric anastomosis was conducted at our centre. Bilioenteric anastomosis was performed for patients who had ≥ 2 donor bile ducts with > 3 mm separation (n=54) or unsuitable recipient bile ducts (n=4). Though HJ was our initial practice of choice (n=23), for the last 8 years HD has been our preference (n=35). We compared incidence of biliary complications between HJ and HD.
Results Baseline demographic parameters, MELD score as well as bilirubin and liver enzymes in the immediate postoperative period and at 3 and 6 months were similar in both groups. Between HD and HJ the occurrence of leak rates (23% vs. 22%), cholangitis (11.4% vs. 17%) and strictures (11.42% vs. 17%) were similar. Need for radiological interventions or re-exploration (11.4% vs. 4.34%) for biliary complications were likewise similar. However 17% of HJ required percutaneous transhepatic biliary drainage (PTBD) vs. 2% of HD (p- value=0.05). Mortality was comparable between HD (20%) and HJ (17%).
Conclusion HD is an alternative to HJ when bilioenteric anastomosis is required following LDLT. As duodenum could be easily accessed using endoscope, the requirement of transhepatic approach for biliary intervention is significantly less in HD as compared to HJ.
Liver transplantation, biliary anastomosis, hepaticoduodenostomy, hepaticojejunostomy.
224
Budd-Chiari syndrome management : A single institution experience
Govind Purushothaman , Rohit Mudadla, Amudhan A, Kamala Kannan R, Saravanan J, Thiruvarul M, Selvaraj T, Jeswanth S
Correspondence- Govind Purushothaman-govindmmc@gmail.com
Department of Surgical Gastroenterology and Liver Transplant, Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, 1, Old Jail Road, Chennai, 600 001, India
Aim To investigate challenges, risk factors, prognostic indicators and treatment outcomes of various methods associated with Budd-Chiari syndrome (BCS) at a tertiary care center.
Methods A retrospective analysis of 100 patients with BCS who underwent radiological intervention (HV/IVC angioplasty, TIPSS), surgical portal decompression shunt procedure (SSPCS, PSRS) and liver transplant.
Results Among 100 patients, 40 patients were excluded from analysis due to death and missed follow–up. In 60 patients with BCS 30 patients underwent various hepatic vein/IVC angioplasty and TIPSS, 11 patients underwent SSPCS and PSRS shunts and remaining 18 patients underwent liver transplant work-up and 1 patient underwent LTX. Radiological intervention was done in 30 patients. Twenty-four patients are doing well and have well preserved liver function with intervention procedure alone. In surgical portal decompression group 9 out of 11 survivors remain symptoms free and with normal liver function. In liver transplant group, 1 patient underwent DDLT. Three years follow-up is good, maintaining liver function and good quality of life. Remaining patients have undergone liver transplant work up. In radiological intervention group 5 patients died of liver failure and one patient lost follow-up. In Surgical shunt one patient died of postoperative liver failure, one due to pulmonary complication and 6 patients died of liver failure while awaiting liver transplant.
Conclusion Effective treatment of BCS requires multidisciplinary approach. Early diagnosis and decompression of porto-mesenteric venous system can provide excellent survival. Accurate assessments of duration of symptoms, extent of thrombosis and liver function are critical in determining the course of treatment.
Keywords Budd-Chiari syndrome management, Portocaval shunt
225
Auxillary partial orthotopic liver transplantation (APOLT) in treatment of acute liver failure: The Amrita experience
Jaya Agarwal , Shweta Malick, Krishnanunni Nair, Johns Shaji Mathew, Christi Varghese, Biju Chandran, Binoj S T, Ramachandran Menon, Dinesh B, Unnikrishnan G, Sudhindaran S
Correspondence- Sudhindaran S-sudhi@aims.amrita.edu
Department of GI Surgery and Liver Transplantation, Amrita Institute of Medical Sciences, Ponekkara, AIMS PO, Kochi 682 041, India
Introduction Acute liver failure (ALF) often affects the young in the prime of life. Over 70% survivors are on medical management and have complete morphological and functional recovery. In the subset of patients who need liver transplantation (LT), if APOLT can be offered, life-long immunosuppression may be avoided. We report a case series of 6 patients who had undergone APOLT for ALF.
Method Out of 810 LT performed at our institute between 2006 and 2019, 68 were for ALF. Out of these 6 were APOLT, the first one being performed in 2011 December. Decision to perform APOLT was made by assessing the hemodynamic stability of the patient and the appearance of the native liver. Post operatively LFT, INR, 6 monthly and 1-year HIDA scan and CT abdomen was done. When the native liver regeneration (NLR) was > 50 % decision to discontinue the immunosuppression gradually was made.
Results Out of 6 patients 3 survived (50%). All patients were below 40 years. Etiology of ALF was hepatitis A (n= 4), yellow phosphorous (n=1) and seronegative hepatitis (n=1). In the surviving patients immunosuppression was given for a mean of 22 months and was gradually withdrawn. None required graft hepatectomy. Sepsis was cause of death in 2 patients whereas brain death in 1. High preoperative ammonia (>200) and non-hepatitis A etiology were predictors of mortality in APOLT patients.
Conclusions APOLT can be offered to ALF patients especially with hepatitis A etiology and preoperative ammonia levels <200.
Keywords Liver transplantation, Acute liver failure
226
Etiology, clinical profile and outcome in patients with portal vein thrombosis
Jithin James , Ramachandran T M, Srijith K
Correspondence- Jithin James-jithinjames87@gmail.com
Department of Gastroenterology, Government Medical College, Medical College Road, Kozhikode 673 008, India
Introduction A regional data on common causes for portal vein thrombosis and to know its prognosis and outcome helps in better understanding of disease and in management. This study was undertaken to determine etiological factors, clinical characteristics, complications, and outcome in patients with portal vein thrombosis.
Methods A cohort study of 40 patients with diagnosis of portal vein thrombosis was conducted. A pre structured proforma was used for collection of data. Patients were followed up for 6 months from the time of diagnosis.
Results Study population was grouped into three strata: C-PVT, non-malignant cirrhotic PVT; N-PVT, non-malignant non-cirrhotic PVT and M-PVT, malignant PVT. N-PVT patients were younger at the time of diagnosis compared to patients with C-PVT or M-PVT (p<0.01). Most common cause of PVT was cirrhosis liver followed by malignancy. Abdominal pain was a common complaint in N-PVT and M-PVT but less frequent in C-PVT (p<0.05). Ascites (p<0.001), splenomegaly (p<0.05), esophageal varices (p<0.001) and jaundice (p<0.01) were more prevalent in C-PVT and M-PVT than in N-PVT. In 80% of patients diagnosis was established by means of Doppler ultrasound. Anticoagulation therapy was administered to 60% of patients and was more common in N-PVT patients (92.3%) than in those with C-PVT (52.9%) or M-PVT (30%) (p<0.01). Out of the 31 patients for whom results of recanalization were available 51.6 % had complete/partial recanalization during 6 month follow-up. Seventy-five percent of patients with recanalization had received anticoagulation. Recanalization was seen in 69.2% of patients in N-PVT group, 50% of patients in C-PVT group (p<0.05). Sixty percent of patients in the M-PVT group and 17.6% patients in the C-PVT group died during follow-up.
Conclusion Partial or complete recanalization was more frequent in patients treated with anticoagulation therapy. The prognosis is variable and highly dependent on underlying disease.
Keywords Portal vein thrombosis, recanalization, anticoagulation.
227
Study of clinical profile and predictors of mortality in spontaneous bacterial peritonitis in cirrhosis of liver
Pankaj Nawghare , Jayant Sakale * , Saurabh Bansal, Sameet Patel, Partha Debnath, Siddhesh Rane, Shubham Jain, Sanjay Chandnani, Pravin Rathi
Correspondence- Pankaj Nawghare-pankaj9ghare21@gmail.com
Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai Central, Mumbai 400 008, India, *Department of Medicine, Government Medical College, Nagpur 440 009, India
Introduction Spontaneous bacterial peritonitis (SBP) is a very common bacterial infection in patients with cirrhosis and ascites which requires prompt recognition and treatment. This study was carried out to identify and understand the clinical profile of SBP, about causative organisms and different mortality indicators in SBP in cirrhotic.
Methods Study was conducted at tertiary care center. All consecutive patients with cirrhosis with ascitic fluid TLC >250 cells /mm3 were included.
Results Forty population were enrolled with 20% were female. Majority of patients were in age group 40-50 years. Mortality was more in males (25%) than female (7.5%). Alcohol was predominant etiology for cirrhosis (85%). Most common presenting complaint was abdominal pain (82.5%) followed by abdominal distention (60%) but both were not significantly associated with mortality. Altered sensorium and reduce urinary output on admission was associated with increase mortality (p<0.05). On examination presence of jaundice, grade 3 ascites and WHC >2 was associated with increase mortality (p<0.05). There was significant association between the degree of hyperbilirubinemia and mortality (p=0.017). Though ascitic fluid albumin < 1 gm is strongly associated with SBP, its association with mortality was not significant. Association of ascitic fluid TLC, sugar and SAAG were also not significant with mortality. Most common organism isolated was E coli. Etiology of cirrhosis didn’t affect mortality. There was less mortality in patients responding to the treatment on day 3 (p=0.001). Most of patients belongs to Child-Pugh class C. Mean MELD score was 24.57 ± 8.45. A highly significant association was found between MELD score and Child-Pugh score with mortality.
Conclusion Spontaneous bacterial peritonitis is often a fatal complication of cirrhosis. Early diagnosis is critical for successful treatment. With use of various mortality indicator response can be predicted.
Key word Cirrhosis, SBP
228
A study of frailty in patients with liver cirrhosis and impact of nutritional intervention on frailty
Ajay Kumar Jain , Mohit Jain, Shohini Sircar, Arun Singh, Amit Joshi, Sumit Singh
Correspondence- Mohit Jain-drmohitmd@gmail.com
Department of Gastroenterology, Choithram Hospital and Reasearch Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction It has been seen that commonly used scores to predict prognosis in cirrhosis are CTP and MELD, however these scores failed to capture the effects of muscle wasting, malnutrition, and functional decline that are present in most decompensated cirrhotic patients, and contribute to excess mortality in this population. Recent Studies have shown that frailty index does have an added role in prognostication of these patients. So, we aim to determine prevalence of frailty in patients of chronic liver disease and to assess the effects of nutritional intervention at 8 and 12 weeks in this patient population.
Methodology This is a prospective non-randomized interventional study for 18 months in patients of cirrhosis. All patients did balance, chair stands and gait speed (SPPB- short physical performance battery) at baseline, 8 and 12 weeks respectively. All patient underwent nutritional assessment at baseline and specific dietary advice was given to achieve protein intake of 1 gm/kg body weight and 30 to 35 K. Cal/Kg body weight per day.
Results Total 340 patients of cirrhosis were screened for frailty, among them 173 patients were recruited based on inclusion and exclusion criteria. Prevalence of frailty in this cohort of patients (n=173) was 34.6% (60/173). Out 173 patients 78 patient completed follow up at 8 and 12 weeks. At baseline out of 78 patients 34 (43.6%) were frail (SPPB < 10). After nutritional intervention 15 (44.1%) and 19 (55.8%) patients showed significant improvement in frailty index (SPPB>10) at week 8 and 12 respectively.
Conclusion This study suggest that about one third of cirrhotic patients are frail at presentation. Nutritional intervention does help in improving frailty which possibly could improve prognosis in this patient population.
Keywords Frailty, Chronic liver disease, Nutrition
229
Spectrum of non-alcoholic fatty liver disease in adult Type 2 diabetes mellitus patients
Nitesh Pandey
Correspondence- Nitesh Pandey-niteshkumarshashi@gmail.com
1Delhi University, Delhi, India, and 2Department of Medicine, Lady Hardinge Medical College, Connaught Place, New Delhi 110 001, India
Background Non-alcoholic fatty liver disease (NAFLD) is an overlooked complication of type 2 diabetes mellitus (T2DM) one of the most common cause of chronic liver disease worldwide.
Aim To study the proportion of NAFLD in T2DM patients. To measure the grade of liver fibrosis using fibroscan and to calculate Bazick’s and NAFLD fibrosis score (NFS) and compare both the scores for advanced liver fibrosis vis a vis fibroscan.
Method One hundred diagnosed between 35-65 yrs of age were included and patients with alcohol intake in past 2 years >140 gm and >70 gm in male and female respectively per week, known liver disease, history of hepatotoxic drug intake, on insulin therapy, ascites and pregnancy were excluded. NAFLD was diagnosed as; fatty liver grade 1, 2, 3 using ultrasonography, transamniitis (AST, ALT >35 IU/L), and fibrosis by fibroscan (F0-F4) and advanced fibrosis was considered as F3 (8.7-10.2) and F4 (≥10.3). Bazick’s score and NAFLD score were calculated and compared vis-a-vis fibroscan for advanced fibrosis.
Results One hundred T2DM patients (69 female/31 male) in age group of 35-65 years enrolled in LHMC, 84 (84%) T2DM patients were identified as having NAFLD. 61% patients had fatty liver, 43% had transamniitis and 60% patient had fibrosis, 23% patient had advanced fibrosis by fibroscan. As per prevalence of advanced fibrosis was 41% and by NFS score it was 50%. The diagnostic accuracy for advanced fibrosis was found to be 61% and 55% in our study for Bazick’s and NFS score respectively. The specificity, sensitivity, NPV and PPV for Bazicks score was 90%, 56.8%, 47.7% and 93.2% respectively, for NAFLD score it was 98%, 51%, 85% and 95% respectively.
Conclusion NAFLD was very common among T2DM patients. Advanced fibrosis was present in about a quarter of T2DM patients. Both Bazick’s and NAFLD fibrosis score were not good for predicting advanced liver fibrosis.
Keywords NAFLD, T2DM, Advanced fibrosis
230
Jaundice in pregnancy: Analysis of etiological factors and maternal and fetal outcome
Vani Malhotra ,
Correspondence- Vani Malhotra-drparveenmalhotra@yahoo.com
Department of Medical Gastroenterology, Post Graduate Institute of Medical Sciences, Medical Road, Rohtak 124 001, India
Introduction Jaundice is a common medical disorder with high maternal mortality and morbidity, acute viral hepatitis being the commonest cause of jaundice in pregnancy.
Aims and Objectives To assess the etiological factors associated with jaundice and its maternal and fetal outcome in pregnancy.
Methods Prospective observational study over one year in pregnant female presenting with jaundice in pregnancy. A detailed history was taken, and all the females were subjected to routine and special investigations like liver function tests, viral markers, coagulation profile and hepatobiliary sonography. Maternal and fetal outcomes were assessed and noted in prestrcured. Performa and analyzed by using Chi-square a with p-value of < 0.05 as significant.
Results Mean age of the patients was 24.12±4.12. Acute viral hepatitis (47.1%) and ICP (35.4%) were the commonest cause of jaundice. Seventy percent of women delivered vaginally and about 30% delivered by cesarean section. Complications were hepatic encephalopathy, ICU stay, thrombocytopenia and requiring ventilator support. Three patients expired as a result of hepatic encephalopathy. Preterm delivery was observed in 41.4 % patient.
Conclusion Jaundice in pregnancy should be promptly diagnosed, investigated and appropriate management should be provided to prevent adverse maternal and fetal complications.
Keywords Jaundice, Acute viral hepatitis, Hepatic encephalopathy, Thrombocytopenia
231
Loss of sphingosine-1-phosphate predicts severe intrapulmonary shunting and hepatopulmonary syndrome in patients with cirrhosis
Sukriti Baweja , Preeti Negi, Arvind Tomar, Anupama Kumari, Swati Thangriyal, Rakhi Maiwall, Shiv Kumar Sarin
Correspondence- Shiv Kumar Sarin-shivsarin@gmail.com
Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Hepatopulmonary syndrome (HPS) is a serious complication of cirrhosis. sphingosine-1-phosphate (S1P): bioactive lipid, maintains the vascular tone and potent vasoconstrictor and may be selectively involved in complications of HPS. We investigated the role of S1P in severity of HPS in cirrhosis patients and its association with systemic inflammation.
Methods HPS was diagnosed by intra pulmonary vascular dilatations (IPVDs) as assessed by sline contrast echocardiography and oxygenation defect confirmed by arterial blood gas (ABG) analysis. Fifty-four cirrhosis patients; 22 with HPS (Gr. A) and 32 without HPS (Gr. B), and 10 healthy controls (Gr. C) were included. Plasma levels of S1P, nitric oxide (NO), TNF-α, IL-1β were measured and also immune profiling for immune cells in peripheral blood by flow cytometry and the gene expression of iNOS, eNOS, S1P receptors, S1P kinases by qPCR.
Results The plasma S1P levels were significantly low in Gr. A compared to Gr. B (10.9±4.2 vs. 51.3±19.2 ng/mL; p=0.0129) and Gr. C (107.2±20.1; p<0.05). In Gr A compared to B, the TNF-α (35.6±18.2 vs. 4.5±1.2 pg/mL; p=0.05) and NO (18.23±2.1 vs. 8.45±1.6 μmol/L; p=0.048) levels were higher, however with comparable IL-1β levels. A progressive decline in S1P levels from mild to severe intrapulmonary shunting in Gr. A patients (mild 8.8± 4.8; moderate 6.4±1.3; severe 1.6±0.2 ng/mL; [p=0.056 mild vs. severe]) and was able to predict severe HPS with AUROC of 0.72; p=0.03; with cut off levels <1.4 ng/mL. Patients in Gr. A than B showed elevated levels of IL-17 producing Th17 cells (4.5%±2.2 vs. 0.5%±0.01; p=0.000) which directly correlated with low levels of S1P (r2>0.3; p=0.00). mRNA levels of iNOS, eNOS, S1PR3 were >6-fold high and SPHK1 levels lower in Gr. A than B (p<0.05).
Conclusion Depletion of S1P levels in cirrhosis with HPS can predict the severity of intrapulmonary shunting. Supplementing S1P may be a potential drug for reducing the intrapulmonary shunting in HPS.
Keywords Hepatopulmonary syndrome, Cirrhosis, Sphingosine-1-phosphate, Vasodilation,
232
Use of entecavir in Indian patients of chronic hepatitis B, experience of a tertiary care centre
Revathy M S, Ajay Kandpal , Sumathi B, Chitra S, Manimaran M, Sathya G
Correspondence- Ajay Kandpal-kandykilroy@gmail.com
Department of Medical Gastroenterology, Government Stanley Medical College, Chennai 600 001, India
Background Entecavir is now readily available in Government hospitals in India. However, there is less data on how it has affected the viral markers in Indian patients of chronic hepatitis B.
Aim To study effects of entecavir treatment in virological and serological profile of chronic hepatitis B patients and monitor side effects in study period.
Methods One hundred chronic hepatitis B patients were included in the study and treated with entecavir (0.5 mg/day) in our hospital. Baseline values were recorded. Periodic follow up was done and virological response, biochemical response and serological conversion rate were assessed at weeks 24, 48 and 96.
Results Mean age was observed to be 42 years. A male preponderance was observed with 80%of the patients being male. At baseline, 92% of the patients were HbsAg positive and 10% HbeAg positive, the mean hepatitis B virus DNA was6.162 log10 IU/mL. The rates of achieving positive virological response increased significantly over the follow-up period of 96 weeks. Loss of HBsAg was recorded in 4.35% (4/92 HBsAg positive) patients at 24 weeks and 8.7% (8/92 HBsAg positive) patients at 96 weeks. A significant clearance of HbeAg and seroconversion to anti-HbeAg was recorded in 30% (3/10 HbeAg positive) patients gradually over the treatment duration. Overall, the treatment with entecavir was well tolerated, and no major adverse event was recorded during the study period.
Conclusion Entecavir monotherapy in Indian clinical practice was well tolerated and resulted in a rapid and significant reduction in viral load. Both virologic and serological response are seen with longer duration of therapy.
Keywords Entecavir, Hepatitis B, Seroconversion
233
Study of alcohol abstinence and relapse in alcohol related liver disease
Neeraj Nagaich 1 , Radha Sharma 2
Correspondence- Neeraj Nagaich-drneerajn@gmail.com
1Department of Gastroenterology, Fortis Escorts Hospital, Jawahar Lal Nehru Marg, Sector 5, Malviya Nagar, Jaipur 302 017, India, and 2RUHS College of Medical Sciences, Kumbha Marg, Sector 11 Road, Pratap Nagar, Jaipur 302 033, India
Objectives Prospective and retrospective study of 451 patients with alcohol use disorders was done with an intent to assess various factors affecting remission and relapse and improve outcome for individuals with alcohol dependence and liver disease.
Methods Patients with ethanol related liver disease and alcohol dependence were enrolled after their presentation in gastroenterology clinic and followed thereafter at 1, 3, 6, and 12 months. Patient assessment and relevant investigations were done. Semi structured clinical interviews, the symptom checklist 90-revised (SCL90-R), addiction severity index (ASI), the Beck Depression inventory (BDI) were recorded. High-risk alcoholism relapse scale-based score was calculated. 2 Patients were reassessed at six and twelve months to determine treatment outcome (abstinence status and duration of continuous abstinence). Data were coded, validated and analyzed using descriptive statistics.
Results A majority of the sample 70 percent (n=315) had significant psychiatric symptoms at intake: 22 percent (n=70) presented with depressive symptoms, 17 percent (n=15) with anxiety symptoms, and 41 percent (n=192) with combined depressive and anxiety symptoms. Forty percent of patients who presented with combined depression and anxiety symptoms were abstinent at six months. These patients had worse prognosis than less symptomatic cohort at intake, including those who presented with depression symptoms alone; in the latter group, 60 percent were abstinent at six months.
Conclusions Concurrent depression or anxiety symptoms low education, lack of motivation for abstinence had a significant negative predictive effect on treatment outcome. Craving was noted as most common cause for relapse in alcohol dependent patients. Higher relapse rate was seen in concomitant opioid dependence, high risk’ situations, previous relapses positive predictors were more number of coping strategies, principally adaptive ones. There is significant association between age at first drink, age at dependence, duration of dependence, other co-morbid diagnosis of patients and relapse.
234
Osteodystrophy in non-cholestatic liver cirrhosis
Gireesh Dhaked , Anubhav Jain, Gaurav Gupta, Sandeep Nijhawan
Correspondence- Gaurav Gupta-kumarggauravpgi@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India
Background Alterations of bone metabolism in patients with chronic liver diseases (CLD) represent an important complication. This pathology is represented by osteoporosis or osteopenia. Thus the present study was undertaken to look for BMD T-score in CLD patients and degree of improvement with supplementation with calcium (1000 mg) + vitamin d (500 IU)+ bisphosphonate (4 mg zoledronic acid intravenously).
Methods Prospective longitudinal case-control study conducted in the department of gastroenterology, SMS Medical College, Jaipur. Patients evaluated with DEXA scan at baseline and at 6 months. The degree of reduced BMD will be co-related with CTP, MELD, BMI, and MAC.
Results A total of 90 patients were screened, 77 patients (85.5 %) had hepatic osteodystrophy. Twenty-four (31 %) has osteoporosis rest had osteopenia. Mean age, BMI, CTP score, MELD score, alkaline phosphatase of patients were 44.8 years, 23.32 kg/m2, 8.45, 19.8, 166.9 IU/mL respectively. Alcohol (73%) was the most common etiology. Most of them were male 97.4% with the mean of Dexa score t value at the lumbar spine and femur neck were 2.1 and 1.66 respectively. Patients taking diuretics had a significant reduction in t score (p <0.05) and lower T score correlated with lower BMI and Lower MAC. To date, a total of 47 patients followed for 6 months. Twenty-nine out of 47 the patient was analyzed for change in the DEXA score. On six-month follow-up mean Dexa score t value at the lumbar spine and femur neck were 1.87 and 1.49 respectively, which was significant improved from baseline (p-value <0.05).
Conclusion Hepatic osteodystrophy is very common in non-cholestatic liver cirrhosis. Degree of fall in BMD co-relates with fall in BMI and MAC and not with MELD and CTP score. To date results of the follow-up, study is suggestive of significant improvement with medical intervention.
Keywords Dual emission X-ray absorption, Bone mineral density, MAC
235
Phyllanthin regulates expression of NFKB/PI3K/AKT pathway in animal model of non-alcoholic fatty liver disease: A preliminary study
Manu Mehta , Ajay Duseja, Sarika Gupta *
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
*Department of Biosciences and Biotechnology, Banasthali Vidyapith, Jaipur, India, and Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction Mechanism of protection of liver injury by Phyllanthin is not clear. Dysregulation of PI3K/AKT pathway contributes to the development of non-alcoholic fatty liver disease (NAFLD). Aim of the present study was to evaluate if the hepatoprotective effect of Phyllanthus niruri in a mice model of NAFLD is related to the regulation ofNFKB/PI3K/AKTpathway.
Methodology Control male C57BL/6 mice were given normal chow diet (group A). Group B mice were fed methionine-choline deficient diet (MCDD) for 4 weeks to make NAFLD model. Control as well as MCDD mice were also administered plant crude extract i.e. Phyllanthus niruri (200 mg/kg) (group C and group D). Control as well as MCDD mice were also administered commercially available product Phyllanthin (2 mg/kg) (group E and group F). Real time PCR expression of NF-KB, AKT, PI3K and IRS-1 genes was studied, and relative expression was calculated using 2-Ct method. β-actin was used as reference gene. Data analyzed using one-way ANOVA.
Results There was significantly increase in mRNA expression of NF-KB (4.78±2.04 vs. 1.06±0.40; p<0.0001), AKT (5.89±2.63 vs. 1.12±0.60; p<0.0001), PI3K (2.20±1.07 vs. 0.66±0.23; p<0.0001) and IRS (4.63±2.36 vs. 1.10±0.50; p=0.001) in group B in comparison to group A. Plant extract (group D) significantly down regulated the expression of AKT (0.90±0.17 vs. 5.89±2.63; p<0.0001), NF-KB (0.84±0.29 vs. 4.78±2.04; p<0.0001), PI3K (0.69±0.25 vs. 2.20±1.07; p<0.0001) and IRS (1.41±1.08 vs. 4.63±2.36; p=0.003) in comparison to group B. Commercial available phyllanthin (group F) also significantly downregulated expression of AKT (1.04±0.39 vs. 5.89±2.63; p<0.0001), NF-KB (0.99±0.45 vs. 4.78±2.04; p<0.0001), PI3K (0.78±0.36 vs. 2.20±1.07; p=0.001) and IRS (1.69±2.09 vs. 4.63±2.36; p=0.015) in comparison to group B.
Conclusion The results of our study demonstrate that the hepatotoprotective effect of crude extract of P. niruri in a mice model of NAFLD is related to the regulation of NFKB/PI3K/AKT pathway.
Keywords Fatty liver, NASH, Hepatic steatosis, Phyllanthin, Mice model
236
COVID-19 presenting with direct hyperbilirubinemia and multi-organ failure
Amey Sonavane , Deepak Gupta, Aabha Nagral, Shankar Bhanushali, Rahul Deotale, Divya Kuckian, Gunadhar Padhi, Aklesh Tandekar, Suvadeep Sen, Tushar Parmar
Correspondence- Amey Sonavane-amey_max@yahoo.com
Department of Gastroenterology, Hepatology and Liver Transplantation, Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Background SARS-CoV-2 can infect liver cells with resultant hepatitis. Furthermore, drug hepatotoxicity, immune-mediated inflammation and pneumonia-associated hypoxia can contribute to liver injury and failure. We describe an interesting case of COVID-19 infection presenting with significant direct hyperbilirubinemia, mild hepatitis, and multi-organ dysfunction.
Case Report A 34-year-old gentleman presented with acute high grade fever followed by increasing jaundice. He was admitted with altered sensorium, hypotension, and anuria. There was no history of previous admissions, drug intake, alcohol consumption or liver disease in the past. He was intubated, ventilated, volume resuscitated, initiated on sustained low efficiency dialysis and inotropes. Blood investigations revealed haemoglobin 8.1 gm%, total leukocyte count 12,310/mm2, platelet count 54,000/mm2 and serum creatinine 6.3 mg/dL. Serum total bilirubin was 21.8 mg/dL with direct bilirubin being 16.93 mg/dL. Serum alanine transaminase and aspartate transaminase levels were 107 U/L and 36 U/L respectively. International normalized ratio, serum gamma glutamyl transpeptidase, albumin and alkaline phosphatase levels were normal. Serology tests for viral hepatitis A, B, C and E were negative. Tests for malaria, dengue, leptospirosis, cytomegalovirus and Epstein-Barr virus were negative. Antinuclear antibody and anti-smooth muscle antibody were negative. Serum immunoglobulin G and ceruloplasmin was normal. Blood tests for hemolysis returned negative. Serum ferritin was 445.7 ng/mL, serum triglyceride was normal and serum fibrinogen was 753 mg/dL. Serum interleukin 6 and C-reactive protein was significantly elevated. He responded to intravenous steroids and supportive management. Inotropes were stopped, acute kidney injury recovered, fever subsided, and he was extubated uneventfully. Serum bilirubin gradually declined to 3.4 mg/dL and patient was discharged uneventfully after 14 days.
Conclusion SARS-CoV-2 can cause mild elevation in serum bilirubin. However, significantly elevated serum bilirubin is an extremely rare presenting feature of COVID-19, thus widening our knowledge about the known spectrum of disease.
Keywords COVID-19, SARS-CoV-2, Hyperbilirubinemia, Liver injury
237
Intolerance to penicillamine treatment needing discontinuation in Wilson’s disease: A retrospective audit
Biswa Ranjan Patra , Mohd. Irtaza, Sanjay Kumar, Praveen Kumar Rao, Sridhar Sundaram, Aditya Kale, Aniruddha Phadke, Akash Shukla
Correspondence- Akash Shukla-drakashshukla@yahoo.com
Department of Medical Gastroenterology, Seth G S Medical College and KEM Hospital, Parel, Mumbai 400 012, India
Background There is scant data about serious adverse events with d-Penicillamine (DPN) resulting in discontinuation of the drug. We aimed to audit penicillamine related severe adverse effects in patients with Wilson’s disease requiring drug withdrawal.
Methods A retrospective audit of prospectively maintained database of patients diagnosed with Wilson’s disease registered in the Liver Clinic at a tertiary care center between December 2006-January 2020 was done. Demographic parameters and details of treatment were noted. We analyzed side effects related to DPN treatment, subsequent therapies following the discontinuation of medication and the reasons for discontinuation.
Results A total of 118 patients with Wilson’s disease, were included in the study. 101/118 (85.6 %) patients were started on DPN and 11 patients (9.3 %) on combination therapy of DPN and zinc, while another six patients (5.0%) received only zinc. Serious side effects were seen in 28/112 patients (25.0%) over a study duration of 860 person years. The most common side effect was bone marrow suppression seen in 16/28 (57.1%) and proteinuria in 7/28 (25%). Two patients developed paradoxical neurological deterioration following DPN administration. Elastosis perforans serpingosa was seen in one patient. DPN was discontinued temporarily in 25/28 patients. In three patients, side effects improved with reduction of dose. Fifteen out of 25 patients were switched to zinc monotherapy, and two to trientine. Reintroduction of DPN with lower dose was attempted in 8 patients out of which 4 tolerated without reappearance of adverse effects.
Conclusion DPN treatment is associated with significant adverse effects mainly related to blood, kidney, and skin, with 1 per 30 person-years. Temporary stoppage of drug with reintroduction at lower dose is an effective and safe option.
Keywords Wilsons, Penicillamine, Intolerance
238
Performance of non-invasive tools to stratify patients with chronic liver disease for risk of future variceal bleeding
Sanchit Sharma , Samagra Agarwal, Srikant Mohta, Ankur Bhardwaj, Deepak Gunjan, Shiv Sarin * , Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and *Director, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Introduction Multiple non-invasive tools (NITs) are validated in compensated advanced chronic liver disease (cACLD) for identifying those at low-risk of varices needing treatment (VNTs) but their role in stratifying risk of variceal bleeding (VB) is unclear. The present study assessed the performance of NITs to stratify risk of VB in cACLD, and their utility for initiating primary prophylaxis.
Methods In this retrospective multicentre analysis, patients with cACLD were classified at baseline using endoscopy (high-risk vs low-risk/no varices) and different NITs (high-risk vs. low-risk for VNTs) like Baveno-VI, expanded Baveno-VI, platelet-MELD, platelet-albumin and ANTICIPATE platelet criteria. Follow-up data for future VB was collected. Rates of VB in different risk subgroups of endoscopic classification and NITs were calculated. Decision curve analysis was conducted to assess net benefit of initiating primary prophylaxis for VB based on different NITs versus endoscopic classification.
Results One thousand two hundred and eighty-four patients of cACLD of different etiologies were included. All NITs predicted VNTs with good accuracy at baseline. Ninety-eight (7.6%) patients developed VB over 20 (9-35) months with 22% events in those with low-risk/no varices at baseline endoscopy. All NITs adequately risk-stratified future VB risk. Low-risk Baveno-VI subgroup developed no VB, while low-risk subgroups of ANTICIPATE, platelet-albumin and expanded Baveno-VI criteria suffered 4%, 8% and 13% of VB respectively. NITs were superior to endoscopy for deciding need for pharmacotherapy when threshold for initiating treatment for VB was kept below 3% while endoscopy was superior beyond it.
Conclusion NITs stratify risk of future VB with good accuracy. NITs may be superior to endoscopy in initiating prophylaxis if threshold for initiating treatment is low.
Keywords Variceal bleeding, Baveno-VI criteria, Varices needing treatment
239
Chylous ascites caused by histoplasmosis: A case report
Akash Mathur , Ankur Yadav, Vinita Agrawal, Manoj Jain, Uday C Ghoshal
Correspondence- Uday C Ghoshal-udayghoshal@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Background Chylous ascites results from blockage of abdominal lymphatics by malignancy, trauma, surgery, and infections. A patient presenting with chylous ascites due to histoplasmosis is presented.
Case report A 53-year-old female with undifferentiated connective tissue disorder and hypothyroidism presented with a 3-month history of anasarca initially responding transiently to prednisolone and diuretics. However, ascites and anasarca recurred along with breathlessness. 25-year-old ago, she received anti-tubercular drugs (ATD) for tubercular lymphadenitis. Examination revealed cervical lymphadenopathy, right-sided pleural effusion (confirmed on chest radiography) and ascites. Echocardiography did not reveal pericardial effusion. Investigations: Hb 14.7 gm/dL, serum total protein and albumin 4.1 and 2.3 g, respectively; 24-h urinary protein: 118 mg. Endoscopic duodenal biopsy (for possible protein-losing enteropathy) was unremarkable. Pleural and ascitic fluids were milky white, had low serum ascitic fluid albumin gradient with high triglyceride (437 mg/dL). A contrast-enhanced CT showed bilateral pleural effusion, ascites, and subcutaneous edema (1 A, B). Cervical lymph node aspiration cytology showed necrosis, no granuloma but acid-fast bacilli (Ziehl-Neelsen stain). As she did not respond to 1-mo ATD, histopathology of an excisional biopsy of the cervical lymph node was done, which showed necrosis, effaced nodal architecture and capsulated fungal elements in histiocytes suggesting histoplasmosis (1 C). A rectal biopsy also showed histoplasmosis (1 D). Serology for the human immunodeficiency virus was negative. With a diagnosis of histoplasmosis, liposomal amphotericin B was started.
Conclusion This rare patient highlights the need for increasing awareness of physicians about histoplasmosis, especially in immunocompromised subjects and the lesson that all acid-fast organisms are not tubercule bacillus.
Keywords Chylous ascites, Ascites, Histoplasmosis
240
An insight into age and gender-wise differences in individual and clusters of metabolic syndrome in fatty liver
Bhargav V Y , Mayank Jain*, Alen Tom, Shweta D, Karthikeyan M U, Anusha B, Preetam Arthur, Chandan Kumar Kedarisetty, Thamarai Selvan S, Jenit Osborn**, Jayanthi Venkataraman
Correspondence- Bhargav V Y-varanasi.b4@gmail.com
*Department of Gastroenterology, Arihant Hospital and Research Centre, 283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India, **Department of Medical Gastroenterology, PSG Institute of Medical Sciences and Research Center, Off Avanashi Road, Peelamedu, Coimbatore 641 004, India, and Sri Ramachandra Medical College and Research Institute, Chennai 600 116, India
Introduction Metabolic syndrome (MS) refers to a clustering of metabolic risk factors with different phenotype combinations. The objective is to determine MS prevalence in men and women above and below 45 years in fatty liver (FL).
Methods Nine hundred and ninety subjects registered in master health check during December 2018 to December 2019. USG abdomen and MS (waist circumference (WC), blood pressure, diabetes status, S. triglyceride, and S. HDL) parameters were collected. Known case of chronic liver disease with various etiologies were excluded (alcohol, HBV, HCV).
Statistical Analysis Unpaired t-test and chi-square test were performed; p 0.05 taken as significant.
Results Three hundred and one had a normal ultrasound, 478 had Grade I fatty liver, Grade II 152 and Grade III 59. In both men and women, with increase in grades of the fatty liver there is an increased incidence of all metabolic syndrome components. MS was significantly high in FL (p .0005), especially Grade I. A significant increase in MS components were seen above the age of 45 years for both men and women. Beyond 45 years, DM (p .0005) and HT (p .0001) in men; and DM (p value .0005), HTN (p value .0001) and TG (p value .037) in women were significant. Below 45 years, WC in women (p value .018); HTN (p value 0.12) and TG (p value .0005) in men were significant. WC + DM were the major MS clusters seen in both men and women, > and < 45 years. MS showed no statistical difference in the 2 genders >45 years.
Conclusion MS in women increases significantly beyond 45 years of age. Waist circumference and DM are the robust clusters of MS.
Keywords Metabolic syndrome, Fatty liver
241
A randomized placebo controlled trial of Tadalafil for erectile dysfunction in patients with cirrhosis
Rakesh Jagdish , Ahemad Kamaal, S M Shasthry, Rakhi Maiwall, Ashok Choudhury, Ankur Jindal, Vinod Arora, Rajan V, Ankit Bhardwaj, Guresh Kumar, Manoj Kumar Sharma, Shiv Kumar Sarin
Correspondence- Rakesh Jagdish-dr.rkj.kapil@gmail.com
Departments of Hepatology and Epidemiology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Erectile dysfunction (ED) is an ignored problem with high prevalence among patients with cirrhosis. Tadalafil has been shown to be effective for ED in non-cirrhotic population. However, there are no placebo controlled randomized controlled trials (RCTs) using Tadalafil for treatment of erectile dysfunction (ED) in cirrhotic patients. This study was planned to evaluate the efficacy and safety of Tadalafil in treatment of ED in patients with cirrhosis.
Methods A total of 140 cirrhotic males with ED (age, 45.5 ± 8.2 years; CTP-A [56.4%]/B [43.6%]; etiology, alcohol 45%, NASH 30%, viral 18.6%) were randomized into Tadalafil 10 mg daily (n=70) and placebo (n=70) arm for 12 weeks. ED was assessed with International Index of erectile function (IIEF) questionnaire (ED diagnosed if EF domain score was <25). Other assessments included quantitative androgen deficiency in the aging male (qADAM) questionnaire; generalized anxiety disorder 7 (GAD-7) questionnaire; patient health questionnaire (PHQ-9); Karnofsky performance score (KPS) and hepatic vein pressure gradient (HVPG) measurement. Primary outcome was proportion of patients having an increase in more than 5 points in EF score.
Results Increase in more than 5 points in EF score was seen in 62.82% in Tadalafil arm (n=44/70), vs. 30% cases in placebo arm (n=21/70) (p<0.001). As compared to placebo, patients taking Tadalafil had significant improvements in orgasmic function domain, intercourse satisfaction domain, overall satisfaction domain, anxiety (GAD 7) score, depression (PHQ 9) score, functional impairment (KPS) score and HVPG. There were no significant differences in side effect profile between groups (2.7% in Tadalafil vs. 1.7% in placebo, p=0.154).
Conclusion Tadalafil significantly improves ED, quality of life and HVPG in CTP-A and B patients with liver cirrhosis, without any major side effects.
Keywords Erectile DCLD, Tadalafil, GAD 7, PHQ9, HVPG, qADAM
242
Comparison of the efficacy and safety of plasma exchange compared to standard medical therapy in patients with severe drug induced liver injury - A randomized controlled trial (NCT04015570)
Satyam Sinha , Meenu Bajpai, Vinod Arora, S K Sarin
Correspondence- Satyam Sinha-satyamsinhacmc5@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Drug-induced liver injury (DILI) carries a mortality of 10% to 14%. Except withdrawal of the offending drug, there are limited therapeutic options. Plasma exchange has been used to treat antibody-mediated diseases and is likely that removal of toxic metabolites by therapeutic plasma exchange (TPE) can improve outcomes in severe DILI.
Aim To study the efficacy and safety of plasma exchange compared to standard medical therapy (SMT) in patients of severe DILI.
Methods Thirty patients with severe DILI, diagnosed based on history and liver biopsy (n-24, 80%) and graded for the severity as by DILIN were randomized to receive SMT arm (Gr A, n=14) or TPE+SMT arm (Gr B, n=16). Normal volume TPE was done on alternate days for minimum of 3 sessions.
Results Of 30 patients, 20 (66.6%) were males with mean age of 40.8+13 yr. Complementary and alternative medicines (CAMs) were the commonest cause of DILI (n=10, 33%). Twenty-eight-day mortality was comparable in both groups (13.3% [4/30], 14.2% [n=2] in Gr. A and 12.5% [n=2] in Gr. B [p=0.56]). Significant reduction was seen in bilirubin and bile acid levels and INR in the TPE arm as compared to the SMT arm at day 7 (Table1). These trends were maintained, and bilirubin levels reduced by 77.7% at day 28 (p<0.002) and the bile acid levels by 68.2%% at day28 (p<0.001). The levels of IL-6/TNF-α/ IL-1β also significantly reduced following each session of TPE (p<0.002). A total of 53 sessions of TPE, mean of 3.02 sessions per patient and a median of 1.1 plasma volume were processed (range: 0.6-2.0) per session. Hypocalcemia (59.2%) and alkalosis (42.9%) were the major adverse events.
Conclusion TPE is very effective in reducing the high bilirubin and bile acid levels and inflammatory markers and may lead to early resolution in patients with severe DILI
Keywords Drug-induced liver injury (DILI), Therapeutic plasma exchange (TPE)
243
Efficacy and safety of early transjugular intrahepatic portosystemic shunt (ETIPS) compared with large volume paracentesis in the management of cirrhosis with recurrent ascites: A randomized controlled trial
Vinay Kumar B R , Ankur Jindall, Vinod Arora, Amar Mukund, Shiv K Sarin
Correspondence- Vinay Kumar B R-drvinaybr@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Refractory ascites is associated with poor survival outcome. Transjugular intrahepatic portosystemic shunt (TIPS) decompresses portal system, reduces ascitic refilling, but with complications. Poor outcome is likely due to delayed intervention. We investigated whether early TIPS (eTIPS, before ascites becomes refractory) would help in better control of ascites, reduced development of new complications and improved survival.
Methods Total 47 patients (M: F-41:6) with recurrent ascites (2 LVPs in last 3 months) were randomized to receive LVP (Gr. A, n=24) or eTIPS (Gr. B, n=23) satisfying inclusion criteria and followed up at month 1, 3, 6 and 12. Primary endpoint of the study i. e. transplant-free survival at 12 months and secondary endpoints like overall survival, and complications analyzed.
Results Among the patients who were randomized, all baseline characteristics were comparable (mean CTP – 8.3 ± 1.49 and 8.9±1.19, MELD score of 13.6±3.5 and 14.9±2.82 respectively). The mean portal pressure gradient reduction was 15.7±3.8 in the Gr. B. Significantly more patients in Gr. B had resolution of ascites (14 (61%) vs. 6 (26%); p=0.03) with lesser requirement of diuretics (11 [48%] vs. 4 [18%]; p<0.05) as compared to Gr. A, with Gr. A more often developed diuretic related AKI (14 [61%] vs. 10 [47%]; p<0.05) at 6 months and hospital re-admission rates (at least >1 admission – 16 [68%] vs. 6 [25%]; p=0.008) and significant increase in MELD score +2.619 (0.636-2.8); p=0.05). The occurrence of HE (12 [53%] vs. 10 [45%]; p=0.2), handgrip strength (change from baseline 1.8 ± 0.37 vs. 2.1 ± 0.41; p=0.7) and infections (7 [30%] vs. 4 [17%]; p=0.4) were not different between groups. Overall, 8 patients died by 6 months of enrolment (2 in Gr. B and 6 in Gr. A; p=0.03) and 2 patients underwent transplant in Gr. A and none in Gr. B. There was no difference in occurrence of between the two groups.
Conclusion Early TIPS in comparison to repeated LVP showed better survival, without any significant increase in occurrence complications.
