63rd Annual Conference of the Indian Society of Gastroenterology, ISGCON 2022—January 5th – 8th, 2023 in Jaipur

ABSTRACTS

Indian Society of Gastroenterology

Plenary Session

001

Fecal microbiota transplantation with anti-inflammatory diet followed by anti-inflammatory diet alone is effective in inducing and maintaining remission over 1 year in mild to moderate ulcerative colitis- A randomized controlled trial

Saurabh Kedia, Shubi Virmani, Sudheer Kumar Vvyyurru, Peeyush Kumar, Bhaskar Kante, Pabitra Sahu, Kanav Kaushal, Mariyam Farooqui, Mukesh Kumar Singh, Mahak Verma, Aditya Bajaj, Manasvini Markandey, Karan Sachdeva, Prasenjit Das, Govind K Makharia, Vineet Ahuja

Correspondence - Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology and Human Nutrition, Room No. 3111, Third Floor, Teaching Block, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Objective Microbiome and dietary manipulation therapies are being explored for treating ulcerative colitis (UC). We aimed to examine the effect of fecal microbiota transplantation (FMT) and anti-inflammatory diet in inducing remission followed by long-term maintenance with anti-inflammatory diet in patients with mild-moderate UC.

Design This open-labelled randomized controlled trial (RCT), randomized patients with mild-moderate (simple clinical colitis activity index [SCCAI] 3 – 9) endoscopically active UC (ulcerative colitis endoscopic index of severity [UCEIS] >1) on stable baseline medications in 1:1 ratio to FMT and anti-inflammatory diet (FMT-AID) vs. optimized standard medical therapy (SMT). FMT-AID arm received 7 weekly colonoscopic infusions of freshly-prepared FMT from multiple rural donors (week 0–6) with anti-inflammatory diet. Baseline medications were optimized in SMT arm. Clinical responders (decline in SCCAI >3) at 8 weeks in both arms were followed till 48 weeks on baseline medications (with anti-inflammatory diet in FMT-AID arm). Primary outcome measures were clinical response and deep remission (clinical-SCCAI <2 and endoscopic-UCEIS <1) at 8 weeks, and deep remission and steroid free clinical remission at 48 weeks.

Results Of 113 patients screened, 73 were randomized, and 66 were included in (35-FMT-AID; 31-SMT) modified intention-to-treat analysis (age-35.7+11.1 years; males-60.1%; disease duration-48 [IQR:24–84] months; pancolitis-34.8%; SCCAI-6 [IQR:5–7]; UCEIS-4 [IQR:3–5]) (Fig. 1). Baseline characteristics were comparable. FMT-AID was superior to SMT in inducing clinical response (23/35 [65.7%] vs. 11/31 [35.5%], p=0.01, OR-3.5 [95% CI:1.3–9.6]), remission (21/35 [60%] vs. 10/31[32.3%], p=0.02, OR-3.2 [95% CI:1.1 – 8.7]), and deep remission (12/33 [36.4%] vs. 2/23 [8.7%], p=0.03, OR-6.0 [95% CI:1.2 – 30.2]) at 8 weeks. Anti-inflammatory diet was superior to SMT in maintaining deep remission till 48 weeks (6/24 [25%] vs. 0/27, p=0.007) (Figs. 2 and 3).

Conclusion Multi-donor FMT with anti-inflammatory diet effectively induced deep remission in mild-moderate UC which was sustained with anti-inflammatory diet over one year.

Keywords Diet, Fecal microbiota transplantation, Standard medical therapy, Ulcerative colitis

002

Gut microbial dysbiosis, gut barrier integrity, and severity of chronic pancreatitis: exploring a mechanistic link using an experimental model

Ambika Prasanna , Aparna Jakkampudi, Priyanka Sarkar, Ranjit Tokala, Subhaleena Sarkar, Sreelatha Chintaluri, Nageshwar Reddy, Rupjyoti Talukdar

Correspondence – Rupjyoti Talukdar - rup_talukdar@yahoo.com

Department of Medical Gastroenterology; Welcome DBT Indian Alliance Labs., Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Pancreatic diseases such as pancreatitis, contribute to marked morbidity and mortality. Recent studies have suggested a link between gut microbial dysbiosis and chronic pancreatitis (CP), but the potential roles of the microflora and the immune system that play a crucial role in maintaining the homeostasis have not been fully elucidated in CP in a mechanistic manner. In this study, we report the changes that occur in the gut microbiome along with the other metabolic factors in the L-Arginine model of CP in a time dependent progressive manner. Along with that, we also evaluated the role of high fat diet in CP disease progression and the gut microbial alterations associated in aggravating the disease.

One of the key findings of this study was the early development of the fibrogenesis (p=< 0.01) in the CPHFD group caused due to diet modulation that continued to remain same until severe CP developed. These findings showed significant correlation of fibrosis score (% area) with relative abundances of few bacterial species including Prevotella copri.

Keywords Chronic pancreatitis, Gut barrier, Gut microbial dysbiosis

003

Prevalence of celiac disease in patients with liver diseases: A systematic review and meta-analyses

Shakira Yoosuf ¹ , Prashant Singh ² , Ashank Khaitan ¹ , Tor Strand ³ , Vineet Ahuja ¹ , Govind K Makharia ¹

Correspondence – Shakira Yousuf - shakira891@gmail.com

¹Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, ²University of Michigan, USA, and ³Innlandet Hospital Trust

Introduction A subset of patients with celiac disease (CeD) have liver involvement in the form of hypertransaminsemia, liver cirrhosis and autoimmune hepatitis. We conducted a systematic review with meta-analyses to determine pooled prevalence of CeD in patients with cryptogenic cirrhosis, all-cause cirrhosis, cryptogenic hypertransaminsemia, and all-cause hypertransaminsemia.

Methods We searched PubMed and EMBASE up to January 2022. Cross-sectional, case-control and prospective cohort studies performing serological tests and/or intestinal biopsy for CeD on patients with cryptogenic cirrhosis, all-cause cirrhosis, cryptogenic hypertransaminsemia and all-cause hypertransaminsemia were included, to calculate pooled estimates of seroprevalence and prevalence of biopsy-confirmed CeD in these four groups.

Results Of 6871 articles screened, 20 articles were included finally in three meta-analyses for cryptogenic cirrhosis, all-cause cirrhosis and cryptogenic hypertransaminsemia. For the all-cause hypertransaminsemia group, a qualitative review of four studies was done instead of a meta-analysis, due to significant differences in studies. The pooled seroprevalence and prevalence (95% CI) of biopsy confirmed CeD in cryptogenic cirrhosis were 15.3% (4.9-29.5%) and 4.6% (2.2-7.5%), respectively. Pooled seroprevalence and prevalence of biopsy confirmed CeD in all-cause cirrhosis were 14.2% (3.9-28.8%) and 0.8% (0-3.4%), respectively. Pooled seroprevalence and prevalence of biopsy-confirmed CeD in cryptogenic hypertransaminsemia were 7.7% (4.7-11.4%) and 5.7% (3.2-8.8%), respectively.

Conclusion Nearly one in 20 patients each with cryptogenic cirrhosis and cryptogenic hypertransaminsemia have CeD, hence they should both be considered high-risk groups for CeD. While prevalence of CeD in all-cause cirrhosis is similar to that in general population, it may be worth screening them for CeD as liver pathology has potential for reversal in them.

Keywords Celiac disease, Liver

004

Long-term safety and efficacy of azathioprine in the management of inflammatory bowel disease: A real-world experience

Rohan Yewale, Balakrishnan S Ramakrishna, Babu Vinish D, Kayalvizhi Jayaraman

Correspondence – Rohan Yewale - rohan2690@gmail.com

Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institute for Medical Science, Vadapalani, Chennai 600 026, India

Background Azathioprine (AZA) is used to maintain remission in inflammatory bowel disease (IBD). Both patients and caregivers harbor apprehensions regarding long-term efficacy and safety of AZA in IBD. We analyzed AZA use and outcomes in a mixed cohort of IBD patients followed up over a long period of time.

Methods Long-term compliance, tolerance, clinical-outcome at last follow-up, type, and duration to onset of adverse-events, and subsequent amendment to treatment, with regard to AZA, were analyzed retrospectively in a cohort of 472 patients with IBD under treatment at a single center in south India between 2013-2022.

Results 320/472 patients (207 Crohn’s disease [CD], 113 ulcerative colitis [UC]) received AZA with a median follow-up of 41 months (IQR 15.5-77.5). Total duration of AZA exposure was 1,359 patient-years with median duration of AZA usage of 33 months (IQR 11.75-60). 26.9% received AZA for >5 years. Mean initiation and maximum doses of AZA were 0.97 mg/kg/day and 1.72 mg/kg/day, respectively. 20.6% experienced side-effects, myelotoxicity (7.2%) and gastro-intestinal intolerance (5.6%) being most common. 6 patients developed malignancy. 39.4% of side-effects were dose-dependent and abated after dose modification or temporary withdrawal of AZA. 38.1% had clinical relapses while on AZA, requiring pulse corticosteroids. 72.7% attained durable clinical-remission (11.8% on AZA monotherapy, 53.1% on combination therapy with 5-ASA and 7.7% on combination therapy with biologics). 6.9% continued to have active disease and 20.4% had >1 relapse after commencement of AZA.

Conclusion AZA is safe, effective, and well tolerated in long-term management of patients with IBD.

Keywords Azathioprine, Inflammatory bowel disease, Long-term efficacy

005

Transfusion related lung complications are uncommon in non-ventilated liver disease patients undergoing low-volume plasma exchange

Vijay Alexander , Jess Rasalam, Snehil Kumar, Vinoi David, Dolly Daniel, Sukesh Chandran, Kandasamy Subramani, Binila Chacko, Ebor Jacob, Lalji Patel, Santhosh Varughese, Vadivukkarasi Jayalakshmi, Kunwar Ashish, Uday Zachariah, Ashish Goel, Chundamannil Eapen

Correspondence – Chundamannil Eapen - eapen@cmcvellore.ac.in

Department of Hepatology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Background Plasma exchange (PLEX) is increasingly used to treat liver disease. We aimed to study transfusion related lung complications - transfusion related acute lung injury (TRALI) and transfusion related circulatory overload (TACO), in patients undergoing low volume PLEX (PLEX-LV) to treat liver disease.

Methods Prospectively accrued data of patients in our department who underwent PLEX-LV (50% of estimated plasma volume exchanged per PLEX session) for liver disease from 2016-2022 was retrospectively analyzed. Patients on ventilatory or oxygen support prior to PLEX were excluded. Incidence and cause of breathlessness during transfusion and within 6 hours of cessation of last transfusion of blood products used for PLEX were analyzed.

Results Fifty-six (baseline ventilatory or oxygenation support required: 51, corona virus disease–19 [COVID-19] infection: 5) of 298 liver disease patients who underwent PLEX-LV during the study period were excluded. Two hundred and forty-two study patients (158 males; age: 38, 3 – 72 years; median, range, acute-on-chronic liver failure: 117, acute liver failure: 74) received 5197 units of fresh frozen plasma (FFP) during 779 PLEX-LV sessions.

Three patients (1.2%, TACO: 2, pulmonary hemorrhage: 1), developed breathlessness within 6 hours of completion of any PLEX session. No patient had TRALI. Incidence of TACO was 0.3% (2/779) of PLEX-LV sessions and 0.04% (2/5197) of FFP units transfused during PLEX. All 3 patients died despite maximal supportive care.

Conclusion We found transfusion related lung complications to be uncommon in non-ventilated liver disease patients (most had liver failure) undergoing PLEX-LV. Careful attention to cumulative fluid balance may help reduce incidence of TACO further.

Keywords Plasma exchange, TACO, TRALI

006

Updated trends of inflammatory bowel disease from the global burden of disease study

Arshdeep Singh ¹ , Khichdee Dharni ² , Sonika Sharma ² , Vandana Midha ¹ , Ramit Mahajan ¹ , Parambir S Dulai ³ , Ajit Sood ¹

Correspondence – Ajit Sood - ajitsood10@gmail.com

¹Department of Gastroenterology, Dayanand Medical College and Hospital, Civil Lines, Tagore Nagar, Ludhiana 141 001, India, ²Punjab Agricultural University, Ferozepur Road, Ludhiana 141 027, India, and ³Feinberg School of Medicine, North-western University Chicago, IL, United States

Background The global burden of inflammatory bowel disease (IBD) has been reported to be increasing. Methodologies and datasets are routinely updated, allowing for more accurate estimates. We report a comprehensive analysis of the disease burden and trends at the global and regional levels from 1990 to 2019, based on data from the updated Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

Methods Incidence, prevalence, deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) were estimated from the GBD-2019 database. The three decadal trends of the disease measures were also calculated.

Results In 2019, there were 4.9 million (4.3-5.5) cases of IBD globally. The age-standardized prevalence and incidence rates (per 100,000 population) decreased from 73.23 (63.8-83.6) and 6.1 (5.3-6.9) in 1990 to 59.2 (52.7-66.4) and 4.9 (4.4-5.6) in 2019, respectively. The highest age-standardized prevalence and incidence rates (per 100,000 population) were recorded in North America, while Oceania recorded the lowest rates (209.5 [195.4-224.4] and 24.5 [22.6-26.7], and 3.87 [3.1-4.7] and 0.5 [0.5-0.7], respectively). High sociodemographic index (SDI) locations had the highest age-standardized prevalence rate, though the rates declined in 2019 compared to 1990. Over the three decades, the age-standardized prevalence and incidence rates increased in the middle, low middle, and low SDI quintiles. The age-standardized rates for deaths, DALYs, YLDs, and YLLs decreased globally, from 1990 to 2019.

Conclusion This updated estimate from the GBD demonstrates an increasing disease burden of IBD in the middle and low SDI locations, while stabilization in the high SDI locations. Continuous monitoring and adjusting estimates may allow for region-specific policies, to address the challenges in tackling IBD.

Keywords Incidence, Inflammatory bowel disease, Prevalence

Young Investigator Award Session

007

The myth of hepatotropism of hepatitis B virus; Placenta a new home for the virus

Ashish Kumar Vyas

Correspondence – Ashish Kumar Vyas - a88_ashish@yahoo.co.in

Department of Microbiology, All India Institute of Medical Sciences, AIIMS Campus Road, Saket Nagar, Habib Ganj, Bhopal 462 026, India

Background The transplacental routes of vertical transmission of hepatitis B virus (HBV) has been known for over a decade. Here we present evidence that suggests HBV can replicate in the placenta.

Methods Forty-one HBsAg-positive pregnant women and 10 controls were enrolled in the study after obtaining informed consent. HBV positives were further divided into the high viral load (HVL) Group and low viral load (LVL) group according to Indian National Association for Study of the Liver (INASL) guidelines 2018. The presence of the HBV DNA in the placenta and expression of NTCP in the placenta was analyzed by qPCR/RT-qPCR and/or immunohistochemistry (IHC). The presence of HBeAg and HBcAg in the placenta was assessed by IHC.

Results NTCP expression was significantly upregulated in trophoblasts of HVL compared to control and LVL groups. Immunostaining of NTCP, HBeAg, and HBcAg on trophoblasts along with the presence of HBV DNA indicated, that these cells are not only susceptible to HBV infection but may also support viral replication. This is further supported by the finding that trophoblasts of the several HBeAg seronegative samples harbored the HBeAg.

Conclusions The presence of the HBV receptor, NTCP in the placenta along with the presence of viral DNA, HBeAg in the placenta of patients without circulating HBeAg suggests that placenta act as a replication host.

Keywords Hepatitis B virus, Vertical transmission, Placenta, Sodium taurocholate co-transporting polypeptide

008

A double blind randomized controlled trial on role of nutritional therapy to prevent recurrence of hepatic encephalopathy in cirrhosis

Barjesh Chander Sharma, Hardik Ahuja, Sanjeev Sachdeva, Bhawna Mahajan, Ashok Sharma, Sushma Bara, Siddharth Srivastava, Ajay Kumar, Ashok Dalal, Ujjwal Sonika

Correspondence – Hardik Ahuja - drhardikahuja@gmail.com

Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, 1, J L N Marg, New Delhi 110 002, India

Background Overt hepatic encephalopathy (OHE) has high cumulative risk of recurrence and is associated with poor survival. The role of nutrition therapy is well documented in cirrhosis but its efficacy in preventing the recurrence of OHE has not been studied.

Methods In this double blind randomized controlled trial (RCT), we randomly assigned 150 cirrhotics with history of OHE in the recent past to receive nutrition therapy (Group I) or no nutrition therapy (Group II) and followed up for 6 months. The primary efficacy end point was the time to first breakthrough episode of HE. The key secondary end points were the time to first hospitalization involving HE, improvement in health-related quality of life, anthropometry parameters, changes in serum cytokines (IL-1,6,10, TNF), endotoxin, myostatin, correlation of baseline arterial ammonia levels, psychometric tests score, critical flicker frequency, child’s score, model for end-stage liver disease (MELD) score with recurrence of OHE.

Results There was significant reduction in the occurrence of breakthrough episode of HE in group I (10 vs. 36, hazard ratio [HR] 0.20 [95%] confidence interval [CI], 0.10 to 0.40; p<0.001), HE related hospitalization (8 vs. 24, HR 0.27 [95%] confidence interval [CI], 0.12 to 0.61; p<0.001), recurrence of HE (15 vs. 53, p<0.001) and mortality (0 vs. 5, p=0.04). Significant improvements in all parameters were seen at the end of 6 months. There was less incidence of MHE, ascites, gastrointestinal bleed and jaundice in Group I.

Conclusions Treatment with nutrition therapy prevented recurrence of OHE, decreased hospitalization and mortality as compared to no nutrition therapy.

CTRI number: CTRI/2020/08/026993

Keywords Ammonia, Health related quality of life, Minimal hepatic encephalopathy, Sarcopenia

009

Crosstalk between the host Gut mycobiome (fungome) and bacteriome with their glycemic status in chronic pancreatitis patients

Sreelekha Chintaluri , Priyanka Sarkar, Subhaleena Sarkar, Misbah Unnisa, Ambika Prasanna, Aparna Jakkampudi, Nageshwar Reddy, V V Ravikanth, Rupjyoti Talukdar

Correspondence – Rupjyoti Talukdar - rup_talukdar@yahoo.com

Department of Medical Gastroenterology; Welcome DBT Indian Alliance Labs., Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Chronic pancreatitis is irreversible fibrotic pancreatic disease. In this study we aimed to determine the crosstalk between the fungome and the bacteriome with the hosts glycemic status. We observed significant clinical differences with the HbA1c levels and RBS levels across the three study groups. On the microbial metagenomic level we observed several bacterial and fungal species to show significant correlation with the glycemic status in both positive and negative manners.

Keywords Bacteriome, Chronic pancreatitis, Cross-talk, Fungome

010

Low serum albumin is the strongest predictor of non-response for anti-TNF therapy in biological naive inflammatory bowel disease patients in resource-constrained regions with inaccessibility to the measurement of drug pharmacokinetics

Peeyush Kumar, Sudheer Kumar Vuyyuru, Prasenjit Das, Bhaskar Kante, Mukesh Ranjan, Sandeep Mundra, Rithvik Gola, Mukesh Singh, Shubi Virmani, Raju Sharma, Govind K Makharia, Saurabh Kedia, Vineet Ahuja

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Background There is an unmet need for defining factors that can predict both primary non-response (PNR), as well as secondary loss of response (SLR), to anti-tumor necrosis factor-α (anti-TNF-α) agents in inflammatory bowel disease (IBD). The present study evaluated clinical, biochemical, and molecular markers of PNR and SLR in patients with ulcerative colitis (UC) and Crohn’s disease (CD).

Methods This retrospective study included patients with IBD treated with anti-TNF-α agents from January 2005-October 2020. Data concerning clinical and biochemical predictors was retrieved from a prospectively maintained database. Immunohistochemistry (IHC) for expression of oncostatin M (OSM), oncostatin M receptor (OSM-R) and Interleukin-7R (IL-7 R) receptor were done on pre-anti-TNF-α initiation mucosal biopsies obtained from IBD biorepository.

Results One hundred-eighty-six patients (CD-118, UC-68) received anti-TNF-α therapy (mean age and median disease duration at anti-TNF-α initiation-34.1±13.7 years and 60 [IQR:28-100.5]) months. Primary non-response was seen in 17% and 26.5% and SLR in 47% and 28% of patients with CD and UC respectively. In CD, low albumin (HR [CI]: 0.07 [0.02-0.20], p<0.001), po stoperative recurrence (HR [CI]: 5.24 [1.9-14.5], p=0.001) and high IL-7R expression (HR [CI]:1.5 [1.04-2.15], p<0.027); and low albumin (HR [CI]: 0.09 [0.03-0.28], p<0.001) predicted PNR on univariate and multivariate analysis respectively. Low albumin (HR [CI]: 0.306 [0.15-0.62], p=0.001) also predicted SLR on multivariate analysis. In UC, low albumin (HR [CI]: 0.07 [0.03-0.20], p<0.001), high CRP (HR [CI]: 1.18 [1.07-1.29], p<0.001) and high OSM (HR [CI]: 1.44 [1.02-2.08], p value<0.04) and OSM-R (HR [95%CI]: 1.33 [0.97-1.81], p=0.07) stromal expression; and low albumin (HR [CI]: 0.108 [0.03-0.39], p=0.001) predicted PNR on univariate and multivariate analysis respectively.

Conclusion Low serum albumin prior to anti-TNF-α therapy initiation significantly predicted PNR in UC patients and PNR as well as SLR response in CD patients. Mucosal markers of PNR were high stromal OSM and OSM -R in UC and high IL7R in CD patients.

Keywords Inflammatory bowel disease, Non-response, Tumor necrosis factor alpha

011

Patients with non-celiac gluten sensitivity exhibit site-specific gut microbial differences than those with irritable bowel syndrome

Kunal Dixit ¹ , Anam Ahmed², Dhiraj Dhotre³, Alka Singh², Wajiha Mehtab⁴, Ashish Chauhan², Vineet Ahuja², Yogesh Shouche³, Govind K Makharia²

Correspondence – Govind K Makharia - govindmakharia@gmail.com

¹Symbiosis School of Biological Sciences, Sus-Pashan Road, Lavale, Pune 412 115, India, ²Department of Gastroenterology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, ³National Centre for Cell Science, NCCS Complex, University of Pune Campus, Pune University Road, Ganeshkhind, Pune 411 007, India, and ⁴Department of Home Sciences, University of Delhi, South Moti Bagh, New Delhi 110 021, India

Objective There is an overlap between symptoms of non-celiac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS). We explored the small intestinal, large intestinal and whole gut microbiota in them to understand if any difference exits in them and we further assess effect of gluten-free diet (GFD) on microbiota in NCGS.

Methods Four hundred and ninety-two patients with IBS (based on Rome IV criteria) were screened for anti-gliadin Ab and diagnosis of NCGS in AGA positive individuals was made on the basis of Salerno criteria. Stool and mucosa-associated (small intestinal and colonic) microbiota was assessed in 130 patients with IBS (AGA negative) 14 patients with NCGS both at the baseline and 6 weeks after GFD to observe the effect of intervention on site specific microbiota profile. Microbiota was analyzed using 16S RNA gene amplicon profiling followed by downstream analysis by DADA2 pipeline and R statistics.

Results NCGS patients exhibited differences in gut microbiota associated with small intestinal as compared to IBS. DESeq2 analysis revealed differentially higher abundance of Stenotrophomonas, Deinococcus, Leucobacter, Solibacillus, and Alcaligenes in NCGS. Moreover, there was reduction in abundances of potential gluten-degrading genera and higher ratio of Prevotella to Burkholderia in duodenal mucosa, which can act as a biomarker for NCGS. There was an increase in bacterial networking and decrease in interindividual variability in the whole gut and site specific (small intestine) microbiota, respectively after GFD.

Conclusion Significant difference exits in small intestinal microbiota of NCGS patients. Six weeks GFD not only alleviates symptoms but also restores microbial diversity considerably.

Keywords 16S rRNA sequencing, Gluten-free diet, Human microbiome, Mucosa-associated, Small intestine

012

Systematic estimation of prevalence of microsatellite instability and Lynch syndrome amongst colorectal cancer patients in India

Harsh Sheth ¹ , Abhinav Jain^2,3, Chandini Patel¹, Prachi Soni¹, Mithun Shah³, Pankaj Shah³, Suresh Advani⁴, Liyana Thomas⁴, Vipul Yagnik⁵, Avinash Tank⁶, Chirag Shah⁷, Bhavesh Thakkar⁸, Darshan Bhansali⁸, Manish Gandhi⁸, Tarang Patel⁸, Natu Patel⁸, Ashok Patel⁸, Ruchir Patel², Ravindra Gaadhe⁹, Chintan Shah¹⁰, Michael Jackson¹¹, Mauro Santibanezkoref¹¹, John Burn¹¹, Jeynathy Eswaran¹¹, Frenny Sheth¹, Jayesh Sheth¹, Sunil Trivedi¹

Correspondence – Harsh Sheth - harsh.sheth@frige.co.in

¹Department of Advanced Genomic Technologies, FRIGE Institute of Human Genetics, FRIGE House, Jodhpur Village Road, Satellite, Ahmedabad 380 015, India, ²Gastro1 Hospital, Center Point, Near Vandematram Cross Road, Gota, Ahmedabad 382 470, India, ³Zydus Cancer Hospital, Zydus Hospital Road, Thaltej, Ahmedabad 380 054, India,⁴Sushrut Hospital, 365, Sant Vershaw Kakkaya Marg, Swastik Park, Chembur, Mumbai 400 071, India, ⁵Nishtha Surgical Hospital and Research Centre, 4th Line, Kilachand Shopping Centre, Station Road, Patan 384 265, India, ⁶Dwarika Clinic, 301 Shilp Arcade, Jodhpur Cross Road, Satellite, Ahmedabad 380 015, India, ⁷Mission Gastro Hospital, 6th Floor Golden Icon, Above Hundai Showroom Besides Qaraar Banquets, Ahmedabad 380 015, India, ⁸CIMS Hospital, Off. Science City Road, Science City, Panchamrut Bunglows II, Sola, Ahmedabad 380 060, India, ⁹GastroPlus Hospital, 4th Floor, Devraj Mall, Near Thakkarbapa Nagar Cross Road, India Colony Road Bapunagar, Ahmedabad 382 350. India, ¹⁰HOC Vedanta Hospital, Science City Road, Sola, Ahmedabad 380 060, India, and ¹¹Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK

Background Colorectal cancer is the fifth most common cancer in India, however, there is a paucity of systematically collected data related to its molecular epidemiology, specifically related to tumor microsatellite instability (MSI) and Lynch syndrome prevalence.

Methods We prospectively recruited 207 unrelated patients who were diagnosed with colorectal cancer (CRC) from whom primary tumor biopsy along with a matched blood sample was obtained. A systematic genetic testing approach in accordance with the UK’s National Institute of Health and Care Excellence was utilized. Briefly, DNA from tumor biopsies were tested for MSI status followed BRAF V600E testing in samples which showed MSI-high result. Germline testing for the mismatch repair (MMR) genes was carried in patients who had MSI-high and BRAF V600E negative tumors.

Results Mean age at cancer diagnosis across the cohort was 52.1 years with male to female ratio of 2:1 and 55% of the patients had tumors in the descending colon or rectum. MSI-high status was observed in 79 patients (40.7%) and, it was inversely associated with age (OR=0.95, 95% CI=0.92-0.97, p=<0.001) and cancers in distal colon and rectum (OR=0.49, 95% CI=0.24-1.00, p=0.05 for distal colon; OR=0.11, 95% CI=0.03-0.39, p=0.001 for rectum). Of these, 76 patients had BRAF V600E negative mutation status (96%). Of these patients, 48 were diagnosed with Lynch syndrome (63%; MLH1=38, MSH2=4, MSH6=4, PMS2=1, EPCAM=1). The variants c.154del and c.306G>T in the MLH1 gene were most commonly observed across Lynch syndrome patients in our cohort.

Conclusions This is the first systematic evaluation of the molecular epidemiology of CRC in India. We observe a high proportion of patients with young onset CRC coupled with high prevalence of MSI-high status and Lynch syndrome. The study results provide a unique opportunity to explore development of novel Lynch syndrome detection and cancer prevention pathway in Indian healthcare settings.

Keywords Colorectal cancer, India, Lynch syndrome, Microsatellite instability, Prevalence

Presidential Posters

013

Long-term gastrointestinal sequelae following Corona virus disease-19: A prospective follow-up cohort study

Rithvik Golla, Sudheer Kumar Vuyyuru, Bhaskar Kante, Peeyush Kumar, David Thomas Mathew, Saurabh Kedia, Govind K Makharia, Vineet Ahuja

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Background and Aims Corona virus disease-19 (COVID-19) is associated with long-term gastrointestinal sequalae; however prospective longitudinal data is sparse. We prospectively studied the frequency, spectrum, and risk factors of post infection functional gastrointestinal disorders/disorders of gut-brain interaction (PI-FGID/DGBI) following COVID-19.

Methods Out of 416 cases with COVID-19, finally 320 cases with 320 healthy spouses/family controls (Group-A) and 280 healthy covid serology negative controls (Group B) were prospectively followed up at 1,3 and 6 months using validated Rome IV criteria to evaluate the frequency of PI-FGID/DGBI.

Results Of 320 cases that had follow-up, at 1 month, 36 (10.9%) developed FGID symptoms. At 3 months, 27 (8.4%) and at 6 months, 21 (6.4%) persisted to have symptoms. At 3 months, 8 (2.5%) had irritable bowel syndrome, 7 (2.2%) had functional diarrhea, 6 (1.9%) had functional dyspepsia, 3 (0.9%) had functional constipation, 2 (0.6%) had FD-IBS overlap, and 1 (0.3%) had functional abdominal bloating/distension. Among the symptomatic at 3 months, 8 (29.6%) were positive for isolated carbohydrate malabsorption, 1 (3.7%) was positive for post infection malabsorption syndrome (PI-MAS) and 1 (3.7%) was positive for intestinal methanogen overgrowth (IMO). None of the healthy controls developed FGID until 6 months of follow-up (p<0.01). The predictive factors at 3 and 6 months were severity of infection (p<0.01) and presence of GI symptoms at time of infection (p<0.01).

Conclusion COVID-19 led to significantly higher number of new onset PI-FGID/DGBI as compared to healthy controls at 3 and 6 months of follow-up. If further investigated a proportion of them can have underlying malabsorption.

Keywords COVID-19, Functional gastrointestinal disorders, Long COVID, Post infection-irritable bowel syndrome

014

Persistent gonadal dysfunction in male Budd-Chiari syndrome patients after successful therapy: Does oxidative stress has a role?

Kashmira Kawli, Aditya Kale, Sidharth Harindranath, Akash Shukla

Correspondence - Akash Shukla - drakashshukla@yahoo.com

Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Acharya Donde Marg, Parel East, Parel, Mumbai 400 012, India

Introduction Hypogonadism is known in patients with Budd-Chiari syndrome (BCS) and is reversible after appropriate therapy.

Methods We performed prospective observational study involving 30 male patients with BCS who underwent appropriate intervention and medical therapy and were followed up for period of 18 months. At 18 months patients underwent biochemical, hormonal assay, and semen analysis. Those patients with persistence of hypogonadism (n=17) and 10 healthy controls were analyzed for reactive oxygen species (ROS)- malondialdehyde (MDA), superoxide dismutase, catalase, endotoxin.

Results Mean age- 27.4 years (interquartile range [IQR] = 19-40 years). Fifteen patients were child A and 2 were Child B at 18 months. Hypogonadotropic hypogonadism was seen in 12 and hypergonadotropic hypogonadism in 5. Sperm count was normal in 9 while 2 had severe oligospermia. Levels of reactive oxygen species were elevated in all patients with BCS however levels were significantly elevated (p=<0.05) for endotoxin (1.4 + 0.42 vs. 0.6 + 0.2), Catalase (1226.85 + 401.4 vs. 242.46 + 206.9). Superoxide dismutase levels were significantly depleted in patients with BCS as compared to healthy controls (3409.4 + 1376 vs. 4907 + 1605, p=0.0013). Although MDA is elevated in patients with BCS (541.16+ 150 vs. 489.17+ 100.26), levels did not reach significance.

Conclusion Hypogonadism can persist in male patients with BCS despite appropriate therapy and after a long follow-up period (18 months). There is definite evidence suggesting role of reactive oxygen species in the persistence of hypogonadism in these patients.

Keywords Budd-Chiari syndrome, Hypogonadism, Oxidative stress

015

Mucosal impedance spectroscopy: For objective real time assessment of mucosal health

Priyanka Arora ¹ , Jaspreet Singh ² , Anuraag Jena ¹ , Surinder Kumar ¹ , Viren Sardana ³ , Siddhartha Sarkar ³ , Lileshwar Kaman ⁴ , Arunanshu Behera ⁴ , Divya Dahiya ⁴ , Ritambhara Nada ⁵ , Cherring Tandup ⁴ , H S Jatana ² , Usha Dutta ¹

Correspondence – Usha Dutta - ushadutta@gmail.com

Departments of ¹Gastroenterology, ⁴Surgery, and ⁵Histopathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, ²Semi Conductor Laboratory, Mohali, India, and ³Central Scientific Instrument Organization, Sector 30-C, Sector 30, Chandigarh 160 030, India

Aim To develop, design and validate a low-cost mucosal impedance (MI) device and determine its role in differentiating diseased mucosa from normal mucosa.

Methods Biocompatible catheter was designed and developed after multiple iterations. It was validated with commercially available catheter and histopathological analysis in blinded manner. Patients undergoing resection of gastrointestinal tract were recruited after informed consent and resected specimens were analyzed ex vivo for MI, within 10 minutes of resection. Average of three MI readings of diseased segment and adjacent normal segment (whenever available) were analyzed. MI values of diseased and normal mucosa was compared by Mann-Whitney U test, Wilcoxon sign ranked test was used for analysis of paired mucosal samples. A p value of <0.05 was considered to be significant.

Results In-house catheter was validated with another commercially available impedance measuring device. It was found to show a high degree of positive correlation (rho=0.616; p<0.001). All diseased vs. normal of 232 patients (mean age 46±15 years [180 inflammatory pathology, 52 malignant pathology]) who were undergoing abdominal surgery were enrolled. Median impedance value of diseased segments was significantly lower than adjacent normal segments of gut in 130 paired samples studied (1832 [727] ohm vs. 2604 [1295] ohm; p<0.001). MI value of segments of gut containing malignant tissue (n=50) and inflammed tissue (n=80) was significantly lower than the MI value of adjacent normal segments of gastrointestinal tract (1880 [977] ohm vs. 2583 [1431] ohm; p<0.001) and (1787 [557] ohm vs. 2515 [1244] ohm; p<0.001) respectively. Median reduction in visually diseased segment was by 712 (661) ohm and percentage reduction was by 24% from adjacent normal segment. Biocompatible endoscopic catheter of 3 mm diameter was developed which has been tested in 3 patients and also found to differentiate diseased from normal mucosa

Conclusion Impedance spectroscopy is effective real time simple objective tool to identify diseased gut mucosa from healthy mucosa.

Keywords Endoscopic catheter, Impedance, Inflammation, Malignancy

016

Prevalence of sarcopenia in patients with inflammatory bowel disease and factors associated with it

Vikram Dharap, Philip Abraham, Devendra Desai, Tarun Gupta, Pavan Dhoble, Nirad Mehta, J Modhe

Correspondence - Philip Abraham - dr_pabraham@hindujahospital.com

Department of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 016, India

Introduction Sarcopenia is a progressive and generalized skeletal muscle disorder with significant reduction in skeletal muscle mass associated with low muscle strength and physical performance. In inflammatory bowel disease (IBD) it is affected by many factors and can be present in patients even when in clinical remission. It has been implicated in various disease complications, affecting its prognosis.

Aims To study prevalence of sarcopenia in patients with IBD and factors associated with it.

Methods Consecutive consenting patients with IBD between June 2021 and June 2022 were enrolled. Associated diseases that could contribute to sarcopenia were excluded. Anthropometric measurements, body mass index (BMI), and mid-arm muscle circumference were recorded. Muscle strength was measured by hand-grip strength (hand-held dynamometer), physical performance by gait speed (4-meters walk test) and muscle mass by measuring skeletal muscle index with single L3-level CT scan. As per European Working Group on Sarcopenia in Older People, 2018 definition, probable sarcopenia had low muscle strength), sarcopenia (low muscle strength and low muscle mass), and severe sarcopenia (low muscle strength, low muscle mass, and low physical performance). Factors associated with sarcopenia were studied.

Results Of 117 patients (65 men; mean age 42.4 years [standard deviation 15.3]; 73 UC, 42 CD, 2 IBD-U), 40 (34.2%) patients had probable sarcopenia, 47 (40.2%) sarcopenia (29 UC, 18 CD) including 10 with severe sarcopenia. Ten (21.3%) patients with sarcopenia were in remission. On univariate analysis BMI, disease activity, hemoglobin, and biologic use showed significant association with sarcopenia; only BMI was significant on multivariate analysis.

Conclusion Sarcopenia was detected in 40% of patients with IBD; one-fifth of them were in clinical remission. Low BMI significantly correlated with occurrence of sarcopenia.

Keywords IBD, Malnutrition, Sarcopenia

017

Early (within two weeks) versus late percutaneous catheter drainage in patients with acute necrotizing pancreatitis

Pankaj Gupta, Harsimran Shah, Shameema Farook, Chaitanya Bendale, Anupam Singh, Jimil Shah, Jayanta Samanta, Harshal Mandavdhare, Vishal Sharma, Saroj Sinha, Usha Dutta, Manavjit Sandhu

Correspondence - Pankaj Gupta - pankajgupta959@gmail.com

Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction Early drainage has been advocated in the management of the symptomatic pancreatic collection. However, there is a paucity of data on the safety and efficacy of early drainage. To compare the results of early (≤2 weeks) vs. late (>2 weeks) percutaneous catheter drainage (PCD) in patients with acute necrotizing pancreatitis (ANP).

Methods This retrospective study comprised consecutive patients with ANP who underwent PCD in the first two weeks of illness. Matched controls that underwent PCD between the 3rd and 4th week of disease formed the comparison group. The technical success rate, clinical success rate, complications, and clinical outcomes were compared between the two groups.

Results Seventy-four patients (median age, 37.1±12.7 years) comprised the study group (I). An equal number of patients with comparable baseline characteristics comprised the control group (II). The mean pain to PCD interval was 10.1±2.9 days in group I vs. 21.6±4.5 days in group II. The procedures were technically successful in all patients in both groups. The clinical success rate was 79.7% in group I vs. 93.2% in group II (p=0.069). There were 23 catheter-related complications (15 minor and 8 major). The incidence of complications was significantly higher in group I (n=17, 22.9%) than in group II (n=6, 8.1%) (p=0.013). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. five patients, p=0.031). All other clinical outcomes were comparable between the two groups.

Conclusion Early PCD within the first two weeks of illness is feasible, effective, and has an acceptable complication rate.

Keywords Acute necrotizing, Catheters, Drainage, Pancreatitis,

018

Stool multiplex molecular polymerase chain reaction assay in comparison to conventional stool tests in detecting gastrointestinal infections as cause of flares of inflammatory bowel disease

Manek Kutar , Devendra Desai, Philip Abraham, Tarun Gupta, Pavan Dhoble

Correspondence – Manek Kutar- mkutar07@gmail.com

Department of Gastroenterology, P. D. Hinduja Hospital and Medical Research Center, Veer Savarkar Marg, Mahim, Mumbai 400 016, India

Introduction Inflammatory bowel disease (IBD) is characterized by intermittent and unpredictable flares. Other than natural history, flares can be caused by superadded gastrointestinal (GI) tract infections. Diagnosis of infection is conventionally made by microscopy and stool culture specimens. These are limited by lengthy turnaround time, low sensitivity, inability to detect agents other than bacteria and effect of pre-test antibiotic usage. Stool multiplex molecular polymerase chain reaction (PCR) assay (BioFire® FilmArray® GI Panel) allows simultaneous detection of nucleic acids from 23 bacteria, viruses and parasites.

Aims

1. To compare infectious organisms detected by Biofire® FilmArray® test and conventional stool test (microscopy and culture) in IBD flare patients.

2. Determine impact of detection of infective agents in the management of flares, as measured by use of anti-infective agents

Methods Single center, prospective, cohort study. Inclusion criteria: Consenting patients above 18 years with IBD flare. Exclusion criteria: Colorectal cancer, toxic megacolon, intestinal perforation, previous IBD surgery. Sample size: 58.

Results The following tables show organisms detected and change in management

	Conventional stool test n (%)	Biofire® n (%)	P value (Chi-square test)
Organism detected	6 (10.3)	32 (55.1)	0.0001
Organism not detected	52 (89.7)	26 (44.9)
Total	58	58

	Conventional stool test n (%)	Biofire® n (%)	P value (Chi-square test)
Change in management	3 (5.1)	11 (18.9)	0.023
No management change	55 (94.9)	47 (81.1)
Positive reports	58	58

Stool Biofire® showed better organism detection rate and more frequent need for change in management as compared to conventional tests. Comparative cost of conventional stool test cost was Indian rupee (₹) 4300 and that of stool Biofire® ₹ 12,000.

Conclusion Stool Biofire®, as compared to conventional stool tests, detected significantly more infective organism in IBD flare and resulted in 4-fold more change in management of the flare.

Keywords Biofire, Flare, IBD

019

2D-Shear wave elastography: A novel non-invasive marker for differentiation between benign and malignant focal lesions of liver

Aditya Verma, Bony George, Srijaya S

Correspondence – Aditya Verma - Adi_cooldude08@yahoo.com

Department of Medical Gastroenterology, Government Medical College, Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background Detection and characterization of focal liver lesions (FLLs) poses a frequent challenge in clinical practice. 2D-shear wave elastography (2D-SWE) is a recent technique which uses acoustic radiation force to induce mechanical vibrations and assess tissue elasticity.

Aims To study the elasticity characteristics of focal liver lesions by 2D shear wave elastography and to determine whether it can be used to differentiate benign from malignant lesions.

Methods All patients with FLL underwent 2D-SWE and elasticity quantification. Contrast-enhanced computed tomography (CECT) or magnetic resonance imaging (MRI) findings were used as the reference method for the diagnosis of FLLs.

Results Two hundred and sixteen patients with FLL were evaluated by the 2D-SWE. 130 patients had malignant FLLs of which 90 had hepatocellular carcinoma (HCC), 20 had intrahepatic cholangiocarcinoma (IHCC) and 20 had metastatic lesions. Of the 86 benign FLL, there were 36 hemangiomas, 12 FNH, 24 simple cysts, 4 complex cysts, and 10 abscesses. Mean liver stiffness of various lesions by 2D-SWE was 65.7 (IHCC), 60.5 (HCC), 45.4 (metastases), 7.6 (hemangioma), 16.9 (FNH), 9.14 (abscess), 8.62 (simple cyst) and 2.95 (complex cyst). ROC analysis revealed that a SWE cut off of 40 kPa could distinguish between benign and malignant lesions with sensitivity of 100% and specificity of 80%. (AUROC of 0.871). The lesion to background liver parenchyma stiffness ratio in cirrhotic patients was 4.81 for IHCC, 3.16 for metastasis and 1.93 For HCC. Therefore in cirrhotic patients, a lesion to liver stiffness ratio < 2 along with SWE of lesion more than 40 kpa favors HCC. However, in non-cirrhotic livers, there was no statistically significant difference between stiffness ratio of various malignant focal lesions.

Conclusion 2D-SWE could be used as a novel, non-invasive adjunct for the differentiation of benign and malignant focal lesions of liver.

Keywords 2-D shear wave elastography, Focal lesion liver, Hepatocellular carcinoma

020

Model for end stage liver disease - Sarcopenia score for prediction of mortality in liver cirrhosis

Hitesh Ramesh, Deepak Suvarna

Correspondence – Deepak Suvarna - drdeepaksuvarna@gmail.com

Department of Medical Gastroenterology, J S S Hospital, Mahatma Gandhi Road, Fort Mohalla, Mysuru 570 004, India

Introduction One of the major limitations of model for end-stage liver disease (MELD) score is its failure to assess nutritional status of patients, thereby underestimating disease severity. So patients with low MELD score, but with sarcopenia may be under prioritized. Our objective was to evaluate if inclusion of sarcopenia within MELD score could improve prediction of mortality in patients with liver cirrhosis.

Methods We evaluated 65 patients with liver cirrhosis for sarcopenia. Sarcopenia evaluation was done bedside using SARC-F questionnaire, Chair rise test and measuring hand grip strength using electronic hand dynamometer. Sarcopenia was defined using previously published hand grip strength cut offs (Asian working group for sarcopenia). Patients with sarcopenia were given additional 10 points to MELD score. Patients with and without sarcopenia were followed up for a period of 6 months.

Results Twenty-nine patients (44.6%) with liver cirrhosis had sarcopenia. Mean hand grip dynamometer strength (kg) was 20.214.57 kg and 31.34 7.93 kg in patients with and without sarcopenia respectively (p-< 0.001). Sarcopenic patients had a higher frequency of ascites (p = 0.618), hepatic encephalopathy (p = 0.53), variceal bleeding (p = 0.47) and SBP (p = 0.43) in comparison to non-sarcopenic patients during 6 months of follow-up. But p value was not statistically significant. The mean MELD Score was 20.62±6.13 and 19.67±6.75 among patients with and without sarcopenia respectively. Mean MELD-Sarcopenia score was 30.61± 6.28 among sarcopenic patients.

Conclusions Sarcopenia was detected in significant patients with cirrhosis of liver. Incidence of liver cirrhosis related complications and mortality was higher among patients with sarcopenia compared to non-sarcopenic patients. Sarcopenia was independently associated with increased risk of mortality. however, modification of MELD score to include sarcopenia (MELD-Sarcopenia score) was not associated with improvement in prediction of mortality at 6 months.

Keywords MELD score, Sarcopenia

021

Evolution of Rosemont`s “indeterminate for chronic pancreatitis” as diagnosed on endoscopic ultrasound in patients presenting with recurrent acute pancreatitis with one year follow-up

Arun Vaidya, Kshaunish Das, Partha Patra

Correspondence – Arun Vaidya - arunvaidya212@gmail.com

Department of Gastroenterology, Seth Sukhlal Karnani Memorial Hospital, and Institute of Post-Graduate Medical Education and Research, SSKM Hospital Road, Bhowanipore, Kolkata 700 020, India

Background and Aim Some patients presenting with recurrent acute pancreatitis (RAP), when undergo endoscopic ultrasound (EUS), are classified as indeterminate for chronic pancreatitis (CP) according to Rosemont criteria. Our aim was to study the clinical and radiological outcome of such patients over a period of one year.

Methods We conducted prospective observational cohort study and included Rosemont “Indeterminate” for CP patients above 12 years of age. All the patients were closely followed up at 3 monthly intervals in pancreatic clinic and subjected to ultrasound abdomen and blood sugar profile 6 monthly. EUS was done after 12 months of baseline EUS. Fecal elastase was performed after 1 year of enrolment.

Results Total 21 RAP patients after excluding chronic pancreatitis on CT abdomen and magnetic resonance cholangiopancreatography (MRCP) undergone EUS. Fourteen were found to be Indeterminate for CP and included in study. Males were 93%. Median age was 26 years. Median duration between first attack of acute pancreatitis (AP) and EUS was 34 months with median of 4 attacks of AP prior to EUS. Most common etiology of RAP was idiopathic followed by ethanol and hypertriglyceridemia. History of smoking present in 36% patients. On 1 year follow-up, 35.7% remained pain free and 28.6% had AP attack. Endocrine and exocrine insufficiency was seen in 1 and 2 patients respectively. Gallstones and sludge were detected in 3 patients on follow-up ultrasound abdomen. Follow-up EUS done in 8 patients revealed Rosemont ‘normal’ in 1, ‘Indeterminate’ in 2, suggestive of CP in 3 and consistent with CP in 2 patients.

Conclusions EUS has high diagnostic yield. Indeterminate for CP is common in younger adults with idiopathic being most common etiology. Rosemont ‘’Indeterminate” progress to definitive CP in majority of patients.

Keywords Chronic pancreatitis, Idiopathic, Indeterminate, Rosemont`s criteria

022

Efficacy and safety of digital single-operator cholangioscopy guided laser lithotripsy for impacted cystic duct stones- A single tertiary care centre experience

Radhika Chavan , Vatsal Bachkaniwala, Chati Gandhi, Sanjay Rajput

Correspondence – Radhika Chavan - drradhikachavan@gmail.com

Department of Medical Gastroenterology, Ansh Clinic, A-1, Jaisinghbhai Park Hirabhai Tower, Nirant Cross Road, Uttam Nagar, Maninagar, Ahmedabad 380 008, India

Background and Aim Cholangioscopy have expanded the horizons of pancreaticobiliary evaluation. Cholangioscopy guided laser lithotripsy have been reported to be safe and effective for difficult bile duct stones. Cystic duct stones (CDS) pose special challenge for endoscopic treatment because of tortuous nature of the cystic duct, so traditionally it is managed with surgery. We aimed to see efficacy and safety of cholangioscopy guided laser lithotripsy for cystic duct stones.

Methods All consecutive patients who underwent laser lithotripsy for cystic duct stones from July 2018 till February 2022 were recruited after obtaining institutional board review approval. Details regarding previous Endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy were maintained prospectively. ERCP was performed in all patients and digital single-operator cholangioscopy (DSOC) with laser lithotripsy (Holmium) was performed. Primary endpoint was complete cystic duct clearance determined by cholangioscopy.

Results Total 167 patients underwent laser lithotripsy for various indication during the study period. Out of 167 patients, 30 patients (median age 45.5 [range 26-73] years, male-20) underwent laser lithotripsy for CDS. Out of 30 patients, 21 patients had retained impacted CDS after cholecystectomy. Median size of CDS was 15 mm (range 11-20mm). Mechanical lithotripsy had failed in 12 patients. DSOC guided laser lithotripsy was utilised in all patients with technical success of 93.3%. CDS clearance was achieved in 29 (96.6%) patients. In one patient procedure was aborted because of respiratory distress. Post ERCP CBD stenting was done in all patients which were removed subsequently (at median 4 weeks). Median duration of procedure was 65 (40-90) minutes. There were few adverse events (mid abdominal pain-5, post-ERCP pancreatitis-2, and death-1). The median follow-up duration was 6 (range 3-43) months.

Conclusions DSOC guided laser lithotripsy is safe and effective for cystic duct stones. It is minimally invasive and can be considered for the management of retained impacted CDS after cholecystectomy.

Keywords Cholangiography, Gallstone, Laproscopic, Lithotripsy, Mirizzi syndrome

023

SoCr score – A novel predictor to assess steroid response in acute severe ulcerative colitis

Antony George, Jijo Varghese, Krishnadas Devadas

Correspondence – Antony George - anthony00590@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Introduction Acute severe ulcerative colitis (ASUC) is a dreaded complication of ulcerative colitis (UC), with high mortality. 15% to 57% of patients fail to respond to systemic corticosteroids, the cornerstone of ASUC management, and might require colectomy or rescue medical therapies like infliximab or cyclosporine. The available predictive models of steroid response are based on western population studies, some utilizing expensive tests like fecal calprotectin. Our study aims to develop a simple predictor model for steroid response in ASUC.

Methodology A prospective observational study was conducted over 7 years (2015-2022). ASUC was defined based on Truelove and Witts criteria. Various clinical and laboratory parameters were assessed on the day of admission.

Results Eighty-seven patients were taken up for the study. Sixteen patients failed to respond to steroids. Among the variables analyzed, albumin, CRP, sodium, and hemoglobin were significant in predicting response to steroids. On regression analysis, CRP and sodium were independent predictors of response to steroids. The coefficient of beta was multiplied by steroid and CRP and the total score was obtained. This was called the SoCr (sodium+CRP) score = (sodium*0.4 – CRP*0.28) score. AUROC of the score was plotted. The score had an AUROC of 0.937. A score of >42 has a sensitivity of 93% and specificity of 83% in predicting response to steroids. The score was validated in a validation cohort of 31 patients. A score of >42 had a sensitivity of 96% and specificity of 88% in the validation cohort. All patients without pancolitis and those with a precipitating factor for colitis exacerbation responded to steroids.

Conclusion SoCr score is a simple prognostic score that can predict response to steroids in ASUC. The absence of pancolitis and lack of a precipitating factor for colitis exacerbation are strong predictors of response to steroids.

Keywords Acute severe ulcerative colitis, Predictors, Score, Steroid response

024

Advantages of routine milking of common bile duct during combined laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography

Vinay V , Sridhar C G

Correspondence – Vinay V - vinay.hvr4@gmail.com

Department of Medical Gastroenterology, GEM Hospital, Pankaj Mill Road, Ramanathapuram, Coimbatore 641 045, India

Background Approximately fifteen percent of patients with gallbladder stones also have common bile duct (CBD) stones [1]. Endoscopic retrograde cholangiopancreatography (ERCP) is combined routinely with laparoscopic cholecystectomy (LC) for concomitant CBD stone and other post-cholecystectomy complications such as bile leak and inadvertent injury. We aimed this study to evaluate the role of CBD milking to prevent complications and to increase rate of biliary cannulation in ERCPs Post-LC.

Methods This study included all cases undergoing combined LC with ERCP as one-step procedure at GEM Hospital, Coimbatore in the period from January 2021 to September 2021. All the complications with percentage of biliary cannulation were noted meticulously to compare with the conventional method of not milking CBD. Patients undergoing LC or ERCP as two-step procedure were excluded.

Results Out of total 68 cases, failed biliary cannulation was recorded in 8 patients in non-milking cases but only 1 in milking of CBD was performed intra-operatively. CBD cannulation time was longer in non-milking group as compared to milking group. Total operative time of 106.5 minutes was less than conventional 122.8 minutes but not statistically significant. Complications like inadvertent PD cannulation in 11 cases (26%) compared to milking group about one case (3%), retained calculi were noted in 6 cases in non-milking group (13.19%) as compared to 3 cases post-milking (4%). Postoperative pancreatitis were observed in 5 cases (11.9%) of non-milking group but in only one case after milking of CBD (3.82%). Average length of Hospital stay was longer in non-milking group.

Conclusions Milking of CBD although difficult in some cases of LC has definite benefit in biliary cannulation during ERCP with reduced operative time and complication rates probably due to effects on sphincter of Oddi but follow-up is required to make it standardised technique in conventional one-step combined LC with ERCP.

Keywords ERCP, Laparoscopic cholecystectomy, Milking of common bile duct

025

Exclusive enteral nutrition mediates gut microbial alterations which correlate with augmented corticosteroid response in patients with acute severe colitis

Aditya Bajaj , Manasvini Markandey, Pabitra Sahu, Sudheer Vuyyuru, Bhaskar Kante, Peeyush Kumar, Namrata Singh, Arti Gupta, Mukesh Singh, Mahak Verma, Govind K Makharia, Saurabh Kedia, Vineet Ahuja

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Introduction Supplementation with exclusive enteral nutrition (EEN) in addition to standard corticosteroid therapy (SCT) has been proven to augment the steroid response rate in patients with acute severe ulcerative colitis (ASUC). EEN is known to alter the gut microbial composition. The present study identifies the changes in gut microbiota driven by EEN in patients with ASUC receiving standard steroid therapy and explores the correlation of the EEN-associated bacteria with changes in clinical parameters over the course of therapy.

Methods Stool samples were collected from 50 patients with ASUC who received either SCT (n=24) or SCT supplemented with EEN (n=20) for a period of 7 days, at baseline (Day 0) and post-therapy (Day 7). Microbiome characterization was carried out using 16S rRNA gene sequencing followed by data processing using QIIME2 and R packages for analysis of diversity and differentially abundant taxa.

Results Seven-day EEN supplementation of SCT in patients with ASUC resulted in enhanced Methylobacterium, Sphingomonas, Limosilactobacillus, Megamonas, Thermus, Viellonella, with a reduction in Ruminococcus gnavus, Gemmiger, Pseudomonas, and Enterococcus. The EEN-mediated enhancement in specific taxa correlated positively with patients’ serum albumin levels and negatively with fecal calprotectin levels. The microbiome abundance dataset and clinical parameters (FCP, CRP, serum albumin levels, and clinical response to EEN) correlated significantly, as analyzed by coinertia analysis. Gut microbial composition of patients who responded to the EEN-augmented SCT showed an enhanced abundance of Coprococcus, Megamonas, Oribacterium, Sediminibacterium, Acidibacter, and Thermus, and reduction in Sutterella, R. gnavus, Collinsella, Dorea, and Morganella, when compared to EEN non-responders. Baseline gut microbiome signature in patients with ASUC predicts a potential response to both the SCT and EEN-supplemented SCT in patients with ASUC.

Conclusion Augmentation of clinical response by EEN-conjugated corticosteroid therapy is accompanied by gut microbial changes in patients with ASUC.

Keywords Acute severe ulcerative colitis, Exclusive enteral nutrition, Gut microbiota

026

Molecular subtyping of pancreatic neuroendocrine tumor and its correlation with clinicopathological outcome: A single institute retrospective study

Saikat Mitra ¹ , Aravind Sekar¹, Divya Khosla², Vikas Gupta³, Kim Vaiphei¹

Correspondence - Saikat Mitra - saikatmitra123@gmail.com

Departments of ¹Histopathology, ²Radiotherapy, and ³Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Introduction Pancreatic neuroendocrine tumors (PanNETs) account for ~3% to 4% of all pancreatic tumors worldwide. The WHO grading and TNM staging in PanNET do not accurately predict the clinical behavior and prognosis. We used immunohistochemistry based molecular subtyping of PanNETs and studied the relation of the mutations with clinicopathological outcome.

Methods In this single institute retrospective study, cases of PanNETs were selected. Immunohistochemistry (IHC) for ATRX, DAXX, Menin, ARX and PDX-1 markers were done on formaline-fixed tissue. FITC-labelled telomere-specific fluorescent in-situ hybridization (FISH) was performed to assess altered telomere lengthening (ALT). The tumors were subtyped based on mutation status and the subtypes were correlated with clinical, pathological features and follow-up.

