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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 177-188

Abstracts of posters presented at TNISGCON March 2021

Date of Web Publication24-Sep-2021

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_26_21

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How to cite this article:
. Abstracts of posters presented at TNISGCON March 2021. Gastroenterol Hepatol Endosc Pract 2021;1:177-88

How to cite this URL:
. Abstracts of posters presented at TNISGCON March 2021. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2022 Aug 18];1:177-88. Available from: http://www.ghepjournal.com/text.asp?2021/1/4/177/326631

  Gastric Cancer in Young Patients With No Alarm Symptoms: Focus on Delay in Diagnosis Top

B. Krishna Kartik Reddy, A. Anand, A. Aravind, Kani Sheik Mohammed, G. Akhilandeswari, Vaishnavi Priya, N. Arun

Department of Gastroenterology, Government Peripheral Hospital, Chennai, Tamil Nadu, India

There has been a tendency in recent years to omit 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. In this study, the frequency of alarm symptoms was assessed in a series of young gastric cancer patients. A retrospective study was carried out on 30 gastric cancer patients ≤ 45 years of age identified from databases in our hospitals between January 2017 and December 2019. Characteristics analyzed included duration and features of dyspeptic symptoms, presence of alarm symptoms, and time interval from the onset of symptoms to diagnosis. Of the 30 patients, 17 were females and 13 were males. Six patients (20%) presented with uncomplicated dyspepsia and 24 patients presented with (80%) alarm symptoms (persistent vomiting, anemia, weight loss, and 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%), heartburn, and nausea. Weight loss was the most common alarm symptom (53.3%), followed by anemia (46.6%). Conclusion: Gastric cancer is not uncommon in patients with dyspepsia aged less than 45 years. Significant proportion of young gastric cancer patients present without alarm symptoms. We need to review the ASGE existing standard age criteria (>45 years) for endoscopy in dyspepsia without alarm features young patients, particularly in high gastric cancer prevalence areas. We also recommend large-scale studies to conclude this.

Keywords: Gastric cancer, dyspepsia, alarm symptoms

  Low-Volume Plasma Exchange and Low-Dose Steroid Improve Survival over 1 Year in Alcohol-Related Acute-On Chronic Liver Failure Patients Top

E. Santhosh Kumar, S. C. Nair, U. Zachariah, A. Goel, S. Varughese, B. Vijayalekshmi, K. A. Balasubramanian, E. Elias, C. E. Eapen

Departments of Hepatology, Transfusion Medicine and Nephrology, Wellcome Trust Research Laboratory, Division of GI Sciences, Christian Medical College, Vellore, Tamil Nadu, India

Aim: The aim of the study is to compare 1-year survival in alcohol-related acute-on chronic liver failure (A-ACLF) patients treated with low-volume plasma exchange (PLEX) and low-dose steroid to those who had standard medical treatment (SMT). Methods: Survival of patients with A-ACLF is poor with limited treatment options. It is uncertain if steroid treatment is beneficial or harmful in A-ACLF patients. PLEX is beneficial in treating ALCF patients. This was a retrospective cohort study conducted from November 2017 to June 2019. A-ACLF patients (APASL 2019 definition) were included. Patients with sepsis or recent gastrointestinal (GI)/non-GI bleed were excluded. Patients treated with low-volume PLEX with low-dose steroid and compared with patients treated with SMT. The study was approved by the institutional review board 50% of plasma volume exchanged with fresh frozen plasma. Three PLEX sessions targeted, further sessions on a case-to-case basis. Tablet prednisolone 10 mg once daily started on day before PLEX and continued till 1–2 weeks after stopping PLEX. Blood cultures were taken before PLEX; prophylactic antibiotic (injection cefaperazone + sulbactum) was given 1 day before PLEX and continued till completion of PLEX. No significant PLEX-related complications were noted. VWF level of 168.42% (±standard deviation 78.6%) by collagen binding activity assay was detected in the pheresed plasma in 18 patients tested. Strength of the study was 1-year follow-up. A possible mechanism how low-volume PLEX and low-dose steroid works in treatment of A-ACLF was explored. Limitations of the study were retrospective study and small number of patients. In this preliminary report, low-volume PLEX with low-dose steroid improves survival over 1 year in A-ALCF patients. In A-ACLF patients with raised serum creatinine, 60% of patients had normal serum creatinine after PLEX. Large randomized controlled trials are needed to validate these findings.

Keywords: Liver failure, mortality, plasma exchange

  A Rare Case of Cystic Pancreatic Neuroendocrine Tumor Top

J. S. Harish Reddy, P. Ganesh, S Shanmuganathan, B Anand, AK Kaushik

Department of Gastroenterology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Pancreatic neuroendocrine tumors (PNETs) are typically solid neoplasms; however, in very rare cases, they present as cystic lesions. We describe a case of a pancreatic cystic lesion presenting as neuroendocrine tumor. This 65-year-old elderly male presented with abdominal pain, and weight loss and jaundice and was evaluated and found to have cystic lesion on computed tomography (CT) abdomen. Further evaluation with endoscopic ultrasound and fine needle aspiration cytology revealed PNET. DOTA positron emission tomography CT of the patient showed distant metastasis to lung, and the patient was referred to the medical oncology for further palliative management of the well-defined cystic lesion measuring 3.5 cm × 3.7 cm × 3.6 cm seen in the proximal body. Conclusion: We report the case of a cystic PNET in the body of the pancreas, which was clinically and radiologically diagnosed as cystic neoplasm of pancreas.

Keywords: Pancreas, cyst, neuroendocrine tumor

  Double Trouble at Hilum Top

Damodar Krishnan, P. Ganesh P, S. Shanmuganathan, A. K. Koushik

Department of Gastroenterology, Sree Ramachandra Medical College, Porur, Chennai, Tamil Nadu, India

Pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma (HCC) is rare and has been reported only in a small case series from East Asia. Spontaneous tumor necrosis and biliary obstruction caused by tumor thrombi, superimposed with bacterial infection, are the two most common pathogenic mechanisms, by which HCC manifests as pyogenic liver abscess. Case Report: A 72-year-old male known hypertensive for the past 25 years, with complaints of yellowish discoloration of the eyes with pale stools progressive over 2 months presented with dull-aching abdominal pain with distention for 3 weeks, also reported anorexia with significant weight loss over this time period. On examination, the patient was moderately built and nourished with stable vitals, icteric with mildly distended abdomen, and tenderness over the right hypochondrium. Investigations revealed leukocytosis with direct hyperbilirubinemia and elevated alkaline phosphatase and gamma glutamyl transpeptidase. Ultrasound of the abdomen showed multiple hepatic abscess with dilated common bile duct and intrahepatic biliary radicle dilation. Magnetic resonance cholangiopancreatography done revealed liver abscess arising from segments VI and VII of the right lobe, extending into subscapsular region with collection, suggestive of a contained rupture. The patient was managed with pigtail drainage of abscess and antibiotics, according to pus culture. HCC, initially presenting as pyogenic liver abscess, predicts a worse prognosis. In a case series study, elevated alpha fetoprotein was used to diagnose HCC when symptoms including fever, chills, right upper quadrant abdominal pain, and weight loss were present in patients that presented initially as pyogenic liver abscess. Pyogenic liver abscess with biliary communication is an important risk factor associated with liver abscess-related mortality. Conclusion: High index suspicion of malignancy is needed in pyogenic abscess presenting with biliary communication, and HCC in such a scenario carries a poor prognosis.

Keywords: Abscess, cancer, liver

  Fifteen Years of Undiagnosed Gastrointestinal Bleed - A Case Report Top

Sudhagar Rengasamy, A. Amudhan, K. Kamalakannan, M. Satish Devakumar, J. Saravanan, T. Selvaraj, Jeswanth Sathyanesan

Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, Tamil Nadu, India

Hemangiolymphangioma (HL) is a rare benign tumor, commonly present in pediatric age group, which involves head and neck. Small bowel HL has been reported as solitary or segmental involvement. Here, we report a case of diffuse small bowel HL, presented as chronic anemia, fatigability, and obscure gastrointestinal (GI) bleeding. Case Presentation: A 42-year-old male presented with a 15-year history of bleeding per rectum, anemia, and fatigability and received multiple blood transfusion. Exact cause could not be identified. Complete hemogram parameters were low requiring further imaging studies. Imaging and intraoperative enteroscopy showed multiple nodular lesion in the mesentry as well as in the mucosa of entire small bowel. Bleeding points were noted in the proximal jejunal lesion which was resected. Histopathological study confirmed as benign HL. Conclusion: HLs are rare tumors of the GI tract. To the best of our knowledge, diffuse HLs of small bowel have not been reported in the medical literature. With this case scenario, one should consider these tumors in the differential diagnosis of obscure lower GI bleed and chronic anemia, as well as explore definitive management options for these benign symptomatic tumors.