Keywords eTIPS, Survival, Recurrent ascites
244
Bioenergetic dysfunction of monocytes is associated with an increased incidence of sepsis and mortality in acute-on-chronic liver failure
Rakesh Kumar Jagdish , Deepanshu Maheshwari, Dhananjay Kumar, Ashini Kumar Hidam, Deepika D, Nidhi Nautiyal, Meenu Bajpai, Rakhi Maiwall, Anupam Kumar, Shiv Kumar Sarin
Correspondence- Rakesh Jagdish-dr.rkj.kapil@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Introduction Functional exhaustion of monocyte phagocytic function has been shown to be associated with increased susceptibility to infection and sepsis in acute-on-chronic liver failure (ACLF). We investigated the pathobiology of compromised phagocytic functions of monocytes in ACLF.
Method Monocytes were isolated from peripheral blood mononuclear cells of ACLF (n=34) patients at hospitalization and of healthy controls (HC, n=6). Energy metabolism of freshly isolated monocytes was determined.
Results Compared to HC, monocytes of ACLF patients (mean age 43 years, M: F 16:1, MELD 30, 61.76% alcohol) showed significant decrease in oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) at baseline, indicating significant defect in both glycolysis (p<0.001) and OXPHOS (p<0.001) in ACLF (Fig. 1A). Real time measurement of change in OCR during sequential treatment of cells with oligomycin, the FCCP (H+ ionophore), and Antimycin-A/rotenone showed significant decrease in ATP linked (p<0.01), proton leak (p<0.01), maximum (p<0.0001) and spare reserve respiration capacity (p<0.0001), suggesting multilevel defects in mitochondrial energy metabolism of monocytes. Compared to HC, ACLF monocytes showed decreased phagocytic capacity (p<0.0001 (Fig. 1B). Inhibition of mitochondrial ATP production by oligomycin, but not glycolysis showed significant (p<0.001) decrease in the phagocytic capacity of healthy monocytes (Fig. 1C). This indicates that mitochondrial ATP fuels the phagocytic function of monocytes and its compromised production severely impairs phagocytic potential of monocytes in ACLF. Among the ACLF group, patients with sepsis at the time of presentation had a significant (p<0.0001) decrease in maximum respiration and ATP linked respiration (p<0.0001) in monocytes as compared to ACLF without sepsis (Fig. 1D). ACLF patients with significantly low maximum (p<0.001) and ATP linked cellular respiration (p=0.01) showed increased 28 day mortality.
Conclusions Defects in mitochondrial energy metabolism compromise the phagocytic capacity of monocytes, which contributes to development of sepsis and increased short- term mortality in ACLF patients.
Keywords ACLF, Monocyte energetics, Sepsis, Cellular respiration, Functional exhaustion
245
A randomized controlled trial (RCT) of efficacy and safety of hemoperfusion or plasma exchange compared to standard medical therapy in patients with acute-on-chronic liver failure
Vinay Kumar B R , Rakhi Maiwall, Ashok Choudhury, Meenu Bajpai, Jaswinder Singh Maras, Guresh Kumar * , Shiv K Sarin
Correspondence- Vinay Kumar B R-drvinaybr@gmail.com
Department of Hepatology, and *Epidemiology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Introduction Acute-on-chronic liver failure (ACLF) has high 28-day mortality of 30% to 40%. Exaggerated hepatic necrosis, inflammation and immune response lead to early organ failure and mortality. We aimed to remove high levels of toxic bile acids, bilirubin, and metabolites from circulation and to modulate the immune mechanisms.
Methods Total of 32 ACLF patients with ACLF with bilirubin >12 mg/dL and INR > 1.5 without any infection or extrahepatic organ failure, were randomized into 3 groups; standard treatment SMT (Gr A, n=11), SMT with hemoperfusion (Gr B, n=11) and SMT with plasma-exchange (Gr C, n=10).
Results The baseline characteristics were comparable (mean age 50.2± 11.5, 44 ± 12 and 47±12.3 yr., male 10:9:8, baseline bilirubin 21.7±7, 26.9±6.1 and 27.6±8.8 mg/dL, bile acid levels 131±7, 126.8±11 and 138 ±10.8 mg/dL, MELD score 29±4.2, 28±3.5 and 31.4±3.4, AARC score 9.5 ±1.8, 8.9±1, 10±0.92). There was no statistical difference in survival SMT vs. HA vs. PE (89%, 0, 89% and 63.3 %, 90%, 72%, respectively) at day 7 and 28 (p=0.12). In comparison with Gr. A, Gr. B had significantly lower incidence at day 7 and 28 of new onset sepsis (27%, 10%, 20% and 45.5%, 20%, 36%) and AKI (27%, 0%, 11% and 45%, 10%, 27%) respectively. In comparison with Gr A, B and C, there was (3.5 and 2.5-fold, p=0.03) and (1.64 and 1.4- fold, p=0.18) reduction in bilirubin and bile acids which were associated with improved survival. Further, bile acid profiling identified persistent increase in cholic acid, glycocholic acid, chenodeoxycholic acid, taurochenodeoxycholic acid, tauroursodeoxy cholate and lithocholic acid (p<0.05), amongst the survivors specially in Gr. B. In comparison to SMT, intervention arms showed significant change in the metabolites of energy metabolism (p<0.05).
Conclusion Artificial liver support in the form of hemoperfusion and plasma exchange, can safely be used and improve the bile acid and metabolic profile of ACLF patients.
Keywords Acute-on-chronic liver failure (ACLF), Bile acids, Metabolites
246
Comparison of efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) and SX-Ella Danis metal stent (SEMS) in the management of refractory variceal bleed in cirrhotics- A randomized controlled trial (NCT-03827681)
Sushrut Singh , Rakhi Maiwall, Ashok Choudhury, Ankur Jindal, Guresh Kumar, Shiv Kumar Sarin
Correspondence- Sushrut Singh-singhsushrut86@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Introduction Refractory variceal bleed carries a high morbidity and mortality in cirrhosis. TIPS (decompresses the high portal pressure) and. esophageal SEMS (compresses varices locally) are used for managing such bleeds; though the efficacy of the two has not been compared.
Aim We compared efficacy and safety of SEMS and TIPS in management of refractory variceal bleed.
Methods Altogether, 46 cirrhotics with refractory variceal bleed were randomized to either SEMS (Gr. A, n=23) or emergency TIPS (Gr. B, n=23). Patients with portal vein thrombosis, HCC and <18 >70 years were excluded. Primary endpoint was 6 week survival and secondary end-points included prevention of re-bleeding for 5 days and development of complications and 3 month survival.
Results Patients in Gr A and B (age [51.2±13.6 vs. 53.9±11.5 yr], p=0.4), MELD score (17.3±3.4 vs. 18.6±3.6, p=0.2), baseline HVPG (21.3±3.7 vs. 20.8 ±4.8 mmHg, p=0.69) were comparable. Six-week survival in Gr. A was significantly lower in Gr A (12/23 [52.2%]) than B (19/23 [82.6%] p=0.027). In Gr A than B, higher very early rebleed (between 48 to 120 hrs) as well as early rebleed (6-42 days) [(26% vs. 4.3%, p=0.04) and (21.7% vs. 0%, p=0.04) respectively] were witnessed. Time to reversal of shock was shorter in Gr. B (8.9±3.7 hrs) than A (32 ±9.6 hrs, p<.001), with shorter ICU (13.9±4.9 vs. 7.6±3.1 days, p<0.001) stay and fewer packed cell units required (4.6 vs. 1.9, p=0.001). More patients in Gr A than B developed sepsis (43.5% vs. 8.7%, p=0.004) and AKI (39.1% vs. 13%, p=0.04), without differences in frequency of ischemic hepatitis (13% vs. 17.4%, p=0.6) and hepatic encephalopathy (39% vs. 52%, p=0.3). Patients in Gr A had significant worsening of liver functions and higher MELD (24±3.9 vs. 19±3.7, p<0.01) than Gr. B at 6 weeks, with lower 3 month survival (39.1% vs. 69.5%, p=0.038).
Conclusion Emergency TIPS is more effective and safe as compared to esophageal SEMS for management of refractory variceal bleed in cirrhosis.
Keywords Variceal bleed, SEEMS, TIPS
247
Addition of testosterone therapy to nutrition and structured exercise is superior to nutrition and structured exercise alone in improving sarcopenia in men with cirrhosis: A randomized controlled trial
Sushrut Singh , Ashok Choudhury, Jaya Benjamin, Guresh Kumar, Shiv Kumar Sarin
Correspondence- Sushrut Singh-singhsushrut86@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Sarcopenia has been shown to be a marker of poor long-term outcomes in advanced cirrhosis. Nutrition supplementation and exercise are the only current approaches for such patients.
Aims and Objectives We compared nutrition and structured exercise (NEx) to NEx with addition of testosterone (NExT) in improvement of sarcopenia.
Methods Altogether, 102 cirrhotic patients with sarcopenia were randomized to receive either nutrition and structured exercise with addition of intramuscular testosterone undeconate 1000 mg every 4 weeks with (NExT, group A, n=50) or only structured exercise and nutrition (NEx, group B, n=52). The primary end-point was increase in appendicular lean mass index (APLMI) by 10%, using dual-energy X-ray absorptiometry (DEXA) and bio-electrical impedance.
Results The mean age, MELD score and CTP score and distribution of patients [Gr A : Child A, B, C 9 (14.06%), 42 (65.6%) and 13 (20.3%) and Gr. B: 10 (15.8%), 41 (65.1%) and 12 (19.04 %) p =0.952], baseline serum testosterone levels were comparable. Significantly more patients achieved primary end-point in Gr. A than B (66% vs. 25%, Odds ratio 5.82 (95% C.I. 2.47-13.74), and had higher ASMI than control group [7.3 ±0.25 vs. 6.90 ±0.21, p<0.01] at the end of 6 months. Patients in the NexT group had better hand grip strength, 6 minute walk distance and lower TNF alpha levels, lower serum ammonia (68.5±13 vs. 90.32±28 μg/dL p <0.05) and higher serum testosterone levels (p<0.001). 38% patients in the NexT arm had improvement in fraility category compared with 13.5% in the NEx arm (p<0.001). During the 6 months, hospitalization was required by 8 (16%) in NExT and 18 (34.6%) patients in NEx group (p=0.03).
Conclusions Administering testosterone to men with cirrhosis, irrespective of baseline serum testosterone levels, significantly increases their muscle mass, bone mass and improves fraility, with reduction in fat mass and need and duration of hospitalization.
Keywords Sarcopenia, Cirrhosis, Testosterone
248
Incidence and clinical outcome of hyponatremia in patients with acute-on-chronic liver failure
Manasa Alla , Vinod Arora, Guresh Kumar, Shiv Kumar Sarin
Correspondence- Vinod Arora-vinod_ucms@yahoo.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Hyponatremia is an important predictor for mortality and outcome in patients with cirrhosis. Incidence of severe hyponatremia (serum sodium <125 meq/l) and its correlation with various clinical outcomes has not been studied in (ACLF) patients.
Methods A retrospective analysis of the electronic data 3,880 patients with APASL ACLF was taken from 2009-2020. Hyponatremia categorized as moderate (125-130), severe (< 125 meq/l). Patients with serum sodium <125 mEq/L were evaluated at baseline, 7, 14 and 28 days. 20% albumin was given to such patients, but no diuretics or vaptan were given. The incidence of acute kidney injury (AKI), hepatic encephalopathy (HE), GI bleed was evaluated at baseline and day 7, 28 day survival determined.
Results Of 3880 ACLF patients, 3043 patients (mean age 44.8 ±12.56 years) had complete and serial data of serum sodium and were analyzed . At baseline moderate hyponatremia (125-130 mEq/l) was present in 1229/3043 (40.4%) and severe hyponatremia (< 125mEq/l) in 491/3043 (16.7%) patients. AKI at baseline (serum creatinine≥1.5 mg/dL) was significantly more in patients with severe hyponatremia compared to moderate hyponatremia (200/491 [40.7%] vs. 250/1221 [20.4%], p=0.001). Patients with severe hyponatremia had a greater persistence of AKI (98/491 [19.95%] vs. 108/1221 [8.8%], p=0.001) and encephalopathy (51/491 [10.4%] vs. 90/1221 [7.3%], p=0.05) at day 7. Patients with serum sodium < 125 mEq/L had a greater need of ICU admission (102/491 [20.7%] vs. 146/1221 [11.95%], p=0.001). On multivariate analysis, serum sodium was predictive of mortality at day 7 (HR 1.08, 95% CI 1.03-1.14s, p= 0.001) and 28 (HR 2.06, 95% CI 1.32-2.01, p= 0.001). 7- day mortality (79/491 [16.08%] vs. 121/1221 [11.95%], p=0.0005) and 28-day (120/491 [24.4%] vs. 228/1221 [18.7%], p=0.008).
Conclusion Serum sodium < 125 meq/L at baseline may be an independent predictor for mortality in ACLF and associated with various adverse clinical outcomes and treatment options remain an important therapeutic option in improving outcomes.
Keywords Hyponatremia ACLF
Pancreas
249
Interim analysis of clinical and autoimmune features in drug-induced Liver Injury
Rahul Deshmukh , Shubham Jain, Sanjay Chandnani, Ravi Thanage, Partha Debnath, Siddhesh Rane, Pravin Rathi
Correspondence – (Rahul Deshmukh- drdeshmukhrahul@gmail.com)
Department of Gastroenterology, Topiwala National Medical College, Mumbai 400 008, India
Introduction To differentiate between immune-mediated drug-induced liver injury (DILI) and autoimmune hepatitis (AIH) may be difficult. DILI has features similar to other liver diseases including AIH. Present study aims to characterize clinical and autoimmune features of DILI by complementary and alternative medicine (CAM).
Methods Data from 31 DILI patients was analyzed. Patients were investigated for levels of immunoglobulin G (IgG), antibodies to nuclear antigen (ANA), anti-smooth muscle (ASMA), and anti–liver-kidney microsomal antibody (anti-LKM). We calculate autoimmune score based on increase in levels of IgG, ANA, SMA, and anti-LKM (assigned values of 0, 1+, or 2+). We categorize patients based on type of injury.
Results Of the 31 cases 12 were males and 19 were females with a median age of 50 years (range 20-75 years). All patients had jaundice on presentation. Fever, rash, itching, and eosinophilia was present in 29%, 7%, 32%, and 26% patients. Mode of presentation was acute hepatitis in 71% (22/31) and ACLF in remaining 29% (9/31). In majority of patients (80%) cause of DILI was CAM. The median duration of drug intake was 90 days (range 15-730 days). Of the 31 cases, 65% had hepatocellular injury and 19% had severe injury, of which 37% were males and 63% were females. On presentation 29% of cases had increased levels of IgG, 29% had increased levels of ANA, 22% had increased levels of SMA. A phenotype of autoimmunity (autoimmune score ≥2) was seen in 48% of cases, of which 33% were males and 66% were females. Mean RUCAM score was (4.6±1.6). Liver biopsy was available in 6 patients. 4/6 (66%) patients had marked interface activity and remaining 2/6 (33%) had mild activity.
Conclusion We found that most cases of DILI due to CAM had hepatocellular injury. Almost half of cases had features of autoimmunity. Females were more affected than males.
Keywords CAM, Autoimmune, DILI
250
Role of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in idioathic acute pancreatitis
Tuhin Mitra, Vinod Kumar Dixit, Sunit Kumar Shukla, Dawesh Prakash Yadav, Piyush Thakur, Ravikant Thakur
Correspondence- Tuhin Mitra-mitra_tuhin@yahoo.co.in
Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
Introduction Approximately 10% to 30% of patients with acute pancreatitis do not have an established etiology after routine investigations and are labelled as having idiopathic acute pancreatitis (IAP). Establishing the etiology in such patients will prevent recurrences and evolution to chronic pancreatitis. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) typically are used to diagnose IAP when conventional methods fail but their exact role has not been determined.
Methods A prospective study of patients admitted initially with diagnosis of IAP to department of gastroenterology in a tertiary care centre was done. These patients underwent MRCP and EUS at least 4 weeks after an episode of acute pancreatitis. The etiological results of EUS and MRCP were compared and analyzed with various clinical variables using suitable statistical tests.
Results A total of 31 patients with IAP were included. EUS and/or MRCP were able to establish at least one etiology in 17 of our patients (54.8%). The diagnoses revealed were gallbladder (GB) microlithiasis, GB sludge, choledocholithiasis, pancreas divisum, pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm and anomalous pancreatobiliary union. Comparing the diagnostic accuracy of both the modalities, EUS (14/31) was able to diagnose more cases than MRCP (8/31). The EUS yield was lower in patients who had a previous cholecystectomy (12.5% vs. 56.5%; p=0.03).
Conclusion EUS and MRCP are useful techniques in the etiological diagnosis of IAP and should be considered complimentary rather than competitive investigations. EUS is better for establishing a possible biliary etiology and MRCP for an anatomical alteration in pancreatobiliary ducts.
251
Pancreatic tuberculosis with obstructive jaundice masquerading as malignancy
Ronak Ajmera, Premashish Kar, Ashish Garg, Rishabh Kothari, Anant Chauhan, Subhasish Mazumder
Correspondence- Subhasish Mazumder-subhasish.dr@gmail.com
Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, W-3, Near Radisson Blu Hotel, Sector 1, Vaishali, Ghaziabad 201 012, India
Pancreatic tuberculosis (TB) is rare form of extra-pulmonary TB even in endemic countries like India with literature only reported as case reports or very small case series. Also pancreatic TB has varied clinical presentation from incidental pancreatic mass detected on imaging to abdominal pain mimicking pancreatitis. We report a case of pancreatic TB who presented to us with jaundice, abdominal discomfort, weight loss and palpable gallbladder. He had long history of loss of weight, abdominal discomfort for 1 year and hence there was low suspicious of malignancy. On USG abdomen he had pancreatic mass lesion compressing distal CBD with upstream biliary system dilatation. He underwent whole body PET-CT which revealed FDG avid heterogenous enhancing mass lesion involving neck and body of pancreas with enlarged necrotic lymph nodes in paratracheal, hilar, peripancreatic, periportal, paraaortic, aortocaval lymph nodes. The findings of PET-CT were more in favour of infective or lymphoproliferative disease. Patient underwent endoscopic ultrasound guided FNA from pancreatic mass and lymph node which were positive for mycobacterium tuberculosis by NAAT (nucleic acid amplification test). Patient underwent ERCP and plastic stent was placed in CBD. Patient was started on antitubercular drugs once LFT improved. Patient was symptomatically better after receiving ATT. Hence clinicians must keep in mind pancreatic TB in patients with obstructive jaundice due to pancreatic mass lesion.
252
SPINK 1 genetic mutation in chronic pancreatitis ‘a single center survey’
Subhra Sulipta Jena , Girish Kumar Pati, Kanishka Uthansingh, Pradeep Mallick, Manas Kumar Behera, Jimmy Narayan, Debakanta Misra, Manoj Kumar Sahu
Correspondence- Girish Kumar Pati-pati.drgirishkumar@gmail.com
Department of Gastroenterology, IMS and SUM Hospital, Bhubaneswar 751 003, India
Introduction Chronic pancreatitis is known to be a complex problem occurring due to several genetic and clinical risk factors. There are already several studies revealing the genetic mutation and their association with clinical risk factors in chronic pancreatitis in different geographic regions, but unfortunately there are no genetic studies on chronic pancreatitis from this part of coastal India.
Aim This study was carried out with an aim to find out the genetic defect of Serine protease inhibitor Kazal-type 1 (SPINK1) gene in chronic pancreatitis patients from this part of coastal eastern India and also their demography and presentations to be evaluated.
Method Consecutive 20 chronic pancreatitis patients attending the Dept. of Gastroenterology of IMS and SUM Hospital, Bhubaneswar were enrolled in this study and evaluated. Two mL of venous blood was collected from each of the patients and the DNA was isolated by salting out method. The genetic defect was evaluated by polymerase chain reaction – restriction fragment length polymorphism (PCR-RFLP) method. Demography and clinical presentations of all the cases were also evaluated.
Result The mean age of presentations of study participants was 33.9±1.089 years. Most of the cases were female i.e. 55% were female. The RFLP result showed that 60% of the patients were genetically heterozygote, whereas 40% patients were genetically mutants for SPINK1. Most of the cases presented with abdominal pain. Most of the cases in this study were nonalcoholic and nonsmoker.
Conclusion This study is unique of its kind as it is the first genetic pilot study from this part of coastal eastern India which evaluated the genetic defects in chronic pancreatitis patients. Further genetic studies with larger number of sample size may be carried out in future to validate our findings.
253
Clinical profile, management and outcomes associated with pancreatic ascites - Our experience from Western India
Mayur Gattani , Pratik Sethiya, Shamshersingh Chauhan, Meghraj Ingle, Saiprasad Lad, Gaurav Singh, Kailash Kolhe, Harshad Khairnar, Pooja Chandak, Akash Shukla, Vikas Pandey
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Department of Gastroenterology, Lokmanya Tilak Muncipal Medical College and General Hospital, Sion, Mumbai 400 022, India
Introduction Pancreatic ascites is a well-recognized sequelae of pancreatitis and is associated with significant morbidity and mortality. We studied the clinical profile, management and outcomes of patients with pancreatic ascites.
Methods This retrospective study investigated 35 patients seen over a period of 5 years with pancreatic ascites who underwent magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP). Management strategies included conservative therapy, endotherapy and surgery.
Results Thirty-five patients (male=29; 82.9%) were included. Associated pancreatic fluid collections (PFC) were documented in 31/35 (88.6%) patients. MRCP demonstrated a leak in 18/35 patients (51.4%) and ERCP did it in 21/30 patients (70%). Most common leak site on ERCP was in body in 13/30 (43.3%) patients followed by head in 5/30 (16.7%) and tail in 3/30 (10%) patients. Stent was placed beyond the leak in 18/21 (85.7%) patients. In 9/30 patients (30%) no leak was found, thus stent was placed empirically. Sphincterotomy was done in 23/30 (76.7%) patients. Endotherapy was successful in 25/30 patients (83.3%) amongst which 8 % had recurrence. Only conservative therapy was successful in three patients amongst which two had recurrence. Site of ductal leak (p=0.008), sphincterotomy (p=0.033) and stent bridging the leak site (p=0.004) were the factors significant for success of endotherapy. Extensive necrosis >30% (p=0.022) and presence of intraductal calculi (p=0.049) were associated with failed endotherapy. Mortality was seen in 1/35 (2.8%) patients.
Conclusions In this study, clinical profile of pancreatic ascites usually involved more severity of pancreatitis and associated PFC. Success rate in management and outcome of pancreatic ascites is high for endotherapy and low for conservative therapy. Combining pancreatic sphincterotomy with transpapillary stenting and stent bridging the leak site increases efficacy of endotherapy.
154
Is plasma osteopontin a novel biomarker in prognostication of acute pancreatitis?
Gautham Morupoju
Correspondence- Gautham Morupoju-m.gautham36@gmail.com
Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India
Introduction Osteopontin (OPN) is an important mediator of inflammation. Its role has not been established for prediction of mortality and complications in acute pancreatitis (AP).
Aim To assess the utility of plasma OPN level on day of admission as early predictor of severity and mortality in AP and compare it with admission C-reactive protein (CRP), procalcitonin (PCT) and prognostic scores like Ranson’s, APACHE II, BISAP and mCTSI.
Methods Sixty-one consecutive patients of AP presenting within 5 days of symptom onset and 20 age and sex matched healthy controls were prospectively enrolled. Admission OPN, CRP and PCT levels were estimated and prognostic scores of AP calculated. These patients were followed till discharge or death. The association of biomarker levels and prognostic scores with severity and mortality was analyzed and utility compared by receiver operator characteristics (ROC) curve analysis.
Results Sixty-one patients (M:F=48:13), age (mean±SD=34.47±13.62 years) were studied. Common cause was alcohol (n=34) (55.74%). Forty-eight (78.6%) patients had mild/moderate and 13 (21.3%) had severe AP. Infected pancreatic necrosis (IPN) and death was observed in 2 (3.4%) and 3 (4.9%) respectively. Mean plasma OPN level on admission for patients and controls was 13.04±3.79 ng/mL and 4.75±1.45 ng/mL respectively. There was no statistically significant difference in OPN levels in mild vs. severe pancreatitis (p=0.464), IPN vs those without IPN (p=0.404) and survivors vs. non-survivors (p=0.404). On ROC curve analysis, Ranson’s score had the highest whereas OPN had the least area under the receiver operator curve (AUROC) for predicting severity and mortality of 0.974 and 0.954, 0.576 and 0.345 respectively in that order.
Conclusion Admission OPN is a suboptimal prognostic marker of AP. Larger studies are required to assess its utility in AP.
255
Diabetes is frequent after an episode of acute pancreatitis: A prospective, tertiary care centre study
Wahid Akbar , Zaheer Nabi, Jahangeer Basha, Rupjyoti Talukdar, Manu Tandan, Sundeep Lakhtakia, Radhika Chavan, Chandrakant Koutarapu, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India
Background Acute pancreatitis (AP) is a known risk factor for the development of new onset diabetes and prediabetes (NODAP). The severity of AP may correlate with the development of NODAP. However, the results in published studies are conflicting. In this study, we aim to determine the incidence and risk factors for the development of NODAP after AP.
Methods In this prospective study, patients diagnosed with AP between March 2019 to May 2019 were followed at 3 months, 6 months and 12 months. Patients with pre-existing diabetes or prediabetes were excluded from the study. The primary outcome of the study was the incidence of NODAP at 1-year which was evaluated using fasting blood glucose, oral glucose tolerance test and HbA1c. The secondary outcomes included risk factors for the development of NODAP.
Results A total of 86 confirmed cases (males 66, mean age 35.5±11.7 years) with AP were enrolled during the study period. The etiologies of AP included alcohol 31 (36%), gallstones 17 (19.8%), post ERCP (3.5%), others (40.7%). The proportion of patients with necrotizing pancreatitis, moderately severe and severe AP were 67.4%, 59.3% and 15.1%, respectively. Overall, diabetes and pre-diabetes developed in 10.46% and 23.25% patients, respectively. NODAP was more common in patients with necrotizing pancreatitis (>30% necrosis) as compared to interstitial pancreatitis (42.9% vs. 17.9%, p=0.044). NODAP was significantly more frequent in patients with moderately severe and severe pancreatitis as compared to mild AP (42.2% vs. 9.1%, p=0.004). NODAP was significantly higher in those requiring a drainage intervention (59.5% vs. 9.1%, p=0.0001). The mean stay in ICU was significantly higher in patients who developed NOD (11±3.38 vs. 4.6±3.17 days, p=0.003).
Conclusions NODAP is common after an episode of AP. Severe pancreatitis, presence of necrosis, requirement of drainage and prolonged ICU stay are the risk factors for the development of NODAP in patients with AP.
256
A rare case of acute pancreatitis in a known primary sclerosing cholangitis with ulcerative colitis
Avinash Reddy Boojala , Vaishnavi Priyaa C, Aravind A
Correspondence- Avinash Reddy Boojala-avinashreddyboojala@yahoo.com
Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai 600 010, India
Introduction Primary sclerosing cholangitis (PSC) is a rare disease associated with IBD with an incidence of 0.4-2 per 100,000. Acute pancreatitis may occur secondary to drug intake in the treatment of IBD. Here we present a very rare case of probably idiopathic acute pancreatitis in a patient of PSC and ulcerative colitis in remission.
Case Nineteen-year-old male presenting initially with anemia, bleeding PR, pruritus and fatigue and weight loss. Past, family history and examination unremarkable. On evaluation, Hb 9.8, T. bilirubin 2.1 mg/dL, direct- 1.3 mg/dL, ALP- 359, SGOT- 107, SGPT- 118, GGT- 69 IU/L. Viral markers- negative. USG s/o hepatomegaly, dilatation of CBD. Colonoscopy ulcerations and diffuse erosions, edema, loss of vascularity till mid transverse colon. HPE s/o active phase of ulcerative colitis. UGI scopy-normal. MRCP: IHBR, CHD, CBD dilated with multiple areas of dilatation and narrowing consistent with PSC. ANA strong positive (+++), homogenous anti DsDNA, p ANCA, anti LKM, SMA, SLA- all negative. IgG total- 2330 (700-1600 mg/dL). AMA- positive. IgM, IgG4-normal. Tumor markers CA 19-9, CEA-normal. Liver biopsy shows sparse lymphocytic infiltrate in rows between cells insinuating the sinusoids and areas of fibrosis suggestive of PSC.
Patient responded to treatment with mesalamine, UDCA and iron and vitamin supplementation and IBD remission achieved. He presented with severe pancreatic type abdominal pain with s. amylase 308U/L and USG s/o pancreatitis after one year of remission of IBD which was managed conservatively.
Conclusion Acute pancreatitis in the absence of PD abnormality or incriminating drugs is extremely rare in the setting of IBD with PSC and needs an extensive genetic and familial work up of the disease and also follow up for development of chronic pancreatitis or pancreatic malignancy apart from the routine surveillance of IBD and PSC.
257
A study of pancreatic exocrine insufficiency in early onset idiopathic chronic pancreatitis
Gauri Kumbhar , Rajesh Sanjeevi, Anuradha Chandramohan, Rajeeb Jaleel, Reuben Thomas Kurien, Ebby George Simon, Amit Kumar Dutta, A J Joseph, Sudipta Dhar Chowdhury
Correspondence- Sudipta Dhar Chowdhury-sudiptadharchowdhury@gmail.com
Department of GI Sciences, Christian Medical College Hospital, Vellore 632 004, India
Introduction Early onset idiopathic chronic pancreatitis (EOICP) is a common form of chronic pancreatitis in India. The present study was done with an aim to identify the prevalence of pancreatic exocrine insufficiency (PEI) in EOICP.
Methods This is an ongoing prospective study in a tertiary care hospital initiated in August 2018. Baseline data as regards demographic variables, duration of disease, pain, diabetes mellitus, steatorrhea, body mass index (BMI), medication use, CT parameters were recorded. PEI was evaluated by faecal elastase-1 assay (FE-1). Patients with FE-1 <100 μg/gm were labelled as having PEI.
Results A total of 100 patients with EOICP were included. Mean age of onset was 24.5 (SD 6.03) years and 46% were females. The average disease duration was 6 (SD 4.8) years. Pain abdomen was present in 98%. The mean BMI was 21.04 (SD 3.61) kg/m2. Calcifications were noted in 61 (75%) patients, mean main pancreatic duct (MPD) diameter was 7.59 (SD 5.01) mm, mean pancreatic thickness was 13.97 (SD 5.53) mm. PEI was identified in 75% of patients. Except for duration of disease, there was no correlation between PEI and sex, age of onset, and diabetes mellitus. We evaluated the association between morphological parameters identified at CT scan with PEI. There was a significant association between MPD diameter, parenchymal width and PEI. However, there was no association between presence of calcification and PEI. Fifty percent patients were on enzyme supplements. Among the patients not on enzymes, subclinical PEI was identified in 18 (48.65%) patients.
Conclusions This study shows that there is high prevalence of PEI in patients with EOICP. Disease duration significantly correlates with the presence of PEI. Pancreatic morphological changes correlate with presence of PEI, indicating PEI may be manifestation of disease progression. Substantial proportion of patients off enzyme supplements had subclinical PEI, therefore all patients need to be tested for PEI.
258
Recurrent acute pancreatitis due to Type 1 C1-Esterase inhibitor deficiency
Avnish Seth , Mahesh Kumar Gupta
Correspondence- Avnish Seth-avnish.seth@fortishealthcare.com
Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Sector - 44, Opposite HUDA City Centre, Gurugram 122 002, India
Background Hereditary angioedema due to C1-esterase inhibitor (C1-INH) is a rare cause of pain abdomen. We present a patient with recurrent acute pancreatitis (RAP) due to C1-INH deficiency.
Case Report Sixteen-years female was hospitalized with epigastric pain with back radiation for one day. Pain was severe, band-like, associated with vomiting and relieved partially on stooping forward. There was history of similar episodes for last 4 years requiring repeated hospitalization. BP was 100/60 mmHg, pulse 100/minute and epigastric tenderness present. Blood counts and LFT were normal, amylase/lipase 2300 U/L/1825 U/L. CECT scan abdomen showed haziness of margins of pancreas with mild peri-pancreatic stranding and no calcification. Evaluation over last 4 years at various centers for RAP including serum calcium and trigylerides, ultrasound abdomen (x4), CT scan, MRI with MRCP and EUS (x 3) were normal. On direct questioning there was history of angioedema of lips, hands, and limbs since early childhood, forcing her to skip school due to swollen lips and colicky pain abdomen. There was no such family history. Side-viewing endoscopy revealed edema and boginess of ampulla of Vater. She was discharged after 48 hours following improvement with IV fluids and symptomatic treatment. C1-INH level was 164 mg/L (range 275-400), C4 8 mg/dL (range 10-40) and C1q 7.2 mg/dL (range 5-8.6). She was diagnosed as C1-esterase inhibitor deficiency, Type 1 and managed with oral Danazol built up to 400 mg daily. There was reduction in number and severity of episodes of angioedema and pain abdomen, but she developed mild hirsutism, weight gain and acne and Danazol was reduced to 100 mg daily and she continues to do well at one year.
Conclusion History of angioedema and C1-INH deficiency should be considered in the check-list of evaluation for RAP. Treatment with Danazol results in amelioration of symptoms.
259
Spectrum and sensitivity patterns of bacterial isolates from infected pancreatic necrosis managed by exclusive percutaneous catheter drainage
Ashok Kumar, Kshitiz Saran , Rohit Gupta, Itish Patnaik, Anand Sharma
Correspondence- Ashok Kumar-drashok.sgpgims@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Introduction Infected pancreatic necrosis (IPN) is associated with high mortality. Information is limited about bacterial infections in IPN managed exclusively with percutaneous catheter drainage (PCD). This study aimed to determine the spectrum and antibiotic sensitivity patterns of bacterial isolates from IPN exclusively managed by PCD.
Methods The database of 156 consecutive acute pancreatitbs patients, hospitalized between May 2018 to April 2020, was analyzed for culture results and antibiotic sensitivities of bacterial isolates from IPN patients exclusively managed by PCD.
Results Thirty patients (age-39.3 yeas, 80% male) with pancreatic necrosis were exclusively managed by PCD; 23 (76.7%) had IPN (43 positive cultures). Six (20%) patients had extra pancreatic infections (9 positive cultures-blood [5], urine [3], tracheal aspirate [1]). Monomicrobial and polymicrobial infection were seen in 10 (43.4%) and 13 (56.5%) IPN cases, respectively. The commonest isolates were Escherichia coli (56.5%), Klebsiella sp. (43.4%), Pseudomonas aeruginosa (39.1%). Other isolated organisms were MRCoNS, Acinetobacter (8.6% each); Serratia, Morganella, Burkholderia, Citrobacter, Enterococcus faecalis, Proteus (4.3% each). On antibiotic sensitivity, most bacteria were sensitive to beta-lactams and carbapenems; Escherichia coli -meropenem (76.9%), piperacillin-tazobactam (69.2%); Klebsiella -colistin (50%); Pseudomonas -gentamicin (88.8%), cefepime (77.7%), piperacillin-tazobactam (77.7). Pan-resistant organisms grew from six (14%) PCD fluid samples (Klebsiella, Escherichia coli -2 each; Pseudomonas, Acinetobacter-1 each) and two (22.2%) extra pancreatic sites (blood- Klebsiella, urine- Pseudomonas). IPN patients had higher organ failures (43.5% vs. 28.6%) and mortality (17.4% vs. 14.3%) than sterile pancreatic necrosis.
Conclusion Bacterial infections were common (76.6%) in pancreatic necrosis exclusively managed by PCD. Escherichia coli, Klebsiella, and Pseudomonas were the most common isolates. Most bacteria were sensitive to beta-lactams and carbapenems. IPN was associated with an increased probability of organ failure and mortality.
260
Prevalence of sarcopenia and it’s impact on patients with chronic pancreatitis
Premkumar K, Debapratim Routh
Correspondence- Premkumar K-drpremgastro@gmail.com
Department of Medical Gastroenterology, Institute of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India
Background Objective and aims: Malnutrition and changes in the body composition are common complications of chronic pancreatitis. We measured the prevalence of sarcopenia and it’s impact on chronic pancreatitis patients. The aims of the study were 1) to determine the prevalence of sarcopenia in chronic pancreatitis 2) to determine risk factors associated sarcopenia 3) to determine the association between sarcopenia and quality of life and 4) to determine the association between sarcopenia and hospitalization in chronic pancreatitis.
Methods This was a cross sectional study conducted on 100 patients diagnosed with chronic pancreatitis from October 2019 to August 2020. Quality of life was measured by the Brazilian version of the short form-36. Patients were classified according to conventional anthropometrics, hand grip strength, timed up and timed go test, body mass index (BMI) and biceps, triceps, suprailiac and subscapular skinfold thickness using the appropriate methods. The primary outcome of sarcopenia was defined according to EWGSOP criteria. Several parameters including alcohol, smoking, exocrine pancreatic insufficiency and pain related symptoms were analyzed for their association with sarcopenia. Statistical tests included the Chi-square, Mann-Whitney and spearman correlation tests with the significance level set at p value less than .05.
Results Amongst 100 patients enrolled in the study, median age was 55.5 years; 68 % were men; 72 % had alcoholic etiology. Smokers were 67%. Prevalence of sarcopenia was 31%. An abnormal low BMI (<18.5 kg/m2) was seen in 30.2% and 57.6% had normal BMI (18.5-25 kg/m2) and 9.6% had BMI in over weight/obese range (>25 kg/m2). Sarcopenia was significantly associated with exocrine pancreatic insufficiency, alcoholic, smoking and pain related symptoms on univariate analysis. Four skin fold thicknesses were also positively correlated with multiple domains of scale used to asses quality of life. Recurrent hospitalization and complications related to chronic pancreatitis were also higher in sarcopenic group compared with their counterparts.
Conclusion Sarcopenia is common complication in chronic pancreatitis patients and associated with adverse health related outcomes.
261
Glycemic status of patients following acute pancreatitis
Arun Solanki , Shubha Immaneni, Premkumar K, Murali R, Chezhian Annasamy
Correspondence- Shubha Immaneni-gastroshubha@gmail.com
Department of Medical Gastroenterology, Madras Medical College, Near Park Town Station, Park Town, Chennai 600 003, India
Introduction Changes in glycemia status over time have never been investigated comprehensively in patients after acute pancreatitis. The primary aim was to determine the incidence of new-onset prediabetes and new-onset diabetes after acute pancreatitis over 9 months of follow-up in a prospective cohort study. The secondary aim was to identify fluctuations of glycemia levels during follow-up.
Methods This was a prospective cohort study conducted on patients with a prospective diagnosis of acute pancreatitis and non-diabetic based on the American Diabetes Association criteria were followed up every 3 months up to 9 months after hospital discharge from October 2019 to August 2020 at Madras Medical College. Incidence of new-onset prediabetes and diabetes over each follow-up period was calculated. Multinomial regression analyses were conducted to investigate the associations between a wide array of routinely available demographic, anthropometric, laboratory and clinical factors.
Results A total of 100 patients without diabetes were followed up. The cumulative incidence of new-onset prediabetes and diabetes was 20% at 6 months after hospitalization and 28% over 9 months of follow-up. Three discrete groups were identified based on HbA1c levels: normal-stable glycemia (40%), moderate stable glycemia (54%), and high-increasing glycemia (6%).
Conclusion This study of changes in glycemia showed that at least one out of five patients develops new-onset prediabetes or diabetes at 6 months of follow-up and more than two out of ten patients in 9 months. Early detection of changes in blood glucose metabolism following an attack of acute pancreatitis will help to reduce the burden of new-onset diabetes after acute pancreatitis.
262
A case of acute pancreatitis with normal serum amylase and lipase value
Jayanta Paul
Correspondence- Jayanta Paul-dr.jayantapaul@gmail.com
Department of Gastroenterology, Desun Hospital, Desun More, 720, Eastern Metropolitan Bypass, Golpark, Sector I, Kasba, Kolkata 700107, India
Introduction There are several causes of acute pancreatitis (AP). In clinical practice, AP is diagnosed by presence of acute pain abdomen, elevated serum amylase and lipase value (> 3 times of upper limit of normal) and ultrasonographic (USG) findings of acute pancreatitis but in only 25% to 50% of patients with acute pancreatitis, pancreas is visualized in ultrasonography. Abdominal pain is the cardinal symptom which occurs in about 95% of cases of AP. Few studies showed that prevalence of alcohol induced pancreatitis is higher than gallstone induced pancreatitis but other study showed opposite result.
Methods/Results In this case, 44 years gentleman was presented with acute pain abdomen, normal serum amylase and lipase value and no pancreatic abnormality in abdominal USG. After diagnosis of elevated serum triglyceride, computed tomography (CT scan) of abdomen was done to exclude hypertriglyceridemia induced AP. CT scan abdomen showed features of acute pancreatitis.
Conclusion Patient with acute pain abdomen and normal serum amylase and lipase value do not exclude acute pancreatitis. Serum lipid profile including triglyceride should be advised in every patient with acute pain abdomen to exclude hypertriglyceridemia induced acute pancreatitis.
Keywords Acute pancreatitis, USG abdomen, High serum triglyceride
263
A case of successful treatment by conservative management of laparostoma in operated case of necrotising pancreatitis with necrotizing colitis
Nisarg Chovatiya , Devendra Chaudhary, Mukesh Pancholi
Correspondence- Nisarg Chovatiya-nishu1971994@gmail.com
Department of General Surgery, Government Medical College and New Civil Hospital, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Closure of the abdomen has always been a challenging task especially in the emergency setting with presence of bowel edema, hemoperitoneum, peritonitis, fecal contamination or intra-abdominal infection. So following infection or due to tension give away of midline laparotomy wound sutures and formation of laparostoma is not uncommon. We here report a case of such laparostoma formed following the give away of midline laparotomy wound suture following intraabdominal infection and tension over suture and successful management of laparostoma conservatively leading to spontaneous closure of laparostoma.
Case presentation A 22-year-old male patient underwent the exploratory laparotomy with right hemicolectomy with pancreatic necrosectomy with end ileostomy formation for necrotising pancreatitis with necrotizing enterocolitis with two ascending colon perforation. There was wound gap in midline laparotomy wound with gross pyoperitoneum with pus coming out through abdominal drains. There was evident sheath gap and laparostoma formation. We managed the patient conservatively. Continuous draining of pyoperitoneum through laparostoma for around a month was done leading to epithelialization and spontaneous closure of laparostoma. Patient was discharged. Eleven months after discharge patient was operated for stoma closure through laparotomy and out of a surprise bowels were healthy without adhesions to each other or to abdominal wall.
Conclusion Conservative management of laparostoma wound with regular dressings involving betadine and metronidazole wash prior to every dressing to drain pyoperitoneum not only prevented suspected mortality from immediate 2nd hit in the form of re-operation but also took care of intra-abdominal infection prevented the inter-bowel adhesions.
Keywords Laparostoma, Conservative management, Regular dressing, Spontaneous closure
264
Case series of rare pancreatic space occupying lesions
Rithu Sebastian , Abraham Koshy, Roy J Mukkada, Antony Paul Chettupuzha, Shelley C Paul, Pradeep George, Maya Peethambaran, Thara Prathap, Pushpa Mahadevan
Correspondence- Rithu Sebastian-rithudec3@gmail.com
Departments of Radiology, Hepatology, Pathology, and Pediatric Gastroenterology, Lakeshore Hospital and Research Centre, NH 47 Byepass, Nettoor, Maradu, Ernakulam 682 040, India
A wide spectrum of benign and malignant diseases can produce a mass in the head of the pancreas. It can be solid (ductal adenocarcinoma, chronic pancreatitis, endocrine tumor) or a cystic lesion (cystic neoplasm, true cyst or pseudocyst). We present two cases of pancreatic actinomycosis and one case of pancreatic tuberculosis.
Case 1 A 79-year-old lady known case of diabetes mellitus, systemic hypertension, chronic kidney disease and chronic calcific pancreatitis presented with history of fever for 2 weeks. There was history of EUS FNAC of pancreatic abscess in 2016. Ultrasound guided FNAC pancreas showed dense inflammatory cell infiltrate and actinomycotic colonies with Splendore Hoeppli phenomenon.
Case 2 A 67-year-old male known case of chronic calcific pancreatitis presented with recurrent episodes of abdominal pain. EUS FNAC done from pancreatic head mass showed occasional clumps of basophilic filamentous bacteria surrounded by Splendor-Hoeppli and a background of acute inflammatory cells suggestive of actinomycosis.
Case 3 A 75-year-old male presented with loss of appetite and weight loss since 1 month. CT abdomen showed a well defined multiloculated cystic lesion abutting the neck of pancreas with multiple rim enhancing lesions in the splenic parenchyma. He underwent EUS which showed a cystic SOL in the pancreas with thick contents and splenic abscess. FNB was done which showed large size caseating granulomas composed of epitheloid cells and Langhans’s giant cells with occasional acid fast bacilli. He was initiated on ATT.