Results A total of 78 cases including 75 PanNET (45 grade 1, 20 grade 2 and 10 grade 3) and 3 pancreatic neuroendocrine carcinoma were identified. ATRX and DAXX mutations were identified in 20.9% and 29.9% of PanNET cases respectively. ATRX mutation was significantly associated with nodal metastasis (p=0.007), higher TNM stage (p=0.004), higher WHO grade (p=0.014), lymphovascular invasion (p<0.001), recurrence (p=0.025). DAXX mutation was significantly associated with a larger tumor size (p=0.007), higher TNM stage (p=0.011), higher WHO grade (p=0.002), lymphovascular invasion (p=0.001), perineural invasion (p=0.046). Altogether, 26 cases (38.8%) showed either ATRX/DAXX mutation (AD mutant subtype) and showed significantly higher tumor size (p=0.035), nodal metastasis (p= 0.001), higher WHO grade (p= 0.001), lymphovascular invasion (p=0.001) perineural invasion (p=0.048) and recurrence (p=0.001). Univariate survival analysis revealed significantly lower overall follow-up in ATRX mutant (p<0.001), DAXX mutant (p=0.007) and AD mutant (p=0.011) subtypes. ALT positivity correlated with higher TNM stage, lymphovascular invasion and AD mutation. Multivariate cox-regression analysis showed ATRX mutation as independent predictor of poorer overall survival (HR=10.1, CI=1.3-76.7, p=0.025).

Conclusion ATRX/DAXX mutant PanNETs have aggressive clinical, histological behavior and are predictors of poor outcome.

Keywords Altered telomere lengthening, ATRX, DAXX, Neuroendocrine tumor, Pancreas

027

Algorithmic approach to differentiate between non-specific and specific etiologies of chronic terminal Ileitis

Karan Sachdeva, Samagra Agarwal, Peeyush Kumar, David Mathew, Sudheer K. Vuyyuru, Bhaskar Kante, Pabitra Sahu,. Sandeep Mundhra, Lalit Kurrey, Shubi Virmani, Pratap Mouli, Rajan Dhingra, Govind K Makharia, Saurabh Kedia, Vineet Ahuja

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Introduction Chronic isolated terminal ileal (TI) involvement (terminal ileitis) may be seen in numerous etiologies including Crohn’s disease (CD) and intestinal tuberculosis (ITB) in addition to other etiologies that may improve with symptomatic management alone. We aimed to improve our previously suggested algorithm to distinguish patients who would merit specific treatment from those who do not.

Methods Patients (n=153) with isolated TI involvement (ulcers or nodularity) following-up at All India Institute of Medical Sciences (AIIMS) (2007-2022) were retrospectively reviewed. A specific (ITB/CD) diagnosis was made based on standardized criteria and other relevant data was collected. The cohort was utilized for validation of previously suggested algorithm while multivariate analysis with bootstrap validation was used to develop a revised algorithm.

Results We included 153 patients (mean age 36.9 years, 70% males, median duration of symptoms 1.5 years) with isolated terminal ileal involvement of whom 109 (71.2%) received a specific diagnosis (69 CD, 40 ITB). Multivariate regression and validation statistics suggested that based on a combination of clinical (blood in stools, weight loss, hemoglobin), radiological (necrotic lymph nodes, long segment ileal involvement) and colonoscopic findings (presence or absence of deep ulcers), an optimism corrected c-statistic of 0.975 and 0.958 could be reached with and without histopathological findings respectively. Based on these, a revised algorithm was developed which showed a sensitivity of 99.08% (95% CI:94.99-99.98) and a specificity of 75.0% (95% CI:59.66-86.81). The positive predictive value (PPV) was 90.76% (95% CI:85.47-94.25) and negative predictive value (NPV) was 97.06% (95% CI:82.32–99.57) with an overall accuracy of 92.16% (95% CI:86.70-95.88). This was a more sensitive and specific than the previous algorithm (accuracy 83.6%, sensitivity 95.4%, and specificity 54.4%).

Conclusion We suggested a revised algorithm to stratify patients of terminal ileitis into those who have a specific etiology and those who need only symptomatic treatment. Our algorithm has the potential to avoid missed diagnosis as well as unnecessary side effects of treatment.

Keywords Algorithm, Crohn’s disease, Terminal Ileitis

028

Significance of fibroblast growth factor receptor heterozygous genotype in the pathogenesis of non-alcoholic fatty liver disease with and without type II diabetes mellitus: A pilot study from Assam

Snigdha Jyoti Das , Purabi Bose, Sangit Dutta ^* , Natasha Kashyap, Aditi Kalita, Sujoy Bose ^**

Correspondence - Purabi Bose - pdbose@cottonuniversity.ac.in

Department of Molecular Biology and Biotechnology, Cotton University Panbazar, Guwahati 781 001, India, ^*Department of Medicine, Gauhati Medical College Hospital, Guwahati 781 032, India, and ^**Department of Biotechnology, Gauhati University, Guwahati 781 014, India

Introduction Non-alcoholic fatty liver disease (NAFLD) in lean patients is suggestive of phenotypic and apparently pathophysiologically distinct; with unsatisfactory documentation of its underlying mechanism(s) at molecular level. Type-II diabetes mellitus (T2DM) is also linked with NAFLD, and therefore a common immunological link may be present. In the present study, we intended in defining the possible role of the polymorphism of the FGFR4 receptor gene and the differential expression of its ligand, FGF19, to bring some insight towards the pathophysiology of NAFLD via molecular genetic analysis in lean patients without or with T2DM.

Methods Blood samples were obtained from clinically diagnosed lean patients having NAFLD (=50), NAFLD with T2DM (=50) and healthy volunteers (=50) with informed consent. Analysis of gene expression at mRNA level and gene polymorphism was done by Real-time-polymerase chain reaction (Real-time-PCR) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) respectively.

Results The genotype analysis of FGFR4 gene showed higher prevalence of heterozygous genotype in patients with NAFLD compared to NAFLD with T2DM (OR=2.667) while it showed significantly lower prevalence of heterozygous genotype in controls compared to the case cohorts. The gene expression of FGF19 at mRNA level exhibited an up-regulation in both the cases in comparison to controls. Upon association with increased liver function tests (LFT) profile markers, although statistically non-significant, expression level of FGF19 was found to be negatively correlated with alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) levels and positively correlated with ALP and aspartate aminotransferase (AST) levels.

Conclusion The data suggests the association of FGFR4 heterozygous genotype with the development of NAFLD and NAFLD with T2DM. However, the upregulation of FGF19 mRNA expression in disease cohorts compared to controls was not found to be statistically significant suggesting the fact that the FGFR4 heterozygous genotype may have some role to play in the pathogenesis of either NAFLD or NAFLD with T2DM rather than its ligand FGF19.

Keywords Fibroblast growth factor (FGF19), Fibroblast growth factor receptor (FGFR4), Messenger

029

Plastic stents versus NAGI bi-flanged metal stent for endoscopic ultrasound guided drainage of walled-off necrosis - A randomized controlled study

Krithi Krishna Koduri , Nitin Jagtap, Sandeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Mohan Ramchandani, Rakesh Kalapala, Rajesh Gupta, Sana Fathimamemon, D N Reddy

Correspondence – Krithi Krishna Koduri - drkrithivk@gmail.com

Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Introduction Endoscopic ultrasound (EUS) guided drainage with either plastic stents or metal stents is the mainstay of walled off necrosis (WON) management. A systematic review of retrospective studies showed similar treatment success for WON by plastic or metal stents. This single center randomized controlled study was designed to evaluate the efficacy of dedicated NAGI bi-flanged metal stent (BFMS) and plastic stents for WON drainage.

Methods Patients with symptomatic WON amenable for EUS-guided drainage were randomized to either BFMS or plastic stents. Patients having altered anatomy, WON not accessible for endoscopic drainage, previous percutaneous drainage were excluded. Primary outcome was comparison of re-intervention free clinical success at 4 weeks, defined as symptom resolution and significant reduction in WON size. Secondary outcomes were treatment success, number of re-interventions, hospital stay and long-term outcomes.

Results A total of 92 patients were randomized either to BFMS (n = 46; mean age 34.9 (12.4) years) or plastic stents (n = 46; mean age 36.8 (11.1) years). There was no significant difference in terms of debris and maximum size of WON in both groups (p > 0.05). Re-intervention free clinical success at one month was observed in 31 (67.4%) in BFMS arm and 20 (43.5%) in plastic stent arm by ITT analysis (p 0.035) and 68.1% vs. 44.2% by PP analysis (p 0.0382). However, overall clinical success was equal in both groups. There was significantly lower number of re-interventions including necrosectomy sessions and hospital stay required in BFMS group. There was no difference in procedure-related adverse events or mortality. Also, there was no significant difference in clinical success, recurrence, DPDS, chronic pancreatitis and new-onset DM up to 6-month follow-up.

Conclusions The bi-flanged metal stent provides higher re-intervention free clinical success at 4 weeks with lower hospital stay without increased risk of adverse events compared to plastic stents for EUS-guided drainage of WON.

Keywords Bi-flanged metal stent, Endoscopic ultrasound, RCT, Walled off necrosis

030

Fatty liver and metabolic syndrome in patients with celiac disease: A systematic review and meta-analysis

Nishant Aggarwal ¹ , Ashish Agarwal², Hasan Alarouri³, Vignesh Dwarkanathan⁴, Sana Dang⁵, Vineet Ahuja⁶, Govind K Makharia⁶

Correspondence – Govind K Makharia - govindmakharia@gmail.com

¹Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA, ²Department of Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India, ³Jordan University of Science and Technology Faculty of Medicine, Ar-Ramtha, Jordan, ⁴Department of Community Medicine, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, ⁵Department of Medicine, Vardhaman Mahavir Medical College and Safdarjung Hospital, NH 48, Near AIIMS Hospital, Ansari Nagar West, New Delhi 110 029, India, and ⁶Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Objective Studies have suggested a high prevalence of fatty liver and metabolic syndrome in patients with celiac disease (CeD). We conducted a systematic review and meta-analysis to assess the prevalence of fatty liver and metabolic syndrome in treatment-naïve patients with CeD and in patients on gluten-free diet (GFD).

Methods The PubMed, Embase and the Cochrane Library databases were searched for original studies. We included full-text articles published in the English language after 1990 that used well-defined criteria for CeD, fatty liver and metabolic syndrome. Of 185 studies identified, seven were included for the analysis. Random effects model was used to calculate pooled prevalence.

Results The pooled prevalence of fatty liver in treatment-naïve patients with CeD was 15.3% (0.153 [95% CI 0.056-0.285], n=867). After initiation of GFD, the prevalence increased to 29.1% (0.291 [95% CI 0.172-0.427], n=869). The pooled prevalence of metabolic syndrome in treatment-naïve patients with CeD was 4.3% (0.043 [95% CI 0.024-0.067], n=1239), which increased to 24.2% (0.242 [95% CI 0.195-0.293], n=1239) after initiation of GFD (Figs. 1 and 2). We did not observe any significant publication bias.

Conclusions The present review has suggested a high prevalence of fatty liver and metabolic syndrome in patients with CeD which increases further with the initiation of GFD. Patients with CeD should thus be regularly screened and monitored for the development of fatty liver and metabolic syndrome. They should be counselled appropriately regarding their diet and inclusion of regular physical activity in their lifestyle.

Keywords Celiac, Fatty liver, Metabolic syndrome, Non-alcoholic fatty liver disease, Obesity

031

FDG PET CT findings in microscopic colitis and its correlation with the disease activity

Antriksh Kumar ¹ , Rakesh Kochhar ¹ , Kaushal Kishore Pasad ¹ , Anish Bhattacharya ² , Rajendra Kumar ² , Shreya Shruti³, Jayanta Samanta¹, Saroj Kant Sinha¹

Correspondence – Saroj Kant Sinha - sarojksinha@hotmail.com

Departments of ¹Gastroenterology, and ²Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, and ³Government Medical College and Hospital, Sector 32, Chandigarh 160 030, India

Background and Aim PET-CT has been used earlier to localize the diseased segments in patients with Crohn’s disease and ulcerative colitis. There is paucity of data on its utility for the diagnosis and evaluation of disease activity in microscopic colitis (MC).

Methods Patients presenting with watery diarrhea were prospectively evaluated from July 2018 to December 2019 for the etiology using various tests including sigmoidoscopy/colonoscopy and colonic biopsy. Those suffering from MC underwent 18-FDG-PET-CT and assessment of disease activity using microscopic colitis activity index (MCDAI). A regional 18F-FDG-PET-CT scan of the abdomen and pelvis was performed, and the images were evaluated in blinded manner. Liver FDG uptake was taken as background and any uptake in large above the background liver activity was taken as abnormal. The maximum SUV (standardized uptake values) was measured in each colonic segment.

Results Fifty-three patients with chronic watery diarrhea were evaluated, of which 29 patients were found to have MC (23 LC, 2 CC and 4 mixed). Diffuse FDG uptake pattern in colon was noted in 20 (69%) patients, focal colonic uptake was present in 8 (27.6%) patients. Even in the colonic segments, diffuse FDG uptake pattern was seen predominantly. The number of patients showing such an uptake pattern were 16 (55.2%) in ascending colon, 11 (37.9%) in cecum and 8 (29.6%) in descending colon. Only four patients mounted some PET enhancement in the small intestine.

Receiver operating characteristic (ROC) curves were formulated to find maximal cut-off values of MCDAI and uptake patterns of PET scan. A significant SUVmax of diffuse uptake pattern in the descending colon had a significant correlation with MCDAI (Correlation Coefficient=0.786, p= 0.021).

Conclusion Most patients with MC show diffuse pattern of uptake in colon. Moreover, FDG-PET-CT may be useful in assessing the the disease activity of MC.

Keywords CT scan, FDG PET, Microscopic colitis, PET

032

No biopsy approach is applicable for diagnosis of celiac disease in adults

Aditya Pachisia , Nishakar Thakur, Shubham Mehta, Alka Singh, Shubham Prasad, Ankit Agarwal, Ashish Chauhan, Sachin Rajput, Rohan Malik, Prasenjit Das, Vineet Ahuja, Govind K Makharia

Correspondence – Aditya Pachisia - adityapachisia.jul20@aiims.edu

Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Introduction While European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) 2020 advocates non-biopsy pathway for the diagnosis of celiac disease (CeD) in children if IgA anti-tissue transglutaminase antibody (anti-tTG ab) titre is ≥10 folds upper limit of normal (ULN) and have a positive IgA anti-endomysial antibody (EMA), data on anti tTG Ab titre based diagnosis of CeD in adults is emerging. We planned to validate if anti-tTG Ab titre >10 folds predicts villous abnormalities of modified Marsh grade ≥2 in Asian patients with CeD.

Methods Relevant data of 937 adults with CeD was extracted from two databases including All India Institute of Medical Sciences (AIIMS) Celiac Clinic and the Indian National Biorepository. The diagnosis of CeD in them were made on basis of standard criteria including a positive anti-tTG Ab and presence of villous abnormalities of modified Marsh grade 2 or more.

Results Only 45.3% of 937 patients had anti tTG Ab titer of ≥10 folds. However, the positive predictive value (PPV) and specificity of anti tTG Ab titre ≥10 folds for predicting modified Marsh grade ≥2 was 99.8% and 98%, respectively. Further at anti tTG Ab titre ≥ 11folds, both the specificity and PPV were 100% for prediction of villous abnormalities of modified Marsh grade ≥2.06).

Conclusions Approximately only half of adult patients with CeD have anti-tTG Ab titre ≥ 10 folds hence qualifying for the non-biopsy pathway for the diagnosis. The specificity and predictive value of anti-tTG Ab ≥ 10 folds for diagnosing CeD are high even in adult patients

Keywords Anti tTG Ab, Celiac disease, Fold rise, Modified marsh score

033

The predictors of non-tumoral portal vein thrombosis among patients with decompensated liver cirrhosis using acoustic parameters of liver and spleen

Shivabrata Dhal Mohapatra, Aditya Verma, Srijaya S

Correspondence – Aditya Verma - Adi_cooldude08@yahoo.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background and Aims Portal vein thrombosis (PVT) that occurs due to poor portal flow, complex thrombophilic disorders and factors leading to endothelial dysfunction, is an increasingly recognized complication in patients with cirrhosis. We tried to assess the acoustic parameters and stiffness of liver and spleen as risk factors associated with non-malignant PVT in decompensated chronic liver disease patients (DCLD).

Methods We prospectively enrolled 502 patients with DCLD (CHILD B/C). All patients underwent detailed clinical evaluation, baseline investigation and ultrasonography. PVT was confirmed by contrast-enhanced computed tomography (CECT) abdomen in patients with ultrasonogram (USG) evidence of PVT or alteration in portal flow dynamics. Acoustic parameters of liver and spleen were assessed by 2D Shear wave elastography (Supersonic Aixplorer). ROC was plotted to derive the best cut-off of parameters for development of PVT.

Results Thirty-nine patients were excluded. Of the 463 patients included, 51 had PVT (11%). It was observed that non-malignant PVT group patients had smaller liver size (11.8±1.8 vs. 12.4±1.5, p=0.032), higher spleen size (14.9±2.3 vs. 13.5±2.2, p<0.01), higher portal vein diameter (PVD, 14.4±3.2 vs. 12.2±1.7, p<0.01), lower portal vein velocity (PVV, 11.5±3.6 vs. 16.7±3.6, p<0.01), higher liver stiffness (61.3±21.7 vs. 55.2±17.1, p=0.02), higher splenic stiffness (50.3±15.1 vs. 36.7±7.5, p<0.01) as compared to non-PVT group. On plotting ROC; PVV <12.5 cm/sec (AUROC 0.86, sensitivity 74%, specificity 88%, NPV 95.9%), PVD >13.7 cm (AUROC 0.75), liver stiffness >66.5 kPa (AUROC 0.72), liver size <11.95 cm (AUROC 0.63) were significantly associated with development of non-malignant PVT (p<0.01). On multiple logistic analysis PVD >13.75 cm (B=1.21, OR:95%CI 3.36]1.05-10.7], p=0.04), PVV <12.5 cm/sec (B= -1.06, OR:95% CI 0.35 [0.13-0.09], p=0.03) were significant risk factors for PVT development in DCLD.

Conclusion The association of higher liver stiffness and smaller liver size as markers of extent of cirrhosis, higher splenic size and stiffness as a reflection of severity of portal hypertension, dilated PV and low PVV indicating sluggish portal flow that trigger thrombosis in the splenoportal axis, were significantly associated with non-malignant PVT in DCLD.

Keywords 2D shear wave elastography, Decompensated cirrhosis, Non-malignant PVT-Portal vein thrombosis

034

Left ventricular diastolic dysfunction: A surrogate predictor of survival in patients with decompensated cirrhosis

Rushil Solanki, Srijaya Sreesh, Krishnadas Devadas, Antony George, Vijay Narayanan, Shivabrata Dhal Mohapatra

Correspondence - Rushil Solanki - rushilsolanki808@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor-Akkulam Road, Near SAT Hospital Medical College Junction, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background and Aims Left Ventricular diastolic dysfunction (LVDD) is a primal manifestation of cirrhotic cardiomyopathy. Few studies have addressed its relationship with mortality outcomes. We evaluated the impact of LVDD along with other parameters on the short-term survival of patients with decompensated cirrhosis.

Method One hundred and ninety-two patients with decompensated cirrhosis underwent investigations including 2D echocardiography with tissue Doppler imaging. The diagnosis of LVDD was based on the American Society of Echocardiography guidelines and the patients were followed up for 6 months.

Results 42.2% (n=81) had grade 1 LVDD and 30.7% (59) had grade 2 LVDD at enrollment. 69.2% (128) were alive at 6 months. Among the non-survivors, 5.9% had no LVDD, 23.4% had grade-1 and 62.1% had grade-2 LVDD (p=<0.001). Median survival of LVDD grades 0, 1, and 2 was 177±3, 163±3, and 122±3 days respectively. Kaplan-Meier survival analysis showed poor survival in patients with LVDD (p<0.001), E/e' ≥10 (p=0.029) and pulmonary capillary wedge pressure PCWP ≥15 mmHg (p=0.003). The Cox regression model showed a hazard ratio of 10.3 for grade-2 LVDD, and 5.7 for any LVDD compared to 1.07 for model for end-stage liver disease (MELD) score as an independent predictor of mortality. MELD score cut-off for predicting mortality was 17 (84% sensitivity:62% specificity). Mortality in patients with MELD >17 was 52.9% with LVDD vs. 9.5% without LVDD (p<0.001), and MELD ≤17 was 16.7% with LVDD vs. 3.4% without LVDD (p=0.08). In multivariate analysis, the MELD score and LVDD were independent predictors of survival. Among echocardiography parameters, patients with a ratio of early filling velocity to early diastolic mitral annular velocity (E/e') ≥10 and PCWP ≥15 mmHg were significantly associated with the severity and mortality of the patients.

Conclusion The presence and severity of LVDD are better predictors of poor transplant-free survival than MELD in patients with decompensated cirrhosis. Therefore, cardiac parameters could be an add-on to the MELD score for prognostication of decompensated cirrhosis patients.

Keywords Cirrhotic cardiomyopathy, Diastolic dysfunction, Echocardiography

035

Urine neutrophil gelatinase associated lipocalin for predicting Type of acute kidney injury (AKI) in patients of decompensated cirrhosis with AKI

Roshan George , Ajay Kumar, Bhawna Mahajan, Ujjwal Sonika, Ajay Dalal, Sanjeev Sachdev

Correspondence – Roshan George - rshngeorge14@gmail.com

Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Introduction The management and outcomes of acute kidney injury (AKI) in decompensated cirrhosis (DC) depends on type of AKI. The differentiation between types of AKI in real world setting is done by clinical adjudication, which has limitations. The present study evaluated the diagnostic accuracy of urine neutrophil gelatinase associated lipocalin (NGAL) in predicting type of AKI among patients of DC having AKI.

Methods Consecutive DC patients with AKI stage 1B or above (International Club of Ascites [ICA] 2015 criteria) seen between March 2020 to February 2021 were evaluated. AKI was typed as acute tubular necrosis (ATN-AKI), Pre-Renal (PRA-AKI) and hepatorenal syndrome (HRS-AKI). The urine NGAL levels were measured at diagnosis of AKI (Day 0) and 48hrs (Day 3) after volume expansion. The AKI type was determined by two study investigators independently using clinical data blinded to urine NGAL levels. The patients were followed up till death or 28 days.

Results Overall 388 DC patients were screened, 86 patients (PRA-AKI n=47, 55%; HRS-AKI n=25, 29%; ATN-AKI n=14, 16%) with mean age 48.73±12.53 years, 74 (86%) males were included. The area under receiver operating characteristic (AUROC) of urine NGAL for differentiating ATN-AKI and non-ATN AKI at day 0 was 0.97 (95% CI 0.95-1.0) and on day 3 was 0.97 (0.94-1.0). The optimal urine NGAL cut-off level on day 0 was 214.98 ug/g creatinine and on day 3 was 200.09 ug/g creatinine for predicting ATN-AKI. The overall mortality was 45.34% and urine NGAL levels were higher in patients who died as compared to those who survived.

Conclusion Urine NGAL has an excellent diagnostic accuracy in predicting ATN-AKI in DC patients. High urine NGAL levels are associated with increased risk of death.

Keywords Acute kidney injury (AKI), Decompensated cirrhosis, Urine neutrophil gelatinase associated lipocalin

Esophagus

036

Proton pump inhibitor therapy in patients with erosive esophagitis- A real world scenario

Mayank Jain

Correspondence – Mayank Jain - mayank4670@rediffmail.com

Department of Gastroenterology, Arihant Hospital and Research Centre, 297 Indrapuri, Near Bhanwarkuan, Indore 452 001, India

Patients with gastroesophageal reflux disease (GERD) are managed with lifestyle changes, dietary interventions, and proton pump inhibitors (PPI).

Aim To determine patterns of PPI use in patients with documented erosive esophagitis (EE).

Methods This prospective study recruited all patients with symptoms of GERD (heartburn and /or regurgitation with or without chest pain) and documented significant reflux esophagitis (Los Angeles grading LA-B or beyond on endoscopy). Lifestyle, dietary changes were initiated and all patients were prescribed twice daily PPI for 8 weeks. PPI was tapered as the requirement beyond 8 weeks. Follow-up was done at weeks 8, 12 and 24. The outcomes analyzed included number of patients where complete PPI withdrawal was possible at week 24 and determinants of continued PPI use at 24 weeks of therapy. Statistical analysis- Chi-square test, Mann–Whitney U-test, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio. P<0.05 was considered as statistically significant.

Results The study cohort included 53 patients- 42 with reflux esophagitis LA-B and 11 with reflux esophagitis LA-C (median age 46 years [22-77 years]; 28 [52.3%] males). There was significant difference in consumption pattern of PPI between week 12 and 24 (p 0.008). At week 12, 15.1% were off PPI and 67% required intermittent dosing. At week 24, 45.3% of cases were off PPI therapy and 43.4% required intermittent dosing. Only 11.3% patients continued drug use at once-a-day dosing. Lower BMI (p 0.01) and age (p 0.01) were linked with complete PPI withdrawal at week 24.

Conclusion The present study highlights that PPI withdrawal is possible in 15.1% and 45.3% cases with EE after week 12 and week 24 of therapy respectively. Lower body mass index (BMI) and age are likely to be associated with PPI withdrawal at week 24.

Keywords Drugs, Esophagitis, Esophagus, Reflux, Response

037

An unusual case of dysphagia in a young male

Sumaswi Angadi, Suprabhat Giri, Sagar Gangadhar, Saidulu Chevigoni, Lohith Kumar V, Abhishek Kamuni, Sukanya Bhrugumalla

Correspondence - Sumaswi Angadi - sumaswia@gmail.com

Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Speciality Block-4th Floor, Punjagutta, Hyderabad 500 082, India

Introduction Dysphagia in young individuals is commonly attributed to esophageal web, strictures, motility disorders, eosinophilic esophagitis or rarely malignancy. Extra esophageal compression as a cause of dysphagia is rarely encountered. An accurate diagnosis is essential to provide appropriate therapy.

Case Report A 39-year-old male, non-smoker, non-alcoholic, a farmer by occupation presented with intermittent fever, shortness of breath associated with cough for 1 year, hoarseness of voice, and dysphagia for 6 months. Dysphagia was progressive for solid food. Systemic examination was unremarkable except for patchy crepitations in the right chest. Cross-sectional imaging revealed a 5.9 × 10.3 × 10.8 cm heterogeneously enhancing mass lesion in the posterior mediastinum. The lesion was seen encasing the left and right main bronchi, left main pulmonary artery, and closely abutting descending thoracic aorta with pericardial involvement. A probable diagnosis of malignancy or tuberculosis was made based on clinical features including hoarseness of voice and imaging findings. Esophagogastroduodenoscopy revealed a smooth extrinsic impression in the mid-esophagus with a fistulous opening covered with necrotic debris on the opposite wall and left vocal cord palsy. Barium swallow examination confirmed a linear fistulous tract in the mid esophagus with long segment luminal narrowing. Subsequently, endoscopic ultrasound with tissue acquisition was performed. Histopathology revealed granulomatous inflammation with septate filamentous hyphal structures. Further, the patient underwent a bronchoscopy and an Aspergillus galactomannan test performed on bronchoalveolar lavage fluid was suggestive of invasive aspergillosis (0.7 ng/mL). The patient was started on intravenous voriconazole and discharged on oral formulation. Over 6 weeks, the patient reported a significant reduction in upper respiratory complaints and dysphagia.

Conclusion Extra esophageal compression is a rare cause of dysphagia. Cross-sectional imaging and endoscopic ultrasonography play an important role in its diagnosis. Invasive aspergillosis in immunocompetent individuals is rare. Prompt diagnosis and appropriate therapy is lifesaving.

Keywords Dysphagia, Endoscopic ultrasound, Invasive Aspergillosis, Mediastinal granuloma

038

Clinical, epidemiological, endoscopic profile and outcome of corrosive injuries of gastrointestinal tract

Chappidi Deepak, Sandeep Nijhawan

Correspondence – Sandeep Nijhawan - sandeepnijhawan16@gmail.com

Department of Gastroenterology, Sawai Man Singh Medical College, New SMS Campus Road, Gangawal Park, Adarsh Nagar, Jaipur 302 004, India

Introduction Corrosive ingestion is one of the important causes of esophageal stricture and gastric outlet obstruction (GOO) in India. This study aims to explore the clinical, epidemiological, and endoscopic profile and outcomes of patients of corrosive ingestion.

Methods This prospective observational study was done on patients presenting with history of corrosive ingestion to SMS Hospital, Jaipur, Rajasthan. Detailed history was recorded, and patients were analyzed on the basis of age, sex, mode of ingestion, intention of consumption, nature of corrosive and clinical symptoms. Endoscopy was done within 24 to 48 hours of admission. Patients were serially followed up and subjected to repeat endoscopy after 6 weeks.

Results Total of 60 patients were enrolled from December 2020 to November 2021. Incidence of corrosive ingestion was higher in males than females (67% vs. 33%). The most common intention of corrosive ingestion was suicidal found in n=42 (70%). Acid ingestion (75%) was more common than alkali ingestion (25%). Chest pain and dysphagia were the most common symptoms at presentation. On endoscopy, 15 (25%) had grade 0, 5 (8%) had grade 1, 25 (41%) had grade 2 and 15 (25%) had grade 3 degree of corrosive injuries. All patients with grade 0, 1, and 2a injury recovered without sequelae. Esophageal strictures were seen in 12 (26%) patients in acid ingestion and 6 (40%) patients in alkali ingestion. GOO developed in 10 (22%) patients of acid ingestion and 6 (13%) patients of alkali ingestion. Both complications were seen in 3 (6%) patients with acid ingestion.

Conclusions Corrosive injury of the upper gastrointestinal tract is a common problem with variable complications. Acid injury is more common. Initial endoscopic grading of injury correlates with outcome. Esophageal complications were common in both acid and alkali ingestion. GOO was more common in acid ingestion.

Keywords Corrosive, Gastric outlet obstruction, Stricture

039

Experience on the diagnostic outcome of high-resolution esophageal manometry from a single-center, tertiary level hospital

Chittuluri Jagadeesh, Chezhian A

Correspondence - Chittuluri Jagadeesh - doctorjd18@gmail.com

Department of Medical Gastroenterology, Madras Medical College, Rajiv Gandhi Government General Hospital, Poonamallee High Road, 3, Grand Southern Trunk Road, Near Chennai Central, Park Town, Chennai 600 003, India

Significance High-resolution esophageal manometry (HREM) has been the method of choice for the evaluation of esophageal motility disorders. There is no local data regarding the use and diagnostic outcome of HREM in the investigation of the patients referred for evaluation of esophageal motility.

Methodology Study Design: Retrospective, cross-sectional. Study Population: Patients referred for evaluation of esophageal motility. Intervention: HREM

Results In this study, total of 103 patients were evaluated using HREM. Majority of the patients included were females, 62 (60.195) and the mean age was 45.71 years. Most of the patients were referred for HREM because of persistent reflux symptoms despite proton pump inhibitor (PPI), 61 (59.22%), followed by dysphagia, 36 (34.95%). For the entire population, the most common HREM finding was abnormal, 66 (64.08%). Majority of patients referred for HREM because of gastroesophageal reflux related disease revealed normal results, 36 (53.73%), on the other hand majority of patients referred for HREM because of dysphagia revealed abnormal results, 35 (97.22%). Overall, an abnormal motility occurred in 66 patients (64.08%). The most common motility abnormality was weak peristaltic disorders in 33 (50.00%) followed by esophagogastric junction (EGJ) disorder in 40 (45.45%). The most common motility disorders based on symptom category were as follows: Dysphagia, Achalasia Type I in 17 out of 35 patients (48.57%); gastroesophageal reflux disease (GERD), ineffective peristalsis in 22 out of 31 patients (70.97%).

Conclusion This study confirms the overall high prevalence of weak peristaltic disorders and underscores the need to further study the pathophysiology and management of this ubiquitous disorder. The finding of achalasia in 83.33% of our patients with dysphagia is consistent with recent reports regarding the rising incidence of this disorder and underscores the need of prompt motility testing in this population.

Keywords High resolution manometry

040

Twenty-four-hour pH-metry alone is inferior to additional impedance monitoring in the diagnosis of gastroesophageal reflux disease, particularly in presence of low gastric acid secretion

Uday C Ghoshal, Sugata Narayan Biswas, Anshuman Elhence, Bushra Fatima, Anand Prakash Agrahari, Asha Misra

Correspondence - Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014. India

Background Current gold standard for the diagnosis of gastroesophageal reflux disease (GERD) is 24-h pH-metry though it fails to detect non-acidic reflux. The sensitivity of 24-h pH-metry alone (both catheter-based and BRAVO capsule) is questionable, especially, if gastric acid secretion is low due to reduced parietal cell mass, Helicobacter pylori-induced gastric atrophy and antisecretory therapy. Accordingly, we analyzed the diagnostic ability of 24-h pH-metry as compared to impedance monitoring in relation to gastric acid levels without antisecretory therapy.

Methods A retrospective analysis of prospectively collected data of 150 patients with suspected gastroesophageal reflux disease (GERD) undergoing 24-h pH impedance study was done.

Results Among 150 patients with symptoms suggestive of GERD, 106 (70.6%) had confirmed GERD diagnosed either by 24-h pH-metry alone (10 [9.4%]), impedance monitoring alone (49 [46.2%]) or both (47 [44.3%]). Reflux of gastric contents was detected by 24-h pH-metry and 24-h impedance monitoring in 57/106 (53.7%) and 96/106 (90.5%) of patients, respectively (p<.00001). Patients with GERD diagnosed by 24-h impedance monitoring had a higher mean gastric pH (2.9 [median 1.3, IQR 5.3]) than those diagnosed by 24-h pH-metry (2.1 [median 1.4, IQR 2.6]) or both (1.6 [median 1.2, IQR 2.1]) (p=0.001).

Conclusion 24-h impedance monitoring detects GERD more often than 24-h pH-metry. Patients with higher mean gastric pH leading to non-acidic reflux were more often diagnosed by 24-h impedance monitoring than 24-h pH metry. Thus, 24-h pH-metry alone is inferior to additional impedance monitoring in the diagnosis of GERD, particularly in presence of low gastric acid secretion.

Keywords Gastroesophageal reflux disease, 24-h pH-metry, 24-h impedance monitoring

041

A case report of contained upper cervical esophageal perforation masquerading as retropharyngeal abscess

Dinesh Kumar Dugganapalli, Umadevi Malladi, B Ramesh Kumar, Sahithya L

Correspondence – Dinesh Kumar Dugganapalli - dugganapalli@gmail.com

Department of Medical Gastroenterology, Osmania Medical College, 5-1-876, Turrebaz Khan Road, Troop Bazaar, Koti, Hyderabad 500 095, India

Perforation of the cervical esophagus is an infrequent but severe condition. Most patients are in their sixties, and esophageal perforation is slightly more common in males. The diagnosis and management of cervical esophageal perforation remains a challenging clinical problem. Several factors, including the difficulty of accessing the esophagus, the lack of a strong serosal layer, the unusual blood supply of the organ and the proximity of vital structures, all contribute to this condition’s high morbidity and to a mortality rate of at least 20%. We present a case of cervical esophageal perforation mimicking retropharyngeal abscess.

Keywords Cervical esophagus, Dysphagia, Esophageal perforation, Retropharyngeal abscess

042

Prevalence of eosinophilic esophagitis in patients presenting with chronic reflux symptoms at a tertiary care centre in South India

Amith Viswanath ¹ , Ebby George Simon¹, Anna B. Pulimood², Kripa Varghese², Amit Kumar Dutta¹, Joseph A J¹, Rajeeb Jaleel¹, Anoop John¹, Ajith Thomas¹, Pegatraju Krishna Bharadwaj¹

Correspondence – Amith Viswanath - amithsvati@gmail.com

Departments of ¹Gastroenterology, and ²Pathology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Eosinophilic esophagitis (EO) has been increasing in prevalence over the past decade. Previous data from India showed a prevalence of 3.2%. The purpose of this study was to determine the prevalence and clinical predictors of EO in patients presenting with chronic reflux symptoms.

Methods This was a prospective cross-sectional study which enrolled consecutive adult patients with chronic reflux symptoms from January 2022 to August 2022. Their symptoms were assessed with the reflux disease questionnaire, straumann dysphagia index and brief esophageal dysphagia questionnaire. Upper gastrointestinal endoscopy was done and endoscopic features of EO were documented. Four quadrant biopsies were obtained from the upper and lower esophagus. EO was diagnosed if the number of eosinophils was >15 per high power field.

Results Out of 197 patients analyzed, four were diagnosed with EO. Out of these, three were male patients. The median age of presentation was 44 years. Heartburn and epigastric pain were present in all four patients. Endoscopy findings were normal in 2 patients (50%). Compared to the non-EO group, EO patients were more likely to have epigastric pain (p= 0.02), higher endoscopic reference (EREFS) score (p=0.004), had microabscesses in histopathology (p =0.002).

Conclusion Prevalence of EO was 2% in this study population of reflux patients. EO should be considered in chronic reflux patients with abnormal findings typical of EO on endoscopy.

Keywords Eosinophilic esophagitis, India, Prevalence

043

Esophageal Crohn's -Always A mystery

Dhruv Shah

Correspondence – Dhruv Shah - dds240791@gmail.com

Department of Gastromedicine, S V P Hospital, N H L Medical College, Ellis Bridge, Ahmedabad 380 006, India

Introduction Crohn's disease of the esophagus is rare. The estimated incidence in adult patients with Crohn's disease is 0.3% to 2%. Esophageal involvement is more common in the pediatric population. We present case of adult esophageal Crohn’s earlier misdiagnosed as esophageal duplication cyst.

Case Report A 36-year-old man with a history of dysphagia, and odynophagia from 2 months. Upper endoscopy suggestive of? Esophageal duplication cyst. Further contrast-enhanced computed tomography (CECT) thorax done suggestive of? Esophageal duplication cyst. GI surgery referred was done and transhiatal esophagectomy with gastric pull up was done and excised esophagus was sent for histopathology examination. Biopsy revealed chronic active esophagitis with noncaseating granulomas and an absence of microorganisms on special stains, which supported a diagnosis of Crohn's disease. Further colonoscopic examination with biopsies through the colon and terminal ileum was found to be insignificant. In the postoperative period patient developed esophagocutaneous fistula, patient was treated with a proton pump inhibitor, a short course of prednisone, and a maintenance regimen that included azathioprine and mesalamine. His esophageal symptoms resolved.

Discussion As illustrated by this case, most reported cases of Crohn’s disease of the esophagus are associated with disease elsewhere in the gut. However, there are rare reports in which Crohn 's disease is presented primarily in the esophagus. Patients with esophageal involvement usually complain of heartburn, odynophagia, dysphagia, and substemal or epigastric pain. Therapy is based largely on the administration of corticosteroids and immunomodulatars (Biologicals).

Conclusion Involvement of the upper gastrointestinal tract by Crohn's disease is usually under-diagnosed or falsely diagnosed. Timely diagnosis and treatment leads to good clinical outcomes. Detail evaluation of Crohn’s mimickers should always be done.

Keywords Biologicals, Dysphagia, Esophageal Crohn’s

044

Dysphagia lusoria: A rare cause of dysphagia

Arun Prasannan, Venkatakrishnan Leelakrishnan, Mukundan Swaminathan, Thirumal Perumal, Ravindra Kantanameni

Correspondence – Venkatakrishnan Leelakrishnan - arunvani9496@gmail.com

Department of Medical Gastroenterology, P S G Hospitals, Peelamedu, Coimbatore 641 004. India

Introduction Dysphagia lusoria is a term used to describe dysphagia as a consequence of vascular compression of the esophagus. The majority of cases of dysphagia lusoria are due to aberrant right subclavian artery causing posterior esophageal compression. Decreased vascular compliance is thought to be the most predominant factor for symptoms of dysphagia. Our report describes a case of late-onset dysphagia secondary to a right aortic arch with an aberrant left subclavian artery, which represents a rare variant of dysphagia lusoria.

Presentation Seventy-two-year-old man presenting with progressive dysphagia and breathlessness for a period of 1 year. Patient is a known case of chronic kidney disease, coronary artery disease, hypertension, diabetes mellitus on treatment for 5 years. He also had abdominal distension, cough and orthopnoea. Examination revealed bilateral coarse creps, pedal edema, ascites. Investigations revealed anemia, sinus tachycardia, elevated troponins, D Dimer, S1Q3T3 in ECG. Echo showed concentric LVH, mild grade 2 diastolic dysfunction pulmonary artery hypertension. CT pulmonary angiogram revealed right sided aortic arch with abberrant origin of left subclavian artery from Kommerell diverticulum compressing esophagus with bilateral pleural effusion, bronchiactasis, dialated pulmonary artery. Endoscopy revealed extrinsic vascular compression in the mid esophagus causing luminal narrowing and pulsations. Barium swallow revealed a large extrinsic compression in the mid esophagus. Patient was adviced surgery in view of significant symptoms, but attenders opted for conservative management.

Conclusion The prevalence in the general population of an aberrant subclavian artery is estimated at 0.4% to 0.7% in the majority of the published literature. Motility abnormalities and esophageal stiffening, aortic elongation with increased traction on the obstructing artery or aneurysmal dilatation in the presence of Kommerell’s diverticulum may contribute to late symptoms. Dsyphagia lusoria due to aberrant left subclavian artery from right sided aortic arch with Kommerells diverticulum is extremely rare cause of dysphagia in elderly patients.

Keywords Aberrant left subclavian artery, Dysphagia lusoria, Right sided aortic arch

045

Leukemic infiltration of esophagus presenting as pseudoachalasia

Uday C Ghoshal, Srikanth Kothalkar, Akash Mathur

Correspondence – Uday C Ghoshal -udayghoshal@gmail.com

Department of Medical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

A 38-year-old male presented with a history of dysphagia, regurgitation, and 5 Kg weight loss for ten months. He also had a history of intermittent low-grade fever every 3-4 months associated with fatigue and generalized weakness for the same duration. One month before admission, he had a history of having right upper limb cellulitis that responded to antibiotics. Examination revealed severe pallor. An esophagoduodenoscopy revealed a dilated esophagus and resistance at the gastroesophageal junction. A timed barium esophagogram showed a hold-up of contrast with distal tapering. The diagnosis of type I achalasia was confirmed on high-resolution solid-state (Sandhill Scientific, Co, USA) esophageal manometry (basal lower esophageal sphincter [LES] pressure 7.2 mmHg, integrated relaxation pressure [IRP] 25 and 27 mmHg, respectively for liquid and viscous swallow, mean distal contractile integral [DCI] 1 and 9 mmHg/cm/s, respectively for liquid and viscous swallow). His Eckardt score on presentation was 6. Given the short duration of symptoms, rapid worsening, recurrent infections and fatigue, he was subsequently evaluated to rule out secondary achalasia. On routine investigations, he was found to have bi-cytopenia (anemia and thrombocytopenia. Hemoglobin was 6 g/dL (normal 11.6 to 15 g/dL) and platelet count was 1 lakh (normal 1.5-4 lakh per cubic millimetre). A peripheral blood smear showed pseudo-rouleaux formation, reduced red blood cells, and 4% blast cells with an abnormal nuclear-cytoplasmic ratio.

Bone marrow aspiration showed particulate and hypercellular smears, constituting approximately 45% blasts and promonocytes and 20% of abnormal monocytes with reduced other hematopoietic elements; blasts positive for cytochemical staining with myeloperoxidase (MPO) stain suggestive of acute myeloid leukemia with monocytic differentiation.

Esophagal biopsy suggested leukemic infiltration. He was started on chemotherapy and nutritional support given through Rylee’s tube to which he responded with resolution of dysphagia.

Keywords AML, Dysphagia, Esophageal mannometry, Leukemic infiltration, Pseudoachalasia

046

Quality of life assessment and dysphagia relief following laparoscopic heller myotomy: Our experience

Phani Kumar Nekarakanti, Vivek Chauhan

Correspondence – Phani Kumar Nekarakanti - phani.nek87@gmail.com

Department of Surgical Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Background Laparoscopic Heller myotomy (LHM) can be performed by blunt dissection technique. Only a few studies have assessed the quality of life (QOL) and relief of dysphagia following LHM. The study reviews our long-term experience and correlate the QOL following LHM by blunt technique.

Methodology This retrospective study was analyzed from a prospectively maintained database (from 2013 to 2021) of a single unit of Department of Gastrointestinal Surgery at G B Pant Hospital, New Delhi. The myotomy was performed by blunt dissection technique in all patients. A fundoplication was added in selected patients. Post-operative Eckardt score >3 was considered as treatment failure. WHO QOL BREF questionnaire was used to evaluate QOL.

Results A total of 100 patients underwent surgery during study period. Of them, 65 patients underwent LHM, 27 underwent LHM with Dor fundoplication, 7 patients underwent LHM with Toupet fundoplication, and one open technique. Five patients had esophageal perforation and was repaired laparoscopically. Eleven patients developed treatment failure post-surgery. The median follow- up of the study cohort was 22 months (range 3-96 months). The mean IRP post-surgery in treatment success group was 9.15 and in treatment failure group was 15.78 (p=0.001). The mean WHO QOL score in physical well-being domain in treatment success vs. failure group 66.16 vs. 49.60 (p=0.001), psychological 55.73 vs. 41.90 (p=0.050), social 67.20 vs. 47.70 (p=0.009), environmental 64.92 vs. 43.70 (p=0.001).

Conclusion LHM by blunt technique have minimal treatment failures with good QOL with successful treatment group.

Keywords Achalasia cardia, Dysphagia, Fundoplication,Heller myotomy, Laparoscopy, Quality of life

047

Bougie versus balloon dilatation in causative-induced esophageal stricture: A retrospective analysis of two decades

Anupam Singh ¹ , Yalaka Rami Reddy ² , Pankaj Gupta ³ , Anuraag Jena ¹ , Jimil Shah ¹ , Saroj Kant Singh ¹ , Rakesh Kochhar ¹

Correspondence – Anupam Singh - anupam.pgi@gmail.com

Departments of ¹Gastroenterology, and ³Radiology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, and ²Gleneagles Global Hospital, Lakdi-ka-pul, Hyderabad 500 004, India

Introduction Endoscopic dilatation is the initial management strategy for caustic-induced esophageal strictures (CES). However, the differences in outcome for different types of dilators used are unclear. We compared the outcomes of CES for the use of bougie dilators compared to balloon dilators.

Methods Between January 1998 and December 2016, all patients with CES were included. Data collected included demographic parameters, type, and intention of caustic substance ingestion, number of strictures, number of dilatations required to achieve 15 mm dilatation, and post-dilatation recurrence. Patients were divided into 2 groups based on the type of dilator used for stricture dilatation, i.e. bougie dilator or balloon dilator. The two groups were compared for the baseline parameter, technical and clinical success, proportion of refractory strictures, recurrence rates after initial success, and major complicate rates.

Results One hundred and eighty-nine patients were included in the study with a mean age of 32.17±12.12 years and 119 (62.9%) being males. One hundred and twenty-two (64.5%) patients underwent stricture dilatation using bougie dilators while 67 (35.5 %) with balloon dilators. Technical success was higher for bougie dilators compared to balloon dilators (90.1% vs. 68.7%, p<0.001). Short-term clinical success (65.6% vs. 46.3%, p=0.01) as well as long-term clinical success (86.9% vs. 64.2%, p<0.01) was more with bougie dilators. Multivariate analysis identified the use of bougie dilators (aOR 4.868, 95% CI: 1.027 – 23.079) short-term clinical success (aOR 5.785, 95% CI: 1.203 – 27.825), and the presence of refractory strictures (aOR 0.151, 95% CI: 0.033–0.690) as independent predictors of the long-term clinical success. Twenty-four (12.7%) patients developed adverse events and were similar for the two groups.

Conclusion Use of bougie dilators increases the clinical success for CES compared to balloon dilators with similar rates of adverse events.

Keywords Controlled radial expansion balloon, Corrosive stricture, Savary Gilliard

048

Endoscopic management of a sick patient with empyema due to unusual cause of esophago-pleural fistula

Viswanath Reddy ¹ , Rakesh Kumar Adi¹, Ravi Shankar Bagepally¹, Sai Reddy Y²

Correspondence – Viswanath Reddy - viswanathdr@yahoo.com

Departments of ¹Gastroenterology, and ²Pulmonology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India

Introduction Esophago-pleural fistula (EPF) is an uncommon condition leading to fatal mediastinitis and empyema with sepsis. Surgery and conservative management are the options. We hereby describe an unusual cause of EPF due to accidental removal of nasogastric tube in a patient with recent cerebrovascular stroke, developed sepsis was managed by endoscopic procedures.

Methods a 52-year-old female who had recent ischemic stroke, being managed in Rehabilitation unit presented with sudden onset of breathlessness and sepsis. Evaluation was suggestive of bilateral empyema. Bilateral intercostal drains (ICD) were placed and broad spectrum antibiotics were given. Clinical suspicion of esophageal rupture was made in view of history of accidental removal of nasogastric tube preceding the catastrophic illness. Endoscopy showed a large defect (3 cm) in lower esophagus with pus draining. Options of surgery and conservative management was discussed with relatives. Due to her poor general condition and recent stroke, conservative management was considered. Esophageal defect was closed using multiple large endoclips (10). Percutaneous gastrostomy (PEG) was placed and through it, a feeding tube was placed into duodenum over guidewire under endoscopic guidance. She showed gradual improvement in terms of response to sepsis, ICDs were removed, and she tolerated PEG-D feeds. Three months later the contrast study showed closure of EPF fistula and endoscopy showed a pseudodiverticulum in the area. She was then started on oral diet and subsequently PEG-D tube was removed. Follow up in outpatient department was gratifying in terms of clinical response.

Results We describe a case of EPF with empyema due to accidental nasogastric tube removal, managed successfully with antibiotics, ICD placement and Endoscopic intervention.

Conclusion Esophago-pleural fistula due to accidental removal of nasogastric tube is rarely described. Empyema management and endoscopic therapy of the large defect with addition of alternative nutritional route helps enhancing healing of the fistula.

Keywords Empyema, Endoscopic closure, Esophago-pleural fistula, NGTube, PEGJ

049

Ugly duckling or just odd one out

Vinod Kolkunde

Correspondence – Vinod Kolkunde - vinodk387@gmail.com

Department of Gastroenterology, Yashoda Hospitals, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India

Introduction Lichenoid esophagitis is a rare pathologic diagnosis, marked by a lichenoid pattern of inflammation in the esophagus without features of lichenoid planus. We present a case of a young male who presented with chronic progressive intermittent dysphagia and was found to have lichenoid esophagitis on esophageal biopsies.

Case Discription A 38-year-old male, no diagnosed comorbidities presented with complaints of progressive intermittent dysphagia to solids for the past 2 years and gradually progressive in nature. The episodes resolved with drinking water. He denied a history of gastroesophageal reflux, nausea, emesis, gastrointestinal bleeding or prior food impaction. He denied drug or tobacco use and reported social alcohol use. Esophagogastroduodenoscopy revealed esophageal stricture with mucosal fraibility. There was no evidence of furrowing, exudates, or findings suggestive of eosinophilic esophagitis.

Discussion Histopathology of lichenoid esophagitis shows apoptotic keratinocytes (civatte bodies) and intraepithelial lymphocytosis. A lichenoid esophagitis pattern may be seen in association with lichen planus, polypharmacy, rheumatologic diseases, and viral infections, including hepatitis and human immunodeficiency virus (HIV), but our patient does not have any history of CTD's, HIV and hepatitis. The majority of patients who present with lichenoid esophagitis pattern or lichenoid planus esophagitis are female. There was no history of lichen planus or skin involvement in our male patient and studies have shown that polypharmacy (>3 medications) and the use of immunomodulatory agents is common among patients with lichenoid esophagitis. Our patient was not taking any medications and was being managed with intermittent PPIs. With scant available literature, lichenoid esophagitis is a rare yet significant etiology of dysphagia, there is a low but documented risk of progression to malignancy.

Keywords Dysphagia, Lichinoid esophagitis, Males

050

Epidemiological study on esophageal carcinoma in south India

Shirish N D , R Selvasekaran, Ramireddy Krishna Chaitanya, R U Rajesh, T Anuvind, H Sairaman

Correspondence – Shirish N D - shirishnd@gmail.com

Department of Medical Gastroenterology, Thoothukudi Government Medical College Hospital, Kamaraj Nagar, Thoothukudi 628 008, India

Introduction Esophageal carcinoma is one of the common gastrointestinal malignancy. There is limited literature on epidemiology of esophageal carcinoma in south India.

Aim and Objectives To study the histological pattern of esophageal carcinoma in southern state of India. The objectives are to evaluate the relation of age, sex, substance abuse in esophageal carcinoma.

Methods We evaluated retrospectively the data of 89 patients with esophageal carcinoma in department of Medical Gastroenterology in Government Thoothukudi Medical College over a period of 3 years from June 2019 to May 2022.

Observation There were total of 89 patients with esophageal cancer, 60 (67.4%) were males and 29 (32.6%) were females, with M:F of 2.0:1. The median age was 58.8 years. Of the 89 patients, history of tobacco was found in 83 (93.3%) patients and alcohol in 26 (29.2%) patients. Majority of tumor was in upper two-third 51 (57.3%) followed by 32 (35.9%) patients in lower one-third of esophagus. In 7 patients both upper and lower esophagus are involved. Squamous cell carcinoma was the histological type involving in 63 (70.8%) patients. Adenocarcinoma was detected in 26 (29.2%) patients.

Conclusion Squamous cell carcinoma is still far more common than adenocarcinoma in India. The upper two third of esophagus is the most common site of esophageal carcinoma in southern state of India.

Keywords Adenocarcinoma of esophagus, Distribution, Sex variability, squamous cell carcinoma esophagus

051

Black esophagus treated with anti-coagulation- An interesting case report

Aastha Jha, Alok Sahu, Maitrey Patel. Apurva Shah, Shravan Bohra

Correspondence – Apurva Shah - apurvashah411@gmail.com

Department of Gastroenterology, Apollo Hospital International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Ahmedabad 382 428, India

Introduction Acute esophageal necrosis (AEN) or black esophagus, is a rare clinical entity, characterized by diffuse circumferential blackened esophageal mucosa, usually affecting the distal esophagus with abrupt normalization at the gastroesophageal (GE) junction. Here we present a case of acute esophageal necrosis, developing post stem cell transplantation.

Case Report We present a case of 59-year-old male patient who underwent autologous stem cell transplantation for multiple myeloma in February 2022. He developed sepsis on Day 10 and was started on broad spectrum antibiotics with inotropic support. On Day 15, he developed hematemesis. Upper gastrointestinal (GI) scopy showed severe ulcerative esophagitis with blackish discolouration of mucosa from 23 cm up to GE junction (Fig. 1a). Biopsy findings were suggestive of inflammation, ulceration, and necrosis, without evidence of granuloma, malignancy, or fungus. He did not have any history of alcohol intake, non-steroidal anti-inflammatory drug use, corrosive agent ingestion or GE reflux history. A contrast CT chest was not done due to presence of acute kidney injury. He was treated with anticoagulation in renal dose (low molecular weight heparin- 40 mg once daily), proton pump inhibitors (PPI) and sucralfate. Patient improved with the same, and injury completely healed within 14 days of initial scopy (Fig. 1c).

Conclusion Probable etiological factors include sepsis, hypo-perfusion related to shock and malnutrition. Treatment relies on aggressive resuscitation, correction of underlying medical conditions, institution of therapy with proton pump inhibitors and sucralfate but use of anti-coagulation for GI bleed paradoxically decreased the bleed in our case considering lower esophageal necrosis due to hypoperfusion/thrombosis. No such case report has been done yet, as per our knowledge for use of anticoagulation in AEN.

Keywords Black esophagus acute necrotizing esophagitis anticoagulation

052

A rare case of esophageal actinomycosis- Case report

Paila Ramesh , A Chezhian, Stefan Agera, Shubha I, Caroline Selvi, Prem Kumar, Aravind A

Correspondence – Stefan Agera - stefanagera@yahoo.com.sg

Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India

Introduction Esophageal actinomycosis is rare and has been reported in immunocompetent and immunocompromized patients. We reporting an unusual case of esophageal actinomycosis in limited cutaneous systemic sclerosis patient on immunosuppressants.

Case Report A 55-year-old female known limited cutaneous systemic sclerosis on immunosuppressants, ILD with pulmonary hypertension, CKD on medical treatment, systemic hypertension presented with difficulty in swallowing since 1-year, insidious onset, progressive, solids >liquids, grade 2, associated with pain during swallowing and occasional vomitings. She denied any recent chemical or foreign body injury of esophagus and physical examination unremarkable. Upper gastrointestinal endoscopy showed multiple well defined round ulcers about 0.5 to 0.5 cm in diameter scattered in the distal esophagus. Histopathological examination of biopsy specimen showed that stratified squamous epithelium with basal cell hyperplasia, extensive areas of hemorrhage, necro inflammatory exudates, sulfer granules and filamental bacterial colonies consistent with actinomycetes. Intravenous penicillin G (20 million units per day) injection was given for 2 weeks, followed by oral amoxicillin 2 gm per day for 6 months on outpatient basis. A repeat upper gastrointestinal endoscopy after 4 weeks of antibiotic treatment was begun showed a remarkable reduction in ulcer size and activity. After 6 months of antibiotic treatment repeat endoscopy revealed no ulcers or microorganisms.

Summary Esophageal actinomycosis is uncommon, but it has been reported in immunocompetent and immunocompromised patients. Esophageal histology should be carefully observed for sulfer granules and filamentous actinomycetes colonies. In this case patient responded to penicillins, but treatment may fail in patients with poor compliance or complicated disease.