Keywords: Gastrointestinal bleeding, hemangiolymphangioma, small bowel

  A Diagnostic Accuracy Study to Validate Fatty Liver Index as Predictor for Fatty Liver in Adult-Native Tamilians, India Top

V. Y. Bhargav

Department of Hepatology, Sri Ramchandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Ultrasound (US) is the first-line investigation to document a fatty liver (FL) but is operator dependent. Hence, there is a need to establish simple and accurate predictors replacing US. Fatty liver index (FLI) is a validated marker. Subjects with an ultrasound diagnosis of normal or FL were included. Basic patient data were obtained, and FLI was calculated. A total of 522 subjects formed the study population. Of these, 326 had FL (Group 1) and 196 had normal liver on US (Group 2). Statistical Analysis: Considering US as the gold standard, the sensitivity, specificity, and negative and positive predictive values (NPV and PPV) of FLI scores were determined. Area under the receiver operator characteristic curve (AUROC) was used to indicate the predictive validity of the FLI. Results: Patients (males and females) with FL were significantly older, with a significantly greater body mass index and waist circumference compared to those without FL. Serum gamma glutamyl transferase and triglycerides likewise were significantly higher in individuals with FL. The FLI score in below 10 negated the presence of FL, with an neutrophil lymphocyte ratio of 0.22% and an NPV of 73.08%. A score of 80 and above predicted the presence of FL with a platelet lymphocyte ratio of 3.61% and above and a PPV of 85.71%. The AUROC of the FLI for predicting FL was 0.702 (95% confidence interval: 0.655–0.749). Conclusion: FLI is likely to have a different cutoff among different ethnic populations in the Indian subcontinent. Hence, FLI cutoff of determinants for the respective population is necessary to predict FL.

Keywords: Fatty liver, fatty liver index, ultrasound

  Double-Scope Technique Improves Identification of Esophagogastric Junction in Peroral Endoscopic Myotomy Procedure Top

A. Dheeraj Kumar, G. S. Sameer Kumar, B. Mahadevan, Piyush Bawane

Department of Gastroenterology, Gleneagles Global Health City, Perumbakkam, Chennai, Tamil Nadu, India

Achalasia cardia is an important cause of motor dysphagia characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter during swallowing. Peroral endoscopic myotomy (POEM) has become the preferred therapy for achalasia owing to its safety and effectiveness. An important predictor of the success and safety of POEM is correct identification of the esophagogastric junction (EGJ) and the extent of myotomy. We encountered a 32-year-old male with Type I achalasia cardia and Eckhardt Symptom Score of 9, had sigmoid esophagus as seen on barium swallow. While performing POEM procedure, we encountered difficulty in identifying EGJ by traditional methods. To overcome this problem, transnasal insertion of pediatric upper esophagogastroscope (5.6 mm) was done through the submucosal tunnel. The position of the EGJ was identified by noting the transillumination of this scope using an adult upper esophagogastroscope in the retroflexed position. This helped in guiding the submucosal dissection in accurate direction. The tunneling was done under the guidance of the second scope and continued up to 2–3 cm into the cardia. Myotomy of the circular muscles was done using IT knife. The patient had an uneventful recovery postprocedure with a significant symptomatic improvement. Conclusion: Double-scope POEM is advancement in POEM technique and is based on the appropriate identification of the cardia in the retroflexed position by using a second ultrathin gastroscope. In one randomized control trial by Grimes et al., the method was used only to confirm the extent of myotomy after completion of myotomy and not during the procedure. Hong et al. have described the simultaneous use of oral insertion of gastroscope and thin transnasal endoscope for better results. This technique does not require any specialized equipment, is useful in sigmoid esophagus and hiatal hernia, and has higher success rate with fewer complications. The present report highlights the fact that double-scope POEM can be used safely for better identification of EGJ and adequate myotomy.

Keywords: Achalasia, endoscopic, myotomy

  Correlation of Neutrophil-to-Lymphocyte Ratio with Severity of Alcoholic Liver Cirrhosis based on Child–Turcotte–Pugh Score Top

Debapratim Routh, I. Shubha, A. Chezhian, K. Premkumar, R. Murali

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Cirrhosis of the liver is known as an end-stage process where healthy normal liver tissue is replaced by the abnormal connective tissue, which induces nodule formation in it. Liver cirrhosis commonly occurs as the result of various causes including viral infections (hepatitis B and C), alcohol, Wilson's disease, autoimmune hepatitis, alpha 1 antitrypsin deficiency, and nonalcoholic fatty liver disease. Several scoring system such as Child–Turcotte–Pugh (CTP) score implicated for predicting severity of liver disease that consists of five variables. Correlation between CTP score with neutrophil-to-lymphocyte ratio (NLR) showed significant moderate correlation (r = 0.511, P < 0.0001). Cutoff value of CTP A and CTP B, C was 2.21 with sensitivity of 73.80% and specificity of 82.10%. Area under the curve (AUC) of this cutoff value was 87% with P < 0.0001. Cutoff value of CTP C and CTP A, B was 2.33 with sensitivity of 84.24% and specificity of 61.40%. AUC of this cutoff value was 75%, with P = 0.048. Mean NLR of CTP A was 2.05 ± 0.18, CTP B was 2.52 ± 0.46, and CTP C was 2.95 ± 0.83, with statistical significant difference. Post hoc test of CTP score with NLR mean value showed significant difference between groups. 82.1% of cases in CTP A were in ≤ 2.21 NLR, 57.1% of cases CTP B were in ≥ 2.33 NLR, and 84.2% of cases CTP C were in ≥ 2.33 NLR. Conclusion: NLR and CTP score have a significant moderate positive correlation. Higher CTP score tends to have higher NLR value.

Keywords: Child–Turcotte–Pugh score, neutrophil-to-lymphocyte ratio, cirrhosis

  A Case Report of Hepatopulmonary Syndrome as the First Clinical Manifestation of Cirrhosis in a Patient with Underlying Interstitial Lung Disease Top

Jophin John, T. Ravishankar, V. Arul Selvan, Senthil Vadivu

Department of Medical Gastroenterology, Coimbatore Government Medical College, Coimbatore, Tamil Nadu, India

A 26-year-old female presented with a history of chronic dry cough and mMRC grade 3 for the past 2 years. Respiratory system showed bilateral coarse crepitation in the mammary, scapular, and axillary areas. Gastrointestinal system showed spleen palpable 3 cm below the left costal margin, with no free fluid. Cardiovascular system was clnically normal. There was no history of fever, loss of appetite, chest pain, or upper gastrointestinal bleed. Her symptoms worsened over the past 6 months which are not responding to medications. Moreover, she is more dyspneic at sitting position when compared to lying down. The extent of interstitial lung disease (ILD) did not explain the persistent hypoxemia; a decision to perform a computed tomographic pulmonary angiogram (CTPA) was taken to rule out pulmonary thromboembolism. A CTPA ruled out pulmonary embolism and in addition showed an aneurysmal dilatation of the pulmonary artery branches in the periphery of lower lobes. Volume-rendered three-dimensional image of CTPA shows dilated distal end of branches of the right lower lobe pulmonary artery. An incidental note was made of a nodularity of the liver margins and large gastroesophageal varices in CTPA, prompting a contrast-enhanced CT of the abdomen that confirmed a cirrhotic liver with stigmata of portal hypertension. A contrast echocardiography, using agitated saline, showed delayed appearance of air bubbles in the left-sided chambers after fifth heartbeat, excluding an intracardiac shunt and supporting the diagnosis of afunctional hepatopulmonary shunt. The comparison of arterial blood gas measurements in the supine and lying down position was suggestive of platypnea orthodeoxia syndrome and disproportionately low diffusing capacity of the lung for carbon monoxide and other corroborative evidence from CTPA, and saline bubble contrast echocardiogram confirms the diagnosis as hepatopulmonary syndrome (HPS), probably type 1 (grade severe) with cirrhosis liver (CHILD-PUGH A) with underlying interstitial lung disease, nonspecific interstitial pneumonia. Results: Our patient possessed all three of the cardinal findings of HPS: cirrhosis and portal hypertension, hypoxemia, and evidence of pulmonary microvascular abnormalities. Usually, HPS severity its severity is often proportional to severity and child status of their cirrhosis. However, she presented with severe disease despite seemingly having compensated CHILD acirrhosis. Moreover, it is very unusual for HPS to be the first symptomatically manifesting sequelae of cirrhosis as it was in this patient; there are few other examples of this happening in the literature. Conclusion: The coexistence of HPS and ILD raises a number of difficulties in the diagnostic and therapeutic approach of both entities and affects progress of both. As many of the symptoms and clinical signs such as clubbing, cyanosis present in both a very high index suspicion is required to diagnose the coexistence.

