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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 1 | Issue 2
Page Nos. 45-85

Online since Tuesday, March 23, 2021

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EDITORIAL  

In this issue of the journal p. 45
BS Ramakrishna
DOI:10.4103/ghep.ghep_9_21  
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REVIEW ARTICLES Top

Low-volume plasma exchange and low-dose steroid to treat severe liver injury p. 47
Uday Zachariah, Santhosh E Kumar, Vijay Alexander, Lalji Patel, Ashish Goel, CE Eapen
DOI:10.4103/ghep.ghep_18_20  
High-volume plasma exchange (PLEX) to treat acute liver failure is now categorized as a Category I indication (i.e., first-line treatment as a stand-alone treatment or with other treatment modalities) by the American Society for Apheresis after a randomized controlled trial of 183 patients demonstrated survival benefit by this treatment. In this review, we provide an introduction to PLEX to treat acute liver failure syndromes for hepatologists and gastroenterologists. From our recent experience of treating 188 patients with acute liver failure syndromes with low-volume PLEX and low-dose steroid, we present five illustrative case histories of patients who benefitted from this management protocol. We discuss some postulated mechanisms how PLEX benefits patients with acute liver failure syndromes. PLEX appears to provide survival benefit in patients with acute liver failure syndromes (severe acute liver injury, acute liver failure, and acute-on chronic liver failure) and may be a nontransplant treatment option for some of these patients, especially in resource-constrained settings.
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ORIGINAL ARTICLE Top

Comparison of complete rockall score, Glasgow–Blatchford score, and AIMS 65 score for predicting in-hospital mortality in patients presenting with upper gastrointestinal hemorrhage at a Tertiary Care Hospital in Southern India p. 55
Anand Totagi, Usha Srinivas, Piramanayagam Paramasivan, Sankaranarayanan Krishnan, Kallipatti Ramasamy Palaniswamy, AT Mohan, Sarojini Ashok Parameswaran, Ubal Dhus, Muthuswamy Hariharan, MS Revathy, Natarajan Murugan, Karunakaran Premkumar, Seshadri Venkatesh, Preethi Mahalingam, Santhosh Kumar
DOI:10.4103/ghep.ghep_20_20  
Background: Multiple risk assessment scores are available to triage and stratify patients presenting with upper gastrointestinal (GI) hemorrhage. This study was conducted to compare the accuracy of complete Rockall score (CRS), Glasgow–Blatchford score (GBS), and AIMS65 score (AIMS65-albumin, INR >1.5, impaired mental status, systolic pressure <90 mm Hg, and age >65) in predicting in-hospital mortality in patients presenting with upper GI hemorrhage to the gastroenterology department at a tertiary care hospital in Southern India. The secondary objectives were to compare these three scores in predicting the need for blood transfusion, any intervention (endoscopic or radiological or surgical intervention), or rebleeding in patients presenting with upper GI hemorrhage. Materials and Methods: This was a retrospective analysis of prospectively recorded data which included 207 patients with acute upper GI hemorrhage admitted at a tertiary care hospital at Chennai over 2 years. Demographic, clinical, laboratory, and endoscopic parameters were recorded. CRS, GBS, and AIMS65 scores were calculated. Data regarding in-hospital mortality, need for blood transfusion, endoscopic intervention, radiological intervention, surgical intervention, and rebleeding were collected. Area under receiver operating characteristic curve (AUROC) was compared between the three scores in predicting in-hospital mortality, need for blood transfusion, intervention, and rebleeding. Results: AIMS 65 score >3 (AUROC 0.92) was a better predictor of in-hospital mortality than GBS (AUROC 0.77) and CRS (AUROC 0.69). AIMS65 was a better predictor of rebleeding (AUROC 0.804) than GBS (AUROC 0.676) or CRS (AUROC 0.623). GBS was a better predictor for need of blood transfusion (AUROC 0.785) than AIMS65 (AUROC 0.691) or CRS (AUROC 0.629). Conclusion: AIMS 65 score (>3) was a better predictor of in-hospital mortality than GBS or CRS in patients presenting with acute upper GI hemorrhage due to either variceal and nonvariceal etiology. AIMS 65 was also a better predictor of risk of rebleeding. GBS was a better predictor of need for blood transfusion and need for intervention.
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Percutaneous endoscopic gastrostomy: A prospective study p. 62
Doraiswami Babu Vinish, Gautham Krishnamurthy, Arulprakash Sarangapani, Kayalvizhi Rajini, Balakrishnan Siddartha Ramakrishna
DOI:10.4103/ghep.ghep_21_20  
Introduction: Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure for establishing enteral access for nutrition. There is a paucity of literature on PEG from the Indian subcontinent. With the rate of complications in the literature showing a downward trend, we aimed to analyze the same in our institute following a standard procedure of PEG tube placement. Methods: The prospective study was conducted including patients referred for PEG placement from August 2017 to December 2019. Data were recorded on a proforma. The primary aim of the study was to determine the rate of complications in patients undergoing PEG, whereas the secondary aim was to determine whether early feeding was associated with increased rate of infection or other complications. Patients were reviewed after 3 days, 1 month, and every 3 months thereafter later with clinical examination. Results: Sixty-seven (83.75%) males and 13 (16.25%) females with a median age of 51 years (range 1–85) were included in the study. Forty-one (51.25%) patients had comorbidities with hypertension being the most common (n = 28). Postoperative placement of the PEG tube was done in 47 (58.75%) patients. Seventy-four patients had underlying neurological or neurosurgical conditions. At the time of PEG placement, 59 (73.75%) had tracheostomy. All procedures were performed in the endoscopic suite, of which two were performed as day care procedures. There were no intraprocedural complications. Feed was started within 2 h in 45 (56.25%) patients and all tolerated feed well. There were no major postprocedural complications. Thirteen patients had clinically suspected PEG site infection, of which 11 patients had a culture-positive organism. All responded to conservative management. Thirty-two patients were on follow-up at a median follow-up period of 2 years. Conclusion: The incidence of complications following PEG tube placement is low. With the standardization of the PEG technique, no major complications were seen in our study. Early PEG feeding was not associated with an increase in the rate of complications.
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CASE REPORTS Top