Conclusion There are only thirteen reported cases of pancreatic actinomycosis to the best of our knowledge. A history of previous pancreatic surgery or stenting was frequently reported. Both our patients had previous EUS FNAC done. Pancreatic tuberculosis is also a rare presentation.
Keywords Pancreas, Actinomycosis, Tuberculosis
265
Systematic review and meta-analysis: Is there any role of antioxidant therapy for pain in chronic pancreatitis
Srikant Mohta , Namrata Singh, Deepak Gunjan, Amit Kumar, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Gastroenterology and Human Nutrition, and Neurology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Chronic pancreatitis is an irreversible disease with increased oxidative stress. The therapeutic role of antioxidants for pain reduction in chronic pancreatitis (CP) however is debatable. We conducted a systematic review and meta-analysis to ascertain their role in pain relief, their effect on quality of life in CP and associated adverse events.
Methods On literature review, we found 668 articles, seven of which were included. Only randomized controlled trials (RCT) were included. Two reviewers extracted the data and assessed the risk of bias. Pain was analyzed by visual analogue scale (VAS) and pain free participants. Results are expressed as standardized mean difference (SMD) or risk ratio (RR) with accompanying 95% confidence intervals and analysis was performed with fixed or random effects model according to heterogeneity. Adverse events and quality of life (QoL) were also assessed.
Results Twelve articles and four articles were eligible for qualitative and quantitative analysis respectively. The four included studies had a total of 352 participants. Pain reduction as measured by visual analogue scale was not significantly different in the antioxidant group compared to placebo (SMD=-0.14 [95% CI=-0.44-0.17]; p=0.38). Number of pain free participants were also similar (OR= 1.59 [0.97-2.59]; p=0.06). Antioxidants were not associated with increased adverse events (OR=2.59 [CI=0.77-8.69]; p=0.12). Qualitative analysis for effect on quality of life did not suggest any significant improvement with antioxidants.
Conclusion There was no significant pain reduction or change in quality of life in patients of CP with use of antioxidants. This makes their routine use in management of CP questionable.
Keywords Antioxidants, quality of life, pain
266
A study on the prevalence of sarcopenia in chronic pancreatitis, CT based assessment at a tertiary center in South India
Damodar Krishnan , Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Medical Gastroenterology, Sri Ramachandra Institute of Health and Research Center, Chennai, India and Sri Ramachandra Institute of Higher Education and Research, Chennai 600 116, India
Introduction Patients with chronic pancreatitis (CP) are at an increased risk of sarcopenia and was associated with increased hospitalization rates and mortality. CT is considered a valuable tool for the assessment of skeletal muscle mass and sarcopenia. We aim to determine the prevalence of sarcopenia using segmented skeletal muscle area, investigate risk factors associated with sarcopenia, and to derive the cut-off value of psoas muscle cross-sectional area (CSA) and muscle thickness for the diagnosis of sarcopenia using segmented skeletal muscle area as the reference method.
Methods Retrospective data on patients' demographic and disease characteristics were collected from medical records during the last 5 years. CT from the archives was taken and CSA of the psoas muscle was determined by manual encircling the outer surface of the muscle and muscle thickness as 2 points transverse diameter, normalized to stature, taking skeletal muscle index as a reference of sarcopenia (defined as SMI < 41.3 cm2/m2 for males and <34.cm2/m2 for females).
Results A total of 133 chronic pancreatitis patients were included, predominantly males 82% (n=109) with mean age of 40.67. CT assessment showed 51.1% of the patients having sarcopenia based on skeletal muscle index. Alcohol as etiology was noted in 54% of sarcopenic patients, PERT usage was noted in 61.76%, and diabetes in 51.47% in sarcopenic patients. Psoas muscle thickness and CSA showed significant association with SMI. Optimal psoas muscle thickness cut off for diagnosing sarcopenia was 23.78 mm/m for males and 21.11 mm/m for females and psoas CSA cut off 3.49 cm2/m2 for males and 2.40 cm2/m2 for females.
Conclusion Psoas muscle CSA measured on a standard axial CT slice can be used as a surrogate for muscle mass in patients with CP. Used in combination with clinical risk factors, including exocrine pancreatic insufficiency and opioid treatment, the method provides a clinically useful means for the detection of sarcopenia in this context.
Keywords Chronic pancreatitis, Sarcopenia, Skeletal muscle index, Psoas muscle thickness
267
Endoscopic ultrasound guided drainage of critically ill patients with walled off necrosis: Which stent to choose?
Gaurav Muktesh , Jayanta Samanta, Jahnvi Dhar, Roshan Agarwala, Balaji Bellum, Anupam K Singh, Saroj K Sinha, Vikas Gupta, Hemanth Kumar, Rakesh Kochhar
Correspondence- Gaurav Muktesh-gauravmuktesh@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction Endoscopic ultrasound guided drainage is the preferred treatment of pancreatic fluid collections (PFC).
Methods Between January 2018 and December 2019, consecutive patients with symptomatic PFC subjected to EUS guided drainage using bi flanged metal stents (BFMS) or double pig tail plastic stents (DPPS) were compared for technical success, clinical success, duration of procedure, need for ICU stay, duration of ICU stay, ventilator need, resolution of organ failure (yes/no), duration for resolution of organ failure, need for necrosectomy, need for salvage percutaneous drainage (PCD), complications, need for surgery and mortality. A subgroup of patients having systemic inflammatory response syndrome (SIRS) and/or organ failure were analyzed separately.
Results Among 130 patients (84.6% males) with PFC (108 WON, 22 pseudocyst) who underwent EUS guided drainage there was no difference in outcome parameters in BFMS and DPPS groups in the entire PFC cohort. Amongst patients with WON, clinical success was significantly higher (93.7% vs. 80%, p=0.039), duration of hospital stay (5 days vs. 10 days, p=0.028) and duration of procedure significantly lower (15.94±7.2 vs. 42.40±11.2 minutes, p= 0.0001) in BFMS compared to DPPS group. Amongst patients with SIRS and/or organ failure the duration of procedure was significantly lower (15.36±6.8 vs. 40.56±10.0, p=0.0001) in BFMS compared to DPPS group.
Conclusion EUS guided drainage in WON using BFMS scores over DPPS. In patients having SIRS and/or organ failure, BFMS may be preferred over DPPS.
Keywords Biflanged metal stent, Double pigtail plastic stent, Organ failure
268
Majority of patients with chronic pancreatitis are deficient in calorie intake and is associated with inflammation and pain
Anoop Saraya, Sumaira Qamar , Namrata Singh, Srikant Gopi, Deepak Gunjan
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Actual energy intake and its deficit in patients with chronic pancreatitis (CP) and association with inflammation and pain pattern are not well studied.
Methods Pre-tested, open ended, semi-qualitative food frequency proforma was used for diet assessment. Total energy (kcal) requirement (TER) was calculated by adding: resting energy expenditure (REE) by Harris-Benedict equation, 30% REE (increased metabolism) and 5% REE (diet-induced thermogenesis). Based on consumption of dietary energy, patients were divided in to: group 1 <90% and group 2 ≥90% TER. Based on pain characterization in last 3 months, patients were divided into three groups: continuous, intermittent and no pain. Serum inflammatory markers (quantitative C-reactive protein [Qcrp] and interleukin-6 [IL-6]) was assessed by ELISA kits.
Results A total of 107 patients (males-82) with mean age 31.2±11.1 years were included. Mean TER was 1901±279 kcal/day and mean energy intake was 1741±575 kcal/day in whole cohort, whereas energy intake was 1437±399 kcal/day in group 1 (n=68 [63%]) vs. 2271±432 kcal/day in group 2 (n=39 [36%], [p=0.0001]). Group 1 had an average 503±366 kcal deficit/day, elevated IL-6 (median:1.5 [0.22-15 pg/mL], p=0.039) and CRP (median: 2.38 [0.02-41 mg/mL], p=0.0447) compared to group 2. Patients having continuous pain (n=17) had significantly lower energy intake (1381±602) vs. intermittent (1793± 526) vs. no pain 1832± 582) and higher qCRP 2.1 (0.4-15) pg/mL, compared to intermittent 1.8 (0.01-11) pg/mL and no pain (1 [0.02-29] pg/mL, [p=0.0267]), similar results were seen for IL-6 (0.0665). Percentage of energy from macro nutrients was similar in both groups. There was no difference in frequency of diabetics/non-diabetics (p=0.970) and patients with steatorrhea/no steatorrhea (p=0.951) in group 1 and 2.
Conclusion Two third patients with CP are 1/4th daily energy deficient in their diet. Also patients with higher inflammation and continuous pain are more likely to have low calorie intake.
Keywords Energy deficit, Inflamation and energy deficieny, CP and energy intake
269
Differential location of growth factors and pancreatic stellate cell activation in chronic pancreatitis
Srikant Mohta , Pooja Goswami, Prasenjit Das, N R Dash, Namrata Singh, Deepak Gunjan, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Gastroenterology and Human Nutrition, Gastrointestinal Surgery, and Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Parenchymal fibrosis in chronic pancreatitis is mediated by various inflammatory cytokines and growth factors. It is characterized by activation of pancreatic stellate cells and start expressing smooth muscle actin (α-SMA). Normal pancreas has predominantly quiescent stellate cells in periductal and perivascular locations and does not express α-SMA. So, we wanted to study the immunohistochemistry (IHC) expression pattern of α-SMA, platelet derived growth factor (PDGF-BB) and transforming growth factor (TGF-β) in the resected specimen of chronic pancreatitis.
Methods A total of 20 biopsies from resected specimen of chronic pancreatitis were included. The expression was measured as compared to control biopsies (breast carcinoma as a positive control for PDGF-BB and TGF-β, and appendicular tissue for α-SMA), and scored based on a semi-quantitative system based on staining intensity and percentage of positive cells was used for objective scoring, which value varies from 0-15. This scoring was done separately for acini, ducts, stroma and islet cells.
Results (Table 1 and Fig. 1) All the patients had undergone surgery for refractory pain and median duration of symptoms was 48 months (IQR). On IHC, α-SMA was not expressed in the acini, ducts or islets but had high expression in the stromal regions (vs. acini, ducts and islet, p<0.01). PDGF-BB was expressed in the acini, ducts and stroma but has highest expression in islet cells (vs. stroma, p<0.01). TGF-β1 was also expressed maximally in islet cells; however, the distribution amongst all locations was statistically similar.
Conclusion α-SMA expression in the pancreatic stroma is an indicator of concentration of activated stellate cells in the stroma, a site for genesis of fibrosis under the influence of growth factors in the local milieu.
Keywords Stroma, Extracellular matrix, Growth factors
270
Clinical profile of acute pancreatitis in tertiary care centre
Niranjan N K , Murali R, Prem Kumar K, Shubha I, Chezhian A
Correspondence- Murali R-muraligastro@gmail.com
Department of Medical Gastroenterology, Institute of Medical Gastroenterology, Madras Medical College, Near Park Town Station, Park Town, Chennai 600 003, India
Introduction Acute pancreatitis is thought to be a local inflammatory process involving premature intracellular activation of digestive enzymes within acinar cells leading to auto digestion of the tissue that can progress to involve distant organs. AP was one of the most common diseases in gastroenterology. Practical understanding of etiology and severity will accommodate in advocate the appropriate treatment.
Method It’s a retrospective observational study carried out over a period of 1 year from September 2019 to August 2020 at Medical Gastroenterology Department ward of Madras Medical College of all acute pancreatitis patients, with regards to demographics and etiology.
Results Data collected from 120 patients was initially assessed for isolation of etiology by using specially self designed etiology assessment form, severity based on Atlanta severity assessment scale (ASAS). Treatment was given according to institute protocol and outcome was measured in terms of length of stay in hospital. Out of 60 patients 48 (40%) patients with alcohol, 66 (55%) with alcohol and smoking, 6 (5%) with gallstones. On severity assessment 84 (70%) patients were mild and 36 (30%) were moderate. On measurement of outcomes 46 (38.3%) patients were better, 50 (41.6%) patients were moderate, and 14 (11.6%) patients were poor control.
Conclusion We conclude that alcohol is the predominant cause acute pancreatitis and smoking adds to the risk. Evaluating cause, severity and management based on the standard guidelines are found to be the safe and effective management of AP to reduce the hospital stay.
Keywords Acute pancreatitis, ASAC, Alcohol, Gallstone
271
Diagnostic performance of cytology, tumor markers and molecular (KRAS and GNAS) testing in pancreatic cystic lesions: Experience from a tertiary care centre in India
Ravi Kumar Sharma , Surinder Singh Rana, Radhika Srinivasan, Rithabhra Nada, Rajesh Gupta
Correspondence- Surinder Singh Rana-drsurinderrana@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background Asymptomatic pancreatic cystic lesion (PCLs) are now being increasingly diagnosed because of widespread use of cross-sectional imaging modalities. There is a clinical dilemma to diagnose it correctly as PCLs are complex group of lesions from benign, premalignant to malignant and data from India on these tumors is scarce.
Methods Consecutive with PCLs seen in our unit from July 2015-September 2019 were prospectively enrolled and underwent endoscopic ultrasound (EUS) and EUS guided cyst fluid aspiration. Air dried slides were sent for cytological evaluation. Cyst fluid CEA, CA19.9, CA72.4, CA125, VEGF were performed by using ELISA and KRAS (exon 2, codon 12 and 13) and GNAS (exon 8, codon 201) mutation analysis were performed by using Sanger sequencing. The final diagnosis was based on histopathology of resected specimen or confirmation in aspirated cyst fluid, or clinical diagnosis with no significant growth on follow-up of >6 months.
Results Hundred consecutive patients (Mean age 49.15±15.9 years, 59 females) with PCLs were enrolled and 94 patients underwent EUS FNA, mean cyst size was 4.23±2.8 cm. On EUS single cyst were found in 92 patients and multiple in 8 patients, location of cyst was 46 in head and uncinate, 27 in body and 35 in tail of pancreas. On cytopathology 23 patients were identified positive for malignancy and 63 patents were found negative for malignancy, 5 patients were false negative and 3 were inconclusive. Mean CEA level at >45.0 ng/mL showed sensitivity of 88.5% and specificity 96.8%, p=<0.001 to differentiate mucinous and non-mucinous cysts. KRAS exon 2 mutation was positive in 14 patients at codon 12. While KRAS codon 13 and GNAS exon 8 codon 201 was negative in all cases.
Conclusion CEA is helpful in differentiation of mucinous and non-mucinous cyst and KRAS gene mutation is helpful in differentiation of malignant and non-malignant cyst.
Keywords Pancreatic cystic lesion-PCL
272
Outcomes of minor papilla endotherapy for pancreatic divisum in patients with recurrent acute pancreatitis
Amol Vadgaonkar , Prabha Sawant, Gaurav Patil, Ankit Dalal, Amit Maydeo
Correspondence- Amol Vadgaonkar-vadu169@gmail.com
Department of Gastroenterology, Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr. E Borges Road. Opp Shirodkar High School, Parel, Mumbai 400 012, India
Background Pancreatic divisum (PD) is the likely cause of abdominal pain in 5% to 10% of patients with recurrent acute pancreatitis (RAP). The outcomes for endotherapy in these patients remains currently unexplored in India.
Methods This is a prospective observational study of RAP patients who underwent endotherapy for PD from June 2018 - May 2020. RAP was defined as >2 episodes of acute pancreatitis (AP) without underlying chronic pancreatitis (CP). PD was diagnosed based on MRCP and/ or EUS. At ERCP, minor papilla guidewire cannulation followed by over the wire sphincterotomy was done. A dorsal duct stent (5-Fr) was placed short-term for 1 month. All patients were followed up at 1, 6, and 12 months’ post sphincterotomy. Pain was assessed by visual analogue score (VAS). The outcomes included technical and clinical success, pain relief and complications.
Results A total of forty-one patients, male = 34 (82.9%); with a mean (SD) age of 29 (11) years were analyzed. Median episodes of RAP prior to endotherapy were 3 (range 3-6). All patients underwent minor papilla sphincterotomy with placement of 5Fr stent and PD stenting (technical success 100%). The clinical success of endotherapy in complete PD was 20/27 (74%), in incomplete divisum 8/14 (57.1%). The mean (SD) length of hospitalization was 3 (1) days. Complications included stenosis of the sphincterotomised minor papilla (n=4), Post ERCP pancreatitis (n=3), sphincterotomy bleed (n=2) and stent migration (n=1). At 12 months, 7 (17.1%) had features suggestive of early CP. Twenty-six (63.4%) patients underwent repeat ERCP with sphincterotomy and pancreatic ductal stenting. The VAS score reduced significantly from baseline as compared to 1, 6 and 12 months (p<.001).
Conclusions Endotherapy with minor papilla sphincterotomy and pancreatic duct stenting looks appropriate as initial therapy in symptomatic complete PD and non-responders may need additional interventions.
Keywords Pancreatic divisum, Minor papilla endotherapy, Pancreatic stenting, Endoscopic retrograde cholangiopancreatography
273
MiR-30b modulates inflammatory response by targeting RIP-140 in pancreatic tumor
Bharti Garg , Nidhi Singh, Safoora Rashid, Surabhi Gupta4, Deepak Gunjan, N R Dash, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background miRNAs are known to skew the immune responses towards development of pancreatic cancer. Upregulation of receptor interacting protein (RIP-140) exacerbates inflammatory events and facilitates the tumorigenesis of pancreatic ductal adenocarcinoma. In this report, we evaluated whether any down regulated microRNA 30b in pancreatic cancer patients orchestrates RIP-140 mediated inflammation with the progression of the disease.
Methods Target scan and PicTar algorithm was used to predict the miRNAs target in RIP-140. N=50 PDAC patient and healthy volunteers were accrued in this study. Taqman assay and SYBR green based qRT PCR was done to validate the expression of miRNAs and their target, respectively, in pancreatic patient tissues and their serum samples. Inflammatory markers (TNF-α, IL-1β and IL-6) levels in serum was detected by ELISA. Infiltration of M1 (CD80+ and CD86+) and M2 macrophage markers (CD204+ and CD163+) in tumor samples was elucidated by flow cytometry. In Invitro setting, CD45+ cells were co cultured with panc-01 cells in transwell system and miR-30b was over expressed in panc-01 to see the effect of miR30b on inflammatory response.
Results miRNA-30b was remarkably found to be down regulated in PDAC samples and pancreatic cancer human cell lines showing upregulation of RIP-40. Low levels of miRNA-30b enhanced the expression of inflammatory markers in serum samples. In addition to that we also found more infiltration of M2 macrophages in tumor samples. Invitro over expression of miRNA-30b in panc-01 reversed these effects when co cultured with CD45+ cells.
Conclusion Our data suggested miR-30b as a plausible target for RIP-140. Low levels of miR-30b and high RIP-140 expression levels both predicts dismal prognosis via increasing inflammation in PDAC patients. Taken together, these findings implicated that over expression of miR-30b may suppress inflammation through suppressing RIP-140 expression highlighting that miR-30b may serve as therapeutic agent in the treatment of PDAC.
Keywords miRNA, RIP-140 (receptor interacting protein), inflammation, M1/M2 macrophages, pancreatic cancer
274
Evaluation of point of care urine trypsinogen dipstick for diagnosing acute pancreatitis in an emergency unit
Amar Simha , Atul Saroch, Navneet Sharma, Ashok K Pannu, Deba P Dhibar, Harjeet Singh, Vishal Sharma
Correspondence- Atul Saroch-atulsaroch@gmail.com
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction Abdominal pain is most frequent presenting symptoms in emergency medicine department. Diagnosis can be as subtle as acute gastritis to mesenteric insufficiency a life-threatening condition. Acute pancreatitis is one of the diseases presenting with symptom of severe abdominal pain. Here in this study we will assess diagnostic accuracy of newly introduced urine trypsinogen dip stick, point of care test for early diagnosis of acute pancreatitis.
Method This diagnostic accuracy study was performed in emergency unit of one of tertiary care hospital of north India. Consecutive patient with abdominal pain duration of less than and equal to seven days and fulfilling inclusion criteria were recruited in this study. Urine trypsinogen dip stick test was performed in all patient and diagnostic accuracy (sensitivity and specificity) were calculated.
Result Total 187 patient were recruited, out of which 90 were cases (acute pancreatitis) while 97 were control (non-pancreatitic cause of abdominal pain). Sensitivity and specificity of urine trypsinogen dip stick test for diagnosis of acute pancreatitis 67.8% and 90.7% respectively, further subgroup analysis in patient of duration of pain less than and equal to 3 days, sensitivity and specificity approach to 72.7% and 91.8% respectively. Positive and negative likelihood ratio is 6.10 and 0.36 (≤ 7 days), 8.9 and 0.3 (≤3 days) respectively. In patient with acute severe pancreatitis diagnostic sensitivity of UTDT is 82%.
Discussion With advantage of bed side point of care testing and better sensitivity/specificity in early days of abdominal pain (<3 days), urine trypsinogen dip stick test will be boon to the resource limited setting where health infrastructure for conducting biochemical test (serum amylase and lipase) is not available.
Keywords Acute pancreatitis, Point of care test, Urine trypsinogen dipstick test (UTDT)
275
Endoscopic removal of proximally migrated pancreatic duct stents: Techniques and their outcome
Sachin H J , Surinder Singh Rana
Correspondence- Surinder Singh Rana-drsurinderrana@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Objective Proximal migration of pancreatic stents is an uncommon, but significant problem that poses risk of pain and pancreatitis. It is a challenging situation to the endoscopist, necessitating surgical retrieval in 10% of cases. We describe our experience with endoscopic removal of different stents with different methods (namely use of grasping forceps, Spy-glass, EUS guided extrusion), complications, and outcome.
Methods A retrospective review of the last 10 years for pancreatic duct stent removal procedures done at our unit was done. The size, type, status (intact or fragmented) and position of migrated stents, the status of PD (pancreatic duct), the method utilized, and the number of sessions needed for extraction, success, complications, and need for surgical retrieval were studied.
Results Sixteen patients (mean age 39.52 years, 13 [81%] males) with migrated proximal stents were studied. Two (12.5%) patients had fragmented stents and rest 14 (87.5%) had whole migrated stents in situ, all of them being of straight type. Fourteen (87.5%) patients had dilated PD. Most (n=10 [62.5%] p=0.022) of them had a stent of 5F size, and most of them were 10 cm (n=10 [62.5] p=0.001) in length. Most of stents were positioned in the genu (n= 8 [50%] p=0.105) and were retrieved mostly with grasping forceps (n=8 [50%] p=0.035). Stents could be removed in 13 (81.25%) patients and retrieval was successful in a single session (n=6 [37.5%]) in the majority. Among the two patients with fragmented stent both of them could be removed, albeit, in one of them, the distal fragment remained in the tail. Two patients reported post-procedure pain (n=2 [12.5%]) and 1 patient needed surgical retrieval.
Conclusion In the hands of an expert endoscopist, endoscopic retrieval of proximally migrated stents using a combination of techniques and accessories is safe and effective. Surgery is rarely needed for stent removal.
Keywords Migrated pancreatic duct stent, Endoscopic removal, Outcomes
276
Renal artery Doppler and clinico-radiological profile of acute kidney injury in acute pancreatitis
Surinder Rana, Nikhil Bush , Pankaj Gupta, Ravi Sharma, Rajesh Gupta
Correspondence- Surinder Rana-drsurinderrana@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background Acute kidney injury (AKI) in acute pancreatitis (AP) is associated with poor prognosis. There is lack of data on renal Doppler findings in patients with AKI due to AP.
Methods Thirty-six patients (41.2±13.79 years; 30 M) of AP with AKI and thirty-nine patients (42.1±12.8 years; 28 M) of AP without AKI were prospectively recruited. All patients underwent renal ultrasound and Doppler analysis at the level of the intra-renal arcuate arteries. RI values between 0.6-0.7 were considered normal. A comparative analysis of demographic, clinical, radiological, and renal Doppler variables was done.
Results 19.4%, 33.3% and 47.2% of the AKI patients presented in AKIN stages 1, 2 and 3 respectively. Patients with AKI had significantly higher frequency of anemia, hypoalbuminemia, lung injury, hypotension, increased lactate, raised procalcitonin, IAH, multiorgan and persistent organ failure with higher mean severity scores (SIRS, BISAP, MMS, APACHE II, MCTSI) in comparison to those without AKI. Need for intervention, duration of hospitalization and mortality (30.5% vs. 7.6%, p-value 0.008) were also higher in the AKI group. Oliguric AKI was present in 22 (61.1%) and dialysis was needed in 18 (50%). On multivariate logistic regression, high initial creatinine value was a significant predictor of the need for dialysis (p-value 0.047, OR-1.9, 95% CI 1.00-3.75). Renal ultrasound revealed increased cortical echogenicity in 22 (61%) patients, compared to none in those without AKI (p<0.05). Peak systolic velocity and resistive indices at the upper, middle and lower poles of bilateral kidneys were comparable between the two groups and no significant differences were noted in their mean values. Among 31 patients with abnormal resistive indices in bilateral kidneys (41.3%), 25 (33.3%) had values <0.6 while 6 (8%) had values > 0.7. 4.
Conclusions AKI is associated with poor prognosis in AP. There are no significant alterations in renal Doppler parameters in patients of AP with AKI.
Keywords Acute kidney injury, Acute pancreatitis, Renal artery doppler, Resistive index
277
Exclusive percutaneous catheter drainage for infected pancreatic necrosis: Outcome and predictors of mortality
Ashok Kumar , Kshitiz Saran, Rohit Gupta, Itish Patanik
Correspondence- Ashok Kumar-drashok.sgpgims@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Virbhadra Road Shivaji Nagar, near Barrage, Sturida Colony, Rishikesh 249 203, India
Introduction Infected pancreatic necrosis (IPN) is associated with high mortality. A proactive percutaneous catheter drainage (PCD) strategy may lead to decreased systemic inflammation and improved outcomes, but the information is limited about exclusive PCD management (without necrosectomy) for IPN.
Methods This study aimed to determine the outcomes of exclusive PCD interventions for IPN patients. The database of 156 consecutive acute pancreatitis patients, hospitalized between May 2018 to July 2020, was analyzed for outcomes of exclusive PCD management (without necrosectomy) for IPN.
Results Thirty patients with pancreatic necrosis were exclusively managed by PCD; 25 (83.3%) survived and 5 (16.7%) died. The survivors and non-survivors had a similar mean age (37.7 ± 11.3 vs. 47.6 ± 14.8 years, p 0.10), male patients (84 vs. 60%, p 0.22), mCTSI (9.28±1.40 vs. 9.20 ± 1.79, p 0.96), degree of necrosis (20:68:12 and 20:40:40 for <30%, 30-50%, >50% necrosis, respectively, p 0.29), infected necrosis (76 vs. 80, p 0.85) and drug resistant bacteria (72 vs. 80, p 0.64).
However, non-survivors group had fewer alcoholic pancreatitis (0 vs. 64%, p 0.03), higher BISAP score (2.6 ± 0.6 vs. 1.7± 0.7, p 0.02), more patients with multiple organ failures (80 vs. 0%, p 0.00); shorter pain onset to hospitalization (9.2 ± 8.1 vs. 27.9 ± 22.3 days, p 0.03) and pain onset to PCD placement interval (20.6 ± 7.6 vs. 39.1 ± 20.8 days. p 0.02), more number of PCDs per patient (1.8 ± 0.8 vs. 1.5 ± 0.9, p 0.33), lower fall in SIRS post PCD (0.6 ± 0.6 vs. 1.7 ± 0.45, p 0.00), shorter PCD dwell time (17.2 ± 6.5 vs. 41.2 ± 38.8 days, p 0.01).
Conclusion For IPN, exclusive PCD management has a high success rate (83.3%). Etiology, severity of pancreatitis, and multiple organ failures are associated with higher mortality.
Keywords Acute pancreatitis, Infected pancreatic necrosis, Percutaneous catheter drainage
278
Outcomes of extracorporeal shock wave lithotripsy in chronic pancreatitis with pancreatic duct calculi
Harshal Gadhikar, Mangesh Borkar , Nisarg Patel, Amol Bapaye, Ashish Gandhi
Correspondence- Harshal Gadhikar-gadhikarhp@gmail.com
Department of Gastroenterology, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India
Introduction The removal of large pancreatic calculi is challenging and ESWL followed by ERCP is standard of care. We assessed overall outcomes including pain relief, ductal clearance, recurrence, and safety following ESWL.
Methods Prospective observational study of symptomatic CP patients with PD calculi (head and body) undergoing ESWL from August 1918-March 2020 was conducted. Patients were evaluated using X-ray, fluoroscopy, USG, CT scan, EUS/MRCP. Number required for calculi fragmentation, pancreatic ductal clearance, efficacy, and safety of ESWL was studied. Pain was assessed using visual analogue scale (VAS). Non-visualization of calculi on fluoroscopy was taken as the end point for ESWL. Patients were followed up for 6 months W.R.T. pain relief and complications.
Results Total of 128 patients; male 89 (69.5%) with a mean age 40.7 (16.1) years were included. Abdominal pain was present as the only symptom in 122 (95.3%), while steatorrhea along with pain was present in 6 (4.7%). Diabetes was present in 64 (50%). Fifty-seven (44.5%) patients required between 1- 5 ESWL sessions, 49 between 6-10 and 22 required >=11 sessions. The mean (SD) ESWL sessions in these patients were 7.2(4.2). Mean (SD) VAS pre-ESWL was 4.3(1.75). At 3 months, 113(88.3%) patients had VAS of 0. At 6 months 126 (98.4%) had VAS score of 0 (p<.001). ERCP, sphincterotomy +/- pancreatic duct stenting was done in 112 (87.5%) patients. ERCP failed in 6, was refused by 5 and lost to follow up in 5 patients. Complete ductal clearance was achieved in 118 (92.2%), whereas partial was in 10 (8.8%). 37 (28.9%) had PD stricture. Twenty-four (18.7%) patients had minor complications like erythema of skin (14.8%) and cutaneous pain (3.9%), while only 1 (0.8%) had serious complication of acute pancreatitis. Six (4.7%) patients had stone recurrence after ESWL during 6 months follow-up period.
Conclusions ESWL is safe and effective modality in CCP patients with PD calculi with good success rates.
Keywords Pancreatic calculi, Extracorporeal shockwave lithotripsy, Safety
279
Endoscopic transpapillary management of pancreatic duct disruption at a tertiary care center in Northern India
Shreya Butala , Samir Mohindra, Gaurav Pandey, Vivek Saraswat
Correspondence- Vivek Saraswat-profviveksaraswat@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Introduction Pancreatic duct disruption occurring as complication of acute necrotizing pancreatitis (ANP), traumatic pancreatitis (TP), chronic pancreatitis (CP), pancreatic malignancies, present with peripancreatic fluid collections (PFC), pancreatic ascites (PA), pancreatic pleural effusion (PPE) or external pancreatic fistulae (EPF) after percutaneous drainage (PCD).
Methods Retrospective review of patients undergoing ERCP between January 2010 to July 2020 for AP or CP complicated by PFC, PA, PPE or EPF was done. Pancreatic duct (PD) disruption was defined partial if upstream PD was visualized or complete if it was not visualized. Clinical success was defined as resolution of collection and removal of percutaneous catheter within 2 weeks of ERCP without the need of second intervention.
Results Sixty-nine patients (54 male, mean age 28 years) with PD disruption( EPF - 22, PFC with ductal communication -21, PA -15, PA+PPE -6, PPE -5) were included. Etiology was ANP- 32 (46.4%), TP-9 (13%), CP-28 (40.6%). PD cannulation was successful in 61 patients (88.4%). Transpapillary stents were placed in 51 (73.91%). PD disruption was successfully bridged by a stent in 21 (30.4%) patients. Stents were not placed in 18 (failed cannulation-8, leak within 3cm from papilla-3, non-delineation of MPD-3, stricture or stone-4). Clinical success was achieved in 42/69 (60.8%) patients. Median duration for resolution of leak after ERCP was 10 days in patients with clinical success vs. 48.5 days in failure group (p-0.001). Median PCD duration after ERCP was shorter in transpapillary stent group (12 vs. 60 days, p-0.005). Three patients developed post-sphincterotomy minor bleeding, two had mild pancreatitis. On univariate analysis, chronic pancreatitis, partial PD disruption, bridging of leak by stent and transpapillary stenting were associated with clinical success.
Conclusion Endoscopic transpapillary management of PD disruption is safe and effective therapy for pancreatic ductal leaks and leads to early resolution of leak.
Keywords Pancreatic duct disruption, Endoscopic transpapillary management
280
Pancreatic bed hemorrhage contributes to late mortality in patients with acute necrotizing pancreatitis
Anshuman Elhence , Saransh Jain, Soumya Jagannath Mahapatra, Rahul Sethia, Varun Teja, Shivam Pandey, Kumble Seetharama Madhusudhan, Pramod Kumar Garg
Correspondence- Pramod Kumar Garg-pgarg10@gmail.com
Departments of Biostatistics, Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and Jainamshree Hospital, E5, 47, Near Bagheera Apartment, E-5, Arera Colony, Bhopal 462 016, India
Introduction Frequency, risk factors of hemorrhage, and impact on survival of pancreatic bed hemorrhage into (peri)pancreatic necrotic collections in patients with acute pancreatitis (AP) are not well studied.
Methods All consecutive patients with AP from January 2015 till March 2020 admitted in a tertiary care academic centre were included prospectively to study frequency, risk factors of hemorrhage, and impact on survival of pancreatic bed hemorrhage. Patients with significant pancreatic hemorrhage were managed according to a predefined protocol. Primary outcome was the effect of pancreatic hemorrhage on in-hospital mortality. Secondary outcomes were risk factors of hemorrhage.
Results Of a total of 363 patients admitted during the study period, 33 (9.04%) patients developed pancreatic hemorrhage during their hospital stay. The cause of hemorrhage were arterial pseudoaneurysm in 21 patients and unlocalized in 12 patients. Radiographic angioembolization was done in all patients with suspected arterial bleed which failed in 3 patients. Surgery was required in 10 patients for persistent bleeding including 7 patients with unlocalized bleeding source. Median time from onset of AP to bleed was 59 (45-68) days. On Cox proportional hazard analysis, persistent organ failure (HR 2.3 [1.1-5.1], p=0.03), use of large bore (20 Fr or above) catheter for initial drainage (HR 3.9 [1.7-9.1], p=0.001) and extensive (>50%) necrosis (HR 3.1 [1.4-6.9], p=0.005) were significantly associated with risk of pancreatic hemorrhage. In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group (p <0.001). Hemorrhage into pancreatic bed was an independent predictor of mortality (OR 5.1 [CI 1.7-14.1], p=0.002) in addition to extensive (>50%) necrosis, persistent organ failure, and infection with multi/extreme drug resistant organisms.
Conclusion Pancreatic hemorrhage occurred in 9% of patients with AP and was an independent predictor of mortality.
Keywords Acute pancreatitis, Organ failure, IPN. Bleeding
281
Alcohol etiology and not poor dietary intake determines sarcopenia in chronic pancreatitis
Srikanth Gopi , Deepak Gunjan, Divya Madan, Namrata Singh, Madhusudhan K S, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Radiodiagnosis, Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Sarcopenia is associated with increasing morbidity and mortality in various chronic disease. Chronic pancreatitis (CP) is a chronic inflammatory disease with various complications and sarcopenia is not well studied in these patients. We aimed to study the prevalence of sarcopenia in chronic pancreatitis and its association with pain severity, complications, dietary intake, exocrine and endocrine insufficiencies.
Methods A prospective observational single center study was conducted from February 2019 to August 2020. All consecutive chronic pancreatitis patients were included, and exclusion criteria was age <18 or >60 years, associated other co-morbidities and history of pancreatic surgery. The sarcopenia was assessed by measuring skeletal muscle index at L3 level and gender specific skeletal muscle index cut offs were taken (<37.3 cm2/m2 for males and <26.7 cm2/m2 for females). All these patients were assessed for clinical details, anthropometry, body composition by bioimpedance analysis, hand-grip strength, 6-meter gait speed and dietary intake.
Results A total of 194 patients (66.5% were males) with mean age of 36±11 years were included in the study. The prevalence of sarcopenia was 22.2% and it was more common in alcohol-related CP than other etiologies (58.1% vs. 24.5%, p=0.001). On multivariate analysis, only alcoholic CP was significantly associated with sarcopenia (OR=3.25 [CI:1.14-0.09], p=0.028). There was a non-significant trend of lower BMI in sarcopenic CP (OR=1.46 [CI:0.98-2.17], p=0.061). There was no statistical significant difference between sarcopenia and non-sarcopenia groups in endocrine deficiency (38.4% vs. 39.5%, p=0.894), exocrine insufficiencies (82.8% vs. 69.8%, p=0,060), mean hand grip strength (32.93±17.4 kg vs. 30.3±15.2 kg, p=0.364), mean 6 m gait speed (1.11±0.18 m/s vs. 1.11±0.17 m/s, p=0.988), daily calorie intake (1477±706 Kcal vs. 1657±577 Kcal, p=0.104) and median CRP levels (1.93 vs. 1.04 mg/L, p=0.246), respectively.
Conclusion Sarcopenia is common in chronic pancreatitis and alcoholic CP has higher chances of developing sarcopenia.
Keywords Sarcopenia, Chronic pancreatitis
Endoscopy
282
Granulomatous pharyngitis - A diagnostic dilemma for an endoscopist/otolaryngologist
Avinash Balekuduru, Mandalapu Narendra Babu , Shruthi Sagar Bongu, Satyaprakash Bonthala Subbaraj
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India
Introduction Endoscopy showing posterior pharyngeal wall lesion without histological confirmation can make the diagnosis and treatment challenging. We here with present a case of granulomatous pharyngitis.
Case Report A 41-year-old male from Middle East, presented with painless progressive dysphagia to solids and hoarseness of voice for 8 years duration. He was operated at multiple hospitals for thickened posterior pharyngeal wall. Otolaryngeal examination revealed scarred soft palate, perforated anterior nasal septum, floppy epiglottis and vocal cord palsy. He had gastrostomy tube placed for nutrition. Endoscopy with balloon dilation was done for posterior pharyngeal wall ulceration, and hypopharyngeal stricture (Fig. 1A, C). He had an inspiratory stridor. On image enhanced endoscopy intrapapillary capillary loops type III-IV were noted on pharyngeal wall (Fig.1A, B). Biopsies were obtained which showed non-specific granulomatous tissue. Immunohistochemistry staining revealed positivity for CD-20, CD-3 and LCA and was negative for CD-56 (Fig.1D). He underwent tracheostomy for stridor. There was no apparent evidence of either tuberculosis or Crohn’s disease. Other causes of granulomatous pharyngitis such as syphilis, sarcoidosis, autoimmune diseases, Wegener's granulomatosis, viral serology or Klebsiella rhinoscleromatis were excluded. Chest radiograph and computed tomography of neck did not reveal any abnormality. Diagnosis of midline granulomatous disease was made. He was treated with mycofenalate mofetil, hydroxychloroquine and tapering dose of prednisolone. He had speech and swallowing physiotherapy. He was able to resume to oral feeds. He is on follow-up for 3 months and his disease has not progressed.
Conclusion Isolated midline granulomatous disease is rarely reported and should be considered in the differential diagnosis of pharyngeal diseases.
283
Spectrum of foreign body ingestion at a tertiary care center
Manish Kumar , Anurag Mishra, Arpan Jain, Ashok Dalal, Ujjwal Sonika, Siddharth Srivastava, Ajay Kumar, Sanjeev Sachdeva, B C Sharma
Correspondence- Manish Kumar-drtomarmanish@gmail.com
Department of Gastroenterology, GB Pant Hospital, 1, J L N Marg, New Delhi 110 002, Indi
Introduction Foreign body ingestion is common in pediatric age group. This study was conducted with the aim to identify the most common age group, types and locations of foreign bodies.
Methods A retrospective study was conducted in G B Pant Hospital, Delhi from October 2015 to December 2019. All patients presented to the hospital with a history of foreign body ingestion during this time period were included. The data were analyzed using descriptive statistics.
Results Total 170 cases of foreign body ingestion were encountered. These included 68.8% males and 31.1% females with a median age of 5 yrs. Though foreign body ingestion was accidental in all children of less than 15 yrs of age, it was either intentional (5.2%) or secondary to esophageal stricture (4.1%) or denture (3.5%) in adults. In majority of the cases, foreign bodies were located in the stomach, 55.8% followed by esophagus, 25.2%. The most common type of foreign body was a coin, 58.2%. Foreign bodies passed spontaneously in 7%. In rest of the patients endoscopic removal was attempted and was successful in 97.4%. Complications were seen in 10% cases. Ulceration at the foreign body site being the most common, 7.6%.
Conclusion Foreign body ingestion is common in pediatric age group particularly among children less than five years old. Special attention is needed to prevent foreign body ingestion in this age group. In our study, coins are the commonest foreign body found, and stomach the commonest location.
284
Comparison between Glasgow-Blatchford score and complete Rockall score for predicting clinical outcome among patients with upper gastrointestinal bleed
Jigar Patel , Ankur Jain, Kaushal Vyas, Sushil Narang
Correspondence- Jigar Patel-jskap1992@gmail.com
Department of Medical Gastroenterology, Sardar Vallabhbhai Patel Institute of Medical Sciences (SVPIMS), Riverfront Road, Ellisbridge, Ahmedabad 380 006, India
Introduction The two commonly used risk scoring systems to categorize patients with upper gastrointestinal bleed (UGIB) into high-risk and low-risk subgroups include the Complete Rockall scoring (CRS) system and the Glasgow-Blatchford scoring (GBS) system. The present study aimed to compare CRS and GBS systems for predicting clinical outcomes of patients of UGIB.
Methods Two hundred patients with the age >18 years who presented with UGIB in the emergency department of SVPIMSR, were enrolled in the study. Patients with past history of variceal bleeding and those who received any treatment before admission were excluded. Diagnostic endoscopy was performed for all assigned patients. Relevant clinical and laboratory parameters were also recorded. In addition, the cases were followed for any episode of rebleeding and 1-month mortality. The outcomes of UGIB were categorized as need for endoscopic intervention and ICU admission, 1-month mortality, rebleeding episode. CRS and GBS systems were calculated for each patient. A receiver operating characteristic (ROC) curve by using areas under the curve (AUC) was used for statistical comparison. P-value less than 0.05 was considered statistically significant.
Results GBS was better than CRS system to predict need of endoscopic intervention (AUC: 0.927 v/s 0.822; p value <0.0001). However CRS system was better than GBS to predict outcome (treated or death) (AUC: 0.997 vs. 0.768; p value <0.0001. There was no statistically significant difference between GBS and CRS systems to predict need of ICU admission (AUC: 0.845 vs. 0.851; p value= 0.8354) and rebleeding at 1 month (AUC: 0.749 vs. 0.728; p value= 0.6063).
Conclusion We found that Glasgow-Blatchford Score is better to predict need of endoscopic intervention, while the Complete Rockall Score is better for 1-month mortality prediction. There was no statistically significant difference between both scoring systems to predict need of ICU admission and rebleeding at 1 month.
285
Endoscopic closure of gastric defect
C Revanth Reddy
Correspondence- C Revanth Reddy-revanthreddy1990@gmail.com
Department of Gastroenterology, Government General Hospital, Kurnool Medical College, Budhwarpet Road, Budhawarapeta, Kurnool 518 002, India
Introduction Incidence of gastrointestinal perforations are increasing due to increase in number of therapeutic procedures (EMR, ESD, POEM, NOTES).
We report a similar case of iatrogenic gastric perforation after partial splenectomy which is closed with endoscopic clips.
Case Report A 48-year-old female presented with complaints of high grade fever, left upper quadrant pain and loss of appetite for 2 weeks. After laboratory and imaging studies patient was diagnosed to have splenic abscess for which she underwent partial splenectomy.
Post operatively after 4 days when patient is allowed to take orally, food particles are noted in drain. 10 mL methylene blue was given through NG tube, dye was seen draining through drains. Gastroenterology reference was given for upper gastrointestinal endoscopy which revealed small 2 cm full thickness defect in stomach wall on the greater curvature at the junction of body and fundus thus diagnosis of gastric fistula is made.
As repeat surgery carries greater risk and morbidity endoscopic closure of gastric defect was planned. After taking consent ovesco clip was applied with suction technique and patient was stable post procedure. Patient improved subsequently tolerated oral feeds and discharged after 4 days.
Conclusion Endoscopic closure is preferred in acute small perforations which are <2 to 3 cm due to high success rate (90%), minimally invasive procedure and short hospital stay. OTSC (over the scope clips) is a new device for the closure of GI defects so it should be an essential component of endoscopic arsenal.
286
Comparison of endoscopic ultrasound guided fine needle aspiration with endoscopic ultrasound guided fine needle biopsy for solid gastrointestinal lesions: A randomized crossover single centre study
Shivaraj Afzalpurkar , Vijay Rai, Nikhil Sonthalia, Gajanan Rodge, Rachit Agarwal, Bhavik Shah, Mahesh Goenka
Correspondence- Shivaraj Afzalpurkar-drshivaraj62@gmail.com
Department of Gastroenterology, Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata 700 054, India
Introduction Endoscopic ultrasound guided fine needle aspiration (EUS FNA) is limited to diagnosis by cytopathology alone while the core histologic tissue can be procured by EUS guided fine needle biopsy (FNB). Majority of the studies comparing EUS FNA and FNB are done in different lesions and/or patients and in different sessions with hardly any studies comparing both the modalities in a single lesion. The purpose of this study was to compare the results of EUS-FNA and FNB performed at the same site in a single session.