Keywords: Gastrointestinal bleeding, endotherapy, embolization

  Upper Gastrointestinal Bleed Managed by Endoscopic and Endovascular Techniques Top

B. Karan, Yugandhar Samireddypalle, M. G. Srinivas

Department of Gastroenterology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

The majority of upper gastrointestinal bleeds (UGIBs) are caused by peptic ulcer disease, which is most commonly located between the gastric antrum and third portion of the duodenum. Endoscopic and supportive medical therapies are the first-line therapies as they are highly effective. However, approximately 10% of all patients either continue to bleed or experience re-bleeding within 48 h of the endoscopic treatment. Hence, endovascular embolization has now become the next line of therapy. The gastroduodenal artery (GDA) is the most common target vessel for embolization as it supplies the territory that is most commonly affected by peptic ulcers. A 72-year-old female presented with hematemesis and melena for the past 2 days in a state of shock. The relatives gave a history of chronic NSAID use for joint pain. The patient had no previous history of upper GI bleed (UGID). On initial examination, the patient had tachycardia (pulse rate: 110/min); blood pressure was not recordable. The patient was admitted to the intensive care unit and resuscitated. Pantoprazole infusion was started. Hemoglobin was 7 g/dl. Other necessary investigations were sent. A computed tomography angiogram showed pseudoaneurysm of GDA measuring 4.2 mm × 4.8 mm noted at a distance of 2.9 cm from the origin of GDA. The surrounding vessels showed no obvious thrombosis/stenosis. The patient was taken up for embolization where superselective gastroduodenal angiogram showed a small pseudoaneurysm; trap door embolization was done with 3 mm × 14 cm and 3 mm × 7 cm coils. Results: The GDA arises from the common hepatic artery. The variable origins of the GDA include the superior mesenteric artery, the left hepatic artery, and the right hepatic artery. The GDA supplies the gastric antrum, proximal duodenum, and the head of the pancreas. UGIB can be variceal or nonvariceal. The causes of nonvariceal UGIB include peptic ulcer disease, Mallory–Weiss tears, erosive gastritis, duodenitis, esophagitis, malignancy, and angiodysplasias. Of these, peptic ulcer disease is the most common cause. Conclusion: UGIB is a potentially life-threatening condition with the overall mortality rates for nonvariceal bleeding approaching 10%. While endoscopic and medical therapies are largely effective, some patients are refractory to such management. In these cases, urgent endovascular embolization of the GDA is potentially lifesaving. Ischemic complications can occur in up to 16% of embolizations. For both GI bleeding and pseudoaneurysm embolization, a distal and proximal embolization is necessary to prevent backdoor perfusion at the site of the bleeding or pseudoaneurysm.

Keywords: Cirrhosis, hepatopulmonary syndrome, interstitial lung disease

  Combined Thoracolaparoscopic and Endoscopic Management of Boerhaave's Syndrome - A New Technique Top

Jeolin Mithun, Poppy Rejoice, Sunil Jeyaharan, Arokia Arul Prakash, John Grifson

Department of Gastroenterology, Dr. John's Digestive Diseases Clinic, Nagercoil, Tamil Nadu, India

Boerhaave's syndrome is a spontaneous rupture of esophagus following barotrauma, due to forceful vomiting. In patients in whom the diagnosis is delayed or presentation is late, the clinical course is usually complicated. Management of Boerhaave's traditionally has been operative primary repair in early cases with staged surgery in delayed cases. A 58-year-old male was referred to us with a delayed diagnosis of spontaneous esophageal perforation. The patient was critically ill with sepsis and ARDS. He was resuscitated and stabilized. A fully covered self expanding metallic stent was deployed to seal the perforation. To prevent stent migration, the SEMS was intracorporeally sutured to the gastroesophageal junction using poly dioxane suture 2-0 sutures. Laparoscopic feeding jejunostomy was done. Left thoracoscopy was performed and thoracic contamination was debrided under vision. The patient recovered well and was discharged on the postoperative day 21. Acombined endocopic and thoracolaparoscopic approach was successful in closure of perforation. Conclusion: In this patient with delayed presentation of Boerhaave's syndrome, a combined endocopic and thoracolaparoscopic approach was successful in closure of perforation and salvaging life.

Keywords: Boerhaave, thoracoscopy, laparoscopy

  Correlation of Neutrophil-Lymphocyte Ratio to FIB-4 in Patients with Chronic Hepatitis B Top

U. S. Umashankar, A. R. Akhilandeshwari, A. Anand, Vaishnavi Priya, N. Arun, Kani Shiekh, A. Aravind

Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Chronic hepatitis B (CHB) is a dynamic condition involving interaction between the hepatitis B virus (HBV), hepatocyte, and host immune system. Inflammatory state plays a pivotal role in the severity of CHB and it is correlated with fibrosis. Neutrophil-lymphocyte ratio (NLR) is a cheap, easily available bedside inflammatory marker. This study was done to assess the role of NLR to assess the fibrosis in CHB patients. Study Population: 50 CHB patients attending digestive health and diseases outpatient department. Study Period: September 2020 to February 2021. Study Type: This was a prospective cross-sectional study Exclusion Criteria: Patients with HCV, HIV, leukemia, autoimmune diseases; patients receiving the blood products transfusion, decompensated chronic liver disease. Mean age of the patients was 36 years. There were 34 males and 16 females. Patients with F0–F2 fibrosis were 22 and mean NLR was 3.12; patients with F3–F4 fibrosis were 28 and mean NLR was 4.1 (P = 0.02). Mean FIB-4 among CHB patients was 5.43. NLR correlates positively with FIB-4 (r = 0.36). Conclusion: CHB is an important health problem which needs long-term follow-up and monitoring NLR values are elevated in CHB patients, which is significantly high among F3–F4 group. NLR correlates positively with FIB-4. NLR may help to estimate the severity of liver disease and improve medical decision-making.

Keywords: CHB, HBV, NLR

  Study of Comparison of Albumin Bilirubin Score to MELD and Child–Pugh Score in Prognosis of Cirrhosis in a Tertiary Care Center Top

M. S. Revathy, B. Sumathi, S. Chitra, M. Manimaran, G. Sathya, I. Kishore

Department of Medical Gastroenterology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India

The aim of this study was to compare the prognostic accuracy of albumin bilirubin (ALBI), MELD, MELD with sodium (MELD-Na), and Child–Pugh (CP) scores in a tertiary care center. One hundred outpatients or hospitalized cirrhotic (78 males, median age 48 years) were studied over a period of 1 year, and ALBI, MELD, MELD-Na, and CP score were calculated and correlated with survival. On multivariate analysis, only factors independently associated with death was the ALBI score (hazard ratio 2.50, 95% confidence interval 1.65–3.70). Conclusion: ALBI score is a simple score requiring only two parameters for its calculation. Hence, it might be a better prognostic indicator of mortality in cirrhosis and may be used in place of MELD, MELD-Na, and CP score.