References

1. Brown JR. Human actinomycosis: a study of 181 subjects. Hum Pathol. 1973; 4:319-33.

2. Arora AK, Nord J, Olofinlade O, Javors B. Esophageal actinomycosis: a case report and review of the literature. Dysphagia. 2003; 18:27-31.

Keywords Esaphagus actinomycosis

Stomach

053

Bovine Colostrum as an alternative long-term management option in patient of common variable immunodeficiency: A case study

Ganesh Muniappan

Correspondence – Ganesh Muniappan - clinic.publications@gmail.com

Department of Gastroenterology, Kovai Medical Centre and Hospital, 99, Avinashi Road, Peelamedu, Indira Nagar, Civil Aerodrome Post, Coimbatore 641 001, India

Introduction Common variable immunodeficiency (CVID), also known as hypogammaglobulinemia is a primary immune deficiency disease characterized by low levels of protective antibodies and an increased risk of infections. CVID is treated with I.V. or S.C. immunoglobulin injections to partially restore immunoglobulin levels. However, due to compliance and cost issues of Ig additional treatments are the need of the hour, which are unfortunately rare. Oral Bovine Colostrum containing IgG, lactoferrin, lysozyme, lactoperoxidase and other nutrients may be a promising potential agent in managing long-term Common Variable Immunodeficiency Disease-associated gastrointestinal (GI) symptoms.

Case presentation A 41-year-old male suffering from CVID since lasts 10 years presented with severe recurrent uncontrollable GI infections requiring IVIG therapy. He was reluctant to continue IVIG, hence considering the evidence of oral hyperimmune bovine Colostrum on immune function and GI symptoms, the combination of bovine colostrum with zinc was selected as an exploratory option. The patient’s improvement of GI symptoms with regular use of combination was assessed through patient-reported outcome measures.

Result The patient showed marked clinical improvement from two months onwards. During the regular follow-up to 20 months, the patient showed an increase in his body weight and an improvement in his biochemical parameters along with gradual normalization in his GI symptoms with no reported adverse event.

Conclusion These results suggest that bovine colostrum improves clinical management of patients with GI symptoms due to CVID, when conventional therapies are not feasible. It should be investigated further with randomized controlled trials (RCTs) for more robust data as an effective and safe alternative therapy.

Keywords Common variable immunodeficiency, Gastrointestinal infection, Hypogammaglobulinemia, Intravenous immunoglobulin, Primary immunodeficiency

054

A rare case of giant fundic polyp in Peutz-Jegher syndrome presenting as gastric outlet obstruction

Srikanth Reddy Keesari , Govind Verma, Sudhir Mysore

Correspondence – Dhiraj Agrawal - dhirajagrawal24@gmail.com

Department of Medical Gastroenterology, Pace Hospital, HUDA Techno Enclave, Hitech city, Hyderabad 500 081, India

Affiliation Peutz-Jegher syndrome (PJS) is a rare polyposis syndrome commonly affecting a small bowl with recurrent obstruction due to polyp related intussusception. Here we present a rare case of giant fundic polyp presented as gastric outlet obstruction.

Introduction PJS characterized by mucocutaneous pigmentation and hamartomatous polyps which can occur anywhere in the GI tract. Commonly it presents as small intestine obstruction1(42.8%), abdominal pain (23.4), rectal bleeding (13.5%), extrusion of polyp (7.2).

Case Report A 58-year-old female presented with pain abdomen, vomiting, bloating sensation since 15 days. Her endoscopy showed large fundal polyp with a large pedicle obstructing pylorus. Contrast-enhanced computed tomography (CECT) showing polypoidal mass from fundus of stomach extending posteriorly into D2 and causing obstruction. She underwent laparoscopic gastrostomy+ reduction of intussusception +stapled partial gastrectomy done. Histopathology revealed hamartomatous polyp, favoring Peutz-Jegher polyp.

Discussion PJS with an incidence of 1 in 200000 live births. It is caused by mutation in the STK11(LKB1) gene. Those affected have multiple hamartomatous polyps, commonest2 sites are small bowel (50%), stomach (36%), colon (21%). Additionally, individuals with PJS have a significantly increased lifetime risk of gastroesophageal, small bowel, colonic and breast cancer. common presentation is obstruction due to intussusception within small bowel occurs more frequently in the jejunum compared to ileum. although the stomach is the second most common site for PJS polyps, gastric outlet obstruction due to gastro-gastric intussesception is extremely rare phenomena. such as in our patient who was admitted with gastric outlet obstruction.

Conclusion PJS with fundic polyp rarely presented as gastric outlet obstruction managed by laparoscopic gastrostomy + reduction of intussception + stapled partial gastrectomy.

References

1. Utsunomiya J, Gocho H, Miyanaga T, Hamaguchi E, Kashimure A. Peutz-Jeghers syndrome: its natural course and management. Johns Hopkins Med J. 1975; 136:71-82.

2. Shalaby S, Akbari K, Spilsbury C. Gastric outlet obstruction in Peutz-Jegher syndrome. Clin Surg. 2020; 5:2886

Keywords Gastric outlet obstruction, Hamartomatous polyp, Peutz-Jegher syndrome

055

Successful closure of bronchogastric fistula with Ovesco clips

Srikanth Reddy Keesari, Govind Verma, Sudhir Mysore, Dhiraj Agrawal

Correspondence – Dhiraj Agrawal - dhirajagrawal24@gmail.com

Department of Medical Gastroenterology, Pace Hospital, HUDA Techno Enclave, Hitech City, Hyderbad 500 081, India

Affiliation A bronchogastric fistulas are rare following transhiatal esophagectomy incidence less than 1% and incidence is higher following transthoracic esophagectomy 5.6% [1]. We present a case of 60 female presented with bronchogastric fistula following transhiatal esophgagectomy for carcinoma esophagus.

Introduction Bronchogastric fistula is a rare complication which occurs between the tracheobronchial tree and stomach in patients who undergo esophagogastric anastomoses. In the early postoperative period [2], the most likely cause of gastrobronchial fistula is dissection injury or post operative mediastinitis. When occur late, the commonest cause is tumor recurrence. others radiation necrosis and tracheobronchial erosion caused by the gastric staple line.

Case Report A 60-year-old female who underwent esophagectomy for carcinoma esophagus followed by chemoradiotherapy in October 2020. Came with cough on intake of food for last 2 years, which increases in supine position. Chest X-ray PA view showed gastric pull up and fibroatelectatic opacity in right mid zone. UGI endoscopy showing ulcer with fistulous opening at 30 cms from incisors. Bronchoscopy showing bronchogastric fistula in right middle bronchi. Endoscopic guided 12 mm Ovesco clips were applied over the fistulous opening. She tolerated oral food intake well after 2 days.

Discussion The management of gastrobronchial fistula following esophagectomy was not well defined. The options available are endobronchial stenting [2] which may not seal of fistula completely, surgical closure have high morbidity and endoscopic closure is new and safe approach.

Conclusion This is one of few reports on successful closure of gastrobronchial fistula using the OTSC-Ovesco clips. Therefore, this case highlights the use of a novel endoscopic approach as a safe and effective modality for bronchogastric fistula closure.

Reference

1. Dugan K, Frye L, Bronchogastric fistula a rare complication following transhiatal oesophagectomy. Chest J. 2017; 8: 903.

2. Dogan E, Turan N, Cobanogie U. American Journal of Cancer Prevention 2015.

Keywords Bronchogastric fistula, Esophagectomy, Ovesco clips

056

Congenital gastric diverticulum in antrum

Ramesh Avula , L R S Girinadh, Vamsi D Yadav

Correspondence - Ramesh Avula - ramesh1072m@yahoo.co.in

Department of Medical Gastroenterology, Andhra Medical College, Medical College Road King George Hospital, Opp. Collector Office, Maharani Peta, Visakhapatnam 530 002, India

Introduction Gastric diverticula are outpouchings of gastric wall. They are rare anatomical abnormalities with prevalence of 0.02% to 0.04%. They are usually found in fundus during routine endoscopy. We herein present a rare case of gastric diverticulum in prepyloric region.

Case Presentation A 40-year-old male patient presented with right upper quadrant pain for last 5 days, increasing postprandially. On evaluation, patient was found to have choledocholithiasis with cholelithiasis. No associated findings of cholecystitis were found. An endoscopic retrograde cholangiopancreatography guided bile duct stone retrieval was planned prior to cholecystectomy. Routine screening upper gastrointestinal endoscopy showed 3 cms x 3 cms gastric wall outpouching in the prepyloric area, associated with few erosions. Patient did not have any symptoms/signs of gastric outlet obstruction, suspicious ulcers or intraabdominal infections. Radiologic investigations did not reveal any adhesions around the diverticulum indicating it to be congenital in nature and unlikely to be the cause of present symptoms in the patient. Biopsy from diverticulum showed nonspecific inflammation. Hence, further treatment was directed towards gallstone disease and gastric diverticulum was managed conservatively.

Conclusion Gastric diverticula, least common type of gastrointestinal diverticula, are mostly congenital (70%) and usually found in fundus. Acquired gastric diverticula are usually found in antrum. Our patient had a congenital gastric diverticulum in antrum, an extremely rare finding. Most gastric diverticula can be managed conservatively like in this patient. However symptomatic large gastric diverticula might require surgical excision.

Keywords Acquired, Congenital, Gastric diverticulum, Gastrointestinal diverticula

057

A rare case report of mantle cell lymphoma presenting as a gastric growth

Harish Kulkarni, Sumit Kumar, Prafulla Kumar, Sai Krishna Katepally, P Shravan Kumar

Correspondence - Harish Kulkarni - drharishsk@gmail.com

Department of Medical Gastroenterology, Gandhi Medical College, Gandhi Hospital, Musheerabad, Padmarao Nagar, Secunderabad 500 003, India

The gastrointestinal (GI) tract is the most common site of extra nodal non-Hodgkin lymphoma (NHL), accounting for 20% to 40% of all extra nodal lymphomas [1]. Mantle cell lymphoma is a type of aggressive mature B cell non-Hodgkin lymphoma comprising 2% to10% of all adult NHL2. It can involve GI tract in 10% to 28% cases. Colon is the most involved site but both the upper and lower GI tract from the stomach to the colon can be involved.

Here we present a rare case of 75-year-old male presenting with dyspepsia and significant weight loss for 3 months. Endoscopy showed a proliferative growth in the antrum of the stomach, biopsy study showed atypical lymphoid proliferation and immunohistochemistry showed CD20-positive (+)/CD5+/cyclin D1+/CD23-negative which was suggestive of Mantle cell lymphoma. Patients with mantle cell lymphoma can be asymptomatic or present with abdominal pain, obstruction, diarrhea, or bleeding. A high index of suspicion is mandatory in elderly patients with GI symptoms. Standard treatment includes a regimen comprising of Rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Median overall survival is 5 to 7 years [3]. A recent study showed that 2-year overall survival rate is 92% and 85% for those younger and older than 65 respectively [4].

References

1. Peng JC, Zhong L, Ran ZH. Primary lymphomas in the gastrointestinal tract. J Dig Dis. 2015; 16:169–76.

2. Shah BD, Martin P, Sotomayor EM. Mantle cell lymphoma: a clinically heterogeneous disease in need of tailored approaches. Cancer Control. 2012; 19:227-35.

3. Leukemia and Lymphoma Society. Mantle Cell Lymphoma Facts. July 2012

4. Karmali R, Switchenko JM, Goyal S, et al. Multi-center analysis of practice patterns and outcomes of younger and older patients with mantle cell lymphoma in the rituximab era. Am J Hematol. 2021; 96:1374-84.

Keywords Mantle cell lymphoma, Non-Hodgkin lymphoma

058

Unusual gastric ulcers (mucormycosis and IgG4 disease related)

Sunil Raviraj Kothakota, Srinivas Nistala

Correspondence - Sunil Raviraj Kothakota - ksrdnb@gmail.com

Department of Gastroenterology, Medicover Hospital, MVP, Visakhapatnam 530 022, India

We would like to present two cases of gastric ulcers of unusual etiologies. The first patient was 45-year-old man, recovering from severe Corona virus disease – 19 (COVID-19) pneumonia presented with hematemesis. Upper gastrointestinal (GI) endoscopy showed two large necrotic ulcers in gastric fundus and antrum. Biopsy was taken and histopathology examination was suggestive of mucormycosis. He was managed with amphotericin B for two weeks followed by posoconazole for 4 weeks. Repeat endoscopy showed completely healed ulcer. The second case was 39-year-old man, presented with abdomen pain and jaundice. He was diagnosed as sclerosing cholangitis on basis of obstructive jaundice and magnetic resonance cholangiopancreatography (MRCP) findings. Gastroduodenoscopy was done, suggestive of malignant looking ulcers in gastric fundus and D2. Histopathology examination and immunohistochemistry (IHC) were suggestive of IgG4 disease. His serum IgG4 level was also on higher side. He improved well with steroid therapy.

Keywords Gastric mucormycosis, IgG4 disease

059

A rare case of primary gastric tuberculosis presenting as linitis plastica

Abhishek Pandey, Monika Jain, G S Lamba

Correspondence - Abhishek Pandey - abhishek86pandey@gmail.com

Department of Gastroenterology, Sri Balaji action Medical Institute, C6 New Multan Nagar, Near Paschim Vihar, New Delhi 110 056, India

Gastric tuberculosis is a rare disease and usually presents as gastric outlet obstruction. Other uncommon presentations include gastrointestinal bleed and gastric perforation.

A case of gastric tuberculosis presenting as linitis plastica is reported here.

A 35-year-old male patient presented with early satiety, anorexia, occasional vomiting, and weight loss of two months duration. Physical examination was essentially normal. Routine investigations including contrast-enhanced computed tomography (CECT) thorax were normal. CECT whole abdomen was done which showed thickness of wall of fundus, body and antrum of the stomach with luminal narrowing along with loss of normal mucosal pattern with multiple enlarged mesenteric lymph nodes, likely suggestive of Carcinoma Stomach- Linitis Plastica.

Upper gastrointestinal endoscopy (UGIE) revealed normal esophagus. Stomach showed diffuse involvement of mucosa, with decreased distensibility, fine granularity and friability of mucosa. Multiple gastric biopsies were taken, which showed acute-on-chronic inflammation, ulceration, dilated crypts, and a few crypt abscesses. Several discrete epithelioid cell granulomas with prominent Langhans giant cells were seen. There was no evidence of caseation. Acid-fast bacilli (AFB) staining was negative. Histological impression of granulomatous gastritis was made with the most likely etiology of tuberculosis.

Patient was initiated on standard 4 drug anti-tubercular therapy (ATT) regimen with advice to follow-up regularly. On the second monthly follow-up there was definite improvement in symptoms.

Patient had improved appetite. Symptoms of early satiety, post meal vomiting were significantly reduced. Patient had also gained weight. At 6 monthly follow-up after initiation of ATT, patient had complete resolution of symptoms. ATT was continued for total duration of 12 months. Upon completion of ATT, repeat UGIE was conducted which showed normal distensibility of stomach, normal nmucosa with normal mucosal thickness.

To conclude, tuberculosis is a endemic disease with high prevalence in India. Its rare presentation as Linitis Plastica on imaging and endoscopy is depicted in this case.

Keywords Gastric carcinoma, Gastric tuberculosis, Linitis Plastica

060

A big fish in a small pond - A rare case of autoimmune gastritis

Shruti Keyal, Shine Sadasivan, Manoj Unni, Roopa Paulose

Correspondence – Shine Sadasivan - drshinesivan21@gmail.com

Department of Gastroenterology, Amrita Institute of Medical Sciences, Peeliyadu Road, Ponekkara, Edappally, Ernakulam, Kochi 682 041, India

We present a case of a 57-year-old lady who presented initially with complaints of heat intolerance and weight loss, followed by complaints of tiredness and fatigue. Subsequently, 2 months later she developed complaints of dyspepsia, abdominal discomfort, and reflux.

Evaluation upon presentation was consistent with Grave’s disease and refractory anemia with B₁₂ deficiency. Further work up was carried out as anemia was refractory to nutritional supplementation. Upper gastrointestinal endoscopy showed features of corpus and funds restricted erythema and edema with thinning of the mucosal folds (Fig.1). Anti-parietal cell and anti-intrinsic factor antibodies were positive. Upper endoscopic biopsies taken as per gastric biopsy mapping protocol showed features of corpus and funds restricted chronic atrophic gastritis with intestinal metaplasia and antralization (Figs. 2, 3). With these findings, we confirmed a diagnosis of autoimmune gastritis (AIG). She was treated with B₁₂ and iron supplementation (oral and parenteral) and neomercazole and had significant clinical improvement upon follow-up.

AIG is an underestimated disease owing to unawareness and under-reporting. Inappropriate biopsy sampling, high number of asymptomatic cases and lack of clarity on the pathogenesis are some of the reasons why the recorded incidence of the disease is about 0.5% to 4% globally. Like with other autoimmune diseases, it very frequently co-exists with at least one other autoimmune illness, most commonly thyroid related (“thryo-gastric syndrome”). Also of concern, is the predisposition to develop gastric NET and gastric adenocarcinoma in about 4% to 12% of these patients.

To the best of our knowledge, there are no such reported cases of AIG from Indian subcontinent. A diagnostic delay is attributed to both physician and patient’s unawareness of AIG. We thus aim at highlighting the need for a proper case finding strategy and hope to attract more attention towards AIG to improve standard of care in our patients.

Keywords Atrophic gastritis, Autoimmune gastritis, H. pylori

061

A curious case of acute gastric dilatation in an infant

Zahabiya Nalwalla, Shivangi Tetarbe, Ruchi Mishra, Ira Shah

Correspondence - Zahabiya Nalwalla - zahabiya.nalwalla@gmail.com

Department of Pediatric Gastroenterology, Hepatology and Nutrition, Bai Jerbai Wadia Children's Hospital, Acharya Donde Marg, Parel East, Parel, Mumbai 400 012, India

Introduction Acute gastric dilatation is characterized by a gut-brain disconnection disorder leading to gradual atony and stretching of the gastric mucosa causing intestinal obstruction. We present a case of an infant with acute gastric dilatation requiring surgical intervention.

Case Report A 1-year-old infant presented with abdominal distension, intermittent abdominal pain and sensation of retching, but inability to vomit since 1 week. X-ray erect abdomen suggestive of gastric dilatation (Fig. 1). Ryle’s tube inserted and 1 liter fluid drained. Baseline investigations were normal. CT abdomen (Fig. 2) was suggestive of grossly over-distended stomach, left dome of diaphragm seems to be elevated by distended stomach. Focal defect 5 × 3.5 cm in posterior aspect of diaphragm. Malposition spleen along long axis of tail of pancreas. Suspected CDH (congenital diaphragmatic hernia) with volvulus. Patient was taken up for a gastropexy with left CDH repair. Child recovered and was discharged.

Discussion Acute gastric dilatation is commonly seen in children secondary after spine, abdominal or thoracic trauma, central or peripheral nervous system conditions such as bulimia and anorexia nervosa. Acute gastric dilatation associated with acute gastric volvulus as a late presentation of congenital diaphragmatic hernia is a rare presentation. An important sign is the sensation of retching but inability to vomit which is attributed to the occlusion of gastroesophageal junction by the distended stomach. Gastric decompression and immediate surgery helps halt the vascular congestion and ischemia.

Conclusion Acute gastric dilatation associated with acute gastric volvulus as a late presentation of congenital diaphragmatic hernia is a rare presentation. Abdominal distension with inability to vomit is a subtle symptom of acute gastric dilatation.

Keywords CDH, Dilatation, Gastric, Infant, Volvulus

062

Parietal cell carcinoma- A rare cause of gastric mass and upper gastrointestinal bleed

Sarthak Malik ¹ , Shreya Shruti², Kim Vaiphei³, Anupam Lal⁴, Jayanta Samanta¹, Saroj Kant Sinha¹

Correspondence - Saroj Kant Sinha - sarojksinha@hotmail.com

Departments of ¹Gastroenterology, ³Histopathology, and ⁴Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India, and ²Government Medical College and Hospital, Sector 32, Chandigarh 160 030, India

Case Presentation We present a case of parietal cell carcinoma presenting with melena and pain abdomen. A 57-year-old Indian male, known diabetic and reformed smoker/alcoholic presented with upper abdominal pain and generalized weakness for three months. He also reported passage of black tarry stools for 3–4 days, about 15 days back, following which he started having general weakness and easy fatigability. Physical examination showed pallor with normal abdominal examination. Investigations revealed hemoglobin to be 10 g/dL and peripheral blood film showed microcytic hypochromic anemia. Liver and renal function test were normal. Contrast-enhanced computed tomography scan of abdomen revealed arterial phase enhancing polypoidal lesion on greater curvature of the stomach. Esophagogastroduodenoscopy showed a six cm size ulcerated, friable mass in proximal body of stomach. Biopsies showed evidence of parietal cell carcinoma. The cells showed glandular arrangement, abundant granular eosinophilic cytoplasm, along with positive immunohistochemistry for pan-cytokeratin. Patient underwent exploratory laparotomy with total gastrectomy, distal pancreatectomy, splenectomy, Roux-en-Y esophagojejunostomy. He received adjuvant chemoradiotherapy. Patient recovered well and became asymptomatic.

Discussion Parietal cell carcinoma is a rare malignant tumor of stomach with a strikingly male (9:1) preponderance. It generally occurs in older males and runs a relatively indolent course. These well to moderately differentiated tumors are usually diagnosed by pathology. Lymph node and distant metastasis occur rarely, hence prognosis is generally favorable.

Conclusion Parietal cell carcinoma is rare cause of gastric mass and upper gastrointestinal bleeding. It is rarely considered in differential diagnosis clinically and diagnosis invariable emerges on histopathology.

Keywords GI bleed, Parietal cell carcinoma, Stomach cancer

063

It’s not malignancy, its menetrier’s !!!

Chitikeshwarapu Sai Kumar, Praveen Reddy Vasepalli

Correspondence – Praveen Reddy Vasepalli - drpraveenreddyv@gmail.com

Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Introduction Menetrier’s disease (MD) is a rare disease that was first described by the French pathologist Pierre Menetrier in 1888. is characterized by the huge expansion of the gastric mucosa, thick mucus secretion, protein loss, and hypochlorhydria [1].

Case Report A 41-year-old female presented with complaints of admitted with loss of appetite, loss of weight (8 kg in 2 months), progressive h/o postprandial vomiting since 2 months. H/o generalized swelling present and loose stools since 2 weeks. Examination showed mild pallor and pedal edema, puffy face. CBP, RFT were normal, LFT showed hypoproteinemia (1.6). INR was normal. Thyroid profile showed elevated TSH (69.3). 2D ECHO was normal. USG abdomen showed dilated stomach with significant thickening of walls of gastric mucosa extending from GE junction to pylorus of stomach and duodenum, thickening of mucosa in the colon from cecum to rectum. Contrast-enhanced computed tomography (CECT) abdomen was more in favor of malignancy? linitis plastica. UGI endoscopy showed grossly hypertrophy mucosal folds with poor distensibility in the body of stomach. Histopathology showed focal hyperplastic and hypermucinous changes, menetrier disease. Evalaution for H pylori was nagetive. Ilio colonoscopy showed edematous colonic mucosa with superficial erosions. Managed conservatively with NJ feeds and thyroxine. Triple regimen for H pylori. She improved symptomatically.

Conclusion Despite having strong clinical and radiological suspicion of malignancy, MD should be one of the differentials of the hypertrophied gastric mucosa with or without H. pylori or hypoalbuminemia.

References

1 Rich A, Toro TZ, Tanksley J, et al. Distinguishing Ménétrier's disease from its mimics. Gut. 2010; 59:1617-24.

Keywords Malignancy, Menetrier’s

064

A study of compliance with Helicobacter pylori eradication therapy in patients with Helicobacter pylori infection

Gauri Kumbhar, Sudipta Dhar Chowdhury, Ajith Thomas, Amit Kumar Dutta, Ebby George Simon, A J Joseph

Correspondence – Sudipta Dhar Chowdhury - sudiptadharchowdhury@gmail.com

Department of G.I. Sciences, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Compliance with therapy is the single most important factor in Helicobacter pylori (H. pylori) eradication which influences treatment failures and subsequent development of antibiotic resistance. The present study was done with an aim to study compliance with H. pylori eradication therapy (HPET) in patients with H. pylori infection.

Methods This was a prospective study conducted between June 2019 to August 2022 at a tertiary care centre in South India. Patients with H. pylori infection who were treated with HPET were interviewed using structured questionnaire. Baseline data as regards demographic variables, presenting symptoms, diagnostic methods of H. pylori infection, HPET regimen details, its side effects, and compliance was noted.

Results A total of 110 patients were included out of which 73 (66.4%) were males. The mean age was 41.39 (SD 12.91) years. Thirty-six (32.7%) patients had presented with postprandial fullness, another 36 (32.7%) had epigastric pain, 23 (20.9%) had epigastric burning whereas 12 (10.9%) had retrosternal burning sensation. H. pylori infection was diagnosed in 71 (64.5%) patients by histopathology, 30 (27.3%) with rapid urease test, and 9 (8.2%) using H. pylori stool antigen by ELISA. One hundred and seven (97.3%) patients were treated with Clarithromycin triple therapy, whereas the remaining three received Bismuth quadruple therapy. Forty-eight patients (43.6%) reported various side effects of HPET. Diarrhea (14.5%) was the most common side effect followed by nausea (10.9%), dysgeusia (10%), abdominal pain (8.2%), vomiting (4.5%), headache (3.6%) and skin rashes (2.1%). Fifteen (13.6%) patients discontinued the treatment owing to side effects. Amongst them, nausea (26%) and headache (26%) were the most common side effects. Majority of them (66.7%) discontinued HPET within three days of initiation while one patient took half the daily dose for two weeks.

Conclusions Side effects of HPET are very common and are the major cause leading to non-compliance. Further studies are warranted focusing on measures to improve compliance with HPET, to increase eradication rates, and reduce the emergence of resistance.

Keywords Compliance, Clarithromycin, Diarrhea, H. pylori eradication therapy, HPET, Side effects

065

Efficacy of clarithromycin based triple therapy for two weeks for eradication of Helicobacter pylori infection

Rajeeb Jaleel, Tintu Varghese

Correspondence – Rajeeb Jaleel - rajeeb80@yahoo.com

Department of Gastroenterology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Multiple regimens are used for treatment of H. pylori infection. Success of eradication depends on compliance of medications and antibiotic resistance data. Clarithromycin triple therapy is commonly used. We aim to assess the efficacy of this regimen in the current study.

Methodology This was a retrospective observational study among adult (>18 years) patients who had H. pylori eradication therapy for 14 days with clarithromycin 500 mg BD, Amoxycillin 1 gm BD and PPI BD. Patients who underwent testing to confirm eradication of infection after therapy were finally included. The clinical and investigation details were recorded. The test for eradication was based on H. pylori stool Antigen assay. Those with negative test considered to have successful eradication. This test was done in patients who were not taken PPIs for last 2 weeks. The proportion of patients with successful eradication of infection was the primary outcome of the study. stool Ag analysis

Results Sixty-two patients were included in this study. Their mean age of the study population was 42.6 year and 41 (74.1%) were Men. Initial H. pylori prior to starting antibiotic regimen was identified based on Gastroscopy biopsy in 36 (58.06%). Post HPET 39/62 (62.9%) of patients were positive for H. pylori stool Ag. In H. pylori non eradication group 32 (82.05%) and 19 (48.7%) were from eastern and southern part of India respectively. Indication for treatment PUD in 11/39 (28.2) in H. pylori eradication and 9/23 (39.1%) in non-eradication group. Amoxycillin, Clarithromycin and Pantoprazole for duration of 14 days was most common regimen used to treat H. pylori infection 60/62 (96.77%). Mean stool Ag level in patients who were stool Ag positive post HPET were 37.14 ng/mL.

Conclusion The failure of clarithromycin based triple therapy was present in significant number of patients with H. pylori infection. This necessitates rethinking of initial regimen of choice.

Keywords H. pylori eradication therapy, H. pylori stool antigen, Triple therapy

Small intestine

066

Prevalence of collagenous ileitis in microscopic colitis: A single-center experience

Kaushal Prasad, V Devraj, Saroj K Sinha, Uma Devi¹

Correspondence – Kaushal Prasad - kaushalkp10@hotmail.com

Departments of Gastroenterology and ¹Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Introduction Involvement of the terminal ileum (TI) in microscopic colitis (MC) rarely been systematically studied and prevalence of collagenous ileitis (CI) in MC is not reported. Aim of present study was to investigate the TI mucosal alterations and to determine the prevalence of CI in cases of MC.

Methods In this prospective study TI mucosa of 55 patients with MC (37 with lymphocytic colitis [LC: male/female ratio 2.7, median age 37 years] and 18 with collagenous colitis [CC: male/female ratio 1.6, median age 37 years]) were examined for TI mucosal alterations. Results were compared with 36 patients with ulcerative colitis (UC) as controls.

Results The TI mucosal biopsies revealed varied histologic pattern with normal mucosa in 5 (9%), intraepithelial lymphocytosis without crypt hyperplasia 24 (43.6%), intraepithelial lymphocytosis with crypt hyperplasia 14 (25.5%), villous atrophy 6 (11%), villous atrophy with CI 2 (3.6%) and CI without villous atrophy in 4 (7.3%) patients. Overall, 6 (10.9%) cases of MC were associated with CI. Out of 8 (14.5%) cases with primary ileal villous atrophy 6 were associated with LC and 2 were associated with CC and both had associated CI. All cases with LC revealed intraepithelial lymphocytosis and/or associated villous atrophy whereas 6 (33.3%) cases of CC were associated with CI.

Conclusions The TI is frequently involved in MC. Intraepithelial lymphocytosis, villous atrophy or CI may be helpful in diagnosing these conditions. Results suggest that the TI may be involved by a similar pathogenic process as the colon in LC and CC.

Keywords Biopsy, Collagenous ileitis, Ileum, Microscopic colitis,

067

A case of chronic diarrhea due to common variable immune deficiency related enteropathy

Ramesh Avula, L R S Girinadh, Vamsi D Yadav, Gangu Ghanashyam, Abhishek S Y

Correspondence - Ramesh Avula - ramesh1072m@yahoo.co.in

Department of Medical Gastroenterology, Andhra Medical College, Medical College Road, King George Hospital, opp. Collector Office, Maharani Peta, Visakhapatnam 530 002, India

Introduction Common variable immune deficiency (CVID), a form of primary immune deficiency disease (PIDD), is a disease presenting with recurrent sino-pulmonary infections in twenties and thirties with estimated prevalence of 1 in 25,000 to 50,000. CVID enteropathy is a phenotypic variant presenting with chronic diarrhea and weight loss. We present herein a rare patient of CVID enteropathy without any history of recurrent sino-pulmonary infections.

Case Presentation A 44-year-old male patient presented with complaints of chronic watery diarrhea and significant unintentional weight loss for last 18 months. Despite treatment with empirical antibiotics anti protozoals and anti diarrheals, he continued to have 10-12 large volume stools per day. On examination, he had severe sarcopenia, loss of subcutaneous fat and oedema. Investigations revealed anemia, hypoprotenemia (both serum albumin and globulin levels were decreased), hypocalcemia, decreased vitamin D levels and increased TSH (8.5 mIU/L). Stool routines were normal. Viral markers were negative. Upper GI endoscopy revealed chronic Helicobacter pylori related gastritis. Biopsy of second part of duodenum showed giardiasis. As patient did not improve on metronidazole, colonoscopy was done which showed few rectal ulcers. Blind biopsy of terminal ileum showed non-necrotizing granuloma. Anti-tTG was negative. Serum immunoglobulin levels were decreased (IgA 401 mg/dL, IgG <21 mg/dL, IgM <3 mg/dL). Absolute CD4 count was decreased (408/uL) and CD4/CD8 ratio reversed (0.34). Antibody levels for diphtheria and pertussis were decreased (non-protective). A diagnosis of CVID related enteropathy was made and patient was suggested treatment with intravenous immunoglobulins (IVIG) and repeat vaccination with killed vaccines.

Conclusion Our case demonstrates that CVID enteropathy should be considered a differential in chronic diarrheas with malabsorption features not responding to routine therapies even in the absence of recurrent sinopulmonary infections. Early diagnosis and treatment can improve the prognosis of the patient.

Keywords Chronic diarrhea, Common variable immune deficiency, Enteropathy, Giardiasis, Intestinal granuloma

068

Ileal stricture due to endometriosis – A case report

Varun Wagle , Sandeep Gopal, Suresh Shenoy, Anurag Shetty, G V Chaithra, Bailuru Vishwanath Tantry

Correspondence - Varun Wagle - varunwagle@yahoo.com

Department of Medical Gastroenterology, Kasturba Medical College Hospital, Ambedkar Circle, Mangalore, Manipal Academy of Higher Education, Manipal, India

Endometriosis is a benign disease which has been described in about 15% of premenopausal women with a peak incidence in the third and fourth decades of life [1]. It is characterized by presence of endometrial glands and stroma located in an extrauterine environment [2]. Although endometriosis is most commonly located in the pelvic cavity, the incidence of bowel involvement ranges from 3% to 37%, primarily in the sigmoid colon and the rectum [3]. Ileal involvement in endometriosis is quite rare with an incidence of only about 7.1% of all intestinal endometriosis cases [4]. Further, small bowel obstruction due to endometrial lesions is an extremely uncommon situation, representing only 0.7% of surgical procedures for endometriosis [5]. Here we present a case of a 34-year-old lady, known case of hypothyroidism, who presented with chief complaints of pain in abdomen, vomiting and constipation of one month duration. Baseline investigations revealed raised C-reactive protein. X-ray abdomen showed multiple air fluid levels. Contrast-enhanced computed tomography (CECT) abdomen was done which was suggestive of inflammatory thickening of terminal ileum. She underwent a colonoscopy which showed ileal obstruction beyond which the scope could not be negotiated. A diagnostic laparoscopy was done which showed dense adhesions in the terminal ileum with fibrotic stricture. Hence right hemicolectomy with ileo-ascending colon anastomosis was achieved surgically. The histopathological analysis of the excised terminal ileum and ileocecal valve was suggestive of ileocecal endometriosis. In this paper, we report this unusual presentation of endometriosis.

Keywords Endometriosis, Ileum, Stricture

069

An unusual cause of a refractory duodenal ulcer

Addagarla Varun, P Shravan Kumar, Sai Krishna Katepally, Tejaswini Tumma, Snehitha Nalluri

Correspondence - Addagarla Varun - prashantigainedy@gmail.com

Department of Medical Gastroenterology, Gandhi Medical College, Musheerabad, Padmarao Nagar, Secunderabad 500 003, India

A duodenal ulcer which does not respond to 6 weeks of proton pump inhibitor (PPI) therapy or 8 weeks of H2B therapy is termed a refractory duodenal ulcer. The common causes of a refractory duodenal ulcer include use of tobacco, alcohol, drugs (NSAIDS, Steroids), persistent H pylori infection. Rare causes include Zollinger-Ellison syndrome, malignancy, Crohn’s disease, mesenteric ischemia and atypical infections like Cytomegalovirus (CMV), syphilis, etc.

Here we present a case of a 75-year-old female who presented with dyspepsia and black tarry stools. Endoscopy revealed a Forrest class 1b ulcer in the first part of duodenum. Ulcer was managed with local adrenaline injection, hemoclip application and anti H pylori therapy. She was readmitted with symptoms of hematemesis after 8 weeks. Repeat endoscopy revealed persistent duodenal ulcer hence biopsy was taken which showed cells with high N/C ratio and salt and pepper appearance with suspicion of neuroendocrine tumor (NET), however immunohistochemistry (IHC) was negative for synaptophysin and chromogranin and positive for cytokeratin 7 and 20 and her gastrin levels were normal. Computed tomography (CT) abdomen revealed a lesion in the head of the pancreas with liver SOL and periportal lymph nodes. Ca 19-9 levels were 4307 U/L. endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) of the pancreatic mass revealed Pancreatic adenocarcinoma.

Pancreatic malignancy presenting as a GI bleed is rare (1.6% according to Wang et al.). Mechanisms include direct invasion (most common), splenic or portal vein invasion causing variceal bleed, bleeding from the pancreatic duct through the ampulla and pseudocyst with pseudoaneurysm formation. According to few recent case series' such cases have a poor prognosis with a 6-month survival rate of only 35%. Most cases are inoperable at presentation and only supportive therapy may be possible. There should be a high index of suspicion of malignancy in cases of refractory duodenal ulcers especially in the elderly.

Keywords GI bleed, Pancreatic adenocarcinoma, Refractory duodenal ulcer

070

Once in a blue moon: Brown bowel syndrome

Siddharth Shukla ¹ , Shreya Shruti², Anupam Lal³, Kaushal Kishore Prasad¹, Jayanta Samanta¹, Kim Vaiphei⁴, Saroj Kant Sinha¹

Correspondence - Saroj Kant Sinha - sarojksinha@hotmail.com

Departments of ¹Gastroenterology, ³Radiodiagnosis, and ⁴Histopathology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India, and ²Government Medical College and Hospital, Sector 32, Chandigarh 160 030, India

Background Evaluation of chronic diarrhea requires multiple investigations in stepwise manner yet the final diagnosis may remain elusive in 10% to 15% of case. Here we present a case of chronic diarrhea due to a rare cause.

Case Presentation A 29-year-old male with bloating, early satiety, and frequent stools for last 8 years. He reported loss of around 30 kg weight in the past 6-8 years. His physical examination showed gross emaciation and body mass index (BMI) of 11.75 kg/m². He had pallor, edema, and bradycardia with heart rate of 46–54 per minutes.

Investigations Blood investigations showed hemoglobin 8 gm%, total protein 4.8 gms with albumin 2.1 gms. Serum tissue transglutaminase antibody was negative. Contrast enhanced computed tomography showed multifocal symmetric mural thickening involving short segment of small bowel with proximal dilatation and mild thickening of ileocecal junction. Barium meal-follow through and enteroclysis corroborated these findings. Colonoscopy and upper gastrointestinal endoscopy were normal. Diagnosis of Crohn’s disease was considered and oral prednisolone and mesalamine were started. He continued to be symptomatic over next two years. Laparotomy showed multiple dilated small bowel loops and no stricture. Ileal biopsy showed lipofuscinosis.

Diagnosis The final diagnosis was confirmed to be brown bowel syndrome. Patient was then started on vitamin E, multivitamins, antioxidants and mesalamine.

Discussion Intestinal lipofuscinosis is a rare disorder that presents as brown pigmentation, occasionally with bowel dilatation and pseudo-obstruction. It co-exists with malabsorption of fat-soluble vitamins, especially vitamin-E. Pathologically, mitochondrial malfunction and degeneration lead to lipofuscin deposition followed by smooth muscle mitochondrial myopathy. Clinical features show motility disorders along with malabsorption features. Treatment involves treating the underlying cause and early initiation of vitamin-E supplementation.

Conclusion We report a rare intestinal disorder, brown bowel syndrome, characterized by the deposition of lipofuscin in the intestinal cells following chronic malabsorption syndrome and vitamin E deficiency.

Keywords Brown bowel syndrome, Chronic diarrhea

071

A case series of eosinophilic gastroenteritis

Jasmeet Singh Dhingra , Nirmaljit Singh Malhi, Rajiv Grover, Achal Garg

Correspondence – Jasmeet Singh Dhingra - doctorjasmeet@gmail.com

Department of Gastroenterology, Advanced Gastroenterology Institute-The Gastrociti, Ludhiana Road, Vth Floor, Orison Hospital, Barewal Road, Ludhiana 141 008, India

Introduction Eosinophilic gastroenteritis (EG) is an inflammatory disorder of the gastrointestinal (GI) tract due to infiltration of bowel wall layers with eosinophils and associated inflammatory changes. The aim of this study is to describe clinical characteristics and treatment response in a series of EG patients from Iran.

Methods This is a retrospective study of all patients diagnosed with eosinophilic gastroenteritis at Advanced Gastroenterology Institute: AGI The GASTROCITI in Ludhiana for a 30-month period from February 2020 to July 2022. Cases were identified using the Department of Endoscopy database. Data were obtained from medical records that included clinical manifestation, endoscopic findings, and histopathological features.

Results Three patients with EG were identified during 30 month period. Two were males and one female. Mean age of the patients was 30 years (ages: 24, 30 and 36). Median duration between symptom onset and diagnosis was 6 (range 3- 9) months. All patients had mucosal involvement in form of ileocolonic ulcers with biopsy specimen showing > 30 eosinophils/HPF. One had subserosal involvement also as diagnosed with bowel wall thickening on CT enterography. All patients had peripheral eosinophilia with mean eosinophil counts approx. 1100. Patients were followed for a median duration of 5 (range 3-12) months. Two patients had remission with oral budesonide treatment and one patient required systemic steroids for response. The relapse rate was 33% as one patient had repeat symptoms 3 months after stopping therapy. Episode of relapse was successfully controlled with a repeat course of corticosteroids.

Conclusion Clinical characteristics and treatment responses of EG patients are variable. Patients need to undergo close follow-up after treatment to detect early signs of relapse.

Keywords Eosinophilic bowel disorder, Eosinophilic enteritis

072

A peculiar endoscopic appearance of duodenal diverticulosis with unusual presentation of iron deficiency anemia

Brij S, Bilal Mir, Rajesh Sharma, Tahir Majeed

Correspondence - Bilal Mir - mir13bilal@gmail.com

Department of Gastroenterology, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India

Background A duodenal diverticulum is commonly encountered in clinical practice and can be found incidentally in 23% of normal people undergoing imaging. Most duodenal diverticulosis is found at the second or third part of duodenum, around the ampulla of Vater with a reported incidence of 67%. In the majority of cases, they are completely asymptomatic and only 5% of patients develop symptoms related to diverticular complications. Duodenal diverticula presenting as iron deficiency anemia (IDA) is rare entity.

Case Report We reported an unusual case of duodenal diverticulosis presenting as iron deficiency anemia. A 50-year-old female with no underlying comorbidity was admitted for evaluation of anemia with a hemoglobin of 9.2 gm/dL. She denied any history of non-steroidal anti-inflammatory drugs and obvious blood loss. Her physical examination revealed thin built, conjunctival pallor. Her baseline blood work was unremarkable except for hypochromic microcytic anemia. Her iron profile was suggestive of IDA, and stool for occult blood was negative. Subsequently she was planned for gastrointestinal endoscopic examination for further evaluation. Her upper endoscopy revealed normal esophagus, stomach, first part of duodenum, and showed the presence of multiple periampullary adjacent diverticula in 2nd part of duodenum with a peculiar ‘net like’ appearance with normal overlying mucosa. Her colonoscopy was normal, and CT enterography revealed findings suggestive of duodenal diverticula. IDA was attributed to duodenal diverticulosis given the extensive duodenal luminal and mucosal deformity and possible iron malabsorption. Conclusion The present case emphasizes upon the varied and rare presentation of a predominantly asymptomatic condition like duodenal diverticula and the diagnosis should not be disregarded while evaluating unexplained IDA.

Keywords Duodenal diverticula, Endoscopy, Iron deficiency anemia,

073

Endoscopic resection of foregut neuroendocrine tumors

Ajay B R, Varun Kesar, Jaseem Ansari, Mangesh Borker, Sanjana Bhagawat, Yash Kanani, Rajendra Pujari, Harshal Gadhikar, Amol Bapaye

Correspondence – Amol Bapaye - amolbapaye@gmail.com

Department of Gastroenterology, Deenanath Mangeshkar Hospital, Deenanath Mangeshkar Hospital Road, Erandwane, Pune 411 004, India

Introduction Carcinoids, a type of neuroendocrine neoplasm most commonly found in the pulmonary and gastrointestinal system. Neuroendocrine tumors (NETs) arise from enterochromaffin cells [1]. Endoscopic resection is now gaining prominence over surgery, traditionally considered the treatment of choice [2]. We aimed to analyze the outcomes of endoscopic management (EMR/ESD/EFTR) of foregut (stomach/duodenum) NET given limited published evidence.

Methods Retrospective analysis of 52 patients who underwent endoscopic resection of histologically confirmed Foregut NET at Deenanath Mangeshkar Hospital (DMH), Pune (tertiary hospital) over a period of 10 years (August 01, 2012 to July 31, 2022).

Results Average age of presentation-58.75 years (range 33-82 y). Total of 84 NETs in 52 (M-38, F-14) patients. Location- First part of duodenum (n=59), second part of duodenum (n=17) and stomach (n=8). Presentation-six as carcinoid syndrome (chronic diarrhea and weight loss) and rest incidental. Macroscopically all were sub mucosal lesions. Average size -11.7 mm (range 7-50 mm). Layer of origin on EUS-Sub-mucosa (3 indenting muscularis propria) Pre-op histopathology of all lesions-NET. None had metastatic disease on imaging (CECT/DOTA). Resection was done by ESD (36), Band EMR (20), EMR (10), EFTR (9), Hybrid ESD (6) Cap EMR (3). Average procedure time-74 mins (range:40-220 mins) Adverse events-8 ESDs (muscle defect) and 1 EMR (bleeding) all managed endoscopically. 64 lesions removed En Bloc and had tumor free margins (Rest 20 underwent Band EMR). Histologically 57 lesions-NET G1 and 7 -NET G2. Median follow-up-18 months (range 1-94 mo). All had complete healing but 3 patients had new lesions-one resected by FTRD and 2 lost to follow-up.

Conclusion Endoscopic management appears safe and effective for management of small foregut NETs with no recurrence. Further large studies are needed to validate our data.

References

1. Kulke MH, Mayer RJ. Carcinoid tumors. N Engl J Med. 1999; 340:858-68.

2. Fujishiro M, Yahagi N, Nakamura M, et al. Successful outcomes of a novel endoscopic treatment for GI tumors. Gastrointest Endosc. 2006,63:243-9.

Keywords Endoscopic resection, Foregut NET

074

A rare case of primary squamous cell carcinoma of duodenum

Shiv Pathak, Sandip Pal

Correspondence – Shiv Pathak - drshivpathak@gmail.com

Department of Gastroenterology, NH-R N Tagore Hospital, Premises No: 1489, Mukundapur Main Road, 124, Eastern Metropolitan Bypass, Mukundapur, Kolkata 700 099, India

Primary malignancies of small intestine are itself rare and maximum cases are of adenocarcinoma in type arising in 2nd part of duodenum. We report here a primary malignancy of 1st part of duodenum of squamous cell carcinoma type and that too growing circumferentially causing gastric outlet obstruction.

Keywords Duodenum, Squamous cell cancer

075

Opioid enteropathy: A common cause of ulceroconstrictive disease of bowel in western Rajasthan

Pranav S Kumar, Chhagan Lal Birda, Taruna Yadav, Binit Sureka, Ashish Agarwal

Correspondence – Ashish Agarwal - drashu123@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India

Introduction Opium addiction is common in western Rajasthan. Opioid-induced bowel dysfunction and narcotic bowel syndrome are well-described gastrointestinal (GI) disorders in patients with opioid abuse. We describe patients with long-term opium addiction presenting with ulceroconstrictive disease of the GI tract (GIT).

Methods We performed a retrospective review of prospectively maintained records of patients with opioid addiction who were diagnosed with opioid enteropathy in the Gastroenterology Department at All India Institute of Medical Sciences, Jodhpur, Rajasthan between July 2021 and June 2022. Opioid enteropathy was diagnosed in patients where all the other possible causes of ulceroconstrictive disease of the bowel were excluded by meticulous evaluation.

Results Twelve patients (mean age: 53.5±6.9 years; 10/11 [90.9%] males) with opioid addiction were diagnosed with opioid enteropathy. The median duration of opioid consumption was 20 (IQR:10-25) years. N=4/11 (36.4%) consumed opium, while n=7/11 (63.6%) consumed opium husk (doda) with the median expenditure of 4000 (IQR: 3000-7000) Rs. per month for opioid purchase. Common symptoms were pain abdomen (100%), slow transit constipation (45.5%), gola formation (45.5%), weight loss (81.8%) and loss of appetite (72.7%). On evaluation, patients had iron deficiency anemia (90.9%), hypoalbuminemia (72.7%), positive stool occult blood (54.6%) with ESR (90.9%) and CRP levels (90.9%). Endoscopy was normal in 81.8% of patients, while pyloric and duodenal stricture and ileocecal valve stricture were found in 1 patient (9.1%) each. Contrast-enhanced computed tomography (CECT) enterography showed multiple short segment jejunal and ileal strictures in 100% of patients. Conservative management with opioid deaddiction, iron supplements, rifaximin and laxatives was done in all patients with endoscopic balloon dilatation of pyloric stricture needed in one patient. Only 5 patients agreed and could undergo successful opioid deaddiction.

Conclusion Long-term addiction to high-dose opium can lead to ulceroconstrictive disease of the GIT. Considering the high prevalence of opium addiction, there is a need to recognize this entity and encourage opium deaddiction.

Keywords Enteropathy, Inflammatory bowel disease, Opium, Strictures, Ulceration, ulceroconstrictive disease

076

A rare case of chronic diarrhea due to eosinophilic enterocolitis with coexisting eosinophilic esophagitis

Ramesh Reddy Avula, L R S Girinadh, Vamsi D Yadav

Correspondence - Ramesh Reddy Avula - ramesh1072m@yahoo.co.in

Department of Medical Gastroenterology, Andhra Medical College, Kukatpally 500 072, India

Introduction Eosinophilic gastrointestinal disorders (EGID) is a rare spectrum of disorders including eosinophilic esophagitis (EOE), eosinophilic gastroenteritis (EGE) and eosinophilic colitis (EC). Around 10% of patients with EGE and EC also have esophageal involvement. We intend to report an extremely rare case of EGID involving esophagus, small intestine and large intestine simultaneously.

Case Presentation A 38-year-old male patient presented with chronic diarrhea, abdominal pain and unquantified weight loss for last 2 months not improving with routine empirical treatment with antibiotics, anti-protozoals and anti-diarrheals. Endoscopy revealed erosions in stomach, duodenum, terminal ileum and proximal colon. Biopsy revealed eosinophilic infiltration in esophagus, terminal ileum and proximal colon. contrast-enhanced computed tomography (CECT) showed multiple skip areas of short and long segment circumferential mural thickening with enhancement in the jejunum and ileal loops in upper mid and lower abdomen causing mild luminal narrowing with pelvic ascites indicating involvement of muscular and probably serosal layer to a lesser degree (absence of obstructive symptoms with minimal ascites) along with predominant mucosal involvement (responsible for clinical symptoms). Patient was treated with elimination diet, systemic corticosteroids and monteleukast. Diarrheal episodes decreased, steroids were tapered after two weeks and shifted to oral budesonide.

Conclusion There is scant data on simultaneous involvement of different segments of gut in EGIDs. Most commonly, esophagus has shown to be involved with eosinophilic gastroenteritis and eosinophilic colitis. We believe it to be one of the first reports to show a simultaneous involvement of esophagus, small intestine, and large intestine along with mucosal and mural involvement. Patient’s symptoms were attributed to predominant small intestinal mucosal involvement. It strengthens the fact that a common underlying pathogenesis causes EGIDs, suggests some degree of underlying muscular layer involvement in patients with predominant mucosal disease and that oral budesonide may be used to successfully treat the disease with minimal systemic adverse effects.

Keywords Eosinophilic gastroenteritis, Eosinophilic gastrointestinal disorders, Streroids

077

A rare case of primary sclerosing cholangitis with celiac disease – Fact or fancy?

Vikas Bharti , Animesh Shah, Prabha Sawant

Correspondence – Vikas Bharti - vikas.bharti12691@gmail.com

Department of Gastroenterology, Gleneagles Global Hospital, 35, Dr Ernest Borges Road, Parel East, Parel, Mumbai 400 012, India

A 50-year-old male, known case of primary sclerosing cholangitis (PSC) since last 5 years, asymptomatic and on treatment Tab. Ursodeoxycholic acid 300 mg TDS, now presented with chronic small bowel diarrhea since last 5 months with weight loss and malabsorption syndrome. Diagnosed with celiac disease (CD) based on serology and histology. Patient did not have associated inflammatory bowel disease (IBD). On endoscopic ultrasound (EUS) patient was found to have a large gallbladder polyp. Patient was started on gluten-free diet (GFD) in view of CD and had significant improvement in diarrhea and weight gain. Though asymptomatic for PSC his liver biochemistries remained unchanged in spite of GFD. Currently patient is better and on follow up for PSC.

Conclusion CD has been found in 2% to 3% of patients with PSC therefore it should be considered as a differential in patients with PSC having malabsorption syndrome. The relationship between the two diseases remains unknown, although an immunologic connection is suspected.

Keywords CD, HLA, PSC

078

Indian national biorepository of well-phenotyped cohort of patients with celiac disease

Alka Kumari ¹ , Sanjay Kumar ² , Divya Sharma ³ , Kunj Bihari Gupta ¹ , Sachin Rajpoot ¹ , Anam Ahmed ¹ , Sushil Falodia ³ , Saroj Kant Sinha ² , Rakesh Kochhar ² , B S Ramakrishna ⁴ , Vineet Ahuja ¹ , Govind K Makharia ¹

Correspondence – Govind K Makharia - govindmakharia@gmail.com

¹Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, ²Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India, ³Department of Medicine, Sardar Patel Medical College, S P Medical College Road, P B M Hospital, Bikaner 334 001, India, and ⁴Department of Gastroenterology, SRM Institutes for Medical Science, Vadapalani, Chennai 600 026, India

Objective There are several fundamental questions that needs exploration using animal models, cell-culture system, and biological material of well-phenotyped longitudinally followed patients with celiac disease (CeD). With support of Department of Biotechnology, we established a national celiac disease-specific biorepository.

Methods The diagnosis of CeD is being made on the standard criteria using standard Indian guidelines. Biological materials including blood (serum, plasma, DNA), duodenal biopsies (blocks, RNA, DNA, microbiome), urine and stool samples in multiple aliquots are being collected and labelled in a way that could survive all potential storage conditions. The samples were maintained and distributed to central biorepository through laboratory information management system (LIMS). Specimens are labelled with a unique number (human-readable forms of barcode), providing a direct link to protected database software including compliance with data privacy.

Results This is an ongoing activity and between September 2017 and March 2022, we have recruited 363 biopsy-proven treatment-naïve patients with CeD and (47 six-months post gluten-free diet), first-degree relatives of CeD (n=135) and controls (n=83). Fasting blood samples (10-12 mL) (separated as serum, plasma and whole blood and aliquoted), stool, urine, and duodenal mucosal biopsies (10-12 peices for RNA, DNA, proteomics, metagenomics etc.) have been collected and stored. Overall, 8148 aliquots of various biological material from 628 subjects has been stored in the biorepository including 12-13 aliquots per patient. We plan to continue recruiting patients and nurture the biorepository.

Conclusion Our national biorepository is likely to be useful for exploring many fundamental questions related with celiac disease.

Keywords Biobank, Gluten, Laboratory information management system, Storage

079

Diagnostic characteristics of anti-endomysial antibody in the diagnosis of celiac disease

Alka Kumari ¹ , Aditya V Pachisia ¹ , Rimlee Dutt ² , Kunj Bihari Gupta ¹ , Sanjay Kumar ³ , Divya Sharma ⁴ , Anam Ahmed ¹ , Vignesh Dwarkanath ⁵ , Prasenjit Das ² , Sushil Falodia ⁵ , Saroj Kant Sinha ¹ , Vineet Ahuja ¹ , Govind K Makharia ¹

Correspondence – Govind K Makharia - govindmakharia@gmail.com

Departments of ¹Gastroenterology and Human Nutrition, ²Pathology, and ⁵Community Medicine, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, ³Department of Gastroenterology, Post graduate Institute of Medical Education and Research, Chandigarh 160 012, India, and ⁴Department of Medicine, Sardar Patel Medical College, S P Medical College Road, PBM Hospital, Bikaner 334 001, India

Background The systematic review and meta-analysis has shown the sensitivity and specificity of anti-endomysial antibody (AEA) in adults to be 88% and 99.6, respectively for the diagnosis of celiac disease (CeD). In our clinical experience, we also found a relatively lower sensitivity of AEA. We prospectively evaluated the diagnostic accuracy of AEA.

Methods In a prospective study, we tested the AEA in patients with CeD who were recruited under an Indian National CeD Biorepository. The gold standard for the diagnosis of CeD was a combination of positive anti-tissue transglutaminase antibody (TG2) and presence of villous abnormalities of modified Marsh grade 2 or more. AEA was detected using immunofluorescence-based assay (Inova Diagnostic IFA kit, USA). The sample size to test the sensitivity and specificity of AEA was 277 and 93 respectively. Patients suspected to have CeD, with negative TG2 were taken as controls. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio (LR) were calculated.

Results Mean fold rise in TG2 titer in treatment-naive patients with CeD was 11.04±7.58 U/mL. The AEA was positive only in 50.9% (141 of 277) patients with CeD and 2 of 93 (2.15) % controls. The sensitivity, specificity, PPV and NPV were 52%, 98%, 98.6% and 42.7%, respectively. Diagnostic odds ratio, positive LR and negative LR for AEA were 52.6, 26 and 0.49, respectively.

Conclusion Only half of Indian adult patients with CeD have AEA positive. If positive, it has high specificity, diagnostic odds ratio, and positive predictive value.

Keywords Anti-tissue transglutaminase antibody, Biorepository, Diagnostic accuracy

080

Role of mycobacteria growth indicator tube and Xpert mycobacterium tuberculosis tests in diagnosing intestinal tuberculosis

Hemanth Chinthala ¹ , Polavarapu Jagadish ¹ , Joy Sarojini Michael ² , Lalji Patel ¹ , Shaleen Dass ³ , Ajith Thomas ¹ , Anoop John ¹ , Reuben Thomas Kurian ¹ , Rajeeb Jaleel ¹ , Sudipta Dhar Chowdhury ¹ , Ebby George Simon ¹ , A J Joseph ¹ , Anna Pulimood ⁴ , Amit Kumar Dutta ¹

Correspondence – Amit Kumar Dutta - akdutta@cmcvellore.ac.in

Departments of ¹Clinical Gastroenterology and Hepatology, ²Microbiology, ⁴Pathology, ³Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Newer microbiological diagnostic tests like mycobacteria growth indicator tube (MGIT) (culture for mycobacterium tuberculosis [MTB] and gene Xpert test (molecular test for detecting MTB) have been found to be useful in diagnosing pulmonary tuberculosis. However, their role in diagnosing intestinal tuberculosis (ITB) is less well studied. We aimed to study the utility of these tests in the diagnosis of ITB.