Methods Consecutive patients with solid gastrointestinal lesions referred for EUS evaluation were randomized to undergo EUS-FNA and FNB using 22G needles with three and two passes respectively. In one group EUS FNA was done followed by EUS FNB, in second EUS FNB followed by EUS FNA.
Results We included 50 patients (62% males, 38% females) with the mean age of 56.58 ± 14.2 years and mean size of the lesions being 2.6 (± 2) cm. The Kappa agreement with final diagnosis for FNA and FNB was 0.841 (almost perfect agreement) and 0.61 (substantial agreement) respectively. The sensitivity, specificity, PPV, NPV, diagnostic accuracy and tissue adequacy of FNA vs. FNB was 85.19% vs. 62.96%, 100% vs. 100%, 100% vs. 100%, 85.19% vs. 69%, 92% vs. 80% and 98% vs. 80% respectively in comparison with final diagnosis. The overall adverse events were noted in 14% patients which included self-limited bleeding (6%), hypotension (4%) and mild acute pancreatitis (4%).
Conclusion Both EUS-FNA and FNB are very safe. EUS FNA is better than EUS FNB in terms of sensitivity, diagnostic accuracy and tissue yield. However, the specificity and positive predictive value were equally good for both the modalities. There was no significant difference whether EUS FNA was performed first or FNB.
287
Foreign bodies (FBs) in colon- Surprises that are never planned
Avinash Balekuduru, Narendra Babu Mandalapu , Satyaprakash Bonthala
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India
Introduction Endoscopic removal of ingested foreign bodies is well documented. But removal of FBs in colonoscopy not well documented. We present 3 cases of FBs which were managed by colonoscopy.
Case Report - Case 1 A 52-year-male presented to us with constipation for 3 days. He used to have anal eroticism with traditional sex toys. But he tried an infant feeding bottle on a tinder date, which he pushed it in too far and could not remove the bottle. The bottle was noted at recto-sigmoid junction on fluoroscopic spot image. Colon-fluoroscopic trans-anal retrieval attempts with snare forceps were futile. A CT followed by mini-laparatomy and sigmoid incision were made for FB removal. He was referred to psychiatry for perversion disorder and to prevent recurrences.
Case 2 A 27-year-old female presented with pelvic pain for 18 months duration. Computed tomography (CT) abdomen and pelvis showed an intrauterine device (IUD) perforating the sigmoid colon without pelvic collections. Sigmoidoscopy revealed displaced IUD at 30 cms from anal verge. Using foreign body forceps and gentle manipulation, IUD was removed under fluoroscopic guidance. Fistulous opening was closed using through the scope clips. Postoperative period was uneventful
Case 3 A 14-year-old male, presented to us after 5 days of accidental history of nail ingestion. He had serial abdominal radiographs which revealed a stuck nail in the left lumbar region without any pneumoperitoneum. Colonoscopy was done in fluoroscopic room without bowel preparation. Nail was noted to be embedded in the stool near the hepatic flexure without any pneumoperitoneum. It was removed using foreign body forceps under colon-fluoroscopic guidance. Follow-up spot image on fluoroscopy did not reveal any complication.
Conclusion Colonoscopy with unprepared bowel, grasped FB maintained in the center of the visual field with close monitoring on fluoroscopy can be effective in FB removal in colon.
288
A retrospective single blinded study comparing efficacy of prucalopride when used as an adjunct with polyethylene glycol in bowel preparation in patients of constipation
Gaurav Kumar Singh , Saiprasad Lad, Pratik Sethiya, Mayur Gattani, Shamsher Singh Chauhan, Swapnil Walke, Kailash Kolhe, Mit Shah, Vikas Pandey, Akash Shukla, Meghraj Ingle
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai 400 022, India, and Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai 400 012, India
Background Colonoscopy is currently gold standard for visualizing colonic mucosa. Presence of constipation is generally associated with poor bowel preparation. We compared effect on colonic cleansing when prucalopride was used as adjunct with polyethylene glycol in patients of constipation.
Methods A retrospective, single blinded controlled study was conducted in outpatient of a tertiary care centre. One seventy patients with constipation were enrolled in two groups of who took only polyethylene glycol (PEG) and other of prucalopride (2 mg one day prior to endoscopy) plus polyethylene glycol (PEG+) for bowel preparation. They underwent colonoscopy by a single blinded experienced endoscopist. Bowel preparation quality was reported by Boston bowel preparation scale (BSS) prior to washing or suctioning. The groups were analyzed for bowel preparation quality and side effects in either groups based on preformed questionnaire.
Results Both groups were comparable in view of mean age and male female ratio. Diabetes was comparable in either group (14- PEG, 13 in PEG+) with 70 patient having functional constipation in both groups. Mean BSS IN PEG group (5.33+/- 1.43) was slightly higher than peg+ GROUP (5.16 + 1.37) although not statistically significant (p value=.44). The side effects of preparation used like nausea, vomiting, abdominal discomfort, headache was higher in peg+ group than peg group although not statistically significant. Post procedure questionnaire suggested patient preferring peg more than the peg plus prucalopride combination (21 vs. 8) (p value <.001).
Conclusion We conclude addition of prucalopride has no additional benefit when used in combination with polyethyleneglycol in bowel preparation in patients of constipation. It may rather lead to noncompliance and inferior bowel preparation in view of increased side effect of nausea, vomiting, bloating, abdominal discomfort and headache.
289
The early endoscopist gets the worm and the later one reports the findings of the endoscopy
Avinash Balekuduru, Gajendra R , Satyaprakash Bonthala Subbaraj
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India
Introduction Soil-transmitted helminths (STH) consist of Ascaris, Trichuris, and hookworm which affect nearly 1.7 billion people globally1. The retrospective study is aimed to investigate the characteristics of the worms detected in an endoscopic unit from January 2015 to December 2019.
Methods and Results Among 31,913 procedures, 45 hookworms, 3 each of hydatid and strongyloidiasis, 2 ascaris, 2 enterobius, one each of fasciolopsis, and taenia saginata were noted. Among them 36 (63%) were asymptomatic. Twelve patients of hookworm had presented with iron deficiency anemia with duodenal erosions on endoscopy. Three patients with hydatid cyst in liver presented with obstructive jaundice and required bile duct clearance. All the patients with strongyloidiasis presented with malabsorption and diarrhea. One patient with fasciolopsis presented with protein losing enteropathy and vomiting of worms. Patients with enterobius had perianal itching. Stool examination was positive only in 7 (12%) of patients. All the patients received either cyclical albendazole (15mg/kg), praziquantel (25 mg/kg) or Ivermectin (200 μg/kg). All the patients were advised regular anthelminthic treatment, health education, sanitation, personal and familial hygiene.
Conclusions Endoscopy is a useful diagnostic approach for intestinal parasitic infections even for asymptomatic patients with negative stool examinations.
References
1. Parija SC, Chidambaram M, Mandal J. Epidemiology and clinical features of soil-transmitted helminths. Trop Parasitol. 2017;7:81-5.
290
Therapeutic endoscopic retrograde cholangiopancreatography in patient of carcinoma gallbladder with situs inversus
Raghav Singhal , Mohnish Kataria
Correspondence- Raghav Singhal-raghavsag08@gmail.com
Department of Gastroenterology, Maharishi Markandeshwar Institute Of Medical Science (MMIMS), Mullana University Road, Mullana 133 207, India
Situs inversus is a congenital anomaly associated with various visceral abnormalities. We present a case of 40-year-old female with painful progressive cholestatic jaundice and cholangitis of three months duration associated with significant weight loss. Examination revealed deep jaundice with hard, tender lump in left hypochondrium. USG and MRI abdomen showed situs inversus with large mass arising from gallbladder neck involving primary biliary confluence and dilated intrahepatic biliary radicles. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out successfully despite situs inversus maintaining the patient in prone position. In conclusion, ERCP can be safely performed in usual position with minor modification of endoscopic manoeuvres.
291
Symptomatic heterotopic gastric mucosa in distal esophagus: A case report
Mahesh Kumar Gupta, Mahesh Gupta , Avnish Seth
1Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurugram, India
Background Heterotopic gastric mucosa (HGM) in esophagus is commonly noted as an inlet patch at endoscopy. We describe a rare patient with symptomatic distal esophageal HGM.
Case Report Forty-year-male presented with retrosternal pain, heartburn and marked odynophagia for 4 weeks. There was no history of ingestion of antibiotics, foreign body or corrosive. There was no history of fever or weight loss. Clinical examination was unremarkable. Endoscopy showed abrupt circumferential transition to salmon pink mucosa at 35 cm from incisors. From 35 cm to 41 cm there were areas of polypoid edematous thickening with few superficial ulcers of 1-3 mm. Squamous epithelium was visualized at NBI from 41 cm to the Z-Line at 43 cm with no hiatus hernia. Biopsy from 35 to 41 cm showed gastric mucosa with parietal cells without dysplasia. Blood counts and biochemistry were normal and serology for CMV and HIV were negative. Contrast enhanced CT scan showed circumferential mural thickening of 7 mm involving distal esophagus with associated polypoid thickening of 26 mm x 6 mm along right lateral wall. He was managed with proton pump inhibitors (PPI) and prokinetics and improved over two weeks. Follow-up endoscopy at 3 months demonstrated healing of ulcers. There was no resolution of polypoid lesion. He remains well on maintenance PPI.
Conclusion Symptomatic heterotopic gastric mucosa in distal esophaguscan be differentiated from Barrett’s esophagus by presence of squamous epithelium distally. Inflammatory mass lesions may develop and mimic esophageal malignancy. Symptoms due to acid production may be prominent and respond to PPI.
292
Lockdown due to COVID-19 and its impact on endoscopy and upper gastrointestinal bleeding - A single centre study
Shruti Sagar Bongu , Avinash Balekuduru
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India
Introduction and Aim COVID-19 pandemic was declared on 11/03/2020 and required Indian government to implement intermittent lockdown to contain the disease from 24/03/2020. Aim of the study was to investigate the effects of lockdown on acute upper gastrointestinal bleeding (UGIB) at our centre.
Methods Records of all the UGIB patients who had undergone endoscopy at our institution during the 3 months- April, May and June in years 2019 (n =1175) and 2020 (n = 554) were retrospectively reviewed and compared. All the procedures were performed by enhanced personal protective equipment.
Results Of the 1729 patients (mean age + SD :61.7±12.7 years, 85 % males) during the two study periods, 64 (3.7 %) had UGIB. Hemetemesis was the most common presenting symptom in 60% of patients. The proportion UGIB among the total endoscopies done was significantly higher during the lockdown period compared to the previous year 5.4% to 2.8% (p value = 0.009). The frequencies of UGIB variceal and non-variceal showed the decline in variceal and increase in non-variceal bleeding due to lock down from 38% to 20% and 62% to 80% respectively but this was not statistically significant. The decline was more marked for need for endotherapy- as 70% to 30% in nonvariceal bleeding (pvalue 0.010). There was no mortality among the subjects.
Conclusions National lockdown resulted in a decrease in the total number of endoscopies as well as the number of UGIB. The proportion of endoscopies done for UGIB during the lockdown was significantly. Establishing standard safety protocol for endoscopy during the pandemic will ensure safety of patients and health care workers.
293
Colonoscopic instillation of cola for clearance of fecaloma in megarectum and sigmoid megacolon
Avnish Seth , Gur Simran Kaur, Mahesh Kumar Gupta, Rinkesh Bansal, Neha Choudhry
Correspondence- Avnish Seth-avnish.seth@fortishealthcare.com
Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurugram 122 002, India
Background Fecaloma is organized hardened stool, usually impacted in rectum and sigmoid colon. Cola, with a pH of 2.5 due to carbonic acid and bubbles of carbon dioxide has been effective in dissolving gastric phytobezoars. We describe colonoscopic instillation of Cola for clearance of fecaloma in a patient with megarectum and sigmoid megacolon.
Case report Seventy-two-year-old lady, bed-ridden with co-morbidities, presented with constipation and progressive abdominal distension for six months. There was history of infrequent passage of small amount of liquid stool without blood or mucus. Physical examination revealed ill-defined, firm, non-tender pitting mass occupying the hypogastrium, left iliac, left lumbar, umbilical and epigastric regions of abdomen. Rectal examination revealed normal anal tone and impacted stool, some of which was removed manually. X-ray abdomen revealed fecal loaded and grossly dilated rectum and sigmoid colon. CT scan showed grossly distended sigmoid colon (12.7 cm) and rectum, loaded with stool. Repeated sodium phosphate enemas and oral polyethylene glycol were unsuccessful in clearing the stool. Colonoscopy revealed grossly dilated rectum and sigmoid colon with large amount of solid fecal matter few superficial sterocoral ulcers. The option of surgery was refused by the family. Following informed consent, 1000 mL of Cola was instilled into the sigmoid colon during colonoscopy. Over the next three hours she passed explosive stool with expulsion of more than 3 litres of fecal matter. The abdominal distension decreased and repeat plain CT scan showed remarkable decrease in the fecal loading. She refused further evaluation and was discharged. A few weeks later, she was subjected to ileostomy with a possibility of idiopathic megarectum with sigmoid megacolon and remains lost to follow-up.
Conclusion Colonoscopic instillation of Cola may be used for clearance of large fecaloma refractory to oral and rectal medication.
294
Life threatening gastrointestinal bleeding due to thrombocytopenia and megakaryocytic blast crisis as presenting symptom of myeloproliferative disorder - A case report
Sushant Sethi , Akash Dobhada, Kailash Mohitey, Rajat Khandelwal
Apollo Hospitals, India
Introduction Myeloproliferative disorders commonly present as unexplained anemia or cytopenias. Overt gastrointestinal (GI) bleeding as an index presentation for underlying hematological malignancy is unusual. Recently we encountered a case of GI bleeding which turned out to have underlying chronic myeloproliferative disorder.
Case summary A 57-year-old male, presented with chief complaints of generalised weakness, decreased appetite and loss of weight for last 6 months along with evening rise of temperature for 1 month. Clinical examination revealed pallor, generalized lymphadenopathy and an enlarged firm spleen. Investigation showed low hemoglobin, high reticulocyte count, raised TLC and low platelet count with peripheral smear showing promyelocytes and metamyelocytes. Stool occult blood was positive. Imaging showed hepatosplenomegaly with multiple enlarged intraabdominal lymph nodes. UGI endoscopy showed a bleeding gastric polyp which was removed by snare polypectomy. Colonoscopy revealed internal haemorrhoids to which sclerosant polidocanol was injected. Patient was doing well when he developed painless hematochezia 6 to 7 times a day. Sigmoidoscopy showed rectal oozing, APC was done, hemostasis achieved. After lymph node and bone marrow biopsy, cytogenetic tests, hematopathologist diagnosed chronic myeloproliferative disorder with megakaryocytic blast crisis. During admission patient developed malena and UGI endoscopy showed diffuse mucosal oozing to which hemoseal application was done to achieve hemostasis. Despite management with multiple transfusions, IV immunoglobulins and IV steroids, patient developed bilateral frontotemporal subdural haemorrhage and succumbed.
Conclusion The reported incidence of hemorrhagic complications in hematological malignancies ranged from 3% to 53%, and resulting deaths ranged from 14% to 24%. In another similiar study it was found that 16 % of patient deaths occur due to major bleeding from gastrointestinal or intracranial haemorrhage. In autopsy finding of MDS patients, it was found that 25 % had evidence of major gastrointestinal bleeding and so must be foreseen when clinical signs are suggestive.
295
Utility of GeneXpert-Mtb/Rif for the diagnosis of intestinal tuberculosis in patients with ileocolonic ulcers.
Cyril Alex , Benoy Sebastian, Sunil K.Mathai, Anil Jose, Mary George, Sajith Sebastian, Santhosh R, Sujith James, Swaran Kumar
Correspondence- Benoy Sebastian-benoygastro@gmail.com
Department of Gastroenterology, Medical Trust Hospital, Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
Introduction Diagnosis of intestinal tuberculosis is challenging with conventional methods due to the paucibacillary nature of the disease and the close similarity it shares with IBD-Crohn’s. Newer PCR based rapid tests like GeneXpert could aid in differentiating and diagnosing intestinal tuberculosis.
Methodology We performed a retrospective hospital record-based study of 39 patients with ileal/colonic ulcers suspected to have ITB on which testing of intestinal tissue for Xpert MTB/Rif was performed. The patients were divided into two groups, a group with a positive diagnosis of intestinal tuberculosis and another group with other alternative diagnosis.
Result Out of the 39 patients studied, 29 (74.35%) patients were male and 10 (25.64%) were female with a mean age of 45.51 yrs. A total no of 12 patients had a positive geneXpert test, of which 7 patients were diagnosed to have intestinal tuberculosis based on clinical suspicion and histological features and were started on ATT.2patients with negative genexpert were also started on AKT. The sensitivity and specificity was 71.4286% (95% confidence interval 30.2561% to 94.8876) and 78.125% (59.5582% to 90.055%) respectively, while the negative predictive value and positive predictive value of GeneXpert-Mtb/Rif for diagnosis of ITB was 92.5926% (74.247% to 98.7065%) and 41.66% (16.4993% to 71.40%) respectively.
Conclusion Gene Xpert/MTB may be used as a diagnostic tool to help differentiate between intestinal tuberculosis and other causes of ileocolonic ulcers.
296
Endoscopy in lockdown
Noopur Mehta , Vaibhav Somani, Niranjan Banka
Correspondence- Noopur Mehta-noopurrmehta@gmail.com
Department of Gastroenterology, Bombay Hospital and Medical Research Centre, MumbI 400 020, India
Introduction There is significant decrease in gastrointestinal (GI) endoscopies during the COVID-19 pandemic due to travel restrictions and concerns of infection amongst doctor, staff and patients. Even emergency endoscopies have been deferred due to fear of SARS-CoV-2 infection.
Aim Aim of this study is to analyse the indications and safety of GI endoscopy during lockdown period.
Methods We did retrospective analysis of the prospectively maintained data of endoscopic procedures performed from 24/03/2020 to 29/08/2020. The data was analyzed for indication of procedure in terms of urgency (emergent, urgent and routine) and de-novo development of SARS-CoV-2 infection in endoscopy department staff, doctors and patients. Pre-procedural COVID testing was not mandatory in our department. Thorough history of exposure was taken and triage was done before the procedure. All the procedures were done wearing level three personal protective equipment. Standard scope cleaning process was followed after each procedure and a gap of 15 minutes was maintained in between procedures. Post procedure, patients were followed up telephonically on every third day and inquired about development of symptoms of SARS-CoV2 infection. Patients who tested negative before the procedures were excluded from the study.
Results A total 274 of various GI endoscopic procedures were performed over a period of 159 days. Indication wise 48% were emergency procedures, 31% were urgent and 21% were routine. Seven emergency bedside procedures were performed in COVID positive patients. Throughout the study period none of the endoscopy staff, consultants and residents were tested COVID-19 positive, or exhibited any signs or symptoms of the disease. None of the patients developed symptoms of SARS-CoV-2 infection till 14 days post procedure.
Conclusion GI endoscopy in lockdown, is not a daunting task. It can be safely performed without pre-procedural COVID testing and should not be delayed because of non-availability of the test.
297
Profile of pediatric patients undergoing upper gastrointestinal endoscopy: A single centre experience
Gautam Nath , Shivaram Prasad Singh, Dinesh Meher, Prajna Anirvan, Pankaj Bharali, Mrinal Gogoi
Correspondence- Gautam Nath-gautamnath7@gmail.com
Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Background and Aim Upper gastrointestinal endoscopy (UGIE) is an important procedure for diagnosis and management of GI problems. There is scanty data on endoscopic findings in children from India. The Department of Gastroenterology at SCB Medical College performs the largest number of endoscopies in children from coastal eastern India. The present study was conducted to analyze the findings of UGIE in children and assess its utility.
Methods This retrospective study was conducted in the Department of Gastroenterology. Endoscopy records of patients below 14 years were obtained from departmental records for the duration May 2016 to February 2020. Data were analyzed to ascertain the common indications for UGIE and document the common GI diseases diagnosed by UGIE in this region.
Results Seven hundred and eighty-seven endoscopies were performed in children during 2016-2020, out of which 62.13% were males and 37.87% females. Upper GI bleeding (UGIB) was the commonest indication for endoscopy (34%) followed by vomiting (14.36%), pain abdomen (13.3%), dyspepsia (11.8%), anemia 74 (9.4%) and foreign body ingestion (5.7%). Other indications like chronic diarrhea (for duodenal biopsy), corrosive ingestion etc. constituted the rest (11.3%). Out of the total 268 cases of upper GI bleeding, 168 (62.7%) were males and 100 (37.3%) were females. Variceal bleeding was the most common cause of UGIB (60.8%) followed by ulcer bleeding (13.05%), gastric erosions bleeding (11.9%), malignancy (1.1%) and Mallory-Weiss tear (0.74%). In 12.3% cases no upper GI source of bleeding could be identified.
Conclusions UGIE is very useful in evaluation of GI problem in children. UGIB is the commonest indication for UGIE. Variceal bleeding accounts for about two thirds of UGIB in children, while one eighth of children bled from ulcer. Other common indications for UGIE are vomiting, pain abdomen, dyspepsia and anemia.
298
Colonoscopy for acute lower gastrointestinal bleed in the pediatric population: Single tertiary care center experience
Mohammad Irtaza , Sridhar Sundaram, Praveen Kumar Rao, Biswaranjan Patra, Akash Shukla
Correspondence- Sridhar Sundaram-drsridharsundaram@gmail.com
Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Parel, Mumbai 400 012, India
Introduction There is paucity of data on acute lower gastrointestinal bleed (LGIB) in the pediatric population with no previous data from India. We aimed to retrospectively audit endoscopy findings in patients less than 18 years of age, presenting with acute lower GI bleed.
Method Retrospective review of endoscopy database at Department of Gastroenterology at a tertiary care centre from Western India between June 2017 until June 2020 was done. Patients with age =18 years with acute LGIB, who underwent colonoscopy within 7 days of onset of bleed were included. Demographic details, endoscopic findings and complications were noted.
Results Fifty-three patients were included in study (male-67%, Mean age=12 years, range:-1-18 years). Most common endoscopic findings were polyps in 21 (39.6%), colitis in 12 (22.6%), SRUS in 6 (11.3%) and hemorrhoids in 3 (5.6%) patients. Eight (15.1%) patients had normal colonoscopy in whom cause remain unidentified on further evaluation. However, no repeat episode was documented on a follow-up of 30 days. Most common location of polyp was rectum (68%). Two patients had multiple polyps. All patients underwent successful polypectomy. Pathology reported juvenile polyps in 19 patients. Out of 12 colitis patients, 3 were diagnosed as inflammatory bowel disease, while 9 had acute infective colitis which resolved completely with conservative management. Patients with infectious colitis had higher incidence of fever (55% vs. 0%), lesser incidence of previous similar events (22% vs. 66%). There was no difference between bleed severity, anorexia, and weight loss amongst those with or without infectious colitis. Those with polyps were younger than those without (8.4 vs. 14.3 years, p=0.000). Males were more likely to have polyps (p=0.014). No complications occurred in this cohort of patients.
Conclusions Polyps are the most common cause of acute lower GI bleeding in patients =18 years of age followed by colitis. Polyps were more common in younger male children.
299
Clinical profile of patients with gastric variceal bleed and outcomes of cyanoacrylate glue injection- Single center experience
Veera Abhinav Chinta , Ganesh P, Shanmuganathan S, Koushik A K, Anand T K
Correspondence- Veera Abhinav Chinta-veeraabhinav.chinta@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research, Chennai 600 116, India
Background Gastric variceal bleed is a complication of liver cirrhosis that causes significant morbidity and mortality. there is substantial variability in prevalence due to the differences in patient characteristics. With advancement of endoscopic techniques, cyanoacrylate injection has become the most accepted intervention.
Aim To identify the clinical profile of gastric variceal bleeding and also determined the outcomes of cyanoacrylate glue injection in relation to primary hemostasis and rebleeding.
Methods This is a prospective observational study of 42 patients who were diagnosed with bleeding gastric varices from October 2018 to January 2020 at SRMC. Patients who underwent glue injection were included and were followed up for 3months for complications.
Results Patients has mean age of 55 years with male predominance of 76.2%. The main etiology is alcohol related cirrhosis in 15 patients (35.7%), melena is main presenting symptom 35.7%. Sarin classification of gastric varcies GOV1 seen in 14 patients (33.3%), GOV2 seen in 18 patients (42.9%), IGV1 seen 7 patients (16.7%) and size of varix ranges from 5 mm-10 mm in 71.4% and >10 mm in 28.5% of patients. 64.3% of patients requiring ICU admissions and 61.9% were requiring blood transfusion. All 42 patients underwent Glue injection and 100% achieved primary hemostasis. 45.2% patients required both glue and EVL banding. The volume of glue required varied among patients 0.5ml in 30.9%, 1 mL in 40.4%, 1.5 mL in 21.4% and 2 mL in 7.14%. The incidence of rebleeding is seen in 5 patients (11.9%), of which 4 patients (9.5%) required Re-Glue injection and 2 patients (4.8%) required BRTO. complications like gastric ulceration, sepsis and embolism were not seen.
Conclusion Bleeding gastric varices were mainly seen among in 5th and 6th decade. Melena is the most common presentation. Cyanoacrylate injection is an effective modality in achieving primary hemostasis however there is still remains a significant of rebleeding.
300
Fully covered stent using novel Shim technique to prevent migration in benign non stricturing esophageal diseases
Deepakkumar Gupta 1 , Amey Sonawane 2 , Aabha Nagral 2 , Shanker Bhanushali 2 , Rahul Deotale 2
Correspondence- Deepakkumar Gupta-dkgt@rediffmail.com
Department of Gastroenterology, Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Introduction In benign non stricturing esophageal disease for example leak, fistula or perforation the use of fully covered stent is a modality of treatment. However, its use is limited due to its high rate of migration and embedment. We use a novel technique of using a proximal release stent and using a silk thread anchored to the proximal end of the stent tied to it before release and then moved through the nose and attached to ear lobe with tape (Shim technique).
Aim To determine the risk of migration and efficacy in using Shim technique in benign non stricturing esophageal disease.
Methods Patient undergoing fully covered stenting for benign non structuring disease over last 24 months were included in this study. Success of deployment and duration of procedure was collected from records. Migration was identified by serial X-ray and also dislodgement of the silk thread tied to the ear lobe. Stent embedment, difficulty in removal of stent and successful closure of leak/fistula was retrieved from records.
Results Fully covered esophageal stent with Shim technique was used in total five cases. 2 Boerhaves syndrome, 1 Post Esophagectomy cervical leak, 1 aortoesophageal fistula, and 1 post balloon dilatation perforation were managed. Stent were placed by experienced endoscopist under guidance of fluoroscopy. Stent deployment were successful in all 5 cases and anchored by Shim technique. Migration happened only in one case of Boerhaves syndrome within 72hours and patient succumbed post-surgery to mediastinitis. In aortoesophageal fistula the patient succumbed to mediastinitis 4 weeks post stent placement. The stent was removed at 4-6 weeks in other cases with complete healing of leak or perforation seen.
Conclusion Fully Covered SEMS using Shim technique in benign esophageal nonstricturing disease has good efficacy with minimal migration rate.
301
Effectiveness of low volume split-dose versus same day morning polyethylene glycol regimen for adequacy of bowel preparation in patients undergoing colonoscopy: A single blinded randomized controlled trial
Venkata Anudeep K , Pazhanivel Mohan, K Senthamizh Selvan, Deepak Chellan, Abdoul Hamide
Correspondence- Pazhanivel Mohan-dr.pazhani@gmail.com
Department of Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Gorimedu, Puducherry 605 006, India
Background Adequacy of bowel preparation is the key for successful colonoscopy which depends on the bowel cleansing regimen. The timing of administration of polyethylene glycol (PEG) for colonoscopy has evolved from previous day evening to the currently recommended split dose regimen. Consumption of entire or portion of PEG on the previous day can interfere with work and sleep. Hence, this single blinded randomized trial was conducted to evaluate the efficacy, tolerability, and acceptability of same-day PEG compared to low volume split-dose PEG for late morning colonoscopy.
Methods A total of 384 patients were randomized to 192 each in same-day [SD] and split-dose [SPL] groups. Both the groups received 10 mg bisacodyl. SD group took two litres of PEG between 5AM and 7AM on the day of colonoscopy. SPL group took one litre of PEG between 6PM and 7PM on the preceding day and another litre between 6AM and 7AM on the day of colonoscopy. The adequacy of bowel preparation was assessed using Boston Bowel Preparation Scale (BBPS). Tolerability was scored by recording symptoms of nausea, vomiting, bloating, and abdominal pain. Acceptability was based on overall satisfaction, willingness to repeat the preparation and interference with sleep.
Results The median (IQR) BBPS in SD group was 8(3) while in the SPL group was 6 (3) and this difference was statistically significant (p<0.001). Similarly, a significantly higher proportion in SD group (86%) achieved adequate bowel preparation (BBPS ≥6) compared to SPL group (73.4%) (p=0.002). There was no significant difference in tolerability, overall satisfaction (p=0.33) or willingness to repeat same regimen (p=0.37) between the groups. Patients in SPL group had more sleep interference before colonoscopy (54% vs. 14.5%, p<0.001).
Conclusion The same day PEG was more effective than split dose in achieving an adequate bowel preparation with added advantage of lesser interference with sleep before colonoscopy.
302
Gastrointestinal endoscopy in infants: A single center experience
Harpreet Kaur Chhabra , Areesha Alam, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, Era Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background Gastrointestinal (GI) endoscopic procedure in infants is an evolving diagnostic and therapeutic tool in management of GI disorder of infancy.
Aim The present study aimed to evaluate the diagnostic role of endoscopy done in infants suffering with diverse GIT symptoms.
Methods This is a retrospective descriptive hospital-based study, conducted from January 2017 to October 2019 in Pediatric Gastroenterology Unit of a tertiary care hospital. All infants (> 1 month old and ≤1 year of age) who underwent GIT endoscopic procedure during the study period were included. Following data were collected from hospital database and patients record sheets: basic demographic data, preliminary diagnosis, indication for endoscopy, procedure done, endoscopic finding, complications, and final diagnosis.
Results A total of 126 infants (104 males, 22 females) of which 34.9% were below 6 months were enrolled in the study. Mean age was 6.69±3.3 months. Mean duration of symptoms was 21.6±16.3 days. Recurrent vomiting (30.9%) was found to be the most common indication for endoscopic evaluation followed by melena (17.5%), hematemesis (15.9%) and chronic diarrhea (13.5%). Upper GI endoscopy was performed in 108 infants and lower GI endoscopy in 35 infants. Mucosal inflammation (eosophagitis; 31.7%, gastritis; 22.2%, duodenitis; 13.5%, proctosigmoiditis; 23% and colitis; 7.9%) was the most common finding in infants who presented with different GI symptoms. Varices were noted in 12.7% and polyps in 4.8% of cases. Other findings were ulcer, foreign body, esophageal stricture and gastric outlet obstruction. Nine out of 39 infants (23%) who presented with recurrent vomiting had a negative endoscopy. No complications occurred either due to procedure or sedation.
Conclusions Pediatric gastrointestinal endoscopy is a high-end, informative, diagnostic and therapeutic procedure in infants done in very few centre across India. Endoscopy helped in comprehensive evaluation and in depth management of various GI disorders in infants.
303
Endoscopic removal of giant rectal polyp in a child- A case report
Gunjan Makkar , Shrish Bhatnagar, Geetika Srivastava
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, Era Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Solitary pedunculated Juvenile rectal polyps (JP) are a recognized cause of painless rectal bleeding in preschool age children however Giant juvenile polyps (greater than 30 mm) are exceedingly rare in children.
A 10-year-old boy with prior history of something coming out of rectum for one year presented with sudden onset of massive painless hematochezia. On evaluation a giant rectal polyp measuring 3 x 3 x 2 cm was found and removed endoscopically. Histological evaluation revealed juvenile adenomatous polyp. To best of our knowledge only few case reports are available where a giant rectal polyp has been removed endoscopically in pediatric age group.
Keywords Polyp, Giant, Endoscopy
304
Endoscopic radial incisional stricturotomy using flushknife followed by balloon dilatation of a benign esophageal anastomotic stricture: A case report
John Christopher Onilla , James Crisfil Fructuoso Montesa
Correspondence- John Christopher Onilla-onillajc@gmail.com
Department of Internal Medicine - Section of Gastroenterology and Digestive Endoscopy, Manila Doctors Hospital, Philippines
Introduction Esophageal strictures develop from various etiologies; peptic strictures from gastroesophageal reflux disease (GERD), caustic ingestion, anastomotic stricture from previous surgery. Benign esophageal strictures are usually managed with dilation using Savary-Gilliard or balloon dilatation. There are a small group of patients with refractory or recurrent stenosis for which alternative treatment modalities may be required. There are only a few reports of the use of needle knife for incisional therapy to manage esophageal anastomotic stricture.
Methods Presentation: This is a case report of a 45-year-old male, known to have recurrent esophageal anastomotic stricture after colon interposition, managed with repeated mechanical dilation who had progressive dysphagia 4 weeks from the previous dilatation.
Results The patient underwent radial incision stricturotomy using Flushknife (Fujifilm) followed by CRE balloon dilatation with no complications. He was discharged stable with no recurrence of symptoms on follow-up after 2 months.
Conclusion Endoscopic incisional stricturotomy using Flushknife followed by CRE balloon dilatation is a safe and effective modality for the treatment of anastomotic stricture provided it is done in a tertiary hospital by an experienced therapeutic endoscopist.
Keywords Case report, Incisional stricturotomy, Esophageal anastomotic stricture
305
Study of gastric mucosal changes and Helicobacter pylori prevalence in patients with metabolic syndrome
Swapnil Patil , Bhumika Vaishnav
Correspondence- Bhumika Vaishnav-bhumika.dholakia@gmail.com
Department of General Medicine, Dr. D Y Patil Medical College, Hospital and Research Centre, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad 411 018, India
Introduction Helicobacter pylori (HP) has been implicated as a causative agent in many non-gastrointestinal diseases like insulin resistance, cardiovascular disorders and diabetes mellitus. Metabolic syndrome (MetS) refers to cluster of diabetes and cardiovascular factors including raised blood pressure, low HDL levels, elevated serum triglycerides (TG) levels, obesity and hyperglycemia. Lifestyle and dietary changes have been attributed to high prevalence of MetS. However, they don’t justify all the MetS cases and hence study of alternative emerging risk factors is necessary. The current study was undertaken to ascertain if any relationship exists between the GI mucosal changes, HP infection and various components of metabolic syndrome.
Methodology Cross-sectional, prospective study done between June 2018 to January 2020 in Maharashtra, India. Total 100 patients who came for UGIE were studied out of which 58 patients had MetS. Gross mucosal changes in the stomach were noted and biopsies were taken from the body and the antrum of the stomach and sent for histopathlogy examination for detection of HP. P value of <0.05 was taken as statistically significant.
Results Out of total 58 patients with MetS 18 were males (31.03%) and 40 were females (68.97%). Average age was 49.81 ± 11.10 years. HP infection was found in 31 out of 58 patients with MetS which was statistically significant. Chronic superficial antral gastritis was the common finding in 39 patients (67.25%). Presence of HP infection positively correlated with higher abdominal obesity (WC), fasting blood glucose levels and Serum TG levels (p<0.05).
Conclusion HP colonization of gastric mucosa may predispose patients to develop MetS. High blood sugar levels, abdominal obesity and high triglyceride levels in MetS were associated with HP infection. Thus, eradication of HP infection may reduce prevalence of metabolic syndrome and in turn the prevalence of cardiovascular disorders in the patients.
Keywords Helicobacter pylori, Metabolic syndrome, Upper gastrointestinal endoscopy
306
Comparison of risk scores for predicting mortality in patients presenting with acute upper gastrointestinal bleed
Damodar Krishnan , Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Medical Gastroenterology, Sri Ramachandra Institute of Health and Research Center, Chennai 600 116, India
Introduction Gastrointestinal (GI) bleeding results in 5% of admissions to an emergency department (ER), with mortality rates ranging from 2% to 15%. Early identification of patients at high risk of death could allow targeted management with early interventions that may improve outcomes. Various risk scores have been developed for risk stratification Glasgow- Blatchford score (GBS), Pre-Endoscopy and Rockall score, AIM-65, and the recently proposed ABC (age, blood parameters, co-morbidities) score. We aim to compare these various risk scores for predicting mortality.
Methods Retrospective data of patients admitted to ER with acute upper GI bleed during the last 2 years (2018-2020) have been collected from medical records including clinical assessment and lab parameters, whether the patient required endoscopic therapy; surgical procedures; radiological intervention; blood transfusion; and mortality.
Results Total of 112 patients were included in the study. Mean age of study population was 53.71 and male predominant with 83.92% (n=94). 76.79% presented with hematemesis and 23.21% with melena. Major co-morbidities included ischemic heart disease (10.71%), cirrhosis (25%) and malignancy (2.68%). 45.3% belonged to ASA category 3 and 25.6% in ASA 2and 28.6% in ASA 1 category. Endoscopic findings included normal in 1%, erosive changes in 20.5%, gastric/duodenal ulcers in 25.6%, variceal bleed in 40.18% and tumor bleed in 0.04%. Endoscopic treatment was done in 46.42% and surgery was undertaken in 0.08%. Mortality was 9.82% (n=11). Based on AUROC, AIM-65 scored over other scores in predicting mortality (AUROC [95% CI] 0.91 [0.85 to 0.97]; p<0.001), GBS 0.82 (0.71-0.93) p 0.001, Pre-Rockall 0.76 (0.63-0.89) p 0.005, Rockall 0.89 (0.82-0.97) p<0.001, ABC 0.79 (0.65-0.90) p 0.003.
Conclusion BP, heartrate, BUN, INR, and albumin showed a significant association with mortality. Risk scores with albumin have better mortality prediction. AIM-65 scored over other risk scores in predicting mortality even better than post endoscopy Rockall score, hence can be used to stratify patients early in the emergency room to prevent mortality.
Keywords Upper GI bleed, GBS, Rockall, AIMS-65, ABC score
307
Effect of sucralfate plus proton pump inhibitors combination versus PPI alone on post EVL band ulcers; A single-centre prospective randomized study
Hameed Raina , Anukalp Prakash
Correspondence- Hameed Raina-hameedraina49@gmail.com
Department of Gastroenterology and Hepatology, Paras Hospital, Phase- I, Paras Hospitals, C-1, Sushant Lok Road, Sector 43, Gurugram 122 002, India
Background/Aim Endoscopic band ligation (EBL) is a universal treatment of large esophageal varices with red colour signs or active bleeding. However, it is complicated with post band ulcers. Proton pump inhibitors plus sucralfate combination is commonly used in post band ligation to prevent it or their bleeding. However, not much literature is available to support it. This study aimed to find the same.
Methods It was a comparative single-blind randomized study. Eligible patients were randomized into a proton pump inhibitor plus sucralfate group (Group A) and a proton pump inhibitor alone group (Group B) after EBL. Check endoscopy was done after two weeks.
Results Two hundred and ten patients, 105 in each group, were evaluated. The baseline demographic and lab parameters were comparable in both the arms. On an average, there were 2.19±0.07 number of ulcers in Group A and 3.76±0.63 number of ulcers in Group B (p< 0.005). The mean size of the largest ulcer was 1.02 ± 0.42 cm in Group A and 2.10 ± 0.67 cm in group B (p<0.05). Post EVL bleeding was present in ten (9.5%) of patients in Group A and twelve (11.4%) in Group B patients with p=0.63. (low albumin [<2.8 mg/dL] was significantly associated with the formation of multiple ulcers on b-variate analysis with OR of 7.7 (95% C: 1.58-42.99).
Conclusions The sucralfate plus PPI is more effective than PPI alone in reducing the occurrence, number, and size of band ulcers. Low albumin as an independent host predictor for multiple ulcer formations
Keywords Esophageal varices, Endoscopic band ligation; Band ulcers; Sucralfate, Proton pump
308
Metabolic outcomes of endoscopic sleeve gastroplasty in patients with obesity
Shivaji Thakare , Prabha Sawant, Gaurav Patil, Ankit Dalal, Amit Maydeo
Correspondence- Shivaji Thakare-dr.shivaji21@gmail.com
Baldota Institute of Digestive Sciences, Gleneagles Global Hospitals, Mumbai, India
Background Endoscopic sleeve gastroplasty (ESG) is a restrictive endoscopic bariatric procedure. In our study, metabolic outcomes of ESG were studied.
Methods In this prospective observational study, we studied the effectiveness of ESG in patients undergoing ESG at our center from June 2018 to May 2020. Patients with BMI ≥28 kg/m2 were included. Anthropometric and laboratory parameters were noted at baseline and postoperatively at 6, 12 and 18 months. The primary outcomes included percent of total weight loss (%TWL) and percent of extra weight loss (% EWL) at 6, 12 and 18 months. Secondary outcomes included changes in metabolic and laboratory parameters after ESG.
Results A total of 74 patients, 65 (87.8 %) females with mean (±SD) age of 43.1±9.8 years were included. The baseline BMI (kg/m2) was 36.76 ± 6.1. The mean % TWL was 17.9 ±5.2 and 20.4 ±5.9, 21.45±6.1 at 6, 12 and 18 months, respectively. The % EWL was 44.2±13.5, 49± 14.2 and 51.4±15.1 at 6, 12 and 18 months, respectively. At the end of 12 months, there was a statistically significant reduction seen in levels of metabolic parameters like systolic blood pressure (p<0.001), waist circumference (p<0.001), glycylated hemoglobin (p<0.001), SGOT/SGPT (p<0.001), and serum triglycerides (p<0.001). Total cholesterol and LDL levels also reduced from baseline but were not significant. Among adverse events, nausea was seen in 38 (51.3%) patients, moderate to severe abdominal pain in 20 (27%) patients, perigastric serous collection (size 2 cms) in 3 (4%) patients and intraoperative bleed in 5 (6.7%) patients were seen.
Conclusions ESG appears safe and effective minimally invasive technique in treating obesity at our center. ESG showed favorable changes in metabolic outcomes with sustainable weight loss up to 18 months.
Keywords Obesity, Endoscopic sleeve gastroplasty, Metabolic outcomesv
309
Efficacy of EUS-guided tissue acquisition in the absence of an on-site pathologist
Balaji Musunuri , Shiran Shetty, Ganesh Bhat, Ganesh Pai C
Correspondence- Balaji Musunuri-balajimbmc@gmail.com
Department of Gastroenterology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576 104, India
Introduction EUS-guided tissue acquisition has been widely used to obtain tissue for the diagnosis of gastrointestinal (GI) lesions with good accuracy and safety, but the diagnostic yield remains highly variable. Hence, we intend to study these outcomes in the absence of on-site cytopathologist.
Methods A retrospective analysis of patients who underwent EUS-FNA for upper GI lesions from September 2018 to March 2020. EUS-FNA had been performed by 2 experienced endosonographers, using the fanning technique with 22-G franseen design needle from Boston Scientific without on-site cytopathologist. Specimens were analyzed through cell blocks and thread biopsies by an experienced pathologist and were categorized into adequate and diagnostic or non-diagnostic.
Results A total of 176 patients were taken into study; male 108 (61.4%) with mean age of 53.6 ± 15.5 years. The lesions were grouped into those arising from pancreas in 110 (62.5%), lymph nodal lesions in 28 (15.9%), bile duct lesions in 16 (9.1%), and the rest in 22 (12.5%) of patients. The mean size of the lesions was 2.8±1.5 cms. The average number of passes was 2.35 ± 0.9. There were no complications observed during or post procedure. The overall adequacy rate of the tissue specimen was 92% for both smears and/or biopsy specimen. The adequacy rate was highest for pancreatic lesions at 95.5%, followed by bile duct lesions (93.7%), lymph nodal lesions (89.3%) and lowest among submucosal epithelial lesions at 77.7%. Among the adequate samples, malignancy was confirmed in 60.49% and benign pathology was seen in 39.5%.
Conclusion EUS guided tissue acquisition by experienced endosonographer yields high adequacy rates and is safe and cost effective in the absence of on-site pathologist at resource limited settings.
Keywords EUS-FNA, EUS-guided tissue acquisition, Tissue adequacy
310
Endoscopic N-butyl cyanoacrylate (NBC) glue injection in management of gastric variceal bleeding: A tertiary care center experience in eastern part of India
Rakesh Kumar Barik , Haribhakti Seba Das, Chittaranjan Panda, Saroj Kanta Sahu, Subhasis Pradhan, Reshu Khandelwal, Dinesh Meher, Gautam Nath, Prajna Anirvan, Pankaj Bharali, Mrinal Gogoi
Correspondence- Rakesh Barik-rakeshkumarbarik.88@gmail.com
Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Aim Endoscopic glue injection is recommended as first-line treatment for bleeding gastric varices (GV). However, there is limited data with this method in eastern India. Our aim was to analyze efficacy and safety of endoscopic glue injection for treatment of gastric variceal bleeding.