Keywords: Albumin bilirubin, Child–Pugh, cirrhosis, MELD, MELD with sodium, prognosis, survival

  Etiology and Frequency of Marked Elevation of Serum Transaminase Levels > 1000 U/L in Adults Top

C. Manoj Kumar, Akilandeswari, S. Kavitha, Arun, A. Anand, A. C. Vaishnavi Priya, K. Jayakumar, S. Kani, A. Aravind

Department of Digestive Health and Disease, KMC, Chennai, Tamil Nadu, India

Marked elevations of aspartate aminotransferases (AST) or alanine aminotransferases (ALT) >1000 U/L can be a marker of severe liver disease with variable etiologies. We aimed to study the etiology of marked elevation of aminotransferases. This was a prospective, observational study during the period from January 2018 to January 2021. All patients > 18 years with AST or ALT > 1000 U/L were identified and included in the study. During the 3-year period, 90 patients were identified of which 60% were males. Mean age was 40 years (range: 18–85). Mean AST was 2874 IU and ALT was 1692 IU. The most common causes of AST or ALT > 1000 U/L were ischemic hepatitis (31, 34%) followed by viral hepatitis (25, 27%), dengue hepatitis (14, 15%), drug-induced liver injury (DILI, 12, 13%), COVID hepatitis (6, 6%), and rat killer poisoning (2, 2%). Among viral hepatitis, hepatitis B, hepatitis E, hepatitis A, and CMV hepatitis were seen in 15, 7, 2, and 1, respectively. Among DILI patients, nine were due to antituberculosis drugs, three from traditional medicines. Two patients were due to rat killer poisoning. AST > ALT was predominantly observed in patients with ischemic hepatitis, dengue. ALT > AST was observed in viral hepatitis and DILI. Conclusion: Ischemic hepatitis, dengue, other viral hepatitis, and DILI are major causes of markedly elevated transaminases.

Keywords: Dengue, ischemic hepatitis, marked elevation of aminotransferases, viral hepatitis

  Role of C-Reactive Protein in Increasing the Efficiency of the Bedside Index of Severity in Acute Pancreatitis Scoring System Top

R. K. Chaitanya, R. Selvasekaran, R. Ramasubramanian

Department of Gastroenterology, Thoothukudi Government Medical College, Thoothukudi, Tamil Nadu, India

The aim is to study the success rates of combination of bedside index of severity in acute pancreatitis (BISAP) scores with C-reactive protein (CRP) values in predicting severe AP. Medical records of all patients with AP admitted to our hospitals from January 2020 to January 2021 were reviewed. To evaluate the severity of AP, the revised Atlanta criteria were used, and patients who developed organ failure lasting more than 48 h were considered to have severe AP. We analyzed patient CRP values at the 24-h mark. Our study population consisted of 216 patients, and according to the revised Atlanta scoring, 170 patients (78.7%) had mild AP, 32 (14.8%) had moderate AP, and 14 (6.5%) had severe AP. Comparing the mild, moderate, ad severe AP groups, we noted a significant difference between the mean hospital stay time, BISAP scores, and CRP values (P < 0.001). Conclusion: CRP when used with BISAP may increase the success of BISAP scoring in predicting the severity of AP.

Keywords: Pancreatitis, severity, scoring system

  Heterotopic Gastric Mucosa in the Proximal Esophageal (Inlet Patch): endoscopic Prevalence, Histopathological Characteristics, and Its Association with Helicobacter pylori Top

Rathod Vivek

Department of Medical Gastroenterology, Kilpauk Medical College, Chennai, Tamil Nadu, India

Background and Study Aim: The previously reported prevalence of gastric heterotopia in the cervical esophagus varies substantially ranging from 0.18% to 10%. Regarding cases with adenocarcinoma within inlet patch (IP), some experts recommend to routinely obtain biopsies from IP for histopathology. The objectives of the study were to prospectively determine the prevalence of IP and association of preneoplasia within IP and to determine the Helicobacter pylori association with cervical IP. Results: In our study group, IP was seen in 34 (32%). Histopathology was performed in antral patients. Fundic type mucosa was the most common histologic type 68.75% (22/32), followed by antral type mucosa 25% (8/32). 2(1.79%) specimens of the inlet patch contained only foveolar epithelium. Intestinal metaplasia was detected in 3 cases (8.82%). H. pylori was identified in the IP in 25% of patients (8/32). Colonization and gastric H. pylori infection were positive in all (8/8) of these patients. Conclusion: The prevalence IP ins underestimated. Preneoplasia within IP seems to be rare, which does not support the recommendation to regularly obtain biopsies for histopathology. Biopsies should be targeted to any irregularities within the H. pylori IP. Colonization of IP is common and is closely related to the H. pylori density in the stomach. These patients might benefit from H. pylori eradication therapy.

Keywords: Cervical heterotopic, gastric mucosa, Helicobacter pylori, inlet patch, metaplasia

  A Study on Clinical Profile of Patients with Ulcerative Colitis and Association of Neutrophil–Lymphocyte Ratio with Disease Severity Top

Arun Dhotra

Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Ulcerative colitis (UC) is a type of inflammatory bowel disease that is an immune-mediated chronic inflammatory condition. Systemic inflammatory conditions such as UC are associated with increased white blood cells count. A growing body of evidence suggests that neutrophil–lymphocyte ratio (NLR) is a useful biomarker of systemic inflammatory response. The study was carried out at Department of Digestive Health and Diseases, Kilpauk Medical College, Chennai, from October 2020 to February 2021. It was an observational study. All the patients coming to our hospital and diagnosed as UC were included. Age- and sex-matched controls were included. Clinical details and colonoscopic findings and laboratory values including white blood cell count, erythrocyte sedimentation rate, C reactive protein, and NLR were noted and analyzed. A total of 34 patients of UC came during this period. 34 age- and sex-matched controls were included. Mean age of the patients was 40.76 ± 10.31 years. Mean age in the control group was 41.56 ± 11.47 years. Out of UC cases, 58.82% were females. 15 patients (44.12%) had active UC and 19 patients (55.88%) had inactive UC, according to modified Truelove-Witts Classification. Among patients with UC, maximum presented with diarrhea (88.24%) and blood in stools (79.41%) and left-sided colitis was more common (41.18%). Extra-intestinal manifestations were seen in 38.23% of the patients, among those peripheral arthralgias were more common. On analyzing laboratory values, the NLR values of active UC group were elevated compared with those of the patients with inactive UC and controls (2.86 ± 0.68, 2.05 ± 0.21, and 1.60 ± 0.24, respectively, P < 0.001). Conclusion: The NLR is a useful biomarker of systemic inflammation response, and it may be a promising marker of disease severity in UC.

Keywords: NLR, ulcerative colitis, severity

  Clinicoetiological Profile and Relationship between Serum Bilirubin Level and Severity of Ulcerative Colitis in a Tertiary Care Hospital in Southern India Top

Chaitanya Katragadda, M. S. Revathy, M. Manimaran, B. Sumathi, Chitra Satya

Department of Medical Gastroenterology, Government Stanley Medical College, Chennai, Tamil Nadu, India

This study we are going to analyze the correlation between serum bilirubin levels and severity of ulcerative colitis (UC) and erythrocyte sedimentation rate levels, which was not studied in the Indian population till now. This is a prospective observational study conducted in the Medical Gastroenterology Department of Stanley Medical College from November 2019 to January 2021. A total of 30 UC patients were included in the study. Mild disease (53.3%) was most common followed by moderate disease (P = 0.046). ESR levels were directly related to severity of disease (P = 0.001) and inversely related with serum bilirubin levels (P = 0.003). Hemoglobin levels were inversely related with severity of UC (P = 0.357) and directly related with serum bilirubin levels (P = 0.160). Conclusion: Serum bilirubin levels were negatively correlated with severity of UC and ESR levels.

Keywords: Btilirubin, ESR, ulcerative colitis

  Outcome of Acute Kidney Injury in Patients with Decompensated Chronic Liver Disease Top

M. S. Revathy, Navin Kumar

Department of Medical Gastroenterology, Government Stanley Medical College, Chennai, Tamil Nadu, India

The aim is to study the causes, course, outcome, and predictors of mortality in decompensated cirrhotic patients with acute kidney injury (AKI). Major causes of AKI in cirrhotic patients include pre-renal azotemia (PRA), acute tubular necrosis (ATN), and hepatorenal syndrome AKI (HRS-AKI). Prerenal AKI usually responds well to plasma volume expansion, whereas HRS-AKI and ATN require specific approaches. Methods: This prospective study examined 125 decompensated cirrhotic patients at a tertiary care hospital over 1-year period. AKI staging was based on new 2015 Ascites Club Criteria. Patients were grouped into three types of AKI: PRA, HRS-AKI, and ATN. Patients were assessed for risk factors for AKI at admission and followed up to 3 months. Survival at 90 days was analyzed. Most patients had AKI Stage 1 (57.7%). PRA (49.1%) and HRS (40.9%) were the predominant types of AKI followed by ATN (10%). Among sepsis, spontaneous bacterial peritonitis was seen in 39.2% of patients, chest infection in 20%, and and urinary tract infection in 10.4%. The overall in-hospital mortality in our study was 13% which increased with increasing severity of AKI (P = 0.0001) and was highest in AKI Stage 3 (P = 0.001) and those required hemodialysis (P = 0.001). There was a significant in-hospital mortality in patients with HRS (23.5%) and in comparison to PRA (4.9%) (P = 0.002). On multivariate analysis, the factors predicting in-hospital mortality were AKI Stage 3, Child C status, and oliguria (P = 0.0003). Conclusion: Sepsis was the most important cause of AKI. Prerenal AKI has a better survival compared to HRS. Higher stage of AKI at presentation, Child C status, and the presence of oliguria are the important predictors of in-hospital mortality.