Methods In this retrospective study, we evaluated the case records of patients with diagnosis of ITB. The disease was in the small and/or large intestine in all the cases. The lesions were detected on colonoscopy or enteroscopy and sample was sent for histopathology and microbiological tests MGIT/Xpert. Clinical details, histopathology findings along with MGIT and Xpert test results were recorded. Final diagnosis of ITB was based on presence of histopathology findings or positive culture or presence of extraintestinal tuberculosis or response to ATT. Diagnostic yield of MGIT and Xpert tests were calculated.

Results Forty patients with a final diagnosis of ITB were included. Their mean age was 37.1+13.4 years and 30 (70%) were males. Median duration of symptoms was 4 months (IQR, 2-11.3 months). Abdominal pain (80%) was the commonest symptom. Fever was noted in 37.5% and diarrhea in 17.5% cases. MGIT culture was positive in 5 (12.5%) cases. Xpert test was positive in two of the five cases with positive MGIT culture report. Another patient had Xpert positive, but MGIT culture was negative. The sensitivity of MGIT culture was 12.5% and Xpert was 7.5%. The combined sensitivity of MGIT and Xpert test was 15%.

Conclusion Newer microbiological tests (MGIT, Xpert) help in the diagnosis of about one-sixth of cases with ITB. The faster availability of results compared to conventional culture is the key advantage but due to the paucibacillary nature of ITB, their yield is quite low.

Keywords Intestinal tuberculosis (ITB), Mycobacteria growth indicator tube (MGIT) test, Xpert

081

Duodeno-duodenal intussusception in a patient with chronic pancreatitis

Srikanth Kothalkar , Akash Mathur, Anshuman Elhence ^* , Uday C Ghoshal

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India, ^*All India Institute of Medical Sciences, Gate No, 1, Great Eastern Road, AIIMS Campus, Tatibandh, Raipur 492 099, India

Introduction Duodeno-duodenal intussusception, characterized by distal invagination of a segment of the duodenum into the duodenum itself, is rare because of the retroperitoneal fixation of the duodenum. We present a case of duodeno-duodenal intussusception in a patient with chronic pancreatitis.

Case Presentation A 53-year-old female with chronic pancreatitis underwent a Frey's procedure along with lateral pancreaticojejunostomy (LPJ) in 2016. However, four years after the surgery, she developed a lower common bile duct (CBD) stricture and was on endotherapy for the same. On presentation, she had recurrent post-meal bilious vomiting, approximately 15 bouts a day, loss of appetite, retrosternal burning sensation and a localized abdomen swelling. On examination, she had epigastric fullness with a BMI of 14.7 Kg/m². Esophagogastroduodenoscopy (EGD) showed mucosal invagination in the first part of the duodenum, suggestive of duodeno-duodenal intussusception, and the scope was negotiated across with difficulty into the second part of the duodenum (Fig. 1A, B and C). A triphasic computerized tomography (CT) scan showed CBD stents in situ, atrophic pancreas and an ill-defined soft tissue in the region of the pancreatic head; also, the duodenum was thickened with doudeno-duodenal intussusception with upstream dilatation of the stomach (Fig. 1D). Tumor marker CA 19-9 was >1200 U/mL (normal 0-37 U/mL). For gastric outlet obstruction due to duodenal intussusception, a nasojejunal tube (NJ) was placed to maintain nutrition. Given the high suspicion of pancreatic malignancy and duodeno-duodenal intussusception, definitive surgical management was planned.

Conclusion This case highlights that duodeno-duodenal intussusception should always be thought of as a cause of gastric outlet obstruction, especially in a patient with post-surgical status and typical endoscopic findings.

Keywords Duodenum, Esophagogastroduodenoscopy, Lateral pancreaticojejunostomy

082

Celiac disease associated with non-cirrhotic portal fibrosis: A case series of three cases

Sayan Malakar , Akash Mathur, Uday C Ghoshal

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Introduction Celiac disease (CeD) is known to be associated with portal hypertension as it has been described with chronic liver disease, Budd-Chiari syndrome, and non-cirrhotic portal fibrosis (NCPF). This is the third case series revealing the association between CeD and NCPF.

Results Three patients (all females, median age of 24.67 years ranging from 17-27 years) were evaluated based on their symptoms. On evaluation, they had iron deficiency anemia and other features of malabsorption. So, they were investigated accordingly. The patients were diagnosed with CeD, based on high anti-tissue transglutaminase antibody titer and duodenal biopsy. On ultrasonography, they had splenomegaly and dilated portal veins without any evidence of chronic liver disease and ascites. Two patients revealed small esophagal varices on upper gastrointestinal endoscopy. The possibility of NCPF was kept. Two patients underwent hepatic venous pressure gradient (HVPG) measurement and transjugular liver biopsies. The mean HVPG was 7.5 mmHg. All the other alternative etiologies were ruled out. On liver biopsy, there was no evidence of chronic liver disease or cirrhosis consistent with NCPF according to the Asia Pacific Association for the Study of Liver (APASL) criteria. They were started on a gluten-free diet (GFD). On follow-up patients’ symptoms, hemoglobin and weight improved after strict adherence to GFD.

Conclusion Association between liver diseases and CeD is well known. The presence of splenomegaly in patients with CeD should prompt clinicians to look for NCPF.

Keywords Celiac disease, Gluten-free diet, Non-cirrhotic portal fibrosis, Splenomegaly

083

Spot stool a1 antitrypsin/elastase ratio as a marker of protein losing enteropathy

Anoop John , Ajith Thomas, Rajeeb Jaleel, Reuben Kurien, Sudipta Chowdhury, Amit Dutta, Ebby Simon, A J Joseph, Gagandeep Kang, K A Balasubramanian, Dilip Abraham, Julie Hephzibah, Junita John

Correspondence – A J Joseph - johny316@gmail.com

Department of Gastroenterology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Diagnosis of protein losing enteropathy (PLE) is most commonly based on the determination of fecal α1 antitrypsin clearance, which is a cumbersome and time-consuming procedure. The aim of the study was to investigate whether spot stool α1 antitrypsin/elastase ratio can be used as a substitute marker in screening patients for PLE.

Methods Patients aged more than 1 year who were suspected as having PLE over a period of 3 years from October 2016 to September 2019 were included. Patient’s stool sample was tested for fecal alpha 1 antitrypsin and elastase by a standard ELISA assay. The patients were given three days of oral Lansoprazole prior to the day of the test and would be asked to take 50 grams of butter daily for three days prior. The study was approved by the Institutional Review Board (IRB No. 10253).

Results Over the study period, 33 patients underwent a scintigraphy scan and the diagnosis was confirmed in 20 patients (60%) with a positive scan. Among the positive patients, median age was 34 years (range: 3-69 years) and 7 (35%) were female. Median serum protein and albumin was 4 g/dL and 1.6 g/dL respectively. The cause of the protein loss were Crohn’s disease 5 (25%), intestinal lymphangiectasia (3), abdominal tuberculosis (2), celiac disease (1), SLE (1), Cronkhite-Canada syndrome (CCS) (1), congestive enteropathy (1) and idiopathic (6). Spot α1 antitrypsin had AUROC of 0.79 for diagnosing PLE and for a cut-off of 0.846 mg/g, sensitivity was 85%, specificity was 70%, compared to AUROC for spot stool α1 antitrypsin/ elastase ratio of 0.78 and for a cut-off of 0.01 mg/g the sensitivity was 85%, specificity was 70%.

Conclusion Spot stool α1 antitrypsin/elastase ratio was comparable to spot stool α1 antitrypsin as screening test for diagnosing protein losing enteropathy.

Keywords a1 antitrypsin, Protein losing enteropathy, Scintigraphy

084

Study of association between duodenal eosinophilia with functional dyspepsia and its subtypes

Mrinal Gogoi, Haribhakti Seba Das, Chittaranjan Panda, Prajna Anirvan, Pankaj Barali, Buddhi Prakash Meena, Padmalochan Prusty, Samir Kumar Hota

Correspondence – Mrinal Gogoi - drmrinalgogoi@gmail.com

Department of Gastroenterology, Srirama Chandra Bhanja Medical College, Behera Colony, Mangalabag, Cuttack 753 001, India

Background Functional dyspepsia (FD) is a chronic GI disorder with no structural disease. Increased duodenal eosinophilia has been linked to FD worldwide.

Aims and Objectives Study the association of duodenal eosinophilia with functional dyspepsia and its subtypes.

Methods An observational study between January 2020 to December 2021. Detailed clinical information, investigation reports, were collected from all patients diagnosed with functional dyspepsia and were included in the study after considering inclusion and exclusion criteria. Biopsy specimens were collected from the distal esophagus, gastric body, duodenal bulb, and the second portion of the duodenum.

Results Seventy-six patients with FD were included in the study among them 41 and 35 patients fulfilled the criteria for epigastric pain syndrome and postprandial distress syndrome respectively as per ROME IV criteria. Mean tissue eosinophil count in the duodenal bulb and D2 was higher than stomach and esophagus. In the duodenal bulb, 20 (26.3%) patients had a high eosinophil count and 32 (42.1%) patients were in the D2. Overall, 44.7% of patients had either duodenal bulb or D2 eosinophilia or combined duodenal bulb and D2 tissue eosinophilia. 29.3% and 31.7% of EPS patients have increased tissue eosinophils at the duodenal bulb and D2 respectively. 29.3% and 31.7% of PDS patients had increased tissue eosinophils in the duodenal bulb and D2 respectively. There is no statistically significant difference in mean tissue eosinophil count in EPS and PDS patients both at duodenal bulb and D2. On multivariate analysis, BMI, High AEC, PPI use, NSAIDs use, and dietary pattern were not associated with increased duodenal eosinophil count.

Discussion In our study mean tissue eosinophil count in the duodenal bulb and D2 was higher than stomach and esophagus. No significant association was found between duodenal eosinophilia with the dietary pattern, BMI, blood absolute eosinophil count, NSAIDs, and PPI intake.

Keywords Duodenal eosinophilia, Functional dyspepsia,

085

Use of a gastroscope for distal duodenal stent placement in patients with malignant obstruction

Saurabh Gaur , Komal Kalla, Mukesh Kalla, Ramesh Roop Rai, Pankaj Shrimal, Nikhil Atoliya, Anant Gupta, Vinayak Kalla, Sumit Patter, Suresh Kumawat, Shreyansh Jain

Correspondence – Saurabh Gaur saurabhgaur64@yahoo.in

Department of Medical Gastroenterology, S R Kalla Memorial Gastro and General Hospital, 78-79, Dhuleshwar Garden, C Scheme, Jaipur 302 001, India

Introduction Duodenal stent placement can be performed effectively and safely by using a Gastroscope in patients with an obstruction at the level of the distal duodenum. Patients with gastrointestinal malignancies may develop an obstruction at the level of the duodenum. Stent placement is a commonly used palliative treatment, because this modality is less invasive. However, stent placement in the distal part of the duodenum (second half of the horizontal part and ascending part of the duodenum) with a therapeutic gastroscope can be difficult. The main factors limiting the use of a gastroscope for distal duodenal stenting are the relatively short endoscope length, and shaft flexibility, which may cause looping of the scope into the stomach.

Method A 75-year-old male, presented to us with c/o recurrent vomiting, patient was evaluated on imaging USG abdomen s/o- large lobulated soft tissue mass lesion in tail region of pancreas abutting DJ flexure/ proximal jejunum, finding confirmed by gastrograffin swallow, contrast-enhanced computed tomography (CECT) abdomen done s/o large pancreatic tail malignancy, infiltrating DJ flexure / proximal jejunum. USG guided fine needle aspiration cytology (FNAC) s/o well differentiated adenocarcinoma. Self-expandable metallic stent (SEMS) placement done and hemoclip applied to prevent stent migration, as compared to earlier cases, the approach and negotiation was much easier. The length of the stricture was determined using contrast fluoroscopy of the duodenum during the procedure. A guide wire was then introduced through the stricture and the stent was advanced over the wire. Stent length was chosen to aim at a length of 1–2 cm more than the stricture. Endoscopy and fluoroscopy were used to follow stent deployment. Immediately after the procedure, an upright abdominal X-ray was performed to assess that no perforation had occurred during the procedure.

Results Success of deployment of SEMS, Easy deployment and minimal negotiation requirement.

Keywords Gastroscope, SEMS

Large intestine

086

An interesting case of inflammatory bowel disease and malignant melanoma

Sandeep Kumar Reddy G

Correspondence - Sandeep Kumar Reddy G - sandeepgaddam02@gmail.com

Department of Gastroenterology, Madras Medical College, Chennai 600 003, India

Inflammatory bowel disease (IBD) patients are at increased risk of skin cancer and lymphoma. Among skin cancer non melanoma skin cancer are more common compared to melanoma in IBD. IBD patient with malignant melanoma is an uncommon/rare finding. Here we present a case of IBD not on biologicals (but on immunomodulatory) developing malignant melanoma. IBD perse and usage of biologicals increase risk of malignant melanoma but immunomodulators are not associated with malignant melanoma. Immunomodulators increase risk of non-melanoma skin cancer (NMSC).

Keywords Biologicals, IBD, Malignant, Melanoma

087

Assessment of anemia profile in patients of ulcerative colitis and correlation with its severity

Manjri Garg, Pranjjal Sindhu, Sandeep Goyal

Correspondence - Sandeep Goyal - sandeepgoyal20000@gmail.com

Department of Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak 124 001, India

Introduction Anemia is most common extraintestinal manifestation in ulcerative colitis (UC) and is associated with mortality. Anemia in inflammatory bowel disease (IBD) is a result of combination of iron deficiency anemia (IDA) and anemia of chronic disease (ACD) with complex pathogenesis. We looked for anemia, its subtypes and correlation with disease severity.

Methods Seventy-five patients were enrolled in this study. Fifty-two patients had moderate,15 had mild and 8 had severe disease activity as per Mayo score. Hemoglobin (Hb), MCV, MCH, MCHC, serum iron, total iron binding capacity (TIBC), transferrin saturation (TfS), CRP and serum ferritin were estimated. Anemia was defined as per WHO criterion. Anemia was classified as IDA, ACD, and mixed as per European Crohn's and Colitis Organisation (ECCO) guidelines. Anemia and iron indices were compared in patients with moderate (group I) and mild + severe (group II) disease activity.

Results The mean age of patients was 34.8±14 years. The mean duration of disease and onset were 28.8±33.8 months (median 12 months) and 32.5±11.5 years respectively. Extent of disease could be assessed only in 43 patients (E3:22, E2:12: E1:11). Forty-five (60%) patients had anemia. IDA and mixed anemia were present in 43 (57.3%) and 18 (24%) patients respectively. None of the patient had ACD. There was no statistical difference in Hb. MCV, MCH, MCHC in group I and II (11.6±1.6 vs. 11.5±2.6 g/dL; 80.3±7.9 vs. 81.0±7.8 fL; 26.3±3.8 vs. 26.0±5.0 pg; 32.3±2.3 vs. 31.2±3.0 g/dL). Similarly no difference was found in serum iron (59.8±26.3 vs. 57.5±39.8 mcg/dL), ferritin (25.8±26.0 vs. 27.3±25.3 ng/mL), TIBC (338±84.4 vs. 316.3±64.8 mcg/dL) and TfS (14.3±10.5 vs. 14.7±14.4%).

Conclusion Anemia was present in 45 (60%) of patients, However, 61 (81.2%) patients had IDA or mixed anemia. Hb, IDA, mixed anemia were independent of disease severity. We stress that the anemia should be evaluated in UC patients with iron indices and not merely Hb levels.

Keywords Hemoglobin, Iron Indices, Ulcerative Colitis Disease Severity

088

Non-invasive markers for predicting endoscopic disease activity in ulcerative colitis

Ahammed M C, Srijith K, Sithara K B, Sunil Kumar K

Correspondence - Sunil Kumar K - sunilcalicut@gmail.com

Department of Medical Gastroenterology, Government Medical College, Kozhikkode, Malappuram 673 639, India

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that diffusely involves various parts of the colon. The Truelove–Witt’s criteria requires many clinical and laboratory parameters which is cumbersome. Moreover, the assessment of mucosal activity via endoscopy is invasive, inconvenient, costly and may be inappropriate in patients with severe UC. No ideal biomarker has been identified to assess mucosal activity in UC.

Aim Whether neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), CRP and CRP to albumin ratio (CAR) is useful in predicting endoscopic severity of UC

Methods Patients with UC, who underwent colonoscopy/ Flexible sigmoidoscopy at Government Medical College, Calicut were enrolled. NLR, PLR, CRP and CRP to albumin ratio were measured at the time of procedure.

Results Thirty-two patients (Male:20, Female:12) were enrolled in the study. Mean age at flare was 43.6 ± 15.3 year. Mean disease duration was 4.38 ± 5.35 years. All the patients were on mesalamine. 34.3% were on Azathioprine at time of flare. Mean time to colonoscopy from symptom onset of flare was 13.9±8.73. 34.3% had severe disease. Patients with moderate disease differed significantly with patients with severe disease in terms of CRP (15.9±13.0 vs, 25.49±5.24, p:0.005) and CAR (4.28±3.29 vs. 7.25±1.25, p:<0.001) and. There were no difference in NLR (3.16±1.18 vs. 3.39±1.68, p:0.775), PLR (196.89±57.3 vs. 164.78±50.48, p:0.327), Hb (10.42±1.83 vs. 9.85±1.33, p:0.235) or albumin 3.77±0.55 vs. 3.51±0.53, p:0.661). When ROC was plotted to differentiate between moderate and severe disease, AUC was highest for CRP (0.746 [0.572-0.921], p:0.02) and CAR (0.753 [0.582-0.924], p:0.02). Performance of NLR (0.515 [0.286-0.743], p:0.88) and PLR (0.662 [0.455-0.868], p: 0.13) was poor.

Conclusion In our study CRP and CAR predicted severity of ulcerative colitis while NLR and PLR did not.

Keywords CAR, CRP, NLR, PLR

089

The role of platelet to lymphocyte ratio and neutrophil to lymphocyte ratio as non-invasive markers of mucosal activity in ulcerative colitis at a tertiary care hospital of Coimbatore

Arshiya Mubin

Correspondence – Arshiya Mubin - arshysp@gmail.com

Department of Medical Gastroenterology, Govt. Coimbatore Medical College and Hospital, No 42, Beside Kovai Litho Press, V C K Layout, Trichy Road, Coimbatore 641 018, India

Introduction Ulcerative colitis (UC) causes idiopathic, chronic, and relapsing inflammation of the gastrointestinal tract. The incidence of UC has rapidly increased in Asia. Endoscopy plays an important role in the diagnosis, treatment, and monitoring of disease activity in UC. However, the assessment of mucosal activity via endoscopy is invasive, inconvenient, and costly, and may be inappropriate in patients with severe UC. Non-invasive inflammatory biomarkers of IBD, such as the WBC count, ESR, and CRP are used in clinical practice. However, no ideal biomarker has been identified to assess mucosal activity in IBD as the currently used biomarkers are nonspecific. Therefore, there is an unmet clinical need to identify biomarkers that can replace the need for an endoscopy to assess mucosal disease activity. This study aims to study the role of platelet to lymphocyte ratio and neutrophil to lymphocyte ratio as biomarkers in UC.

Methods Fifty patients with UC (2 lost follow-up) who underwent measurement of fecal calprotectin (FC) and endoscopy and 96 matched healthy controls. NLR and PLR were compared between the patients and healthy controls. The endoscopic activity was divided into 2 groups: group 1 (mild to moderate inflammation) and group 2 (severe inflammation) according to the Mayo endoscopic score in UC.

Results To diagnose UC, the optimal cut off of NLR and PLR was 2.26 (sensitivity 54.2%; specificity 90.6%) and 179.8 (sensitivity 35.4%; specificity 90.6%) respectively. The optimal cut off to differentiate group 1 and group 2 was 3.44, 175.9, and 453 μg/g for NLR, PLR, and FC, respectively (sensitivity, 63.6% vs. 90.9% vs. 81.8%; specificity, 81.1% vs. 78.4% vs. 73.0%; positive likelihood ratio, 3.364 vs. 4.205 vs. 3.027; AUC, 0.714 vs. 0.897 vs. 0.813). PLR had the highest AUC and positive likelihood ratio.

Conclusion NLR and PLR help differentiate patients with UC from healthy controls. NLR, PLR, and FC indicate endoscopic activity and may reflect intestinal mucosal conditions.

Keywords IBD, Markers, NLR, PLR, UC

090

Hepatobiliary and pancreatic manifestations in inflammatory bowel disease: Data from tertiary referral center

Mayur Satai, Arun Vaidya, Aditya Kale, Amrit Gopan

Correspondence - Mayur Satai - mayursatai72764.mss@gmail.com

Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Acharya Donde Marg, Parel East, Parel, Mumbai 400 012, India

Background and Aims There are various hepatobiliary and pancreatic manifestations seen in Crohn’s disease (CD) and ulcerative colitis (UC). We evaluated their prevalence in inflammatory bowel disease (IBD).

Methods Prospectively collected IBD clinic data from January 2012 to June 2022 was reviewed retrospectively.

Results Two hundred and ninety-five IBD patients (180 [61%] males, median age 39 y). The majority (247, 83.7%) were UC. Hepatic manifestations were seen in 38 (13.2%, 23 [60.5%] males), 10.9% UC and 22.9% CD (p=0.023) (Table 1). Radiological evidence of fatty liver was present in 27 (9.2%), liver cyst 4 (1.4%), hemangioma 3 (1%), cirrhosis 3 (1%) and portal vein thrombosis in 1 (0.3%). Seropositive status for hepatitis B and C were seen in 4 (1.4%) and 2 (0.7%) cases respectively. Raised liver enzymes were: AST (11.2%), ALT (7.4%) and alkaline phosphatase (2.3%). UC, but not CD with hepatic manifestations had significantly lower albumin levels (3.1g/dL vs. 3.4 g/dL, p=0.05). Biliary manifestations were seen in 16 (5.1%, 11 [68.7%] males), 5.3% in UC and 6.2% in CD. Cholelithiasis was present in 12 (4.1%), cholecystitis 2 (0.7%), gallbladder polyps 2 (0.7%) and primary sclerosing cholangitis (PSC) in 3 (1%) patients. One patient had an AIH-PSC overlap. There was no significant association of severity of IBD with any manifestation. Pancreatic manifestations were seen in 5 (1.7%). 4 patients had azathioprine induced and 1 had idiopathic acute pancreatitis.

Conclusion Hepatobiliary and pancreatic manifestations were present in nearly one-fifths IBD patients without any gender predilection. Hepatic manifestations, most common being fatty liver, were more common in CD than UC, with lower albumin levels in UC with liver involvement.

Keywords Fatty liver, Hepatobiliary, IBD, Pancreatic

091

Clinical utility of rifaximin in Indian gastroenterology practice – Results of a nation-wide survey among >200 gastroenterologists

Shailesh Pallewar, R V Lokesh Kumar, Kamlesh Patel

Correspondence - Shailesh Pallewar - shaileshpallewar@lupin.com

Lupin Ltd, Kalpataru Inspire, Opp Grand Hyatt, Santacruz East, Mumbai 400 055, India

Introduction Functional gastrointestinal disorders (FGIDs), now called as disorders of gut brain interactions are very common conditions across the world and are associated with poor quality of life and high healthcare utilization. Irritable bowel syndrome (IBS) is one of the most common forms of FGID and in India, reported prevalence of IBS based on several population-based studies varies between 4.2% to 7.5%. Rifaximin is a broad-spectrum, non-absorbable antibiotic used in the treatment of several GI disorders. In India, approved indications of rifaximin include non-invasive bacterial diarrhea and hepatic encephalopathy (HE), rifaximin’s approval for IBS in India is still awaited.

Methods This nation-wide structured questionnaire-based survey was conducted through an online platform (EnSight –Imagica Health) to ascertain the views of Indian gastroenterologists regarding role and clinical utility of rifaximin in managing various GI disorders.

Results Overall, 232 gastroenterologists completed this survey. It was observed that, rifaximin was prescribed primarily for the treatment of HE and diarrhea by 18.1% and 18.5% gastroenterologists respectively. Importantly, 21.9% and 24.1% gastroenterologists prescribed rifaximin primarily in patients with small intestinal bowel overgrowth (SIBO) and IBS-D respectively. For managing IBS-D, only 23.3% clinicians prescribed rifaximin at 550 mg TID for 14 days (as per the USFDA prescribing information), however, approximately 64% clinicians use 400 mg strength TID for 14 days. For managing IBS, 57.3% gastroenterologists reported that 2-week rifaximin treatment provided adequate symptomatic relief for up to 10 weeks. In relapsed patients, 8.5% gastroenterologists reported no clinical benefit of 2-week repeat rifaximin treatment whereas 79.2% gastroenterologists reported that 2-week repeat-treatment with rifaximin is effective and well tolerated.

Conclusion Among various GI indications, rifaximin is most commonly used in the management of IBS-D in Indian gastroenterology settings and is an effective and well tolerated.

Keywords Diarrhea, Irritable bowel syndrome, Rifaximin, SIBO

092

A cross-sectional observational study of self-reported treatment adherence in inflammatory bowel disease (ulcerative colitis) patients attending SMS Hospital, Jaipur

Hitesh Sharma , Rupesh Pokharna

Correspondence - Hitesh Sharma - hits8309@gmail.com

Department of Gastroenterology, Sawai Man Singh Medical College, New S M S Campus Road, Gangawal Park, Adarsh Nagar, Jaipur 302 004, India

Introduction Ulcerative colitis (UC) is characterized by periods of relapse and remissions, so maintenance therapy is required lifelong by patients. Due to frequent dosing and sometime inconvenient methods of administration (enema, suppositories) and medication side effects non-adherence to treatment in UC patients is emerging problem. Non–adherence to treatment is important factor for occurrence of relapse in future, increase healthcare cost, high risk of disability and complications. The aims of our study were to find the prevalence, reason, and predictor of non-adherence to medical therapy in inflammatory bowel disease (UC) patients.

Methods This cross-sectional study included the patients of UC recruited between January 2020 to March 2022. Adherence was assessed with questionnaire (interview based) that also includes patients clinical, personal, and sociodemographic profile and reason of non–adherence.

Results A total of 112 patients of UC were included, there were 66 (58.9%) males and 46 (41.1) were females; mean age was 33.4±12.4 years; mean duration of disease was 3.8±3.96 years. Eighty-one (72.3%) patients were non-adherent (taking 80% or less of advised-dose) to medication. The reason for non-adherence were:cost of treatment 39 (48.1%), felt better 19 (23.5%), forgetting dose 5 (6.1%), frequent drug dosing 2 (2.5%), life-long treatment 3 (3.7%), alternative treatment 8 (9.8%) and adverse effects of medication 5 (6.2%). Patients socioeconomic class (p=0.013), occupation (p<0.001) and education (p=0.001) have positive association with adherence. Patients in upper-middle and lower -middle socioeconomic class with educated and employed were highest adherent (66.6%), whereas patient from lower socioeconomic class who were illiterate and unemployed were least adherent (15%). Conclusion Over 70% patients with UC was non-adherent in our study, cost of treatment and felt better was commonest cause. So proper counselling and improving knowledge about UC is must and gastroenterologist should also focus on it.

Keywords Inflammatory bowel disease, Non-adherence, Ulcerative colitis

093

Melanosis coli - A case report

Jitendra Singh , Jitendra Kumar Singh

Correspondence - Jitendra Singh - drmuktiprakash@gmail.com

Department of Gastroenterology and Hepatology, M L N Medical College, George Town, Prayagraj 211 002, India

Introduction A 65-year-old male presented to our department with 5 year history of constipation along with laxative intake for last 5 years on daily basis.

Methods His physical examination was normal. His ultrasound did not show any significant abnormalities. His routine blood investigation were also normal. We planned him for a full length colonoscopy. His colonoscopy showed blackish pigmentation of colonic mucosa which was more in the right colon. Multiple biopsy were taken throughout colon. His histopathology report showed macrophage in lamina propria with brown-black pigmentation in the cytoplasm. Histochemical staining showed these pigments stained to Fontana- masson and was suggest of Melanosis coli. Patient was advised to stop the laxative. Melanosis coli is a benign condition seen in patients using anthraquinone- based laxative which is more common on right side of colon.

Conclusion Elderly people are at risk of developing Melanosis coli especially those with chronic constipation [1]. In our case patient was consuming a laxative which contained senna as active ingredient. Since mucosa appear to be brown, black it can be easily confused with ischemic colitis. Histologic finding of ischemic colitis which differentiate it from Melanosis coli includes distortions of crypts, edema, hemorrhagic changes in mucosa and submucosa [2]. There is increased incidence of adenoma in patients with melanosis coli due to easier detection of adenoma against the dark staining of colonic mucosa [3].

(Blackish brown pigmentation of colonic mucosa)

References

1. Ahasan HM, Khan MAI, Mahbub S, et al. Melanosis coli- an atypical presentation. J Med. 2010; 11:183-5.

2. Theodoropoulou A, Koutroubakis IE. Ischemic colitis- clinical practice in diagnosis and treatment. World J Gastroenterol. 2008; 14: 7302-8.

3. Blackett JW, Rosenberg R, Mahadev S, Green PHR, Lebwohl B. Adenoma detection is increased in the setting of Melanosis coli. J Clin Gastroenterol. 2018;52:313-8.

Keywords Constipation, Melanosis

094

Environmental risk factors for inflammatory bowel disease- Ulcerative colitis

Nadiya M E , Rupesh Pokharna

Correspondence – Rupesh Pokharna - nadiya16688@gmail.com

Department of Gastroenterology, Sawai Man Singh Medical College, New S M S Campus Road, Gangawal Park, Adarsh Nagar, Jaipur 302 004, India

Introduction Inflammatory bowel disease (IBD) both ulcerative colitis (UC) and Crohn’s disease are rising in India. Environmental factors and westernization of diet and lifestyle have been associated. This study was aimed to assess the risk factors for IBD UC from Western Indian state of Rajasthan.

Methods Prospective, single center, case control study including 165 IBD UC patients and 165 asymptomatic healthy controls. A simple printed questionnaire assessing the risk factors and disease characteristics of UC was prepared and both the patients and controls were asked to fill. Odds ratio (OR) and 95% confidence interval was calculated and p value less than 0.05 was considered significant.

Results The study didn't show any difference in prevalence of UC in urban or rural population. The disease was more prevalent in men compared to women (OR 1.071, 0.82-1.38) and presented in third decade of life in majority (1.830, 1.52-2.19). Patients with UC had lower body mass index (OR 2.185, 1.52-3.14). In this study toxin abuse like smoking and surgery like appendicectomy were seen as risk factors for UC (OR 4.5, 3.19-8 and 3.1, 1,5-5). Consumption of milk was associated with higher risk of UC in this study population. This study didn't find cooking oil, high fiber diet, consumption of fruits and vegetables OR junk food to be protective OR causative for UC.

Conclusion This study highlights the environmental risk factors for IBD UC from a single center in western state of Rajasthan.

Keywords IBD UC

095

Unusual rectal foreign bodies – Challenges in management

Mamindla Kiran, Govind Verma, M Sudhir, Dhiraj Agrawal

Correspondence - Dhiraj Agrawal - mamindlarakesh233@gmail.com

Department of Medical Gastroenterology, PACE Hospital, Metro Pillar Number C1775, 18, Hitech City Road, HUDA Techno Enclave, HITEC City, Hyderabad 500 081, India

Introduction Rectal foreign bodies diagnosis and management is difficult, Due to wide variations in type of object, host anatomy, time from insertion, injuries, and local contamination. Reluctant to seek medical advice and provide details makes situation more difficult.

Case Report Twenty-four-year-old male presented to emergency department with anal pain, on history he had inserted a foreign object into the rectum. CT shows non – metallic foreign body located high in the rectum Without any evidence of free air in the peritoneum. colonoscopy- 15 × 6 cms size plastic cylindrical tube observed in the rectum, under mild sedation anal canal dilated with anal dilator and foreign body removed with both endo and flouro guidance with artery forceps. Patient discharged in a stable condition.

Twenty-seven-year-old male presented with severe pain abdomen and anal pain. On history he had inserted handheld bidet shower into the rectum. CT – abdomen shows metallic hand held shower confirmed in the rectum with free fluid in the pelvis. ?Perforation, patient taken for emergency laparotomy. Intra operatively multiple (3) perforations in the upper and mid rectum with free fluid in the pelvis with contamination observed. Removal of foreign body done. Resection of segment of rectum with rectosigmoid anastomosis with peritoneal lavage with loop ileostomy done. Patient discharged in a stable condition.

Discussion Rectal foreign body diagnosis and management varies widely with each patient. systematic approach for diagnosis, assessment for foreign body size and location should be mandatory.

Keywords Foreign body, Laparotomy, Rectum

096

Extensive invasive mucormycosis in post liver transplant patient

Mamindla Rakesh Kiran, Govind Verma, M Sudhir, Dhiraj Agrawal, Phani Krishna Ravula, Suresh Kumar S, Santhosh Kumar Ganapathi

Correspondence - Dhiraj Agrawal - dhirajagrawal24@gmail.com

Department of Medical Gastroenterology, Pace Hospital, Metro Pillar Number C1775, 18, Hitech City Road, HUDA Techno Enclave, Hitec City, Hyderabad 500 081, India

Introduction Fungal infections are rare and feared complication in liver transplant recipient, with high rates of morbidity and mortality. Current estimates are about 5%. Most common organisms are Candida and Aspergillus, both constitutes 80% of cases. Rare causes are Mucor, Cryptococcus, Histoplasma.

Case Report A 44-year-old male with decompensated chronic liver disease with MELD- Na score 28, underwent living donor liver transplantation. intra operatively he had requirement of inotropic support. patient started on immunosuppression. On POD-6 patient developed rejection (moderate cellular rejection – RAI score–6/9) treated with methyl prednisolone pulse therapy, after that Patient developed low grade fever and reduced consciousness, black necrotic discharge around surgical site, with drop in hemoglobin, underwent colonoscopy – findings of terminal ileum shows nodularity, cecum and ascending colon shows a large circumferential ulceration with sloughed out/ballooned necrotic mucosal layer, he underwent debridement of wound with limited ileo-cecal resection. Histology suggestive of invasive mucormycosis of intestine with angio and muscular invasion.

Patient treated with liposomal amphotericin – B, his condition gradually worsened with increased requirement of ionotropes, decreased urine output, raise in creatinine and decreased level of consciousness, despite intensive care management and regular monitoring patient not survived.

Discussion Mucor rarely involves the gastrointestinal (GI) tract. In GI most common site of involvement is stomach than colon. Abdominal pain, altered bowel habits, fever are the presenting symptoms, it may rarely present as mass lesion mimicking carcinoma colon, sometimes leads to bowel necrosis and perforation.

Conclusion Invasive fungal infections leads to high mortality in transplant patient, identification of high risk group and prophylactic anti-fungal therapy decreases devastating complications in this patients.

Keywords Fungal infection, Mucor, Tranplant

097

Non-inflammatory bowel disease colitis: Uncommon cause of a common presentation

Nirmaljit Singh Malhi, Jasmeet Singh Dhingra, Rajiv Grover, Achal Garg

Correspondence - Nirmaljit Singh Malhi - njsmalhi@hotmail.com

Department of Gastroenterology, Advanced Gastroenterology Institute-The Gastrociti, Opposite Grandwalk Mall, Barewal Road, BRS Nagar, Ludhiana 141 008, India

Introduction Hereditary angioedema due to C1-inhibitor deficiency (HAE-C1-INH) is a rare disease, which induces an acute attack of angioedema mediated by bradykinin. It can cause serious abdominal pain when severe edema develops in gastrointestinal (GI) tract. Such patients with repeated episodes can have presentation like aubacute intestinal obstruction (SAIO).

Methods We herein present a 48-year-old female patient with HAE-C1-INH, who underwent recurrent episodes of SAIO with abdominal colic in past. She frequently needed hospitalizations with the administration of opioids due to severe abdominal pain.

Result HAE-C1-INH should be considered, when evaluating patients with unidentified recurrent abdominal pain. Characteristic bowel findings were non-inflammatory edema, normal acute phase reactants (ESR/CRP/PCT) and severe pain. On evaluation, serum C4 was 9.8 (10-40 mg/dL), serum C3 was 49.7 (90-170 mg/dL) and C1 Esterase inhibitor protein was 164 (195-345 mg/L). Computed tomography (CT) enterography scan findings of mucosal enhancement, extensive submucosal oedema of the intestinal tracts, mesenteric congestion and edema and colectasia during acute attack.

Fig 1: Abdominal computed tomography scan in this patient during acute attack shows bowel wall edema.

Medical interview focusing on past history revealed history of minimal facial and upper extremity edema. She did not have a positive family history or any such episodes in childhood. Patient was started on prophylactic daily Danazol (200 mg) and remained symptom free for 1 year follow-up. On recovery as she was symptom free all medications were stopped by herself and after 2 months of stopping medications, she had a relapse requiring admission and opioid administration. Icatibant, a selective bradykinin B2 receptor antagonist, available for self-administration during an acute attack could not be used due non availability in our country.

Conclusion HAE-C1-INH can present like SAIO. High index of suspicion is necessary for identification and prompt therapy leads to excellent treatment response.

Keywords Intestinal angioedema, NIBDC

098

Colonoscopic intralesional injection of Coca-Cola for evacuation of large rectal fecaloma

Avnish Kumar Seth , Jitendra Mohan Jha

Correspondence - Avnish Kumar Seth - akseth2003@yahoo.com

Department of Medical Gastroenterology, Manipal Hospital, Sector 6, Dwarka, Delhi 110 075, India

Introduction Fecaloma is a large mass of organized hardened feces causing impaction, usually in rectum and sigmoid colon. Management includes digital evacuation, use of clearance enema or oral laxatives. We present use of intralesional injection of Coca-Cola for evacuation of large rectal fecaloma refractory to other treatment modalities.

Case Report A 81-year-old male with long standing constipation, presented with inability to pass stool and severe pain in rectum for one month and difficulty in passing urine for one day. Examination of abdomen was unremarkable. Per-rectal examination revealed rounded 10 cm diameter hard non-pitting fecaloma in rectum that could not be crushed digitally. Abdominal X-ray and non-contrast computerized tomography (NCCT) scan confirmed presence of solid stool with distension of rectum and sigmoid colon. Attempts at clearance of stool with conventional methods were unsuccessful. At colonoscopy (Olympus CF-H180AL), large mobile fecaloma was noted in distal rectum with presence of solid fecal matter in proximal rectum and sigmoid colon. Following informed consent, two liters of Coca-Cola was instilled with 50 mL syringe through the working channel of colonoscope into descending and sigmoid colon, leading to evacuation of stool, but the rounded fecaloma was retained in the rectum. 50 mL of Coca-Cola was then injected into the fecaloma with 21-G endoscopic sclerotherapy needle. After 5 minutes, the hard fecaloma could now be crushed against the sacrum and was successfully evacuated digitally.

Discussion We have described previously published the use of colonoscopic instillation of Coca-Cola for clearance of fecaloma. However, large fecaloma may be refractory to available methods and may need disintegration prior to successful evacuation. Technique of intra-lesional injection of Coca-Cola has been previously described in a single report from South Korea.

Conclusion Colonoscopic intralesional injection of Coca-Cola followed by digital evacuation is effective for removal of rectal fecaloma refractory to conventional treatment.

Keywords Colonoscopic injection Coca-Cola, Colonoscopic removal, Fecaloma

099

Use of indigenous Dr Seth’s fecaloma basket along with Coca-Cola instillation for colonoscopic clearance of large colonic fecaloma

Avnish Kumar Seth , Jitendra Mohan Jha

Correspondence - Avnish Kumar Seth - akseth2003@yahoo.com

Department of Medical Gastroenterology, Manipal Hospital, Sector 6, Dwarka, Delhi 110 075, India

Introduction Fecaloma, large masses of organized hardened faeces in rectum and distal colon, are often refractory to conventional treatment. We present use of Indigenous Fecaloma Basket, designed by us, for fragmentation of large fecaloma followed by evacuation with Coca-Cola instillation.

Case Report Six-year-old male with constipation since infancy presented with inability to pass stool for two weeks. There was no history of pain abdomen or vomiting. The child was differently abled and was previously operated for congenital hydrocephalus and undescended testes. On examination the child weighed 18 Kg and was confined to bed. Abdominal examination revealed multiple non-pitting hard masses in hypogastrium, left iliac fossa, umbilical and left lumbar regions. Oral polyethylene glycol and sodium phosphate enema showed no result. Non-contrast CT scan confirmed large fecaloma in rectum, sigmoid and descending colon with density up to 184.5 HU. Under sedation, a large rectal fecaloma was disintegrated digitally and evacuated. Colonoscopy (Olympus, PCF-PH190L/I) revealed multiple large fecaloma of up to 5 cm dia till splenic flexure. Dr Seth’s Fecaloma basket (Manish Medi Innovation, 3 steel wires, basket opening length 1500 mm, basket diameter 60.75 mm, catheter dia 2.3 mm) was introduced through the working channel and the fecaloma were captured and crushed. Instillation of 540 mL of Coca-Cola (30 mL/Kg) at splenic flexure resulted in complete evacuation of fragmented fecaloma, aided by abdominal compression. Parents did not consent for full-thickness rectal biopsy.

Discussion We have previously published the use of colonoscopic instillation of Coca-Cola for clearance of fecaloma. However, large fecaloma may be refractory to treatment with available methods. Commercially available endoscopic baskets, designed for use in polyps and bile duct stones, may be too small to capture large fecaloma.

Conclusion Indigenous Fecaloma Basket enables colonoscopic capture and disintegration of large fecaloma. Colonoscopic instillation of Coca-Cola then results in complete clearance of fecaloma fragments.

Keywords Colonic fecoloma, Dr Seth’s Fecoloma basket

100

A case report on multiple polyps of gastrointestinal tract

Uday Vadicherla, Muthu Kumaran, I Shubha, A Aravind, Caroline Selvi, A Chezhian, R Murali

Correspondence - Uday Vadicherla - uday.vadicherla@gmail.com

Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India

Introduction The liberal use of endoscopy leads to an increase in detection of polyps in gastrointestinal tract. Incidence of polyps during endoscopy 6%, 4.6% and 7% to 42% in stomach, duodenum, and colon respectively.

Case Discussion A 27-year-old male patient presented with dyspeptic symptoms on examination found to be having macrocephaly, on face patient having multiple tiny papules (trichilemmomas) on face and also on hands. On 0ral examination patient having multiple oral papillomas on tongue and gum hypertrophy. On genital examination hyper pigmented flat lesion seen on glans penis.

On esophagogastroduodenoscopy (EGD) we noticed multiple tiny polyps in distal esophagus and in second part of duodenum. Then we proceeded to colonoscopy, found multiple polyps in entire colon. On histopathology examination confirms polyps as hamartomatous type. Ultrasonography (USG) of neck, which shows multiple colloid cysts in both lobes of thyroid. Fine needle aspiration cytology (FNAC) of this showed nodular colloid goiter. USG of scrotum showed multiple hypoechoic lesions, suggest hamartomas or lipomatosis of testis. With all these above findings patient fits into Cowden syndrome diagnostic criteria by Pilarski et al.

Keywords Hamartomatous polyp, Papilloma, Trichilemmomas

101

Roots of a colonic tree- A rare endoscopic finding in ulcerative colitis

Aastha Jha, Alok Sahu, Maitrey Patel, Apurva Shah, Shravan Bohra

Correspondence – Apurva Shah- apurvashah411@gmail.com

Department of Gastroenterology, Apollo Hospital International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Estate, Ahmedabad 382 428, India

Introduction Although usual endoscopic findings in ulcerative colitis consist of mucosal erythema, edema, ulcerations and pseudo polyposis, other uncommon presentations have also been noted. Filiform polyposis is a rare entity noted in cases of inflammatory bowel disease, which is characterized by multiple, long, slender, worm like projections, consisting of submucosal core lined with normal mucosa. Here we present a case with multiple intertwined filiform polyposis noted in a case of ulcerative colitis.

Case Report We present a case of 41-year-old male patient, known case of ulcerative colitis for 5 years, who presented with persistent diarrhea. Patient was on oral mesalamine for a few years and was not taking steroids or immune suppressants. Upon endoscopic evaluation, patient was found to have multiple, thin, long (5-6 cm in length), slender, worm-like projections, resembling the stalk of polyps, without the heads. These were very similar to those like roots of a tree. Patient also had an entire area of erythema and loss of vascular pattern in the left colon, suggestive of ongoing inflammatory activity. Histopathology of the polypoidal projections showed normal colonic mucosa, although that of the erythematous mucosa was suggestive of chronic active inflammation. He had evidence of flare.

Conclusion This type of giant filiform polyposis is formed by chronic inflammation of the large bowel mucosa, with repeated ulceration and healing leading to the formation of worm-like polypoid projections. They may mimic adenomatous polyps or may even be mistaken for a malignancy. It is important in such cases to take multiple biopsies, to rule out dysplasia or invasive malignancy, although it has rarely been reported. If asymptomatic, requires periodic observation and follow-up. However, if associated with active IBD, surgical resection should only be considered for severe active colitis.

Keywords Filiform polyposis, Ulcerative colitis

102

Fecal calgranulin is an alternate stool biomarker to differentiate inflammatory bowel disease from irritable bowel syndrome (diarrheal type)

Santhosh Kumar ¹ , Rajeeb Jaleel ² , Tintu Varghese ³ , Stephen Benny ² , Ira Praharaj ³ , Sudipta Chowdhury ² , Reuben Thomas ² , Ebby Simon ² , A J Joseph ² , Amit Kumar Dutta ²

Correspondence – Amit Kumar Dutta - akdutta1995@gmail.com

Departments of ¹Hepatology, ²Gastroenterology, and ³Wellcome Research Unit, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Background Calgranulin C (S100 A12), a novel biomarker was reported to be stable in stored stool (at room temperature) for longer duration (7 days) compared to calprotectin (2-3 days). We aimed to compare the diagnostic accuracy of calgranulin with calprotectin for differentiating inflammatory bowel disease (IBD) from irritable bowel syndrome with diarrhea (IBS-D).

Methods We prospectively studied patients (≥18 years) with active IBD (Asia-Pacific consensus criteria) and IBS-D (Rome III criteria). We excluded patients with blood in stools. All patients had colonoscopy in addition to other laboratory tests. Sample size of 55 patients in each group was needed to detect 15% difference in diagnostic accuracy between calprotectin and calgranulin. Informed consent was taken and the study was Institutional Review Board approved. Fecal samples were collected prior to colonoscopy preparation and stored at -80° celsius. Calgranulin was measured using IDK^® S100A12 ELISA and calprotectin using EDI quantitative fecal calprotectin ELISA Kit. The laboratory staff were blinded.

Results We studied 113 patients, aged 38.3 (±13.6) years with 84 men (74.3%), 56 IBD patients (30 Crohn’s disease [CD], 25 ulcerative colitis [UC] and one indeterminate colitis) and 57 IBS-D patients. The baseline symptomatology and BMI of the patients were comparable. The median calgranulin was significantly different between IBD (19.5 [3.9-54] ug/g) compared to IBS-D patients (1.9 [0.26-6.25] ug/g), p<0.00001. Calgranulin had AUROC of 0.77 for differentiating IBD from IBS-D and for a cut off of 8 ug/g, sensitivity was 66.1%, specificity was 79% with diagnostic accuracy of 78.9%, compared to AUROC for calprotectin of 0.88 and for a cut-off of 92.6 ug/g the sensitivity was 82.1%, specificity was 75.4% with diagnostic accuracy of 75.4%. AUROC of calgranulin for differentiating CD and IBS-D was 0.74 and for differentiating UC from IBS-D was 0.84.

Conclusion The diagnostic accuracy of fecal calgranulin is comparable to fecal calprotectin for differentiating IBD from IBS-D.

Keywords Calgranulin, Calprotectin, Inflammatory bowel disease, Irritable bowel syndrome

103

Colorectal carcinoma presenting as pyogenic liver abscess

Antony George , Devika Madhu, Nidhin R, Prasanth T S, Krishnadas D

Correspondence – Antony George - anthony00590@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Introduction Colorectal carcinoma is a common malignancy worldwide with well-established symptoms. Liver abscess as the presenting sign of occult colorectal malignancy has rarely been reported. We present a case of colorectal carcinoma presenting as pyogenic liver abscess.

Case Summary We report a 60-year-old healthy male, chronic smoker, and alcoholic, who presented with complaints of abdominal pain in the right hypochondrium, which was associated with high-grade fever with chills of 2 weeks duration. General examination revealed features of SIRS, with temperature – 101 Fahrenheit, tachycardia (pulse-96/minute), and resting tachypnea (respiratory rate – 24/minute). Abdominal examination revealed tenderness in the right hypochondrium. Blood workup revealed a total leukocyte count of 17,900 cells/microlitre with a neutrophil count of 87%, ESR of 120, and elevated ALP -209 (125). His procalcitonin levels were 14.7 (0.25). He was treated with broad-spectrum antibiotics after obtaining blood cultures. Tumor marker analysis revealed high carcinoembryonic antigen (CEA) levels – 132. contrast-enhanced computed tomography (CECT) abdomen revealed multiple ill-defined peripherally enhancing hypodense lesions in the left lobe of the liver suggestive of pyogenic liver abscess, 2 well defined hypodense lesions in the right lobe of the liver suggestive of metastatic lesions, and a focal asymmetric wall thickening of 6.1cm length involving the distal transverse colon and splenic flexure, with multiple enlarged pericolic lymph nodes; suggestive of colorectal carcinoma. Colonoscopy the following day revealed a circumferential polypoidal growth at splenic flexure beyond which scope could not be negotiated and a pedunculated polyp in descending colon. Histopathology revealed moderately differentiated adenocarcinoma. He was given 6 weeks of antibiotics and planned for radiotherapy.

Conclusion Increased awareness that pyogenic liver abscesses can be the initial presentation of colorectal carcinoma is imessential. Timely diagnosis and early treatment can improve the outcome of colorectal neoplasm. Colonoscopy is necessary to identify the origin of unexplained liver abscess.

Keywords Abdominal pain, Colorectal carcinoma, Pyogenic liver abscess, SIRS

104

Frequency of thiopurine induced myelosuppression in Indian patients with inflammatory bowel disease: A randomized controlled trial comparing full dose initiation versus gradual escalation

Alok Singh , Sanjeev Sachdeva, Siddharth Shrivastava, Ajay Kumar, Ashok Dalal, Ujjwal Sonika, B C Sharma

Correspondence – Alok Singh - dralokkgmu92@gmail.com

Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Background and Aim Myelosuppression is most dreaded adverse reaction to Azathioprine (AZA) treatment with a reported 7% cumulative incidence. We aimed to compare the incidence of myelosuppression in patients with full dose initiation versus gradual escalation of AZA.

Methods Forty patients of inflammatory bowel disease (IBD) were recruited over one year. They were randomized into two groups (group A, group B) of 20 each. Randomization was done in 1:1 ratio based on computer generated tables. Group A received full dose initiation of AZA at 2 mg/kg and group B (gradual escalation) received 1 mg/kg and the dose was uptitrated to 1.5 mg/kg and 2 mg/kg at 4 weeks and 8 weeks respectively. All patients were clinically followed for 24 weeks.

Results Seventeen patients were included in analysis in each group as 3 patients were lost to follow-up in each group. Median age was 32 years and 30 years in group A and B, respectively. Fourteen and 15 patients were of UC; 3 and 2 patients were of CD respectively in group A and B. During follow-up post AZA initiation, 2 (11.8%) patients in group A and 4 patients (23.5%) in group B relapsed (p=0.65). Two patients (11.8%) in each group developed myelosuppression. Median time to development of leucopenia was 10 weeks (range 4-12 weeks). Absolute neutrophil counts (ANC) in group A showed a trend towards lower median values as compared to Group B particularly after 4 weeks of initiation of AZA. On univariate analysis serum protein, albumin and bilirubin were found to significantly associated with leucopenia. However, on multivariate analysis none of these factors were significant.

Conclusions Patients with full dose initiation had comparable relapses in follow-up period as compared to gradual escalation group. Incidence of myelosuppression was similar in both the groups.

Keywords Azathioprine, Leucopenia, Ulcerative colitis

105

Case series of colonic mucormycosis in covid pandemic

Vinod Raman , Ravi Shankar B

Correspondence – Ravi Shankar B - vinodraman220@gmail.com

Department of Medical Gastroenterology, Yashoda Hospitals, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India

Introduction Mucormycosis-fungal infection (ubiquitous). Class – Zygomycetes (1). Predisposition in COVID infection. Gastrointestinal (GI) mucormycosis is rare. Outcome is usually fatal.

Case 1 A 54-year-old male, presented with lower GI Bleed. Treated with remdesivir and Oxygen support. Colonoscopy: Cecal ulceration and black pigmentation (Fig. 1). KOH stain – Aseptate Hyphae (Fig. 2).Treated with Liposomal amphotericin B. Semiurgent surgery: right hemicolectomy done, Succumbed to death.

Case 2 A 58-year-old male came for lung transplantation. K/C/O –DM2, Hypertension. On ECMO day 38, CT abdomen showed sigmoid colon perforation with fecal peritonitis. Emergency laparotomy+sigmoid colon resection +end colostomy. Histopathology confirmed mucormycosis (Fig. 3). Deteriorated and succumbed.

Discussion 2nd wave Covid – several cases of rhino-orbito cerebral mucormycosis.GI mucor rarely reported. Complaints of fever, nausea, abdominal pain, GI bleed and perforation. Predisposing factors: diabetes, steroids, immunocompromised states. Endoscopy : large ulceration with necrosis, black pigmentation

Diagnosis KOH mount, PCR, Treatment – Inj. Liposomal amphotericin B – 5 mg/kg/day for 3 weeks followed by oral posaconazole (2). Prognosis is usually poor (3).

Conclusion GI mucormycois is a rare disease and should be considered in patients with lower GI bleed and perforation. Prompt attention needs to be given for early diagnosis and appropriate treatment.

Keywords Colitis, GI bleed, Perforation

106

A rare case of primary cecal lymphoma

Lohith Kumar V R , Suprabhath Giri

Correspondence – Lohith Kumar V R - drlohithkumar@gmail.com

Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India

Introduction Gastrointestinal tract is the most common site of extranodal lymphoma, of which non-Hodgkin’s lymphoma (NHL) comprises 4% of total cases. Primary lymphoma arising from the colon is very rare accounting only 0.2% to 1% of all colonic malignancy.

Case Report Sixty-three-year-old old gentleman presented with 2 months history of mass in the right iliac fossa with mild dragging pain, progressive weight loss and anorexia with no change in bowel habits, GI bleed, fever. On examination 8 × 6 cm firm, tender mass with restricted mobility noted extending from right lumbar region to RIF. CT scan showed circumferential wall thickening in the caecum and terminal ileum with loco-regional lymph nodal mass of 16 × 10 cm. Colonoscopy revealed proliferative lumen occluding polypoidal growth in the cecum. Histopathology was suggestive of cecal lymphoma. Further, immunohistochemistry (IHC) markers showed CD10, CD 20,CD3 and Bcl2 positivity, cyclin D1-negative, Ki67-42% diagnostic of diffuse large B cell lymphoma. Whole body PET CT showed FDG avid abdominal (SUV max 29.6) and mediastinal lymphadenopathy (SUV max 8.02) with diffuse circumferential wall thickening of right colon (SUV max35.97). He was diagnosed to have ceacal lymphoma-DLBCL, stage III (Lugano).The patient was started on R-CHOP regimen.

Conclusion Primary ceacal lymphoma is very rare, it should always be considered in the differential diagnosis. Management depends on the clinical features and staging; requiring multi-disciplinary approach including surgery, chemotherapy.

Keywords Ceacal lymphoma, Colon, Extra nodal lymphoma, R-CHOP

107

Cytomegalovirus colitis in inflammatory bowel disease: A case series

Rishabh Agarwal , Naresh Bhat, Anupama N K, Amit Yelsangikar, Kayal Vizhi N, Raghu B M

Correspondence – Rishabh Agarwal - rishabhagarwal90@gmail.com

Department of Gastroenterology, Aster CMI Hospital, No. 43/2, New Airport Road, NH.7, Hebbal, Sahakara Nagar, Bengaluru 560 092, India

Cytomegalovirus (CMV), is an opportunistic pathogen, known to complicate the course of treatment in patients with inflammatory bowel disease (IBD). It has been found to exist more in immunocompromised than immunocompetent individuals, more in ulcerative colitis than in Crohn's disease.

We present a series of 5 cases where CMV was encountered in the course of IBD, and our experience with the treatment, complications, and outcome. Diagnosis is based on suspicious endoscopic lesions, serology, histopathological features, and tissue PCRs. Effective antiviral drugs are available, but they come with a set of frequent adverse events. Hence, the treatment of CMV colitis should be supervised.

Humans are the only reservoirs for CMV. CMV replication should be differentiated from CMV mediated disease. It is also important to differentiate IBD flare from CMV. CMV increases the risk of hospitalization in IBD patients. It may reduce response to biologicals. It has also been reported that IBD patients with CMV mediated disease have higher rates of colectomy. However, some studies have showed no effect of CMV infection on IBD in remission. CMV and its treatment, both are known to cause bone marrow suppression, which can be lethal if unchecked. Nevertheless, it should be actively looked for and treated for better outcomes.