Methods We prospectively studied 463 portal hypertension patients from December 2017 to December 2019 at Gastroenterology Department, SCB Medical College, Cuttack. Bleeding GV underwent injection of one to three mL of glue in one sitting and repeat injections were administered after two to three weeks whenever required. Patients were evaluated in terms of primary hemostasis, recurrent bleeding, complications and in-hospital mortality.
Results Thirty-five bleeding GV patients underwent glue injection. Male: female, 19:16 (54%:46%). Causes of varices–cirrhosis 18 (51%), EHPVO 15 (43%), noncirrhotic portal hypertension 1 (3%), Budd-Chiari syndrome 1 (3%). Out of 35 patients, 22 had GOV2, 12 had IGV1 and one had IGV2. Twenty-three patients had large varices and 12 had medium sized varices. Initial hemostasis was achieved in 33 (94%) patients. During follow-up, bleeding recurred in 6 (17%) patients. Median time to rebleed was 60 days (15-180 days). Five patients underwent repeat glue therapy for rebleeding and all five patients had achieved homeostasis after injection glue. One patient was referred for shunt surgery. The average volume of glue injected per session was 2 (0.2) mL per patient. The average amount of glue needed per patient was 2.5±1 mL. For 10 patients, repeated sessions of glue injections were given to achieve gastric variceal obliteration. Three patients had mild abdominal pain and one patient had mild fever. There was no distant embolization and channel block or damage to lens of the endoscopes noted during these procedures.
Conclusion Endoscopic glue injection is safe and effective in achieving hemostasis of bleeding GV and their eradication.
Keywords n-butyl cyanoacrylate, Gastric varices, Variceal bleed
311
Endoscopic retrograde cholangiopancreatography in pediatric patients performed by experienced endoscopists from a tertiary care center in western India
Akash Shukla, Aditya Kale , Mohit Aggarwal, Sridhar Sundaram, Manish Dodmani, Abhijeet Karad, Nitinkumar Ramani, Aniruddha Phadke
Correspondence- Akash Shukla-drakashshukla@yahoo.com
Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Parel, Mumbai 400 012, India
Introduction There is sparse data from India about indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population.
Methods Retrospective analysis of the prospectively maintained endoscopic database was performed to identify paediatric patients (age </=18 years) from January 2017 to September 2020 who underwent ERCP at Gastroenterology Department of Seth GSMC and KEM hospital. Demographics and details about the procedure including indication, type of sedation, cholangiopancreatogram findings, type of endotherapy done, technical and functional success as well as complications were noted. All procedures were done using standard duodenoscopy (Olympus TJF-Q180V) by experienced operators (experience of more than 300 ERCP procedures with selective cannulation rate of more than 95%).
Results Seventy-two procedures were done in 56 patients during the study period (Mean age 13 years; range:3-17 years; 60% male). ERCP for biliary and pancreatic diseases was performed in 20 (35.7%) and 36 (64.2%) cases respectively. ERCPs were done for choledocholithiasis 11 (55%), bile duct injuries/leaks 4 (20%), biliary strictures 3 (15%), choledochal cyst 2 (10%), and chronic pancreatitis 22 (61.1%), pancreatic duct injuries/leaks 6(16.6%), pancreas divisum 4 (11.1%), recurrent acute pancreatitis 3 (8.3%), anomalous pancreatobiliary union 1 (2.7%) amongst biliary and pancreatic indications respectively. General anesthesia, total intravenous anesthesia and endoscopist directed sedation was given in 26 (36.2%), 41 (56.9%) and 5 (6.9%) procedures respectively. No sedation related adverse events were noted. Cannulation was successful in 35 (83.3%) pancreatic and 25 (86.2%) biliary procedures respectively. In 10 (13.8%) procedures, pre-cut sphincterotomy was done for cannulation. Technical success in 63 (87.5%) and functional success in 62 (86.1%) procedures. Reasons for failure include failed cannulation 6 (8.3%) and failed guidewire passage across stricture 4 (5.5%). There was no correlation between technical failure and age, sex or type of ERCP. Complications include mild post ERCP pancreatitis and bleeding in 3 (4.1%) and 1 (1.3)% cases respectively.
Conclusion ERCP is safe and effective for evaluation and management of various biliary and pancreatic diseases in children.
Keywords ERCP, Pediatric patients
312
Epidemiology and clinical profile of endoscopic retrograde cholangiopancreatography patients in tertiary care hospital in South India
Chaitanya Katragadda , Revathy M S, Sumathi B, Manimaran M, Chitra S, Satya B
Correspondence- Chaitanya Katragadda-chaitan.katragadda@gmail.com
Department of Medical Gastroenterology, Government Stanley Medical College, Chennai 600 003, India
Introduction and Aim Endoscopic retrograde cholangiopancreatography (ERCP) is universally established modality in evaluation and treatment of suspected biliary and pancreatic diseases. The aim of this study is to evaluate our experience in ERCP and to study the etiology, indications and findings of ERCP and complications of the procedure.
Methods This is a retrospective study carried out in the Department of Medical Gastroenterology at Govt. Stanely Medical College, Chennai. All the patients who underwent ERCP from January 2020 till August 2020 were included in the study. Etiology, indications, findings of ERCP and procedure related complications were assessed in these patients.
Result Records of 73 consecutive patients who underwent ERCP were analyzed, out of which 46 (63%) were males and 27 (37%) were females. Most common indications were choledocholithiasis (61.6%), biliary stricture (13.6%) and periampullary growth (9.5%). Other less common etiologies were portal biliopathy (4.1%), head of pancreas mass (2.7%), cholangiocarcinoma (2.7%), pancreatic duct stricture (1.3%), duodenal growth (1.3%) and traumatic bile duct injury (1.3%). In choledocholithiasis, single stone was found in 22 (48.8%), multiple stones were found in 10 (22.2%) and sludge was seen in 13 (28.8%) patients. Black pigment stones were seen in 78% and yellow cholesterol stones seen in 22%. Periampullary diverticulum was noted in 6 (8.2%). Sphincterotomy was performed in 44 (60.2%) patients. Biliary cannulation failed in 5 patients and stone retrieval failed in 1 patient. Post ERCP pancreatitis was seen in 2 (2.7%) patients.
Conclusion The most common indication for ERCP was choledocholithiasis followed by biliary stricture and periampullary growth. In choledocholithiasis single stone and black pigment stones were common. Sphincterotomy was the most common procedure performed.
Keywords ERCP, Choledocholithiasis, Pigment stones, CBD stricture, Sphincterotomy
313
Early pre-cut fistulotomy reduces the fluoroscopy time and radiation dose in patients with difficult biliary cannulation
Harshal Mandavdhare
Correspondence- Harshal Mandavdhare-hmandavdhare760@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Background Role of pre-cut fistulotomy in reducing fluoroscopy time and radiation dose in difficult selective biliary cannulation is unknown.
Methods This is a prospective randomized controlled trial where patients with difficult biliary cannulation were randomized into 2 groups, viz, Group I -Early pre-cut fistulotomy after difficult biliary cannulation at 5 minutes and Group II- Late pre-cut fistulotomy after failure of conventional methods of selective biliary cannulation for 15 minutes. We compared the success rates of selective biliary cannulation along with fluoroscopy time and radiation dose, the complication rates, need for repeat Endoscopic retrograde cholangiography (ERC) and need for other interventions in early and late pre-cut fistulotomy.
Results Of the 130 eligible patients screened, 40 patients were randomized. The technical success was comparable between early and late group. The ERC time was less and the fluoroscopy time and radiation dose were significantly less in the early group (4 minutes [3, 6] vs. 15 minutes [8, 28], p=0.001) and (1.35 mGy [0.90, 1.63] vs. 2.40 mGy [1.58, 3.25], p=0.010) respectively. In the late group, 60 % required need for rescue pre-cut fistulotomy. One patient from late group developed PEP while 1 from early developed perforation. Three needed other interventions due to failed second attempt.
Conclusion Early pre-cut fistulotomy has comparable technical success and reduces the time and dose of fluoroscopy as compared to late pre-cut fistulotomy for difficult biliary cannulation.
Keywords Pre-cut, Fistulotomy, Fluoroscopy, Radiation dose
314
Efficacy, safety and medium term outcomes of endoscopic full thickness resection and various defect closure techniques for gastrointestinal tumors
Muppa Indrakeela Girish , Amol Bapaye, Parag Dashatwar
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India
Background Endoscopic full-thickness resection (EFTR) is a minimally invasive NOTES technique described to achieve resection of epithelial tumors extending deeper than the mucosa or associated with significant submucosal fibrosis and subepithelial tumors (SET). This study reports our experience with EFTR and various defect closure techniques.
Methods Retrospective observational study included 42 patients. Patients found to have either SET or epithelial tumor on gastrointestinal endoscopy during evaluation of various gastrointestinal symptoms. Pre-procedure EUS, CT scan in all. Resultant defects were closed using various methods-TTSC or OTSC, endoscopic suturing, clip and loop. Follow-up assessments include endoscopy and CT scan.
Results This study comprised 42 patients, 30 male, 12 females. Mean age 56. 3 years (19-83). Layer of origin (EUS)- GIST (18) and leiomyoma (5) arising MP, NET (7) – SM and MP. Mean EFTR procedure time - 162 min (range 20 – 424). Mean resection specimen size - 3.0 cm. R0 resection 28/33, margin positive 5/33, morcellation 6/33. Mean defect closure time -17.9 mins (2-50 mins). Closer methods-TTSC 19, endoloop+TTSC-6 Padlock-3, padlock+TTSC – 2, padlock+ endoloop + TTSC- 1, Padlock + Apollo overstitchendosuture-1, Omental patch + TTSC-2, Ovesco clip - 2, Apollo overstitch endosuture - 2. Histology GIST – 18 (46.1%, low grade – 17, high grade - 1), NET- 7 (17.9%, WHO grade- grade 1- 4 , grade 2 - 3), leiomyoma- 5 (12.8%), Schwannoma-3 (7.6%), gastric duplication cyst - 1 (2.5%), ectopic pancreas 1 (2.5%), neurofibroma - 1 (2.5%), parietal cell hyperplasia-1 (2.5%), adenomatous proliferation with high grade dysplasia-1 (2.5%), hyperplastic granulation tissue-1 (2.5%).Two adverse events- laceration and perforation. Follow-up – 3 months - 100% no residual lesions,1-3 yrs -60-80% no residual lesions, after 3 yrs 56% asymptomatic and no residual lesions.
Conclusion EFTR with various defect closure techniques appears to be safe, effective for various GI neoplastic lesions.
Keywords EFTR, SET, Closer techniques
315
Concomitant endoscopic fundoplication after per oral endoscopic myotomy (POEM + F) for prevention of post gastroesophageal reflux - Medium term results
Parag Dashatwar , Amol Bapaye, Siddharth Dharamsi
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India
Background and Aim Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia (AC), however post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM+F) is a recently described technique to reduce post-POEM GER. This single-center study reports short and medium-term outcomes of POEM+F.
Methods Retrospective analysis of prospectively maintained database of patients subjected to POEM+F. Abstracted data included demographics, achalasia type, pre-POEM Eckardt score (ES), prior therapy and follow-up. All patients were subjected to POEM+F. Follow-up was at 3-monthly intervals for one-year. Follow-up assessments included post-POEM ES, GerdQ score, EGD findings – wrap integrity and esophagitis and pH studies. GER was defined according to the Lyon consensus guidelines.
Results Twenty-five patients were subjected to POEM+F, mean age (SD) – 40.13 (13.66) years, 12 females. POEM+F technically successful in 23/25 (92%) patients. Significant dysphagia improvement seen in all 25 (mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respectively, p< 0.05). Mean total procedure and mean fundoplicationtime (SD) was 115.6 (27.2) and 46.7 (12.4) minutes respectively. Procedure times significantly reduced after initial 5 cases. Median follow-up was 12-months (IQR 9 – 13). At follow-up, conclusive GER on the basis of abnormal EAET was seen in 2/18 (11.1%) patients. On ITT analysis, an intact wrap was found in 19/23 (82.6%) patients. Grade A erosive esophagitis with normal EAET was seen in additional 4/22 (18.1%) and was of borderline significance. GerdQ scores remained high in one patient with abnormal EAET. Two (8%) minor delayed adverse events required no additional intervention.
Conclusions POEM+F is safe and reproducible. Incidence of post-POEM+F GER is lower than that after traditional POEM. These results are maintained at medium-term follow-up.
Keywords POEM F, GERDQ, EAET
316
Safe guarding ourselves with bare minimum in resource constraints setting against COVID-19 our experience in tertiary care center
Muppa Indrakeela Girish , Amol Bapaye, Mangesh Borkar, Sachin Palnitkar, Harshal Gadhikar, Rajendra Pujari, Lalit Shimpi, Suhas Date
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India
Background SARS-CoV-2/Novel Corona Virus-19 (COVID-19) has become a global pandemic. COVID-19 can be easily transmitted in an endoscopy suite, there is high risk of infection during endoscopic procedures. Adequate protection of HCP is utmost important.
Methods Retrospective study who underwent endoscopic procedures during COVID-19 pandemic. Patients were pre-screened and risk was categorized into urgent (GI bleed, urgent feeds, biliary sepsis) and semi-urgent (GI cancers, ERCP for hepatobiliary pancreatic cancers, EUS for diagnosis of malignant conditions) for endoscopic procedures according to APSDE guidelines. Prior to procedure hemogram, chest X-ray, CRP done to all patients. HCW’s used modified PPE (cap, mask, shield, gown, gloves). Anesthesia preference- TIVA (midaz, fentanyl, propofol), GA with intubation. Gap between each procedure 20-30 mins. Divided our clinical force into two teams and followed the rotation policy on weekly basis. Procedures were performed in positive pressure rooms with air conditioning settings- MTR power 5.5KW, fan TSP-626Pa, fan speed -1198 RPM, Disch vol -11.6m/s, motor frame size-132S-4, efficiency– 89.4% and nearly 30 mm of W.C positive pressure.
Results Four hundred and sixty-seven patients (70.9%; male =312 [66.8%]; median age = 57) underwent endoscopy procedures- from March 20th to June 20th, 2020. One hundred and ninety (40.7%) patients had one or more comorbidities with hypertension being commonest comorbidity in 142 (28%) patients. Commonest symptom was GI bleed in 121 (25.91%) patients. Five hundred and seven procedures, 274 (54%) diagnostic, 233 (46%) -therapeutic. Interventions ERCP – 85 (36.5%), EUS – 7 (3%), esophageal stenting-9 (3.9%), PEG- 22 (9.4%), EVL-35 (15%) 6 (1.2%) died during hospitalization following terminal illness. Follow-up of patients according to different procedures 2 weeks – 1 month did not develop covid -19 symptoms and were not detected positive.
Conclusions Proper precautions there was no event of cross COVID-19 viral transmission between healthcare workers and patients. Judicious use of basic tests we followed will help in resource constraints settings like peripheral hospitals and nursing homes.
Keywords: Covid 19, Endoscopy , Risk Stratification
317
Closure with composure! tracheoesophageal closure- Novel endoscopic technique
Ashish Gandhi , Amol Bapaye, Balasaheb Pawar, Mangesh Borkar
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Department of Gastroenterology, Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India
Tracheoesophageal fistula (TEF) can either be congenital or acquired, etiology being benign or malignant. Acquired TEF in adults can be severe and life threatening especially when complicated with recurrent aspirations. Spontaneous closure of TEF is rarely encountered and require stenting or surgery as the modalities of addressing TEF. Endoscopy can be a quick and convenient modality to address such fistulas averting the need of prolonged and invasive surgeries. Experience with occluder devices has been less however. We present our experience of HARTER Lifetech ASD septal occluder device to tackle TEF.
TEF closure using an HARTER Lifetech ASD occluder was practiced electively on 1 patient who presented with chronic cough. Endoscopy revealed TEF of 6-7 mm diameter located 26 cm from incisors. Edge of fistula was fulgurated using APC probe. Under combined endoscopy and bronchoscopy guidance, HARTER Lifetech ASD septal occluder device placement was done. We used HARTER Lifetech ASD septal occluder device with waist size of 12 mm, proximal disc size of 22 mm (esophageal end) and distal disc size 26 mm (tracheal end). Procedure was tolerated well. Post procedure patient developed Pneumothorax which required drainage. Follow-up bronchoscopy after 2 weeks showed occluder device in situ with no airway lumen compromise. At follow-up visit after 1 month, there was significant relief in cough. Barium swallow revealed no further leak. Follow-up endoscopy showed in-situ device. Patient was started on semi-solid diet which is being tolerated well.
In this case report (video), TEF closure with novel endoscopic technique using HARTER occluder device requires simple manipulations and is a well tolerated procedure.
Keywords Tracheoesophgeal fistula, ASD closure, HARTER Lifetech
318
Study of endoscopic findings in upper gastrointestinal bleeding in tertiary care centre
Zameer Ahamed, Chitra S, Manimaran M, Sathya G, Sumathi B, M S Revathy
Correspondence- Zameer Ahamed-zameer.343@gmail.com
Department Medical Gastroenterology, Stanley Medical College, 1, Old Jail Road, Chennai, 600 001, India
Introduction and Aim Acute gastrointestinal (GI) bleeding is a life threatening emergency that remains a common cause of hospitalization worldwide. The etiology of acute upper GI bleed varies with each geographical region. Early recognition and appropriate management protocols, significantly reduces morbidity and mortality. Study aimed endoscopic findings in patients with acute upper GI bleeding.
Methods This was a retrospective study conducted in a tertiary care centre in Government Stanley Medical College and Hospital, Chennai. In this study we analyzed the records of consecutive patients admitted with upper GI bleeding over period of 8 months from January 2020 to August 2020.
Results We analyzed 194 consecutive patients diagnosed with acute upper GI bleeding, 151 (77.1%) patients were males and 43 (22.9%) were females, mean age of presentation was 45 and plusmn; 5.2 years. On etiological association shown history of alcohol use disorder 105 (54.1%), smoking 45 (28.3%), analgesic abuse 14 (7.2%) and on antiplatelet drugs 10 (5.1%). On endoscopic evaluation esophageal varices 101 (52.6%), esophagitis 32 (16.4%), duodenal ulcer 28 (14.4%), gastric ulcer 18 (9.2%), Mallory-Weiss tear 5 (2.5%) and normal endoscopic finding was seen in 10 (5.1%) of patients.
Conclusion The present study reported that portal hypertension as the most common cause of upper G bleeding followed by peptic ulcer disease. The most common endoscopic lesions reported were esophageal varices, followed by esophagitis and duodenal ulcer.
319
Measures to contain exposure to endoscopy department staff during the COVID-19 pandemic while providing quality care- A clinical audit from a large volume tertiary center
Amol Bapaye, Mangesh Borkar , Muppa Indrakeela Girish, Sachin Palnitkar, Harshal Gadhikar, Rajendra Pujari, Suhas Date, Lalit Shimpi
Correspondence Amol Bapaye - amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India
Background SARS-CoV-2, global pandemic, causes aerosol borne viral illness (COVID-19). GI endoscopy, an aerosol generating procedure, carries high-risk for transmission. Despite several guidelines, protecting healthcare workers (HCW) and patients from cross transmission remains a challenge. This study elaborates measures implemented at a high-volume tertiary center to reduce transmission risk and also discusses outcomes.
Methods Since pandemic began, department functioning was as per modified APSDE guidelines. Elective endoscopy procedures stopped, only emergency and semi-emergent procedures scheduled. Important differences from guidelines– routine COVID testing not employed, triage protocol– history of symptoms/exposure, blood count including differential count, CRP, chest X-ray within 48 hours of scheduled procedure. All HCWs used modified-PPE (cap, mask, face shield, surgical gown, gloves). All procedures performed under propofol/GA with endotracheal intubation. Departmental staff divided into two working groups by weekly rotation to avoid simultaneous exposure of all. Air-conditioning settings modified to reduce positive pressure and improve ventilation. Minimum 30-min-interval between procedures. Social distancing norms enforced in patient waiting/recovery areas.
Results During 3-month period (March’20-June’20), 467 patients (70.9% male, mean age 57 years) underwent 507 endoscopic procedures vs. 2110 procedures in preceding 3-months (22.9% of regular workload). One hundred and ninety (40.7%) patients had associated comorbidities. Indications for endoscopy– GI bleed–121 (25.9%), severe abdominal pain–89 (19%), suspected cancer–128 (27.4%), obstructive jaundice and cholangitis–67 (14.3%), others–253 (54.1%). Two hundred and seventy-four (54%) diagnostic, 233 (46%) therapeutic procedures. Therapeutic– ERCP–85 (36.5%), EUS–7 (3%), feeding access including esophageal/enteral stent– 9 (3.8%), treatment for GI bleed–35 (15%). Six (1.2%) patients died during hospitalization due to non-COVID causes. Follow-up as per protocol– no occurrence of COVID symptoms in any patients at 2 weeks post procedure, none detected positive. No HCWs developed COVID symptoms or tested positive during 3-month period.
Conclusions This audit demonstrates low incidence of cross transmission of SARS-COV-2 between patients and HCWs by using measures listed above. At reduced workload of 25% of normal, department could serve patients in need of emergency/semi-emergency endoscopic intervention.
Keywords Covid 19, Endoscopy, Triage
Motility Disorders
320
Evaluation of esophageal motor function in patients with gastroesophageal reflux using multiple rapid swallows
Mayank Jain , Vinodini Agrawal
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre, 283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India
Background Multiple rapid swallow (MRS) is a complementary test performed during high resolution esophageal manometry.
Aims To assess the MRS findings in patients with gastroesophageal reflux disease (GERD) who have normal peristalsis and minor motility disorders.
Methods This is a retrospective analysis from a prospectively maintained database of patients referred for HREM study to our centre. The details recorded included age, sex, symptoms with duration and upper gastrointestinal endoscopy reports. HREM data included basal inspiratory and expiratory pressures, median integrated relaxation pressure and peristaltic pattern. Three MRS sequences were recorded per patient. The inhibition and contraction phases were interpreted for each MRS sequence.
Results A total of 68 patients (38- normal motility, 30 minor motility disorders) formed the study cohort. Hiatus hernia was commoner in GERD patients with minor motility disorders (p 0.02). Patients with minor motility disorders were more likely to have poor peristaltic reserve than patients with normal peristalsis (p<0.05). MRS patterns in inhibition and contraction phases are similar in three MRS sequences for patients with normal peristalsis, while in patients with minor peristaltic disorders, the inhibition phase is significantly discordant on repetitive MRS swallows. (p 0.049).
Conclusion In GERD patients, those with normal peristalsis are more likely to have normal MRS pattern. On the contrary, those with minor peristaltic disorders have a higher incidence of poor peristaltic reserve and show significant discordance in the inhibition phase of MRS.
321
Bowel habit pattern of patients with self-reported constipation at out patient department in north east part of Bangladesh
Madhusudan Saha , Bimal Chandra Shil, Mohammed Kamal Uddin
Correspondence- Madhusudan Saha-madhunibedita@yahoo.com
Department of Gastroenterology, North East Medical College, Bangladesh, North East Medical College, Sylhet, Bangladesh, Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
Aim This study was designed to see the symptoms and bowel habit pattern of patients presenting with self reporting constipation at Out Patient Department in a tertiary care hospital.
Method This study was conducted in out patient Department of gastroenterology department in North East Medical College Hospital during January 2017 to December 2018. Total 228 consecutive patients with self reported constipation were enrolled in this study. Patients with history of abdominal surgery, known chronic disease, age below 18 years, pregnant women, patients using drugs like anti-depressant, anti-psychotic and patients unwilling to take part in the study were excluded. Demographic data, symptoms, bowel habit pattern and character of stool were recorded at in a pre-designed data sheet.
Result Total 228 patients, male 130 (57%), female 98 (43%), age varying from 18 to 81 years (mean 38.7±15.10) were included. Among them 127 patients (55.7%) had daily bowel motion with frequency one to seven and 101 patients (44.3%) had infrequent stools. Sixteen patients (7.0%), 182 patients (79.8%) and 30 patients (13.2%) had feeling of complete bowel evacuation all time, days a week and almost never respectively. Among the patients 127 (55.7%), 29 (12.7%), 06 (2.6%), 02 (0.9%) and 64 (28.1%) complained of hard, soft, semi liquid, liquid and stool of variable consistency respectively. In this study 159 (63.73%), 21 (9.21%) and 43 (18.85%) patients were regularly taking proton pump inhibitor (PPI), anti- diabetic drugs and anti-hypertensive drugs respectively.
Conclusion Patient’s perception regarding constipation does not always match the traditional medical definition. Symptoms like stool consistency, volume, and feeling of incomplete evacuation are more important to patients’ perception regarding constipation.
322
Quality of life, prevalence of psychiatric comorbidities and extraintestinal functional disorder in patients with functional gastrointestinal diseases
Abhinav Jain , Himanee Patel
Correspondence- Abhinav Jain-dr.a.j.12320@gmail.com
Department of Gastroenterology, CIMS Hospital, Science City Road, Science City, Panchamrut Bunglows II, Sola, Ahmedabad 380 060, India
Introduction Functional gastrointestinal disorders (FGID) patients report poor health-related quality of life (HRQOL) and experience high rates of psychiatric comorbidity and extraintestinal functional disorders (EIFD). The data from India on this is sparse.
Methods A hospital based cross-sectional study was carried on outpatient basis December 2019 to March 2020. Thirty-five patients with functional gastrointestinal diseases diagnosed on basis of ROME-IV criteria were identified. A survey was undertaken using SF-36 questionnaire, hospital anxiety and depression scale and somatic symptom scale-8. Prevalence of EIFD and history of functional disorders in family were also noted.
Results The most prevalent FGID were functional bloating (28.5%), irritable bowel syndrome (IBS) (25.7%) and functional dyspepsia (25.7%). EIFD were seen in 33 (94.3%) of patients, the commonest being headache (80%), halitosis (51.42%), and dysguesia (40%). Nearly half (48.6%) the patients had a history of FGID and/or EIFD among family members. Anxiety and depression was seen in 13 (37.1%) and 19 (28.6%) patients, respectively. Eight (22%) patients had both anxiety and depression. The somatic symptom burden was high and very high in 20% and 34.2%, respectively. No differences in prevalence of psychiatric comorbidities was seen with relation to type of FGID. The overall QoL was low with a mean score of 49.5 (SD 12.5). The domains of QoL with the lowest scores were role-emotional (mean 19.75 [SD 26.19]), followed by role-physical (mean 22.50 [SD 29.67]).
Conclusion There is a high prevalence of psychiatric comorbidities like depression and anxiety, EIFD, family history of functional disorders in patients with FGID. These patients have a high somatic symptom burden and a poor QoL.
323
Long-term outcomes of per-oral endoscopic myotomy in esophageal motility disorders: A large, single centre study
Arun Karyampudi , Zaheer Nabi, Mohan Ramchandani, Rajesh Goud, Santosh Darisetty, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India
Background Per-oral endoscopic myotomy (POEM) is an established modality of treatment in achalasia and non-achalasia spastic motility disorders of esophagus. However, there is limited data on the long-term outcomes of POEM. In this study, we aim to evaluate the efficacy of POEM in patients with a minimum follow-up of five-years.
Methods The data of patients who successfully underwent POEM and completed at least five-years follow-up were analyzed from a prospectively maintained database. The primary outcome of the study was clinical success (Eckardt≤3) at age; 5-years after POEM. The secondary outcomes included the prevalence of dysphagia and symptoms of gastroesophageal reflux disease (GERD). Multivariate analysis was performed to analyze the predictors of dysphagia and symptomatic and GERD on long-term follow-up.
Results Two hundred and twenty-five only; patients (males 129, mean age 40.7 and plusmn;14.3 years) completed a minimum of 5-years follow-up. The spectrum of motility disorders included idiopathic achalasia (type I 28.4%, type II 60%, type III 6.2%) and Jackhammer esophagus or distal esophageal spasm (3.1%). POEM was technically successful in 217 (96.4%) patients. The data for long-term follow-up was available in 201 (89.3%) patients. The median follow-up was 69 months (range 60-81). In intention to treat analysis (considering technical failures and lost to follow-up as failures), the overall long-term success was 87.5%, 84.3% (type I), 91.8% (type II), 78.6% (type III) and 85.7% (Jackhammer esophagus/ distal esophageal spasm). Clinical success was lower in type III achalasia (p=0.002). Young age was an independent risk factor for the development of dysphagia on follow-up (p=0.002). Clinical GERD was detected in 30.6% patients. On multivariate analysis, female sex, high Eckardt score at 5-years and dysphagia of any degree were independent predictors of symptomatic GERD after POEM.
Conclusion POEM is an effective and durable treatment modality for achalasia and other non-achalasia spastic motility disorders. Clinical GERD is detected in nearly one-third patients.
324
Spectrum of anorectal manometry and balloon expulsion test findings in patients with chronic constipation at a tertiary care centre in India
Suresh Chawla , Mohinish Chhabra, Hardeep Singh Dua, Amandeep Raghuvanshi, Amit Kumar
Correspondence- Mohinish Chhabra-mohinish.chhabra@fortishealthcare.com
Departments of Gastroenterology, Medical Technology and GI Physiology, Fortis Hospital in Mohali, Sector 62, Sahibzada Ajit Singh Nagar Punjab 160 062, India
Background and Aims Constipation is a common problem encountered in GI practice. The patients referred to tertiary care hospital poorly respond to laxatives and require a thorough work up for the fecal evacuation disorder.
Methods Retrospective data of 87 consecutive patients (2017 to 2020) with chronic constipation (Rome III) referred for ARM and BET was analyzed.
Results Eighty-seven patients (51.88 ± 19.21 years, 51 males, 36 females) had history of incomplete evacuation out of which history of digital evacuation (n=20), rectocele (n=2), anal fissure (n=5), trauma (n=3), surgery (n=28), Parkinson (n=1), diabetes (n=9), hypertension (n=4), hypothyroidism (n=4) was observed. On ARM, Type 1 dyssynnergia was seen in n=57, Type 2 and 3 dyssynnergia was present in n=3 patients each. N=52 patients couldn’t expel the Balloon in one minute. Rectal hyposensitivity was noted in n=47 and hypersensitivity in n=5. mean sensation volume, urge volume and pain volume was 72.13±52.21, 182.18± 74.75, 242.71±89.96 cc respectively. Recto anal inhibotory reflex (RAIR) was absent in n=1, cough reflex was absent in n=12 patients. Mean anal length of the study population was 3.69 ± 0.77. Biofeedback therapy was effective in all the patients who underwent it (n=13).
Conclusion Rectal hyposensitivity and Type 1 dyssynnergia were the most common observations of our study. Hence it is important to have a thorough workup in patients with chronic constipation to rule out FED to avoid laxative abuse and multiple doctor visits as biofeedback therapy shows promising results in such category of patients.
Keywords Anorectal manometry, FED, Dyssynnergia
325
Effect of moderate aerobic exercises on symptoms of functional dyspepsia
Siddhesh Rane , Partha Debnath, Sanjay Chandnani, Prasanta Debnath, Parmeshwar Junare, Ravi Thanage, Pankaj Nawghare, Bharati Asgaonkar, Qais Contractor, Pravin Rathi
Correspondence- Siddhesh Rane-sid.6173@gmail.com
Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai Central, Mumbai 400 008, India
Introduction Functional dyspepsia is a commonly encountered entity worldwide and is difficult to treat. Most of the treatment modalities have low quality evidence for use, except for proton pump inhibitors. Aerobic exercise has been shown to improve the symptoms but its direct effect on symptoms has never been studied. Objective was to study the effects of moderate aerobic exercise on symptoms of functional dyspepsia and to compare the effect of conventional treatment alone vs. exercise plus conventional treatment.
Methods Out of 112 patients, 72 were randomly divided into controls (conventional treatment) (n=36) and experimental (aerobic exercise for 30 minutes per session, 5 times a week for 6 weeks with conventional treatment) group (n=36). Both groups were assessed on day 1 and at the end of 6 weeks, using Glasgow dyspepsia severity score (GDSS), Depression anxiety stress scales-42 (DASS 42) and Visual analogue scale (VAS).
Results Pre-treatment GDSS, DASS 42 and VAS in the experimental group were significantly different as compared to the post-treatment scores (p=0.00019, p=0.0002, p=0.00019 respectively). Even in the control group, pre- and post-treatment GDSS, DASS 42 and VAS scores were significantly different (p=0.00019, p=0.0002, p=0.00019 respectively). However, on head-to-head comparison of the 2 groups, scores at the end of 6 weeks were significantly different (p< 0.05), in favor of the experimental group.
Conclusion Aerobic exercise with conventional treatment is more effective than conventional treatment alone for functional dyspepsia.
326
Incidence and risk factors associated with development of post infection irritable bowel syndrome (PI-IBS) - A one-year prospective longitudinal study
Rishabh Agarwal , Rekha Patil
Correspondence- Rishabh Agarwal-rishabhagarwal90@gmail.com
Department of Internal Medicine, Jawaharlal Nehru Medical College, KAHER, India
Introduction Post-infection irritable bowel syndrome (PI-IBS) is seen following an episode of acute gastroenteritis (AGE). There is paucity of literature in this field with respect to Indian population. This F study aims to evaluate the incidence of PI-IBS and identify the risk factors associated with it.
Methods This prospective study was carried out over a period of one year on AGE patients admitted in KLE Dr. Prabhakar Kore Hospital, Belgaum. Clinical and demographic characteristics were noted, risk factors evaluated, and previous or current IBS was ruled out by means of an IBS questionnaire. The patients were followed up after 6 months to look for development of IBS (ROME IV criteria).
Results Out of 100 hospitalized AGE patients, one-fourth i.e. 25 developed PI-IBS after 6 months. Out of these, 18 patients had IBS-D type and remaining 7 had IBS-C type. The factors significantly associated with PI-IBS were younger age, longer duration of AGE, depression, abdominal cramps. On multivariate logistic regression analysis, longer duration of acute gastroenteritis (>7 days) (p-value=0.0040) and presence of abdominal cramps (p-value=0.0130) were found to be significantly influencing the development of PI-IBS at 6 months.
Conclusion One fourth of the patients in our study developed PI-IBS after 6 months of AGE episode. Younger age, depression, longer duration of diarrhea and abdominal cramps were statistically significant risk factors for development of AGE. Physicians should keep a high suspicion for PI-IBS, in patients with predisposing risk factors. The possibly involved molecular mechanisms in the pathogenesis of PI-IBS should be investigated for better understanding of the disease, and to plan and strategize therapeutic options.
Keywords PI-IBS, Gastroenteritis, Diarrhea, ROME, IBS
327
Subtypes of functional constipation based on colonic transit time and anorectal manometry
Ashish Chand , Mandhir Kumar, Munish K Sachdeva
Correspondence- Ashish Chand-ashishchanddewangan@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
Chronic constipation is a common complaint in the general population worldwide as well as in India. It may be idiopathic or secondary. Idiopathic constipation is classified as functional constipation (FC) and IBS-C. Proportion of FC among patients of idiopathic chronic constipation is higher than IBS-C. We studied 100 patients of FC. Majority were male (70%). Colonic transit time (CTT) was measured by using radio-opaque markers and anorectal manometry by high resolution water perfusion system. Mean age of patient was 41y ±14.7, maximum were in 21-30 years and 31-40 years of age group. Common complaints were excessive straining (100%), feeling of incomplete evacuation (99%) and blockage (93%). Straining ≥ 30 min, sensation of blockage, feeling of lumpy hard stool and manual evacuation is significantly associated with dyssynergic defecation (p-<0.05). BSFS1 and 2 stool consistency were reported more by those who had dyssynergia (p <0.05). Solitary rectal ulcer syndrome was found in 13% of patients and all had dyssynergic defecation (DD). DD was found in 66 patients. Type 1 DD was most common 46, found in followed by type 2- 17 and type 4-3 patients. Mean resting anal and squeeze pressure were found high among patients of DD. CTT showed slow colonic transit in 25% patients. Sixty percent of patients with slow transit had BSFS1 or 2.
In conclusion majority of patients of FC who presented to tertiary care facilities may have defecative disorder or slow colonic transit or a combination of the two because majority had already been treated at primary health care facilities and had inadequate response whereby were suffering from refractory constipation.
Keywords Chronic constipation, Functional constipation, Dyssynergic defecation, Colonic transit time, Anorectal
328
Can maximal anal squeeze pressure predict the diagnosis of dysynergic defecation during anorectal manometry?
Ajay K Jain , Amit Joshi, Shohini Sirkar, Abhilash Surela, Sudhanshu Yadav
Correspondence- Amit Joshi-dradjoshirajkot@gmail.com
Department of Gastroenterology, Choithram Hospital and Reasearch Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction Constipation affects 11% to 18% of adults and is frequently underreported. A multicentric study in India found the prevalence of self-reported constipation of about 53%. Pelvic floor dyssynergia or dysynergic defecation constitutes about half of constipation which can be diagnosed by anorectal manometry. There-fore we aimed this study to evaluate the various anorectal manometric parameters like basal anal pressures, maximal squeeze pressures and rectal sensations in patients with dysynergic defecation and their utility in predicting the diagnosis.
Methods Present study is retrospective observational study of patients who underwent anorectal manometry for evaluation of constipation at the department of gastroenterology, Choithram Hospital and Research Centre, Indore, M.P. from 1/3/2015 to 31/2/2020. Patients were divided into two groups: A: Dysynergic defecation group and B: Non-dysynergic defecation group and various parameters were analyzed and compared between the two groups with appropriate statistical tests.
Results During the study period 98 patients underwent anorectal manometry for evaluation of constipation. Of these 74 patients (75.51%) had dysynergic defecation and 24 (24.48%) had normal anorectal manometry findings. The mean age of presentation was in forth decade (49.28 years) in dysynergic defecation group (49.28 years) and in fifth (53.20 years) decade in normal anorectal manometry group. Finger evacuation was exclusively seen in dyssynergic defecation group (9%, p=0.044). There was no statistical difference in basal anal pressures between the two groups. Maximal squeeze pressures were significantly higher in dysynergic defecation group. No significant differences were seen in rectal sensations in both the groups.
Conclusions 1) Dysynergic defecation affects in fourth decade with male preponderance. 2) Use of finger evacuation can clinically distinguish between dysysnergic defecation and non dysynergic defecation. 3) Patients with dysynergic defecation have high maximal squeeze pressures. 4) Rectal sensations is not a sensitive manometric parameter to diagnose dysynergic defecation.
Keywords Dysynergic defecation, Anorectal manometry, Maximal squeeze pressures, Rectal sensations
329
Physiological management of irritable bowel syndrome with Psyllium husk: Novel aspects
Pankaj Garg, Sohail Singh Sodhi
Correspondence- Pankaj Garg-drgargpankaj@yahoo.com
Department of Colorectal Surgery, Garg Fistula Research Institute, 1043, Sector 15, Panchkula 134 113, India and Govt Medical College, Chandi Path, Sector 32B, Sector 32, Chandigarh 160 047, India
Introduction Psyllium husk is bowel regulator and could work very effectively in irritable bowel syndrome (IBS) provided it is taken in proper quantity and with adequate water. This and other physiologic steps (FEED) were studied.
Methods IBS patients (Rome IV criteria) were prescribed FEED regimen,
(F) - Fiber (Psyllium-Ispaghulla husk), 5 tsf (25 grams) with 500 mL water/day
(E) - Elevation of feet by small bench (12-16” height) while on toilet-commode,
(E) - Exercises of abdominal muscles
(D)- Drinking (500 mL) water in morning.
Earlier 5-10 grams of soluble fiber (psyllium) has been studied which provide only partial relief. Daily fiber requirement is 35-40 grams/day whereas the intake is <15 grams/day. So, this deficiency of 20-25 grams fiber needs to be supplemented daily to maximise the relief in IBS patients. Second aspect is the amount of water taken along with the fiber. Psyllium absorbs water, takes water to the rectum, thereby making stools softer and bulkier. However, for this to happen optimally, adequate water must be taken along with the fiber intake (@25 mL water/gram fiber, 500 mL water with 25 grams fiber/day). These aspects which markedly increases the efficacy of fiber supplement was ignored by previous studies. Elevating the feet while sitting on toilet commode straightens the rectoanal canal which by relieving functional obstruction makes defecation process easier and less strainful. Drinking water in morning and doing abdominal wall exercises while sitting on toilet-commode activate gastrocolic reflex and help in bowel regulation. All these physiological steps (FEED) when implemented together, helps to regulate bowel and provide substantial relief in IBS.
Results In the pilot study, FEED was recommended to 7 patients of IBS (4-IBS with constipation, 2-IBS with diarrhea, IBS mixed). After 6 weeks, all patients responded well to this physiological treatment and reported a major relief (>90%) in their symptoms.
Conclusions Physiological (non-pharmacological) treatment (FEED) can play a major role in the management of IBS. Irritable bowel syndrome, psyllium husk, physiological management
330
Efficacy of biofeedback therapy in patients with dyssynergic defecation
Ashish Agarwal , Samagra Agarwal, Deepak Madhu, Abhinav Anand, Mukesh Ranjan, Saurabh Kedia, Vineet Ahuja, Govind Makharia, Anoop Saraya
Correspondence- Govind Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Multiple studies have demonstrated the beneficial effects of biofeedback therapy for dyssynergic defecation. However, data from India is limited. This study was planned to assess the efficacy of biofeedback therapy for dyssynergic defecation.
Methods In this retrospective analysis from a prospectively maintained database, all patients with symptomatic dyssynergic defecation who completed at least six sessions of weekly multicomponent biofeedback therapy between July 2018 and March 2020 were included. Patients with any structural abnormality in the defection unit, uncontrolled hypothyroidism, uncontrolled diabetes, and hypercalcemia were excluded. Efficacy of biofeedback therapy was assessed as the reduction in the modified Cleveland constipation severity score and global bowel satisfaction based on visual analogue scale at the end of biofeedback therapy.
Results Fifty-three patients received biofeedback therapy of which, 45 patients (Mean age 41.4+17.1; 73% males) were included in the analysis. The median duration of symptoms was 5 (IQR: 3-10) years. Thirty-two (71.1%), 4 (8.9%), 7 (15.6%) and 2 (4.4%) patients had type I, type II, type III and type IV pelvic floor dyssynergia, respectively. There was a significant improvement in the median modified Cleveland Constipation Severity Score with biofeedback therapy (before 7 [IQR:4-9] vs. after 3 [IQR:1-5]; p<0.001). Biofeedback therapy was effective (>25% reduction in constipation severity score) in 37 (82.2%) patients. 84.4% patients had satisfactory (>20%) global bowel satisfaction with biofeedback therapy.
Conclusion The study reaffirms that biofeedback therapy is highly effective in patients having dyssynergic defecation.
Keywords Biofeedback, Pelvic floor dyssynergia, Anorectal
331
To study normal values on high-resolution anorectal manometry in healthy volunteers in India
Rahul Deshmukh1, Sanjay Chandnani1, Shubham Jain1, Pratik Tibdewal2, Nitin Ramani2, Pravin Rathi1, Akash Shukla2
Correspondence – Rahul Deshmukh-drdeshmukhrahul@gmail.com)
1Department of Gastroenterology, Topiwala National Medical College, Mumbai 400 008, India, 2Department of Gastroenterology, Seth G S Medical College, Mumbai 400 012, India
Introduction High-resolution anorectal manometry (HRAM) is used for determination of anorectal disorder. There are differences in data on effects of gender and age on anorectal function. The data on normal anorectal pressure and sensation are sparse. Our hypothesis is that values in Indian population might be different from others. This study aims: (1) To obtain normal data sets of anorectal function using HRAM and (2) Influence of gender and age on anorectal functions in healthy volunteers in India.
Methods In our population healthy volunteers underwent HRAM using a 24-channel water perfused catheter. We determined anorectal pressures, recal sensation and balloon expulsion time. Measurements were recorded during rest, squeeze, and push with and without balloon inflation. Informed consent was taken.
Results HRAM was performed in 93 healthy volunteers of which 29 were females. Median age was 38 years (ranges: female 18–65 years; male 18–76 years). Volumes of first sensation (47±28 mL) and (34±17 mL), urgency (114±44 mL) and (98±35 mL) and MTV (maximum tolerable volume) (162±52 mL) and (154±50 mL) in males and females respectively. Anal canal length (1.86±0.68 cm vs. 2.5±0.68 cm), anal push residual pressure without inflation (59±21 mmHg vs. 81±22 mmHg) and first sensation (34±17 ml vs. 47±28 mL) were significantly lower (p<0.05) in females compared to males. No statistical difference was found in resting anal pressure, maximum squeeze pressure, push residual pressure with inflation, urgency to defecate and MTV in males and females. Mean anal resting (91±29 mmHg) and mean squeeze max pressure (155±38 mmHg) were lower in >50-year age group compared to <50-year age group (100±28 mmHg) and (169±45 mmHg) respectively. Balloon expulsion was failed in 30 (32%) study participants.