Keywords: AKI, ATN, HRS

  Correlation of Computed Tomography Scan and Upper Gastrointestinal Endoscopy in Predicting Upper Gastrointestinal Tract Injury in Acute Corrosive Poisoning: A Prospective Study Top

Sambit Kumar Bhuyan, I. Shubha, Caroline Selvi, K. Premkumar, R. Murali, A. Chezhian

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Corrosive ingestion is associated with high morbidity and mortality. The gold standard tool in the assessment of mucosal damage is OGD within 72–96 h of ingestion, which plays a major role in predicting further management. Endoscopy is an invasive procedure and may not be performed in all cases immediately, in those cases who need to use a non-invasive tool to predict mucosal injury and predict future complication in acute corrosive poisoning patients. This study is to correlate thoracoabdominal computed tomography scan grading with endoscopic injury grading (Zargar Classification) in corrosive injury patients This is a prospective cross-sectional study conducted at RGGGH, over a duration of 6 months from September 2020 to Februar y2021. Data such as age, sex, symptoms, substance consumed, endoscopic finding, time of endoscopy after corrosive ingestion, and computed tomography (CT) scan finding were collected. Endoscopic injury grading was done according to Zargar Classification from 0 to 4 and CT scan grading was done from 1 to 4. Statistical data were analyzed. A total of 31 patients were included in study with a mean age 31.79 ± 16.33. There were 71% males and 29% females. 17 (54.8%) patients consumed acid and 14 (45.2%) consumed alkali. CT chest had sensitivity of 62.45% and specificity of 100% in detecting esophageal injury. Similarly, CT abdomen had sensitivity of 42.3% and specificity of 100% in detecting gastric injury. CT chest had negative predictive value of 28.5% and CT abdomen had NPV of 25% in detecting esophageal and gastric injury, respectively. Conclusion: CT scan cannot be considered as a sensitive tool in ruling out upper gastrointestinal mucous injuries following acute caustic ingestion. However, CT scan is highly specific enough in both esophageal and gastric injury. Hence, CT scan cannot be an important noninvasive tool in all cases of acute corrosive poisoning.

Keywords: Corrosive, injury, oesohpagus

  Clinical Profile and Outcome in Acute-On Chronic Liver Failure Patients in a Tertiary Care Hospital Top

Veera Abhinav Chinta, Vikranth Chunduri, Damodar Krishnan, P. Ganesh, S. Shanmuganathan, A. K. Koushik

Department of Gastroenterology, Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

The study was conducted to determine the primary etiologies, clinical profiles, precipitating factors in patients with acute on chronic liver failure and to assess the performance of Asia PAcific Association for Study of Liver Acute on Chronic Liver Failure Reseaarch Consortium, Chronic Liver Failure Consortium Acute on Chronic Liver Failure, Model for End stage Liver Disease sodium, and Child Turcotte Pugh scores in determining the 30-day mortality rate. A retrospective observational study was done on 75 patients, admitted with ACLF either according to Asia Pacific Association for Study of Liver or European Association for Study of Liver Chronic Liver Failure criteria. Patients satisfying either or both of these criteria were included in the study. The patient's demographics, baseline investigations, and mortality data are collected, and relevant scores were calculated. Results: Of 75 patients, 64 (85.3%) were male and 11 (14.7%) are female. Alcohol-related cirrhosis is the most common etiology of CLD (65.3%) followed by hepatitis B (14.7%). Recent alcohol intake is the most common precipitating factor (30.7%) and sepsis (29.3%) is the second most common. The overall mortality is 37.3%. Mean AARC, CLIF-C ACLF, MELD NA, and CTP scores are significantly higher in mortality group versus survivors (13.3 vs. 9.06, 68.07 vs. 52.13, 37.32 vs. 28.45, 13.14 vs. 11.81, respectively). Area under the ROC (AUROC) was calculated for various scores to determine the 30-day mortality. The highest Area Under Receiver Operating Characteristic was for AARC score (0.975), followed by CLIF-C ACLF Score (0.967), are significantly higher than MELD NA (0. 882) and CTP score (0.810). Conclusion: ACLF has high in-hospital mortality of 37.3% 30-day mortality. Among the available prognostic scores, AARC and CLIF-C ACLF predict mortality better than others.

Keywords: AARC, CLIF-C, ACLF

  Role of Platelet Indices in Predicting the Severity of Acute Pancreatitis: A Cross-Sectional Study Top

S. Rajeevan

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Acute pancreatitis is an acute inflammatory process of the pancreas. Severe pancreatitis has high mortality rate and persistent organ failure. Serological markers play only a modest role in predicting the severity of acute pancreatitis. Studies analyzing the role of platelet indices in acute pancreatitis have provided conflicting results. Platelet indices are calculated easily but often overlooked by clinicians. This study aims to assess whether platelet indices are useful in predicting severity of disease in acute pancreatitis. This is a cross-sectional study conducted over 6-month duration. 75 consecutive patients with acute pancreatitis were selected as the pancreatitis group. 75 patients with functional dyspepsia were selected as the control group for platelet indices. Clinical parameters, complete blood count including platelet indices, amylase, lipase, blood sugar, blood urea, creatinine, sodium, and potassium were documented on days 1 and 3. 2012 Revised Atlanta Criteria were used for assessing disease severity. ROC analysis was done to find out the cutoff values of each parameter to predict the severity of pancreatitis. Sensitivity and specificity were calculated to assess the validity of each parameter in predicting the outcome. The mean age of the patients with acute pancreatitis was 37 ± 9.7. Majority of the patients were males (80%). The most common etiology was alcohol (81.6%). Moderately severe (21.3%) and severe pancreatitis (29.3%) were combined as severe pancreatitis group for statistical analysis. Patients with severe pancreatitis had higher pulse rate and respiratory rate but lower PaO2/FiO2 and systolic blood pressure than nonsevere cases. Total White Blood Cell count (P Value:. Conclusion: Mean platelet volume and platelet–lymphocyte ratio on day 1 and day 3 can be used as noninvasive biomarkers to predict the severity of disease in acute pancreatitis without any added cost.

Keywords: Mean platelet volume, Neutrophil lymphocyte ratio, pancreatitis, platelet indices, platelet lymphocyte ratio

  Endoscopic Management and Outcomes among Patients with Bile Leak of Various Etiologies at a Tertiary Care Center Top

S. Arun, I. Shubha, Caroline Selvi, K. Premkumar, R. Murali, A. Chezhian

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Bile leak is a common complication of cholecystectomy, and it is also observed in other conditions such as ruptured liver abscess, hydatid cyst, and trauma. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management for such conditions and achieves favorable outcomes. Our aim of the study was to evaluate the efficacy and outcomes of endoscopic management for bile leak with various etiologies and to assess the in-hospital mortality, duration of hospital stay, and requirement of repeat stent exchange after 6 weeks. A single-center retrospective analysis of patients with symptomatic bile leak who were referred for endoscopic management at the Department of Gastroenterology in a tertiary care hospital between January 2018 and January 2021. Results: In total, 37 patients presented with bile leak due to various etiologies in this 3 years. The etiologies for bile leak were post cholecystectomy injury in 24 (64.8%), liver abscess in 3 (8.1%), and hydatid cyst in 6 (16.2%) patients. Majority of the patients had postsurgical bile leak, with the most common site of leak being cystic duct stump leak. All patients were managed with ERCP, sphincterotomy, and stent placement for 6 weeks, except for one patient who required surgery due to complete transection of Common Hepatic Duct. The primary outcome was achieved in 32 (86%) of 37 patients. There was no in hospital mortality for this bile leak patients. Conclusion: Majority of bile leak managed even on elective basis by ERCP yielded good results without any complications.