Keywords Colitis, Cytomegalovirus, IBD

108

Relationship of mucosal urease producing organisms and disease activity in patients of ulcerative colitis: A prospective cross-sectional study

Bigyan Maharaj ¹ , Anurag Jena², Pallab Ray³, Neelam Taneja³, M R Shivaprakash³, Mini P Singh⁴, Anupam Kumar Singh², Vishal Sharma², Kaushal Kishor Prasad², Arun Kumar Sharma², Rakesh Sehgal⁵, Usha Dutta²

Correspondence – Usha Dutta - ushadutta@gmail.com

Departments of ¹Internal Medicine, ²Gastroenterology, ³Medical Microbiology, ⁴Virology, and ⁵Medical Parasitology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction Microbial dysbiosis in inflamed areas in patients of ulcerative colitis (UC) signifies the role of ongoing infection leading to perpetuation of disease activity. We planned a study to compare the prevalence of mucosal urease producing bacteria in patients with UC and study its relationship with disease activity.

Methods A prospective cross-sectional study was conducted at our tertiary care hospital from February 2021 to June 2022. All patients underwent clinical evaluation, endoscopy (Mayo score assessment) and blood investigations after informed consent. Patients undergoing colonoscopy for indication other than UC without any colonic inflammation were taken as controls. A mucosal biopsy specimen taken from the inflamed mucosa and adjacent visually non-inflamed mucosa was placed in the rapid urease test (RUT) media (Pylo Dry® Kit, India). After 1/2-hour, positive result (color change yellow to pink) indicated the presence of a urease-producing organism]Results A total of 78 UC cases and 33 controls were recruited. Fifty-one patients of UC had active disease (22 patients had severe disease). In UC, mucosal biopsy from inflamed areas more often had evidence of RUT positivity as compared to adjacent non-inflamed areas in the same patient (p=0.039). RUT performed using mucosal biopsy in severe UC more often showed positivity as compared to controls (18/22 [81.8%] vs. 18/33 [54.5%]; p=0.037). RUT performed using mucosal biopsy in patients of UC more often showed positivity as compared to controls (57/78 [73.1%] vs. 18/33 [54.5%]; p=0.056).

Conclusion Mucosal biopsy in patients with severe UC had more often evidence of urease producing organisms than controls. Mucosa associated microbiota profile may have a role in driving inflammation.

Keywords Inflammatory bowel disease, Microbiota, Multiplex PCR

109

Gastrointestinal mucosa associated microbial profile and disease activity in patients of ulcerative colitis: A prospective study

Bigyan Maharjan ¹ , Anurag Sachan ² , Anuraag Jena ² , Pallab Ray ³ , Neelam Taneja ³ , M R Shivaprakash ³ , Mini P Singh ⁴ , Devyani Sharma ⁵ , Anupam Kumar Singh ² , Vishal Sharma ² , Kaushal Kishor Prasad ² , Arun Kumar Sharma ² , Rakesh Sehgal ⁵ , Usha Dutta ²

Correspondence – Usha Dutta - ushadutta@gmail.com

Departments of ¹Internal Medicine, ²Gastroenterology, ³Medical Microbiology, ⁴Virology, ⁵Medical Parasitology, Level 4, F Block, Post Graduate Institute of Medical Education and Research, Nehru Hospital Extension Block, Sector-12, Chandigarh 160 012, India

Introduction Mucosa associated microbiota (MAM) are shown to drive gut inflammation. Their role in disease activity in ulcerative colitis (UC) is largely unknown. We planned to study fecal and MAM profiles in UC and compare them with controls.

Methods A prospective study was conducted at our university from February 2021 to June 2022. Patients underwent clinical evaluation, endoscopy (Mayo-Score assessment) and blood investigations after consent. Patients undergoing colonoscopy for indication other than UC without colonic inflammation were taken as controls. Mucosal biopsies were taken from inflamed and adjacent non-inflamed areas for bacterial and fungal culture. Stool was evaluated for microscopy, culture, and PCR (E coli and Entamoeba histolytica).

Results Seventy-eight cases (51 active; 27 in remission) and 33 controls were included. Mucosal bacterial culture in patients with severe UC more often grew organisms than controls (15/18 [83.3%] vs. 14/30 [46.7%]; p=0.01). Mucosal bacterial culture in severe UC more often grew organisms than non-severe disease (15/18 [83.3%] vs. 30/52 [57.7%]; p= 0.05). Stool bacterial culture was similar between cases and control (p=0.97). Patients with UC more often had stool PCR positivity for E. histolytica compared to controls (14/54 [25.9%] vs. 2/25 [8%]; p=0.065). Stool fungal culture was more often positive in those with active UC compared to controls (23/31 [74.3%] vs. 14/28 [50%]; p=0.055). Patients with severe UC more often grew pathogenic organisms either one of bacteria/fungi/E. histolytica or both or all compared to controls (p=0.037). Inflamed mucosa more often grew pathogenic bacteria and fungi compared to adjacent normal looking mucosa (p= 0.039).

Conclusion Mucosal culture from patients grew more often pathogenic organisms and stool PCR positivity for E. histolytica than controls. Inflamed areas more often grew pathogenic organisms compared to adjacent normal mucosa. Careful assessment to exclude infection is required before starting immunosuppression.

Keywords Inflammatory bowel disease, Microbiota, Multiplex PCR

110

Clinical profile and outcomes of Cytomegalovirus colitis in acute severe ulcerative colitis

Ashis Choudhury , Anoop John, Rajeeb Jaleel, Reuben Thomas Kurien, Sudipta Dhar Chowdhury, Amit Kumar Dutta, Ebby George Simon, A J Joseph

Correspondence – Anoop John - johny316@gmail.com

Department of Gastroenterology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Cytomegalovirus (CMV) infection is common in ulcerative colitis and has been shown to be potentially harmful. This 12-year retrospective observational study aims to find o the prevalence, clinical profile and outcomes of CMV colitis in patients admitted with flare of ulcerative colitis.

Methods All patients admitted to Department of Gastroenterology, Christian Medical Collge, Vellore between 2010 and 2022 with a flare of ulcerative colitis were included. Data analysis was done with regards to their clinical presentation, diagnostic profile, treatment, and outcomes. CMV superinfection was diagnosed if any of the three tests were positive i. e. CMV PCR in colonic biopsy or blood and colonic histopathology.

Results Among 360 patients with acute flare of ulcerative colitis, 127 (35.2%) had confirmed CMV infection and in 188 (52.2%) CMV was ruled out. Forty-five (12.5%) patients were excluded due to incomplete evaluation. Eleven patients with histological evidence of CMV improved without any antiviral treatment. Twenty-seven (21.2%) patients were treated for CMV with antivirals. Among the patients treated, 16 were female (59.2%), mean age was 36.7 years (15-63), median duration of hospital stay was 19 days (4-56) and antivirals were initiated at median 8th day (2-26) of hospital stay. Patients were treated with ganciclovir and/or valganciclovir. Out of the 27 patients who were treated for CMV, 20 (74.07%) patients improved, 4 (14.8%) patients underwent subtotal colectomy, 2 (7.4%) patients discharged in a moribund state after failure of medical treatment and 1 (3.7%) patient died. 8 (29.6%) patients developed leukopenia/thrombocytopenia on treatment of which one required G-CSF treatment, one required withholding antivirals for a few days and remaining 6 were continued on the drug with careful monitoring.

Conclusion Medical antiviral therapy for CMV was usually well tolerated among ulcerative colitis patients; however, CMV superinfection was associated with poor outcomes.

Keywords CMV colitis, Superinfection, Ulcerative colitis

111

Relationship of colonic mucosa associated microbial profile and disease activity in patients of ulcerative colitis

Bigyan Maharjan ¹ , Anurag Sachan ² , Anuraag Jena ² , Pallab Ray ³ , Neelam Taneja ³ , M R Shivaprakash ³ , Mini P Singh ⁴ , Devyani Sharma ⁵ , Anupam Kumar Singh ¹ , Vishal Sharma ¹ , Kaushal Kishor Prasad ¹ , Arun Kumar Sharma ¹ , Rakesh Sehgal ⁵ , Usha Dutta ²

Correspondence – Usha Dutta - ushadutta@gmail.com

Departments of ¹Internal Medicine, ²Gastroenterology, ³Medical Microbiology, ⁴Virology, and ⁵Medical Parasitology, Level 4, F Block, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India

Background and Aim Mucosa associated microbes are shown to drive the gut inflammation and their role in disease activity in ulcerative colitis (UC) is largely unknown. We planned to study fecal and mucosa associated microbial profile in these patients and compare with those in remission and controls.

Methods Prospective study was conducted at our university hospital (February 2021-June 2022). Patients underwent clinical evaluation, endoscopic assessment, and laboratory investigations after informed consent. Patients without any colonic inflammation undergoing colonscopy were enrolled as controls. Mucosal biopsies were taken from inflamed mucosa and adjacent non-inflammed areas for bacterial and fungal culture. Stool was evaluated for microscopy, culture, Multiplex PCR for diarrhogenic E. coli and PCR for Entamoebahistolytica.

Results The mean age and gender of the cases (n=78; 51 active disease and 27 in remission) and control (n=33) was similar. Mucosal bacterial culture in patients with severe UC more often grew organisms than controls (15/18 [83.3%] vs. 14/30 [46.7%]; p=0.01) and those with non-severe disease (15/18 [83.3%] vs. 30/52 [57.7%]; p=0.05). Inflammed mucosa more often grew pathogenic bacteria and fungi compared to adjacent normal looking mucosa (p= 0.039). Patient with UC had numerically higher stool PCR positivity for E. histolytica compared to controls (14/54 [25.9%] vs. 2/25 [8%]; p=0.065). Stool fungal culture positivity was numerically higher in those with active UC compared to controls (23/31 [74.3%] vs. 14/28 [50%]; p=0.055). Patients with severe UC more often grew pathogenic bacteria/fungi were PCR positive for E. histolytica compared to controls (20/22 [90.9%] vs. 23/33 [69.7%]; p=0.037). However, stool bacterial culture was similar between cases and control (p=0.97).

Conclusion Mucosa associated microbial profile in patients with UC more often showed presence of infection than controls. Inflammed segments of colon more often grew pathogenic bacteria and fungi compared to adjacent relatively normal looking mucosa.

Keywords Inflammatory bowel disease, Microbiota, Multiplex PCR

112

Ulcerative colitis-associated inflammation and fecal microbiota transplantation drive compositional alterations in the relatively conserved human colonic crypt-associated microbiota

Manasvini Markandey ¹ , Aditya Bajaj ² , Mahak Verma ² , Preksha Gaur ³ , Shubi Virmani ² , Mukesh Singh ² , Prasenjit Das ² , Chittur Srikanth ³ , Dhiraj Kumar ⁴ , Saurabh Kedia ² , Vineet Ahuja ¹

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Departments of ¹Gastroenterology, New Private Ward, ²All India Institute of Medical Sciences, Ansari Nagar East, New Delhi 110 029, India, ³Regional Centre for Biotechnology, 3rd Milestone, Faridabad-Gurgaon Expressway, Faridabad Road, Faridabad 121 001, India, and ⁴Cellular Immunology Group, International Centre for Genetic Engineering and Biotechnology, Aruna Asaf Ali Marg, New Delhi 110 067, India

Introduction Intestinal crypts form a pristine gut biogeographical niche, homing the intestinal stem cells and being the closest neighbours to underlying lamina propria. Initially believed to be sterile, the crypt lumen was recently shown to inhabit a conserved microbial population. However, identity of the crypt-associated microbiota (CAM) remains elusive. Present study is among the first to illustrate the CAM composition in health and its deviation during ulcerative colitis (UC), and the effect of fecal microbiota transplantation (FMT) on the structure of this community.

Methods Recto-sigmoidal biopsies from controls, and from patients with mild-moderate UC before and after FMT, (n=26) were subjected to methacarn-fixation, followed by paraffin-embedding, sectioning and laser-capture microdissection-assisted crypt isolation. DNA isolated from micro-dissected samples was subjected to 16S rRNA gene sequencing. The bacterial presence in colonic crypts was confirmed using fluorescence in-situ hybridization. Microbiome data analysis was carried out by using QIIME2 and R packages.

Results Colonic crypts were found to be sparsely inhabited by bacterial cells in both control and diseased tissue samples. 16S-amplicon sequencing revealed a unique bacterial community, distinct from MAM, with an over-representation of aerobic Actinobacteria (Cutibacterium, Rothia, Prausenella) and Proteobacteria (Sphingobium, Paracoccus, Skermanella) members. The community displays significant resilience to UC-associated inflammation and also to the microbiome restorative effects of FMT, except for minor alterations, as evident from the similar α and β-diversity indices and unperturbed core members across the control, disease and treatment groups. UC mediated addition of Prauserella and loss of Cutibacterium from CAM, while FMT resulted in addition of Sphingobium, Paracoccus, Kocuria and Cutibacterium, accompanied by loss of Lawsonella and Paracoccus.

Conclusions A gut bacterial community, enriched in aerobic bacteria, resides in the colonic crypts, and undergoes taxa-level alterations during UC and in response to FMT.

Keywords Crypt-associated microbiota, Fecal microbiota transplantation, Laser capture microdissection, Ulcerative colitis

113

Fecal microbiota transplantation in patients with mild to moderate ulcerative colitis is associated with early clinical response in a real-world setting

Vineet Ahuja , Shubi Virmani, Bhaskar Kante, Sudheer Kumar, Peeyush Kumar, Mukesh Singh, Govind K Makharia, Saurabh Kedia

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Background Fecal microbial transplantation (FMT) is efficacious in patients with ulcerative colitis (UC). There is a large knowledge gap in the number of FMT sessions required for the response and timing of the response to FMT.

Methods In this open-label, single center (All India Institute of Medical Sciences, New Delhi, 2019-2022) study, patients with mild-moderate UC who were refractory to conventional therapy were subjected to FMT. Patients received up to 7 sessions of freshly prepared FMT once a week, administered colonoscopically. Clinical assessment using SCCAI (simple clinical colitis activity index) was done at each follow-up FMT session for 8 weeks. Clinical remission is defined as SCCAI ≤ 3 and response as the decrease in SCCAI scores by 3 points.

Results Forty-one patients of active UC (mean age 33.9±11.05 years, 61% males, the median duration of disease 48 months, 63.4% left side colitis, 36.6% pancolitis, median SCCAI at baseline 6) were included, of which 26 (63.4%) had a clinical response, and 23 (56%) had clinical remission at week 8. Twenty patients (48.8%) were early responders with the median time to achieve clinical response as early as 1 week. There was no significant difference in baseline demographic, clinical, endoscopic and laboratory features between responders and non-responders at week 1. There was a significant improvement in PRO (patient reported outcome) scores at week 1 correlating the early clinical response.

Conclusion Half of the patients with mild to moderate UC refractory to conventional therapy achieved clinical response on FMT as early as 1 week. Studies including a large number of patients are required to assess the predictors of early response including the microbiota characteristics.

Keywords Fecal microbiota transplantation, Ulcerative colitis

114

Long-term efficacy and safety of fecal microbiota transplantation in patients with mild to moderate ulcerative colitis

Vineet Ahuja , Shubi Virmani, David Mathew, Bhaskar Kante, Sudheer Kumar, Peeyush Kumar, Sandeep Mundhra, Mukesh Singh, Govind K Makharia, Saurabh Kedia

Correspondence – Vineet Ahuja - vineet.aiims@gmail.com

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Background Studies on fecal microbiota transplantation (FMT) as induction therapy in patients with ulcerative colitis (UC) have shown success yet reports on long-term outcomes including efficacy and safety are lacking, which were evaluated in this study.

Methods In this retrospective analysis, patients with mild-moderate UC were administered weekly/twice weekly FMT (freshly prepared through colonoscopy) in addition to standard of care between July 2017-March 2020. Short-term response was assessed using clinical/endoscopic indices and long-term response was assessed in terms of steroid use, biological requirement, colectomy, or hospitalization. Primary outcome was long-term safety (multi-drug resistant infection (MDR), infection requiring hospitalization or development of any new medical condition) and efficacy (long-term composite relapse requiring biologicals/oral steroids/colectomy/hospitalization).

Results Twenty-six patients were included (mean age-33.42±9.47 years, males-50%, median SCCAI 7 [5-8] and UCEIS-5 [3-6]). Patients received median of 5 (2-7) FMT sessions. Fifty percent and 30.7% patients achieved clinical response and remission, and endoscopic response and remission were noted in 46.1% (n=12/26) and 26.9% (n=7/26) patients respectively at 8 weeks. Median follow-up duration after FMT was 42 (range - 27–57) months. Fourteen patients (53.8%) experienced composite long-term relapse at a median duration of 6 months (range:3 – 40). Among clinical responders, the proportion of patients free of long-term relapse at 6, 12, 24, 36 and 48 months were 92.3%, 76.9%, 69.3%, 80%, and 66.7% respectively. No patient developed MDR infection, infection requiring hospitalization or any new medical condition.

Conclusion No new safety signal was reported after a reasonably long follow-up period of FMT. However, <50% were free of long-term composite relapse requiring biologicals/oral steroids/colectomy/hospitalization.

Keywords Fecal microbiota transplantation, Ulcerative colitis

Liver

115

Real-world evaluation of response to conventional hepatitis B vaccination strategy in cirrhosis- A brief report

Mayank Jain

Correspondence - Mayank Jain - mayank4670@rediffmail.com

Department of Gastroenterology, Arihant Hospital and Research Centre, 297 Indrapuri, Near Bhanwarkuan, Indore 452 001, India

Introduction The response rates to hepatitis B vaccination in adult patients with cirrhosis range from 16% to 79% in different populations. The aim was to determine response rates to hepatitis B vaccination and its determinants in adult patients with cirrhosis of liver.

Methods Patient inclusion-Adult patients (>18 years) with cirrhosis of liver were screened for HBsAg, anti-HBc and anti-HBs. Those who were negative for all were advised vaccination. Patient exclusion- We excluded patients who were known HBsAg positive, on oral antiviral drugs, who did not complete the recommended vaccination schedule and those who were lost to follow-up. Vaccination strategy-for vaccine naïve patients, dose of 20 mcg intramuscular in deltoid region was administered at 0, 1 and 6 months. For those with prior history of vaccination but negative anti-HBs titres, dose of 40 mcg was used at 0, 1 and 6 months.

Definition of response-Patients with anti-HBs titres >10 IU/L were considered responders and those with titres <10 IU/L were labelled as non-responders.

Baseline demographic parameters, anthropometry, Model of end-stage liver disease (MELD) score and history of prior vaccination were compared between the two groups.

Statistical tests used were numbers, percentages, Chi-square test and Mann-Whitney U test. A p value of <0.05 was considered significant.

Results The study cohort included 164 patients- median age 43 (18-68) years and 67% males (110). On follow-up at 2 months after last dose of vaccination, 103 (62.8%) had anti-HBs titre >10 IU/L. Of these, 54 (52.4%) had titres >100 and 49 (47.6%) had titres ranging from 10-99. Non-responders were significantly older than responders (48 vs. 41 years, p 0.01).

Conclusion The response rate to hepatitis B vaccination in adult patients with cirrhosis of liver is 62.8%. Older patients are more likely to be non-responders.

Keywords Cirrhosis, Hepatitis, Infection, Prevention, Vaccination

116

Standard volume plasma exchange is safe and effective for patients with acute liver failure

Moiz MD Vora, Anand V Kulkarni, Nagaraja Rao Padaki, Kalyan Rakam, Pragati Naik, Baqar Ali Gora, Sameer Shaikh, Anand Gupta, Sowmya Iyenger, Mithun Sharma, Rajesh Gupta, Nageshwar Reddy

Correspondence – Moiz Vora - moiz_vora@yahoo.com

Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Mindspace Road, AIG Hospital, Hyderabad 500 032, India

Background Plasma exchange (PLEX) is an effective bridging therapy for patients with acute liver failure (ALF).There are no studies comparing the efficacy of standard volume (SV) vs. high volume (HV) PLEX. Therefore, we aimed to compare the safety and efficacy of SV with HV-PLEX.

Methods Patients with ALF who underwent PLEX were included in this retrospective study. The primary outcome was to compare the transplant-free survival among SV and HV-PLEX groups at 30-days. Secondary objectives were to compare the effect of SV and HV-PLEX on total bilirubin, INR, ammonia levels, SOFA and MELD Na scores, and to assess the adverse events related to PLEX.

Results A total of 17 patients underwent PLEX:SV-8 and HV-9. The mean age and severity scores were similar among both the groups. Most common cause of ALF was viral (50% in SV vs. 44.45% in HV) in each group. 50% in SV and 34% in HV group satisfied King’s College Criteria for liver transplantation (p=0.41). Each patient in both the groups underwent a median of 2 sessions of PLEX. There was a significant decrease in serum bilirubin levels and prothrombin time in both the groups post-PLEX. Post-PLEX, the change in total bilirubin, INR, ammonia, SOFA, and MELD Na score was comparable (Fig. A). Mortality at seven days was similar among both groups (SV-12.5% vs. 33.3% in HV; p=0.57). Mortality at day 30 was 25% in SV compared to 67% in the HV group (p=0.1). On Kaplan Meier analysis, transplant-free survival at day 30 was similar in both the groups (p=0.26) (Fig. B). Two patients in the HV group developed volume overload features and were managed conservatively compared to none in the single volume group.

Conclusions Standard volume plasma exchange has similar efficacy as high-volume plasma exchange on severity scores. Standard volume plasma exchange is safe and effective for patients with acute liver failure.

Keywords Acute liver failure, Effective, High volume and single volume plasma exchange

117

Prevalence of sarcopenia in patients with chronic liver disease and its correlation with Child-Turcotte-Pugh and model for end-stage liver disease scores

Nitin Bhople , Deepak Lahoti

Correspondence - Deepak Lahoti - deepaklahoti@hotmail.com

Department of Gastroenterology, Max Super Speciality Hospital Patparganj, A-108, Indraprastha, Extn, Patparganj, Delhi 110 092, India

Introduction Sarcopenia is common problem in patients with chronic liver disease (CLD). There is scarcity of data in Indian population. To study prevalence and correlation of sarcopenia with model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) score in Indian population. A total of 103 patients with CLD were enrolled over a period of 18 months.

Methods Sarcopenia was evaluated by Hand grip strength (HGS), Psoas muscle index (PMI) using CT scan, 4-meter walk test (4 MW - Gait speed) and the results were taken into consideration for calculation of probable, confirmed, severe sarcopenia respectively. Correlation of sarcopenia with various stages of CLD was based on CTP and MELD scores obtained. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0 software using appropriate tests. For all statistical tests, p value less than 0.05 was taken to indicate a significant difference.

Results Study group comprised of 35% female and 65% male. Mean average PSOAS area was 704.44, mean PMI was 254.73, mean HGS was 25.78, mean 4 MW was 1.77 and mean MELD score was 18.03. Sarcopenia prevalence was 55.3% in CTP C, 31.6% in CTP B and 13.2% in CTP A. Significant worsening of sarcopenia was noted with higher scores of CTP class and MELD scores. We found the prevalence of sarcopenia based on HGS (probable) to be 36.89%, according to PMI (confirmed) to be 33.1%, 4 MW (severe) test to be 19.4%.

Conclusions Sarcopenia is very common in patient with CLD in Indian population. Its severity seems to be worsened with stage of liver disease.

Keywords CTP score, MELD score, Sarcopenia

118

Treatment of amebic liver abscess: Comparison of catheter drainage and single time percutaneous needle aspiration: Randomized controlled trial

Kapil Mohata, Sandeep Nijhawan

Correspondence – Sandeep Nijhawan - sandeepnijhawan16@gmail.com

Department of Gastroenterology, Sawai Man Singh Medical College, New SMS Campus Road, Gangawal Park, Adarsh Nagar, Jaipur 302 004, India

Background and Aims Treatment of liver abscesses comprises combination of antibiotics and image guided percutaneous needle aspiration (PNA) or percutaneous catheter drainage (PCD). There is debate regarding choice of these interventions as first line of management. Aim was to compare results of ultrasound guided PCD with single time PNA to evaluate the clinical and radiological resolution.

Methods Fifty patients (42 males; 8 females, 18–65 years) who were diagnosed with amebic liver abscess (>6 cm in size) divided into two groups of 25 patients each, namely single time PNA group (Group A) and the PCD (Group B). Effectiveness of either treatment was measured in terms of duration of hospital stay, days to achieve clinical improvement, 50% reduction in abscess cavity size and total/near total resolution of abscess cavity. The patients were followed up every week for a month and every month for 6 months.

Results Single time PNA was effective in 16 (64%) of the 25 patients while PCD was therapeutic in 23 (92%), without any major complications. Patients in group B showed earlier clinical improvement then group A (7 days vs. 21 days), 50% reduction in volume of abscess cavity (7 days vs. 28 days) and total resolution of abscess cavity was found significantly earlier in group B then group A (35 days vs. 90 days). Average hospital stay in B and A group was (2.3 days and 3.8 days) respectively. Baseline TLC, LFT was comparable in both groups.

Conclusion PCD is better than single time PNA in treatment of larger liver abscesses.

Keywords Percutaneous needle aspiration, Percutaneous catheter drainage

119

To study the prevalence of spontaneous portosystemic shunts in decompensated cirrhosis patients and its relationship with cirrhosis related complications – A prospective study

Deepanshu Khanna, Rishabh Kothari, Premashish Kar

Correspondence – Premashish Kar - premashishkar@gmail.com

Department of Gastroenterology, Max Superspeciality Hospital, Vaishali, Gurgaon 122 001, India

Introduction Spontaneous portosystemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis complications. This study is done to detect the prevalence of portosystemic shunts in liver cirrhosis patients and analyze its prognostic role.

Method We conducted a prospective observational study where ninety-two patients with decompensated cirrhosis were evaluated based on history, physical examination, biochemical tests, and abdominal CT angiography findings. Follow-up was done after 6 months for development of cirrhosis-related complications.

Results Out of the 92 cirrhotic patients, 57.6% of patients had SPSS (L-SPSS + S-SPSS) detected by multi-detector computed tomography (MDCT) angiography. Overall, we found L-SPSS in 24 (26.1%) patient, S-SPSS in 29 (31.5%) patients and no shunt identified in 39 (42.4%) patients. Of all patients, splenorenal shunt 25 (27.2%) is the most frequent type followed by paraumbilical shunt (20.7%). Previous decompensating events including hepatic encephalopathy (HE), ascites, SBP and gastrointestinal bleed were experienced more frequently by the L-SPSS group followed by S-SPSS and W-SPSS group. Regarding follow-up, decompensating events episodes of HE developed more frequently in patients with L-SPSS 10 (41.7%) than patients with S-SPSS 7 (24.1%) followed by W-SPSS 5 (12.8%).

Conclusion In summary, all cirrhotic patients should be studied with radiological imaging in order to detect the presence of portosystemic shunt. In several cases, patients with large SPSS had a more impaired liver function and more frequent complications of portal hypertension so these patients would probably benefit from a closer surveillance and more intensive therapy. Moreover, the identification of SPSS became crucial in selected cases, in which the embolization of large SPSS may be associated with improved survival and liver function, as well as preventing the recurrence of HE or variceal bleeding.

Keywords Hepatic encephalopathy, Liver cirrhosis, Portal hypertension, Spontaneous portosystemic shunts, Varices

120

Acute Cytomegalovirus hepatitis in an immunocompetent adult in tertiary care center

Vinay V, M Juned Khan

Correspondence – Vinay V - vinay.hvr4@gmail.com

Department of Medical Gastroenterology, GEM Hospital, 45, Pankaja Mills Road, Palaniappa Nagar, Sowripalayam Pirivu, Ramanathapuram 641 045, India

Objective Challenging differential diagnosis.

Introduction Acute Cytomegalovirus (CMV) virus has an incubation period of about 4 to 6 weeks. Symptoms of CMV infection vary and depend on factors including the age and immune status of the patient. It usually presents as asymptomatic infection in immuno-competent individuals whereas severe disease is usually seen in immunocompromised patients.

Case Report Fifty-three-year-old male patient known case of chronic liver disease. Patient is known alcoholic consumes alcohol occasionally. Presented with history of yellowish discoloration, itching, swelling of abdomen since 3 weeks. History of alternative medication was present. Treatment history was 2 cycles of plasma exchange. Patient was referred to our hospital for liver transplant. Routine etiology was normal, non hepatotrophic viruses work was sent. CMV IgM and IgG was positive. Trans jugular liver biopsy was done which showed inclusion bodies.

Results The patient was treated with valganciclovir that resulted in rapid improvement in clinical status as well as normalization of the liver enzymes. Patient is being followed up on monthly basis now liver function test is normalized. Patient has be delisted form transplant list.

Conclusion This case report presents a rare case; of immunocompetent; male with acute CMV hepatitis who responded favorably to antiviral therapy.

Keywords Cytomegalovirus hepatitis, Immunocompetent, Liver transplant

121

Severe persistent steroid refractory cholestatic viral hepatitis A: Mycophenolate sodium to rescue. A case series

Pathik Parikh

Correspondence - Pathik Parikh - pathik269@gmail.com

Department of Hepatology and Liver Transplant, Zydus Hospitals, Zydus Hospitals Road, Sarkhej - Gandhinagar Highway, Sola, Ahmedabad 380 054, India

Introduction Hepatitis A is usually a self-limiting illness. However, rarely it leads to persistent jaundice with pruritus. None of the pharmacological agents have been proven to be useful. This leads to significant deterioration in quality of life of the patients. As treating physicians, we need to think out of the box to alleviate their symptoms. We report here a case series of 5 patients who responded to mycophenolate sodium

Case Series Five patients with acute hepatitis A have been included. The median age was 45 years and 3/5 were males. The mean duration of jaundice was 58 days. All patients had jaundice and severe pruritus. The mean bilirubin was 35 mg/dL. The presentation parameters are described in Table 1. The alternate etiological workup, liver ultrasound and liver biopsies were carried out in all. All patients were treated with symptomatic treatment, antihistaminic, cholestyramine, ondansetron, sertraline, ursodeoxycholic acid and multi vitamins. All patients received steroids for minimum 2 weeks before presentation. Two patients underwent therapeutic plasma exchange for 3 cycles without prolonged benefit. All patients were started on Mycophenolate sodium 720 mg per day in two divided doses. All 5 patients showed consistent improvement in symptoms and biochemistry with normalization of liver tests in median 5 weeks duration. None of the patients developed any drug related adverse effects.

Discussion The mechanisms of liver injury in hepatitis A remain incompletely understood. While virus-specific CD8+T cells have long been considered a major cause of HAV-induced liver injury. MMF inhibits de novo purine synthesis, which is indispensable for the proliferation of lymphocytes, induces the apoptosis of activated T cells, suppresses the production of pro-inflammatory cytokines, and augments regulatory T cells thereby halting the ongoing hepatocyte damage. Further studies are warranted to validate our findings.

Keywords Jaundice, MMF, Pruritus, Viral hepatitis

122

A case report of abdominal wall hematoma in a case of decompensated chronic liver disease with ascites and overt gastrointestinal bleeding post diagnostic paracentesis

Suraj Kumar, Bhashyakarla Ramesh Kumar, Malladi Uma Devi, Sahitya Reddy, Venkannagari Vikas Reddy, Zeeshan Ali Mohammed, Rahul Vijay Vargiya

Correspondence - Suraj Kumar - surajkumarcsk6@gmail.com

Department of Medical Gastroenterology, Osmania General Hospital, 15-5-104, Begum Bazar, Afzal Gunj, Hyderabad 500 012, India

Introduction Ascites complicating cirrhosis is associated with poor prognosis. Hemorrhagic complications are rare events after paracentesis despite coagulopathy. Performing the procedure under ultrasound guidance can decrease the risk of such complications.

Methods A 60-year-old female with hypertension presented with jaundice since two-months, abdominal distension and swelling of both lower limbs for 10 days, melena for 3 days, decline in urine output for 3 days. No history of alcohol consumption, known liver disease, transfusions, tattooing, family history of liver disease in the past.

Results Hemoglobin 6 g/dL, WBC 6500/mm³, platelet 2.8 L/mm³, serum bilirubin 10.58 mg/dL, direct bilirubin 7 mg/dL, AST 446 U/L, ALT 138 U/L, ALP 378 U/L, albumin 2 g/dL, BUN 9 mg/dL, serum creatinine 1 mg/dL, serum Na 130 meq/L, serum K 3.7 meq/L, serum chloride 102 mEq/L, HIV, HBsAg, HCV - non reactive; prothrombin time 21 sec, ascitic fluid analysis – clear pale yellow colored fluid, 26 WBC/mm³, No RBCs, SAAG 1.66, protein – 0.84 g/dL, ADA – 18 U/L, culture sterile. USG showed cirrhosis of liver with gross ascites; endoscopy showed low-grade esophageal varices, mild portal hypertensive gastropathy; ECG normal, 2D Echo showed concentric LVH. Her CTP - 12, MELD-Na score - 29 points. 8 hours post paracentesis patient had pain and swelling over the site of paracentesis worsening over next 5 hours for which patient underwent non contrast CT scan of abdomen revealed hyperdense collection of 25 cm*5.5 cm*5.4 cm in the intermuscular plane in left anterior abdominal wall extending from left lumbar to left iliac fossa region - abdominal wall hematoma with gross ascites and cirrhosis of liver. Despite best efforts patient succumbed within next 24 hours.

Conclusions Hemorrhagic complications despite being a rare event need to be diagnosed and treated early because it can be rapidly fatal which can be avoided by USG guided procedure. This case also brings up the question whether patients undergoing paracentesis need to undergo tests like thromboelastography for better risk stratification.

Keywords Abdominal paracentesis, Abdominal wall hematoma, Ascites

123

Seroprevalence of hepatitis B virus among pregnant women in India: A systematic review and meta-analysis

Suprabhat Giri ¹ , Shradhanjali Sahoo¹, Sumaswi Angadi¹, Shivaraj Afzalpurkar², Sridhar Sundaram³, Sukanya Bhrugumalla¹

Correspondence - Suprabhat Giri - supg19167@gmail.com

¹Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta Road, Punjagutta Market, Punjagutta, Hyderabad 500 082, India ²Apollo Multispecialty Hospital, 58, Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata 700 054, India and ³Tata Memorial Hospital, Parel East, Parel, Mumbai 400 012, India

Objectives Hepatitis B virus (HBV) infection during pregnancy is associated with perinatal transmission contributing to the pool of HBV infection in the population. There is a wide variation in the reported data on the seroprevalence of hepatitis B virus in pregnant patients from various parts of India. Hence, a systematic review and meta-analysis was conducted to determine the pooled seroprevalence of HBV and its associated demographic factors.

Methods A comprehensive literature search of Medline, Scopus, and Google Scholar was conducted from January 2000 till April 2022 for studies evaluating the prevalence of HBV in pregnant patients from India.

Results A total of 44 studies with data on 272,595 patients were included in the meta-analysis. The pooled prevalence of hepatitis B surface antigen (HBsAg) in pregnant women was 1.6% (95% confidence interval [CI], 1.4 – 1.8). Among patients with HBsAg positivity, the pooled prevalence of hepatitis B e antigen was 26.0% (95% CI 17.4 – 34.7). There was no significant difference in the odds of HBV seroprevalence based on the age (< 25 years vs. > 25 years) (Odds ratio [OR] 1.07, 95% CI 0.74 – 1.55), parity (primipara vs. multipara) (OR 1.09, 95% CI 0.70 – 1.70) or area of residence (urban vs. rural) (OR 0.88, 95% CI 0.56 – 1.39). However, the odds of HBV seroprevalence in those with no or primary education was higher than in those with secondary level education or higher (OR 2.29, 95% CI 1.24 – 4.23). Prior history of risk factors was present in 13.5% to 22.7% of patients indicating a vertical mode of acquisition.

Conclusion There is a low endemicity of HBV among pregnant women in India. Risk factors are seen in less than 25% of the cases, indicating vertical transmission as the predominant mode of acquisition, which can be reduced by improving vaccination coverage.

Keywords Epidemiology, Hepatitis B, Meta-analysis, Pregnancy

124

Biopsy proven liver injury induced by DPP4 inhibitors: Report of two cases

Naveen Make, B S Ramakrishna, Babu Vinish, Rohan Yewale, Kayalvizhi Jayaraman, Parag Papalkar

Correspondence - Naveen Make - navnchand9@gmail.com

Department of Medical Gastroenterology, SIMS Institute for Medical Sciences, SRM Institutes for Medical Sciences, Metro No.1, Jawaharlal Nehru Road, Landmark, next to Vadapalani, Chennai 600 026, India

Diabetes mellitus is a very common disease and dipeptidyl-peptidase-4 (DPP-4) inhibitors are one of the commonly used oral antihyperglycemic agents for diabetes. DPP-4 inhibitors blocks the degradation of incretin and enhances incretin levels, which stimulate insulin secretion and decreases glucagon production. They are effective in lowering glycosylated hemoglobin (Hb A1c) and improves fasting and postprandial glucose levels DPP-4 inhibitors have a favorable safety profile in clinical trials. Further investigation is needed as rare side effects arise in post-marketing surveillance. Some important but rare side effects of DPP-4 inhibitors are a potential risk for pancreatitis and thyroid cancer. In clinical practice, a drug-induced liver injury is not a common side effect in patients taking DPP-4 inhibitors. We report two cases of drug-induced liver injury caused by sitagliptin and teneligliptin. Our patients developed hepatocellular and cholestatic type of injury. The diagnosis was based upon the temporal relationship of drugs and altered liver enzymes, subsequent improvement of liver enzymes upon discontinuation of the medication and liver biopsy findings suggestive of drug induced liver injury. Clinicians must be aware of the rare but potential consequence of liver injury from DPP4 inhibitors

Keywords Diabetes mellitus, Dipeptidyl peptidase-4 inhibitors, Drug induced liver injury

125

A case of severe alcoholic hepatitis with leukemoid reaction

Vinoth Sermadurai, Kannan Mariappan, Ramani Ratinavel, Vijai Shankar Chidambara Manivasagam, P B Sriram

Correspondence – Vijai Shankar Chidambara - manivasagam-vijaishankar.c@gmail.com

Department of Medical Gastroenterology, Madurai Medical College, Panagal Road, Alwarpuram, Madurai 625 020, India

Alcoholic hepatitis is a pro-inflammatory liver disease associated with short-term morbidity and mortality. The pathophysiology behind alcoholic hepatitis is attributed to oxidative stress, impairment of fatty acid oxidation, and generation of reactive oxygen species. Hematologic abnormalities are rather common in moderate-to-severe alcoholic hepatitis, with moderate leukocytosis (<20,000/uL) a frequent finding in these cases. Leukamoid reaction can occur in patients with severe alcoholic hepatitis and was poor prognositc sign. A 35-year-old male admitted with complaints of jaundice for the past 2 months not associated with prodromes and cholestatic features with moderate ascites, no history of hematemesis and malena, no overt hepatic encephalopathy. On evaluation total count was 50000 cells/mm³, total bilirubin 34.5 mg/dL, direct 20.2 gmg/dL:, AST 80 U/L, ALT 32 U/L, PTINR 2.5, urea 46 mg/dL, serum creatinine 1.2 mg/dL, blood culture, urine culture were negative, CT chest was normal, CT abdomen showed fatty liver, OGD was normal, serum procalcitonin was 0.9. Patient was treated with IV antibiotics and total count was persistently high, Bone marrow was normocellular marrow and no blast or atypical cells. Patient was started on Tab. Prednisolone 40 mg/day and day 7 total bilirubin 30.1 and total count was reduced to 27300 cells/mm³ at day 7. Patient was discharged and on follow-up. Patients with severe alcoholic hepatitis can present with high leukocyte count and after ruling out sepsis, patient can be started on steroids.

Keywords Leukemoid reaction, Severe alcoholic hepatitis, Steroids

126

Prevalence of sarcopenia and its correlation with clinical outcomes in chronic liver disease patients

Padma Lochan Prusty, Shivaram Prasad Singh, Sarthak Swarup, Prajna Anirvan

Correspondence - Padma Prusty - padmalochanprusty1989@gmail.com

Department of Gastroenterology, Srirama Chandra Bhanja Medical College, Behera Colony, Mangalabag, Cuttack 753 001, India

Background and Objectives Sarcopenia is common in patients with chronic liver disease (CLD) and is characterized by decline in muscle mass, muscle strength, and physical performance and often leads to poor clinical outcomes. We aimed to determine the prevalence of sarcopenia and assess the clinical impact of sarcopenia on CLD patients.

Methods One hundred and one consecutive CLD patients were assessed clinically (hand grip strength, chair stand test, gait speed test) and radiologically (CT scan of abdomen l3 smi, ultrasound of both thigh muscles using mean rectus muscle area) for evaluation of sarcopenia.

Results The prevalence of sarcopenia was found to be 72.3%. Majority of the patients were males (88.1%) with a mean age of 47.91; 9.69 years. There was no difference in the prevalence of sarcopenia with regard to etiology of CLD (alcohol related vs viral etiology). The proportion of p atients with sarcopenia was significantly higher in patients with CTP-B and C cirrhosis (p value;0.005). Serum albumin levels were significantly lower in patients with sarcopenia. CT l3 smi score and mean rectus muscle area were significantly lower in patients with sarcopenia (p value;0.005). CT l3 smi score of 46.65 cm/m² and mean rectus muscle area of 2.36 cm² had a sensitivity and specificity of 93% and 94% and 82% and 81% respectively in diagnosing sarcopenia. Aurocs of CT l3 smi and mean rectus muscle area were 0.95 and 0.85 respectively. Mortality and number of hospitalizations were significantly higher in patients with confirmed and severe sarcopenia (p value;0.005). However, on multivariate analysis only male sex and CTP score were independent predictors of mortality.

Conclusion Presence of sarcopenia is significantly associated with greater number of hospitalizations and mortality. CT l3 smi and mean rectus muscle area on USG can be used to assess sarcopenia with considerable accuracy.

Keywords l3 smi, Rectus muscle area, Sarcopenia

127

Platelet-albumin-bilirubin scoring system in predicting outcome of acute variceal bleeding in patients with cirrhosis

Anupama Swarna, Murali R, Aravind A, Caroline Selvi K, Premkumar K, Chezhian A, Muthu Kumaran, Shubha I

Correspondence - Anupama Swarna - anupama.swarna92@gmail.com

Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India

Introduction Acute variceal bleeding is a frequent, ominous complication of liver cirrhosis and portal hypertension and is responsible for high morbidity and mortality. There are several scoring systems to predict outcome in variceal bleeds, each with its own limitations. This report, however, evaluates the predictive power of rebleeding of the Platelets-Albumin-Bilirubin (PALBI) score in patients with cirrhosis presenting with acute variceal bleeding.

Methods All the patients who attended to our hospital with acute variceal bleed from 2021-2022 were included in the study. Subjects underwent upper GI endoscopy. Patients were followed for 90 d after the control of acute bleeding for occurrence of rebleeding. PALBI scores were calculated from admission labs, and correlated with control of bleeding, rebleeding. Subjects were divided into PALBI 1, 2 and 3 groups and assessed for 90 d rebleeding rates. Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were calculated for the patients to grade severity of the disease and to correlate with PALBI.

Results Of the 130 patients, mean age was 52.6 years; 80 were male (61.5%), 62 CTP-A (47.7%), 53 CTP-B (40.8%), 15 CTP-C (11.5%); 63 PALBI-1 (48.5%), 23 PALBI-2 (17.7%), and 44 PALBI-3 (33.8%). 1 patient died during hospitalization. The AUROC for predicting rebleeding in acute variceal bleeding was 0.732, 0.710, and 0.818 for CTP, MELD and PALBI scores, respectively.

Conclusion PALBI score on admission is a good prognostic indicator for patients with acute variceal bleeding and predicts rebleeding.

Keywords Acute variceal bleeding, Platelet-albumin-bilirubin score, Rebleeding

128

Platelet indices and neutrophil lymphocyte ratio as a non-invasive diagnostic marker for spontaneous bacterial peritonitis in cirrhotic patients in a tertiary care centre in western Tamil Nadu

Baraneedaran Selvarajan, Arulselvan V, Ravishankar T, Senthil Kumar P, Senthil Vadivu V

Correspondence - Baraneedaran Selvarajan - selva.baraneemmc@gmail.com

Department of Medical Gastroenterology, Coimbatore Medical College and Hospital, 2/328 Kamaraj Nagarpethathalapalli Post, Krishnagiri 635 002, India

Introduction Liver cirrhosis is the clinical end stage of different entities of chronic liver disease. Ascites are the most common complication, and around 60% of patients with compensated cirrhosis develop ascites within 10 years of disease onset. Spontaneous bacterial peritonitis (SBP) is a major cause of morbidity and mortality in cirrhotic patients with ascites and the prevalence is about 10$ to 30%. Platelets are considered an important source of pro-thrombotic agents associated with inflammatory markers. The other biomarkers consists of the neutrophil-to-lymphocyte ratio (NLR), which reflects systemic inflammation. The aim of this study was to investigate whether platelet size alterations measured by mean platelet volume (MPV) and platelet distribution width (PDW) along with neutrophil lymphocyte ratio would be useful in predicting SBP.

Methods In this prospective observational study a total of 100 patients with ascites due to cirrhosis were enrolled. The diagnosis of AFI was made on the basis of the presence of at least 250 cells/mL polymorphonuclear leukocyte in the ascitic fluid, with or without positive ascitic fluid culture in the absence of hemorrhagic ascites and secondary peritonitis.

Results Thirty patients out of 100 patients had SBP, and the incidence was high in CHILD C. A statistically significant increase was observed in the SBP group with respect to MPV, PDW and NLR when compared to cirrhotic patients without SBP (p < 0.01).

Conclusion Our study shows that MPV, PDW and NLR is increased in cirrhotic patients with SBP. Platelet indices and NLR measurement can considered to be an accurate diagnostic test in predicting AFI, possibly due to an ongoing systemic inflammatory response.

Keywords Mean platelet volume, Neutrophil lymphocyte ratio, Platelet distribution width

129

A rare case of hepatomegaly and constipation

Jithin John, Avisek Chakravorty, Devika Madhu, Ravindra Pal, Shivabrata Dhal Mohapatra, Aditya Verma, Jacob Raja, Gayathri S, Prasanth T S, Shanid A, Krishnadas Devadas

Correspondence - Jithin John - jithin4john@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background Intrahepatic cholestasis can be caused by varied causes. Usually, the first symptom is jaundice which is followed by pruritis. Here we have an interesting case of hepatomegaly with intrahepatic cholestasis, whose symptoms started with constipation.

Case Scenario Fifty-two-year-old, female, with no prior comorbidities, developed constipation, 6 months back and was treated with complementary and alternative medicines (CAMs) for the same with no significant benefits. She also had fatiguability, gradual unintentional weight loss, and a dragging right hypochondrial pain over the last 4 months. Two weeks back, she developed jaundice followed by pruritis and she was referred to us with suspicion of CAMs induced hepatitis. Physical examination revealed icterus, hepatosplenomegaly, and shiny nails. Her baseline investigation showed cholestatic jaundice and an ultrasound abdomen showed hepatosplenomegaly with no extrahepatic obstruction. Etiological evaluations for hepatitis were all negative except for evidence of autoimmune hepatitis (prebiopsy score of 6/6). She was incidentally detected to have hypercalcemia with a serum calcium of 15.1 mg/dL. She was evaluated for the same and found to have suppressed iPTH and elevated serum ACE level. CECT chest and abdomen were done, which showed multiple hypodense hypoenhancing lesions suggestive of granuloma in the liver and spleen. There was also intraabdominal and mediastinal lymphadenopathy. Liver biopsy revealed multiple noncaseating granulomas and periportal fibrosis. All other causes of granulomatous hepatitis were ruled out. A diagnosis of multisystemic sarcoidosis with predominant hepatosplenic involvement was made. She was started on oral prednisolone. With treatment, her calcium normalized and hence constipation resolved. Her LFT also improved over 3 months of treatment.

Conclusions Sarcoidosis can present with constipation secondary to hypercalcemia. Clinicians should be aware of hepatosplenic sarcoidosis as a potential cause of hepatosplenomegaly intrahepatic cholestasis in adults.

Keywords Constipation, Hepatosplenomegaly, Hypercalcemia, Intrahepatic cholestasis, Sarcoidosis

130

A study of portal vein thrombosis: Clinical presentation, management and treatment outcomes in a tertiary care centre

Aakash Shah, Nitesh Bassi, Ishan Mittal, Shishirendu Parihar, V K Dixit, D P Yadav, S K Shukla, Anurag Tiwari, Vinod Kumar Yadav

Correspondence - Aakash Shah - aakashshah4186@gmail.com

Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Background Portal vein thrombosis (PVT) is defined by complete or partial obstruction of blood flow in the portal vein, due to the presence of a thrombus in the lumen. In general population the lifetime risk of getting PVT is reported to be 1%, in cirrhotics it ranges from 4% to 15%. Frequency of diagnosis of PVT is increasing.

Objective To describe clinical presentation and assess outcomes of PVT.

Methods Fifty-three patients were included from 2021-22 from Department of Gastroenterology. All the details were extracted from the patient records and follow-up was done in this retrospective and prospective observational study.

Results Out of 53 patients, Male: Female ratio was 2:1 mean age being 37 ±6.5 years. Cirrhosis (40%) was the most common etiology, followed by inflammatory states (14%), prothombotic states (11%), infection (10%), carcinoma (6%) (HCC, Ca. GB, papillary Ca of thyroid, adenocarcinoma colon), and surgical intervention (3%). No etiology was identified in 8% of the patients. The most common complaints were abdominal pain (69%), GI bleed (47%), ascites (21%), fever (14%) and hepatic encephalopathy (5%). 17% patients had acute PVT, 83% had chronic PVT. 9.43% patients had coagulation disorders. Most common site was PV (49%), followed by SMV (17%), SV (17%). 64% patients had varices on endoscopy. 83% patients showed PVT on colour doppler ultrasound, and rest were diagnosed with CT abdomen. 51% patients were anticoagulated, 49% patients required beta blockers. Endoscopic interventions were carried out in 37.7% patients. Resolution of varices was noted in 37.7% patients and PV recanalization noted in 24.5% patients with a mean duration of 7±2 months. 19% patients had mortality due to causes like MODS (51%), GI bleed (34%), septic shock (15%).

Conclusion Majority of patients had local or systematic risk factors for PVT. Anticoagulation led to recanalization in more patients and varies regressed with combination of endoscopic and pharmacologic therapies.

Keywords Anticoagulation, Chronic liver disease, Portal vein thrombosis

131

Budd-Chiari syndrome: Clinical, etiological and radiological profile of 35 patients in a tertiary care center

Nitesh Bassi, Aakash Shah, Ishan Mittal, Shishirendu Parihar, V K Dixit, S K Shukla, D P Yadav, Anurag Tiwari, Vinod Kumar Yadav

Correspondence – Nitesh Bassi - drniteshbassi7881@gmail.com

Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Background Budd-Chiari syndrome (BCS) consists of disorders causing hepatic venous outflow obstruction (HVOTO) either at the level of the hepatic veins (HV) or at the inferior vena cava (IVC).

Objective To study clinical, etiological and radiological profile of BCS.

Methodology Thirty-five consecutive patients of BCS admitted to Department of Gastroenterology, IMS, BHU between July 2021 and July 2022 were evaluated. The diagnosis was made on the basis of Doppler ultrasonography and CT/MR venography.

Results Twenty-three (65.7%) patients presented with chronic disease, 9 (25.7%) with sub-acute disease and 3 (8.5%) with acute disease. The common presentation findings were: ascites 30 (85%), pedal edema 28 (80%), abdominal pain 25 (71%), dilated veins on abdomen and flanks 22 (63%), tender hepatomegaly 18 (52%) and jaundice in 14 (40%) cases. Twenty-eight (80%) cases were diagnosed with Doppler ultrasonography and 7 (20%) with CT/MR venography. The obstruction was seen in isolated HV in 19 (54.2%), isolated IVC in 5 (14%), and both in 11 (32%) patients. Etiologically 3 (8.5%) cases had idiopathic membranous obstruction in IVC, 2 (5.7%) had lupus anticoagulant positive, malignancy related in 2 (5.7%), protein S deficiency in 2 (5.7%), antithrombin III deficiency in 2 (5.7%) cases and 1 (3.3%) case each of: pregnancy related, chronic myeloid leukemia, hyperhomocystinemia, acute severe ulcerative colitis and 1 patient with celiac disease developed BCS with dysplastic nodules. Nineteen cases (54.2%) were idiopathic. Patients were started on anticoagulants and subjected to percutaneous recanalization, TIPSS or liver transplantation accordingly.

Conclusion BCS usually presents with abdominal distention, pedal edema, tender hepatomegaly, dilated veins and jaundice. Chronic presentation is more frequent. Most commonly obstruction was seen in isolated HV. Idiopathic and inherited/acquired hypercoaguble states were the most common etiology. Majority of patients were detected on Doppler ultrasonography.

Keywords Budd-Chiari syndrome, Hypercoaguable state, IVC membrane, TIPSS

132

Impact of sarcopenia on health-related quality of life impairment in cirrhotic patients in a tertiary care centre in western Tamil Nadu

Ben Xavier, Senthil Vadivu

Correspondence – Senthil Vadivu - dr_sva@yahoo.com

Department of Medical Gastroenterology, Coimbatore Medical College, Avinashi Road, Peelamedu, Civil Aerodrome Post, Coimbatore 641 018, India

Introduction Health-related quality of life (HRQOL) is becoming a key component in the evaluation of chronic diseases. Quality of life is variably impaired in cirrhosis, even in uncomplicated patients. Development of sarcopenia is closely related to declined liver function, which also impairs HRQOL. Its prevalence in patients with cirrhosis is estimated to be 40% to 70%. The prevalence of sarcopenia was marginally significantly higher in patients with CTP B or C than in those with CTP A. Chronic liver disease questionnaire (CLDQ) is a frequently used, self-administered, disease specific instrument for measuring the QOL in patients with CLD, regardless of its cause and severity. A study conducted in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry had translated CLDQ into Tamil (CLDQ-T) and showed good performance characteristics in assessing QOL in Tamil-speaking patients with CLD. The aim of this study is to study the impact of sarcopenia on HRQOL impairment in cirrhotic patients.

Methods A total of 115 cirrhotic patients (mean age, 46 years; range: 35–75 years; 96 male [83.47%]) were analyzed. The CLDQ-T was used to assess HRQOL. The Chi-square and Pearson’s coefficient were used for analysing correlation between sarcopenia and other variables

Results Sixty-five (56.52%) patients had sarcopenia. Sarcopenia was present in 19.1% in CHILD A, 44.8% in CHILD B and 89.3 % in CHILD C cirrhotics. Sarcopenia had a moderate negative correlation with HRQOL as assessed by CLDQ-T particularly in relation with systemic symptoms and activity.

Conclusion The patients with sarcopenia were found to have lower overall HRQOL as per CLDQ-T.

Keywords CLDQ-T, HRQOL, Sarcopenia

133

Evaluating the clinical, laboratory, and management profile in patients of liver abscess from eastern Uttar Pradesh

Shishirendu Parihar , Ishan Mittal, Aakash Shah, Nitesh Bassi, V K Dixit, S K Shukla, D P Yadav, Anurag Tiwari, Vinod Yadav

Correspondence – Shishirendu Parihar - shishirendu.parihar@gmail.com

Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Background Since hippocrates, liver abscess has been recognized. Even today, it is a problem with mortality and morbidity rates. A minimally invasive approach to treating this condition has been made possible by recent advances in diagnostic and interventional radiology.

Objective To study patients with liver abscesses for their clinical characteristics, microbial etiologies, and treatment outcomes.

Methods A cross-sectional study was conducted from April 2021 to June 2022 on 100 consecutive liver abscess patients from OPD, Emergency, and IPD at the Department of Gastroenterology, Institute of Medical Sciences, and Banaras Hindu University. History, examination, and laboratory investigations were recorded. Ultrasound-guided aspiration was done, and samples were investigated.

Results The mean age of patients was 42.24±8.24 years. The majority of them were having chronic alcohol abuse (78%). Pain abdomen (100%), fever (95%), anorexia (92%) and nausea/vomiting (56%) were the most common symptoms. Hepatomegaly (90%), pallor (40%) and pleural effusion (32%) were the most common signs. The abscesses were predominantly in the right lobe (73%) and solitary (63%). The abscess etiologies were 65% amebic and 20% pyogenic, 9% were having mixed etiology whereas 6% were culture negative. Percutaneous needle aspiration was done in 64%, catheter drainage in 32%, and surgical intervention for rupture in 4% of patients. Mortality was 3%, all reported in the surgical group. Solitary abscesses were amebic, whereas multiple abscesses were pyogenic (p<0.001).

Conclusions The commonest presentation was a young male alcoholic having a right lobe solitary amebic liver abscess. Most patients of liver abscess can be managed with drugs and minimal radiological intervention.

Keywords Alcohol, Gastroenterology, Liver abscess, Microbial etiologies

134

Diagnostic performance of FIB-4, FIB-5 and APRI in the assessment of advanced fibrosis in non-alcoholic fatty liver disease

Khushboo Madaan, Monika Jain, Gurwant Singh Lamba

Correspondence - Khushboo Madaan - khushboomadaan@yahoo.com

Department of Gastroenterology, Sri Action Balaji Medical Institute, A 4 Block, A 6 Block, Paschim Vihar, New Delhi 110 063, India

Introduction Non-alcoholic fatty liver disease (NAFLD) is one of the most common cause of liver disease worldwide which contributes to the morbidity and mortality of liver disease. Liver stiffness measurement (LSM) is an important prognostic marker and measured most conveniently by transient elastography. However, availability of transient elastography is the limiting factor. Biochemical and clinical scores are indirect methods of measuring liver fibrosis. In this study we evaluate biochemical scores FIB-4, FIB-5 and APRI in distinguishing low grade from advanced fibrosis in NAFLD.

Methods Present study consists of 206 NAFLD patients presenting from September 2020 to May 2022 to Sri Action Balaji Medical Institute. LSM was done using FibroScanâ and clinical and biochemical parameters were recorded. Data were categorised into low and advanced fibrosis depending on LSM. FIB-4, FIB-5 and APRI scores were calculated and their predictive value for advanced fibrosis determined and compared.