Conclusion: HRAM parameters anal canal length, anorectal pressure and volume are influenced by age and gender (significantly low in females). Results must be interpreted concerning gender and age-adapted normal values. Anorectal pressure and rectal sensation are different from other population. Balloon expulsion was negative in one third at end of 1 minute in our population.
Keywords: Anorectal function, High-resolution anorectal manometry (HRAM), Healthy volunteers
Pediatric Gastroenterology
332
Presentations, management and outcome of upper gastrointestinal bleeding in children admitted in a tertiary care endoscopy unit in South India
Sajith Sebastian , Benoy Sebastian, Sunil K Mathai, Mary George
Correspondence- Sajith Sebastian-drsaseneeruvelil@gmail.com
Department of Medical Gastroenterology, Medical Trust Hospital, Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
The aim of this study was to find out whether the causes of pediatric upper GI bleeding to our center and outline their presentations and treatments. Children presenting to Endoscopy unit of Medical Trust Hospital, Kochi with upper GI bleeding for a year and half from December 2018 to June 2019 were evaluated and included in the study after obtaining a informed consent from the parents. Information retrieved from patient's records and results of upper GI endoscopy regarding etiology of bleeding, managements, and the mortality rate were also analyzed.
Results Age distributions of paediatric patients presented with UGI bleeding shows most common age of presentations were between 2-5 years of age, followed with 8-12 years both of which occurred in 33.34%. Males presented slightly more with UGIB. Children's presented with UGIB presented with Melena in 33.4%, hematemesis in 22.22%. Children’s with accidental foreign body ingestions also present with UGI Bleeding in 11.13%. But none of them presented with major bleeding with hypotension or required blood transfusion. Most common cause of UGIB was gastric and duodenal erosion´s as par with other studies. No source was identified in 1/3rd of patients during the initial endoscopy. While one patient had a Dieulafoy's lesion picked up and managed in subsequent endoscopy.
Conclusion Our findings showed that most common sources of upper GI bleeding in pediatric patients from our center was due to gastric and duodenal erosions. We conclude that the causes of upper GI bleeding in children in our center, a developing country, are not different from those in developed ones. Various regions of the world have reports indicating variation in the source, etiology, cause and approaches for pediatrics GI bleeding. Furthermore, multicenter studies considering various countries or review articles investigating the mentioned issues in GI bleeding of children is essential.
333
Role of gastrointestinal endoscopy in children with functional abdominal pain
Shrish Bhatnagar, Aashlesha Kritika , Saba Ekta
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background and Study Aims Rome 4 criteria has classified pediatric functional abdominal pain (FAP) into 4 variants i.e. functional dyspepsia (FD), functional abdominal pain not otherwise specified (FAP-NOS), irritable bowel syndrome (IBS), abdominal migraine (AM). However, there is lack of information on endoscopy and histopathological findings in this subset of children. Hence our study was to evaluate the endoscopic and histopathological findings in children with FAP.
Methods It was prospective observational study. 110 children (aged 4 to 17 years) with diagnosis of FAP according to Rome 4 criteria were enrolled from paediatric OPD. All children underwent gastrointestinal endoscopy and biopsy.
Results Most of the children belonged to age group 6-12 yrs (52.7%). Majority of children were girls (n=62, 56.4%). Fifty-eight (52.7%) children were suffering from FD, 42 (38.2%) children suffering from FAP NOS, 9 (8.2%) had IBS and 1 child had AM. In view of small sample size the IBS and AM patient were removed from statistical analysis. Endoscopic assessment showed 28 (42.3%) children with FD had significant lesions while it was seen only in 2 (4.8%) children with FAP NOS (p<0.001. Rapid urease test for H pylori was positive in 30 (51.7%) of children with FD, while only 1 in FAP NOS (p<0.001). Histopathological assessment collaborated with endoscopic assessment in both the categories. Thirty-five children of FD had evidence of mucosal inflammation against only 4 children of FAP NOS group (p<0.001). On follow-up 96.6% children with FD improved when given treatment with PPI and H. pylori (in positive cases).
Conclusion Indian children with functional dyspepsia have evidence of significant endoscopic and histopathological abnormalities including H pylori infection. Hence, we recommend that children with functional dyspepsia should be subjected to both upper GI endoscopy and H pylori evaluation while FAP-NOS usually do not require the same.
334
A challenging case of unusual liver mass in a teenage girl
Viswanathan M S , Anand Khakkar, Satheesh Ramamurthy
Correspondence- Viswanathan M S-vichums@rediffmail.com
Department of Pediatric Gastroenterology, Children's Hospital, India, Apollo Hospital, Chennai, India
History and Examination A 14-year-old girl presented with intermittent epigastric pain, vomiting and amenorrhea for 3 months. On examination: Growth was appropriate, anicteric, tenderness over epigastrium, and significant hepatomegaly. Otherwise normal.
Evaluation Hb 11, other CBC normal. LFT - AST-52 u/L, ALT-54 u/L, GGT-95 u/L, Normal bilirubin and synthetic function. Ultrasound abdomen revealed diffuse right liver lobe mass, otherwise unremarkable. Alfa-fetoprotein: normal. MRI abdomen: diffuse right lobe hepatic mass (17.8 cm x 13.3 cm) with compression of intrahepatic IVC, suggestive of hepatic adenoma. Liver biopsy confirmed hepatic adenoma.
Management In the multidisciplinary (MDT) meet options were discussed. In view of the risk of postoperative acute liver failure following a complete mass resection and technical surgical challenges it was decided to reduce the size of the mass by embolization in the interim. Two sittings of selective embolization of tumour branches of right hepatic artery was done, with 6 months interval. Post embolization syndrome following first sitting was medically managed, second embolization uneventful. Tumor significantly reduced to 12.1 cm x 9.8 cm and left lobe enlargement was noted. Then she underwent surgical excision of the hepatic adenoma along with right hepatectomy. She recovered well postoperatively and remained clinically well at 12 months follow-up.
Discussion Hepatocellular adenomas (HCAs) are extremely rare during childhood with varying histopathological features. HCA can be sporadic but is more frequently associated with oral contraceptive use and metabolic liver disease. In our patient there was no history of oral contraceptive use, underlying liver disease or genetic predilection. In view of risk of rupture/bleed we intervened.
Conclusion Hepatic adenoma, particularly large one is extremely rare in childhood and needs MDT management. Huge adenoma can be successfully reduced by selective embolization technique before high risk surgery to achieve optimal postoperative outcome.
335
Button battery ingestion: Experience from a tertiary center
Syed Shafiq , Harshad Devarbhavi, Balaji Gurappa, Mallikarjun Patil
Correspondence- Syed Shafiq-syed.dr.s@gmail.com
Fortis Hospital, Bannerghatta Road, Bengaluru, India, and Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, India
Introduction The ubiquitous use of portable electronic devices has resulted in an increased incidence of button battery (BB) ingestion in the pediatric population and represents a distinct category of ingested foreign body due to high morbidity and mortality. The aim of this study is to report our experience in the management of BB ingestion.
Methods A study involving 56 pediatric patients who presented to our Hospital Emergency Department with BB ingestion between December 2016 and November 2019. Data with respect to patient age, sex, time of presentation to emergency department to endoscopic retrieval of BB, the endoscopic findings, and adverse events if any was collected.
Results A total of 56 patients were enrolled in our study, of whom 33 (59%) were boys and 23 (41%) girls. The mean age was 3.3 years (range 6 months to 13 years). In 10 (17.8%), the BB was beyond the reach of esophagogastroduodenoscope and passed off spontaneously without any adverse events while in 27 (48.2%) patients, BB from the stomach was retrieved without any difficulty. A total of 19 (33.9%) patients had impacted BB. Amongst 9 patients with impacted BB in the cricopharynx, two went on to develop esophageal stricture needing serial dilatations. The most serious adverse event occurred in one patient with perforation and peritonitis needing laparotomy.
Conclusions: A vast majority of the ingested BBs pass off spontaneously or require minimal endoscopic intervention. Adverse events arise when BBs are of a larger diameter (>10 mm) and get impacted in the esophagus.
Keywords Button battery, Impaction, Endoscopic retrieval, Laparotomy
336
Fatal outcome of perforating lower esophageal button battery in a child
Shubhika Garg , Taranum Fatima, Areesha Alam, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background Impacted button battery (BB) in the esophagus can be fatal unless managed urgently.
Case characteristics A 2-year-old male child presented with respiratory distress from three weeks. Chest X-ray suggested a radiopaque foreign body, which was confirmed to be esophageal BB during esophagoscopy and subsequently removed. Corrosive nature of BB had perforated the lower esophagus leading to pyopericardium and pyothorax.
Outcome Inspite of appropriate antibiotics and surgical drainage, child died of sepsis.
Message Impacted esophageal BB should be removed as an emergency procedure. Any delay might lead to poor outcome.
Keywords Button Battery, Esophagus, Perforation
337
Safety and efficacy of endoscopic retrograde cholangiopancreatography in children: Ten years’ experience from a single tertiary care center
Syed Shafiq , Harshad Devarbhavi, Mallikarjun Patil
Correspondence- Syed Shafiq-syed.dr.s@gmail.com
Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru 560 034, India
Introduction The role of endoscopic retrograde cholangiopancreatography (ERCP) both as a diagnostic and therapeutic tool is well established in adults, while there is a paucity of data regarding its safety and efficacy in the pediatric population. The aim of our study was to evaluate the outcomes of ERCP in the management of pancreaticobiliary diseases in children (<18 years) by adult gastroenterologists using standard duodenoscopes.
Methods Consecutive patients aged 18 years or less who underwent ERCP from January 2010 to December 2019 were identified from our endoscopy database. Data pertaining to patient demographics, indications, success at cannulation of the desired duct, findings on cholangiopancreatogram, and adverse events if any were recorded.
Results A> total of 175 ERCP procedures were performed on 159 children, aged between 3 years to 18 years with 93 (58.5%) males and 66 (41.5%) females. The most common indications for ERCP were chronic pancreatitis (CP) with pancreatic duct disruption and/or acute exacerbations (n=93) followed by choledocholithiasis with biliary pancreatitis (n=41) and with cholangitis (n=4), choledochal cyst (n=12), and traumatic pancreatic duct disruption (n=10). Less common indications included pancreas divisum (n=6), PCC (n=3), hepatic hydatic cyst with biliary communication (n=2), traumatic liver laceration (n=1), progressive familial intrahepatic cholestasis with intractable pruritus (n=1), primary sclerosing cholangitis (n=1) CBD stricture status post-surgery for rhabdomyosarcoma (n=1). Cannulation was successful in 95% of the patients. Adverse events were noted in 4 patients (2.2%), post-ERCP pancreatitis in 3 patients and one had post-sphincterotomy bleed, all of whom were managed conservatively. There was no procedure or anesthesia related mortality.
Conclusions ERCP when performed by expert endoscopists is a relatively safe and effective procedure in children. Our study shows a predominance of pancreatic over biliary disorders as an indication for ERCP.
Keywords Endoscopic retrograde cholangiopancreatography, Pediatric, Chronic pancreatitis, Choledocholithiasis, Pancreatic duct leak
338
Pediatric liver abscess in Covid-19 era- Causal or casual?
Amarinder Oberoi , Naina Chakravarty, Vishrutha Poojari, Sagar Mehta, Ira Shah
Correspondence- Amarinder Oberoi-amarinderoberoi@gmail.com
Department of Pediatric Gastroenterology and Hepatology, Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel, Mumbai 400 012, India
COVID-19 has rapidly spread all over the world. Little is known about hepatic infections associated or aggravated in pediatric age groups.
Objectives To study the incidence of liver abscess in pediatric patients between January 2019 to August 2020 and the impact of COVID-19 pandemic on demographics of the same.
Design A retrospective cohort study of 29 patients diagnosed as liver abscess at a tertiary care Pediatric Centre in India. The patients presented between January 2019 August 2020. The cases reported from January 2019 to February 2020 were classified as “Pre-Covid cases” and the ones there after as “Intra-Covid cases”. Factors associated with liver abscesses were analyzed by Fischer’s exact test and Student t test. P value <0.05 was considered significant.
Results Twelve (40%) patients presented in the Intra-covid months whereas 17 (60%) in the pre-Covid period of which 2 were COVID-19 positive. Boys predominated in the pre-Covid era (59%, n=10) whereas a female preponderance was seen in the intra-Covid period (68%, n=7) (p=0.462). Table 1a and 1b depicts the factors associated with liver abscess in the pre- and intra-Covid period. Salmonella typhi was isolated in the pus culture in one patient while no other aerobic organisms could be isolated other cases. There was no mortality in our study.
Conclusions Prevalence of liver abscesses was higher in the COVID-19 era. During the Covid period, the lesions were multiple and had higher volume of pus requiring pigtail insertion, as well as longer hospital stay with prolonged duration of intravenous antibiotics. Further studies are needed to determine if there is a difference in the causative organisms during the COVID period, and whether COVID-19 causes a change in the epidemiological prevalence of bacterial infections in the community.
Keywords Liver abscess, Children, COVID-19
Surgical Gastroenterology
339
A simple novel concept to conservatively manage refractory spasm in acute fissure-in-ano: Defecation put on-hold temporarily (DePOT)
Pankaj Garg, Sohail Singh Sodhi
Correspondence- Pankaj Garg-drgargpankaj@yahoo.com
Department of Medical Gastroenterology, Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India
Introduction Severe spasm and pain in acute fissure-in-ano is primarily aggravated by defecation. Fissure are usually constipated and the shearing force of the hard stools aggravates the spasm. Moreover, the ‘narrowed’ anal outlet due to spasm further increases the impact of this shearing force.
Methods Acute fissure-in-ano patients with refractory spasm were managed by DePOT (defecation is put on-hold temporarily) regimen. This not only provided immediate pain relief but would also led to earlier resolution of fissure-in-ano by removing the aggravating factor (defecation process). While implementing DePOT, the daily requirements of protein, minerals, vitamins, water, and fats were taken care of. This was done by liquid diet having zero fiber plus full nutrition (oral rehydration solution [ORS], vitamin supplementation and protein [whey] supplementation [50-60 grams/day]). Once these nutritional needs of the patient are taken care of, then it is not difficult for the patient to sustain on the liquid diet for a week. An enema is given on the first day of the DePOT regimen to evacuate the rectum so as to avoid hardening of residual stools already present in the rectum.
Results DePOT was also prescribed for seven days to four patients of acute fissure-in-ano with refractory spasm in whom conservative management was not working (26-year/male, 23-year/female, 34-year/female, 29-year/male). All patients except the third patient, had immediate pain relief and the acute spasm improved progressively over next 7-10 days. The third patient had to stop DePOT after 3 days as she developed an intersphincteric abscess and was operated for the same.
Conclusion The DePOT regimen puts defecation process on hold for a week by zero fiber, full nutrition, liquid diet. It is a simple, novel, economical, safe and easily reproducible concept to provide immediate relief and helps prevent surgery in acute thrombosed hemorrhoids and acute fissure with refractory spasm.
Keywords Acute anal fissure, Fissure-in-ano, Defecation
340
Novel non-surgical treatment of intractable bleeding in hemorrhoid patients on anti-coagulants
Pankaj Garg, Sohail Singh Sodhi
Correspondence- Pankaj Garg-drgargpankaj@yahoo.com
Department of Colorectal Surgery, Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India
Introduction Bleeding hemorrhoids can be extremely troublesome in patients on anti-coagulants/anti-platelet drugs, especially in high-risk elderly patients, who are also unfit for surgery. There is no effective management available in such a scenario. Regular rectal enema as conservative treatment (REACT) is a new non-surgical life-saving concept which was tried in these patients.
Methods The root causes bleeding (bursting of hemorrhoids) are increased straining, prolonged time spent during defecation and increased frequency of motions. If these root causes of hemorrhoidal rupture could be eliminated by converting the act of defecation from an active mechanism to a passive one, then it would be extremely effective in controlling the bleeding and relieving the symptoms. Regular daily enema does precisely this. It is like a rectal wash and almost completely removes the need to strain for defecation. It also decreases the time spent during defecation. It simply gives time to the torn hemorrhoids to repair themselves, thus stopping bleeding and diffusing the emergency situation. In the study, the enema was given once daily for ten days. REACT was repeated if bleeding happened again.
Results REACT was tried in two patients (76 yrs/F, 82/M) who and presented with persistent bleeding for three weeks due to grade III hemorrhoids. Both were on anti-coagulants and had developed anemia (Hb-6.2, 7.3 gm/dL). Due to associated comorbid conditions (cardiac and cerebrovascular), the anti-coagulants couldn’t be stopped and surgery was very high risk. Both the patients were advised REACT with sodium-phosphate rectal enema for 10 days The bleeding stopped in both patients within 3 days. Both the patients were doing well after 6 months of follow-up.
Conclusions REACT is a new, simple, safe, economical, non-surgical, domiciliary and effective method to stop bleeding in hemorrhoids patients on anti-coagulants and having associated comorbidities (especially the patients whose anticoagulants cannot be stopped).
Keywords Hemorrhoids, Bleedings, Anti-coagulants
341
Synchronous esophageal and gastric malignancy presented as gastrointestinal bleeding: Curative resection by single sitting endoscopic sub mucosal dissection
Rohan Maydeo, Pravin Suryawanshi
Correspondence- Rohan Maydeo-rohanmaydeo@gmail.com
Department of Surgery, MGM Medical College, Aurangabad, India
Introduction With the improvement and advancements in endoscopic imaging, the diagnosis of the synchronous multiple primary early cancers in esophagus and stomach is increasing, while the traditional surgery for these malignancies are radical and much more invasive leading to significant morbidity. With evolving experience, endoscopic submucosal dissection (ESD) has become the preferred treatment option of early cancer in the digestive tract.
Case Summary Sixty-four-year old male, chronic smoker and alcoholic, presented with history of recurrent melena and severe anemia requiring blood transfusion. Upper gastrointestinal endoscopy revealed mid esophageal lesion (Paris 0-IIA) and gastric antral lesion (Paris 0-IIB). On endoscopic biopsy esophageal lesions was moderately differentiated squamous cell carcinoma and gastric lesion was intramucosal adenocarcinoma. On endoscopic ultrasound esophageal lesion was arising from mucosal layer with intact muscularis propria (T1a, N0) and gastric lesion was superficial without invasion of the submucosa (T1 N0). Patient underwent ESD of both lesions in single sitting with complete en-block excision of the lesion. On follow up check endoscopy at 3 months and 6 months, no evidence of recurrence lesion was observed.
Conclusion Endoscopic submucosal dissection is a feasible option for curative resection of early malignancies of the gastro-intestinal tract.
Keywords Early GI malignancy, ESD, Synchronous malignancy
342
Unusual presentation of a large GIST in extraintestinal site: An intra-operative surprise and challenging diagnostic dilemma
Govind Purushothaman, Jeswanth S
Correspondence- Govind Purushothaman-govindmmc@gmail.com
Department of Surgical Gastroenterology and Liver Transplant, Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College and Hospital, No. 1, Old Jail Road, Chennai 600 001, India
Introduction GISTs are rare mesenchymal tumors that can arise in any part of the GIT. Most of these tumors arise in the stomach and small intestine. It should be noted that, GISTs that originate from outside of the GIT, are defined as EGISTs and are usually arise from omentum, mesentery and retroperitoneum, adjacent, but separate from the stomach and the intestine. EGIST accounts for 10% of all GISTs.
Case Study Sixty-year-old male presented with left hypochondrial pain for 1 week with fever and vomiting, no addictions. Examination showed non tender mass in left hypochondrium, not moving with respiration. Blood investigations were normal. USG abdomen showed 8*10 cm cystic lesion in epigastrium, abutting inferior margin of liver and distended gallbladder and cholelithiasis. MRI showed a 15*7.2*8 cm bilobed lobulated thick walled lesion, ? pancreatic pseudocyst in body and tail projecting anteriorly into lesser sac, wall thickness of 7 mm, with normal MPD in head and uncinate region, with cholelithiasis. With a preoperative diagnosis of pseudocyst pancreas, patient was planned for cystogastrostomy. However intraoperatively there was a large multilobulated cystic lesion, 15*15*20 cm ?arising from tail of pancreas with areas of hemorrhage inside the lesion along with solid components, extending from gastric pylorus to splenic hilum abutting stomach posterior wall to transverse mesocolon, suggestive of an extraluminal neoplasm. The patient thus underwent distal pancreatectomy along with splenectomy and cholecystectomy (in view of cholelithiasis). Histopathology report showed gastrointestinal stromal tumor, staining positive for CD 117.
Conclusion We present a case of EGIST which masqueraded as pseudocyst pancreas on imaging. Other than individual case reports and small case series on EGIST, the number of cases has been limited. Further studies on the pathogenesis, behavior, and molecular biology of EGIST are needed before evidence-based diagnostic or prognostic recommendations can be made.
Keywords Extra-gastrointestinal stromal tumor incidence
Nutrition
343
Hospital malnutrition and its clinical significance in children with acute viral hepatitis
Wamique Khan, Shashwat Jha, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, Era's Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Introduction Hospital malnutrition is malnutrition diagnosed at any time during hospital stay. Hospital malnutrition which depends on various factors is common in pediatric inpatients as their nutritional status often deteriorates during hospital stay. Acute viral hepatitis in children is a major public health problem in both developing and developed countries .Given the protein catabolism and higher energy requirement and dietary taboos associated with acute viral hepatitis, energy intake will probably be inadequate, increasing the risk of hospital malnutrition and its complications. Hence we planned this study to identify nutritional risk in hospitalized children with acute viral hepatitis and to evaluate its correlation with clinical outcome.
Methods This cross-sectional study was conducted for a period of 18 months with a sample size of 70. All admitted children between 6-16 years who were clinically diagnosed as acute viral hepatitis were included. Nutritional assessment was done at admission, discharge, 2 weeks and 3 months post discharge. Nutritional assessment included W/A;H/A;W/H, and BMI. Nutritional risk screening was done by PYMS scoring system and on that basis the children were classified into high, medium and low risk patients. Outcomes were assessed in two aspects Nutrition and disease related.
Results The mean age of the cases was 10.10±3.71 years with maximum age of the cases was 16 years and minimum was 5.5 years. At the time of admission and discharge, 37.1% cases were at high risk, 38.65 were at medium risk and only 24.3% at low risk. The mean length of hospital stay of high-risk cases was maximum 13.23±1.48 days and minimum 4.12±2.12 days in low risk cases (p<0.001). The mean hospital expenses of high-risk cases was maximum Rs 3589.62±395.98 (p<0.001).
Conclusions Hospitalized children of acute viral hepatitis with high nutritional risk have significantly higher length of hospital stay and hospital expenses
344
Combination of sarcopenia and high visceral fat predict poor outcomes in patients with Crohn’s disease
Gurasis Boparai , Saurabh Kedia, Devasenathipathy Kandasamy, Raju Sharma, Kumble Seetharama Madhusudhan, Nihar Ranjan Dash, Pabitra Sahu, Sujoy Pal, Peush Sahni, Rajesh Panwar, Sudheer K Vuyyuru, Bhaskar Kante, Davesh P Yadav, Venigalla Pratap Mouli, Govind Makharia, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Departments of Gastroenterology, Gastrointestinal Surgery, and Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Sarcopenia and visceral fat independently predict poor outcomes in Crohn’s disease (CD). However, combined influence of these parameters on outcomes in unknown. We estimated the prevalence of sarcopenia and its combined influence with visceral fat on outcomes in CD.
Methods This retrospective study evaluated skeletal muscle index (SMI-cross-sectional area of five skeletal muscles normalized for height), visceral and subcutaneous fat area and their ratio (VF/SC) on single slice computed tomography (CT) images at L3 vertebrae in CD patients (CT done between January 2012-December 2015, patients followed till December 2019). Sarcopenia was defined as SMI <36.5 cm2/m2 and 30.2 cm2/m2 for males and females respectively. Disease severity, behavior, and long-term outcomes (surgery and disease course) were compared with respect to sarcopenia and VF/SC ratio.
Results Forty-four patients (age at onset:34.4±14.1 years, median disease duration:48 [24–95] months, follow-up duration:32 [12–53.5] months, males:63.6%) were included. Prevalence of sarcopenia was 43%, more in females, but independent of age, disease severity, behavior and location. More patients with sarcopenia underwent surgery (31.6% vs. 4%, p=0.01). VF/SC ratio was also significantly higher in patients who underwent surgery (1.76+1.31 vs. 0.9+0.41, p=0.002), and a cut-off of 0.88 could predict surgery with sensitivity and specificity of 71% and 65% respectively. On survival analysis, probability of remaining free of surgery was lower in patients with sarcopenia (59.6% vs. 94.1% p=0.01) and those with VF/SC ratio >0.88 (66.1% vs. 91.1%, p=0.1), and lowest in those with both sarcopenia and VF/SC>0.88 than those with either or none (38% vs. 82% vs. 100%, p=0.01).
Conclusion Combination of sarcopenia and high visceral fat predict worse outcomes in CD than either of two.
345
Refeeding syndrome in a child with celiac disease: A rare entity
Hina Tabassum , Anantika Garg, Pallav Singhal, Sumaiya Shamshi, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background Refeeding syndrome is a rare and life-threatening pathology ascribed in those celiac patients who deteriorated clinically after initiation of a gluten-free diet (GFD) and had biochemical parameters such as hypophosphatemia, hypokalemia, hypocalcemia, and hypoalbuminemia.
Case characteristics Four-year-old girl presented with complaint of constipation, abdominal distension, vomiting, failure to thrive and anorexia. The child was emaciated and weighed 10.3 kg. Had pallor, distended abdomen but no organomegaly. Upper GI endoscopy was done showing D2 bald mucosa with scalloping. Duodenal biopsy had Marsh Gr 3c features. She was diagnosed as celaic disease and was discharged on GFD with weight gain of 500 g. However, she was readmitted after 12 days with complaint of poor oral intake, diarrhea and pain abdomen. She had severe dehydration with severe anemia and CHF. On investigation hypophosphatemia, hypokalemia, hypocalcemiaemia and hypoalbuminemia was present suggestive of refeeding syndrome. Patient was managed in the PICU with IV antibiotics, albumin and PRBC transfusion along with correction of all metabolic abnormalities as per protocol. Gradually, her enteral feeding was resumed and was discharged on 12 days, with weight gain of 2.9 kg, receiving GFD with oral supplementation of calcium and phosphorous.
Message Refeeding syndrome in children with celaic disease is a rare but known entity. It can result in prolonged hospital stay and even death if not recognized and treated promptly. Prevention is the key to avoid metabolic, physiologic and multi-organ complications.
Keywords Refeeding syndrome, Celiac disease
346
Clinico-epidemiological profile of patients undergoing feeding procedures in a tertiary care center- A descriptive cross- sectional study
S Rajeevan , A Chezhian, K Premkumar, R Murali, I Shubha
Correspondence- A Chezhian-chezhianannasamy@gmail.com
Department of Medical Gastroenterology, Madras Medical College, Near Park Town Station, Park Town, Chennai 600 003, India
Introduction Feeding procedures are done when patients are unable to take adequate nutrition orally. This could be due to gastrointestinal pathologies, critical illness, encephalopathy, etc. Patients with dysphagia can have oropharyngeal or esophageal pathologies. This study tries to characterise the clinicoepidemiological profile of patients undergoing feeding procedures in a tertiary care centre.
Methods Descriptive cross-sectional study conducted in Medical Gastroenterology Department of Madras Medical College for 1 year duration (September 2019 to August 2020) in 344 patients.
Results Of the 344 patients studied 263 (76.5%) were males and 81 (23.5%) were females. 82% of patients who underwent nasogastric tube (NGT) insertion and 62.9% of dilatation were males. Feeding procedures done were (NGT) insertion (66.3%), esophageal dilatation (25.9%), esophageal self-expanding metal stent (SEMS) (0.6%) and percutaneous endoscopic gastrostomy (PEG) (0.3%). 7% of patients underwent both dilatation and NGT insertion. Most of the patients had grade 3 dysphagia (61.9%). The median age of feeding procedures was 55 years (NGT-58 years; dilatation- 52 years). The most common indications for NGT insertion were carcinoma of oropharynx (46.9%), hypopharynx (29.4%) and esophagus (10.1%). The most common indications for esophageal dilatation were carcinoma of esophagus (34.8%) and hypopharynx (21.3%). Two patients with carcinoma esophagus underwent SEMS. PEG was done for a case of neurogenic dysphagia. Carcinoma esophagus affected upper third in 49.6% and middle third in 37.4% cases. Squamous cell carcinoma (96.9%) was the most common histological variant among malignancies. Corrosive injuries requiring feeding procedures were mainly of Grade 2B (60%) severity.
Conclusion In this study the most common feeding procedure was NGT insertion. Oropharyngeal cancer and esophageal cancer were the most common indications for NGT insertion and dilatation respectively. Squamous cell carcinoma was the most common histological variant in malignancies. Among corrosive injuries, acid poisoning and grade 2B injuries were more common.
Keywords Feeding, Dysphagia, Dilatation
Biliary Tract
347
A rare case of obstructive jaundice caused by tuberculosis
Dharmendra Tyagi
Correspondence- Dharmendra Tyagi-drdtyagi89@gmail.com
Department of Gastroenterology, Kurnool Medical College, Budhwarpet Road, Budhawarapeta, Kurnool 518 002, India
Introduction Extrapulmonary involvement occurs in one fifth of all TB cases and out of them, 60% have no evidence of pulmonary infection in chest radiograph or in sputum. Tuberculosis can present as a obstructive jaundice but it is a very rare entity with only a few cases reported. We are reporting unusual case of multiple enlarged tuberculous lymph nodes compressing the common bile duct in the retro pancreatic region and causing obstructive jaundice.
Case Report A 27-year-old male patient presented as yellowish discolouration of urine for 5 days with history of clay colored stool. There was no history of fever, vomiting, weight loss, abdominal pain and distension. Patient had history of contact with tuberculosis patient. On physical examination, icterus was present but normal GI examination. In laboratory investigation, LFT showed the pattern of obstructive jaundice. USG showed CBD dilatation of 9 mm.
MRCP showed cystic lesion at posterior aspect of head of pancreas with loss of fat plane appearing hyperintense on T2W and STIR images while hypointense on T1W images. Multiple small cysts seen in lesion. Size of lesion 29×24×38 mm. This lesion compressing CBD with diameter 11 mm. So patient kept for EUS which showed multiple, enlarged, discrete to ill defined, hypoechoic lymph nodes in per pancreatic and hilar region with few lymph nodes were matted and these lymph node were compressing the distal CBD causing proximal CBD dilatation of 8.7 mm with normal pancreatic duct. EUS guided biopsy was taken which showed granulomatous lymphadenitis with caseating necrosis indicated tubercular lymphadenopathy.
Conclusion Isolated peripancreatic tuberculous lymphadenitis is extremely rare. It is a diagnostic challenge and for that a high index of suspicion is needed and should be considered in the context of the peripancreatic or pancreas head mass especially in a young adult.
348
Demographic, clinical, biochemical and microbial spectrum of cholangitis patients admitted at a tertiary care centre in North India
Arpan Jain , Gaurav Padia, Anurag Mishra, Manish Kumar, Ujjwal Sonika, Ashok Dalal, Ajay Kumar, Siddharth Shrivastava, Sanjeev Sachdeva, Barjesh Chander Sharma
Correspondence- Arpan Jain-drjain.arpan@gmail.com
Department of Gastroenterology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, 1, J L N Marg, New Delhi 110 002, India
Background Acute cholangitis is the infection of the biliary tree with life threatening outcomes. The aim was to analyze the clinical profile, microbial spectrum and outcome of patients with cholangitis at our centre.
Methods A prospective observational study of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis (as per Tokyo guidelines) due to any biliopancreatic disorder from July 2019 to December 2019. Bile samples collected during ERCP were sent for culture and sensitivity. The demographic profile, clinical and biochemical profile, microbial spectrum along with their sensitivity patterns and patient outcome were studied. The data analysis was done with SPSS 23.
Results A total of 92 patients were included with median age of 49 (Range 15-85 years). Females comprised 73.9% (n=68). Etiology of cholangitis was mainly benign, most common being choledocholithiasis (n=42,45.6%). Cholangitis with underlying malignancy was less common (n=17,18.5%). Charcot’s triad (n=44,47.8%) was more common than Reynod’s pentad (n= 3,3.3%). Renal failure was the predominant organ failure (n=14,15.2%) and 12 cases had hypotension at admission (8 patients required inotropic support). Mean leukocyte count was 16876±6496/mm3, bilirubin and alkaline phosphatase (ALP) levels were 9.60 ± 7.18 mg/dL and 596±471 U/L, respectively. Mean serum procalcitonin levels were 3.19 ± 1.8 ng/mL. Most frequent organism identified on bile culture was E. coli (n=35,38%) followed by pseudomonas (n=20, 21.7%) and Klebsiella (n=7, 7.6%) and was sterile in (n=28, 30.4%) cases. Most sensitive antibiotic was imipenem followed by tigecycline and piperacillin/tazobactum. Multidrug resistant organisms (n=25, 27.2%) were also identified. Mean hospital stay was 8 ± 7.6 days, with most cases being discharged (n=80, 87%) and with mortality in 12 patients.
Conclusion Gram negative organisms were the most frequent cause of cholangitis with E. coli and pseudomonas being the most common. Emergence of multidrug resistant organism mandates judicious use of antibiotics in hospital settings. Cholangitis was more frequent due to benign etiologies.
349
Impacted distal pancreatic duct calculus causing obstructive jaundice and double duct sign
Gursimran Kaur 1 , Mahesh Kumar Gupt, Avnish Seth
Correspondence- Avnish Seth-avnish.seth@fortishealthcare.com
Gastroenterology and Hepato-Biliary Sciences, Fortis Memorial Research Institute, Gurugram 122 002, India
Background Simultaneous dilatation of common bile duct and pancreatic duct, the double-duct sign, is considered an ominous finding at imaging and usually suggestive of peri-ampullary malignancy.
Case Report 32-year-old male presented with pain epigastrium and right upper abdomen with jaundice for 3 days. The pain was severe, exacerbated with meals and was radiating to the back. There was history of episodes of similar pain without jaundice for last 3 years. There was no history of fever, weight loss, alcohol intake, steatorrhea or diabetes. On examination there was icterus and marked epigastric tenderness. Bilirubin was 6.5 mg/dL, ALT 1450 U/L, GGT 760 U/L, lipase 90 U/L, CA-19.9 58 U/mL. MRCP showed dilated entire MPD of up to 8 mm with clubbing of side branches and possible impacted stone at distal end. Bile duct dilated 9 mm with no filling defect. EUS confirmed double duct sign with changes of chronic pancreratitis with impacted distal MPD stone and dilated CBD till distal end with no filling defect. ERCP showed bulky ampulla and of 7 mm diameter impacted stone was removed from distal PD with needle-knife pre-cut and manipulation. 10F X 8 cm plastic tannenbaum stent was placed in CBD and 7F X 8 cm percuflex plastic stent was placed in PD. Pain abdomen and LFT improved rapidly. Both stents were removed at 3 months and he continues to do well on medical treatment for chronic pancreatitis.
Conclusion Impacted distal pancreatic duct stone can present with obstructive jaundice and double duct sign.
350
IgG4-related sclerosing cholangitis: A great mimicker
Hemant Nayak, Sunil Jee Bhat , Manas Kumar Panigrahi, Subash Chandra Samal
Correspondence- Hemant Nayak-drhemantnayak@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction IgG4-related sclerosing cholangitis (IgG4 SC) is the biliary manifestation of IgG4 related disease often in association with autoimmune pancreatitis. Here we report two patients of IgG4 SC mimicking primary sclerosing cholangitis and carcinoma head of pancreas, respectively.
Case 1 A 16-year-old boy presented with history of recurrent self-limiting episodes of jaundice and pruritus for last 4 years. liver function tests (LFT) suggested cholestatic jaundice. Ultrasound abdomen was non-contributory. Magnetic resonance cholangiopancreatography (MRCP) was characteristic for multiple intrahepatic biliary strictures with beaded appearance and long segment narrowing in distal segment of common bile duct (CBD). Serum IgG4 level was raised 227 mg/dL (80-120 mg/dL). Contrast enhanced computed tomography (CECT) of abdomen revealed bulky pancreas. After receiving prednisone 40 mg daily for 2 months, jaundice settled and biliary strictures resolved on repeat MRCP. He is on maintenance azathioprine 50 mg without any relapse in last 8 months.
Case 2 A 54-years-old woman presented with abdominal pain, weight loss and anorexia for 2 months. Her physical examination revealed marked pallor, mild icterus, and left axillary lymphadenopathy. Laboratory investigations showed pancytopenia, hyperbilirubinemia, mild transaminitis and elevated alkaline phosphatase. CECT abdomen revealed bulky pancreas and CBD dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) revealed distal CBD stricture and beaded appearance of pancreatic duct in head of pancreas. Serum IgG4 was significantly raised (815 mg/dL). We suspected IgG4 SC. Patient received oral prednisolone 40 mg for 4 weeks and tapered over next 8 weeks. After 8 weeks, all her symptoms and signs improved. Repeat ERCP after 2 months revealed complete resolution of pancreatic and biliary strictures. No relapse was noted till 6 months of follow-up.
Conclusions IgG4 SC is an important treatable disease and it greatly mimicks other benign and malignant diseases of the pancreato-biliary system.
351
Profile of malignant obstructive jaundice in a tertiary care centre of West India
Partha Debnath , Rahul Deshmukh, Pankaj Nawghare, Sameet Patel, Parmeshwar Junare, Ravi Thanage, Sanjay Chandnani, Qais Q Contractor, Pravin Rathi
Correspondence- Partha Debnath-partha628@gmail.com
Department of Gastroenterology, Topiwala National Medical College, B Y L Nair Hospital, Mumbai 400 008, India
Introduction Malignant obstructive jaundice is one of the common causes of referral to a Gastroenterologist. Our study aimed to identify the etiology and clinical profile of malignant obstructive jaundice cases in our center.
Methods One hundred patients with malignant obstructive jaundice over a period of 1 year (January 2019- February 2020) were studied. The diagnosis was based on imaging findings along with cytology/histopathology. Demographic, clinical, biochemical, Imaging, ERCP, and cytology findings were recorded.
Results Of the 100 patients mean age was 57.47±13.87 years (median age 60 years), 54% of patients were females. The mean duration of symptoms before diagnosis was 1 month. Cholangiocarcinoma was the commonest etiology (36%), followed by gallbladder cancer (26%), ampullary carcinoma (22%), carcinoma head of the pancreas (13%), lymphoma (2%), and one case of retroperitoneal neuroendocrine tumor with liver metastasis (1%). Clinical profile of patients included jaundice (100%), abdominal pain (68%), loss of appetite (50%) and weight (40%), fever (27%), abdominal mass (29%), pruritus (20%), vomiting (14%). 64% of patients of gallbladder cancer had a history of cholelithiasis. Cholangitis was present in 32% gallbladder cancer, 25% in cholangiocarcinoma, 30% in ampullary carcinoma, 7.7% in carcinoma head of the pancreas. Imaging was suggestive of type 1 block in 100% patients with ampullary carcinoma and carcinoma head of the pancreas, and type1, type 2, type 3, type 4 block was seen in (36%/30%/6%/28%) gallbladder cancer, (44%/15%/0%/41%) of cholangiocarcinoma cases. Advanced stage disease (stage 3 and 4) at diagnosis was seen in 72% of gallbladder cancer, 55.5% in cholangiocarcinoma, 46.2% in carcinoma head of the pancreas.
Conclusion Cholangiocarcinoma (36%) is the most common etiology of malignant obstructive jaundice in our center. The majority of the cases occur in the older age group with slight female preponderance (54%). Majority of the patients presented in an advanced stage.
352
Endoscopic ultrasound for characterization of distal common bile duct block- Is it better than MRCP?
Rahul Kakkar , Shraddha Sharma, Naveen Yadav, Sewaram Chaudhary, Sabir Hussain, Narender Bhargawa, Sunil Dadhich
Correspondence- Rahul Kakkar-kakkarrahul1805@gmail.com
Department of Medical Gastroenterology, Dr. S N Medical College, Residency Road, Near Sriram Excellency Hotel, Opposite Petrol Pump, Sector-D, Shastri Nagar, Jodhpur 342 003, India
Background Endoscopic ultrasound (EUS) is a novel technology which is being increasingly utilised to visualize the gastrointestinal tract as well as nearby structures mainly liver, gallbladder, pancreas, biliary tract and lymph nodes. EUS guided FNAC or biopsy helps to obtain tissue diagnosis. Role of EUS has now increased from diagnostic tool to therapeutic tool.
Aim To compare the efficacy of EUS with MRCP in the characterisation of pathology in patients presented with surgical obstructive jaundice (SOJ).
Methods We have planned a study in our department in patients who presented with clinical and radiological findings of SOJ. The study included 255 patients from January 2019 to July 2020. Both EUS and MRCP were done in these patients. In case of mass lesions, EUS guided FNAC was done either from mass lesion or from metastatic lymph nodes, whichever feasible.
Results The most common pathology was choledocholithiasis (n=110), followed by pancreatic malignancy (n=57), gallbladder (GB) malignancy with common bile duct (CBD) involvement (n=45), distal CBD cholangiocarcinoma (n=17), ampullary malignancy (n=16), hilar cholangiocarcinoma (n=5) and choledochol cyst (n=5). In our study, we found that EUS is superior than MRCP for the characterization of lesions causing distal CBD block (sensitivity of EUS and MRCP was 98.9% and 95.8% respectively) while MRCP is better in case of hilar block (sensitivity of MRCP and EUS were 94.6% and 83.8% respectively) and both have equal efficacy in evaluation of mid CBD block (sensitivity of 100% for both MRCP and EUS).
Conclusions EUS has very high sensitivity and specificity for the characterization of distal CBD lesions in patients presented with SOJ as compare to MRCP. It also has an additional advantage of obtaining tissue for diagnosis as compare to other diagnostic modalities.
353
Laparoscopic single-stage management of cholecystogastric fistula- A rare case report and review of literature
Anandkumar Jayaram , Narayan Prasad, Kavya Taranath
Correspondence- Anandkumar Jayaram-anandsgn@gmail.com
Department of General and Minimally Invasive, RMV Hospital, No 138, RMV 2nd Stage, AECS Layout, Sanjay Nagar, Bengaluru 560 094, India
We hereby present a very rare case report of cholecystogastric fistula in an elderly female patient, which was managed by laparoscopic single stage approach. Patient had on and off abdominal pain and bloating sensation. After thorough investigation, patient was taken up for laparoscopic cholecystectomy for chronic calculous chlecystitis. Intraoperatively, incidentally along with lot of adhesions to the gallbladder there was a cholecystogastric fistula which was managed by laparoscopic single-stage approach entirely. We here by present this case, highlighting the rarity of its incidence, the clinical findings and complications associated, diagnostic imaging and, the surgical approaches and its technical challenges in managing such cases and the review of literature as a video presentation link attached below.
354
Clinical profile of acute cholangitis in tertiary care centre
Shubha Immaneni, Sambit Kumar Bhuyan , Premkumar K, Murali R, Chezhian Annasamy
Correspondence- Shubha Immaneni-gastroshubha@gmail.com
Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India
Introduction Cholangitis defined as inflammation of biliary tract, mostly caused by bacterial infection and obstruction of bile duct or hepatic duct. Acute, cholangitis characterized by abdominal pain, jaundice, and fever (Charcot’s triad) as well as confusion and septic shock (Reynolds’ pentad). This study was to know different etiology of cholangitis patients attending tertiary care Hospital.
Method It’s a retrospective observational study carried out over a period of 1 year from September 2019 to August 2020 at Medical Gastroenterology Department ward of Madras Medical College of all acute cholangitis patients, diagnosed using updated Tokyo Guidelines, with regards to demographics and etiology.
Results Total 180 patients diagnosed with cholangitis, 94 were male and 86 were female, with mean age of 51years. One hundred and fifty-five (80%) were acute suppurative cholangitis, 22 (12%) were recurrent suppurative cholangitis, two were primary sclerosing cholangitis and one was IgG4 related cholangitis. Common causes of acute cholangitis were choledocholithiasis (57%), CBD stricture (18%) which includes benign stricture (11%) and malignant stricture (7%), malignant CBD occlusion (15%) which includes ampullary tumor (10%), pancreatic tumor (3%) and bile duct tumor (2%). Other rare causes that leads to acute cholangitis were pancreatitis 3%, EHPVO with portal biliopathy 2%, postoperative bile duct injury 2%, post ERCP 2% and duodenal diverticulum 1%. Out of 88 acute cholangitis patients with choledocholithiasis 39 (25%) were male and 49 (31%) were female. Severity grading of acute cholangitis patients were 26% mild, 43% moderate and 32% severe.