Keywords: CHD, bile leak, ERCP

  Correlation of Sarcopenia with Increased Risk of Decompensation of Cirrhosis Top

M. S. Revathy, B. Sumathi, S. Chitra, M. Manimaran, G. Sathya, Rakesh Jha

Department of Medical Gastroenterology, Government Stanley Medical College, Chennai, Tamil Nadu, India

The aim is to study the correlation of sarcopenia with increased risk of hepatic encephalopathy (HE), upper gastrointestinal (UGI) bleed, and hepatorenal syndrome-acute kidney injury (HRS-AKI). Psoas muscle area on Computed Tomography at L3 vertebrae was used to calculate skeletal muscle index (SMI), previous episodes, and types of decompensation noted in the past. Results: Spearman's coefficient shows negative correlation of SMI with number of HE (−0.744, confidence level [CL] 99%, P = 0.001), number of UGI bleed (−0.598, CL 99%, P = 0.002), and number of HRS-AKI (−0.786, CL 99%, P = 0.001). SMI showed positive correlation with 6-min walk test (+0.676, CL 99%, P = 0.001). Multivariate regression analysis of SMI with number of HE in the past showed (unstandardized coefficient − 5.07, standard error [SE] 1.623, confidence interval [CI] 95% −8.4–1.67, P = 0.04), SMI with HRS-AKI in the past (unstandardized coeffcient − 4.91, SE 1.76, CI 95% −8.5 to − 1.24, P = 0.01). Kruskal–Wallis test of Child Turcotte Pugh with HE in the past (P = 0.004), HRS-AKI (P = 0.005), SMI (P = 0.003), 6 min walk test (P = 0.003). Conclusions: Sarcopenia is an important factor to access risk of decompensation and thus mortality in patient with cirrhosis.

Keywords: Hepatic encephalopathy, hepatorenal syndrome, skeletal muscle index, sarcopenia

  Role of Red Cell Distribution Width as a Tool to Assess Severity of Chronic Liver Disease Top

E. Pavan, I. Subha, R. Murali, A. Chezhian, K. Premkumar, S. Caroline

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Red blood cell distribution width (RDW) is a measurement of the size variation and an index of the heterogeneity of circulating red blood cells. It is a well-established parameter for identifying the cause of anemia. RDW has been indicated to be an inflammatory indicator in a variety of diseases. The aim of the study was to compare the values of RDW in alcoholic and nonalcoholic liver cirrhosis and to determine if RDW follows the severity of disease according to Child-Pugh score severity and Model for End stage Liver Disease Sodium score. This was a cross-sectional observational study done for a period of 3 months with sample size of 108 patients who are diagnosed with chronic liver disease (CLD). Patients have been divided into two groups, first group were alcoholics and the other were nonalcoholics. Severity of CLD was determined by Child-Pugh score and MELD NA score. RDW was measured using the automatic analyzer (Sysmex). Normal range of RDW was 11%–15%. Correlation between RDW and CTP score and MELD NA score has been analyzed. Results: Out of 108 patients, 86 were male and 22 were female. There were 66 alcoholic and 42 nonalcoholic. In alcoholics, the mean RDW was 20.52%, and in nonalcoholics, the mean RDW was 17.48%. Significant difference was observed between RDW of alcoholic and nonalcoholic cirrhosis (P = 0.005). There was no significant correlation between RDW and CTP class and MELD-NA score neither in alcoholics nor in nonalcoholics. Conclusion: This study showed that RDW has significant difference between alcoholic and nonalcoholic CLD but no significance correlation according to CTP severity and MELD NA score.

Keywords: RDW, MELD, CLD

  Emergency Hepatectomy for Breathlessness Top

Mohammad Riyaz, S. Jeswanth, T. Selvaraj, A. Amudhan, R. Kamalakannan, M. Thiruvarul, J. Saravanan, Satish Devkumar

Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, Chennai, Tamil Nadu, India

Hepatic hemangiomas are the most common of all liver tumors. The prevalence of hemangioma in the general population ranges from 1% to 20%. Hemangiomas measuring 10 cm or more are referred to as giant hemangiomas and can present with fibrosis, thrombosis, and calcifications. Complications are mostly observed in large hemangiomas such as (1) alterations of internal architecture, such as with inflammation; (2) coagulation abnormalities, which could lead to systemic disorders such as hemorrhage and subsequent hemoperitoneum; and (3) compression of adjacent structures. Whatever the size, there is no treatment for asymptomatic hemangioma. Indications for treatment include severe symptoms, complications, and inability to exclude malignancy arterial embolization, surgical resection or enucleation, and liver transplantation. We present a unique case of a 65-year-old female presented with progressive and deteriorating. The available treatment options include breathlessness for the last 6 months with giant hemangioma compressing right lung, inferior vena cava, and right ventricle, for which emergency right hepatectomy was done.

Keywords: Hemangioma, resection, liver

  Addressing the Gastric Outlet Obstruction and Feeding Issue in High Surgical Risk Patients – Endoscopic Approach Top

M. Srinivasan, Jeswanth Sathyanesan

Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, Tamil Nadu, India

Nutritional support is a vital part for any patient where the oral dietary intake is not meeting the metabolic requirement. Enteral feeding is the best preferred method for nutritional support of any patient with functional gastrointestinal system. Various surgical and endoscopic methods employed for insertion of tube for feeding depending upon the patient need and general condition. Percutaneous endoscopic gastrostomy (PEG) is considered to be better option among sick patients due to its less invasive procedure and can be done under sedation. A 74-year-old female patient presented with abdomen pain and after on admission diagnosed to have carcinoma sigmoid colon. She underwent surgery – left hemicolectomy; patient had severe sepsis and AKI-managed accordingly. The patient in debilitated state presented to our hospital after 1 month postoperative and admitted in intensive care unit for further management. Her nutrition could not be supplemented adequately with parenteral nutrition for long time since her enteral feeding could not be established because of high nasogastric output and an episode of aspiration. Upper Gastro Intestinal endoscope showed Gastro Jejunostomy status with efferent limb obstruction with stasis. On initial endoscopy, scope could not passed into the efferent limb on repeated attempts because scope was fully consumed in the stomach. We did placed a PEG tube for gastric decompression and then endoscopy passed inside the E limb then using guide wire nasojejunal (NJ) tube placed in the efferent limb for feeding. In our case, placement of PEG fixed the stomach in position with parietal wall and made the efferent limb negotiation and NJ placement easy. Hemicolectomy with colorectal anastomosis was done. On postoperative day 7, she developed anastomotic leak and underwent dismantling of anastomosis and end colostomy with stump closure. Conclusion: Enteral tube feeding is mainly considered for sick patients with insufficient oral intake. Meanwhile, gastric decompression is needed for gastric outlet obstruction. In such patients with high surgical risk/high risk for general anesthesia, PEG with NJ tube can be a temporary/permanent option for enteral feeding.

Keywords: PEG, NJ tube, GJ

  Simultaneous Approach for Massive Colorectal Liver Metastasis - A Case Report Top

N. R. Venkatesh, A. Amudhan, M. K. Satish Devakumar, R. Kamalakannan, J. Saravanan, M. Thiruvarul, T. Selvaraj, Jeswanth Satyanesan

Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India

Colorectal cancer (CRC) is third most common cancer in the world. About two-third of patients with CRC will develop metastasis at some point of time. Liver is the most common site of distant metastasis. Among the various surgical options available for synchronous colorectal liver metastasis (CRLM), the most preferred options are either liver first approach or simultaneous approach. Though one-stage surgery is not advocated for tumors requiring major hepatectomy, we are presenting a case where simultaneous extended right hemicolectomy and extended right hepatectomy were done (21 cm × 19 cm × 14 cm weighing 3.5 Kg) for a patient with CRC with massive liver metastasis. Case Presentation: A 54-year-old male with no known comorbidities presented with upper abdominal mass, abdominal pain, loss of weight, and appetite for 3 months. On evaluation, he was found to have growth in hepatic flexure without features of intestinal obstruction and 21 cm × 19 cm × 14 cm size metastasis in the right lobe of liver. Colonoscopy biopsy was reported as moderately differentiated adenocarcinoma. Positron emission tomography-computed tomography was done which ruled out extra hepatic metastasis. After discussion with multidisciplinary team, simultaneous resection was planned. Extended right hemicolectomy and extended right hepatectomy were done. His postoperative period was uneventful. Conclusion: Surgical resection for liver metastasis and colonic primary are usually not done when it requires major hepatectomy. With this presentation, we suggest surgical resection for major CRLM can be done safely in surgically fit patients.

