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   Table of Contents - Current issue
April-June 2022
Volume 2 | Issue 2
Page Nos. 41-86

Online since Wednesday, March 23, 2022

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Urine trypsinogen-2 as a noninvasive screening test for predicting post-ERCP pancreatitis (PEP) p. 41
Rohan Vijay Yewale, Doraiswami Babu Vinish, Kayalvizhi Jayaraman, Naveen Chand, Parag Papalkar, Balakrishnan Siddartha Ramakrishna
Background and Objectives: post endoscopic retrograde cholangiopancreatography pancreatitis (post-ERCP) pancreatitis (PEP) is a notorious complication of ERCP procedure with varying incidence and severity across literature. There is a dearth of screening modalities which can accurately predict PEP in the immediate postprocedure period. The objective of our study was to assess the reliability of a rapid urine trypsinogen-2 dipstick test in predicting PEP at 4 h post-ERCP. Methods: This was a prospective, single center, analytical study conducted over a period of eighteen months among 124 patients who underwent ERCP for various biliary indications at SRM Institute for Medical Sciences Hospital, Chennai. Patients with acute or chronic pancreatitis and those undergoing any form of pancreatic endotherapy were specifically excluded. Urine samples were collected at 4 h postprocedure and tested for trypsinogen-2 using a commercially available, rapid urine dipstick test with a lower limit of detection of 50 mg/L. Patients were subsequently followed up for a day and assessed clinically and biochemically for the development of PEP. Results: After excluding 57 patients out of the 124 as per the exclusion criteria, a total of 79 patients who underwent ERCP for various biliary indications were ultimately enrolled for the study and subsequent analysis. Three out of the seventy nine patients in the study population were diagnosed to have PEP (3.79%) and one out of the three patients developed severe acute PEP. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of urine trypsinogen-2 at 4 h post-ERCP as a predictor of PEP were 66.7%, 92.1%, 25%, 98.3% and 91.1%, respectively. Serum lipase levels were elevated more than or equal to three times upper limit of normal in a total of eleven patients (11/79). 8/11 patients had asymptomatic hyperlipasemia. Median serum lipase level in patients with PEP was 864 U/L. Conclusion: Urine trypsinogen 2 dipstick can be reliably used as a screening test in ruling out PEP and guiding clinicians in discharging patients on the day of ERCP procedure. However, larger, blinded studies with lesser logistic limitations are needed to provide further evidence to extrapolate our data and advocate the utilization of this test in routine practice.
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Regional differences in bile acid composition in gallbladder bile p. 47
J Ramana Ramya, Mayank Jain, M Mary Sheeba, K Thanigaiarul, R Karvembu, Vijaya Srinivasan, V Vaithiswaran, S Narayana Kalkura, Jayanthi Venkataraman
Background: Chemical and structural analyses of gallstones (GS) from the Indian subcontinent has shown that the formation of GS type is dependent on regional and dietary factors. Aim of the Study: The aim is to determine the proportion of primary and secondary bile acids in gallbladder (GB) bile in patients with GS from South and North India using high-performance liquid chromatography (HPLC). Materials and Methods: Standards for primary and secondary bile acids were prepared and concentrations were determined by reversed-phase C18 HPLC column. Thirty-three GB bile samples from southern India and 28 samples from northern states of India were analyzed for differences in the proportion of primary and secondary bile acids. Ethics Committee of Gleneagles Global Health City, Chennai, approved the study. Statistical Analysis: concentration of bile acids (in mmol/L) were expressed as median and range. Chi-square test and Mann–Whitney U-test were applied. A P < 0.05 was considered as significant. Results: The median concentrations of cholic acid (CA) (P = 0.005) and its derivative deoxycholic acid (DCA) (P < 0.006) were significantly high in GB bile samples from South India with no differences in the concentration of chenodeoxycholic acid between the two samples. Furthermore, samples from North India had a significantly higher proportion of lithocholic acid (LCA) and low DCA compared to samples from South India. Conclusion: Primary bile acid CA and its derivative is high in GB bile from South; the proportion of hepatotoxic LCA is significantly high with low concentrations of DCA in bile samples from North India.