Acute obstructive suppurative pancreatic ductitis secondary to intraductal stones p. 66
Avinash Bhat Balekuduru, Bongu Shruti Sagar, Satyaprakash Bonthala Subbaraj
DOI:10.4103/ghep.ghep_19_20  
Pancreatic sepsis secondary to infected necrosis or pancreatic abscess is a well-known clinical entity. Acute obstructive suppurative pancreatic ductitis (AOSPD) in the setting of chronic calcific pancreatitis is a rare complication that is seldom reported. We report two cases of AOSPD who underwent successful pancreatic endotherapy.
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Ampullary stone in chronic pancreatitis causing obstructive jaundice and cholangitis p. 69
Sandheep Janardhanan, Allwin James, Alagammai Palaniappan, Ramesh Ardhanari
DOI:10.4103/ghep.ghep_27_20  
Cholangitis is very rarely caused by impaction of a pancreatic stone in the papilla. An elderly male presented with obstructive jaundice and cholangitis that was caused by an impacted pancreatic stone. He presented as fever of 2 weeks duration and was referred as case of periampullary neoplasm for palliative stenting. However, an endoscopic retrograde cholangiopancreatogram was done which revealed the impacted stone. Precut papillotomy was done to release the stone, which led to the resolution of cholangitis.
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Pulmonary nocardiosis: Life-threatening complications of antitumor necrosis factor-α treatment for Crohn's disease p. 72
Hemanta Kumar Nayak, Manas Kumar Panigrahi, Srujana Mohanty, Chandan Kumar, Subash Chandra Samal
DOI:10.4103/ghep.ghep_29_20  
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. We share our experience of such opportunistic infection (pulmonary nocardiosis) in a young male with Crohn's disease on injection adalimumab. The patient was managed with appropriate antibiotics and after therapy, prophylaxis with cotrimoxazole was initiated. Adalimumab was re-introduced, as he developed flare-up of the perianal disease on follow-up. Atypical opportunistic infection requires a meticulous approach to reach early diagnosis to prevent poor outcomes.
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CLINICAL PERSPECTIVE Top

High-resolution esophageal manometry in clinical practice – An Indian perspective p. 75
Mayank Jain
DOI:10.4103/ghep.ghep_22_20  
High-resolution esophageal manometry (HREM) is a technique to determine the function of esophageal musculature and the integrity of the lower esophageal sphincter. This test is commonly used for evaluation of nonobstructive dysphagia, assessment of peristaltic reserve before anti-reflux surgery, symptoms of regurgitation, and noncardiac chest pain unexplained by endoscopic evaluation. The current review deals with the spectrum of esophageal motility disorders in India and reviews the technique and reporting of HREM. The clinical utility of HREM in Indian setting with special reference to challenges faced has been discussed in detail.
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HOW I DO IT Top

Pelvic floor physiotherapy rehabilitation for dyssynergic defecation: An approach tailored to an Indian setting p. 82
Umamakeswari Venkatesa, M Srinivas, Mayank Jain, Jayanthi Venkataraman
DOI:10.4103/ghep.ghep_23_20  
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