Keywords: Colon cancer, metastasis, surgery

  Fixing the Unfixed – A Rare Case of Upper Gastrointestinal Bleed Top

Rohith Mudadla, A. Amudhan, K. Satish Devkumar, R. Kamala Kannan, J. Sarvanan, M. Thiruvarul, T. Selavaraj, Jeswanth Satyanesan

Institute of SGE and Liver transplantation, Stanley Medical College, Chennai, Tamil Nadu, India

Dieulafoys lesion is an uncommon but important cause of recurrent upper gastrointestinal (GI) bleeding. Extra gastric location of Dieulafoys lesion is rare. We report a case of Dieulafoys lesion in the second part of duodenum and discuss our approach in diagnosing and management of this uncommon entity. A 50-year-old gentleman with no previous history of addictions or non steroidal anti inflammatory drug usage presented with severe anemia and recurrent episodes of melena for which was transfused 21 units of blood during the last 4 months. Multiple upper GI endoscopy done elsewhere found no ulcerations in the stomach or growth with fresh blood in the duodenum but could not identify the source of bleed and suspected to have hemobilia or hemosuccus pancreaticus. Colonoscopy and computed tomography abdominal angiogram was done which was normal. His hemogram parameters showed hemoglobin - 3.2 gm% and platelet count - 24,000 at the time of current admission. As the patient had no history of pain abdomen, hemobilia or hemosuccus pancreaticus was ruled out and upper GI endoscopy was done at our institute with high suspicion of having duodenal Dieulafoys lesion which revealed single bleeding submucosal vessel from the lateral wall of second part of the duodenum and endoscopic banding of the lesion was also done. Conclusion: Endoscopic diagnosis of extra gastric Dieulafoys lesion is difficult because of small size and obscure location of the lesion. Epinephrine injection, sclerotherapy, argon plasma coagulation, and surgery have been described as various modalities to treat this lesion. Endoscopic band ligation is an effective safe alternative treatment option which can achieve good results to deal with Dieulafoys lesion.

Keywords: NSAID, bleed, gastrointestinal

  Unusual Cause of Ascites Top

Harshit Kamal, S. Jeswanth, T. Selvaraj, A. Amudhan, R. Kamalakannan, M. Thiruvarul, J. Saravanan, Sathish Devakumar

Institute of SGE and Liver Transplantation, Government Stanley Medical College, Chennai, Tamil Nadu, India

Hepatic hemangiomas are the most common of all liver tumors. The prevalence of hemangioma in the general population ranges from 1% to 20%. Hemangiomas measuring 10 cm or more are referred to as giant hemangiomas and can present with fibrosis, thrombosis, and calcifcations. Complications are mostly observed in large hemangiomas such as (1) alterations of internal architecture, such as with inflammation; (2) coagulation abnormalities, which could lead to systemic disorders such as hemorrhage and subsequent hemoperitoneum; and (3) compression of adjacent structures. Whatever the size, there is no treatment for asymptomatic hemangioma. Indications for treatment include severe symptoms, complications, and inability to exclude malignancy. Conclusion: The available treatment options include arterial embolization, surgical resection or enucleation, and liver transplantation. We present an unusual case of a 45-year-old female who presented with progressive dyspnea and ascites for the last 6 months with two giant hemangiomas compressing inferior vena cava, for which emergency central-sparing hepatectomy was done.

Keywords: Ascites, hemangioma, liver

  Total Anatomical Resection of Segment VIII using the Ultrasound-Guided Bipolar Resection Technique Top

P. Karikal Chakravarthi, A. Amudhan, M. Satish Devakumar, R. Kamalakannan, J. Saravanan, M. Thiruvarul, T. Selvaraj, Jeswanth Satyanesan

Institution of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India

Hepatocellular carcinoma (HCC) is the fifth most common cancer, the third most common cause for cancer death in the world, and a major cause of death in patients with chronic hepatitis C virus infection. A complete or partial fully anatomical resection of segment 8 is generally considered a demanding procedure. Several techniques have been proposed to perform anatomic segmental resection of segment 8, but all are considered challenging to perform. The posterosuperior location of the segment 8, its boundaries represented by the right and middle hepatic veins at the caval confluence, and the complete absence of anatomical landmarks on the liver surface, particularly in the cirrhotic liver, are the main reasons accounting for its complexity. A 57-year-old male presented to our outpatient department with the complaints of pain abdomen, loss of appetite, and loss of weight for 2 year. During the blood workup, he found to have hepatitis C viral (HCV) infection. His HCV quantitative Polymerase Chain Reactionwas 669,015 IU/mL and he was started on anti-HCV drugs. After 2 weeks of treatment, his titer became normal, and surgery was planned. In contrast computed tomography, a well-defined mildly hyperintense lesion 5 cm × 5.3 cm noted in the segment VIII of liver which shows arterial enhancement with venous washout. Alpha beta protein was 20 ng/ml. His liver function test, Coagulation profile and renal function were within normal limits. His Child Pugh-Turcotte score was A and The Model for End-Stage Liver Disease was 9. He underwent ultrasound (USG)-guided segment resection VIII resection and his postoperative period was uneventful. Conclusion: Hepatectomy remains the standard treatment for HCC, but sufficient hepatic functional reserve is necessary. Even though technically demanding procedure, segment VIII resection can be safely done using USG-guided bi-polar resection technique.

Keywords: HCC, HCV, resection

  Endoscopic Management of Massive Pleural Effusion Top

Roshni Gopinath, Kanthasamy Kumar, Poppy Rejoice, A. Shafque, G. Geetha, U. Ramukrishnan, Kishore Kumar

Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Pleural effusion is a common medical problem. Causes include diseases local to pleura or underlying lung, systemic conditions, organ dysfunction, and drugs. Identification of etiology is critical for effective management. Case Presentation: A 40-year-old male, alcoholic for the past 20 years, admitted in our hospital with breathlessness and abdominal pain for the past 20 days. Pain was mainly in the epigastric region with radiation to back. He had a history of recurrent attacks of acute pancreatitis in the past. On examination, he was tachypneic, breath sounds diminished in the left hemithorax, and dull percussion note. He had tenderness in the epigastrium but no organomegaly, pedal edema, or ascites. Contrast-enhanced computed tomography (CECT) scan of thorax showed massive left-sided pleural effusion with collapse of the lower lobe of left lung. CECT abdomen showed features of chronic pancreatitis. Magnetic Resonance Cholangio Pancreatography revealed irregular and dilated main pancreatic duct and multiple loculated collections in pancreatic tail and perisplenic area. Linear communication is present between pleural cavity and perisplenic collection. Thoracocentesis revealed exudative pleural effusion. Pleural fluid amylase was 16,782 U/L and serum amylase 456. Pancreaticopleural fistula was diagnosed. He was treated with intercostal tube drainage and injection octreotide. The patient did not improve. Hence, we proceeded with Endoscopic Retrograde Cholangio Pancreatography and stenting of pancreatic duct. The patient improved, Inter Costal Drain was removed after 3 weeks, and she was discharged. Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis, which occurs due to posterior disruption of pancreatic duct. 1% of pleural effusions in the setting of pancreatitis are due to formation of pancreaticopleural fistula. Patients are usually managed by medical, endoscopic, or surgical treatments. ERCP helps to identify the fistulous track and simultaneous stenting of pancreatic duct. Conclusion: Pancreaticopleural fistula diagnosis starts with clinical suspicion and compatible clinical picture. High pleural fluid amylase is the key to diagnosis. Conclusion: Imaging modalities are very important and MRCP is the most sensitive investigation. Endoscopic management combined with somatostatin analogs results in closure of fistula and symptomatic improvement.