Results Our study comprised of 75.24% male patients and 24.76% female patients. Liver stiffness values across all the patients had a median value of 16.15 (IQR 6.33 – 46.23). 37.38% of the patients had low grade fibrosis (≤ 9 kPa) and 62.62% patients high grade (>9 kPa) based on (LSM). Comorbidities of the patients were comparable in either group but liver disease related complications were higher in the advanced fibrosis group. All three scores excellently distinguished low grade from advanced fibrosis. AUC of FIB-4, FIB-5 and APRI were, 0.91, 0.95 and 0.89 respectively, sensitivity 76.74%, 88.31% and 89.14% respectively and specificity 93.51%, 90.70% and 83.12% respectively. The cut-off values of FIB-4, FIB-5 and APRI were 1.16, -8.36 and 1.03 respectively.

Conclusion Non-invasive scoring systems can be used as surrogates for liver stiffness in resource poor centres. FIB-5 could be a optimal trade off considering its high AUC and optimum sensitivity and specificity.

Non-alcoholic fatty liver disease Non-alcoholic fatty liver disease.

Keywords APRI, FIB-4, FIB-5, Liver stiffness measurement, Transient elastography

135

Hepatitis B virus serological screening in an outpatient clinic should include HBsAg, anti-HBs (titre) and anti-HBc (Total): A single centre experience

Jayanthi Venkataramanan

Correspondence - Jayanthi Venkataramanan - vjglobal2018@gmail.com

Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, 1, Mount Poonamallee Road, Sri Ramachandra Nagar, Chennai 600 116, India

Background HBsAg screening remains the gold standard for screening hepatitis B virus infection (HBV) in the outpatient clinic.

Aim To determine the profile of HBV infection in an outpatient clinic using HBsAg, anti-HBs (titre) and anti-HBc (total) serological markers.

Methodology Patients attending the outpatient clinic between January 2019 and June 2022 with symptoms pertaining to liver disease were included. Patients already diagnosed as chronic HBV infection/hepatitis irrespective of the “e” antigen status and hepatitis B viral load were also included. Patients were categorized as incidental HBV infection (HBsAg positive; anti -HBc [total] positive), past infection (anti-HBc [total]; anti-HBs positive) and occult HBV infection (HBsAg; anti-HBs negative). To understand the vaccination status, patients were categorized as unprotected if all the 3 markers were negative and as vaccination protected if anti-HBs alone was positive with a titre > 10 IU/L. Patients who did not have details of all the 3 markers were excluded.

Results A total of 931 patients had screening for HBV infection. Table summarises the observation of the viral screening strategy) (No. [%])

Conclusions Apart from managing HBsAg patients, screening for past and occult HBV infection (12%) will support screening other family members. Also, one can enforce the need for regular 6 monthly surveillance for hepatocellular carcinoma. Vaccination protocol can also be imposed.

Keywords Hepatitis B virus, Past and occult HBV, Serology

136

Clinical implications and risk factor analysis of hepatitis B reactivation in patients receiving chemotherapeutic agents

Kondala Yedupati, Vijaishankar Chidambaramanivasagam

Correspondence – Vijaishankar Chidambaramanivasagam - vijaishankar.c@gmail.com

Department of Medical Gastroenterology, Madurai Medical College, Panagal Road, Alwarpuram, Madurai 625 020, India

Background and Aim Hepatitis B virus (HBV) reactivation after chemotheraphy is associated with significant morbidity and mortality and its prevention decreases the risk factor for liver decompensation and mortality. The aim of the study is to know the risk factors for hepatitis B reactivation in a chemotheraphy patients and their clinical profile and follow-up the patients on HBV therapeutic agents.

Materials We included 75 patients who were previously negative for hepatitis B and become positive subsequently during the chemotheraphy. We compared age, sex, past history of blood transfusion, tattooing, surgery, family history of jaundice, tumour type, staging of tumor, liver function test, complete blood count, real time PCR analysis of HBV DNA. All the patients are treated with antivirals and subsequent follow-up done from 2020-2021.

Statistical Analysis It’s a prospective study. Fisher’s exact test was used to compare categorical variables. For non-parametric data Mann–Whitney test was used.

Results Age group > 40 (n=73.3%), female sex (n=75%), past history of surgery (n=65.5%), stage IV tumors (87.3%), combination chemotheraphy drugs76.7%, cycles of chemotheraphy > 6 cycles (66.7%), mean duration from chemotheraphy to onset of jaundice is 4.8 months during the follow-up study 8 patients were developed cirrhosis and portal hypertension, 2 patients were dead, remaining 60 patients showed response to antivirals and follow-up fibroscan value after 6 months mean value is 6.9 kpa.

Conclusion Post chemotheraphy viral reactivation is a preventive disease. Eventhough patients are HBsAg negative we have to screen for anti-HBs, anti-core antibodies, and DNA load. And post chemoreactivation can increase the risk of cirrhosis in population groups at risk for cirrhosis. Post chemo hepatitis B have good outcome if recognized early and treated.

Keywords Chemotheraphy, Cirrhosis, Hepatitis B reactivation

137

Multiple liver SOL in chronic hepatitis C – Not always hepatocellular carcinoma

Moiz Vora, Janardhan Babu

Correspondence - Moiz Vora - moiz_vora@yahoo.com

Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Mindspace Road, AIG Hospital, Facility Block, Hyderabad 500 032, India

An Indian woman, 57 years of age, presented with chief complaint of mild right upper quadrant discomfort and dull aching pain, easy fatigability and anorexia.

Anti HCV was found to be reactive. Quantitative HCV RNA (PCR) was found to be positive (705302 IU/mL).

Abdominal ultrasound showed hepatomegaly and multiple round target shaped hypoechoic nodules of varying size were noted scattered in both lobes of liver with largest nodules measuring 5.7 × 3.8 cm and spleen was normal in size. Serum AFP was normal and CA19.9 was elevated - 312 U/mL. Serum LDH was 1458 U/L and uric acid was 7.5 gm/dL. Whole body PET CT scan showed enlarged liver, FDG avid (SUV max 14.2), multiple well defined homogenous hypo enhancing, hypodense lesion in both lobes of liver, largest 6.1 × 5.0 cm in segment VIII of liver.

True cut biopsy showed atypical lymphoid infiltrate with mild nuclear atypia, occasional mitosis, sheets of atypical round to pleomorphic cells having medium to large round vesicular, dark stained nucleus with inconspicuous nucleoli and scant cytoplasm. IHC was positive suggestive of non-Holdings lymphoma B cell type.

This patient has been planned for 3 cycles of R-CHOP chemotherapy (combination of rituximab, cyclophosphamide, vincristine, doxorubicin and prednisolone) followed by response assessment.

Primary B-cell lymphoma of the liver is an extremely rare tumor and is thus frequently overlooked diagnosis. An increased incidence of lymphoma has been reported in patients with chronic hepatitis C. Hepatitis C virus is known to be a lymphotropic virus.

Keywords Hepatitis C, Hepatocellular carcinoma, Lymphoma, Response, Space occupying lesions, Therapy

138

Hepatitis C virus genotype and antiviral response to oral direct acting antivirals in patients with chronic hepatitis C at a tertiary care hospital in North India

Rangat Sharma, Vijant Singh Chandail

Correspondence - Rangat Sharma - drrangat94@gmail.com

Department of Internal Medicine, Government Medical College and Hospital, Maheshpura, Chowk, Bakshi Nagar, Jammu 180 001, India

Introduction Hepatitis C virus (HCV) infection is the leading cause of chronic liver related diseases including cirrhosis and hepatocellular carcinoma. Currently, no effective vaccine is available for HCV infection. HCV is most commonly seen in IV drug abusers and CKD patients on maintenance hemodialysis (MHD). The treatment of HCV infection with pegylated interferon alpha and ribavirin leads to a sustained virological response. But a better understanding of HCV lifestyle has resulted in development of several potential directly acting antivirals (DAAs) targeting viral proteins. Directly acting antivirals give high rates of sustained virological response (SVR). Sofosbuvir and Velpatasvir combination is usually recommended in Genotype 1 and 3 in addition to ribavirin in Genotype 3 and Sofosbuvir and Dacletasvir are recommended in Genotype 4.

Aims and Objectives To observe various HCV genotypes and antiviral response to oral directly acting antivirals (DAAs) in patients with chronic hepatitis C.

Methods This study enrolled 440 HCV positive patients in which HCV RNA viral load and genotype was done. Antiviral response was observed after completing 12 weeks of antiviral treatment based on different genotypes by repeating HCV RNA viral load.

Result Among 440 patients, most common genotype found in this hospital was 3 followed by 1, then 4 and among 440 HCV positive patients, 121 completed 12 weeks of DAAs and 100% SVR was observed among these patients illustrating good response of DAAs in HCV infection.

Keywords HCV genotype, Oral antiviral response

139

Validation of non-invasive tests in predicting fibrosis in non-alcoholic fatty liver disease patients in Indians

Samir Hota , Shivaram Prasad Singh, Pallavi Bhuyan

Correspondence - Samir Hota - samir.hota@gmail.com

Department of Gastroenterology, Srirama Chandra Bhanja Medical College, Behera Colony, Mangalabag, Cuttack 753 001, India

Background and Aim Simple non-invasive tests for liver fibrosis like APRI, BARD, NFS, FIB-4 are easy to perform and cheap [1,2]. However, there is paucity of data about these non-invasive tests for prediction of fibrosis in Indian non-alcoholic fatty liver disease (NAFLD) patients since most of the derivation/validation studies have been conducted in western populations. Hence there is a need to assess utility of these non-invasive methods for predicting fibrosis in Indian patients. Aim of this study is to compare various non-invasive scores (APRI, NFS, BARD, FIB -4) with fibro-scan and liver biopsy to predict fibrosis in Indian NAFLD patients.

Methods Patients attending Gastroenterology OPD in SCBMCH, Cuttack were screened for the NAFLD by abdominal USG. Age and sex matched healthy controls were recruited from attendants of patients. Non-invasive scores like NAFLD fibrosis score (NFS), aspartate-aminotransferase (AST)/platelet ratio (APRI), Fib-4, BARD scores were calculated. Measurement of hepatic stiffness was done by transient elastography (TE) and liver-biopsy was performed in patients who gave consent for the procedure.

Results Total number of patients were 136 with mean age and BMI 41.5 ± 9.5 years and 26.64± 3.37 kg/m sq respectively. Twenty patients were diabetic and 16 were hypertensive. The AUROC under APRI, NFS, BARD, FIB-4 and FIBROSCAN were 0.455, 0.479, 0.772, 0.821, 0.834 respectively. At a cut-off of 1.82,1.5,2.26 and 7.95 NFS, BARD, FIB-4 and Fibroscan were 80%, 80%, 60% and 80% sensitive and 32%, 52%, 87%, 90% specific respectively.

Conclusions BARD, FIB-4 and Fibroscan are non-invasive markers of fibrosis that can be utilized as screening tools for Indian NAFLD patients for detection of fibrosis. At a cut-off of 7.95 kpa, the sensitivity and specificity for demarking stage 3/4 fibrosis by Fibroscan was 80% and 90% respectively.

Keywords Indians, NAFLD, Non-invasive tests

140

Hepatitis C and celiac disease a rare association

Mukti Prakash Meher

Correspondence - Mukti Prakash Meher - tiku.vssmc@gmail.com

Department of Gastroenterology and Hepatology, M L N Medical College, Prayagraj, George Town, Prayagraj 211 002, India

Introduction A 70-year-old male presented with loose stool for last 8 weeks and hematemesis last 2 day.

Methods Esophagogastroduodenoscopy revealed 4 column grade 2 varices, for which variceal band ligation done. biopsy taken at the time of endoscopy revealed intraepithelial lymphocytosis, crypt hyperplasia and chronic inflammatory infiltrate in lamina propria along with subtotal villous atrophy. Patient was found positive for anti HCV antibody.

Result USG abdomen showed coarse liver Echotexture along with dilated portal vein (13 mm), moderate ascites IgA anti TTG was highly elevated with a value of 78.82 U/mL. HCV RNA level was 99780 IU/mL. complete blood count revealed, hemoglobin 7 gm/dL, total leukocyte count of 15300, platelet count of 50000. Liver function test revealed serum bilirubin 2.92, SGOT-80, SGPT-70, serum protein-6.81, serum albumin-2.42. patient managed conservatively with gluten-free diet, iron supplementation, antibiotics, human albumin, diuretics, calcium, and discharged with stable vitals. His hemoglobin showed a rise from 7 g/dL to 11g/dL. His diarrhea also settled. Patient was started on sofosbuvir and velpatasvir combination.

Conclusion The prevalence of celiac disease in patient with chronic liver disease is at least 1.5%, which is 15 times higher than that in general population [1]. A case report has shown that cell mediated inflammatory response to HCV may involve T cell restricted to human leukocyte antigen (HLA)-DQ2, the class II HLA allele linked to celiac disease4. HCV has been identified to cause autoimmune processes [2, 3] like development of antinuclear antibodies, lichen planus, Sjogren’s syndrome. Therefore, HCV infection also may have an increased prevalence of celiac disease, which is also an autoimmune disease.

(Histopathology showing intraepithelial lymohocytes and villous atrophy)

Keywords Celiac disease, Crypt hyperplasia, Hematemesis

141

Emergence of carbapenem, colistin resistant bacterial and drug resistant fungal infections in cirrhotic patients

Nikhil Jalori, Deepak Lahoti, Vibhu V Mittal

Correspondence – Nikhil Jalori - nicks2090@gmail.com

Department of Gastroenterology, Max Super Speciality Hospital, 108A, IP Ext, I.P.Extension, Patparganj, Delhi 110 092, India

Background Infection is one of the commonest events leading to hospital admissions in cirrhotic patients. They may trigger decompensation and represent an important cause of increased mortality [1]. We prospectively studied the spectrum of various bacterial and fungal infections along with comorbidities and prognostic factors like and tried to assess their impact on outcome of cirrhotic patients .We attempted to evaluate how outcomes depended on factors like stage of liver disease, microbial resistance, appropriate antibiotics usage and whether outcomes were significantly different from patients who did not have infections.

Methods This prospective observational study was conducted in tertiary care centre of North India. We recruited 220 patients of liver cirrhosis including 127 patients with infections and 93 without infections. Data was collected about demographics, clinical profile and investigations done for management of these patients.

Results Bacterial infections were isolated in 117 (53%) of total patients. 110 out of 152 pathogens isolated were MDR (72.3%). Based on the mode of acquisition of infection, the majority of infections were CA-68 (54%), followed by HC-35 (27%) and nosocomial -24 (19%). Fungal cultures were positive in 24 (15.7%) cases, with Candida sp. being most common-20 (13.1%). ESBL-E (19.7%), CRE (17.7%), CORE (10.5%), Acinetobacter (4.6%) were commonest MDR infections, followed by MDR Candida (8.5%), VRE and others. Patients with multidrug-resistant bacteria had significantly higher mortality-19 (24.68%) vs. 8 (5.59%), duration of stay (8 ± 4.58 vs. 5.51 ± 3.72), the incidence of septic shock-31 (40.26%) vs. 12 (8.39%) and poor response to empiric antibiotics-59 (76.62%) vs. 39 (27.27%) when compared to patients with no infections or infections with the susceptible organism.

Conclusions These findings suggest an increasing prevalence of MDR bacterial and fungal infections in patients with CLD. The presence of infection, especially with MDR, has been associated with poor outcomes.

Keywords Cirrhosis, Drug resistance, Infections

142

Outcome of plasma exchange in rat killer poisoning induced acute liver failure at a tertiary care centre from southern India

Allwin James, Alagammai P L, Srividhya Manjunath, Ramesh Ardhanari

Correspondence - Allwin James - gastroallwin@gmail.com

Department of Medical and Surgical Gastroenterology, Meenakshi Mission Hospital and Research Centre, Lake Area, Melur Main Road, Madurai 625 107, India

Introduction Rat killer compound (yellow phosphorus) is a commonly available rodenticide. It is protoplasmic poison causing multiorgan failure. Dose of >1 mg/kg is almost fatal [1, 2]. Here we present clinical profile, observations, and outcome of plasma exchange at our institute.

Methods Study was designed as observational study between July 2021 to July 2022. Any rat killer poison consumption during the study period was included. Demography, clinical presentation, indications, tolerability, and outcome of plasma exchange were analyzed.

Results Forty-eight patients were included. Mean age was 29. All patients were started on N-acetyl cysteine infusion irrespective of dosage. Fifty percent (n=24) had presentation within 24 hours of consumption. Cake formulation of toxin appeared less toxic than paste. Patients who had no decontamination (gastric lavage within 2 hours of consumption), hemodynamic instability (hypotension–not responding to volume challenge), presence of hepatic encephalopathy, high toxin dose, higher lactate levels at admission (> 4), delayed presentation (> 72 hours of consumption), worsening of liver and renal functions despite plasma exchange, had poor outcome (p< 0.05). Indication for therapeutic exchange was based on presence of acute liver failure, bone marrow toxicity. 60% (n=29) underwent plasma exchange for above indications. Three developed hypotension during procedure. Number of sessions was based on LFT and coagulopathy with linear relationship. Nineteen percent (n=9) had bone marrow toxicity at presentation. Neutropenia with increased absolute monocyte count was most common bone marrow toxicity. Leucopenia improved with therapeutic plasma exchange in all patients. Isolated marrow toxicity was seen in 2 patients. New onset diabetes insipidus seen in 4 patients, improved with oral/ nasal desmopressin and fluid management. Despite plasma exchange mortality was seen in of 18% [5].

Conclusion Plasma exchange has emerged as potential therapeutic option for ALF due to rat killer poisoning with favorable outcome in our tertiary care centre.

Keywords Acute liver failure, Plasma exchange, Rat killer poisoning

143

Therapeutic plasma exchange as a bridge therapy in patient with alcohol related acute- on-chronic liver failure

Srividya Manjunath , Alagammai P L, Allwin James D

Correspondence – Alagammai P L - alagammai.pl@icloud.com

Department of Medical Gastroenterology, Meenakshi Mission Hospital and Research Centre, Lake Area, Melur Road, Madurai 625 107, India

Introduction Acute-on-chronic liver failure (ACLF) is characterized by acute hepatic decompensation, organ failure and high short-term mortality. The ideal treatment for ACLF in the absence of overt organ failure and sepsis is liver transplantation. However, it is feasible only in a subset of patients resulting in high waitlist mortality (67%). Therapeutic plasma exchange (TPE) is now emerging as a bridge therapy in such patients. It is said to help by removal of inflammatory cytokines facilitating native liver regeneration. TPE has shown survival benefit in patient with hepatitis B related ACLF. In this observational study, we aim to look at the benefits of using TPE in patients with alcohol ACLF.

Results A total of 20 male patients were included in the study. TPE was considered for patients with organ failure, Acute kidney injury due to HRS/bile cast nephropathy and those who were not candidates for steroid therapy for severe alcohol hepatitis. Fifteen patients survived at the end of treatment whereas 5 did not. Baseline bilirubin, creatinine, INR were not significantly different between the two groups. Non survivors had higher MELD admission (34.4+/- 6.50) as compared with survivors (32.2+/-5.20), p 0.40. Those with higher grade of encephalopathy (grade III – IV) did not survive even with TPE. Post TPE there was significant reduction in MELD score in survivors by 7 points (25.13+/-3.39, p 0.001) vs. non survivors (29 +/- 5.24, p 0.038). Forty-five percent patients (9) had bile cast nephropathy, 77% of whom had AKI. Twenty percent has AKI with no bile cast nephropathy. AKI however was more severe in patients with bile cast and in these patients, AKI resolved completely after TPE.

Conclusion TPE may be considered as a bridge to survival in patients with alcohol ACLF, who are otherwise poor candidates for steroids or immediate liver transplantation.

Keywords Alcohol ACLF, Bile cast nephropathy, Plasma exchange

144

Survival analysis of patients undergoing plasma exchange for acute liver injury due to rodenticide poisoning at a tertiary care center in Western Tamil Nadu

P S Kirpal, V Arulselvan, T Ravishankar, P Senthilkumar, A Senthilvadivu

Correspondence – P S Kripal - kripal1118@gmail.com

Department of Medical Gastroenterology, Coimbatore Medical College, Avinashi Road, Peelamedu, Civil Aerodrome Post, Coimbatore 641 018, India

Introduction Acute liver failure (ALF) due to rodenticide poisoning is a common indication for emergency liver transplantation in South India [1]. Yellow phosphorus (YP) is the main constituent of commonly available rodenticides in India. Mortality due to YP poisoning has ranged from 20% to 30% in various reports [2, 3].

The only definitive management for acute liver failure following rodenticide poisoning is urgent liver transplantation (LT). The usefulness of plasma exchange (PLEX) in improving survival in acute liver failure due to rodenticide poisoning in settings where there is poor accessibility to liver transplant is being increasingly recognized [3, 4]. This study examined the 28-day transplant free survival rates among patients with acute liver failure due to rodenticide poisoning who underwent PLEX at a tertiary care hospital in Western Tamil Nadu.

Methods Consecutive patients who underwent PLEX for acute liver failure due to rodenticide poisoning during the study period, who met Tamil Nadu chapter of Indian Society of Gastroenterology (TN-ISG) guidelines [5] criteria for PLEX were observed during treatment period and followed up untill 28 days. Baseline characteristics of patients, type of PLEX administered and survival rates at 28 days were observed.

Results Twenty patients underwent PLEX for acute liver failure due to rodenticide poisoning during the study period of 6 months. Mean age of the study population was 32.5 years (range 17-68) and 12 (60%) were males. The median INR at time of first PLEX was 4.8 6 (30%) had grade 2 or higher hepatic at the time of initiation of PLEX. All Patients received low volume response guided PLEX using ultrafiltration technique. Survival rate at 28 days was 90% (18),10 patients (50%) responded to single cycle of PLEX.

Conclusion PLEX is likely to significantly improve liver transplant free survival in acute liver failure due to rodenticide poisoning.

Keywords Acute liver failure, Plasma exchange (PLEX), Rodenticide poisoning

145

Hepatic hematoma – A rare postoperative complication of endoscopic retrograde cholangiopancreatography

Dandi Kranthi, Amol Dahale, Girish Muppa

Correspondence - Amol Dahale - amolsd1986@gmail.com

Department of Medical Gastroenterology, Dr D Y Patil Medical College and Research Centre, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Pune 411 018, India

Introduction Nowadays, endoscopic retrograde cholangiopancreatography (ERCP) is the most minimally invasive procedure used to treat biliary and pancreatic disease. ERCP has the highest incidence of complications ranging from 2.5% to 8% with mortality rate ranging from 0.5% to 1%. An exception ERCP complication is represented by subcapsular hematoma. Since 2000, world literature has no not reported more than 20 cases. In this case report, we described a further rare case of subcapsular hepatic hematoma manifested only with abdominal pain and drop in hemoglobin.

Case Presentation A 26-year-old postpartum female with no comorbidities presented with complaints of jaundice and right upper quadrant pain. Magnetic resonance cholangiopancreatography (MRCP) was suggestive of cholelithiasis with choledocholithiasis. ERCP was suggestive of choledocholithiasis. Common bile duct (CBD) clearance with stenting was done. Four to six hours post ERCP, patient developed abdominal pain in right upper quadrant. On examination pulse rate was 120/min, blood pressure – 80/40 mmHg and patient had severe tenderness in right hypochondrium with no signs of peritonitis. Bed side ultrasonography showed subcapsular hematoma (14 × 14 × 11 cm) in right lobe of liver which was confirmed by cross sectional imaging. patient was further deteriorated, hemogram showed fall in hemoglobin to 6 mg/dL following day. Patient was resusciated started on ionotropes, multiple packed cell volume transfusion were given. She was managed conservatively and was discharged. on three months of follow-up, repeat scan showed decrease in size of liver hematoma.

Conclusion Hepatic injury and hematoma of the liver are rare and dreaded complication of ERCP and in most needs intervention in the form of surgery or pigtel drainage (if infected). Treatment is decided on case-to-case basis.

Keywords ERCP complications, ERCP, Hepatic hematoma

146

Influence of esophageal flap valve on esophageal variceal bleeding

Jay Chudasama, Harsh Gandhi

Correspondence - Jay Chudasama - jaychudasama2905@gmail.com

Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India

Introduction Increased exposure to gastric acid in patients with abnormal gastroesophageal flap valve (GEFV) may lead to increase esophageal variceal bleeding.

Aim To investigate the relationship between GEFV and esophageal variceal bleeding episodes.

Methods It is an interim analysis of a cross-sectional study involving 109 patients with esophageal varices and flap valve of any grade. Patients are divided into two groups on basis of Hill’s grade of flap valve (Hill‘grade 1, 2-normal and Hill’s grade 3, 4-abnormal). They are assessed with esophagogastroduodenoscopy and incidence of variceal bleeding and size of varices (Two groups: largeb[>5mm] and small [<5 mm] varices) are compared with Hill’s Grade of flap valve.

Results This study included 109 patients out of which 72 had normal and 37 had abnormal flap valve. Number of bleeding episodes was significantly higher in patients with esophageal varices who had abnormal flap valve compared to whom having normal flap valve (Mean number of bleeding episodes- 2.5 vs. 1.1, p<0.001). Predominantly, patients with abnormal flap valve had larger varices while patients with normal flap valve had smaller varices (94.6% vs. 73.6%, p<0.001).

Conclusion Abnormal GEFV is independent risk factor for esophageal variceal bleeding.

Keywords Esophageal varices, Hill'grade

147

To assess response to steroids in patients with Autoimmune hepatitis and validate SURFASA score

Harsh Gandhi, Shubham Jain

Correspondence - Harsh Gandhi - harshgandhi345@gmail.com

Department of Medical Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai Central, Mumbai 400 008, India

Introduction In autoimmune hepatitis (AIH) patients, response to steroids and optimal timing of liver transplantation (LT) always remains controversial. Aim of study is to assess response to steroids at day 3 and to validate SURFASA score in our population group. SURFASA score can identify patients who are non-responders to steroids. LT-free survival is higher in patients with a SURFASA score <-0.9.

Methods It is interim analysis of observational retrospective and prospective study involving 27 patients of AIH divided into acute AIH, acute severe (AS) AIH and acute on chronic liver failure. Response to steroids was assessed in these 3 groups of patients.

Results Out of 27 patients, 14 patients (51.9%) presented as acute AIH, 10 (37%) as acute-on-chronic liver failure (ACLF), 3 (11.1%) as AS AIH. Mean age of the patients was 47.7 (SD – 13.9) years, 66.7 % (18) of which were women. All patients who died (6) belonged to ACLF group. Patients who died have SURFASA score in range of -1.18 to -3.14 and patients who survived have SURFASA score in range of -4 to -5.1 (p<0.001). While traditional scores such as Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) at D0 and D3 of starting steroids were also accurate (p<0.001).

Conclusion SURFASA score is useful in predicting steroid response and patient survival. But the thresholds of the SURFASA score may differ in different populations depending on various factors.

Keywords Autoimmune hepatitis, Steroids, SURFASA score

148

Comparative study of proportion of cardiac disease in patients of non-alcoholic fatty liver disease with or without metabolic syndrome

Majid Khan, B. Vishwanath Tantry, Sandeep Gopal, Anurag Shetty, Suresh Shenoy

Correspondence - B. Vishwanath Tantry - tantrybv@gmail.com

Kasturba Medical College Hospital, Ambedkar Circle Mangalore, Manipal Academy Of Higher Education, Manipal 575 001, India

Introduction Non-alcoholic fatty liver disease (NAFLD) is a worldwide public-health problem affecting up to 1/3rd of adults, Prevalence of NAFLD in India is 9% to 32%, it is frequently associated with metabolic syndrome. Cardiovascular disease (CVD) is the leading cause of mortality among patients with NAFLD (accounting for about 40% of total deaths). This study was undertaken to evaluate the risk of CVD in NAFLD patient with or without metabolic syndrome.

Methods This is a analytical cross-sectional study conducted on 40 patients having NAFLD (diagnosed by ultrasonogram [USG] abdomen and liver stiffness by Fibroscan), and these patients were screened for the presence or absence of metabolic syndrome and divided into two groups (NAFLD with or without metabolic syndrome). Subsequently these group of patients underwent cardiovascular screening by ECG, 2D Echocardiography and TMT.

Results Among the 40 NAFLD patients, 25 (62.5%) patient had NALFD without metabolic syndrome and 15 (37.5%) patients were with metabolic syndrome. Among 40 NAFLD patients, 7 (17.5%) patients had cardiovascular disease. In NAFLD patients without metabolic syndrome 4 (16%) patients had CVD (3 patient had concentric LVH and 1 patient had concentric LVH with ventricular ectopics). Among NAFLD patients with metabolic syndrome 3 (20%) patients had CVD (2 patients had coronary artery disease - TMT positive and 1 patient had concentric LVH).

Conclusion NAFLD patients with metabolic syndrome had significant coronary artery disease as compared to none in NAFLD patients without metabolic syndrome, all individuals with NAFLD should be screened for features of metabolic syndrome and cardiovascular disease.

Keywords Cardiovascular disease, Metabolic syndrome, NAFLD

149

Acanthosis nigricans-A rare cutaneous association in progressive familial intrahepatic cholestasis type 3

Rahul Vijayvargiya , Bhashyakarla Ramesh Kumar, Uma Devi, Sahitya L, M D Zeeshan, Ch. Suraj, Vikas Reddy

Correspondence - Rahul Vijayvargiya - rahul.sanwariya1990@gmail.com

Department of Medical Gastroenterology, Liver Care Unit, Osmania General Hospital, Afzal Gunj, Hydearabad 500 012, India

Introduction Progressive familial intrahepatic cholestasis (PFIC) refers to heterogeneous group of autosomal recessive disorders of childhood that disrupt bile formation and present with cholestasis of hepatocellular origin [1]. Defects in ABCB4, encoding the multi-drug resistant 3 protein (MDR3), impair biliary phospholipid secretion resulting in PFIC type 32. Acanthosis nigricans is a cutaneous manifestation of an underlying condition. It usually develops in in skin folds, such as the back of the neck, axilla, and groin, where it presents as velvety hyper-pigmented patches with poorly defined borders [3].

Case Report A 12-year-old female who is known case of PFIC type 3 came for follow-up with chief complaints of pruritus and increased pigmentation over neck region and forehead. Dermatology opinion took for that and Skin biopsy done which suggestive of acanthosis nigricans.

Discussion Acanthosis nigricans is most commonly associated with diabetes, insulin resistance, internal malignancy, hormone disorders or with the use of certain medications like systemic glucocorticoids and oral contraceptives [4]. The pathophysiological process behind acanthosis nigricans appears to be related to the proliferation of fibroblasts and the enhanced stimulation of epidermal keratinocytes [5]. In literature association with PFIC is not mentioned. Here, we reporting a case of Acanthosis nigricans in PFIC type 3 patients.

References

1. Jacquemin E. Progressive familial intrahepatic cholestasis: genetic basis and treatment. In: Pediatric liver. Clin Liver Dis. 2000; 4:753-63.

2. Jacquemin E. Role of multidrug resistance 3 deficiency in pediatric and adult liver disease: one gene for three diseases. Semin Liv Dis. 2001; 21:551-62.

3. Burke JP, Hale DE, Hazuda HP, Stern MP. A quantitative scale of acanthosis nigricans. Diabetes Care. 1999; 22:1655-9.

4. Habif, Thomas P. (2009). Clinical dermatology (5th ed.). Edinburgh: Mosby. ISBN 978-0-7234-3541-9.

5. Jeong KH, Oh SJ, Chon S, Lee MH. Generalized acanthosis nigricans related to type B insulin resistance syndrome: A case report. Cutis. 2010; 86:299-302.

Keywords Acanthosis nigricans, PFIC

150

Role of serum phosphate levels in acute-on-chronic liver failure patients to predict short-term mortality

Rohit Wagh, Meghraj Ingle, Vikas Pandey, Shamshersingh Chauhan, Vipul Choudhari

Correspondence - Meghraj Ingle - drmeghraj@gmail.com

Department of Medical Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Lokmanya Tilak Medical College and Hospital, Sion, Mumbai 400 022, India

Introduction Acute-on-chronic liver failure (ACLF) is an acute hepatic insult manifesting as jaundice and coagulopathy complicated within 4 weeks by clinical ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease/cirrhosis and is associated with a high 28-day mortality. Given the property of rapid regeneration power of the liver, the metabolic and synthetic demands increase adenosine triphosphate (ATP) production by rapidly dividing liver cells. Increase in ATP synthesis requires inorganic phosphate, increasing the flux of phosphate into the liver causing hypophosphatemia in patients with a healthy functioning liver. Therefore, hyperphosphatemia could identify a group of ACLF patients with insufficient functional liver mass and help in predicting adverse outcomes.

Methods It is an observational study in a tertiary care centre. We took 92 diagnosed patients of ACLF and followed them over a period of 28 days. All baseline demographic details, routine blood workup, viral markers, serum phosphate, serum lactate, autoimmune profile (wherever necessary) were done. All the patients were followed up prospectively and 28-day mortality was compared with baseline serum phosphate levels and other parameters.

Results Most common acute insult included alcoholic hepatitis-47.82% (44), alcoholic hepatitis with drug induced liver injury- 10.86% (10), infections-9.78% (9), etc. while chronic insult included alcohol only-75% (69), autoimmune hepatitis-7.6% (7), chronic hepatitis B only-6.5% (6), cause unknown- 6.5% (6), etc. 28-day mortality was seen in 11.9% (11) ACLF patients. Hyperphosphatemia (≥ 4.5 g/dL) was seen in all 11 (100%) patients who died within 28 days and only in 5 (6%) out remaining 81 remaining survivors (p value >0.05).

Conclusion Higher serum phosphate level was associated with increased 28-day mortality and can be used as a predictor of short-term mortality in ACLF patients.

Keywords ACLF, Mortality, Serum phosphate

151

Liver mass presenting as acute cardiorespiratory failure

Raya Venkatesh Reddy, Rishi Raman, Shiran Shetty, Balaji Musunuri

Correspondence - Raya Venkatesh Reddy - venky.medical99@gmail.com

Department of Gastroenterology and Hepatology, New OPD Building, Kasturba Medical College, MAHE, Tiger Circle Road, Madhav Nagar, Manipal 576 104, India

Introduction Sarcomatoid carcinoma (SC), also known as spindle cell carcinoma, is a malignant tumor type of unclear pathogenesis. Usually presents as abdomen pain. We reporting a rare presentation of liver mass. Case: A 58-year-old male nil morbidities presented with history of exertional dyspnea, fatigue and right upper quadrant pain since 1 month. On examination patient is having tachypnoea, tachycardia, and hypoxia. Investigations showed hypoxia and primary respiratory acidosis on ABG. 2D echo showed EF–36%, restrictive filling pattern in left ventricle with some extracardiac structure compressing right atrium. Serology is negative, AFP – 10 ng/mL, NT PRO -BNP – 20926 pg/mL. Triphasic contrast-enhanced computed tomography (CECT) abdomen showed 17*16*15cms large exophytic lesion with peripheral enhancement and central necrosis, lesion is noted to compress the right atrium. Ultrasound-guided biopsy of the lesion showed pleomorphic spindle cells with extensive area of necrosis. Immunohistochemistry (IHC) showed positive for Cytokeratins (CK), epithelial membrane antigen (EMA) and vimentin, negative for C – kit and PDGFR oncogene suggestive of primary hepatic sarcoid carcinoma. Patient is planned for emergency surgical decompression, but patient succumbed and died due to cardiac failure.

Discussion HSC has been reported in 1.8% of all surgically resected HCCs and in 3.9% to 9.4% of the autopsied cases. Primary hepatic sarcoid carcinoma (PHSC) typically presents as a mass with peripheral enhancement, central necrosis. Using immunohistochemical staining, the detection of CK, EMA and vimentin may be useful for the diagnosis of PHSC. The preferred treatment for PHSC is surgical resection. The prognosis of PHSC is particularly poor due to its high malignancy and local recurrence rates, venous invasion and intrahepatic, distant and lymph node metastasis.

Conclusion In conclusion, PHSC is an aggressive tumour type, which is characterized by a rapid clinical course. Early detection and radical resection may improve patient prognosis.

Keywords Cardiac failure, Primary hepatic sarcoid carcinoma

152

Association of liver dysfunction in corona virus disease-19 patients

Santosh Kumar, Santosh Kumar Nayan

Correspondence - Santosh Kumar - santimd25@gmail.com

Department of Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Bailey Road, Sheikhpura, Patna 800 014, India

Background Many of the pioneer studies from China in the context of corona virus disease-19 (COVID-19) have reported liver involvement as high as 60% among patients with COVID-19 infection. The presence of ACE2 receptors in the liver and systemic inflammation along with drug induced damage are the possible mechanisms. The current study was aimed to assess the liver function abnormalities among patients infected with COVID-19 and to find any association with respect to other patient characteristics.

Methods An observational study with cross-sectional design was done by Department of Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna. Three hundred adult patients with confirmed SARS-CoV-2 infection on real-time reverse transcription–polymerase chain reaction (RT-PCR) who were admitted in the hospital between -------------- and -------------- were considered for inclusion in the study. Prior ethical approval was obtained from the Institutional Ethics Committee.

Results The mean age was 45.7 years with male dominance. Male to female ratio was 2.4. Study participants were divided in 4 groups based on the grade of symptoms of COVID-19. Majority (69.3%) had mild symptoms. Overall abnormal liver function tests (LFTs) was observed in 55.7% patients. Alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP) were elevated in 50.3%, 53.3% and 53.3% cases respectively. The levels of AST, ALT and ALP between different groups based on severity of disease symptoms was also statistically significant.

Conclusion Liver dysfunction is not very uncommon in COVID-19 patients. Available literature suggests that gastrointestinal involvement with deranged liver enzymes are noted among a significant number of patients.

Keywords COVID-19, Liver dysfunction, Liver enzymes

153

Diabetic with emphysematous liver abscess: A case report

Subburathinam Gopalan , Vijai Shankar C, Kannan M, Ramani R

Correspondence - Vijai Shankar C - vijaishankar.c@gmail.com

Department of Medical Gastroenterology, Madurai Medical College. Panagal Road, Alwarpuram, Madurai 625 020, India

Gas forming organisms can affect a variety of organs with liver being involved very rarely. Emphyseatous liver abscess is a condition where the abscess cavity contains air with an incidence of 6% to 24%, more prevalent in southeast Asian populations. The usual culprit is Klebsiella pneumoniae in 80% cases, while E. coli, salmonella, and clostridium perfrigens are seen in 20% cases [1, 2]. Patients usually present only with fever and malaise attributable to poorly controlled hyperglycemia in most of the cases as it masks the severity of the underlying pathology. Due to a high mortality rate ranging from 27% to 30%, this condition warrants timely diagnosis, intensive care, and prompt intervention [3].

We herein present a case of 54-year-old diabetic and hypertensive female, who had a poor glycemic control, with previous history of laparoscopic cholecystectomy and total abdominal hysterectomy with bilateral salphinoopherectomy. She was brought with fever, abdominal pain, jaundice, and oliguria. Basic investigations revealed leucocytosis, prerenal azotemia, direct hyperbilurubinemia with 4-fold rise of liver enzymes. Computed tomography of the abdomen showed a cystic necrotic mass with multiple air fluid levels involving the segments 5 and 6 of liver, suggestive of emphysematous liver abscess. The patient underwent an emergency ultrasound guided percutaneous drainage of the abscess. Klebsiella pneumoniae was grown in both pus and blood cultures and the patient was treated with intravenous antibiotics according to sensitivity reports. During the course of treatment, patient showed clinical improvement and recovered from renal failure. The drain was removed after 18 days and discharged. This case emphasises the need for suspecting emphysematous liver abscess in a patient with poorly controlled hyperglycemia as prompt intervention can prevent mortality.

Keywords Emphysematous liver abscess, Gas forming organism, Klebsiella

154

Non HFE hemochromatosis - The uncommon variant

Mohammed Zeeshan Ali , Ramesh Kumar B, Uma Devi M, Sahitya L, Rahul Vijayvargiya, Suraj Kumar Ch., Vikas Reddy V

Correspondence - Mohammed Zeeshan Ali - drzeeshanali53@gmail.com

Department of Gastroenterology, Osmania Medical College, Osmania General Hospital, Afzalgunj, Hyderabad 500 012, India

Hemochromatosis is a rare multisystem disorder due to defect in the regulation of gastrointestinal iron absorption leading to abnormal deposition of inorganic iron in parenchymal tissues. These defects are commonly due to abnormal regulation of Hepcidin. More than 90% of the cases of hereditary hemochromatosis are HFE gene related, and minority are non HFE related hemochromatosis. The four common non HFE hereditary hemochromatosis are caused by mutation in hemojuvelin, hepcidin, transferrin receptor 2 and ferroportin genes. Commonly these mutations are associated with more severe course of disease compared to HFE hemochromatosis. Awareness and high degree of suspicion is needed to not misdiagnose this non HFE mutation disease as end stage liver disease with iron overload or due to secondary hemochromatosis. Early diagnosis of these mutations in the patient and their family members and initiation of treatment before organ failures develop will help the patient lead a normal life.

Keywords Hereditary hemochromatosis, HFE gene mutation, Iron overload, Non HFE hemochromatosis

155

Granulomatous disease with hepatic involvement in a south Indian female

Kishwanth Rayappan , Kannan M, Ramani R, Vijai Shankar C, Sriram P B

Correspondence – Kannan M - kan7@gmail.com

Department of Medical Gastroenterology, Madurai Medical College, Panagal Road, Alwarpuram, Madurai 625 020, India

Granulomatous diseases involving the liver may present as a primary process or as a manifestation of a systemic disease. Sarcoidosis, a multi systemic granulomatous disease of unknown etiology usually manifests with lung and skin lesions. Liver is involved in about 50% to 80 % of the cases without abdominal symptoms while 5% to 25% of the cases present with clinically significant liver involvement in the form of hepatomegaly and raised alkaline phosphatase [1, 2]. It has been extensively studied in African American population, while in India, it is still in its early stages of evaluation and it can be assumed that it is being under reported [3]. We herein present a case of sarcoidosis in a middle aged south Indian female with symptomatic liver involvement. She presented with right upper quadrant abdominal pain and non-productive cough for 6 months. There was no jaundice or cholestatic symptoms. Clinical examination revealed hepatomegaly with the liver spanning up to 22 cm and a mild splenomegaly. Her basic lab investigations showed an elevation of ESR, globulin levels and a predominant cholestatic pattern of liver function derangement with a fourfold increase in alkaline phosphatase. Computed tomography of the chest showed bilateral hilar lymphadenopathy with reticulonodular infiltrates. After ruling out infections and autoimmune causes by serological tests, Sarcoidosis was suspected and was supported by elevated serum angiotensin converting enzyme levels and liver biopsy findings of non-caseating granuloma. She responded symptomatically well to steroids and is being followed up. This case illustrates a clinical entity rare in Indian population and reiterates the need for consideration of sarcoidosis as a potential diagnosis in a population where the disease is less studied.

Keywords Hepatic, Indian, Sarcoidosis

156

Epidemiological profile of acute hepatitis patients hospitalized in a tertiary care center in Western India

Pankaj Nawghare, Shubham Jain, Vishal M, Saurabh Bansal, Sanjay Chandnani, Pravin Rathi

Correspondence - Pankaj Nawghare - pankaj9ghare21@gmail.com

Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India

Introduction Acute hepatitis is major global burden in India. However, an epidemiological study depicting situation of acute hepatitis in Western India is missing. We conducted this study to elucidates the epidemiology, risk factor, clinical features, and outcome among clinically suspected AVH cases.

Methods This was a single center, retrospective study conducted at tertiary care center. We recruited data retrospectively from discharge/death file. Patients with history compatible with acute hepatitis with a deranged liver function test were enrolled for analysis.

Result Total 14,236 patients admitted from 1st January 2018 to 31st December 2019 were analyzed. 1840 patients with acute hepatitis were included in study. Mean age of population was 30.92±24.2 years with majority being males (62.7%). Most common symptom was nausea (72%). Other common symptoms were abdominal pain (54%), fever (48%) and generalized weakness (45%). Icterus was seen in 80%, while hepatomegaly seen in 32% cases. One hundred and eight (5.9%) patients were having underlying cirrhosis. 2% and 1.1% of patients presented with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Hepatitis E (63.7%) was predominant etiology followed by hepatitis A (17.5%) and hepatitis B (9.3 %). Drug-induced liver injury (DILI) constitute for 4.8 % of cases. Among patients with DILI, majorities were taking herbal and complementary medication (86%). Autoimmune hepatitis and Wilson disease constitute 3% and 0.3% of cases respectively. Coinfection was seen in 3% cases. Case fatality rate in our study was 2.3%, with all patients were having either ALF or ACLF at presentation. Only shortcoming of our study was it include only patients who were admitted to hospital and not from community.

Conclusion Acute hepatitis is continued to be major health problem in India. Majority of cases still attributed to hepatitis E due to poor sanitary condition. ALF and ACLF is associated with poor outcome.

Keywords Acute hepatitis, Hepatitis E, Male

157

A prospective randomized comparative four arm intervention study of efficacy and safety of saroglitazar and vitamin E in patients with non-alcoholic fatty liver disease/ non-alcoholic steatohepatitis-An interim analysis

Bilal Mir, Brij Sharma, Rajesh Sharma, Vishal Bodh, Ashish Chauhan

Correspondence - Bilal Mir - mir13bilal@gmail.com

Department of Gastroenterology, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India

Background and Aim Among available pharmacotherapies, vitamin E and Saroglitazar are used in India for non-alcoholic fatty liver disease (NAFLD). However, no head-to-head comparative study for these drugs is available. In this prospective intervention trial, we studied the efficacy and safety of saroglitazar and vitamin E for patients of NAFLD/non-alcoholic steatohepatitis (NASH).

Methods We prospectively analyzed 104 patients of NAFLD grouped into four study arms as, saroglitazar 4 mg daily alone (n=28) vs. vitamin E 800IU daily (n=22) alone vs vitamin E and saroglitazar combination(n=24) vs. placebo (n=30). All the demographic variables, anthropometric data and biochemical parameters including liver function tests were noted. All patients underwent fibro elastography to determine the severity of steatosis as controlled attenuation parameter (CAP) and fibrosis as liver stiffness measurement (LSM). Reassessment with repeat blood testing and fibro elastography was done after 24 weeks of treatment and results were recorded.

Results The mean age of study population was 45±12 years with mean body mass index (BMI) 29±11, among which 60% were males. Compared to placebo, saroglitazar alone, vitamin E alone and combination therapy significantly improved serum alanine transaminase (ALT) (43% vs. 22% ,47% vs. 25% and 55% vs. 20% respectively; p=<0.03, p=<0.04 and p=<0.02).The reduction in CAP was seen more with combination therapy compared to individual drug alone (p=<0.04) and the reduction in LSM was greater with saroglitazar limb compared to vitamin E and combination therapy (p=<0.05). Improvement in glycemic and lipidomic parameters were comparable between saroglitazar alone and combination therapy but less pronounced with vitamin E, with respect to placebo. The rates of adverse events were comparable between groups except for body aches that were more common in saroglitazar group.

Conclusions Both saroglitazar and vitamin E significantly improved liver biochemistry, CAP and LSM. However, the combination therapy showed better efficacy in LSM and CAP reduction along with biochemical, glycemic and lipidomic parameters.

Keywords Fibroelastography, Non-alcoholic fatty liver disease, Saroglitazar

158

Prevalence of frailty in cirrhotic- A observational study

Yogesh Bairwa , Meghraj Ingle, Saiprasad Lad

Correspondence - Meghraj Ingle - dryogeshbaiwa@gmail.com

Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai 400 022, India

Background Frailty is increasingly recognized as a major prognostic factor in cirrhosis Its assessment and intervention towards performance improvement is an important step in the management of liver cirrhosis. In this study, we aimed to assess the prevalence of frailty in patients of liver cirrhosis in a tertiary care center.

Methods Ninety-three patients were enrolled in this observational cohort study. Frailty assessment was done using compares fried frailty index (FFI), clinical frailty index (CFI), short physical performance battery (SPPB), Edmonton frail scale (EFS), LFI, Eastern Cooperative Oncology Group (ECOG), Karnofsky performance scale (KPS); Instrumental activity of daily living. The primary outcome was a prevalence of frailty in cirrhotic patients, then its prevalence in different subgroups according to etiology, Child-Turcotte-Pugh (CTP) score; model for end-stage liver disease (MELD) score.

Results Seventy-three (81.1%) males and 13 (18.9%) females with a mean age of 43.89; 9.67 years were included. The most common cause of cirrhosis was alcoholic liver disease (47.7%) followed by hepatitis B (14.1%) and hepatitis C (7.8 %). The prevalence of frailty based on LFI (46.67%), KPS (35.55%), FFI (38.9%), CFI (38.90%), SPPB (47.80%), EFI (31.20%), IDAL (31.10%), ECOG (36.70%). There was no significant difference of prevalence among different indexes (p value; 0.05).

Conclusions The prevalence of frailty based on LFI is 46.67 %. LFI, KPS, FFI, CFI, SPPB, EFI, IDAL, and ECOG are comparable in frailty assessment in patients with cirrhosis.

Keywords Child-Turcotte-Pugh (CTP), Frailty, Liver frailty index, Model for end-stage liver disease

159

Prevalence of chronic hepatitis B, hepatitis C and human immunodeficiency virus infection in people who inject drugs, and barriers to care for antiviral therapy: A prospective integrated deaddiction and microelimination cohort study

Anchal Sandhu, Madhumita Premkumar, Abhishek Ghosh, Debashish Basu, Ajay Kumar Duseja, Sunil Taneja, Arka De, Vishesh Kumar, Surender Sehrawat, Shikha Guleria, Jasvinder Nain

Correspondence - Madhumita Premkumar - drmadhumitap@gmail.com

Department of Hepatology, Post Graduate Institute of Medical Education and Research, Nehru Hospital Extension Block, Sector-12, Chandigarh 160 012, India

People who inject drugs (PWID) are at a high risk of developing chronic viral hepatitis B (HBV) and HCV infections as well as human immunodeficiency virus (HIV) infection due to unsafe injection practices. PWID report high social stigma, and often fail to seek treatment or complete direct-acting antivirals (DAAs) therapy. In addition, they are at risk of other substance use disorders (SUD).

Methods We screened 760 consecutive PWID reporting to the Drug De-addiction and Treatment Centre (DDTC) of Postgraduate Institute of Medical Education and Research, Chandigarh for chronic viral hepatitis using enzyme linked immunosorbent assay (ELISA) assays for HBsAg and anti-HCV and human immunodeficiency virus (HIV) rapid antigen test. Those testing positive on the screening test underwent confirmative testing and viral load estimation, and were then provided integrated free-of-charge DAAs+DDTC therapy under the National Viral Hepatitis Control Programme (NVHCP).

Results We screened 760 PWID (all male, mean age 25.5±3.72, rural 18.6%). Of them, 1.3% were HIV positive, 50.1% were anti-HCV reactive and 13.2% were HBsAg positive. Despite the fact that 381 individuals tested positive for an anti-HCV antibody, only 36 (9.4 %) agreed to go for HCV viral load testing. 9.4 % were found to be viremic and treated with Sofosbuvir-Daclatasvir for 12 weeks, with adherence 86.1% SVR-12 rate. Use of heroin (28.3%), alcohol (13.1%), smoking (16.2%), chewing tobacco (4.1%), and marijuana (3.9%), pain medication (0.5%) were the predominant SUD, alone or in combination Barriers to care were that 60.1% were unaware about the free DAAs under NVHCP, 32.0% reported social stigma and 7.8% claimed lack of access to specialized care.

Conclusion We report a high prevalence of undiagnosed HCV, HBV and HIV infection in PWID at our centre, who are at risk of transmitting to others as well as getting reinfected despite treatment. So integrated viral therapy and deaddiction is essential to encourage therapy acceptance with high cure rates.

Keywords DDTC, HBsAg, Hepatitis C, HIV, PWID

160

Low skeletal muscle strength parallels the nutrient deficit among Indian patients with cirrhosis

Pallavi Gindodia , Roopam Negi, Roopam Madan, Richa Bhargava, Pankaj Singh, Vikas Singla, Ayushi Singh, Dhairya Madan ^*

Correspondence - Kaushal Madan - k_madan_2000@yahoo.com

Centre for Gastroenterology, Hepatology and Endoscopy, Max Institute of Liver and GI Sciences, 1 2, Press Enclave Marg, Saket Institutional Area, Saket, New Delhi 110 017, India, and ^*Himalayan Institute of Medical Sciences, Joly Grant, Bhania Wala, Dehradun 248 140, India

Introduction Malnutrition as assessed by low muscle mass and/or low muscle strength is prevalent in patients with cirrhosis. One of the factors leading to sarcopenia, is poor nutrient intake.

Aim To determine the association of skeletal muscle strength with nutrient intake among Indian cirrhotics.

Methods Consecutive patients with cirrhosis attending the OPD or admitted to Max Centre for Gastroenterology, Hepatology and Endoscopy were included. Patients with history of or current presentation with ascites, hepatic encephalopathy or variceal bleeding were labeled as decompensated cirrhotics. Skeletal muscle strength was measured using Jamar type hand grip dynamometer using the average of 3 measurements from the dominant hand. Nutrient intake was assessed using 24-hour recall to calculate the calories and proteins taken by the patients.

Results Between December 2021 and July 2022, 56 patients with cirrhosis (44 compensated and 12 decompensated; 80.7% males; median age 56 (29-81) years) were included. The HGS was lower among patients with decompensated cirrhosis, but it did not reach statistical significance (17.5 [9.33-29.60] vs. 19.3 [9.66-29.60] kgs; p=0.550), probably because of lower number of decompensated cases. Low HGS was significantly correlated with low calorie intake (Spearman’s correlation coefficient 0.305; p=0.010) but not with low protein intake (Spearman’s correlation coefficient 0.027; p=0.823).

Conclusions Low calorie intake may be the driving factor for low muscle strength among Indian cirrhotics, so replenishment of calories may help in improving their nutritional parameters.

Keywords Calorie intake, Cirrhosis, HGS, Muscle strength

161

A study of prevalence, precipitating factors and predictors of acute kidney injury in patients with cirrhosis of liver and its impact on in-hospital mortality

Nikhil Gandhi, B N Choudhury, Mallika Bhattacharyya, Utpal Jyoti Deka, Jayanta Nanda, Preeti Sarma, Pallab Medhi, Antara Sen

Correspondence - Nikhil Gandhi - nikhilgandhi93@gmail.com

Department of Gastroenterology, Gauhati Medical College, Narakasur Hilltop, Bhangagarh, Guwahati 781 032, India

Introduction Patients with cirrhosis are prone to develop acute kidney injury and is one of the common complications occurring in 20% to 50% of hospitalized patients. Development of acute kidney injury (AKI) has a dismal prognosis with an estimated mortality of about 50% in 30 days. Thus, aim of our study is to determine the prevalence, precipitating factors and predictors of AKI in cirrhotic patients and its impact on in-hospital mortality.

Methods A prospective observational study was conducted in 252 consecutive cirrhotic patients hospitalized in our department from January 2021 to July 2022. Patient’s demographic data and clinical profile was collected using a standardized proforma. Biochemical, hematological and abdominal imaging was done in all patients. All patients were then followed up until discharge or death.

Results Out of 252 patients, 215 (85.3%) were males with a mean age of 48.49 and 46.82 years for those with and without AKI respectively. The prevalence of AKI was 28.57% (72/252). Out of 72 patients with AKI, 35 patients died (48.6%), accounting for 39.8% of all in-patient mortality. Most patients who died had stage-3 AKI (37.1%). There was a significant association between AKI and mortality (p≤0.05). The major precipitating factors of AKI were infections (66.67%), refractory ascites (13.8%), gastrointestinal bleeding (12.5%) and herbal medications (6.9%). On multivariate analysis, MELD-Na score, sodium levels, presence of ascites and infections were independent predictors of development of AKI.

Conclusion AKI is common in patients with cirrhosis of liver with high in-hospital mortality. Early identification and recognition of these precipitants and independent predictors of AKI may help in prompt treatment with reduction in patient mortality and treatment cost.

Keywords Acute kidney injury, Cirrhosis of liver

162

Anthropometric and metabolic profiles and their association with advanced fibrosis in patients with non-alcoholic fatty liver disease

J ithin John, Prasanth Sudheendran, Jijo Varghese, Shanid Abdul Sathar, Krishnadas Devadas

Correspondence - Jithin John - jithin4john@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background and Aims Advanced fibrosis is the most important predictor of overall mortality in patients with non-alcoholic fatty liver disease (NAFLD). Identifying people at high risk of fibrosis and referring them for fibrosis assessment is of paramount importance. We tried to assess various anthropometric as well as metabolic factors and their association with advanced fibrosis.

Methods Cross-sectional observational study including 1617 patients of NAFLD. Baseline clinic-demographic, anthropometric and metabolic profiles were noted. Liver fibrosis was assessed using Vibration Controlled Transient Elastography (VCTE) with VCTE ≥ 9.9 kPa is taken as advanced fibrosis. Univariate as well as multivariate logistic regression was used to identify the independent predictors of advanced fibrosis.

Results The mean age was 43.3 years with a mean body mass index (BMI) of 26.28. Among 1617 NAFLD patients, 225 (16.2%) had advanced fibrosis. The mean age was higher in the advanced fibrosis group (50.8 vs. 42.1 p<0.001). Gender was not significantly different between the two groups. Even though high-density lipoprotein (HDL) and triglyceride were significant in the univariate analysis, multivariate analysis did not show the same. Binary logistic regression analysis showed that BMI, waist circumference, hip circumference, and waist-hip ratio (WHR) were significantly higher in the advanced fibrosis group. Diabetes mellitus as well as the increasing trend of metabolic components significantly contributed to advanced fibrosis.