Conclusion From this study it is concluded that choledocholithiasis and CBD stricture were most important cause of acute cholangitis. Early clinical diagnosis and accurate diagnostic workup including etiology-oriented imaging is needed for prompt and appropriate management of cholangitis.
Keywords Acute cholangitis, Choledocholithiasis, CBD stricture
355
Bronchobiliary fistula - A rare complication secondary to portal cavernomatous cholangiopathy
Tejaswini Tumma , Ramesh Kumar B, Ramanna Macherla
Correspondence- Tejaswini Tumma-tejaswinitumma@gmail.com
Department of Gastroenterology, Osmania General Hospital, Afzalgunj Road, Afzal Gunj, Hyderabad 500 012, India
Introduction Bronchobiliary fistula is a rare condition consisting of communication between biliary tract and bronchial tree presenting with bilioptysis and suspicious pneumonia. The management of this condition is challenging with limited current evidence to date.
Case Report We are reporting a 45 yrs male patient presenting with complaints of cough with green coloured sputum and shortness of breath since 2 months. He is a K/C/O portal cavernoma. He had a past history of right liver lobe abscess with rupture into pleural cavity 4 years back.
Investigations TSB – 1.61 mg/dL, ALP – 628 IU/L, sputum is positive for bile pigments. Ultrasound abdomen – portal cavernoma with mild central IHBrD. Chest X-ray – right lower lobe patchy consolidation. MRCP – stricture at CHD and CBD level secondary to portal biliopathy with mild upstream IHBrD. ERCP was done confirming the stricture and on dye injection leakage of dye into right lower lobe of lung noted.8Fr DPT CBD stent deployed with free flow of bile noted. Bilioptysis and dyspnea decreased after stenting and CXR was cleared of patchy consolidation. Symptoms again recurred after 2 months and patient underwent stent exchange. Despite improvement for short-time symptoms recurred again. So patient was referred for surgery. He underwent shunt procedure in view of portal cavernoma and fistula was identified and closed.
Conclusion Bronchobiliary fistula is a serious complication associated with high morbidity and mortality and requires high index of suspicion for diagnosis and requires well planned management strategy.
Keywords Portal cavernoma, Bilioptysis, CHD stricture, Broncho biliary fistula
356
A case report of rare congenital anomaly of gallbladder and cystic duct
Jigar Aagja , Manish Chaudhari
Correspondence- Jigar Aagja-jigaraagja@gmail.com
Department of General Surgery, Government Medical College Surat, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Congenital anomalies of the gallbladder are rare and can be accompanied by other malformations of the biliary or vascular tree. Anatomical variations of cystic duct (CD) are frequently unrecognized. It is important to be aware of these variations prior to any surgical, percutaneous, or endoscopic intervention procedures. A phrygian cap is a congenital abnormality of the gallbladder with an incidence of 4%. A case of calculous cholecystitis with phrygian cap and low insertion of cystic duct along with pancreatic bead on left posterior part of CHD which was identified on MRCP. Patient operated as laparoscopic cholecystectomy. This case is reported for its rarity and difficulty in operating. Postoperative period is uneventful.
Pharygian Cap, congenital anomaly of GB and CD.
357
A rare case of choledochal cyst with pancreatic divisum and complex anamolous pancreaticobiliary junction
Bontha Vineesha , Shanmuganathan Subramanyam, Ganesh Panchapakesan
Correspondence- Bontha Vineesha-bontha.vineesha@gmail.com
Department of Medical Gastroenterology, Sri Ramchandra Institute of Higher Education And Research, Chennai 600 116, India
A 16-year-old female child with no significant past illness presented to the outpatient department with 10-day history of abdominal pain and high colored urine. The pain was localized to the right upper quadrant, associated with nausea and vomiting and was intermittent, each episode lasting for 3-4 hours. The patient reported normal colored stools. Patient did not report fever, pale stools or pruritus during the course of illness. Examination was remarkable for scleral icterus and mild tenderness over the right hypochondrium. Blood investigations were done, showed cholestatic jaundice (total bilirubin: 2.99 mg/dL, direct bilirubin: 1.63 mg/dL, alkaline phosphatase: 319 IU/L, alanine transaminase: 204 IU/L, aspartate transaminase: 125 IU/L, serum albumin: 4.3 g/dL). Abdominal ultrasonography showed a normal liver size and echo texture, dilated common bile duct (1.8 cm) along with dilated intrahepatic biliary radicles. Multiple calculi were noted in the gallbladder, with wall thickening suggestive of calculous cholecystitis. An MRCP (magnetic resonance cholangiopancreatography) was done. The findings were suggestive of a choledochal cyst (type IV a) along with a complex type of anomalous pancreatobiliary ductal union and a variant of pancreas divisum with choledocholithiasis. Patient was taken up for ERCP (endoscopic retrograde cholangiopancreatography) under general anesthesia. Ampulla was noted deep in 2nd part of duodenum. Selective bile duct cannulation was done and guidewire was placed into the right intrahepatic duct. Cholangiogram confirmed the findings of MRCP. Endoscopic biliary sphincterotomy was done. Balloon trawling was done to extract CBD stones. Multiple tiny calculi and sludge was extracted. Biliary stenting was done using a double pigtail stent of size 7Fr. Patient improved symptomatically, and liver functions normalized over a week. Patient was referred to a specialized center for surgery.
Keywords Choledochal cyst, Pancreatic divisum, Abnormal pancreatico biliary malunion
358
Preoperative risk factor used for verification of operative grading system for conversion from laparoscopic cholecystectomy to open cholecystectomy
Palak Paliwal , Krishnanand Anand
Correspondence- Palak Paliwal-dr.palakpaliwal@gmail.com
General Surgery, L N Medical College and J K Hospital, J K Town Kolar Road Sector, Sarvadharam C Sector, Bhopal 462 042, India
Introduction Laparoscopic cholecystectomy is the most commonly done procedure for gallstone disease. Preoperative prediction factors are helpful to categorize patients and take timely measures. The CLOC score compromises of preoperative variable such as patient demographics, indications for surgery, ASA grade, admission type and ultrasound findings. The key aspects of operative grading system (OGS) include: 1) gallbladder appearance and amount of adhesions, 2) degree of distension/contracture of gallbladder, 3) ease of access, 4) local/septic complications, and 5) time taken to identify the cystic artery and duct. OGS grades the difficulty into mild, moderate, severe and extreme. This study is a prospective observational study with the aim to predict intraoperative grading score for conversion from laparoscopic to open cholecystectomy.
Methods This study was done at L N Medical College, Bhopal of 100 patients who underwent laparoscopic cholecystectomy from June 2018 to June 2020. Inclusion criteria are patient >18 years, giving informed consent, with acute or chronic cholecystitis with cholelithiasis. A comparison was made between the preoperative risk factors and intraoperative findings based on OGS. The outcome measures are prediction of conversion from laparoscopic to open cholecystectomy, bile duct injury, intraoperative and postoperative complication and duration of hospital stay.
Result Out of 100 cases, 14 cases were converted into open procedure. The cases with intraoperative complications like bile leak, bile duct injury etc were found to be 19. In converted cases, 1 case fell into moderate grade, 3 into severe grade and 10 into extreme grade. Also, 4 cases underwent bile duct exploration and repair in the same sitting while 2 cases underwent delayed bile duct exploration. Out of 100 cases, 3 cases were associated with postoperative complications.
Conclusion Operative grading system provides a better scoring system and aids the surgeon in making decision in case of difficult cholecystectomy.
Keywords Operative grading system, Preoperative risk factors, Laparoscopic cholecystectomy, Open cholecystectomy
359
Endoscopic therapy of traumatic bile leaks
P Abdul Samad , Shravan Kumar P, Uma Devi M, Sai Krishna K, Issac Abhilash M, Kishan N, Sri Ram S, Anirudh K, N S V M Krishna M, Swapnika G, Abhinay Raja Rao P, Tarun B, Gurunath B, Sivarama Krishna D
Correspondence- P Abdul Samad-samad.abdul30@gmail.com
Department of Gastroenterology, Gandhi Medical College, Musheerabad, Secunderabad 500 003, India
Traumatic bile leaks often result in high morbidity and prolonged hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Our study objective was to evaluate the efficacy of the endoscopic management of a traumatic bile leak. We performed a retrospective case review of patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP) after traumatic bile duct injury secondary to blunt trauma (motor vehicle accident or fall from height) for management of bile leaks at our tertiary hospital. Three patients underwent ERCP for the management of a traumatic bile leak over a 1-year period. The etiology included blunt trauma from motor vehicle accident in 2 patients or fall from height accident in 1 patients. Liver injuries were grade III in 1 patient, grade IV in 2 patients. All patients were treated by biliary stent placement, and the outcome was successful in 3 of 3 cases (100%). The mean duration of follow-up was 90 days. There were no ERCP-related complications. In our case review, endoscopic management with endobiliary stent placement was found to be successful and resulted in resolution of the bile leak in all 3 patients. Based on our study results, ERCP should be considered as first-line therapy in the management of traumatic bile leaks.
360
Prevalence of gallbladder stasis in patients with asymptomatic and symptomatic gallstones
Tejinder Kaushal, Chhagan Lal Birda , Pankaj Gupta, Raghu Ram, Dimple Kalsi, Divya Dahiya, Lileswar Kaman, Harshal S Mandavdhare, Vishal Sharma, Arun Kumar Sharma, Usha Dutta
Correspondence- Usha Dutta-ushadutta@gmail.com
Departments of Gastroenterology, General Surgery, Internal Medicine, and Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction Among patients with gallbladder cancer (GBC), 80% have gallstones (GS), most of whom are asymptomatic. Gallbladder (GB) stasis in patients with GS promotes development of preneoplastic lesions. The prevalence of GB stasis in patients with asymptomatic gallstones (AGS) is not known. We conducted a study to determine the prevalence of GB stasis among patients with AGS and compare it with symptomatic GS(SGS).
Methods Consecutive patients with GS were enrolled in a prospective case-control study after informed consent. Patients with symptomatic (SGS) and asymptomatic gallstones (AGS) were recruited as cases and controls based on the presence/absence of biliary symptoms. All patients underwent clinical and ultrasound assessment at 30 and 60 minutes post-fatty meal for gallbladder ejection fraction (GBEF). Gallbladder stasis (GBS) was defined as GBEF <40%. Chi-square and Mann-Whitney U tests were used for comparison and p< 0.05 was taken as significant.
Results The mean age and gender profile were similar in the SGS (n=50) and AGS (n=37) groups. Dyspepsia symptom score and biliary symptom scores were significantly higher in patients with GBS compared to no GBS (5 [3.25,6] vs. 4 [3,5]; p=0.003) and (32 [0,35] vs. 0 [0,33]; p=0.001) respectively. GBEF at 30 minutes showed a significant negative correlation with dyspepsia score (-0.230, p=0.03) and biliary symptom score (-0.216, p=0.04). All the patients with SGS had history of definite biliary colic with median biliary symptom score of 34 (IQR-32,35). Median dyspepsia symptom scores were significantly higher in SGS group compared to AGS (5 [4,6] vs. 3 [2,4]; p<0.001). Median GBEF at 30 minutes and 60 minutes were significantly higher in patients with AGS compared to SGS (43.3 [22,61] vs. 28.2 [17,48]; p=0.029) and (47 [33,82] vs. 41 [28,63]; p=0.020) respectively; though both were suboptimal. Patients with SGS more often GB stasis than those with AGS (66% vs. 40.5%, p=0.018).
Conclusions GBEF was significantly lower in patients with SGS compared to AGS. GB stasis was present in 40% of patients with AGS and 66% in patients with SGS. GB stasis was associated with higher dyspepsia and biliary symptom scores.
Keywords Gallbladder stasis, Asymptomatic gallstones, Gallbladder ejection fraction
361
Prevalence of H. pylori infection in patients with gallstone disease and its relationship with gallbladder function
Tejinder Kaushal , Chhagan Lal Birda, Nikhil J Bush, Pankaj Gupta, Raghu Ram, Priyanka Popli, Divya Dahiya, Lileswar Kaman, Harshal S Mandavdhare, Vishal Sharma, Arun Kumar Sharma, Usha Dutta
Correspondence- Usha Dutta-ushadutta@gmail.com
Departments of Gastroenterology, General Surgery, Internal Medicine, and Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
Introduction Patients with gallstone disease (GSD) are at increased risk for gallbladder cancer (GBC). H pylori (Hp) has been identified as a cofactor in the pathogenesis of GBC. Prevalence of Hp in patients with GSD and its relationship with GB function is not known. This study was planned to study prevalence of Hp and its relationship to symptom profile and GBEF in patients with GSD.
Methods Consecutive patients of GSD in a prospective cross-sectional study between March 2019 to November 2019 were enrolled. All patients underwent clinical, demographic and ultrasound abdomen assessment for GS and gallbladder ejection fraction (GBEF). GBEF was calculated after 30 and 60 min of standard fatty meal. Gallbladder stasis was defined as GBEF<40%. Sera was analyzed for anti H. pylori IgG antibody. Upper gastrointestinal endoscopy (UGIE) was done to assess for Hp related changes and biopsies were taken for histopathology and rapid urease test (RUT). Chi-square and Mann-Whitney U tests were used for comparison and p value < 0.05 was taken as significant.
Results Patients with GS (n=87) with a mean age of 48.5±14.9 yrs (F:73.6%) were evaluated. Multiple stones were present in 61%. Mean GBEF at 30 min was 35±21% and at 60 min was 48±26%. GB stasis was present in 55.8% (48/87) patients of GS. UGIE showed antral hyperaemia in 95.4% and duodenitis in 35.3% of the patients. Hp+vity by RUT or serology, was seen in 40% patients; of which RUT was positive in 75%. Active Hp infection (RUT +ve) was more often associated with gallbladder stasis (45.7% vs. 15.6%, p=0.1); however, it was not significant. However, active Hp infection was more often associated with very low GBEF (<30%) (14/27 vs. 7/41, p=0.01).
Conclusion Patients with GS had high overall prevalence (40%) of Hp infection, of which 75% was active. Active Hp infection was more often associated with GB stasis.
Keywords Gallbladder stasis, H. pylori, Gallstone disease
Miscellaneous
362
Abdominal gas – Patients’ perception sometimes differ from medical knowledge
Madhusudan Saha, Bimal Chandra Shil
Correspondence- Madhusudan Saha-madhunibedita@yahoo.com
Department of Gastroenterology, North East Medical College, Bangladesh, North East Medical College, Sylhet, Bangladesh, Sir Salimullah Medical College and Mitford hospital, Dhaka, Bangladesh
Aim and Objectives Patients try to correlate varieties of symptoms with abdominal gas. So, this study was designed to see the patients’ view regarding abdominal gas and its relation with medically explained symptoms.
Method Consecutive patients with complain of abdominal gas were included in this study. Their demographical information and explanation of symptoms resulting from abdominal gas, they believed were recorded on a predesigned data sheet. Statistical analysis was done using SPSS 20 version.
Result Total 346 patients, male 239 (69.1%), female 107 (30.9%), age varying from 17 to 83 years (mean 38.27) were enrolled. Common symptoms were bloating (fullness) of abdomen (194, 56.1%), abdominal pain (164, 47.41%), belching or eructation (149, 43.1%), heart burn (137, 39.6%), anorexia (124, 35.8%), nausea (120, 34.7%), noisy bowel (88, 25.4%), chest pain (79, 22.8%), headache (56, 16.2%), whole body pain (58, 16.8%), incomplete bowel evacuation (185, 53.5%), excess flatus (76, 22.4%), movement of gas to different part of body including head 87 (25.1%) and expulsion of hot air from ear, nose and head in 69 (19.9%) patients. Among them 107 (30.9%) patients believed abdominal gas to be a curable disease with treatment and 222 (64.2%) believed it to be a relapsing disease even after treatment. And 307 (88.7%) patients were taking proton pump inhibitor (PPI) as its remedy regularly.
Conclusion Most of the symptoms of patients can be explained by abdominal gas. Again, some patients have a misperception regarding some symptoms like heart burn, noisy bowel and sense of incomplete bowel evacuations are also related with abdominal gas. But in some instances causal relations with patients’ symptoms and abdominal gas could not be explained by medical knowledge. These difference in perceptions might be related to their personal thinking and social, cultural, educational, economic condition.
363
Assessing prevalence of microsatellite instability and Lynch syndrome amongst colorectal cancer patients in India
Harsh Sheth 3 , Abhinav Jain 1 , Chandni Patel 4 , Suresh Advani 7 , Liyana Thomas 7 , Mithun Shah 8 , Pankaj Shah 8 , Vipul Yagnik 6 , Avinash Tank 2 , Darshan Bhansali 1 , Manish Gandhi 1 , Tarang Patel 1 , Natu Patel 1 , Ashok Patel 1 , Chirag Shah 1 , Bharat Parikh 5 , Frenny Sheth 4 , Jayesh Sheth 4 , Sunil Trivedi 4 ,
Correspondence- Harsh Sheth-harsh.sheth@frige.co.in
1 CIMS Hospital, Science City Road, Science City, Panchamrut Bunglows II, Sola, Ahmedabad 380 060, India, 2 Dwarika Clinic, 301 Shilp Arcade, Jodhpur Cross Road, Satellite, Ahmedaba, 380 015, India, 3 FRIGE's Institute of Human Genetics, Frige House, Jodhpur Gam Road, Satellite, Ahmedabad 380 015, India, 5 HOC Vendant Hospital, Near, 1st Floor, Vedanta Institute of Medical Sciences, Lalit Kunj Society Road, Navrangpura, Ahmedabad 380 009, India, 6 Nishtha Surgical Hospital and Research Centre, 4th Line, 1st Floor, Kilachand Shopping Centre, Station Road, Patan 384 265, India, 7 Sushrut Hospital, Mumbai, India, and 8 Zydus Cancer Hospital, Ahmedabad, India
Microsatellite instability (MSI) and Lynch syndrome (LS) prevalence in colorectal cancer (CRC) patients is estimated to be 15% and 3% in European populations. Microsatellite instability (MSI) testing in all CRC patients is now recommended by NCCN and NICE guidelines to detect LS patients. However, since prevalence estimates from India are not available, no such practice guidelines are available in India. We aim to systematically assess the prevalence of MSI and LS in CRC patient population from India. Venous blood and primary tumor biopsies were prospectively collected and analyzed for MSI using Promega fragment length analysis assay and BRAF V600E using Q-PCR. Patients with MSI-high BRAF-negative tumor biopsies were assessed for LS using germline DNA sequencing of the mismatch repair genes (MLH1, MSH2, MSH6, PMS2 and EPCAM). Within 1 year of a 3 year study, 62 patients have been recruited with CRC. Average age of recruitment was 51±15 years, 71% were males and ~45% of cancers originated in rectum. MSI testing in these patients show MSI-high phenotype in 20 patients (32%). Of these, 17 patients (85%) were negative for BRAF V600E mutation. Germline testing in these patients have shown known and novel mutations in the MLH1 and PMS2 genes. More than 90% of LS patients had a mutation in MLH1 gene with highest occurrence of c.156delA mutation. Ad hoc analysis of the prospective study cohort suggests higher prevalence of MSI and LS in CRC patient population in India. Analysis of the entire patient cohort (n=300) in 2022 will provide a robust estimate of the prevalence of MSI and LS in CRC patients in India. These estimates would help in formulation of national guidelines for MSI testing, LS diagnosis and aspirin based chemoprevention strategies of CRC in India.
364
Ingested foreign body in children’s - A single centre study from South India
Sajith Sebastian , Benoy Sebastian, Mary George
Correspondence- Sajith Sebastian-drsaseneeruvelil@gmail.com
Department of Medial Gastroenterology, Medical Trust Hospital, Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
A total of 32 cases of foreign body ingestion in aerodigestivive tract who underwent endoscopy in Medical Trust Hospital, Kochi between October 2018 until June 2019 were selected for the study. All the cases selected and studied in detail for age, sex, incidence, type of foreign body, site of lodgement, presenting symptoms of were noted.
Results A total of 32 children's were included in the study which including both male children's (15, 46.87%) and female children's (17, 53.12%). Gender distribution and Site of foreign body females presented slightly more commonly following a foreign body ingestion. Of the children s admitted with symptoms of foreign body ingestion, the most common site of FB lodgement were in post cricoid and lower esophagus (9.375%). Others side of impaction were base of tongue, pyriform area, upper esophagus, stomach and duodenum. No foreign body were seen in OGD in 13 % of males and 16 % of female children with suspected foreign body ingestion. Presentation of foreign body ingestion. The most common presentation was a foreign body sensation or something struck in the throat after an accidental ingestion which occurred in 43.75 % of children’s followed by odynophagia and dysphasia occurring in 25% and 21.82% children´s. 15.6% had no complaints on presentation expect history of foreign body ingestion. Type of foreign body and site of presentation 18.75% presented were impacted coins. other foreign body found were fish bone, metal pins, batteries, and food impactions.
Conclusions Expert hands and clinical skills are necessary for early and safe removal. It is necessary to educate the parents about keeping away the article from reach of children and to observe the activity of child will prevent the higher incidence of a foreign body in children.
365
In today's era of high resolution-anorectal manometry and magnetic resonance defecography - Would you still use the finger?
Pratik Sethiya , Mayur Gattani, Shamshersingh Chauhan, Gaurav Kumar Singh, Saiprasad Lad, Kiran B, Kailash Kolhe, Harshad Khairnar, Sneha Deshpande, Vikas Pandey, Akash Shukla, Meghraj Ingle
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Departments of Gastroenterology, and Radiology, Lokmanya Tilak Muncipal Medical College and General Hospital, Sion, Mumbai 400 022, India, and Departments of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai 400 012, India
Background Magnetic resonance defecography (MRD) and high-resolution anorectal manometry (HR-ARM) are advanced tools for defining pelvic floor anatomy and thus help in detection of dyssynergia. Digital rectal examination (DRE) is a simple bedside test done on outpatient basis which has also shown to detect dyssynergia in patients with constipation with high sensitivity. The objective of the study was to evaluate usefulness of DRE as compared with HR-ARM and MRD as a marker for detection of dyssynergic defecation (DD).
Methods Thirty patients of chronic constipation (CC) defined by ROME IV criteria were enrolled. After ruling out structural causes of constipation using colonoscopy, all patients were subjected to undergo DRE and subsequently HR-ARM, blinded to DRE findings. MRD was reported by radiologist who was also blinded to the findings of DRE and ARM. The diagnostic yield of DRE was compared with that the HR-ARM and MRD.
Results Dyssnergia was diagnosed on DRE in (24/30) 80%, on ARM (23/30)76.6%, MRD 26.6% (8/30) of patients. The sensitivity, specificity, positive predictive value (PPV) of DRE in diagnosing DD were 90.91%, 57.14%, 86.96% respectively with correlation coefficient of 0.452 and p=0.01. Digital maneuvering significantly correlated with DD on HR-ARM (correlation coefficient of 0.43 and p=0.02) whereas paradoxical anal sphincter relaxation and DD correlated significantly with HR-ARM (correlation coefficient of 0.49 and p=0.006). Correlation of excessive descent on DRE with anorectal descent and rectocele on MR defecography (correlation coefficient 0.34 p=0.06) and (correlation coefficient 0.33 p=0.07) respectively was not statistically significant.
Conclusion DRE is useful bedside test in diagnosing DD with high sensitivity and PPV compared with HR-ARM. MRD is useful modality in identifying structural etiology for chronic constipation.
366
Evaluating etiology and clinical profile of infectious causes of febrile jaundice other than viral hepatitis (A to E)
Chaitanya Teja Annam , Ambika Prasad Mohanty
Correspondence- Ambika Prasad Mohanty-ambika.mohanty1@kims.ac.in
Department of General Medicine, Kalinga Institute of Medical Sciences, KIIT University, Campus No:5, KIIT Road, Patia, Bhubaneswar 751 024, India
Background Fever with jaundice is a common entity seen in routine practice. This manifestation is seen in many individuals infected with viral hepatitis A to E. Excluding these hepatotropic viruses, many other pathogens can clinically manifest as fever with jaundice which include bacteria, protozoa, fungi, and non-hepatotropic viruses.
Aim and Objectives India, being a tropical country, the study aims to evaluate the tropical and other infectious causes barring viral hepatitis A to E, which manifest as fever associated with jaundice.
Methods This study includes 60 patients admitted in Kalinga Institute of Medical Sciences from 2019 who were found to have febrile jaundice after initial evaluation by liver function tests and hepatotropic viral markers (HBsAg, anti-HCV IgM, anti HAV IgM, anti HEV IgM). Routine laboratory parameters, chest X-ray, ECG was performed in all cases. Appropriate investigations like specific serological, radiological investigations and cultures were performed to identify the causal pathogen. Patients infected with hepatotropic viruses, if associated with any other confounding organisms responsible for their clinical picture were included in this study.
Results Out of 60 patients, 23 (38.3%) patients were found to have scrub typhus (4 had associated encephalopathy). Dengue was found in 8 (13.3%) patients (3 had dengue associated with scrub typhus). Malaria was identified in 5 (8.3%) patients (2 had associated scrub typhus). Four (6.6%) patients had tuberculosis (2 are on ATT) and 3 (5%) patients had varicella-zoster clinically. S. typhi was found in 2 (3.3%) patients. K. pneumonia, E. coli, A. baumannii, B. cepacia, E. feacalis were isolated in other individuals. Among these 21 patients had associated transaminitis (elevated AST/ALT >3 times of ULN). Eleven cases had hepatomegaly and 5 were found to have splenomegaly. Ten cases had septic shock of which 4 could not be revived. No definitive etiology was found in 10 patients.
367
Eosinophilic ascites as rare unusual initial presentation of eosinophilic gastroenteritis
Santhosh R , Benoy Sebastian, Anil Jose Kokkat, Mary George, Cyril Alex, Swaran Kumar, Sujith James
Correspondence- Benoy Sebastian-Santumail18@gmail.com
Department of Gastroenterology, Medical Trust Hospital, Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
Thirty-three-year-old male presented with progressive abdominal distension and discomfort associated with nonspecific abdominal pain of 1 week duration.
Physical examination was unremarkable except for ascites.
Routine labs showed high eosinophilic count with leukocytosis in hemogram and peripheral smear, AEC-7890 cells/cumm. Stool exam was nil contributory.
Abdominal sonogram showed moderate to gross ascites, no features of CLD/portal hypertension. Ascitic fluid cytology and cell block were suggestive of low SAAG high protein ascites, ascitic fluid TC-15,600 cells/cumm, AEC-13,950 cells/cumm.
Prior to current admission there was also a history of consuming seafood containing prawns followed by loose stools and pain abdomen for 2 days which was self-limiting.
EGD showed mild duodenitis. Biopsy from D2, Antrum, esophagus showed histopathologic evidence of eosinophilic gastroenteritis. CT thorax and abdomen showing diffuse esophagial wall thickening and edematous and thickened small bowel loops. He was treated albendazole, ivermectin and PPI. Within a week there was significant improvement in symptoms. He was not put on steroids as there was clinical improvement on PPI and antielminthics. There was no ascites on repeat ultrasound scan of abdomen done two weeks later. He remained asymptomatic even at one-year follow-up.
Conclusion Eosinophilic ascitis is a rare unusual presentation of eosinophilic gastroenteritis, usually occurs in serosal involvement. Mostly ascites is mild and not clinically significant and usually associated with abdominal pain. Rarely, isolated ascites can be the initial presentation.
368
A rare case of concurrent primary gastric and bone diffuse large B cell lymphoma
Chunduri Vikranth, Chunduri Venkata Viswa Vikranth , Ganesh Panchapakesan, Shanmugnathan Subramanyam
Correspondence- Chunduri Vikranth-chvv.vikranth@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai 600 116, India
Primary bone lymphoma (PBL) is an uncommon clinical entity and a rare non-Hodgkin's lymphoma presentation. PBL accounts for less than 5% of malignant bone tumors, 4% to 5% of extranodal lymphoma, and less than 1% of all non-Hodgkin's lymphoma.
Primary gastric lymphoma (PGL) is rare cancer, but it is the most common site for extranodal non-Hodgkin lymphoma. We report a rare case of concurrent presentation of a bone lymphoma and gastric lymphoma. The patient presented with a slow-growing swelling around the knee joint for two years. Positron emission tomography incidentally picked up an FDG avid lesion in the fundus of the stomach. Tissue specimens of both the lesions were obtained and conformed to have diffuse large B cell lymphoma on histology and immunochemistry. He was followed up with the oncology department and treated with R-CHOP regimen (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin (vincristine), and prednisone).
369
Preoperative successful thrombectomy and thrombolysis of acute extensive splanchnic venous system and TIPSS thrombosis in a child with Budd-Chiari syndrome- Creating a window to enable living donor liver transplantation
Amey Sonavane , Aabha Nagral, Deepak Gupta, Shaji Marar, Vikram Raut, Ketul Shah, Amruthraj C, Ashok Thorat, Ambreen Sawant, Harshit Chaksota, Abhijit Bagade, Suresh Vasanth, Darius Mirza
Correspondence- Amey Sonavane-amey_max@yahoo.com
Gastroenterology, Hepatology and Liver Transplantation, Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Background Preoperative extensive portal vein (PV) thrombosis can pose a technical challenge during liver transplantation. Extensive and diffuse thrombosis of the splanchnic venous system may even necessitate multivisceral transplantation. We describe the case of a pediatric patient with Budd-Chiari syndrome (BCS) and decompensated cirrhosis, who developed extensive acute thrombosis of the portospleno-mesenteric venous system prior to living donor liver transplantation (LDLT). We used a combination technique of thrombus aspiration using a novel trans-TIPPS approach followed by thrombolysis to achieve complete pre-operative resolution of the thrombus.
Case Report A 10-year-old child with BCS who had underwent a prior TIPPS, presented with TIPPS thrombosis, ascites, hepatic encephalopathy and hepatopulmonary syndrome (HPS). Two days prior to a planned LDLT, he developed an acute extensive thrombosis of the portospleno-mesenteric venous system. As the window for a prompt LDLT was fast fading due to multiple and recurrent episodes of decompensation and severe HPS, a decision to perform interventional radiology guided mechanical thrombectomy and thrombolysis was taken. Using a retrograde right transjugular trans-TIPSS approach, mechanical thrombus aspiration using a 6F shuttle sheath was performed. This was followed by thrombolysis using tissue plasminogen activator (tPA). Post procedure, there was near-total recanalization of all the veins (Fig. 1). He was then started on intravenous tPA and continuous heparin infusion. This allowed the creation of a brief window to enable LDLT. Intraoperatively, PV showed complete re-canalization with a good flow. A triangulated reconstruction of left hepatic vein to IVC/right hepatic vein and donor left PV to right main PV was performed. Post LDLT, anticoagulation was continued with intravenous heparin followed by subcutaneous enoxaparin and oral warfarin. He was discharged uneventfully.
Conclusion In prudently selected patients, performing an early mechanical and chemical thrombolysis of an extensive acute splanchnic venous thrombosis can help expedite a planned LDLT.
370
Retrospective study of inflammatory bowel disease unclassified at tertiary care hospital
Ajay Kumar Oli , Rohit N Maidur, Preetham S Hurakadli, Anita P Javalgi, Palaksha K Javaregowda, Mallikarjuna Goni
Correspondence- Ajay Kumar Oli-ajay.moli@gmail.com
Department of Biomedical Science, SDM Research Institute for Biomedical Sciences, Shri Dharmasthala Manjunatheshwara University, 5th Floor, Specialty Block, SDMCMS&H, Campus, Manjushree Nagar, Sattur-Dharwad 580 009, India, Department of Gastroenterology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University Dharwad-580 009, India, Department of Pathology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad 580 009, India, and SDM Research Institute for Biomedical Sciences, Shri Dharmasthala Manjunatheshwara University, 5th Floor, Specialty Block, SDMCMS&H, Campus, Manjushree Nagar, Sattur- Dharwad 580 009, India
Background Inflammatory bowel disease unclassified is allocated to cases of colitis where endoscopic and histological findings are not adequate to differentiate between ulcerative colitis and Crohn’s disease. Altered bowel, functional bowel, irritable bowel, esoinophilic colitis and microscopic colitis in its histological distinct patterns, lymphocytic colitis, infective colitis, and bacterial colitis are increasing common causes of non-bloody diarrhea. There appears to be an association with other autoimmune conditions, and also there is be variability in patient journey from referral to treatment.
Aim To know the frequencies of unclassified inflammatory bowel diseases/to evaluate various causes of unclassified inflammatory bowel diseases.
Methodology It is an observational study. All the cases diagnosed as IBDU in the department of gastroenterology from the year 2015 to 2019 were included in the study. Cases with incomplete evaluation of suspected IBDU cases were excluded from the study. Diagnosis of IBDU was made based on clinical, radiological, endoscopy and histopathologic findings.
Results Total cases included from study period were 226.These patients were diagnosed with altered bowel, irritable bowel, functional bowel, lymphocytic colitis, infective colitis, bacterial colitis and eosinophilic colitis with 115 (66.86%), 09 (5.23%), 10 (5.81%), 9 (5.23%), 19 (11.04%), 07 (4.06%) and 03 (1.74%) respectively. The average age of the patients ranged from 17-40 years and many cases were >40 years.
Conclusion Unclassified inflammatory bowel disease is not infrequent problem for the gastroenterologist and should be considered in the evaluation of IBD with clinical features. Extra awareness and extensive biopsy sampling are required in order to avoid an erroneous diagnosis purely based on histological mimicry of changes seen in bacterial colitis and infective colitis.
371
Autoimmune ascites -A diagnostic dilemma
Umashankar U S , Nithin K R, Anand A, Arun N, Akhilandeshwari, Vaishnavi Priya, Aravind
Correspondence- Umashankar U S-us14us@gmail.com
Department of Digestive Health and Disease, Government Kilpauk Medical College, Chennai 600 010, India
Abnormal accumulation of fluid within the peritoneal cavity is defined as ascites. The commonest cause of ascites among Indians’ is cirrhotic portal hypertension, accounting for 80% of cases. Others includes tuberculosis, malignancy, heart failure and pancreatic disease. Autoimmune disorders are rare cause. Here we present a rare case of undifferentiated connective tissue disorder (CTD) associated ascites.
Case Forty-five-year-female presented with h/o 6 months h/o dry cough, exertional dyspnoea, and abdominal distension. No h/o jaundice, decreased urine output, lower limb swelling. No h/o photosensitivity, oral ulcers, joint pain, skin tightening. O/E pallor+ CVS, respiratory and CNS examination was unremarkable. Abdominal examination showed presence of shifting dullness.
Investigations Hemoglobin 8.4 g%, platelet 7.4 lakhs, LFT A/G reversal with normal enzymes, viral markers negative, ascitic fluid shows low SAAG, high protein ascites with normal ADA, and amylase; ascetic fluid geneXpert and cytology for malignant cells was negative. Normal urine routine. Thyroid profile-normal, 2D echo-normal. USG abdomen moderate ascites, liver normal echotexture. Portal vein doppler was normal. CECT abdomen liver normal, moderate ascites, no evidence of malignancy, CA 19.9, CEA, CA125 was normal. Fibroscan normal, UGI scopy and colonoscopy was normal, HRCT chest- interstitial lung disease (ILD) NSIP pattern. ANA was strongly positive1:1000, anti scl70, anti Ro-52, anti SS-A positive. Diagnostic laparoscopy no evidence of malignancy or tuberculosis. Since patient was not fulfilling any diagnostic criteria of autoimmune disease, a diagnosis of undifferentiated CTD with CTD associated ILD, CTD associated ascites was made. Patient was started on hydroxychloroquine and steroids. Patient became symptomatically better and in follow- up.
Conclusion To the best of our knowledge and review of literature autoimmune ascites in a patient with undifferentiated CTD with normal liver and normal cardiac status is unreported. Though rare, yet treatable autoimmune cause should be kept as a differential diagnosis.
372
Significant weight loss due to abdominal aortic compression (diaphragmatic aortic hiatus syndrome): A rare type of median arcuate ligament syndrome
Mahesh Kumar Gupta , Rinkesh Kumar Bansal
Correspondence- Mahesh Gupta-guptamahesh1982@gmail.com
Department of Gastroenterology and Hepatobiliary Science, Fortis Memorial Research Institute, Sector - 44, Opposite HUDA City Centre, Gurugram 122 002, India
Background Median arcuate ligament syndrome is a rare condition caused by compression of celiac artery with or without celiac ganglia by median arcuate ligament (MAL). Most of the patients asymptomatic due to celiac compression but may present with complaints like bloating, nausea, vomiting, postprandial epigastric pain, and other non-specific symptoms.
Case A 37-year-old male with sober personal history, hospitalized with multiple episodes of severe epigastric postprandial pain and bilious vomiting over last 2 months. Weight loss of about 10 kg also present. No other significant past medical history. On clinical examination hemodynamically stable but mild dehydration present, rest was normal. His BMI was 21kg/mt2.On per abdomen examination everything is unremarkable. His laboratory report of hemogram, renal function tests, liver function tests, lactate, LDH, iron, C-reactive protein, amylase and lipase within normal limits. Ultrasound abdomen also normal. CT angiography revealed moderate external compression and luminal narrowing of aorta by the MAL at the diaphragmatic hiatus. Rest of the aorta and its branches shows normal contrast opacification. Visualized abdominal organs and bowel normal. Endoscopy was unremarkable. Doppler showed reduced flow distal to compression. After informed consent underwent laparoscopic division MAL causing compression. Normal flow pattern conformed intraoperatively and postoperatively by doppler. He is asymptomatic and gain 6 kg weight, with 2 months follow- up period.
Conclusion Diaphragmatic aortic hiatus syndrome is a rare cause and should be considered in the checklist for evaluation of postprandial pain and weight loss. Computed tomography angiography is diagnostic. Laparoscopic resection is curative.
373
Do the patients of COVID-19 with predominant gastrointestinal presentations behave differently from those with classical presentations?
Manoj Kumar Gupta , Anup Sarkar, Tryambak Samanta, Saubhik Ghosh, Kalidas Biswas
Correspondence- Manoj Gupta-mkgupta.pintu@gmail.com
Division of Hepatology, Medical Gastroenterology, Medical College, Kolkata, India
Background Lack of clarity remains whether COVID-19 patients with predominant gastrointestinal complaints differ in basic descriptive parameters, natural course and outcome in comparison to those cases with classical presentations. So, our objective was to determine whether such difference exist between these two group of patients.
Methods Consecutive patients admitted in Medical College, Kolkata in-between May 2020 to July 2020 were enrolled. The classification into the subsets was based on predominant subjective complaints of the patients in the 1st 5 days of illness. The parameters assessed were age, gender, presence of comorbidity, symptomatology duration, need of ICU care and case fatality rate.
Results Of the 678 patients enrolled, 23 (3.4%) subjects complained of predominant gastrointestinal symptomatology. The mean ± SD of age of presentation in years (46.9 ± 10.4 vs 53.7 ± 13, p=0.01) and duration of symptoms in days (7.9 ± 5.3 vs. 10.8±4.7, p=0.004) were significantly less in patients with gastrointestinal symptoms. The sex ratio and presence of comorbidity did not differ statistically (p 0.93 and 0.5 respectively). Though ICU care (5.9% vs. 1.3%) and death rate (2.4% vs. 0.4%) were proportionally higher in patients with classical symptoms, they were not found to be significant (p>0.05).
Conclusion Our study failed to show any significant difference of outcome between COVID- 19 patients with classical and gastrointestinal symptoms, though there was some dissimilarity in demographic and clinical parameters. Further studies in this regard with special emphasis on background viral genomic aspects need to be done to find out the basis of any difference, if any which in turn will assist to modify guidelines in clinical settings for such subset of cases.
374
A rare presentation of abdominal TB - Retroperitoneal mass
Radhika Nittala , Manas Behera, Jimmy Narayan, Debakanta Mishra, Manoj Sahu, Girish Pati, Ram Gopal Teja K, Srinith Patil, Swarup Pattnaik
Correspondence- Radhika Nittala-drnradhika@gmail.com
Department of Medical Gastroenterology, IMS and SUM Hospital, Bhubaneswar 751 003, India
Introduction TB can involve any part of the gastrointestinal system. It is the sixth most common type of extrapulmonary tuberculosis. Our country has the highest burden in the whole world. We are reporting a case of a young male who had rare presentation of abdominal tuberculosis.
Case report A 17-year-old male presented with pain in the right lower quadrant of abdomen, loss of appetite and weight loss since 2 months and dysuria since 2 weeks. He had no history of cough, fever, or bowel disturbance. He was averagely built and moderately nourished. On general physical examination, no abnormality was detected, and abdominal examination revealed mild tenderness in the right iliac fossa. His routine hematological parameters showed high CRP and ESR with normocytic normochromic anemia. CECT abdomen showed long segment circumferential thickening of the terminal and distal ileum with ill defined retroperitoneal mass in right pelvic wall in close proximity to the ileocecal mesentry, right psoas and terminal ilem. And this mass was involving right distal ureter resulting in moderate hydronephrosis. Colonoscopy showed multiple ulcers in the terminal ileum with surrounding edematous and friable mucosa with luminal narrowing. Biopsy was done from the terminal ileum. FNAC was done from mass adjacent to the thickened small bowel. Both biopsy and FNAC showed numerous epitheloid granulomas and multinucleated giant cells with histiocytes. Further, AKT was started and his symptoms improved. Review USG KUB was done after 1 month, it showed resolution of hyderonephrosis. The patient is now on ATT and doing well.
Conclusion Tuberculosis can rarely present as retroperitoneal mass with hydronephrosis. Early suspicion and diagnosis can help in initiating the treatment early.
375
Clinical profile of gastroenteropancreatic neuroendocrine tumors: Single center experience in a teritary care center in southern India
Ravindra Kantamaneni , Mukundan S, Prudhvi Krishna Chandolu, Kartikeyan R K, Nikhil Kenny Thomas, L Venkatakrishnan
Correspondence- L Venkatakrishnan-ravindra.mbbs@gmail.com
Department of Medical Gastroenterology, PSG Institute of Medical Sciences and Research Center, Off Avanashi Road, Peelamedu, Coimbatore 641 004, India
Background Gastrointestinal is the commonest site for neuroendocrine tumors (NET). appendix, ileum, rectum are considered to be common sites. Majority of tumors have an indolent course. Some of them are diagnosed incidentally and few have disseminated disease and also present as metastatic disease.
Methods We retrospectively analyzed the data in Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore over a period of 10 years from Jan 2010 to July 2020. Gastroenteropancreatic NETs were included in the study. Clinical details, site of tumor, metastasis at the time of diagnosis were reviewed.
Results Our analysis showed a male predominance with ratio of 3:1 with a mean age of 51.6667±5.56 Of the 12 tumors, the commonest site was found to be duodenum 4 (33.3%), followed by pancreas 3 (25%) and stomach 2 (16.6%), appendix, sigmoid colon, ileum were 1 (8.33%) each. The disease was localized in 4 patients (33.3%) and with metastasis 8 (66.6%). Most of gastric and duodenal NETs were localized where as pancreatic NETs have metastasis at presentation.
Conclusion This analysis showed gastrointestinal pancreatic NET are not rare and incidence of these tumors is increased over the past decade due to availability of higher imaging and increased rate of biopsy.
376
Clinical, endoscopic and histological characteristics of gastrointestinal graft versus host disease and its outcome after allogenic hematopoietic stem cell transplantation
Pradipkumar Vekariya , Pazhanivel Mohan, Senthamizh Selvan, Smita Kayal, Abdoul Hamide
Correspondence- Pazhanivel Mohan-dr.pazhani@gmail.com
Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Gorimedu, JIPMER Campus, Puducherry 605 006, India
Introduction Graft versus host disease (GVHD) is a common cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Skin, gastrointestinal tract and liver are commonly affected in GVHD. The outcome of gastrointestinal acute GVHD is poor and depends on clinical, endoscopic, or histological severity. We retrospectively studied the frequency, clinical profile, and outcome of acute gastrointestinal GVHD following allogenic HSCT.
Methods Patients who underwent allogenic HSCT between December 2018 and May 2020 were included. The clinical symptoms, gastroscopy or colonoscopy findings, histopathology, details of treatment and outcome of acute gastrointestinal GVHD were analyzed.
Results Eighteen patients underwent allogenic HSCT. A total of 8 (44.4%) recipients developed acute gastrointestinal GVHD. Their median age was 29.5 years (12-36) with a male preponderance (n=5). The median duration of onset of GVHD was 41 (17-92) days after HSCT. All patients received fludarabine and busulfan followed by GVHD prophylaxis. Six recipients had matched sibling donor, one had matched unrelated donor and another had mismatched sibling donor. All except one had 10/10 HLA matching. The symptoms of nausea, vomiting and anorexia were seen in five; abdominal pain in two and diarrhea in five recipients. A total of 11 endoscopic procedures were performed: gastroscopy in two, sigmoidoscopy in three and both upper and lower gastrointestinal endoscopy in three patients. The endoscopic findings included mucosal edema, erythema, erosions, ulcerations, and bleeding. The Freiburg endoscopic severity was grade 4 in two, grade 3 in one, grade 2 in two and grade 1 in six. Histopathology showed apoptosis of crypt epithelial cells and dropout of crypts in four patients. All patients received step-up treatment using steroids, cyclosporine-A, mycophenolate-mofetil, ruxolitinib and etanercept. Mortality was observed in four recipients (50%).