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Transgastric pancreaticogastrostomy: A novel technique for the management of pancreatico-enteric stenosis after pancreaticoduodenectomy p. 51
Gautham Krishnamurthy, Patta Radhakrishna, Doraiswami Babu Vinish, Karthikeyan Damodaran
Pancreatico-enteric stenosis (PES) is a long-term complication following pancreaticoduodenectomy (PD). The incidence of clinically relevant PES is likely to improve with better outcomes following PD for benign and neoplasms with favorable prognosis. Endoscopy and surgical techniques have been described addressing PES with revision of pancreatico-enteric anastomosis (PEA) being the most common performed surgery. Dense adhesions in the lesser sac especially after postoperative pancreatic fistula can be prohibitive to access the PEA. We describe a technique for postPD PES, transgastric pancreaticogastrostomy, that avoids lesser sac dissection and enables performing a wide anastomosis. Thus, it has the potential to reduce postoperative morbidity.
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EUS guided tissue acquisition from the retroperitoneal mass, reason to caution – Case report and review p. 55
Shankar Zanwar, Kamyani Deshpande, Ravisagar Patel
We recently encountered an unexpected immediate complication while doing an endoscopic ultrasound-guided fine-needle biopsy in a patient with a retroperitoneal abdominal mass lesion found on cross-sectional imaging. The case is presented and the literature reviewed. The endosonologist should be prepared for eventualities after puncture for retroperitoneal masses.
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Rare case reports of hepatocellular carcinoma with inferior vena cava and right atrium tumor thrombus and extension into left renal vein p. 58
Parimita Barua, K Narayanasamy, Santhi Selvi, Prem Kumar
Hepatocellular carcinoma with tumor thrombus extending to hepatic vein, inferior vena cava (IVC), and right atrium is rare and considered to be fairly advanced with a poor prognosis. We report two such cases from a single tertiary care center in South India. Treatment options in such patients are limited as the disease is extensive. We conducted a literature search for such case reports on PubMed. Compared with published literature, one of our cases had hepatic vein, IVC, left renal vein with tumor thrombus in the right atrium which has not been reported so far. Both the patients were started on systemic chemotherapy but succumbed to illness 4 and 7 weeks after initiation of chemotherapy.
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Autoimmune pancreatitis presenting as obstructive jaundice – A diagnostic challenge p. 62
Mansoor C Abdulla, Rooby Erachamveettil Hamza, Jithin S Panicker
Autoimmune pancreatitis (AIP) is a rare form of pancreatitis which can mimic carcinoma head of the pancreas or distal cholangiocarcinoma, causing the diagnostic dilemma. A 64-year-old postmenopausal woman presented with jaundice, generalized itching, and intermittent low-grade fever for 2 weeks. On evaluation, she had a bulky pancreas on imaging and distal biliary stricture on magnetic resonance cholangiopancreatography. She was planned for Whipple's resection, but her serum immunoglobulin G4 (IgG4) was very high. She was started on oral high-dose steroids considering the possibility of AIP and had significant improvement after 2 weeks of treatment. AIP can mimic distal cholangiocarcinoma and can cause a diagnostic challenge in patients admitted with obstructive jaundice. The presence of high serum IgG4 level and treatment response to steroids help in making the diagnosis. This case reminds the readers to consider AIP in patients with obstructive jaundice who have imaging findings of distal cholangiocarcinoma to avoid unnecessary operations on patients without cancer.
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Uncommon etiology of upper GI bleed p. 65
Hema Vijayalakshmi Varadarajulu
Abnormal fistulous communications between the esophagus and respiratory tract are life-threatening conditions which need to be diagnosed at the earliest and managed appropriately. Bronchoesophageal fistula (BEF) is a rare endoscopic finding. It is commonly due to esophageal malignancy in adults, benign etiologies being very rarely encountered during endoscopy. In this case report, we discuss a BEF arising from a mid-esophageal diverticulum, which presented with recurrent hematemesis.