Conclusions NAFLD subjects having higher BMI, higher waist circumference, higher hip circumference, and higher WHR should be referred for fibrosis assessment at the earliest. Mid-arm circumference and triceps skin fold thickness have no relationship with advanced fibrosis. Advancing age (more than 50 years) and the presence of diabetes mellitus are useful predictors of advanced fibrosis. Gender, lipid profile, and systemic hypertension are not good predictors for advanced fibrosis.

Keywords Advanced fibrosis, Anthropometry, Metabolic profiles, Non-alcoholic fatty liver disease

163

Role of C-reactive protein and neutrophil-to-lymphocyte ratio for predicting the outcome in patients with cirrhosis and decompensation

Banwari Yadav, M Manimaran

Correspondence - M Manimaran - drbanwari2003@gmail.com

Department of Medical Gastroenterology, Stanley Medical College, No.1, Old Jail Road, George Town, Chennai 600 001, India

Background and Aim The role of clinical parameters such as systemic inflammatory response syndrome (SIRS) in predicting the infection remains unclear in cirrhosis patients. The aim was to evaluate the usefulness of inflammatory markers namely C-reactive protein (CRP) and the neutrophil-to-lymphocyte ratio (NLR) for diagnosis of infection and predicting the outcomes in hospitalized cirrhotic patients.

Methods A prospective study was carried out in Department of Medical Gastroenterology. The study included 67 cirrhotic patients consecutively hospitalized from November 2021 to May 2022. The presence of overt infection and survival was evaluated. CRP concentration, NLR, model for end-stage liver disease (MELD) score and the presence of SIRS were assessed.

Results Sixty-seven patients were included, 46 were male, 21 female. Out of them SBP 32 (47.7%), UTI 14 (20.8%), cellulitis 3 (4.47%), while 18 were without any infection at admission. Mean CRP in SBP (42±21.2 mg/L), UTI (28±19.67 mg/L), cellulitis (36±23.90 mg/L), without infection (04±2.1 mg/L), p-value 0.006). Elevated NLR was seen in patients with infections as compared to patients without infections. SIRS in infections group was 89%, while in non-infection group was 12.09%. Odds ratio for CRP and NLR in predicting HRS-AKI was 8.66. AUROC for CRP in mortality at 5 months (0.64 p-value 0.002) and NLR 0.32 (p-value 0.08).

Conclusions Both CRP and NLR helps in assessing infections at admissions, however CRP predict mortality at 5 months more than NLR.

Keywords C-reactive protein, Infection, Liver cirrhosis, Neutrophil-to-lymphocyte ratio

164

A rare case of cholestatic jaundice

Prafulla Singh, Harish Kulkarni, Sumit Kumar, Sai Krishna Katepally, P Shravan Kumar

Correspondence - Prafulla Singh - prafulla0singh@gmail.com

Department of Gastroenterology, Gandhi Medical College, Musheerabad, Padmarao Nagar, Secunderabad 500 003, India

Idiopathic adulthood ductopenia (IAD) is a rare chronic cholestatic liver disease of unknown cause characterized by loss of the interlobular bile ducts. Since the symptoms and presentation of IAD can be nonspecific, it continues to be a diagnosis of exclusion. There are two types of IAD, In Type 1, ductopenia is <50% of portal tracts and has benign course while in type 2 ductopenia is >50% leading to cirrhosis and liver failure.

Here we report a case of 30 years old male presented with jaundice and pruiritus. On evaluation, bilirubin and serum alkaline phosphatase were found to be elevated. Viral markers, autoimmune profile and chronic liver disease work-up was unremarkable. Ultrasonography (USG) and magnetic resonance cholangiopancreatography (MRCP) were normal. Liver biopsy showed absence of interlobular bile ducts in 40% of portal triad suggestive of IAD (Type 1). Type 1 has benign course that responds to ursodeoxycholic acid (UDCA). We advised UDCA to the patient and his symptoms, serum bilirubin and alkaline phosphatase (ALP) levels improved. Till now, less than 100 cases was reported in medical literature [1,2,3].

References

1. Kaung A, Sundaram V, Dhall D, Tran TT. A case of mild idiopathic adulthood ductopenia and brief review of literature. Gastroenterol Rep (Oxf). 2015;3:167-9.

2. Moreno A, Carreño V, Cano A, González C. Idiopathic biliary ductopenia in adults without symptoms of liver disease. N Engl J Med. 1997;336:835-8.

3. Park BC, Park SM, Choi EY, et al. A case of idiopathic adulthood ductopenia. Korean J Intern Med. 2009; 24: 270–3.

Keywords Cholestatic jaundice, Idiopathic adult ductopenia

165

Prevalence of prolonged QTc and its impact on liver transplantation outcomes in a cohort of patients with liver cirrhosis. A single centre experience

Saranya Sankar, Fathimathu Zahra, Mathew Jacob, Mohammed Fawas. Biju Chandran, Sudheer Mohammed, Charles Panackel

Correspondence - Charles Panackel - charlespanackel@hotmail.com

Integrated Liver Care, Aster Medcity, Kuttisahib Road Cheranelloor, South Chittoor, Kochi 682 027, India

Introduction Prolonged QTc is an early marker of cirrhotic cardiomyopathy. It is correlated with ventricular arrhythmias and sudden cardiac death in etiologies other than liver cirrhosis.

Aim To evaluate the prevalence of prolonged QTc in a cohort of patients with cirrhosis liver evaluated for liver transplantation. To analyze the correlation of prolonged QTc with the severity of the liver disease.To look at the impact of prolonged QTc on peri-transplant cardiac morbidity and mortality.

Methods A single centre retrospective analytical observational study. All patients with complete data to evaluate the etiology and severity of the liver disease. Patients with an electrolyte imbalance, drug intake or cardiac conditions that could account for prolonged QTc were excluded. Patients were divided into three groups based on the severity of liver disease (Group-1 MELD-Na £20, Group-2 MELD-Na 21-29, Group-3 MELD-Na ³30). Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) 21.0 software.

Results During the study period, 139 patients fulfilled the inclusion criteria. The mean age was 51.65±8.86. The study population was predominantly males, 116 (83.45%). The mean MELD-Na was 23.32±6.15. The etiology of liver disease was predominantly non-alcoholic steatohepatitis (NASH) in 78 patients (56.1%), ALD in 46 patients (33.09%), AIH in 12 (8.6%) and others 3 (2.1%). The mean QTc in the study cohort was 454.11±41.12 (Group -1 451.29±40.84, Group-2 457.99±40.50, Group -3 453.74±31.85). Prolonged QTc was seen in 85 patients (61.15%) Group 1 - 59.18%, Group 2 - 64.79%, Group 3 – 52.63%. All patients with prolonged QTc underwent uneventful liver transplantation.

Conclusion Prolonged QTc is common in patients with liver cirrhosis. In the current study, prolonged QTc did not correlate with the severity of liver disease, probably because of the low number of patients in group 3. Prolonged QTc was not associated with increased cardiovascular morbidity or mortality peri-transplant.

Keywords Cirrhotic cardiomyopathy, Liver cirrhosis, Prolonged QTc

166

Performance of Baveno VI and expanded Baveno VI criteria for avoiding endoscopy in Indian patient with compensated advanced chronic liver disease

Pallavi Gindodia, Kaushal Madan, Richa Bhargava, Sawan Boppana, Vikas Singla, Ayushi Singh, Jatin Aggarwal, Abhaya Indrayan

Correspondence - Kaushal Madan - k_madan_2000@yahoo.com

Centre for Gastroenterology, Hepatology and Endoscopy, Max Institute of Liver and GI Sciences, 1 2, Press Enclave Marg, Saket Institutional Area, Saket, New Delhi 110 017, India

Introduction More and more cirrhotics are being diagnosed at an early stage, known as compensated advanced chronic liver disease (cACLD). It is impractical to subject this population to screening endoscopy. There is a need to validate the Baveno VI and expanded Baveno VI criteria to avoid doing a screening endoscopy in Indian setting.

Aim To assess the performance of Baveno VI and expanded Baveno VI criteria among Indian patients with cACLD.

Methods Consecutive patients with cACLD (liver stiffness >15) of any etiology, were included. Patients without a recent (within last 6 months) upper GI endoscopy report, and those with any history of decompensation in the past were excluded. Patients with a liver stiffness value, (LSM) >20 kPa and with platelet counts >1.5 lacs/mm³ were said to be meeting the Baveno VI criterion. Patients with LSM >25 kPa and platelet counts >1.1 lacs/mm³ were said to be meeting the expanded Baveno VI criterion for avoiding doing an endoscopy. The presence of low-risk esophageal varices on endoscopy was considered as confirming the findings of the non-invasive criteria and presence of high risk varices or h/o variceal bleed were considered as negative confirmation.

Results Of 69 cACLD, 31 were excluded. Of the 38, 22 (57.9%) were males and the median age was 56.5 (30-76) years). The sensitivity, specificity, positive predictive value and negative predictive value of Baveno VI criterion for avoiding screening endoscopy were 14.8%, 83.3%, 80% and 17.8% respectively. The corresponding values for expanded Baveno VI criterion were 30.8%, 83.3%, 88.8% and 21.7% respectively.

Conclusions More data is needed to assess the performance of both Baveno VI and expanded Baveno VI criteria in Indian patient with cACLD.

Keywords Baveno VI criteria, Fibroscan, Platelet counts

167

Emerging trends of bacterial infections in patients with liver cirrhosis - A clinical audit from a tertiary centre in western India

Jaseem Ansari, Harshal Gadhikar, Sanjana Bhagwat, Amol Bapaye, Nisarg Patel, Sachin Palnitkar, Mangesh Borkar, Ajay B R

Correspondence – Harsha Gadhikar - gadhikarhp@gmail.com

Department of Gastroenterology, Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital, Kothrud, Deenanath Mangeshkar Hospital Road, Erandwane, Pune 411 004, India

Introduction Bacterial infections in liver cirrhosis (LC) patients cause acute-on-chronic liver failure (ACLF), multi-organ dysfunction (MODS) and is a leading cause of mortality. Antibiotic resistance is fast emerging, reemphasizing judicious utilization of antibiotics. The aim was to study the clinical and microbiological profile of LC patients with bacterial infections.

Methods Retrospective analysis of prospectively maintained database of LC patients. Three hundred and seventy-eight patients with LC admitted from January 2019 to December 2021. One hundred and eleven patients with infections included. Clinical, laboratory, microbiological data and sensitivity patterns analyzed.

Results Total admissions = 131, out of these, readmissions = 20, same infection = 12. Child-Turcotte-Pugh (CTP) score C 90/131 (68.7%). MELD Na < 15- 9/131 (6.8%); MELD Na >15- 122/131 (93.1%). 63/131 (48%) – AKI.

Culture positive (urine, ascites, sputum/endotracheal aspirate, skin, abscess, urethral discharge, blood) = 116, urine 45/116 (38.7%) > bacteremia 22/116 (18.9%). Gram negative infections - 90/116 (77.5%), gram positive infections – 26/116 (22.4%). Nosocomial infections 14/116 (12%). 30/116 (25.8%) - MDR; E. coli most common. 26/116 (22.4%) – XDR; K. Pneumonia most common.

SBP incidence 52/131 (39.6%); CTP C 42/52 (80.7%), CTP B 10/52 (19.2%); 36 typical and 16 atypical presentation (hepatic encephalopathy 12, breathlessness 3, hematemesis 1). Nosocomial SBP 3/20 culture positive SBP (15%). Commonest microorganism - E. coli 8/20 (40%) for SBP. 14/20 (70%) and 7/20 (35%) culture positive SBP resistant to 3rd-4th gen cephalosporins and piperacillin-tazobactam (PT). 3/8 (37.5%) on norfloxacin primary prophylaxis-developed culture positive SBP; 2/3(66%) resistant to quinolones. 46/81 (56.7%) and 41/86 (47%) culture sensitivity pattern resistant to PT and carbapenems.

49/131(37.4%) – ACLF. Mortality 42/111 (37.8%); CTP C 27/42 (64.2%), CTP B 13/42 (30.9%), CTP A 2/42 (4.7%); 23/42 (54.7%)-ACLF; 33 (29.7%) deaths during same admission.

Conclusion Emerging incidence of quinolone resistance emphasises the need to improvise antibiotic prophylaxis against SBP. Empirical antibiotic strategy needs to be revised in view of the high MDR/XDR rates especially in recurrent infections.

Keywords Acute on chronic liver failure, Bacterial infections, Liver cirrhosis

168

Prognostication of survival following pharmacologic treatment in decompensated cirrhosis with hepatorenal syndrome-Acute kidney injury

Vijay Narayanan, Antony George, Jesse Jacob, Krishnadas Devadas, Srijaya Sreesh

Correspondence - Vijay Narayanan - vijaynh@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background and Aims Hepatorenal syndrome-acute kidney injury (HRS-AKI) is one of the most challenging complications of advanced liver disease and is associated with extremely high mortality. The early identification of factors that predict short-term mortality in HRS-AKI is crucial to fast-track patients for liver transplantation. We assessed the outcomes of pharmacologic treatment and predictors of mortality in patients with HRS-AKI

Methods Eighty-four patients diagnosed to have HRS-AKI (based on the new ICA definition) who were treated with terlipressin and albumin were included. The response to pharmacologic therapy was assessed. Patients were then followed up for a duration of six months and factors which predict six-month survival were analyzed. Survival analysis was performed using the Kaplan–Meier method with log-rank test for comparison between the groups. Cox regression models were used to assess the association of clinical characteristics with overall survival.

Results Eighty-four patients with HRS-AKI were included. A complete response to therapy was seen in 54.8%, partial response in 14.3%, and no response in 31%. The factors associated with six-month mortality were the presence of hepatic encephalopathy, baseline stage of AKI, model for end-stage liver disease sodium score (MELD Na), and non-response to pharmacologic treatment. Treatment non-responders had higher mortality as compared to complete responders at one month (27% vs. 9%) and six months (74% vs. 45%). Mean transplant-free survival at six months was significantly longer in the treatment responders (148 days vs. 90 days, log-rank p<0.001). Cox regression analysis revealed that the independent predictors of six-month mortality were response to treatment (HR=0.527, p- 0.004) and MELD Na > 23 (HR=1.071, p-0.018).

Conclusion Response to pharmacologic treatment and MELD-sodium score are independent predictors of six-month mortality in HRS-AKI. Treatment non-responders have higher mortality and should be identified early to expedite liver transplantation

Keywords Acute kidney injury, Hepatorenal syndrome, Mortality

169

Knowledge, behavior and patterns of substance use disorder in people who inject drugs with chronic hepatitis C virus infection

Shikha Guleria, Anchal Sandhu, Madhumita Premkumar, Abhishek Ghosh, Debashis Basu, Ajay Duseja, Sunil Taneja, Arka De, Jasvinder Nain, Surender Sehrawat, Vishesh Kumar

Correspondence – Madhumita Premkumar - drmadhumitap@gmail.com

Department of Hepatology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India

Background As previously reported, the National Viral Hepatitis Control Programme of India in the state of Punjab has a cure rate of 90.1% for people who inject drugs (PWID) with hepatitis C virus (HCV) infection, but a dropout rate of 15.6%. However, due to perceived stigma, PWID and patients with ongoing substance use disorders or injection drug use avoid general clinics, delaying referral until drug abstinence is confirmed. This leads to additional infections, breaks in treatment, and risk of drug-resistant HCV variants spreading among PWID.

Methods An integrated care team used a combination of directed acting antiviral agents (DAAs) to provide combined deaddiction therapy and management for HCV infection. We examined the knowledge, behavior; patterns of substance use disorder in PWID and assessed the risk factors for treatment failure and reinfection in patients who had been sent for specialized treatment for drug addiction.

Results We enrolled 300 PWID with viremic HCV infection (99.6% men; mean age 28 years; 91% literate and 33.3% married). Of them, 252 (84%) underwent deaddiction at Postgraduate Institute of Medical Education and Research, Chandigarh, and were given DAAs based treatment. Patients with active IDU had a cure rate of 90.4% and had 89.6% adherence. The cure rate in those with interruptions was reduced at 57.1%. Although 81.6% of PWID had accurate knowledge of the spread of HBV and HCV infection, only 39.6% of people had family members tested for HBV/HCV. Approximately 1% of people received herbal treatment, and 42% received hepatitis B vaccinations. Use of heroin (12.6%), alcohol (29.3%), nicotine (26.3%), chewing tobacco (1.6%), intravenous drugs (5%), marijuana (7.33%), opium (3.33%) and pain medications (2.33%) were reported, alone or in combination. Buprenorphine (246, 82%), nicotine patch (22,7.3%), ketorolac (20,6.6%) and nicotine gum (14,4.6%) were used as deaddiction therapy with counseling.

Conclusion DAAs based treatment ensures cure rate >90% in PWID who adhere to therapy.

Keywords Direct-acting antiviral agents, Drug resistant, Hepatitis C, PWID, Treatment

170

KGHeBTA (King George’s Medical University Hepatitis B Therapeutic Algorithm): A new cocktail, ready to be sipped and clinico-epidemiological spectrum of hepatitis B

Ajay Patwa ¹ , Amar Deep², Pratishtha Mishra¹, Sumit Rungta², Anil Gangwar², Ankur Yadav², Virendra Atam¹, Kamlesh Kumar Gupta¹, Bhaskar Agrawal³, Sanjeev Kumar Verma⁴

Correspondence - Ajay Patwa - drajaymd12345@gmail.com

Departments of ¹Medicine, ² Medical Gastroenterology, ³Prosthodontics, and ⁴Pediatrics, King George's Medical University, Chowk, Lucknow 226 003, India

Background There is lack of a simplified and comprehensive, diagnostic, and therapeutic algorithm for hepatitis B for day-to-day practice. There is lack of large-scale data on prevalence of different clinical stages, testing circumstances and risk factors for hepatitis B from our region. We tried to fulfil these gaps by our study.

Methods KGHeBTA (King George’s Medical University hepatitis B therapeutic algorithm), a new simplified and practical version of diagnostic and therapeutic algorithm for hepatitis B, was developed, primarily based on standard existing guidelines. Prevalence of different clinical stages of HBsAg positive patients, attending our hepatobiliary clinic, was estimated and their treatment records reviewed retrospectively. Testing circumstances and risk factors were noted.

Results Among 1508 data record sheets, 421 were complete. 221 had detectable hepatitis B virus DNA. 21% were cirrhotic and 79% non-cirrhotic. 72% were incidentally detected asymptomatic hepatitis B (IDAHB), 7% hepatitis B with acute symptoms (HBWAS), 0.7% acute hepatitis B (AHB) and 22% chronic hepatitis B (CHB). 20% patients were eligible for antivirals and 80% patients were not eligible. 32% patients were actually treated with antivirals due to inclusion of some special indications as pregnancy and family history. Screening during various medical illnesses (40%) was the most common and during health camps (0.2%) the least common testing approach. Road-side shaving (52%) was the most common and intravenous drug abuse (0.2%) the least common risk factor for detection of hepatitis B in our data pool.

Conclusions HBsAg positive patients can be easily worked up and treated based on the proposed algorithm (KGHeBTA). According to the algorithm, about one fourth to one fifth of all HBsAg positive patients were eligible and treated with oral antivirals. Most of the patients were IDAHB screened during medical illnesses. Roadside shaving and intravenous drug abuse were the most and the least common risk factors.

Keywords Chronic hepatitis B, HBV-DNA, Natural history, Risk factors, Testing approaches

171

Carotid intima-media thickness as a non-invasive tool to assess the risk of atherosclerotic cardiovascular disease in lean and non-lean non-alcoholic fatty liver disease patients

Jithin John, Avisek Chakravorty, Rushil Solanki, Devika Madhu, Ravindra Pal, Vijay Narayanan, Shivabrata Dhal Mohapatra, Yamuna R Pillai, Krishnadas Devadas

Correspondence - Jithin John - jithin4john@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background and Aims Non-alcoholic fatty liver disease (NAFLD) is now identified in normal body weight individuals also, termed lean NAFLD. Cardiovascular disease (CVD) is the major cause of mortality in NAFLD patients. We tried to assess the risk of atherosclerotic CVD in lean NAFLD individuals, by measuring the carotid intima media thickness (CIMT).

Methods Cross-sectional observational study including 120 patients of lean NAFLD (BMI<23 kg/m²) and 120 non-lean NAFLD (BMI≥23 kg/m²). Baseline demographic and clinical data was noted, including measurement of hemogram, liver biochemistry, lipid profile and homeostasis model assessment-estimated insulin resistance (HOMA-IR). Liver fibrosis was assessed using vibration controlled transient elastography (VCTE). CIMT was measured using standard software in carotid doppler ultrasound. Data was compared between the 2 groups, and factors independently predicting CIMT were determined using multivariate linear regression.

Results Lean NAFLD patients had significantly lesser mean waist circumference, total and visceral body fat percentage compared to non-lean patients (p<0.001 for all). Both groups had comparable waist-hip ratio (p=0.639). Non-lean NAFLD group had significantly higher H0MA-IR and serum triglycerides (p<0.001 for both). Other parameters of lipid profile and liver biochemistry were comparable. 55.8% of lean NAFLD population had metabolic syndrome, compared to 80.8% of the non-lean (p<0.001), by NCEP ATPIII criteria. At least one component of MetS was present in 92.5% of the lean population. Liver fibrosis by VCTE was similar in both the groups (p=0.162). When the groups were taken as a whole, CIMT was comparable (p=0.626), but in the 18-40 years age group, lean NAFLD subjects had significantly higher CIMT (p=0.034). Serum ALT, serum LDL and VCTE were found to independently predict the CIMT. Serum alanine transaminase (ALT) >75 IU/mL, serum low-density lipoprotein (LDL) >134 mg/dL and VCTE >9.4 kPa were the optimum cut-offs for predicting a high CIMT.

Conclusions Lean NAFLD subjects tend to have an equal risk of atherosclerotic CVD when compared to their overweight/ obese counterparts. Serum ALT, LDL and liver elastography values independently predict CIMT in NAFLD patients.

Keywords Carotid atherosclerosis, Carotid intima-media thickness, Lean NAFLD

172

A rare cause of hepatitis with multiorgan dysfunction

Prasanna Gore , Gaurav Mehta, Vatsal Kothari, Tanu Singhal, Sameer Tulpule

Correspondence – Gaurav Mehta - gaurav.mehta@kokilabenhospitals.com

Department of Gastroenterology, Kokilaben Dhirubhai Ambani Hospital, Rao Saheb, Achutrao Patwardhan Marg, Four Bungalows, Andheri West, Mumbai 400 053, India

Case History A 58-year-old male came with complaints of fever, abdominal pain, vomiting, burning micturition, abdominal distension since 4-5 days. Preliminary blood test revealed Crp:29.182, PCT:8.05, AST:422, ALT:235, creatinine:3.23, bicarbonates:18.36, total bilirubin :9.49, direct bilirubin:8.52, indirect bilirubin:1.37, sodium :128, potassium:4.32, anti-HEV IgM: positive, scrub typhus IgM positive, leptospira and varicella IgM was positive. CPK:40.9, Hb:13.5, WBC:13440, platelets:165000. Patient had vesicles all over his trunk biopsy from ruptured vesicle: herpes infection, HSV1 and HSV 2 IgM and IgG antibodies positive. Patient was started on antibiotics and antifungals. ANA positive and speckled pattern and ASMA positive, autoimmune profile negative, C3,C4 levels were normal, In view of persistent deranged LFT trangjugular liver biopsy was done suggestive of foci of geographic hemorrhagic necrosis correlating with herpes hepatitis. In view of persistent hyperbilirubinemia, rising creatinine, breathlessness, disorientation, HSV hepatitis. Patient was started on Inj.Acyclovir. Patient became increasingly hypoxic and desaturated to 82% patient was intubated and mechanically ventilated CSF was positive for HSV, In view of thrombocytopenia and high counts and hypergammglobinemia SPEP was sent suggestive of polyclonal B cell activation suspected. Patient was on regular hemodialysis in ch w of worsening creatinine and creatinine improved, Inj.Methylprednisolone started in view of worsening parameters under antibiotics cover and steroids tapered gradually, patient improved well and recovered well.

Final diagnosis: Disseminated HSV 1 and 2 Infection (hepatitis and encephalitis) With MODS (AKI, LRTI) and polyclonal B cell activation syndrome with hypergamma globulinemia.

Keywords Hepatitis, HSV, Hypergammglobinemia, MODS

173

Vanishing bile duct syndrome due to dapsone toxicity

Nitin Pai, Chaitanya Lodha, Sahil Rasane

Correspondence - Chaitanya Lodha - drchaitanyalodha@gmail.com

Department of Gastroenterology, Ruby Hall Clinics, Rajeev Gandhi Infotech Park, MIDC Phase No 1, Plot No, P-33, Hinjawadi, Pune 411 057, India

Introduction Many dermatologic and non-dermatologic conditions need daspone therapy. Obligatory (dose-dependent) adverse drug reactions include hemolytic anemia, methemoglobinemia and hypersensitivity reactions to dapsone called the dapsone hypersensitivity syndrome.

Case Report A 23-year-old male, teacher by occupation, presented with insidious onset jaundice for 1 month which was progressively increasing associated with pale stools associated with dull aching low intensity right upper quadrant abdominal pain, low grade intermittent fever for 1 month, He also complaint of recent onset difficulty in opening mouth, lip swelling. He gave no history of gastrointestinal bleed, ascites, altered sensorium. He gave history of recurrent pustular nodular swelling in bilateral axilla, groin for 4 years. He took herbal/allopathy medications on and off for 4 years for the same. The patient was started on dapsone in December 2020 suspecting leprosy in view of multiple lesions. Dapsone stopped on 10/2/2021. On examination, he had scarring over the mandibles, bilateral tender axillary lymphadenopathy, thick velvety plaques over the axilla, groins, lower abdomen and neck with skin tags and multiple discharging sinuses with pus. On evaluation, serum IgG level was 20 mg/dL, contrast-enhanced computed tomography (CECT) showed hepatomegaly with mild diffuse fatty infiltration, splenomegaly, and multiple splenic infarcts. Gastroscopy (RHC) Kodsi grade I esophageal candidiasis, no other abnormality. Gastroscopy (RHC) Kodsi grade I esophageal candidiasis, no other abnormality. Transabdominal liver biopsy was suggestive of chronic intrahepatic cholestatic liver injury with mild hepatitis and marked ductopenia favoring vanishing bile duct syndrome. Drainage of the infected hidradenitis suppurativa was done and patient was started on antibiotics per the sensitivity report. Steroids were started 7 days later with a normal procalcitonin.

Conclusion High index of suspicion for early diagnosis of dapson hypersensitivity. Monitor patients for development of dapsone hypersensitivity syndrome. If drug is not withdrawn, it could have deleterious and potentially fatal effects due to major organ dysfunction

Keywords Dapsone hypersensitivity syndrome, Dapsone toxicity, Vanishing bile duct disease

174

Ciprofloxacin induced vanishing bile duct syndrome - A case report

Kishore Kumar Rajaram, Kandasamy Alias Kumar E, Poppy Rejoice R, Shafique A

Correspondence - Kishore Kumar Rajaram - Kishorebonne@gmail.com

Department of Medical Gastroenterology, Tirunelveli Medical College, 3, High Ground Road, Palayamkottai, Tirunelveli 627 011, India

Introduction Vanishing bile duct syndrome (VBDS) refers to a group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts leading to cholestasis. It has been described in different pathologic conditions including infection, ischemia, adverse drug reactions, autoimmune diseases, allograft rejection, and humoral factors associated with malignancy. Prognosis is variable and partially dependent upon the etiology of bile duct injury. We report a case of a 52-year-old male who developed vanishing bile duct syndrome a month later after using ciprofloxacin.

Methods Case Report - A 52-year-old male patient presented to us with jaundice, pruritus and easy fatiguability associated with weight loss. He had a history of diarrhea for which he has been treated with ciprofloxacin. Personal history was unremarkable. Physical examination revealed scratch marks and his conjunctivae were icteric. Laboratory investigations showed 17.6 mg/dL total bilirubin, 11.5 mg/dL conjugated bilirubin, 35 IU/L alanine transaminase, 320 IU/L gammaglutamyl-transpeptidase, 358 IU/L alkaline phosphatase, and 10 mm/h erythrocyte sedimentation rate (ESR). Serologic tests were negative for viral hepatitis A, B, C and E. Abdominal ultrasound showed that liver had homogeneous texture with normal bile ducts and gallbladder.

Result After ruling out the common causes such obstruction, infection by magnetic resonance cholangiopancreatography (MRCP), hepatitis panel then he was screened for autoimmune hepatitis and Wilson disease also. Finally, patient was subjected for percutaneous liver biopsy with Cytokeratin 7 staining, which showed >50% duct loss.

Conclusion VBDS should be considered when liver injury and cholestasis develop after antibiotics commencement. The level of suspicion must be further heightened when more common causes of cholestasis, such as biliary obstruction, are excluded. Early recognition of this association and cessation of the causative agent are paramount to achieving a successful outcome.

Keywords Cholestasis, Ciprofloxacin, Vanishing bile duct syndrome

175

Clinical implications and risk factor analysis of hepatitis B and C reactivation in patients receiving chemotherapeutic agents

Kondala Yedupati, Vijaishankar Chidambaramanivasagam, Kannan Mariappan, Ramani Ratinavel, Sriram P

Correspondence – Vijaishankar Chidambaramanivasagam - vijaishankar.c@gmail.com

Department of Medical Gastroenterology, Madurai Medical College. Panagal Road, Alwarpuram, Madurai 625 020, India

Aim Aim of the study is to assess the risk factors for post chemotherapy hepatitis B and C reactivation and their clinical profile.

Materials Study group included 87 post chemotherapy viral reactivation patients of Government Rajaji Hospital, Madurai of which 75 patients had hepatitis B and 12 patients had hepatitis C reactivation. Demographic profile of individuals, history of blood transfusion, tattooing, surgery, family history of jaundice, tumour type, staging of tumor, duration of onset of jaundice after starting therapy, radiotherapy, liver function test, complete blood count, real time PCR analysis of HBV DNA and HCV RNA were analyzed. All deserving patients were treated, and subsequent follow-up done from 2020-2021.

Statistical Analysis It’s a prospective study. Fishers’ exact test was used to compare categorical variables. For non-parametric data Mann –Whitney test was used.

Results Post chemotherapy reactivation seen predominantly in age > 40 years (n=73.3%), female (n=75%), past history of surgery (n=65.5%). Majority of patients were on chemotherapy for carcinoma breast stage IV (87.3%), 68.6% individuals have silent reactivation, HBV associated icteric hepatitis 28.4%. Alkylating agent and antimetabolite combination therapy causing major reactivation in our study population (76.7%). Patients presented with reactivation after 6 cycles of chemotheraphy (66.7%) and mean duration from chemotheraphy to onset of jaundice is 4.8 months. Majority of the patients (67+12 patients) showed response to antivirals and follow up fibroscan value after 6 months mean value is 6.9 kpa. HCV reactivation is seen < 40 years more with hematological malignancy.

Conclusion Hepatitis B reactivation is more common than hepatitis C reactivation, elder age, female, usage of combination chemotheraphy agents, stage IV breast tumors, duration of chemotherapy and radiotheraphy are risk factors. Hepatitis C reactivation more in younger age and associated with hematological malignancies.

Keywords Chemotheraphy, Cirrhosis, Hepatitis B reactivation, Hepatitis C reactivation

176

A case of hepatic visceral larva migrans

Saurabh Gaur, Komal Kalla, Mukesh Kalla, Ramesh Roop Rai, Pankaj Shrimal, Aman Manocha, Alok Verma, Sumit Patter, Shreyans Jain, Suresh Kumawat

Correspondence – Saurabh Gaur - saurabhgaur64@yahoo.in

Department of Gastroenterology, S R Kalla Memorial Gastro and General Hospital, 78-79, Dhuleshwar Garden, C Scheme, Jaipur 302 001, India

Introduction Visceral larva migrans (VLM) is a systemic manifestation of migration of second stage larvae of nematodes through the tissue of human viscera. The liver is the most common organ to be involved due to its portal venous blood supply. Presenting a case of 16-year-old boy from a rural background presented with intermittent abdominal pain, malaise, loss of appetite and restlessness for 3 months.

Method Blood investigation revealed microcytic hypochromic anemia and eosinophilia (blood eosinophil count being 27%, AEC-1610 cu/mm). Serum alkaline phosphatase raised (885 IU/L), other liver function parameters normal. Coagulation profiles were normal. Serum α-fetoprotein came normal (<0.5 IU/mL). Ultrasound abdomen showed ill-defined hypoechoic lesions in right lobe of liver. Contrast-enhanced computed tomography (CECT) scan of the abdomen showed large hypodense SOL with multiloculated cystic areas (5.7 × 6.4 × 7.2 cms) in segment 6/7 of liver. A provisional diagnosis of hepatic lesions associated with parasitic infestation was made. The stool examination for entamoeba histolytica, giardia and ascaris ova and cyst were negative along with their serology. The values of serum IgE levels were also high (1860 IU/L).

USG guided fine needle aspiration cytology (FNAC) of the lesion with Giemsa stains showed cellular smears comprising mixed inflammatory cells predominantly consisting of eosinophils with few degenerated cells were also seen. No parasites were identified in the smears. The findings were suggestive of eosinophilic abscess, thus with correlating radiological findings, a final diagnosis of visceral larva migrans was made.

Results The patient was empirically given 400 MG twice daily albendazole for 5 days. The patient was totally relieved of his symptoms and complete resolution of hepatic sol seen.

Conclusion We can say in developing countries peripheral eosinophilia with hepatic Sol, one must keep the differential diagnosis of parasite infestation.

Keywords Hepatic SOL, Visceral larva migrans

177

Prevalence and predictors of significant liver fibrosis among Type II diabetes mellitus patients attending primary healthcare facilities

Aayushi Rastogi, Archana Ramalingam, Manya Prasad, Umesh Kapil, Guresh Kumar, Shiv Kumar Sarin

Correspondence – Aayushi Rastogi - rastogiaayushi6@gmail.com

Department of Clinical Epidemiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India

Background Patients with type 2 diabetes mellitus (T2DM) are at high risk for significant liver fibrosis, and have accelerated progression to advanced liver fibrosis and cirrhosis. Despite the high burden of T2DM prevalence estimates for significant liver fibrosis among T2DM are limited, from a country like India, which is recognized as the diabetic capital of the world. The present study aimed at assessing the prevalence of significant liver fibrosis among T2DM in primary healthcare settings using transient elastography as a screening tool.

Methods A cross-sectional study was undertaken between 2021-22 in previously diagnosed patients with diabetes seeking medical care in primary healthcare clinics of Delhi, India. A mobile screening unit with trained research staff administered a brief questionnaire to assess the personal and family medical history and behavioral risk factors. They also measured the anthropometric parameters and drew a venous blood sample for biochemical testing. Transient elastography was performed and significant liver fibrosis was defined as liver stiffness measurement of ≥7.9 kPa. Univariable and multivariable analysis was done to find out the factors associated with significant liver fibrosis using STATA v-14 with statistical significance considered at p-value <0.05.

Results: A total of 1674 participants with diabetes were included in the study with a mean age of 52±11.4 years and 55% were males. Prevalence of significant liver fibrosis was 24% (95% CI:21.9%-26.1%) among patients with diabetes. Older age, use of insulin, uncontrolled glycemic levels, morbid obesity, raised waist circumference, history of hypothyroid disease dyslipidemia, viral hepatitis, harmful use of alcohol, high socioeconomic status and occupation classified based on physical activity, were important predictors of significant liver fibrosis among diabetes patients (Table 1).

Conclusions The study highlights the high prevalence of significant liver fibrosis among T2DM in primary healthcare settings.

Keywords Diabetes mellitus, Liver fibrosis, NAFLD, Obesity, Screening

178

A rare cause of prolonged cholestatic hepatitis – Hepatic sarcoidosis

Siddharth Shukla ¹ , Shreya Shruti², Kim Vaiphei³, Anupam Lal⁴, Jayanta Samanta¹, Saroj Kant Sinha¹

Correspondence –Saroj Kant Sinha - sarojksinha@hotmail.com

Departments of ¹Gastroenterology, ³Histopathology, and ⁴Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, ²Government Medical College and Hospital, Sector 32, Chandigarh 160 030, India

A 46-year-old diabetic female presented with jaundice and pruritus for four weeks. She had cholecystectomy five years back. Physical examination revealed deep icterus and mild hepatomegaly. Investigations showed total bilirubin 16 mg%, 4-6-fold elevated transaminases and 6-8-fold elevated alkaline phosphatase. Ultrasonography showed mild hepatomegaly and normal biliary system. Viral markers (hepatitis A–E), ANA, SMA, AMA and tissue transglutaminase antibody were all negative. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound showed normal biliary system. These investigations were repeated after 4-5 weeks, and results were similar. Due to intense pruritus despite medical treatment, endoscopic retrograde cholangiopancreatography (ERCP) and external biliary drainage was done. Jaundice and pruritus improved partially within 2 weeks, but mild jaundice persisted and alkaline phosphatase remained elevated. computerized tomography (CT) scan of chest/abdomen and positron emission tomography (PET) scan showed evidence of hilar and mediastinal lymph node enlargement with changes of interstitial lung disease. angiotensin converting enzyme level was elevated, Mantoux test was negative and liver biopsy showed granulomatous inflammation consistent with sarcoidosis. Her symptoms improved with oral prednisolone, but she relapsed twice on tapering dose of prednisolone. Azathioprine was added (1.5 mg/kg) which she continued for two years and tapered off. There was no relapse over next one year.

Discussion and Conclusion Sarcoidosis is systemic granulomatous disease characterized by non-caseating granulomas which most commonly occur in lungs. Hepatic involvement is not uncommon but prolonged cholestatic hepatitis is rare and is generally not considered in differential diagnosis of such syndrome. Here we are reporting rare manifestation of sarcoidosis in the form of prolonged cholestatic hepatitis.

Keywords Cholestasis, Hepatic Sarcoidosis

179

Clinical profile and treatment of hepatocellular carcinoma in a tertiary care hospital

Swaapnika Vemulapalli, Venkatakrishnan Leela, Mukundan S, Thirumal P, Karthikeyan R K, Arun P, Ravindra K

Correspondence – Swaapnika Vemulapalli - swaapni1792@gmail.com

Department of Medical Gastroenterology, P S G Institute of Medical Sciences and Research, Avinashi Road, Peelamedu, Coimbatore 641 004, India

Background Hepatocellular carcinoma (HCC) is the sixth most common malignancy reported worldwide accounting for significant mortality and morbidity, especially in chronic liver disease patients. The incidence of HCC is 2.8 per 100,000 population per year in 2015. Hepatitis B remains the main etiology of HCC accounting for about 50 percent of cases followed by hepatitis-C. There is increasing incidence of HCC which is mainly due to incr

easing incidence of non-alcoholic steatohepatitis (NASH) and better surveillance of HCC among high risk groups. Hence this study is aimed to assess the clinical profile and treatment of HCC in a tertiary care hospital.

Methods A cohort (retrospective and prospective) study of 150 patients of HCC patients from January 2012 till August 2022 who presented to Gastroenterology and Hepatology Clinic at PSG Hospital, Coimbatore were included in the study.

Results Total patients analyzed were 150. Of those males were 83% (n=124) and females were 17% (n=26) with majority belonging to low socioeconomic status 30% (n=45). Mean age at diagnosis was 57.3±10.1 yrs.13% (n=20) were incidentally detected where 77% (n=115) had symptoms. 60% (n=90) presented with chief complaint of pain abdomen followed by weight loss in 40% (n=60). In 30.4% (n=46) etiology was identified as hepatitis B followed by 20.2% (n=30) with NASH and 10.4% (n=16) were alcoholic. Mean model for end-stage liver disease (MELD) score was 12.14±8.2.40.8% (n=60) had alpha-fetoprotein (AFP) more than 400 ng/mL at presentation. 42% (n=63) presented with Barcelona Clinic Liver Cancer (BCLC) stage C followed by 29% (n=44) with stage B. Distant metastasis were noted in 20% (n=30) with most common site being lung which is involved in 8% (n=12). 40% (n=60) had invasion in to portal vein leading to tumoral thrombosis. Treatment options were given to 83% (n=124), among which systemic chemotherapy was given in 42% (n=52) and trans arterial chemoembolization (TACE) in 31% (n=47).

Conclusion Emphasis to be made on earlier detection of HCC by adherence to screening protocols which will provide varied therapeutic options leading to better quality of life.

Keywords Alcohol, Hepatitis B, Hepatocellularcarcinoma

180

Incidence of hepatocellular carcinoma in patients of hepatitis C following treatment with directly acting antivirals: Study from tertiary care center in Tamil Nadu

Dhanush Thomas, Venkatakrishnan Leelakrishnan, Mukundan Swaminathan, Thirumal Perumal, Kartikayan S, Arun P

Correspondence – Dhanush Thomas - dhanush26@gmail.com

Department of Gastroenterology, P S G Institute of Medical Sciences, Off, Avinashi Road, Peelamedu, Coimbatore 641 004, India

Introduction Chronic hepatitis C the leading risk factor for hepatocellular carcinoma (HCC) among cirrhotics. In patients with cirrhosis de novo HCC occurs at rate of 3-7%. With recent advent of highly effective DAA, irrespective of the stage of liver disease, 90% of patients achieved SVR. Recent studies reported an increased incidence of denovo and recurrent HCC in patients treated with DAA.

Aim and Objective To assess the incidence of HCC in HCV cirrhotic patients who achieved SV

R after treatment with DAA.

Methods Type of study: Retrospective study. Place of study: PSG Hospitals, Coimbatore. Inclusion criteria - chronic HCV patients with cirrhosis. (1) Age > 18 years, treated with DAA. (2) Patient should achieve SVR after treatment with DAA. Exclusion criteria were non cirrhotics, who do not achieve SVR 12 after treatment with DAA and HCC before DAA treatment.

Results One hundred patients with chronic HCV infection treated with DAAs were included. HCV RNA viral load was rechecked at 4 weeks, end of treatment, 12 and 24 weeks. 66/100 have cirrhosis of liver. These patients were followed up for 6+/- 22 months. This report includes a series of 9 patients who developed HCC after achieving SVR. The patients were 3 males and 6 females of age around 55-76. There was no evidence of HCC pre-treatment. The predominant genotype was genotype 4. Sofosbuvir + ribavirin was prescribed to 2 (22.2%), sofosbuvir+ribavirin+daclatasvir to 2 patients (22.2%). Ledipasvir+Sofosbuvir to 5 patients (55.5%). sVR at week 12 was achieved in 9 cases (100%). Most of these new lesions were small; <3 cm in 5 patients (55.5%), 3-5 cm in 3 cases (33.3%), while 1 patient had a lesion > 5 cm. All patients developed HCC after an average of 8 months after achieving SVR.

Conclusion Rigourous screening of HCC during and post DAA should be done.

Keywords Cirrhosis, Direct acting antivirals, Hepatitis C, Hepatocellular carcinoma

181

Two different entities or the same?

Kishore Kumar Rajaram , Kandasamy Alias Kumar E, Poppy Rejoice R, Shafique A

Correspondence – Kishore Kumar Rajaram - kishorebonne@gmail.com

Department of Medical Gastroenterology, Tirunelveli Medical College, 3, High Ground Road, Palayamkottai, Tirunelveli 627 011, India

Introduction Non-cirrhotic portal fibrosis (NCPF) clinically characterized by features of portal hypertension-moderate to massive splenomegaly, with or without hypersplenism, preserved liver functions, and patent hepatic and portal veins. According to the consensus statement of the Asia Pacific Association for the Study of the Liver (APASL) on NCPF, the disease accounts for approximately 10% to 30% of all cases of variceal bleed in several parts of the world including India.

Methods: Case Report A 20-year-old female with 2 months of gestation presented with complaints of easy fatiguability. Routine blood investigations revealed bicytopenia. USG shows massive splenomegaly with collaterals, but portal vein doppler study shows normal portal vein diameter and portal velocity. Then she was treated blood transfusion. After transfusion patient developed hemolytic jaundice, which resulted in spontaneous abortion with expulsion of dead fetus. Direct and indirect Coombs test also negative. Peripheral smear study shows dimorphic anemia with thrombocytopenia. Patient underwent endoscopy to rule out varix and GI cause of blood loss. Esophagogastroduodenoscopy (EGD) showed Grade 1 esophageal varix. Then ceruloplasmin and ophthalmology examination was done, which turns out to be normal. Autoimmune hepatitis panel was negative except ANA which was positive. As per rheumatologist opinion, she was screened for connective tissue diseases. Finally, she had Low C3 and C4 levels with Ro52 positivity alone (dsDNA and anti-histone was negative).

Result Liver biopsy shows normal lobular architecture with portal vein sclerosis with possibility of non-cirrhotic portal fibrosis. Patient was started on treatment with steroid (? connective tissue disease) and beta blockers.

Conclusion NCPH, which is a rare under-recognized condition both clinically and pathologically, should be considered in persons who have clinical manifestations of portal hypertension in the absence of cirrhosis. In case of middle-aged women, we have to think in terms of connective tissue diseases like SLE, APLA.

Keywords Non cirrhosis, Portal hypertension, SLE

182

Downregulation of TLR7 and status of HbsAg and HbeAg may act as predictive marker for HBV mother to child transmission

Simanta Kalita, Subhash Medhi, Panchanan Das, Sangitanjan Dutta

Correspondence – Subhash Medhi - subhashmedhi@gauhati.ac.in

Department of Bioengineering and Technology, Gauhati University, Gopinath Bordoloi Nagar, Jalukbari, Guwahati 781 014, India

Background and Purpose Hepatitis B virus (HBV) infection is one of the major contributor of global disease burden and its vertical transmission is a major concern to health care. The intriguing role of toll-like receptors have not been yet extensively studied in HBV mother to child transmission (MTCT). In this study the expression pattern of TLR 7mRNA were analyzed in venous blood samples collected from 25 HBsAg+ve mother during delivery from Gauhati Medical College and Hospital, Guwahati, Assam and it is correlated with HbsAg, HbeAg and HbeAb.

Methodology HbsAg, HbeAg and HbeAb were detected using ELISA and TLR7 mRNA expression is performed by real-time polymerase chain reaction (RT-PCR).

Results and Discussions Downregulation of TLR-7 was found to be statistically significant among mother HbeAg positive samples with the majority of the n=12 samples showing downregulation with mean fold change value of 0.55±0.24 (p=0.00, <0.05). A similar down-regulation of TLR7 mRNA pattern was observed for cord blood HbsAg positive samples (p=0.002) and HBV DNA positive venous blood (n=11) and cord blood (n=13).

Conclusions The study concludes that the downregulation of TLR7 along with HBsAg and HbeAg status may be an indication of vertical transmission of HBV.

Acknowledgments: The authors acknowledges the Department of Science and Technology, Govt. of India, Ministry of Science and Technology, New Delhi 110 016, for providing DST INSPIRE Fellowship for doctoral program.

Keywords HBV, mRNA, MTCT, TLR7

183

A rare presentation of massive hepatomegaly secondary to amyloidosis

Chhagan Birda, Yadav Suresh Chand, Isha Stutee, Rengarajan Rajagopal, Jyotsna Naresh Bharti, Ashish Agarwal

Correspondence – Ashish Agarwal - drashu123@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India

Background Hepatomegaly is a common sign and can result from multiple inflammatory, infiltrative, and congestive disorders. We here report a case of patient with massive hepatomegaly that uncovered a diagnosis of systemic amyloidosis.

Case Report A 46-year-old female, presented with complaints of continuous pain and perception of lump in right upper abdomen for 8 months. She also had constitutional symptoms including easy fatigability, anorexia, and significant weight loss. On examination she had massive, firm hepatomegaly. Her lab investigations revealed elevated alkaline phosphatase (ALP), hypergammaglobulinemia and dyslipidemia. Contrast enhanced computed tomography (CECT) scan of chest and abdomen showed cardiomegaly and massive hepatomegaly. Further evaluation including echocardiogram, cardiac and abdominal magnetic resonance imaging (MRI) were suggestive of systemic infiltrative disorder. Abdominal fat pad, rectal and bone marrow biopsies were negative for amyloid but liver biopsy showed characteristic apple-green birefringence on Congo red staining. For characterization of misfolded protein, myeloma work up was done which was suggestive of light chain disease for which patient is being planned for hematopoietic stem cell transplantation (HSCT).

Conclusion Amyloidosis should be considered in patients presenting with hepatomegaly, raised ALP and other organ system involvement.

Keywords Systemic amyloidosis hepatomegaly multiple myeloma

184

Platelet to lymphocyte ratio as a non-invasive biomarker in assessing fibrosis in hepatitis C related liver disease

Uma Devi Malladi, Dinesh Kumar Dugganapalli, Jagveer Singh, Tony Pious, Bhaavan Paladugu

Correspondence – Dinesh Kumar Dugganapalli - dugganapalli@gmail.com

Department of Medical Gastroenterology, Osmania Medical College, 5-1-876, Turrebaz Khan Road, Troop Bazaar, Koti, Hyderabad 500 095, India

Background Liver fibrosis is common problem in hepatitis C virus infection. Its evaluation is important for prognosis

Aim Evaluate the platelet to lymphocyte ratio (PLR) as non-invasive predictive marker of liver fibrosis in HCV patients and to compare PLR to transient elastography in assessing liver fibrosis.

Methods Thirty-five patients were recruited underwent physical examination and various clinical examination for assessing fibrosis. Transient elastography measurement using echosens fibroscan was performed. Patients were classified in to those with mild fibrosis (F1-F3) and significant fibrosis (F4) and compared with platelet to lymphocyte ratio. data analyzed using independent t test and International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) software method.

Results The average age of the patients was 46±9.57 years, mainly men (n=18;51.4%) and 37.15% (n=13) had significant fibrosis (F4). PLR was lower in patients with significant fibrosis F4 vs. non F4 (81.13±38.55 vs 133.35±80.08; p = 0.035). APRI and FIB-4 were also calculated comparable with PLR (p <0.05). Age, platelet count, total serum bilirubin, liver stiffness, APRI, FIB-4 and PLR were predictors of significant fibrosis (p<0.05).

Conclusion Platelet to lymphocyte ratio (PLR) can be used as predictive marker for assessing significant fibrosis and is comparable to transient elastography and other non-invasive markers like APRI and FIB-4.

Keywords APRI, Hepatitis C, Platelet to lymphocyte ratio, Transient elastography

185

Fibroscan as a non-invasive tool in the study of liver fibrosis in non-alcoholic fatty liver disease

Sharathchandra Khanappanavar , Nandeesh H P, Deepak Suvarna, Aradya H V, Vijaykumar T R, Ganesh Koppad, Hitesh M R

Correspondence – Sharathchandra Khanappanavar - khanappanavar.sharathchandra@gmail.com

Department of Gastroenterology, J S S Hospital, Mahatma Gandhi Road, Fort Mohalla, Mysuru 570 004, India

Introduction The prevalence of non-alcoholic fatty liver disease (NAFLD) in India is reported to be between 9% to 32%. Simple and non-invasive, quantitative laboratory tests and radiological testing for the assessment of liver fibrosis in NAFLD have evolved to estimate the presence of steatohepatitis.

Inclusion Criteria Patients with fatty liver on ultrasonogram (USG). Patients 18 to 80 years of age of either sex. Exclusion criteria Alcohol intake >20 gm per day, HBsAg reactive, positive for anti-HCV, HIV, tuberculosis, Study design: Prospective study, duration: January 2021 to August 2022, Sample size:100.

Method of collection of data Patients will be selected for study according to all inclusion and exclusion criteria. A detailed history, clinical and laboratory data of these patients was recorded as per the questionnaiore. The Fibroscan scores will be then correlated with NAFLD, fibrosis score and fibrosis- 4 score.

Results In our study, 58 males 42 were female. prevalence of NAFLD in men was higher of 100 NAFLD patients, 43 showed no fibrosis (F0), 42 showed mild to moderate fibrosis (F1-F2), 15 severe fibrosis (F3-F4). Among the NAFLD patients with advanced fibrosis (n =15), 60 were male and 40 female. In our study 76% patients had Grade 1 fatty liver, 14% had Grade 2 and 10% had Grade 3. The mean stiffness scores for these grades was 5.66, 8.51 and 15.92 kpa respectively.

Conclusion Age cannot be used as a predictor of hepatic fibrosis in NAFLD. Male patients are more likely to suffer from advanced fibrosis than female patients. Diabetes, hypertension, obesity and hypertg are important risk factors for causing NAFLD. Therefore, NAFLD can be regarded as a hepatic manifestation of metabolic syndrome. FIB 4 score can diagnose likelihood of having advanced fibrosis or no fibrosis but cannot exclude minimal fibrosis. Statistically significant strong positive correlation was observed between Fibroscan and FIB4.

Keywords Diabetes, Fatty liver, Fibroscan

186

Neuroinflammation and its role in the pathogenicity of hepatic encephalopathy in patients with acute liver failure (Type A), in patients with cirrhosis (Type C) with hepatic encephalopathy

Madhu Chopra, Madhumita Premkumar, Anuradha Rakesh Kumar, Vashista Chakraborti, Ajay Duseja, Yogesh Kumar Chawla, Radha Krishan Dhiman^*

Correspondence – Radha Krishan Dhiman - rkpsdhiman@hotmail.com

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, and ^*Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Background Hepatic encephalopathy (HE) is a neuropsychological condition, caused by ammonia, cerebral edema, and inflammation in patients with hepatic impairment, such as acute liver failure (ALF) or cirrhosis. Using the postmortem necropsies, we investigated the role of neuroinflammation, oxidative stress and cerebral edema in the pathogenesis of HE in ALF and cirrhosis patients.

Methods Brain tissues from 26 patients, including disease control (DC) without any liver/neurological disorder (n=10), liver cirrhosis with HE (n=10), and ALF (n=6) were collected at the time of autopsy. Wet and dry weight technique was used to determine the percentage of brain water (BW) content. The qRT-PCR and immunohistochemistry (IHC) were used to evaluate the expression of microglial markers (Iba-1, OX-42), proinflammatory cytokines (IL6,TNF-α,IL-1β), oxidative/nitrosative marker (Hsp-27, iNOS). The markers of blood brain barrier (BBB) (MMP-9, Occludin-1, Claudin-5) was demonstrated by IHC. Further, we also used ELISA technique to investigate the expression of IL-6 and IL-1β

Results The BW% was increased in patients with ALF and cirrhosis with HE in comparison with DC. In ALF patients, mRNA expression of Iba-1(p=0.009), OX-42 (p<0.001), IL-6 (p<0.001), TNFα (p=0.018), IL-1β (p=0.021) and iNOS (p=0.029) was upregulated as compared to DC. In patients with cirrhosis with HE the mRNA expression of OX-42, IL-6, TNF-α, IL-1β, Hsp-27, was found to be upregulated, but only Iba-1 expression level was significantly elevated (p=0.024). IHC analysis demonstrated the increased expression of Iba-1 (p<0.001), IL-1β (p=0.001), Hsp-27 (p=0.029), and iNOS (p=0.002) in patients with ALF, whereas in cirrhosis with HE patients, only Iba-1 (p=0.004) expression was statistically significant. Expression of MMP9, Occludin-1, and Claudin-5 markers showed the increased intensity through IHC in endothelial cells in patients with ALF compared to DC. The quantitative analysis performed through ELISA showed the increased concentration for IL-1β and IL-6 in ALF patients in comparison to cirrhosis with HE and DC.

Conclusion We demonstrated a substantial activation of the microglia through the expression of proinflammatory cytokines and oxidative/nitrosative markers in the cortical region of patients with ALF, as well as in patients with cirrhosis and HE, but with lower expression. Neuroinflammation due to excessive microglia activation might led to cerebral edema in patients with ALF and liver cirrhosis with HE

Keywords ALF, Cirrhosis, HE, Neuroinflammation

187

Role of cardiac scintigraphy-Myocardial perfusion imaging in diagnosis of cirrhotic cardiomyopathy

Vishesh Kumar, Madhumita Premkumar, Bhupendra Kumar Sihag, Ankur Gupta, Ashwani Sood, Ajay K. Duseja, Sunil Taneja, Arka De, Sahaj R, Nipun Verma, Surender Sehrawat, Jasvinder Nain, Anchal Sandhu, Shikha Guleria

Correspondence – Madhumita Premkumar - drmadhumitap@gmail.com

Department of Hepatology, Zydus Hospitals, Zydus Hospitals Road, Near Sola Bridge, Sarkhej – Gandhinagar Highway, Ahmedabad 380 054, India

Background Cirrhotic cardiomyopathy (CCM), defined as chronic cardiac dysfunction (LV systolic or diastolic dysfunction) in patients with cirrhosis, may be improved by therapy. The Echocardiographic E/e’ ratio is a predictor of survival in left ventricle diastolic dysfunction (LVDD) independent of the severity of the liver disease.

Methods In this study we evaluated objective imaging modalities like stress myocardial perfusion imaging (MPI) and multigated acquisition (MUGA) scan in cirrhotic cardiomyopathy and compared it with standard transthoracic echocardiography (TTE) with tissue doppler imaging (TDI) and speckle-tracking. We determined if these patients had underlying myocardial perfusion defects and also if diastolic dysfunction could be assessed using nuclear scintigraphy.

Result A total of 30 patients diagnosed with CCM (mean age 50±9.8 yrs, 70% male, 60%-ethanol-related, 16% NASH) were recruited the mean MELD Na was 13.7±4.2, of whom 73.3% were on beta blocker therapy. Mean E/e’ was 8.25±3.9 and cardiac output was 4.7± 2.7 L/min. On MPI scan, only 2% had reduced ejection fraction and 3.3% had evidence of myocardial perfusion defects. MPI scan showed 10% had evidence of reduced cardiac contractility. All 30 patients showed changes on electrocardiography including QTc prolongation (>403 ms). The Global longitudinal strain (GLS) score showed a good correlation with E/e’ ratio.