Conclusion Gastrointestinal GVHD was observed in about half of our allogenic HSCT recipients and had a dismal prognosis.
377
To study clinicopathological profile of gastrointestinal tuberculosis and assess treatment response and outcome
Sahil Parmar , Vineet Gupta, Sudhir Gupta, Harit Kothari, Amol Samarth
Correspondence- Vineet Gupta-guptavintu@gmail.com
Department of Gastroenterology, Government Medical College and Super Specialty Hospital (SSH), Nagpur 440 009, India
Background Abdominal tuberculosis (TB) is defined as infection of the gastrointestinal tract, peritoneum, abdominal solid organs and abdominal lymphatics with Mycobacterium tuberculosis. Abdominal TB is one of the most common forms of Extrapulmonary TB. Early diagnosis and initiation of anti-tuberculous therapy is essential to prevent morbidity and mortality.
Aims To study clinicopathological profile of gastrointestinal tuberculosis and assess treatment response and outcome.
Methods This was a hospital based prospective study in Department of Gastroenterology in a tertiary care referral center from January 2019 to June 2020. The study variables included socio-demographic characteristics (i.e. age and sex), clinical presentation, HIV coinfection, radiological findings, endoscopic findings, Mantoux, ESR, GeneXpert and response rate to anti-tubercular drugs. Patients were followed at monthly interval in the intensive phase and then two monthly till the completion of treatment.
Results Out of total 96 cases, 44 (45.83%) were males and 52 (55.17%). Maximum incidence of GITB was seen in 21-30 years age group. Abdominal pain (96.72%) was the most common presenting symptom. Luminal involvement was seen in 43.05% of patients out of which ileocecal junction (82.5%) was the most common site involved. Ascites was seen in 41.66% patients. A positive gene xpert was reported in 7.5% cases out of total 96 GITB cases. 4.1% patients develop complications in form of decompensation of cirrhosis and 6.2% in form of hepatitis.
Conclusion Nonspecific features of the abdominal tuberculosis result in difficulty in establishing diagnosis. A high index of suspicion is therefore necessary for early diagnosis of abdominal. Neither clinical features nor laboratory findings are conclusive of GITB, histopathological findings by themselves provide a gold standard in the diagnosis.
378
Reduction in incidence of corrosive poisoning during this COVID-19 pandemic
Viswanath Donapati , Ravi Shankar Bagepally, Guduru R Srinivas Rao, Rami Reddy Y, Bharani
Correspondence- Viswanath Donapati-viswanathdr@yahoo.com
Department of Gastroenterology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India
Introduction COVID-19 pandemic is troubling the entire world in most aspects. One good aspect which we noted was an overall reduction in poisoning cases particularly corrosive ingestion.
Methods We did a retrospective analysis of the number of poisoning cases hospitalized at our tertiary care centre from March 2019 till August 2020 with particular reference to corrosive ingestion who underwent endoscopy. The age group of patients included was above 12 years. We looked at differences in the incidence of corrosive ingestion before the lockdown (March 2019-February 2020) and after the lockdown (March 2020-August 2020).
Results We had 160 cases of poisoning admitted during March 2019 till February 2020 and of them 35 were corrosive ingestion cases (21.8%). Fifteen of the 35 were males (42.8%). Five patients of the 35 cases died (14.3%) due to complications related to corrosive ingestion like renal failure, sepsis and multiorgan failure. Seven of them (20%) required feeding jejunostomy. There were 68 cases of poisoning of which 11 were corrosive cases (16%) from March till August 31. 8 of the 11 cases were females (72.7%). Two of the 11 patients died (18.1%) due to complications. Three of them (27.2%) required feeding jejunostomy. There was considerable reduction of the overall incidence of poisoning and particularly corrosive ingestion. Our hypothesis was that during lockdown period, there was more family bonding and more emotional stability.
Conclusion There was an overall reduction in number of poisoning cases particularly corrosive ingestion during this COVID-19 pandemic.
379
Clinic-pathological profile of gastrointestinal stromal tumors - A retrospective study from a tertiary center in South India
Damodar Krishnan , Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research, Chennai 600 116, India
Introduction Gastrointestinal stromal tumors (GIST) comprise 1% to 3% of all malignant gastrointestinal (GI) tumors. GIST is the most common mesenchymal tumour of the GI tract. GISTs are extremely heterogeneous from a clinical perspective. We aim to explore the clinical and pathological profile of all newly diagnosed GIST including clinical presentation, morphology (gross and microscopic), location of tumours, risk stratification and management among patients admitted in a tertiary centre in South India.
Methods Retrospectively analyzed cases diagnosed as GIST (HPE with IHC) either by diagnostic biopsy or postoperatively during the past 4 years (2016-2020).
Results During the study period 20 patients fulfilled the inclusion criteria and data were analyzed. The median age was 56.2 years with a male-female ratio of 2:1 (14 males and 6 females). The mean age for men was 58.3 and for women 51.2. Four (20%) patients had metastatic disease and unresectable or incompletely resected disease. The most common primary site was small intestine in 10 (50%) patients which were followed by the stomach in 5 (20%) patients. The most common site of metastases was liver in 2 (50%) patients. Median tumor size was 6.2cm (range 5cm -20 cm). Nine (45%) patients had mitotic counts of >5/50 HPF. Spindle cell type was the predominant histological type 80% and CD117 was found to be positive in 14 patients (70%). Nine patients received treatment with imatinib for more than 6 months and 3 patients who underwent surgery presented with metastasis or recurrence of disease on follow-up.
Conclusion In our study of GISTs, the commonest site of the tumor was detected to be small intestine followed by stomach, the majority were of the high-risk malignant category and of pure spindle cell morphology. Limited numbers had follow-up after imatinib therapy and showed recurrence of the disease.
380
Primary falciform ligament necrosis- An unusual case of abdominal pain
Arun Dhotra , Anand A, N Arun, Akhilandeshwari, Vaishnavi Priya, Kani Shaikh, Aravind
Correspondence- Arun Dhotra-arun.dhotra88@gmail.com
Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai 600 010, India
Introduction Falciform ligament, is a broad and thin fold of peritoneum that divides the liver into left medial and right lateral lobe. It attaches liver to diaphragm and anterior abdominal wall. Primary or isolated falciform ligament necrosis is rare entity and often confused with gall bladder diseases due to its presenting symptoms.
Case A 46-year-old male presented to our hospital with symptoms of pain upper abdomen which was continuous and dull aching type since 2 months. No history of nausea, vomiting, fever, obstipation or loose motion. Per abdomen- mild epigastric tenderness. Per rectal examination– normal.
Investigations CBC, RFT, LFT, S. amylase, viral markers, Erect AXR, CXR were normal USG abdomen suggestive of acalculous cholecystitis. UGI endoscopy- normal.
CECT abdomen Non-enhancing heterodense lesion with air pockets noted extending along the falciform ligament to anterior abdominal wall till umbilical region with surrounding inflammatory changes and minimal fluid collection. Left branch of portal vein (PV) not visualized- features suggestive of falciform ligament necrosis and inflammation.
PV Doppler normal.
Surgical gastroenterology opinion taken. Surgical excision of ligament was done. Postoperative period uneventful. Patient symptoms relieved and patient is on follow-up.
Conclusion Primary Falciform ligament inflammation and necrosis is a rare condition. It is difficult to diagnose as it is often confused with other intra-abdominal pathologies especially gallbladder diseases. CECT abdomen should be preferred over USG abdomen for its diagnosis. Surgery is the treatment of choice. It should be considered as one of the possibilities in cases presenting with pain abdomen with other common causes ruled out.
381
GIT and hepatic manifestations of Covid-19 in a tertiary care centre
Pavankumar Evuri , Chezhian Annasamy
Correspondence- Chezhian Annasamy-chezhianannasamy@gmail.com
Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India
Background The clinical syndrome caused by SARS-CoV-2 was called COVID-19 and became a pandemic from March 2020. Predominant clinical manifestations are fever, dry cough, and dyspnea. Multiple gastrointestinal (GI) symptoms, including diarrhea, nausea/vomiting, and abdominal pain, as well as liver enzyme abnormalities have been variably reported. This study aims to comprehensively outline the various GIT and hepatic manifestations of this virus.
Methods A cross sectional observational study carried out from July 1st to July 30th at Madras Medical College Hospital, Chennai – a tertiary care COVID hospital. Data obtained from the RT PCR positive COVID in patients by selected questionnaire and lab reports, analyzed with regards to GIT and hepatic manifestations.
Results Out of 118 patients diagnosed to have COVID by RT PCR, 69 were male and 49 female. Mean age 55.6 years. Eighteen (15.2%) have GIT manifestations. Nine (7.6%) have diarrhea as a most common GI symptom, 6 (5%) nausea or vomiting, 3 (2.5 %) abdominal pain. Isolated GI symptoms were reported in 2 patients. Diarrhea presented earlier to respiratory symptoms in one patient. Fifteen (12.7%) patients have liver function test abnormalities. SGOT and SGPT both elevated but SGOT levels more than SGPT in 13 out of 15 patients.
Conclusion Digestive symptoms are not uncommon in patients with COVID-19 and in some cases digestive symptoms may occur isolated or earlier to onset of respiratory symptoms. Hence GIT symptoms should be addressed promptly for early diagnosis and proper management. Attention should also be paid to monitor regularly liver function during the course of COVID-19.
382
Normative values of various parameters defining sarcopenia among Indian adult population
Subham Choudhary , Manav Wadhawan, Prem Kumar Ganesan, Sugandha Dhawan, Payal Mittal, Ajay Kumar, Amrish Sahney
Correspondence- Manav Wadhawan-manavwadhawan@gmail.com
Department of Radiodiagnosis, Dr B L Kapur Memorial Hospital, 5, Pusa Road, Near Rajendra Place Metro Station, New Delhi 110 005, India
Introduction Sarcopenia is defined as decrease in muscle mass and function (performance or strength). Sarcopenic parameters are crucial for precise diagnosis and management of various medical conditions and must be formulated as per local population.
Objective To study the quantitative analysis of various sarcopenic parameters in Indian population.
Methodology This cross-sectional study was conducted at a super speciality hospital in New Delhi among 2002 normal Indian individuals over a period of one year. Normative values for all abdominal muscles and individually for psoas and erector spinae muscles were measured using the latest software, Tomovision Slice0matic version5.0 with Alberta protocol. Standardized psoas muscle thickness (PMTH), psoas muscle index (PMI), erector spinae muscle index (ESMI), total skeletal muscle index (SMI) and skeletal muscle radiation attenuation (SMRA) were computed. Their mutual relationships and correlations between either sex were determined statistically by applying Pearson’s and student’s t test.
Results A total of 2002 individuals, including 1308 males and 694 females, underwent CT evaluation. PMTH (mm/m) was observed to be 15.87±2.67 in males versus 12.61±2.46 in females (p=0.0001); PMI (cm2/m2) was 6.69±1.40 in males vs 5.57±1.18 in females (p=0.0001); ESMI (cm2/m2) was 16.5±2.55 in males vs. 14.62±2.6 in females (p=0.0001), SMI (cm2/m2) was estimated to be 51.00±5.70 in males vs. 43.93±6.05 in females (p=0.0001) and SMRA was 55.80±3.91 HU in males vs 52.36±3.67 HU in females (p=0.0001). Cut off values for PMTH, PMI, ESMI, SMI and SMRA for sarcopenia at L3 vertebral level were observed to be 10.53 mm/m, 3.89 cm2/m2, 11.40 cm2/m2, 39.59 cm2/m2 and 47.98 HU among males and 7.69, 3.20, 9.42, 31.83 and 45.01 among females.
Conclusion Normative values of sarcopenic parameters for either sex among Indian adult population would enable future studies on sarcopenia in various medical conditions.
383
Incidental retroperitoneal ancient neurilemmoma- A rare variety of neurilemmoma
Mukesh Pancholi, Devendra Chaudhri, Divya Sinhar
Correspondence- Mukesh Pancholi-dr_mpancholi@yahoo.co.in
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Ancient neurilemmoma are rare variants of tumors which arise from the peri-neural Schwann cells. These tumors are termed “ancient” because of the degenerative features such as cyst formation, hemorrhage, calcification, and hyalinization are acquired with increasing age in these tumors. They are benign, slow growing and usually detected only incidentally or due to local symptoms. Although most schwannomas are benign tumors, those that are associated with von Recklinghausen disease are malignant in 5% to 18% of cases. Retroperitoneal schwannomas account for only 0.5% to 5% of all cases and are extremely uncommon. They are well encapsulated and recurrences following complete surgical excision are uncommon.
Case Study A 70-year-old Hindu male patient presented with bilateral lower limb pain, fever and headache. On blood investigations patients was found to be positive for Falciparum. With normal abdominal examination, radiological examination was suggestive of an incidental well-defined heterogeneous mass lesion measuring 4.8 x 4.8 cm is seen along left anterior surface of left psoas muscle in the left retroperitoneal space. Preoperative biopsy report was suggestive of predominantly fibro collagenous tissue and few benign spindle cells. Exploratory laparotomy and excision of the retroperitoneal mass was done. Overall histological features were suggestive of atypical neurilemmoma (ancient neurilemmoma).
Conclusion Retroperitoneal ancient schwannoma is rare variety of schwannoma with least chance of malignant transformation.
Keywords Ancient, Retroperitoneal schwannoma, Neurilemmoma, Benign, Excision
384
A case of left diaphragmatic hernia in blunt abdominal trauma
Vedant Wankhede , Manish Chaudhari, Jawansingh Manja
Correspondence- Vedant Wankhede-vedwankhede786@gmail.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India and Government Medical College and New Civil Hospital, Majuragate, Surat, India
Background Adult onset diaphragmatic hernia is rare condition with variable manifestation. Majority of adult onset diaphragmatic hernia is associated with trauma. Traumatic diaphragmatic injury is known to present with the wide range of symptoms, and most patients would have some symptoms due to abdominal organ herniation. These injuries may be left unrecognized when they occur but often uncovered in days during work related symptoms. Diaphragmatic hernia is repaired by laparotomy or thoracotomy or both. Here we present a diaphragmatic hernia in blunt abdominal trauma presented with chest pain, breathlessness that was repaired via laparotomy. Operative approach of diaphragmatic defect closure is given below.
Case presentation A 50-year-male patient came to casualty with 7 day history of chest pain and breathlessness. It is due to fall down in well 7 days ago while walking on road. Chest X-ray suggestive of left pleural effusion along with collapsed left lung. Patient is further evaluated in the form of CT abdomen which confirmed herniation of stomach and large bowel in left hemithorax. Consolidation of right lower lobe also present.
Conclusion Traumatic injury of diaphragm is rare and for diagnosis required heigh index of suspicion for diagnosis and late diagnosis result in wide range of symptom.
Keyword Diaphragmatic, Hernia, Laparotomy
385
Primary mesorectal hydatid cyst in presacral area of pelvis: An unusual case of echinococcosis
Aman Balar , Devendra Chaudhary, Mukesh Pancholi
Correspondence- Aman Balar-aman.animax@gmail.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Hydatid disease is a parasitic infectious disease caused by Echinococcus granulosus. The parasite can form cysts in any part of the body with the liver and lung being the most common organs. It can rarely occur in other organs like the muscle, bone and pelvis. Mesorectal fossa hydatid cyst is rare. Surgical excision is treatment modality of choice and accepted to be curative with a very low recurrence.
Case presentation A 48-year-old male presented with complaints of pain while defecating since 4 months. During clinical examination, abdomen was soft and nontender, proctoscopic examination was found to be normal. USG was suggestive of anechoic lesions with multiple septations in pelvic region. CT scan was suggestive of discrete cystic density lesion with septations and dependent debris. MRI scan was suggestive of multi-loculated cystic lesion in mesorectal fossa. There were no such cysts found in any other organ. Patient received antihelminthic medications for 1 month before surgery. During surgery the cyst was excised from mesorectal fossa and was apparent to be hydatid cyst as it contained small daughter cysts. The cavity of the cyst was irrigated with 3% NaCl as a scolicidal agent. Preventing spillage of the contents of the cyst and use of scolicidal agents are mandatory to decrease the rate of recurrence. Histopathological examination confirmed the hydatid disease. Postoperatively, the patient was put on albendazole and patient’s symptoms disappeared after surgery.
Conclusion We conclude that Echinococcus granulosus can affect any organ in the body from head to toe, and a high suspicion of this disease is justified in endemic regions. Moreover, medical treatment should be given in the preoperative period as well as in the postoperative period for 4-6 weeks but surgical intervention is inevitable.
Keywords Hydatid cyst, Mesorectal fossa, Scolicidal agent
386
A case of post thyroidectomy tracheomalacia in multinodular colloid goitre with Hashimoto’s thyroiditis
Aditya Baraiya , Devendra Chaudhary, Mukesh Pancholi
Correspondence- Aditya Baraiya-adityabaraiya1@gmail.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Post-thyroidectomy tracheomalacia has been a rare complication of thyroid surgery. High degree of suspicion is required to diagnose such grave complication in order to give timely management. Acquired tracheomalacia in patient with thyroid mass results from degeneration of myoelastic component due to continuous compression/infiltration by thyroid mass. We here present a case of post-thyroidectomy tracheomalacia and its successful conservative management.
Case presentation A 31-year-old female an operated case of right hemithyroidectomy came with recurrent neck swelling. We suspected toxic multinodular goitre of residual left lobe. Patient was kept on maximum dose of oral anti-thyroid agent yet patient was hyperthyroid. After 10 days of medical management and titration of doses patient was made near euthyroid and operated for left sided hemithyroidectomy for left lobe multinodular colloid goitre with intrathoracic extension. Intraoperatively, thyroid mass found to be grossly displacing trachea and esophagus towards left side, raising concern of possibility of postoperative tracheomalacia. On completion of surgery patient was given extubation trial, but due to breathing difficulty and stridor, patient was re-intubated and kept on T-piece ventilation with oxygen support so we suspected tracheomalacia and tracheostomy was done. Attempts were made to remove tracheostomy tube without success. On 15th postoperative day thyroid profile was suggestive of hypothyroid state so we started supplementation for the same and discharged patient on levothyroxine 25 microgram OD. On subsequent follow up 1 month after discharge trial to remove tracheostomy tube was given with success and dose of levothyroxine was titrated to levothyroxine 50 microgram OD. Patient is on regular follow-up and euthyroid on levothyroxine supplementation without any complications.
Conclusion High degree of suspicion for postoperative tracheomalacia in case of thyroidectomy for large mass and timely diagnosis and management can avert rare but catastrophic event with necessary precaution.
Keywords Tracheomalacia, Thyroidectomy, Tracheostomy
387
Successful treatment in case of angiomyolipoma of right kidney abutting IVC with spontaneous bleeding itself
Dharmesh Chauhan , Devendra Chaudhary, Mukesh Pancholi
Correspondence- Dharmesh Chauhan-hip31777@gmail.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Renal angiomyolipoma (AML), also referred to as renal hamartoma, is a rare solid tumor without malignant characteristics. The inheritance pattern of renal AML is autosomal dominant. Renal angiomyolipoma (R-AML) is a benign mesenchymal neoplasm that includes smooth muscle cells, adipose tissue and thick-walled blood vessels in different compositions. It is usually asymptomatic and found incidentally by routine imaging techniques and rarely becomes symptomatic. The prevalence of R-AML in the general population is between 0.3% to 3% and females are 4 times at risk than males . It develops 80% sporadically and might be a clinical sign of tuberous sclerosis.
Case presentation A 32-year-old, male patient presented to OPD with abdominal distension and abdominal pain with no history of trauma. On clinical examination abdominal distension was present and ballotable mass palpable in right hypochondrium and lumber region. On ultrasonographic examination approx. 20 x 11 cm sized large well-defined heterogeneous echo texture lesion with evidence of multiple hypoechoic areas within. p/o myolipoma.
On CECT abdomen approx. 12.8*13.6*17.9 cm (AP*ML*SI) sized well defined soft tissue density lesion with hyperdense component (HU +56) (s/o hemorrhage) and fat density component noted in right suprarenal region with ill defined posterior wall noted. Superiorly lesion abuts inferior surface of the right lobe of liver with preserved fat plane. Right adrenal gland not seen separately from lesion.
Exploratory laparotomy with right side nephrectomy with en mass removal with large hematoma was done. On histopathological examination all finding suggestive of angiomyolipoma of right kidney, immunoreactive for SMA (smooth muscle actin), vimentin and focally immunoreactive for HMB45.
Keywords Nephrectomy, Angiomyolipoma
388
A rare case of non-traumatic spontaneous acute extradural hematoma in a patient with sickle cell disease
Nilesh Vaniya , Praveen Sharma
Correspondence- Nilesh Vaniya-nilvaniya9@gmail.com
Department of General Surgery, New Civil Hospital, Ring Road, Opp Stem Cell Hospital, Khatodra Wadi, Majura Gate, Surat 395 001, India
Background Non traumatic spontaneous epidural hematoma is a rare and often unmentioned complication of sickle cell F. It is often associated with skull bone infarction. An 18 yrs old boy with sickle cell anemia who developed persistence headache during a vaso-occlusive crisis. Brain CT revealed a right frontal extradural hematoma (EDH) compressing on the brain. No other etiologic factor was identified. A right frontal craniotomy and evacuation of the hematoma was performed.
Case report An 18-year-old male with sickle cell disease was admitted to another hospital to receive treatment for headache and vomiting with no improvement after one day of hospitalization. CT brain revealed a right frontal extradural hematoma with midline shift. An emergency craniotomy with evacuation of extradural hematoma was performed. The patient was discharged with normal neurological examinations on the fifth postoperative day.
Results Non traumatic spontaneous EDH is a rare occurrence; in SCD patients is rarer still. A high index of suspicion is required in the diagnosis and treatment of EDH in patient with sickle cell anemia. Operative management is associated with excellent outcomes as demonstrated in our index patient. It is often associated with skull bone infarction. An eighteen-year old boy with sickle cell anemia who developed persistence headache during a vaso-occlusive crisis. Brain CT revealed a right frontal EDH compressing on the brain. No other etiologic factor was identified. A right frontal craniotomy and evacuation of the Haematoma was performed and he made good recovery.
Conclusion Spontaneous EDH is a rare occurrence; its occurrence in SCD patients is rarer still. A high index of suspicion is required in the diagnosis and treatment of EDH in patient with sickle cell anemia. Operative management is associated with excellent outcomes as demonstrated in our index patient.
Keywords Sickle cell disease, Extradural hematoma, Craniotomy, CT brain
389
Laparoscopic primary acquired lumbar hernia repair with intraperitoneal onlay mesh (IPOM) repair approach
Khushbu Badami , Devendra Chaudhari, Mukesh Pancholi
Correspondence- Khushbu Badami-khushbu.badami@gmail.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Lumbar hernias are rare among all other hernias in which abdominal contents protrude through a defect in the posterolateral abdominal wall. Hafner et al. stated that general surgeons will get only one opportunity to repair a lumbar hernia during their lifetime. Lumbar hernia was first suggested by P. Barbette in 1672 and R.J.C. Garangeot published a case for the first time in 1731. Since then, only about 300 cases have been reported. We here describe a successful case of laparoscopic primary acquired lumbar hernia Repair with IPOM approach in a 65-year-old female patient who had a complain of reducible abdominal swelling with no other com plains.
Case presentation A 65-year-old female patient presented to OPD with right sided reducible, gradually progressive abdominal swelling for 2 years, with impulse on coughing, diagnosed as a primary acquired lumbar hernia. Laparoscopic right lumbar hernia repair with IPOM approach was done; intraoperatively, all the contents including terminal part of ileum, ileocecal junction, cecum, appendix , proximal part of ascending colon with its mesentry were reduced. 6 × 5 cm2 sized defect seen.15 cm2 sized circular parietex composite pre-placed sutures mesh kept and fixed. There were no postoperative immediate complications. Patient was discharged on 4th postoperative day.
Conclusion Laparoscopic lumbar hernia repair is effective as there is minimal tissue handling with very little dissection of surrounding tissues with minimal to no postoperative morbidity.
Lumbar hernia, laparoscopic repair, IPOM approach, parietex composite pre-placed sutures mesh.
390
Lumbar hernia: Sutureless tensionfree meshplasty
Anuj Mehta , Praveen Sharma
Correspondence- Anuj Mehta-Anujmehta_101@yahoo.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Introduction Lumbar hernia is an uncommon abdominal wall hernia. It develop through weakening of posterolateral abdominal wall associated with Petit’s triangle or Grynfeltt-Lesshaft triangle. In lumbar hernia bowel, omentum, or pre-peritoneal fat herniates through the lumbar triangles. Lumbar hernias have been misdiagnosed as lipomas, muscle strains, fibromas, abscesses, and kidney tumor. It is more common in males between 50-70 years old and are more frequent on the left side. We here report a case of such lumbar hernia in which we have done successful repair through sutureless tensionfree meshplasty.
Methods A 40-year-old male patient with presented with right sided lumbar region swelling since 2 years. On USG evaluation there was 3 cm defect noted in anterior abdominal wall in right lumbar region. An open approach through a posterolateral lumbar incision, content dissected up to the neck of the sac, extraperitoneal fat excised, herniation was through the superior lumbar triangle, loose lumbar fascia adjacent to the defect was dissected enough to create flaps for approximation, fascia was approximated with interrupted prolene stitches, attenuated muscle layers were dissected by undermining thereby creating good muscle flap, prolene mesh was placed over this fascial layer. The muscle flaps were approximated over the mesh.
Results The postoperative recovery was uneventful. The patient has followed up for six months with no recurrence.
Conclusion Awareness of the anatomy of the lumbar triangles is essential for prompt diagnosis of lumbar hernias. Repair can be done by both laparoscopic and open approach. Open sutureless tensionfree meshplasty is an easy, safe, and effective means of curing this rare surgical condition.
Keywords Lumbar hernia, Sutureless tensionfree meshplasty, Petit's triangle, Grvnfeltt-lesshaft hernia
391
Successful operative management of a rare case of celiac axis neuroendocrine tumor
Bhargav Patel , Praveen Sharma
Correspondence- Bhargav Patel-bhargavdnp@gmail.com
Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001. India
Introduction Neuroendocrine tumor (NET) is a rare type of tumor that arises from neuroendocrine cells. These cells have traits of both nerve cells and hormone-producing cells and release hormones into the blood in response to signals from the nervous system. Neuroendocrine tumors can develop anywhere in the body, but most occur in the digestive tract, pancreas, rectum, lungs, or appendix. We report a case of excision of neuroendocrine tumor of celiac axis. The patient's postoperative course was unremarkable. Excision of the celiac axis tumor may be safely performed in selected patient.
Method A 49 yr/F patient presented with abdominal pain and vomiting since 3 weeks. On USG evaluation there was 82 x 61 mm2 sized heterogenous echo texture lesion with evidence of minimal vascularity and foci of calcification noted involving left lobe of liver (p/o neoplastic etiology). CECT abdomen and pelvis was done afterwards which suggested presence of neuroendocrine tumor of celiac axis. An open approach through Chevron incision taken, mass of about 7 x 7 cm2 found behind the left lobe of liver, arising from celiac axis. Mass separated from surrounding structure, excised and sent for histopathological examination.
Result The postoperative recovery was uneventful. The patient has followed up for 1 year with no complications.
Conclusion This was the first case operated at our centre for excision of neuroendocrine tumor involving celiac axis. Open as well as laproscopic approach can be done, but open approach provides better safety, visualization with less complications.
Keywords Celiac axis tumor, Neuroendocrine tumor, Abdominal mass
392
Gastrointestinal and hepatic involvement in patients with COVID-19 infection at a tertiary care centre in Northern India: An observational prospective study
Mohammed Ajmal , Manjunath Totaganti, Anirudh Mukherjee, Mukesh Bairwa, Ajeet Bhadoria, Itish Patnaik, Sahaj Rathi, Anand Sharma, Rohit Gupta
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Gastroenterology, All India Institute of Medical Science, Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Introduction Since the outbreak of Corona Virus Disease 2019 (COVID-19) in December 2019, various digestive symptoms have been frequently reported in patients infected with the virus. The exact magnitude of gastrointestinal and liver involvement remains uncertain.
Methods In this descriptive, cross-sectional, study, we enrolled confirmed patients with COVID-19 who presented from June till August 2020. All patients were confirmed by real-time PCR and were analyzed for clinical characteristics, laboratory data, and treatment. The patients were followed throughout their hospital stay and their outcomes noted.
Results In the present study, 180 patients including 117 patients with COVID-19 and full clinical and laboratory data were analyzed. The average age was 43.4 years (SD±14.9), including 121 men and 59 women. Most common presentation to the hospital was with fever in 82 patients (70%), followed by cough (45.3%), dyspnea (37.6%) and sore throat (25.6%). We found that 17 patients (14.5%) reported a digestive symptom, including diarrhea (10 [8.5 %] cases), vomiting (8 [6.8 %] cases), and abdominal pain (5 [4.3%] cases). Deranged LFTs in asymptomatic patients (n=63) were noted with bil >1.2 [5 (7.9%)], AST >45 (19 [30%]), ALT >40 (23 [36.5%]), ALP >270 (11 [17.5%] and bil>1.2 [17 (14.5%]), AST >45 (42 [35.9%]), ALT>40 (59 [50.4%]), ALP>270 (27 [23%]) in symptomatic patients.
Conclusion Digestive symptoms are seen in 15% of patients with COVID-19 infection. Deranged LFT is common even in asymptomatic patients, however, abnormal LFTs are more commonly seen in symptomatic patients.
Keywords Covid-19, Gastrointestinal, Hepatic
393
A study on pain and palliative management in advanced gastrointestinal tract malignancy
Vivek Joshi , Mahadevan Balakrishnan, Mayank Jain, Madhankumar Rathnasabapathy, Sitaraman Balajisubramanian, Jayanthi Venkataraman
Correspondence- Vivek Joshi-vivekjoshi91@gmail.com
Department of Medical Gastroenterology, Arihant Hospital and Research Centre, Indore, India, Gleneagles Global Health City, Chennai, India, and Sri Ramachandra Institute for Higher Education and Research, Chennai, India
Introduction Pain is highly prevalent in cancer population. One third of patients with cancer related pain receive inadequate pain management.
Methods The study was done on patients with advanced and inoperable gastrointestinal (GI) malignancies at institute of Gastrointestinal and Hepatobiliary Sciences, Gleneagles Global Health City, Chennai, between 1st August 2018 to 31st December 2019. Demographic data, laboratory parameters and radiological investigations, baseline visual analogue scale (VAS) score and subjective global assessment (SGA) were recorded on first contact along with details of medical, endoscopic, and palliative interventions as performed. Analgesic pain ladder approach was followed for pain management. Follow-up to assess response was done using VAS score and SGA at the end of 3 months or death within this period.
Results Seventy-one patients were included in the study. Most of them were old aged males. Out of 7 malignancies, hepatocellular carcinoma (HCC) was the most common tumor (57.8%) in study group. 40.8% patients had metastatic cancer. Baseline mean VAS score of study population was 5.13 ± 2.38 and highest was in carcinoma gallbladder patients (8.0 ± 2.0). Most patients were having baseline SGA rating B (69%). Tramadol was the most commonly used analgesic (35.22%) followed by combination of tramadol and fentanyl (26.76%). the most common palliation was transarterial chemoembolization (TACE) in HCC (80.5%) and biliary self-expanding metal stent (SEMS) in carcinoma pancreas (77.8%). There was statistically significant reduction in VAS score in HCC (p<0.001), carcinoma pancreas (p=0.009) and colorectal cancer (CRC) (p=0.022). 15.5% patients moved from SGA rating B to rating A, 9.9% moved from SGA rating B to rating C, and 9.9% moved from SGA rating C to rating B.
Conclusion Analgesic pain ladder approach is effective in cancer pain management. But there is need for patient-tailored treatment for better outcomes.
Keywords Advanced gastrointestinal malignancy, Pain and palliative management, Visual Analogue Scale
394
Anti-epileptic drugs and DRESS syndrome- masquerading as extrahepatic biliary obstruction
Shodhan Aithal, Rohit Maidur
Correspondence- Rohit Maidur-rohitmaidur@gmail.com
Department of Internal Medicine, SDM College of Medical Sciences, SDM University, Manjushree Nagar, Sattur Colony, Dharwad 580 009, India
Introduction Systemic manifestation of adverse drug reaction have been studied extensively. Anti-epileptic drugs (AED) associated DRESS (drug reaction with eosinophilia and systemic symptoms) is a known entity. They are usually idiosyncratic in nature and patients commonly present to dermatologist due to skin manifestations with associated mortality of 10%. Our study aims to know the pattern of hepatic manifestation and correlation with drug dosage and duration in DRESS along with associated morbidity.
Methods Clinical and laboratory parameters of four proven cases of DRESS syndrome according to RegiSCAR criteria were studied, who presented to internal medicine and medical gastroenterology department in a tertiary care hospital.
Results Manifestations were seen across different age groups (2nd, 3rd, 4th and 7th decade) with female preponderance (3 out of 4). Phenytoin was the common AED with mean dose of 300 mg/day. Duration of AED usage till clinical manifestation varied from 4 weeks to 2 years. Absolute eosinophil count was elevated (mean AEC- 2144). Hepatic involvement in the form of cholestatic hepatitis (3 of 4) and skin rash (2 of 4) were seen. Two patients had prolonged hospitalization for >1 week and both had hepatic manifestation necessitating additional workup.
Conclusion Skin rash need not be the presentation in all patients with DRESS syndrome. It is of idiosyncratic in nature. Patient can present with fever of unknown origin to internal medicine mimicking infective causes and masquerading as Extra-hepatic biliary obstruction (EHBO) to gastroenterology, necessitating further workup for the same. Hepatic involvement in DRESS syndrome is associated with prolonged hospitalization and increased morbidity.
395
Clinical profile of patients with gastrointestinal malignancy at a tertiary care centre in Odisha
Mrinal Gogoi
Correspondence- Mrinal Gogoi-DRMRINALGOGOI@GMAIL.COM
Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Background Gastrointestinal malignancies account for significant number of cases managed in tertiary care centres. Although they are managed by medical or surgical oncology department, most patients are diagnosed or seek initial medical attention in gastroenterology department.
Aim This study was done to analyze clinical profile of patients diagnosed with gastrointestinal malignancies.
Method Detailed clinical information, investigation reports were collected from all patients admitted and diagnosed with gastrointestinal malignancies between January 2019 to January 2020 were included in the study.
Results Total 650 patients with various gastrointestinal malignancies were hospitalized in the gastroenterology department. Mean age of presentation was 48±6 and among them 380 (58.4%) were male. Among various gastrointestinal malignancies 26% were diagnosed as carcinoma gallbladder, which represent the maximum number of cases. Other malignancies include carcinoma esophagus (5%), carcinoma stomach (14%), carcinoma duodenum (0.5%), periampullary cancer (5%), carcinoma head of pancreas (11.5%), cholangiocarcinoma (20%), hepatocellular cancer (5%), carcinoma colon (8%), carcinoma rectum and rectosigmoid (5%). Most cases of carcinoma gallbladder presented at late stage with jaundice. In periampullary and cholangiocarcionoma common presentation was jaundice (78%) and in 20 % cases initial presentation was cholangitis. Hepatocellular cancer patients commonly presented with jaundice and ascites. Most cases of carcinoma rectum presented with bleeding per rectum. Among carcinoma stomach patients 60% cases presented with gastric outlets obstruction.
Conclusion Carcinoma gallbladder is the most common gastrointestinal malignancy in Odisha with female predominance and usually presented at advanced stage. Among other malignancies few cases like carcinoma colon and stomach were detected on screening gastrointestinal endoscopy for nonspecific gastrointestinal symptoms like loss of appetite, early satiety and anemia due to chronic blood loss.
Keywords Gastrointestinal malignancies, Carcinoma gallbladder
396
Non-invasive assessment of cardiovascular risk using carotid intima media thickness in patients with inflammatory bowel disease- Does non-alcoholic fatty liver disease add on to the risk?
Anju Krishna K , Krishnadas Devadas, Sandesh K, Nidhin R, Ravindra Pal
Correspondence- Ravindra Pal-docravindrapal@yahoo.com
Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction We compared the CIMT of patients with IBD and subjects without IBD to know the association between subclinical atherosclerosis in IBD and the cardiovascular risk. We also looked at whether NAFLD is an important factor affecting CIMT in IBD.
Methods Descriptive study on 80 patients with IBD and 80 subjects without IBD conducted in a tertiary care hospital. Subjects aged more than 55 years, obese individuals, patients already diagnosed with cardio/cerebrovascular disease and those with other chronic inflammatory conditions were excluded. The demographic, anthropometric and disease related data were recorded. Baseline blood investigations including CRP and ESR were done. CIMT was measured using B mode Doppler imaging. Presence of fatty liver and Shear wave elastography of the liver were assessed. The quantitative data were compared using students t test and the qualitative data by Chi square test. Pearson and Spearman correlation was done to find out the factors correlating with CIMT.
Results Age, sex distribution and traditional cardiovascular risks (hypertension, diabetes and dyslipidemia) were comparable in both groups. The CIMT was higher in patients with IBD as compared to controls (0.532±0.091 vs. 0.476±0.038, p=.000). On analysing the factors affecting CIMT in patients with IBD, those with NAFLD as an extraintestinal manifestation had increased CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP and ultrasound grades of fatty liver had positive correlations with CIMT. There was no change in CIMT with disease type (UC/CD), extent of disease, disease activity or severity of disease. Multivariate regression analysis showed that age and ultrasound grading of fatty liver (R2=0.576, p=.000) were independent predictors of CIMT.
Conclusion We found that CIMT, was increased in patients with IBD as compared to controls. Age and NAFLD were independently associated with increased CIMT in IBD. Patients with IBD especially those with NAFLD may require enhanced monitoring for cardiovascular events.
Keywords Inflammatory bowel disease. Ulcerative colitis. Crohn’s disease; Carotid intima media
397
Unexplained pain abdomen due to alternative medicines
Ajay Jain , Arun Singh, Sohini Sirkar, Amit Joshi, Sumit Kumar Singh, Abhilash Surela, Sudhansu Yadav
Correspondence- Arun Singh-arunptsv@gmail.com
Department of Gastroenterology, Choithram Hospital and Research Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction In last three decades there is increasing use of various alternative medicines for the treatment of various chronic disorders. These drugs are claimed as wonder drugs for chronic illness. How-ever many of these drugs contain very high level of heavy metals including lead and its accumulation leads to abdominal pain of variable severity. Therefore we planned this study “to analyze those patients who were consuming these unnamed indigenous drugs and presented with severe abdominal pain”.
Methods This is an observational case series of prospectively maintained data of all patients having unexplained abdominal pain and found to have an elevated blood lead level from 2011 to 2019. Lead toxicity was diagnosed when the blood lead level was more than >25 ug/dL as per the recommendation of the Centers for Disease Control and Prevention (CDC). All these patients were further interrogated for chronic diseases for which they were consuming these alternative medicines.
Result Total sixty-six patients of unexplained abdominal pain from 2011 to 2019 were recruited, out of sixty-six patients, seventeen had elevated blood lead levels. All seventeen patients had a history of ingestion of herbal medicines for more than six months. Among these seventeen patients, six were taking for D.M., one for hypertension, two for arthritis and remaining eight for infertility, and sexual dysfunction. Basophilic stippling was seen in one patient. Fourteen patients had low haemoglobin with median value 9.7g/dL. Mean serum blood lead level were 87.1 ug/dL (range from 26.3-428 ug/dL). None of them required anti-chelating agent.
Conclusion 1. Lead toxicity because of alternative medicine is not uncommon cause of otherwise unexplained abdominal pain with anemia. 2. Most of these patients do not require a chelating agent for the treatment. 3. There is an urgent need to bring these alternative medicines under strict regulations for displaying its constituents and their concentration.
Keywords Alternative medicines, Lead toxicity, Pain abdomen
398
Preventive role of hepatitis C and B oral antiviral drugs in Covid-19 infection
Parveen Malhotra
Correspondence- Parveen Malhotra-drparveenmalhotra@yahoo.com
Department of Medical Gastroenterology, Post Graduate Institute of Medical Sciences, Medical Road, Rohtak 124 001, India
Introduction Researchers have suggested role of antiviral drugs for treatment of Corona Viruses which includes anti-HIV drugs and oral antivirals for hepatitis C and B like velpatasvir, sofosbuvir, daclastavir, ledipasavir and tenofovir.
Aims To determine the prevalence of Covid-19 infection in patients taking oral antiviral drugs for hepatitis C and B and the number of patients who developed Covid-19 infection while being on treatment with above antivirals.
Methods There were two groups which were followed for six months. The first group included those patients who were on treatment for hepatitis C and B since 1st March, 2020. The second group included patients who developed Covid-19 infection while being on oral antiviral drugs for hepatitis C and B.
Result First group included 3100 patients of hepatitis C who were on sofosbuvir 400 mg and daclastavir 60 mg or sofosbuvir 400 mg and velpatasvir 100 mg and 600 chronic hepatitis B patients who were on tablet tenofovir 300 mg, since 01.03.2020 till 30.09.2020, none developed Covid-19 infection. In second group, out of 30,000 confirmed Covid-19 infection in above duration, four patients were found to be positive for hepatitis C, out of them two completed their treatment one year back and two were yet to start treatment. Hence, practically none was on oral antiviral drugs for hepatitis C when got Covid-19 infection. Only two patients developed Covid-19 infection while on tenofovir for chronic hepatitis B.
Conclusion This study can be taken as indirect evidence of efficacy of above oral antivirals in Covid-19 infection which has to be confirmed on larger clinical trials.
Keywords Velpatasvir, Sofosbuvir, Daclastavir, Ledipasavir, Tenofovir, Hepatitis C, Hepatitis B, Covid-19, Oral antivirals
399
Safeguarding ourselves with bare minimal in resource constraints setting against Covid -19 our experience in tertiary care center
Muppa Indrakeela Girish , Amol Bapaye, Mangesh Borkar, Sachin Palnitkar, Harshal Gadhikar, Rajendra Pujari, Suhas Date, Lalit Shimpi
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Deenanath Mangeshkar Hospital and Research Center, Pune, India, and Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
Background SARS-CoV-2/Novel Corona Virus-19 (COVID-19) has become a global pandemic. COVID-19 can be easily transmitted in an endoscopy suite, there is high risk of infection during endoscopic procedures. Adequate protection of HCP is utmost important.
Methods Retrospective study who underwent endoscopic procedures during COVID-19 pandemic. Patients were pre-screened and risk was categorized into urgent (GI bleed, urgent feeds, biliary sepsis) and semi-urgent (GI cancers, ERCP for hepatobiliary pancreatic cancers, EUS for diagnosis of malignant conditions) for endoscopic procedures according to APSDE guidelines. Prior to procedure hemogram, chest X-ray, CRP done to all patients. HCW’s used modified PPE (cap, mask, shield, gown, gloves). Anesthesia preference- TIVA (midaz, fentanyl, propofol), GA with intubation. Gap between each procedure 20-30 mins. Divided our clinical force into two teams and followed the rotation policy on weekly basis. Procedures were performed in positive pressure rooms with air conditioning settings- MTR power 5.5 KW, fan TSP-626Pa, fan speed -1198RPM, Disch vol -11.6 m/s, motor frame size-132S-4, efficiency– 89.4% and nearly 30mm of W.C positive pressure.
Results Four hundred and sixty-seven patients (70.9%; male =312 [66.8%]; median age = 57) underwent endoscopy procedures- from March 20th to June 20th 2020. One hundred and ninety (40.7%) patients had one or more comorbidities with hypertension being commonest comorbidity in 142 (28%) patients. Commonest symptom was GI bleed in 121 (25.91%) patients. Five hundred and seven procedures, 274 (54%) diagnostic, 233 (46%) -therapeutic. Interventions ERCP – 85 (36.5%), EUS – 7 (3%), esophageal stenting-9 (3.9%), PEG- 22 (9.4%), EVL-35 (15%) 6 (1.2%) died during hospitalization following terminal illness. Follow-up of patients according to different procedures 2 weeks – 1 month did not develop Covid-19 symptoms and were not detected positive.
Conclusions Proper precautions there was no event of cross COVID-19 viral transmission between healthcare workers and patients. Judicious use of basic tests we followed will help in resource constraints settings like peripheral hospitals and nursing homes.
Keywords Covid 19, Risk stratification, PPE
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61st Annual Conference of Indian Society of Gastroenterology, Virtual Diamond Jubilee ISGCON 2020, 19-20th December 2020. Indian J Gastroenterol 39 (Suppl 1), 1–127 (2020). https://doi.org/10.1007/s12664-020-01133-9
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DOI: https://doi.org/10.1007/s12664-020-01133-9