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Use of variceal banding in gastric polyps bleed-A prototype technique in children p. 68
Dhanasekhar Kesavelu, Radhakrishnan Satheesan
An 8-year-old girl with a known history of Peutz‒Jeghers syndrome presents a history of hematemesis to the emergency room following an episode of reaching in the early hours of the morning. Her initial evaluation showed a hemodynamically stable child but had multiple episodes of retching which were managed conservatively. She has had a past history of acute pancreatitis for which she was in pancreatic supplements and she also had a magnetic resonance imaging of the brain which was normal. She presented with a history of ileo-ileal intussusception for which she was operated 5 years ago with an end-to-end anastomosis and she has been asymptomatic since. Her annual endoscopic surveillance showed polyposis of the colon which was resected and she was under constant follow-up. She had an episode of hematemesis was an acute episode which needed evaluation with an upper gastrointestinal (GI) endoscopy which showed the presence of polyps in the gastric antrum and pylorus with Grade 2 esophageal varices. She underwent prophylactic variceal banding for her esophageal varices. Further upper GI endoscopy evaluation showed the presence of polyps in the gastric antrum, body, and pylorus. We decided to use the variceal bands to ligate the gastric polyps as an unorthodox conventional technique, as the risk of bleeding and perforation are high in polypectomy. We Find banding of gastric polyps a very safe and effective method to remove gastric polyps in the stomach.
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Rare genetic disorder unveiled on evaluation of occult gastrointestinal bleed p. 71
Jo Varghese, Premkumar Dinu Abirami
The incidence of gastrointestinal (GI) bleed secondary to vascular ectasias in GI tract remains very less, accounting to only about 4%–5% of nonvariceal bleed. Most patients remain asymptomatic unless evident as iron deficiency anemia. We report of similar case scenario in a 65-year-old man who presented with recurrent anemia, treated with multiple blood transfusions for 6 years. The patient was found to have multiple lingual, nasal, gastric, and duodenal telangiectasias with arteriovenous malformations in the liver and lung. Considering the history, clinical findings, and investigations, a diagnosis of Osler-Weber-Rendu syndrome/hereditary hemorrhagic telangiectasia was made based on Curaçao criteria and the patient was treated with tamoxifen and argon plasma coagulation.
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Extramedullary chronic myeloid leukemia – A rare cause of ascites p. 74
Vinoth Sermadurai, Kannan Mariappan, Ramani Ratinavel, Vijai Shankar Chidambara Manivasagam
Chronic myeloid leukemia (CML) is a hematopoietic stem cell disease characterized by anemia, extreme blood granulocytosis and granulocytic immaturity, basophilia, often thrombocytosis, and splenomegaly. Extramedullary disease (EMD) occurs in CML blast crisis. In literature, peritoneal involvement in CML chronic phase is reported very rarely to the best of our knowledge. A 60-year-old male patient presented with complaints of significant weight loss over 1-month duration and abdomen distension for 7 days. The patient was pale and had massive ascites on presentation. Blood investigations showed a total count of 61.9 × 109 L, and liver disease was ruled out on imaging. Ascitic fluid analysis showed high protein, elevated adenosine deaminase, ascitic fluid acid-fast bacillus staining was negative, and GeneXpert negative for tuberculosis. Upper gastrointestinal endoscopy and colonoscopy were normal. Ascitic fluid cytology, though negative for malignant cells, showed myeloid precursor cells. Peripheral smear showed a leukemoid reaction. Bone marrow aspiration showed blast <3%. BCR/ABL1 was detected in leukocytes of peripheral blood. The patient was diagnosed with CML – chronic phase with peritoneal involvement as massive ascites – and was started tablet imatinib 400 mg OD and had favorable response to treatment after 3 months with the resolution of ascites and on follow-up. Extramedullary CML such as peritoneal disease serves as a predictor of future blast crisis, and close monitoring is needed for patients with EMD at initial presentation.
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Clostridioides difficile Infection in Patients with COVID-19 p. 78
Mayank Jain
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Impact of age on esophageal motility in patients with gastroesophageal reflux p. 80
Mayank Jain
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Ladd procedure in intestinal malrotation p. 83
Rathnaswami Arunachalam
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Gastroenterology elsewhere p. 85
Kayalvizhi Jayaraman
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