Keywords: ERCP, MRCP, pleural effusion

  An Interesting Case of Abdominal Pain Top

G. Geetha, E. Kandasamy Kumar, Poppy Rejoice, A. Shafque, Roshni Gopinath, U. Ramukrishnan, R. Kishore Kumar

Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Jejunal intussusception is one of the rare variants. It accounts only 10% of all adult intussusception cases. Common causes were pedunculated polyp, Menetrier's disease, hamartomas, and gastrointestinal stromal tumor. We report a patient with jejunal intussusception secondary to hyperplastic polyp in the proximal jejunum. A 72-year-old male admitted with the complaints of abdominal pain for 2 weeks periumbilical region which is accompanied by nausea, vomiting, and loose tools and melena for 2 weeks. On examination, patient afebrile, anemic, BP-120/80, PR-72/min and RR– 20/min. P/A soft no palpable mass. CBC showed anemia and P/S study showed microcytic hypochromic anemia. USG abdomen showed normal study. OGD scopy and colonoscopy showed normal study. CECT abdomen showed jejunojejunal intussusceptions with lipoma as lead point. Single balloon enteroscopy shows 5 cm × 7 cm size sessile polyp noted in proximal jejunum which is attached by stalk. We did a polypectomy by using single balloon enteroscopy and snare. It was removed. Biopsy report showed hyperplastic polyp of jejunum. Postprocedure, the patient was stable. His Hb improved. Intussusception defined as invagination of proximal part of small bowel along with its mesentery into a distal segment can lead to impaired peristalsis obstruction and vascular compromise. Polyps can form the leading edge for intussusception. Intussusception is more common in children and rare in adults. Hyperplastic polyp is more common in large bowl, especially rectosigmoid region. In our case, it was found in small bowel, which is rarely reported. For children, 90% were idiopathic. For adults, 60% were due to benign lesion, and 30% were malignant. Benign lesions such as hamartoma, Peutz-Jegher polyp, IFP in 90% cases. Hyperplastic polyps have been reported as a rare cause of adult jejunal intussusception. Conclusions: Intussusception in adults is rare especially secondary to hyperplastic polyp. Most common diagnostic tools for intussusception is abdominal computed tomography.

Keywords: Polyp, intestine, intussusception

  A Case of IgG4-Related Sclerosing Cholangitis Masquerading as Wilson's Disease Top

C. Shadiya

Department of Medical Gastroenterology, Government Coimbatore Medical College, Coimbatore, Tamil Nadu, India

Case Presentation: A 25-year-old male patient with no previous comorbidities presented with recurrent episodes of pruritus, yellowish discoloration of eyes and urine, fatigue, and upper abdominal pain for a period of 2 years. The patient was initially diagnosed as having Wilsons's disease and was treated with zinc for the last 1 year. Over this period, patient's condition worsened and he developed severe pruritus and deepening of jaundice. On admission, he was icteric, with multiple nodular lesions over the extensor aspects of limbs. Clinical examination revealed hepatomegaly. Blood investigations revealed anemia with conjugated hyperbilirubinemia, elevated ALP, ESR, CRP, and ANA positivity. Autoimmune profile for hepatitis was negative. Ultrasonography abdomen showed hepatosplenomegaly. MRCP showed mild intrahepatic biliary radicle dilatation. Serum IgG and IgG4 were elevated. Liver biopsy done showed features of bile duct paucity, lymphoplasmacytic inflammation of the portal tract with feathery degeneration, and cholestasis suggestive of IgG4-related sclerosing cholangitis. The patient was treated with prednisolone and showed a good clinical and biochemical response. Hence, a diagnosis of IgG4-related sclerosing cholangitis was made.

Keywords: Cholangiopathy, liver, disease

  A Study of Platelet Indices as Noninvasive Assessment of Nonalcoholic Fatty Liver Disease Top

N. K. Niranjan, Chezhian Annasamy, I. Shubha, K. Premkumar, Carolina Selvi, R. Murali

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

In this single-center cross-sectional case–control study performed over a period of 3 months, 49 patients with nonalcoholic fatty liver disease (NAFLD) and 30 healthy volunteers attending medical gastroenterology department, RGGGH, Chennai, were enrolled and complete blood counts with automated differential counts were performed and values of platelet count, platelet distribution width, and mean platelet volume were analyzed. Gender and age and mean diastolic blood pressure were similar among the NAFLD patients and the control group (>0.05). NAFLD patients had significantly higher systolic blood pressure, waist circumference, and BMI compared to the controls (<0.01). Patients with NAFLD had lower PC and higher MPV and PDW compared to the controls (<0.05). Conclusion: Patients with NAFLD have significantly higher values of PCT, PDW, and MPV when compared to the healthy controls. Further studies are needed to establish their potential use for prediction of the degree of liver steatosis and fibrosis in NAFLD patient.

Keywords: Liver disease, indices, diagnosis

  Case Report of Wilson's Disease in Three Siblings Top

R. K. Chaitanya, R. Selvasekaran, R. Ramasubramanian

The Department of Medical Gastroenterology, Thoothukudi Government Medical College, Thoothukudi, Tamil Nadu, India

Case Presentation: Wilson's disease is an inherited autosomal recessive disorder of copper metabolism. Clinical signs, biochemical parameters, histologic findings, and/or ATP7B genetic testing are required to diagnose Wilson's disease. A 14-year-old girl presented with complaints of jaundice for 4 months and abdominal distension for 10 days. She was eventually investigated and was diagnosed to have Wilson's disease. She was having two younger sisters who were investigated and were found to have asymptomatic Wilson's disease. Their parents were also investigated for Wilson's disease. This case report highlights the importance of screening for siblings of Wilson's disease patient to start therapy as early as possible to prevent development of hepatic and neuropsychiatric complications.

Keywords: Liver disease, Wilson, family history

  A rare complication of a common disease – Chronic Alcoholic Presented with Signs and Symptoms of Acute Pancreatitis Top

N. Lavanya

Department of Digestive Health and Diseases, GPH, Anna Nagar, Kilpauk Medical College, Chennai, Tamil Nadu, India

Case Presentation: A 35-year-old chronic alcoholic presented with signs and symptoms of acute pancreatitis and was admitted. Initial contrast-enhanced computed tomography (CT) abdomen revealed necrotic collection in body and tail of pancreas. The patient developed sudden onset hemetemesis inward. After stabilization, upper gastrointestinal scopy was done which showed only prominent fundal vein. CT angio was done which showed a splenic artery peudoaneurysm. The patient was referred to interventional radiology and transcatheter splenic artery coil embolization was done. Splenic artery pseudoaneurysm is a very rare local complication of pancreatitis. It can prove to be fatal if not diagnosed and managed promptly. Management can be surgical-splenectomy or via transcatheter embolization.

Keywords: Bleeding, pancreatitis, alcoholic

  Crohn's like Colitis in a Young Girl with Albinism: Is IT HERMANSKY PUDLAK Syndrome? Top

Pradip Vekariya, Ramalingam Rajendiran, Kuppusamy Senthamizh Selvan, Abdoul Hamide

Department of Gastroenterology, JIPMER, Puducherry, India

Oculocutaneous albinism (OCA) is an inherited disorder of melanin synthesis. Common genetic disorder associated with OCA is Hermansky-Pudlak syndrome (HPS). HPS is characterized by pulmonary fibrosis, platelet dysfunction, and systemic ceroid deposition. HPS types 1 and 4 have been reported to be associated with granulomatous colitis, ileitis, or perianal disease. It is unclear whether granulomatous colitis is part of HPS or a separate entity associated with Crohn's disease (CD). Here, we present a case of granulomatous colitis in a patient with oculocutaneous albinism. A 15-year-old girl presented with lower abdomen pain and bloody diarrhea for 8 months. She had lost 7 kg of weight during this period. There was no fever, cough, or breathlessness. Examination showed generalized skin depigmentation and pallor. Ophthalmological examination revealed bilateral jerky horizontal nystagmus, absent pigmentation of the iris, and reduced retinal pigmentation. Rectal examination showed a perianal fistula at 5o' clock position. Blood investigation showed iron deficiency anemia and normal platelet function test. Computed tomography enterography showed thickening of sigmoid and descending colon and perianal fistula. Colonoscopy showed multiple linear ulcers in sigmoid and descending colon. Histopathology revealed granulomatous colitis suggestive of CD. She achieved clinical response and remission with corticosteroids. She was started on azathioprine for maintenance of remission. Conclusion: Granulomatous colitis has been described in oculocutaneous albinism of HPS. They share clinical features of ulcerative colitis and histopathology consistent with CD. The anorectal involvement in colitis associated with HPS also resembles CD. It is hypothesized that colitis in HPS results from their genetic susceptibility to classical CD. The therapeutic response of colitis in HPS to medications used in CD also suggests a possible association between the two diseases.

Keywords: Crohn's disease, colitis, albinism

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