Conclusion Use of MPI/MUGA scans are a useful adjunct to TTE and TDI in patients with CCM as it provides information on undiagnosed coronary artery disease and left ventricle (LV) and right ventricle (RV) function separately.

Keywords Cirrhotic Cardiomyopathy, Echocardiography, Left ventricle dystolic dysfunction, Stress thallium

188

Prolonged steroid refractory cholestatic viral hepatitis A: Mycophenolate sodium to rescue. A case series

Pathik Parikh

Correspondence – Pathik Parikh - pathik269@gmail.com

Department of Hepatology and Liver Transplant, Zydus Hospitals, Zydus Hospitals Road, Near Sola Bridge, Sarkhej – Gandhinagar Highway, Ahmedabad 380 054, India

Introduction Hepatitis A is usually a self-limiting illness. However, rarely it leads to persistent jaundice with pruritus. None of the pharmacological agents have been proven to be useful. This leads to significant deterioration in quality of life of the patients. As treating physicians, we need to think out of the box to alleviate their symptoms. We report here a case series of 5 patients who responded to mycophenolate sodium.

Case Series Five patients with acute hepatitis A have been included. The median age was 45 years and 3/5 were males. The mean duration of jaundice was 58 days. All patients had jaundice and severe pruritus. The mean bilirubin was 35 mg/dL. The presentation parameters are described in Table 1. The alternate etiological workup, liver ultrasound and liver biopsies were carried out in all. All patients were treated with symptomatic treatment, antihistaminic, cholestyramine, ondansetron, sertraline, ursodeoxycholic acid and multi vitamins. All patients received steroids for minimum 2 weeks before presentation. Two patients underwent therapeutic plasma exchange for 3 cycles without prolonged benefit. All patients were started on Mycophenolate sodium 720 mg per day in two divided doses. All 5 patients showed consistent improvement in symptoms and biochemistry with normalization of liver tests in median 5 weeks duration. None of the patients developed any drug related adverse effects

Discussion The mechanisms of liver injury in hepatitis A remain incompletely understood. While virus-specific CD8+T cells have long been considered a major cause of HAV-induced liver injury. MMF inhibits de novo purine synthesis, which is indispensable for the proliferation of lymphocytes, induces the apoptosis of activated T cells, suppresses the production of pro-inflammatory cytokines, and augments regulatory T cells thereby halting the ongoing hepatocyte damage. Further studies are warranted to validate our findings.

Keywords Jaundice, MMF, Pruritus, Viral hepatitis

189

Lenvatinib induced tumor lysis syndrome in hepatocellular carcinoma

Manjeet Goyal , Arshdeep Singh, Shivam Kalra, Ajit Sood

Correspondence – Manjeet Goyal - manjeetgoyal@gmail.com

Department of Medical Gastroenterology, Dayanand Medical College and Hospital Tagore Nagar Civil Lines, Ludhiana 141 001, India

Hepatocellular carcinoma (HCC) constitutes more than 90% of primary tumors of the liver. Its incidence is on the rise and varied paraneoplastic manifestations have been reported. One such entity is the tumor lysis syndrome (TLS). TLS is a metabolic emergency resulting from the lysis of tumor cells leading to acute kidney injury (AKI), dyselectrolemia and, if left untreated, can lead to mortality. Lenvatinib, an oral multi-tyrosine kinase inhibitor is currently the first-line therapy for unresectable HCC. Though TLS is extremely rare in patients with HCC, we hereby report a case of TLS in a patient of HCC treated with Lenvatinib.

Keywords Hepatocellular carcinoma, Lenvatinib, Tumor lysis syndrome

190

Restrictive transfusion strategy was safe and reduced prophylactic use of blood products for plasma exchange port insertions in patients with liver disease

Vijesh V S ¹ , Santhosh E Kumar ² , Dolly Daniel ³ , Tulasi Geever ³ , Sukesh C Nair ³ , Joy Mammen ³ , Vinoi G David ⁴ , Santosh Varughese ⁴ , Kunwar Ashish Singh ² , Ashish Goel ² , C E Eapen ² , Uday George Zachariah ¹

Correspondence – Uday George Zachariah - udayzachariah@cmcvellore.ac.in

Departments of ¹Clinical Gastroenterology and Hepatology, ²Department of Hepatology, ³Department of Transfusion Medicine and Immunohematology, ⁴Nephrology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Background Liver disease patients have deranged conventional coagulation parameters, which are not indicative of the rebalanced coagulation status.

Methods Retrospective study of consecutive patients undergoing plasma exchange (PLEX) for liver disease from October 2016 to February 2022. Early study period (2016-2019), patients with abnormal conventional coagulation parameters, were transfused prior to port insertion. Subsequently, during late study period (2020-2022), a restrictive transfusion policy was used, which coincided with the expanding use of ROTEM.

We aimed to measure the difference in prophylactic blood product usage and procedure related bleeding between the liberal vs. restrictive transfusion groups. All PLEX port were placed under USG guidance by trained personnel.

Results We studied 263 patients (age 35 [23-48] years) with MELD of 31 [25-38], acute on chronic liver failure [41.8%], acute liver failure [28.5%]). 117 patients received liberal prophylactic blood products transfusion compared to 146 where a restrictive transfusion strategy (ROTEM guidance followed). Thrombocytopenia (<50000/cumm) and coagulopathy (INR >1.5) were similar in early and late study periods (9.4% vs. 6.8%, p value 0.45 and 88.9% vs. 84.9%, p value 0.35).

For PLEX port insertion, prophylactic transfusion (FFP [35.4%], cryoprecipitate [2.7%], platelets [2.3%]) was given to 98 (37.2%) patients. 67.5% (79/117) patients in liberal transfusion received prophylactic products compared to 13% (19/146) in restrictive transfusion group; p value < 0.001. The number of FFP units received among patients in the liberal transfusion group was higher than restrictive transfusion group (4 vs. 0; p value< 0.001). Local bleeding during insertion was noted in 3 (1.1%) patients (2 in liberal and 1 in restrictive transfusion group) with major bleed in one.

Conclusion Restrictive transfusion strategy helped to reduce prophylactic blood product use for PLEX port insertion without increasing bleeding risk among liver disease patients.

Keywords Bleeding, Plasma exchange, Restrictive transfusion

191

A study of the prevalence of acute and chronic liver diseases among newly detected HBsAg positive subjects: A single centre experience

Chitta Ranjan Khatua ¹ , Shivaram Prasad Singh²

Correspondence – Chitta Ranjan Khatua - chittamedicine@yahoo.co.in

¹Department of Gastroenterology, MKCG Medical College, Berhampur, Odisha, and ²Kalinga Gastroenterology Foundation, Bajrakabati Road, Cuttack 753 001, India

Background Hepatitis B surface antigen (HBsAg) positive individuals are frequently encountered during routine health check-ups, blood donation, antenatal check-up, family screening, evaluation of liver related illness and other health related conditions. Many of them have various forms of serious liver diseases which goes undetected.

Aims We performed a prospective study to study the spectrum of liver diseases including chronic liver disease (CLD) and hepatocellular carcinoma (HCC) in newly detected HBsAg positive subjects.

Methods This study was conducted in consecutive patients with newly detected hepatitis B virus (HBV) infection attending the Gastroenterology OPD of MKCG Medical College, Berhampur between July 2020 and July 2022. Serological, biochemical, radiological and endoscopic evaluation was performed to study the type and severity of liver diseases.

Results Five hundred and eight HBV positive subjects were enrolled. Three hundred and ninety (76.8%) of them were males. While 71.2% (362) did not have significant liver disease, 28.8% (146) had various liver diseases like acute viral hepatitis (5.9%), chronic liver disease (CLD) (20.5%), and HCC (2.4%). Patients without liver related illness (71.2%) were younger than the patients with liver related illness (39.3±14.2:44.9±13.7; p<0.001). Among the patients with liver related illnesses, unfortunately only 18 (12.3%) HBsAg positive subjects were aware of the consequences of HBV infection. Besides, 9 (6.2%) had history of discontinuation of antiviral treatment, while 9 (6.2%) had HBV infection among family members.

Conclusion About one fourth of HBV infected patients had significant liver related disorders; of them a tenth had HCC at the time of evaluation. Patients with liver related illness were older in comparison to other HBsAg positive subjects, and most of the patients presented during fifth decade. Among HBV infected subjects, the awareness about the consequences of HBV infection was very poor.

Keywords Chronic liver disease, Hepatitis B surface antigen, Hepatitis B virus

192

To evaluate the prevalence of spontaneous portosystemic shunts in decompensated cirrhosis patients and its prognostic significance

Rishabh Kothari, Deepanshu Khanna, Premashis Kar

Correspondence – Premashis Kar - premashishkar@gmail.com

Department of Gastroenterology, Max Superspeciality Hospital, Sector 1, Vaishali, Ghaziabad 201 010, India

Introduction Spontaneous portosystemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis complications. This study is done to detect the prevalence of portosystemic shunts in liver cirrhosis patients and analyze its prognostic role.

Method We conducted a prospective observational study where ninety two patients with decompensated cirrhosis were evaluated based on history, physical examination, biochemical tests, and abdominal CT angiography findings. Follow-up was done after 6 months for development of cirrhosis-related complications.

Results Out of the 92 cirrhotic patients, 57.6% of patients had SPSS (L-SPSS + S-SPSS) detected by MDCT angiography. Overall, we found L-SPSS in 24 (26.1%) patient, S-SPSS in 29 (31.5%) patients and no shunt identified in 39 (42.4%) patients. Of all patients, splenorenal shunt 25 (27.2%) is the most frequent type followed by paraumbilical shunt (20.7%). Previous decompensating events including hepatic encephalopathy, ascites, SBP and GI bleed were experienced more frequently by the L-SPSS group followed by S-SPSS and W-SPSS group. Regarding follow-up, decompensating events episodes of HE developed more frequently in patients with L-SPSS 10 (41.7%) than patients with S-SPSS 7 (24.1%) followed by W-SPSS 5 (12.8%).

Conclusion In summary, all cirrhotic patients should be studied with radiological imaging in order to detect the presence of portosystemic shunt. In several cases, patients with large SPSS had a more impaired liver function and more frequent complications of portal hypertension so these patients would probably benefit from a closer surveillance and more intensive therapy. Moreover, the identification of SPSS became crucial in selected cases, in which the embolization of large SPSS may be associated with improved survival and liver function, as well as preventing the recurrence of HE or variceal bleeding.

Keywords Hepatic encephalopathy, Liver cirrhosis, Portal hypertension, Spontaneous Portosystemic shunts, Varices

193

An interim proteomics analysis of the longitudinal study reveals biological pathways and predictive proteins in acute kidney injury with decompensated cirrhosis

Inder Bhan Singh , Arka De, Vivek Kumar, Ashok Kumar Yadav, Virendra Singh

Correspondence – Virendra Singh - virendrasingh100@hotmail.com

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction The development of acute kidney injury (AKI) in decompensated cirrhosis (DC) adversely impacts pre- and post-transplant outcomes. The prognosis of AKI in DC is difficult to study non-invasively. We hypothesized that urine proteomics could provide insight into the various pathways involved in the development of AKI in DC.

Method In this ongoing prospective longitudinal study we are enrolling patients with DC in the outpatient setting and following them up for the development of AKI. So far out of 78 patients, 11 developed AKI on following. We compared the baseline urinary protein of these 11 AKI patients with 11 propensity matched patients who did not develop AKI. AKI was defined according to International Club of Ascites criteria. Urine protein profiling was done using liquid chromatography-mass spectrometry (LC-MS) and was inferred using proteome discoverer 2.5. Pathways involved in the genesis of AKI were identified using various bioinformatic tools (gprofiler for gene ontology (GO), string and cytoscape for networking, reactome for pathway analysis). Hypergeometric distribution test was used to determine whether specific pathways are enriched. Probability score obtained was corrected for false discovery rate (FDR) using the Benjamani-Hochberg method.

Results LC-MS reveals several pathways that were putatively involved in the development of AKI. One hundred and ninety-two 261 identifiers in the sample were found in Reactome. Proteomic analysis revealed that 231 out of 2000 proteins were significantly increased in AKI group and 168 had ≥log2 difference in comparison to patients without AKI. Significant pathways identified included neutrophil degranulation, Extracellular matrix organization and degradation, innate immune system, FCERI mediated MAPK activation, FCERI mediated NF-kB activation, classical antibody-mediated complement activation and scavenging of heme from plasma (Fig. 1).

Conclusions Urinary proteomics suggests that pathways involved in immunity and inflammation play an important role in the development of AKI in patients with DC in the outpatient setting.

Keywords Acute kidney injury, Cirrhosis, Proteomics

194

10% fall in serum bilirubin predicts survival in patients with hepatitis B related liver failure undergoing low volume therapeutic plasma exchange

Vijay Balaji Muthukumaran ¹ , Kunwar Ashish Singh ² , Santhosh Kumar E ² , Santosh Varughese ³ , Vinoi David ³ , Dolly Daniel ⁴ , Gayathiri K C ⁴ , Subramani K ⁵ , Kishore Pichamuthu ⁵ , Ashish Goel ² , Uday George Zachariah ² , Eapen C E ²

Correspondence – Vijay Balaji Muthukumaran - vijaybalaji.psg@gmail.com

Departments of ¹Gastroenterology, ²Hepatology, ³Nephrology, ⁴Transfusion Medicine and Immunohaematology, and ⁵Critical Care, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Background and Aims Plasma exchange (PLEX) is a promising novel therapy improving survival in patients with liver failure syndromes. The aim of the study was to estimate the 30-day transplant free survival in patients undergoing PLEX-LV (low-volume PLEX) for acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) due to hepatitis B virus (HBV) infection.

Methods We retrospectively analyzed patients who underwent PLEX-LV for ALF and ACLF due to viral infections between January 2018 and June 2022. Baseline parameters and dynamic change (Delta: Pre-PLEX-Post-PLEX %) in severity parameters after PLEX-LV were noted. 30-day outcome was assessed.

Results Of the 358 patients who underwent PLEX-LV for liver disease, 34 had viral infection (HBV=21, HAV=4, HEV=3, EBV=3, dengue=2, HSV=1). Twenty-one patients with HBV related liver failure (ALF:9, ACLF:12; M:57, age:50, 22-67years; median, range; MELD score:31, 21-49; plasma VWF antigen:428, 148-1063 IU/mL) underwent PLEX-LV (sessions: 3,1-5; volume per session:1400,875-1600 mL). 14/21 (67%) patients survived at 1-month (ALF:6/9; ACLF:8/12). Of the 5 (56%) patients with ALF who met Kings College criteria for emergency liver transplantation, 3 (60%) survived with PLEX-LV at 1-month.

None of the baseline severity parameters (MELD score, plasma VWF antigen etc.) predicted 1-month survival in these patients who underwent PLEX-LV. On analyzing the dynamic change after PLEX-LV, delta bilirubin (p=0.0001; AUROC:1), delta MELD (p=0.020) and delta VWF (p=0.033; AUROC: 0.8,0.6-1) were statistically significant predictors of 1-month survival. All 14 patients with serum bilirubin decrease >10% survived at the end of 30 days whereas all 7 patients who did not achieve the 10% decrease in serum bilirubin died within 30 days. In the study patients, one (4.76%) had transfusion related circulatory overload.

Conclusion Low volume PLEX (PLEX-LV) appears to improve outcome in patients with HBV related ALF and ACLF. In patients with HBV related liver failure who undergo PLEX-LV, a decrease in serum bilirubin of >10% with plasma exchange predicts 1-month survival.

Keywords Acute liver failure, Acute-on-chronic liver failure, Hepatitis B virus, PLEX-LV

195

A case of hepatic amyloidosis presenting as rapidly progressive hepatic failure

Adarsh C K , Pooja Krishnappa, Bhuvan Shetty, Vamshi A

Correspondence – Adarsh C K - adarshck@gmail.com

Department of Medical Gastroenterology, BGS G1leangles Global Hospital, 67, Uttarahalli Main Road, Sunkalpalya, Bengaluru 560 060, India

Introduction Hepatomegaly (57% to 83%) and elevated ALP (86%) are the most common presentations in hepatic amyloidosis. Patient may have associated ascites, most likely due to concurrent heart failure or hypoalbuminemia. Rarely ascites may result from peritoneal amyloidosis. CLD, rapidly progressive hepatic failure and portal hypertension are rare.

Case Report An elderly male aged 67-year-old presented with complaints of abdominal distension of 2 months duration (requiring recurrent LVP), pedal edema and progressive jaundice of one month duration, no pruritus. Investigation done outside showed Hb-14.4, TC-11490, Plt-205000, INR-2.17, TB/DB-5.2/3.6, AST-135, ALT-63, ALP-226, albumin-2.2, creatinine-1.2, Na-129 and ANA -positive. Ascitic fluid analysis showed High SAAG, low protein ascites. CT abdomen showed hepatomegaly with nodular margins with gross ascites. UGI endoscopy showed small esophageal varices, mild PHG. Patient was referred to us for TIPS/liver transplant in view of refractory ascites. Patient underwent TJLB in view of hepatomegaly, rapid progression, normal platelets and ANA positivity. Biopsy showed dense deposition of pale eosionophilic acellular material-amyloid. BM biopsy showed moderately hypercellular marrow and plasmacytosis (25%). Immunofixation EP positive for lambda band. PET CT showed hepatomegaly with diffuse homogenous enhancement with no FDG avid lesion. Patient developed bleed PR, sigmoidoscopy showed rectal ulcers. Rectal biopsy showed focal ulceration with amyloid deposits. He was diagnosed to have IgG lambda myeloma with liver and GIT involvement, hepatic amyloidosis with PHTN with ascites, esophageal-varices, rectal-ulcer with amyloid deposits. Hematology opinion taken and was started on chemotherapy. Patient had altered sensorium, GI bleed, AKI and MODS within one week. He was admitted at nearby hospital, dialyzed, was on ventilator and passed away.

Conclusion Hepatic amyloidosis presenting as rapidly progressive liver failure is a rare entity. Diagnosis of hepatic amyloidosis needs to be considered in presence of atypical features of CLD/portal hypertension.

Keywords Hepatic amyloidosis, Liver failure, Trans jugular liver biopsy

196

Prevalence of lean and non-obese non-alcoholic fatty liver disease in India: Systematic review and meta-analysis

Arka De, Naveen Bhagat, Akash Roy^*, Manu Mehta, Priya Singh, Aamir Bashir, Ajay Duseja

Correspondence – Arka De - arkascore@gmail.com

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India, and ^*Institute of Gastrosciences and Liver Transplantation, Apollo Multispecialty Hospital, 58, Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata 700 054, India

Introduction Non-alcoholic fatty liver disease (NAFLD) has emerged as a major cause of chronic liver disease. Although most patients with NAFLD are obese, it is being increasingly recognised in non-obese and lean individuals. We performed a systematic review and meta-analysis to assess the prevalence of lean and non-obese NAFLD in India.

Methods Systematic search of PubMed, Embase, Scopus, and Google Scholar was done to retrieve studies from India (published in any form till 10th August 2022) which reported the proportion of lean or non-obese individuals among patients with NAFLD, or the burden of lean or non-obese NAFLD among the general population. Lean and non-obese were defined as BMI <23 kg/m² and <25 kg/m², respectively. Quality of included studies was graded as poor, average or high-quality using Hoy’s checklist. Heterogeneity was assessed using Cochran’s Q (p<0.1) and I2 ≥50%. Both fixed and random effects model were used depending upon heterogeneity. Publication bias was assessed using Begg’s test.

Results Sixteen studies meeting the eligibility criteria were included in the meta-analysis. All the studies were of average quality. Among patients with NAFLD, the proportion of those who were lean or non-obese were 17.5% (95% CI: 13.8-21.5%) and 34.2% (95% CI: 29.7-38.9%). Among the general population, the prevalence of lean and non-obese NAFLD were 6.4% (95% CI: 4.7-8.2%) and 10.9% (95% CI: 6.6-16.3%). There was significant heterogeneity for all analyses and random effects models have been reported. However, there was no publication bias.

Conclusion Although uncommon the burden of lean or non-obese NAFLD is not trivial in the Indian subcontinent.

Keywords fatty liver, Lean, NAFLD

197

The clinical profile of non-tumoral portal vein thrombosis in 463 patients with decompensated liver disease from a tertiary care centre in south India

Shivabrata Dhal Mohapatra , Jacob Raja, Srijaya Sreesh

Correspondence – Srijaya Sreesh - jacobraja.as@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Backgrounds and Aims Portal vein thrombosis (PVT) is defined as thrombosis of the portal vein and branches of splenoportal axis. Incidence of PVT in compensated liver disease is between 0.6% to 5% and up to 25% in advanced disease. Presence of PVT in decompensated chronic liver disease (DCLD) is associated with significant morbidity and mortality. We evaluated the proportion and risk factors associated with non-malignant PVT in DCLD patients.

Methods Five hundred and two patients with DCLD were enrolled over a period of 1.5 years. Patients underwent detailed clinical history and evaluation, baseline investigation and ultrasonography. Contrast-enhanced computed tomography (CECT) abdomen was performed in patients with USG evidence of PVT or alteration in portal flow dynamics.

Results Thirty-nine patients were excluded. Fifty-one of the 463 patients included had PVT (11.0%). Duration of cirrhosis >4 years (p<0.01), non-alcoholic steatohepatitis (NASH) related etiology (p<0.01), prior history of obesity (p<0.01), dyslipidemia with high serum cholesterol and low-density lipoprotein (LDL) (p<0.01), clinically evident sarcopenia (p<0.01), first initial decompensation of cirrhosis as upper gastrointestinal bleed (UGIB), ≥2 prior UGIB (p=0.002), poorly controlled ascites (p<0.01), ≥2 history of episodes of SBP (p<0.01), platelet count <66.5 × 109/L (p=0.002), leukocyte count <5350/cu mm (p<0.01) were significantly associated with PVT group. There was no difference between CHILD B and C status, among the 2 groups. On multiple logistic regression analysis, ≥2 prior endoscopic variceal ligation, SAAG >1.95 were found as independent risk factors for development of PVT in DCLD patients.

Conclusions Proportion of non-malignant PVT in decompensated cirrhosis was 11%. Presence of poorly controlled ascites, prior history of UGIB, high SAAG, low platelet count as markers of severity of portal hypertension in cirrhosis are significantly associated with non-malignant PVT in DCLD. Patients with prior history of obesity and dyslipdemia, with NASH related cirrhosis are at high risk for the development of PVT.

Keywords Decompensated chronic liver disease, Hepatocellular carcinoma, Non-malignant portal vein thrombosis

198

Full dose sofosbuvir-velpatasvir in chronic hepatitis C in end-stage renal disease patients

Aadil Ashraf, Altaf Shah¹, Muzaffar Wani

Correspondence – Aadil Ashraf - draadilgastro@gmail.com

Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India, and ¹Sher-i-Kashmir Institute of Medical Sciences, (SKIMS), SKIMS Main Road, Soura, Srinagar 190 011, India

Background India is witnessing high hepatitis C virus (HCV) infection burden in patients of chronic kidney disease. Due to nonavailability of costly recommended directly acting antiviral drugs in ESRD, pan-genotypic combination of Sofosbuvir-Velpatasvir can become an economical option. Data regarding treatment with this combination is scarce. Ours is the largest study from Indian subcontinent.

Objectives The study was undertaken to assess the efficacy, safety and side effect profile of Sofosbuvir-Velpatasvir in ESRD and patients on hemodialysis.

Participants Included both in and outpatient treatment naïve anti-HCV positive ESRD patients after proper informed consent.

Methodology The study was conducted from 1st September 2018 till February 2021. All the patients were evaluated for liver disease. All the patients received open label combination of sofosbuvir and velpatasvir (400 mg/100 mg). The primary and secondary endpoint was to assess sustained virological response (SVR12) and safety profile respectively. Institutional Ethical Clearance (IEC) was sought before starting the study.

Results One hundred and sixty-two patients were included in the study. Mean age in our study population was 43.08±12.08 years. Mean creatinine in our study population was 7.01± 2.61 mg/dL. One hundred forty-two (87.6 %) achieved viral clearance at 4 weeks of therapy. One hundred and sixty (98.7%) of the patients achieved end of treatment viral clearance and same number of patients maintained viral clearance 12 weeks after stopping the treatment (SVR12). Significant difference was seen in pre and post treatment serum bilirubin and ALT levels. No significant difference was found in pre and post treatment Sr albumin, creatinine and other parameters. The adverse effects noticed were nausea (20%), vomiting (18%), headache (10%), weakness (7%).

Conclusion Our study showed excellent efficacy with the safety profile of this drug combination in the studied population.

Keywords HCV in ESRD, HCV in hemodialysis, Sofosbuivir

199

Sarcopenia is associated with hepatic encephalopathy in patients with cirrhosis

Jayanta Nanda , Bikash Narayan Choudhury, Mallika Bhattacharyya, Utpal Jyoti Deka, Bhaskar Jyoti Baruah, Nikhil Gandhi, Preeti Sarma, Antara Sen, Pallab Medhi, Juchidananda Bhuyan, Suranjana Hazarika

Correspondence – Jayanta Nanda - jaynan1987@gmail.com

Department of Gastroenterology, Gauhati Medical College, Narakasur Hilltop, G M C Hospital Road, Bhangagarh, Guwahati 781 032, India

Introduction Sarcopenia is an important burden in liver cirrhosis patients representing a negative prognostic factor. We investigated whether a decrease in muscle mass and muscle strength was associated independently with the occurrence of hepatic encephalopathy (HE).

Methods Patients diagnosed with chronic liver disease were enrolled from February 2022 to July 2022. Mid arm muscle circumference (MAMC) was used to assess sarcopenia. For the present study sarcopenia is defined as MAMC less than 5 th percentile for age. Handheld dynamometer was used to assess muscle grip strength. Cut off for decreased muscle strength is defined according to BMI. Multivariate logistic regression was performed keeping HE as the standard reference. Statistical analysis done using Statistical Package for Social Sciences (SPSS) version 25.

Results Total of 146 patients were analyzed. Of the total patients 116 (79.5%) and 102 (69%) patients had sarcopenia and decreased grip strength respectively. Mean MAMC in sarcopenic group was 19.13 cm (SD,1.78) as compared to 22.73 cm (SD, 1.68) in patients having normal muscle mass. Patients having normal and decreased grip strength have a mean dynamometer score of 28.26 kg (SD, 5.3) and 20.48 kg (SD, 5.5) respectively. Sarcopenic patients had higher prevalence of HE as compared with patients having normal MAMC (34% vs. 10%, p = .007). Also patients having decreased grip strength had more frequency of HE as compared to patients having normal grip strength (35% vs. 13%, P=.009). By multivariate regression analysis, sarcopenia (p=0.004), hypokalemia (p=0.019) and total bilirubin (p=.005) were independently associated with occurrence of HE. Decreased grip strength was not associated independently with HE (p=.465).

Conclusion Sarcopenia and hypokalemia but not decreased grip strength were independently associated with occurance of HE in patients with cirrhosis.

Keywords Cirrhosis, Grip strength, Hepatic encephalopathy, Hepatology, Nutrition, Sarcopenia

200

Safety and efficacy of Saroglitazar in improving FIB4 index in non-alcoholic fatty liver disease/non-alcoholic steatohepatitis population - A 52-week, real world experience

Mayank Mehrotra

Correspondence – Mayank Mehrotra - mehrotramayank24@gmail.com

Department of Gastroenterology, Regency Hospital Ltd., 112/335 A, Swaroop Nagar, Near Madhuraj Hospital, Kanpur, India

Background and Aims Non-alcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease worldwide and affects around 30% of the adult population in Asia. The fibrosis scores are reasonable options for diagnosis and assessing treatment progression in routine practice. The Fibrosis-4 index (FIB-4) has been shown to be a prognostic marker of liver-related outcomes in patients with NAFLD. We evaluated the efficacy and safety of Saroglitazar 4 mg OD in NAFLD/NASH in routine clinical practice.

Methods A total 94 documented NAFLD patients (90.4% males and 64.5% non-diabetics) with elevated LFT (mean AST 60.4+21.3 and ALT 90.2+39.5) and baseline mean fibrosis scores (FIB4 1.37+0.6, NFS-1.47+1.11, APRI 0.84+0.33), were prescribed on Saroglitazar 4 mg OD, and the effectiveness was analyzed based on changes in LFT, FIB4 Index and triglycerides level at 12 and 24 weeks. Out of 94 patients, 44 were followed up and also analyzed at 52 weeks. The study population was of mean age 38.1±11.2 years and mean BMI 26.5+3.6 kg/m². 90.4 % patients (n=85), (severe fibrosis n=8, indeterminate fibrosis n=77) at baseline have elevated one or more fibrosis score. The data was analyzed to find out improvements at 12, 24 and 52 weeks from baseline and statistical significance was established using paired sample T- test.

Results The study shows statistically significant improvements in the measured parameters from baseline. Also, there was significant improvement in overall FIB 4 score by 12.7%, 27.9% and 39.9% at 12, 24 and 52 weeks respectively, with 80.9% patients (n=76) in low FIB4 range after 24 week and 97.7% after week 52, compared to 51.1% (n=48) patients at baseline.

Conclusions The study shows Saroglitazar 4 mg OD as a safe and effective treatment option for NAFLD/NASH, with significant improvement in all liver related parameters.

Keywords FIB-4 index, NAFLD, Saroglitazar

201

Therapeutic plasma exchange helps in management of pregnancy associated liver failure

Sushovan Baidya, Ashish Goel, Santosh Varughese, Dolly Daniel, Subramani Kandasamy, Santosh Kumar E, Asish Singh, Uday George Zachariah, C E Eapen

Correspondence – Sushovan Baidya - drsushovanbaidya@gmail.com

Department of Hepatology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction We present an unusual case of peri-partum acute-on-chronic liver failure complicated by thrombotic microangiopathy managed successfully with therapeutic plasma exchange.

Case A 21-year-old female (G1P1), with no history of gestational diabetes mellitus or hypertension, delivered a 3.5 kg healthy girl baby at 39 weeks by caesarean section. She was noted to have ascites during surgery and postoperatively developed decrease in urine output, worsening ascites, along with abdominal pain and jaundice. She became hypotensive with deterioration in sensorium. On presentation she had ascites, splenomegaly, lactic acidosis, thrombocytopenia (platelet count-15000/cmm), hyperbilirubinemia (S. bilirubin-18 mg/dL), coagulopathy (INR-3.5) and acute kidney injury (S. creatinine- 2.5 mg/dL). On imaging there was ascites, splenomegaly, attenuated portal vein replaced by collaterals and no retained products of conception. Gastroscopy showed small esophageal varices. Presence of thrombocytopenia, kidney injury, high schistocytes (9.88%) on peripheral smear, raised LDH and low ADAMTS 13 (24%) suggested thrombotic microangiopathy, thus a probable post-partum HELLP syndrome.

Etiological evaluation was negative for alternate aetiology of thrombotic microangiopathy (e.g. tropical fever syndromes, Wilsonian crisis, sepsis etc.). Besides supportive management, which included mechanical ventilation and renal replacement, the patient underwent five sessions of therapeutic plasma exchange (PLEX). A plasma volume of 7300 mL was replaced with an equal volume of fresh frozen plasma over 7 days. The patient was also given broad spectrum antibiotics with low dose steroids. The patient showed gradual improvement in general condition and renal function and discharged in a stable state after an in-hospital stayof 51 days, which included 25 days on ventilator and 40 days in intensive care unit. The patient remains well after 10 months of follow-up.

Conclusion Thrombotic microangiopathy is not uncommon in the peri-partum period and often associated with HELLP syndrome. The case highlights the role of therapeutic plasma exchange in managing these patients.

Keywords Plasma exchange, PLEX, HELLP syndrome

202

Predictors of response to standard medical therapy in hepatorenal syndrome (HRS-AKI) patients

Ajay Kumar, Roshan George, Bhawna Mahajan, Ujjwal Sonika, Ashok Dalal, Sanjeev Sachdeva

Correspondence – Roshan George - rshngeorge14@gmail.com

Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Introduction The HRS-AKI is managed with vasoconstrictor drugs and albumin (SMT) however overall resolution occurs in about 30% to 40% patients; also treatment is associated with significant adverse effects. The present study was done to find the predictors of response in HRS-AKI patients managed with SMT.

Methods The consecutive decompensated cirrhosis (DC) patients who were diagnosed as HRS-AKI (International Club of Ascites [ICA] 2015) seen between March 2020 and February 2021 were enrolled. The patients were treated with vasoconstrictor (terlipressin or noradrenaline) and 20% human albumin. HRS-AKI response to treatment was defined as per ICA 2015 criterion, those who had complete response of HRS-AKI were classified as ‘responders’ and patients with partial response and no response of HRS-AKI were classified as ‘non-responders’.

Results Overall 25 HRS-AKI patients (mean age 49.52±13.7 years and 21 [84%] males) were enrolled. The 9 (36%) patients had infections (spontaneous bacterial peritonitis n=6, pneumonia n=2 and bacteremia n=1), mean arterial pressure was 80.04±9.35 mmHg, mean Child score was 10.9±2.3 and mean MELD score was 29.84±6.87 respectively. The vasoconstrictor therapy used was terlipressin (n=24) and noradrenaline (n=1), 14 patients were responders and 11 were non-responders. On multivariate analysis higher platelet count (p=0.04) and high Interleukin-6 (IL-6) (p=0.02) were predictors of response to SMT.

Conclusion Platelet count and IL-6 levels are predictors of response to SMT in HRS-AKI patients however further studies need to be done to evaluate their role.

Keywords Decompensated cirrhosis, HRS-AKI, Vasoconstrictor

203

Acute cytomegalovirus hepatitis in immunocompetent patient

Vinay V

Correspondence – Vinay V - vinay.hvr4@gmail.com

Department of Medical Gastroenterology, GEM Hospital, Pankaj Mill Road, Ramanathapuram, Coimbatore 641 045, India

Objective Challenging differential diagnosis.

Introduction Cytomegalovirus (CMV) has an incubation period of about 4 to 6 weeks. Symptoms of CMV infection vary and depend on factors including the age and immune status of the patient. It usually presents as asymptomatic infection in immuno-competent individuals whereas severe disease is usually seen in immunocompromised patients.

Case Report A 53-year-old male patient known case of chronic liver disease. Patient is known alcoholic consumes alcohol occasionally. Presented with history of yellowish discoloration, itching, swelling of abdomen since 3 weeks. History of alternative medication was present. Treatment history was 2 cycles of plasma exchange. Patient was referred to our hospital for liver transplant. Routine etiology was normal, non hepatotrophic viruses work was sent. CMV IgM and IgG was positive. Trans jugular liver biopsy was done which showed inclusion bodies.

Results The patient was treated with valganciclovir that resulted in rapid improvement in clinical status as well as normalization of the liver enzymes. Patient is being followed up on monthly basis now liver function test is normalized. Patient has be delisted form transplant list.

Conclusion This case report presents a rare case of immunocompetent male with acute CMV hepatitis who responded favorably to antiviral therapy.

Keywords Cytomegalovirus hepatitis, Immunocompetent, Liver transplant

204

Cardiac dysfunction in chronic liver disease: 2 D echo cardiograph and tissue doppler study

Devarakonda-Madhusudhana

Correspondence – Devarakonda Madhusudhana - madhudevarakonda77@gmail.com

Department of Medical Gastroenterology, Narayana Medical College and Hospital, Chinthareddipalem, Nellore 524 002, India

Echocardiography is a non-invasive method to find cirrhotic cardiomyopathy in chronic liver disease. Important to evaluate cardiovascular function and filling dynamics in every patient with cirrhosis, especially if the patient is a candidate for any intervention that may affect hemodynamics or diseases that place stress on the heart.

The aim of this study was to find out the prevalence of cardiac changes in patient with chronic liver disease using conventional echocardiography and a tissue Doppler study to correlate the clinical profile and echocardiographic changes in patients with chronic liver disease.

Methodology We identified 100 patients at Department of Medical Gastroenterology, Narayana Medical College and Hospital as part of cross-sectional observational study in chronic liver disease of any cause was made on the basis of clinical history and examination, biochemical and serological evaluation, and ultrasonographic imaging, and selected case, subjected for conventional echocardiographic study and tissue Doppler imaging to assess the cardiac status.

Results In the study, majority of patients were males (n=60, 60%) in the age group of > 40 yr. Over all prevalence of cardiac abnormalities were found in 53%. The prevalence of cardiac abnormalities 57.9% in Child class C, 45.7% in Child class B, 50% in Child class A, increased with severity of chronic liver disease. As per Chi-square test (62.2% vs. 37.8%; p> 0.05). Increased prevalence of cardiac abnormalities found in ethanol related chronic liver disease as per Chi-square test (66% vs. 34; p>0.05). Among cardiac abnormalities, prevalence of diastolic dysfunction was 88%, Systolic dysfunction was 16%, and pulmonary arterial hypertension was 41%. High prevalence of subclinical cardiac abnormalities in chronic liver disease patients, advising an echocardiogram for patients with cirrhosis (CTPS - B and C) will be beneficial in early screening.

Keywords Chronic liver disease, Conventional echo, CTPS, (Child-Turcott-Pugh score), Diastolic, Systolic,Tissue doppler

205

Alcohol drinking patterns among patients of liver disease admitted to a tertiary care hospital in Gujarat

Aakash Sethi , Jaya Pathak, Kalpita Shringarpure, Kaatyayani Choudhary, Gayatri Laha

Correspondence – Aakash Sethi - sethiaakash22@gmail.com

Government Medical College, Vinoba Bhave Road, Anandpura, Vadodara 390 001, India

Introduction The amount, duration and type of alcohol consumption is related to the occurrence of alcoholic liver disease (ALD). Consumption more than 160 grams (men) and 90 grams (female) puts a patient at risk for developing ALD. However, this data is unavailable for the Indian scenario; given the genetic differences among Asians and Western population, this data would be useful. We aim to estimate the duration, amount and the drinking pattern which leads to development of ALD

Methods One hundred and twenty admitted adult patients and consuming alcohol were included and divided into two groups - ALD group- patients having no other cause for liver disease and consuming hazardous levels of alcohol based on alcohol use disorder identification test (AUDIT-C) scores. Non-ALD group- Rest all patients. The amount of alcohol consumed was first recorded in ml and then converted to grams using Nayak et al's. study. The groups were compared using the Mann-Whitney test. Quantitative data was expressed using mean±SD or median with IQR.

Results Seventy-three ALD and 47 non-ALD patients were included. The median duration of alcohol intake was eight years (IQR= 5 years). Commonly patient drank country made liquor (82.6%). The mean amount of alcohol consumed (absolute alcohol*duration*frequency) in ALD group was 3557.14 year alcohol (SD=1658.03) and in the non-ALD group was 1654.29 (SD=610.08) (p=0.010).The hazardous drinkers consumed 360.14 (SD=170.92) gm of absolute alcohol per day while the non-hazardous drinkers consumed 126.67 gm (SD=44.22) (p=0.007).

Limitations Recall bias could be present as patients were chronic drinkers. Patients could be reluctant to fully and accurately disclose their alcohol intake.

Conclusion We found that drinking about 360 gm/day of absolute alcohol conferred statistically significantly higher chances of developing alcoholic liver cirrhosis and hepatitis. However, less than 1/3rd patients developed alcoholic liver cirrhosis due to alcoholism.

Keywords Alcohol drinking pattern, Alcoholic liver disease, Hazardous alcohol consumption

206

Zinc deficiency as a marker of severity of chronic liver disease

Rahul Sangwan, Ritesh Kumar Gupta, Lokesh Kumar Sharma

Correspondence – Rahul Sangwan - drrahulsangwan323@gmail.com

Department of Internal Medicine, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Road, Type III, Connaught Place, New Delhi 110 001, India

Introduction Chronic liver disease is a common health problem in the developing world. Zinc is an essential trace element playing a pivotal role in liver functioning. The aim of the study is to compare the S. zinc levels in patients with the severity of chronic liver disease on basis of Child-Turcotte-Pugh (CTP) scoring and to compare S. zinc levels in patients with compensated and decompensated chronic liver disease.

Methods The cross-sectional observational study was conducted for a period of 1 year and 6 months on 105 patients of the 18-65 years age group, who presented with chronic liver disease irrespective of severity and underlying etiology. Patients were classified into three groups on the basis of CTP scoring (CTP-A, B, C). All patients’ serum zinc was collected and its value was compared with the other groups.

Results 1. Zinc deficiency is more profound with increasing severity of chronic liver disease. There is a strong negative correlation between CTP score and S. zinc (rho = -0.8) and was statistically significant (p<0.001). 2. Zinc values are much lower in the decompensated chronic liver as compared to compensated liver disease. The mean values of serum zinc in CTP-A was 67.1 μg/dL, in CTP-B was 48.2 μg/dL, and in CTP-C was 31.6 μg/dL.

Conclusion Zinc deficiency is commonly encountered in chronic liver disease. Zinc deficiency is aggravated with the severity of chronic liver disease. Hence, zinc shall be measured routinely in patients of chronic liver disease and can be regarded as a marker of its severity.

Keywords Chronic liver disease, Cirrhosis, Zinc

207

A study on prevalence of adrenal insufficiency in patients with acute and chronic liver failure with short Synacthen test

Chevigoni Saidulu , Sukanya Bhrugumalla

Correspondence – Sukanya Bhrugumalla - sukanyab92@gmail.com

Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India

Introduction Adrenal reserve depletion and overstimulation of the hypothalamus-pituitary-adrenal (HPA) axis are causes for adrenal insufficiency (AI) in critically ill individuals. Cirrhosis is a predisposing condition for AI as well. Both stable cirrhotics and liver transplant patients have been reported to have AI. Presence of AI in liver disease increases the risk of cardio circulatory compromise, infections, and mortality. Hence, we aimed to study the prevalence of AI in patients with acute and chronic liver failure which can help in prognostication.

Methods This prospective observation study was conducted in at a tertiary care center in South India. Adrenal insufficiency assessed by low dose short Synacthen test giving 1μg of synthetic ACTH (Syntropac) intravenously followed by measuring serum cortisol level at baseline (>5 μg/dL) and 60 min later. A level >500 nmol/L (18 μg/dlL) denoted normal response.

Results Twenty-five patients (23 males, mean age) were recruited. The commonest etiology was ethanol (76%). Among these, 80% and 20% of the patients were CTP C and CTP B, respectively. Adrenal insufficiency before SST was seen in 16%, and after SST seen in 40%. Adrenal insufficiency significantly correlating with short Synacthen test (SST) test (p< 0.031) and total bilirubin (p<0.042) levels. No correlation was observed with hepatic encephalopathy, AKI, SBP, variceal status, CTP score, and MELD-Na.

Conclusion Measurement of serum cortisol level after SST increases the probability of diagnosis of adrenal insufficiency compared to basal serum cortisol levels.

Keywords Addrenal insufficiency, Cirrhosis, Short synacthen test

208

Non-cirrhotic portal hypertension: Clinical profile and progression to liver cirrhosis

Santosh Hajare, Aditi Rao

Correspondence –Aditi Rao - docaditi289@gmail.com

Department of Gastroenterology, J. N. Medical College, JNMC KLE University Campus, Nehru Nagar, Belagavi 590 010, India

Background and Aim Non-cirrhotic portal hypertension (NCPH) is a heterogenous group of liver disorders of vascular origin, leading to portal hypertension [1]. NCPH is a common cause of portal hypertension in Japan and Indian subcontinent, constituting up to 30% and 40% of the cases respectively, while only 3% to 5% of portal hypertension in Western countries is attributed to NCPH [2]. The mean age of NCPH patients varies from 25-35 years [3]. The present study was undertaken up in a tertiary care centre in North Karnataka to determine the epidemiology and clinical profile of patients presenting with NCPH and the incidence of patients progressing from non-cirrhotic stage to cirrhotic stage.

Methods A retrospective clinical study, with 136 presenting with NCPH patients, was conducted. Patients with variceal bleed and other abdominal complaints were included for the study. All the patients were subjected to the upper/lower GI endoscopy (EUS, Olympus, USA).

Result In total, 136 subjects were used for the study. Out of which 90 subjects presented with NCPH. The prevalence of NCPH to become CLD was 24.44% (15.57%-33.32%). And mean time for NCPH subjects to become CLD was 3.68 years.

Conclusion The prevalence of NCPH to become CLD was more in middle aged people than compared to children. And mean time for NCPH subjects to become CLD will be at least 3 years. Within this period of time patients presenting with NCHP can be diagnosed.

References

1. Khanna R, Sarin SK. Non-cirrhotic portal hypertension–diagnosis and management. J Hepatol. 2014; 60:421-41.

2. Jayanthi V, Jain M, Vij M, Varghese J. Natural history of non-cirrhotic portal fibrosis-a tropical experience. Gastroenterol. Hepatol. Open Access. 2017; 6:00185.

3. Patwary MI, Rahman M, Mojumder K. Non-cirrhotic portal hypertension: current concepts and modern management. Bangladesh Medical Journal. 2014; 43:170-6.

Keywords Cirrhosis, Hypertension, Portal pressure, Venous pressure

209

Single centre experience on outcome of idiosyncratic drug induced liver failure treated with low volume plasma exchange and low dose steroid

Kunwar Ashish Singh, Santhosh Kumar E, Uday Zachariah, Vinoi David, Dolly Daniels, Subramani Kandasamy, Kishore Pichamuthu, Ashish Goel, C E Eapen

Correspondence – Kunwar Ashish Singh - ashish0212@gmail.com

Department of Hepatology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Background We present our experience with low volume PLEX (50% of estimated plasma volume exchanged per session) and low dose steroids to treat idiosyncratic drug-induced liver injury (I-DILI) patients with liver failure.

Methods We analyzed data on patients with I-DILI (diagnosed as per RUCAM score), treated with low volume plasma exchange (PLEX) and low dose steroid (Prednisolone: 20 mg OD, with rapid taper) in our department from 2016 to 2022. All eligible patients were counselled regarding liver transplant. Baseline and dynamic parameters (post-PLEX) were assessed as predictors of 1-month outcome.

Results Forty-eight I-DILI patients (probable: possible:: 41:7, 27 males, age 38.5 [14-84] years, median [range]; MELD score: 30 [24-43]) underwent plasma exchange for acute (ALF- 23) and acute-on-chronic (ACLF- 25) failure. Causative agents were complimentary and native medication (50%), antimicrobials (22%), antiepileptics (8%), antitubercular drugs (5%), hormonal pills (5%) and others (10%). Twenty-seven patients had encephalopathy (ALF:23, ACLF:4). Study patients underwent 3 (1-7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma was exchanged per session. One-month survival was 34/48 (71%) (ALF: 13/23, ACLF: 21/25). None of the patients underwent liver transplant. In the ACLF group, 30-day survival was 84% and 90-day survival being 59%. Of 20 ALF patients who fulfilled Kings College Criteria for liver transplantation,12 patients (60%) survived with plasma exchange. In ALF, none of the baseline parameters predicted survival. Area under ROC for ΔVWF was 0.83 (95% CI: 0.64-1.0) for predicting survival. At least 25% fall in plasma Von Willebrand factor antigen (VWF) from baseline predicted significantly improved survival (HR: 0.28, 95% CI: 0.1-0.81, p-value: 0.012, sensitivity: 73%, specificity: 87%).

Conclusion Plasma exchange appears a promising treatment option in I-DILI patients not opting for liver transplantation with dynamic change in VWF after PLEX predicting survival in patients with ALF.

Keywords ACLF, ALF, DILI, PLEX, VWF

210

Prevalence, predictors and outcomes of multi-drug resistant bacterial colonization in cirrhosis in-patients: A longitudinal study

Nipun Verma, Venkata Divakar Reddy P, Archana Angrup, Manisha Biswal, Arun Valsan, Pratibha Garg, Parminder Kaur, Sahaj Rathi, Arka De, Madhumita Premkumar, Sunil Taneja, Pallab Ray, Ajay Duseja, Virendra Singh

Correspondence – Nipun Verma - nipun29j@gmail.com

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction Due to unclear evidence, we evaluated the prevalence, predictors, and outcome of MDROs colonization in cirrhosis in-patients.

Methods We prospectively recruited cirrhosis patients from a tertiary-care hospital over 1.5 years. Surveillance cultures, phenotypic drug susceptibility, and genotypic testing for MDROs from multiple sites (rectum, nasal, composite skin, and central line hub [c-hub]) were performed at admission and follow-up. Clinical data, risk factors, and outcomes of patients were analyzed.

Results Of 125 patients aged 49 years, 85.6% males, 60.8% ACLF, 99 (79.2%) were identified MDRO colonizers (by phenotype or genotype). MDRO-colonization at rectum, nose, skin, and c-hub was seen in 72.7%, 30.0%, 14.9%, and 3.3% patients, respectively. Patients were colonized with ESBL (71/125), CRE (67/125), MDR-enterococcus (48/125), MDR-acinetobacter (21/125), or MRSA (4/125). Among colonizers with phenotypic resistance (91/99), the isolates were MDR (80.2%) or PDR (19.8%). The commonest genotype among all-GNBs, Enterococcus, and Staphylococcus sp. was NDM (56.8%), VanA (42.5%), and MecA (66.7%), respectively.

MDRO colonizers were likely to have alcoholic hepatitis, smoking, upper-middle socioeconomic status, healthcare exposure, systemic infections, broad-spectrum antibiotics exposure, and norfloxacin prophylaxis in the past 3 months than non-colonizers (p<0.05).

MDROs colonization increased the risk of infection by MDROs at admission (OR: 8.45, 95% CI: 1.09-65.58, p=0.017) or follow-up (OR: 7.46, 95% CI: 2.39-23.28, p<0.001). MDRO colonizers had a higher prevalence of cerebral failure (p<0.05). Patients with multiple sites (≥1) MDRO colonization (prevalence: 30%) were associated with multi-organ failures and poorer 30-day survival than those with none or single-site colonization (22.2% vs. 52.4%, p=0.004). MDROs infection (prevalence: 57.6%) (HR: 1.874) and MELD (HR: 1.048) were independent predictors of 30-day mortality after adjusting for age and colonization status.

Conclusions A high burden of MDROs colonization and infections is hazardous in cirrhosis. MDROs colonization, especially at multiple sites increases the risk of MDRO infections, multi-organ failures, and mortality in cirrhosis.

Keywords Cirrhosis, Colonisation, CRE, ESBL, Infections, Mortality, MRSA, Multi-drug resistance

211

Bispectral index: A bedside tool for assessment of hepatic encephalopathy in patient with acute-on-chronic liver failure

Surender Singh Sehrawat, Madhumita Premkumar, Jasvinder Nain, Rohit Mehtani^*, Yogendra Kumar, Ajay Duseja, Sunil Taneja, Kamal Kajal, Shiv Soni

Correspondence – Madhumita Premkumar - drmadhumitap@gmail.com

Department of Hepatology. Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, and ^*Amrita Hospital, Mata Amritanandamayi Marg Sector 88, Faridabad 121 002, India

Introduction Hepatic encephalopathy (HE) is clinically assessed by using West Haven Criteria (WHC) and hepatic encephalopathy scoring algorithm (HESA). These scoring tests show inter-observer variability. So, we conducted a prospective, observational study to objectively assess hepatic encephalopathy (HE) in patients with acute-on-chronic liver failure (ACLF) by using the Bispectral index (BIS). The primary outcome was correlation of BIS with the grade of HE.

Methods Thirteen patients of CANONIC ACLF with HE grades ≥2 were prospectively enrolled and followed for 90 days. Assessment of HE was done using WHC and HESA scoring tests. Optic nerve sheath diameter (ONSD) was measured with ultrasound and available for nine patients. Average BIS over 10 minutes was assessed on day 1, day 4 and day 7. BIS was measured post 1hour of stopping sedation for patients who were on mechanical ventilation. Spearman’s rank correlation coefficient was used to find the correlation between BIS and severity of HE.

Results A total of 31 BIS recordings were made in 13 patients on day 1, day 4, and day 7. BIS had a negative correlation with WHC grade (Spearman’s rank correlation coefficient (ρ) = -0.5622, p=0.001). BIS was increased on day 7 (82.8±14.32) compared to day 1 (80.23±20.46). However, the ONSD (mm) values are also increased on day 4 (4.533±1.042) and day 7 (4.764 ± 0898) as compared to day 0 (4.422±1.118).

Conclusion Bispectral index is a helpful tool for objective assessment of HE, and it moderately correlates with grade of HE in ACLF. So, BIS can be used in the objective assessment of HE grades. However, the presence of artifacts, low signal quality index and high EMG activity hamper its clinical utility.

Keywords Acute-on-chronic liver failure, Bispectral index, Hepatic encephalopathy, Optical nerve sheath

212

Incidence of first episode of overt hepatic encephalopathy in patients with liver cirrhosis

Buddhi Meena , Haribhakti Seba Das, Chittaranjan Panda, Pankaj Bharali, Prajna Anirvan. Mrinal Gogoi, Padmalochan Prusty, Samir Kumar Hota

Correspondence – Buddhi Meena - prakashmeena86@yahoo.com

Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Behera Colony, Mangalabag, Cuttack 753 001, India

Background Hepatic encephalopathy (HE) is a watershed moment in the natural history of cirrhosis and its development indicates poor prognosis. Many factors associated with development of overt HE. However, there are few studies available in this part of world. Our study aimed to assess incidence of first episode of overt HE.

Methods One hundred and one consecutive patients with cirrhosis (Child A-C) and portal hypertension without previous HE were enrolled in this study, from June 2021 to November 2022. The incidence first episone of HE, model for end-stage liver disease-sodium (MELD-Na) score and the bilirubin–albumin–beta-blocker–statin score (BABS) were calculated.

Results 62.3% patients were males and 37.7% patients were females. 7.7%, 41.6% and 29.7% patients belonged to Child A B and C respectively. The most common cause of cirrhosis was alcohol followed by hepatitis B and non-alcoholic steatohepatitis (NASH) related and the mean MELD- Na was 17.9 and BABS score was -3. 15 patients developed HE over mean follow-up of 1 year.

Conclusion Out of total 101 patients, 14.85% patients developed first episode of HE. Majority of patients who developed HE belonged to Child C category and had higher MELD-Na scores.

Keywords Hepatic encephalopathy

213

“Restricted sedative use” policy may improve survival in patients with rodenticide induced hepatotoxicity

Asisha Janeela , Ashish Goel, Uday George Zachariah, Kundavaram Paul Prabhakar Abhilash, Kishore Pichamuthu, Ebor Jacob James, Debasis Das Adhikari, Subramani Kandasamy, C E Eapen

Correspondence – C E Eapen - eapen@cmcvellore.ac.in

Department of Hepatology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Background Acute liver dysfunction may affect drug metabolism in liver, lead to sedative overdose, drowsiness, respiratory depression and contribute to mortality. This study aims to analyze use of sedatives in patients with rodenticidal hepatotoxicity.

Methods Details of sedative use and outcomes were studied from IP charts and e-pharmacy records of patients admitted with rodenticide ingestion under Department of Hepatology (2014 – 2021).

Results Of 120 patients with rodenticide hepatotoxicity (F: 71; age: 22 years, median; acute liver injury: 72, acute liver failure: 41), 103 consumed yellow phosphorus. All patients were managed as per standard-of-care including plasma exchange (54/120 patients). None underwent liver transplant. 25/120 (20.8%) patients received sedatives (all intravenously) - dexmedetomidine (9), midazolam (9), haloperidol (9), lorazepam (5) and fentanyl (5). Indications for sedative use: agitation (19/25), endotracheal intubation (12/25). All received standard doses of sedatives. 15/25 patients who had received sedative, had worsening of oxygen saturation, 15/25 (60%) patients had worsening sensorium and died. Hospital stay was prolonged in patients who received sedatives (8.16 vs. 7.88 days). Mortality was significantly higher in patients with sedative use (15/25, 60%) as compared to patients with no sedative use (9/95, 9.5%); (HR: 14.3, 95% C.I: 5 – 41, p-value: <0.001). Of 21 patients who had low sensorium at admission; there was only 1 death in 8 patients who did not receive sedatives compared to 8/13 (61.5%) deaths in those who received sedatives (p-value -0.1).

Conclusion Most (95%) rodenticidal hepatotoxicity patients were managed without sedatives. Sedative use was associated with respiratory depression, worsening sensorium and increased risk of death. A “restricted sedative use” policy in these patients may improve survival.

Keywords Poisoning, Rodenticide, Sedative

214

Cutaneous aspergillosis precipitating acute-on-chronic liver failure in alcohol associated cirrhosis: A case report

Ganesh C P , Jayant Agarwal, Nipun Verma, Harsimran Kaur, Shiva Prakash, Sunil Taneja, Ajay Duseja

Correspondence – Nipun Verma - nipun29j@gmail.com

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction Cutaneous mycosis is generally not angio-invasive and improves with topical treatment. We report an interesting case of angio-invasive cutaneous aspergillosis resulting in acute-on-chronic liver failure (ACLF) and mortality in a cirrhosis patient.

Case Summary A 32-year-old male, alcohol consumer and smoker had a hospitalization 1.5 months back for 7 days with alcoholic hepatitis, liver, coagulation, and renal failure for which he was managed conservatively and improved. On 1 month follow-up he developed spontaneous bacterial peritonitis without any organ failures, for which he received injection polymyxin that was continued as outpatient-parenteral-antimicrobial-therapy (OPAT). Seven days post-therapy patient had a recurrence of fever and jaundice and was hospitalized. Sepsis screen revealed sterile blood/urine/ascitic fluid cultures, elevated galactomannan (2.6), normal leukocyte counts, and necrotic plaques with yellowish brown crusting with surrounding brown reticular purpura and irregular margins of 4 × 5 cm at the right forearm near intravenous cannulation site (Fig.1A) and similar plaque of 2 × 3 cm at the dorsum of the left hand (Fig.1B). Investigations showed hyperbilirubinemia (7.2 mg/dL), coagulopathy (INR: 1.6), no-SBP (ANC:170), and normal paranasal sinuses, renal, cerebral, pulmonary and circulatory functions. With the diagnosis of acute decompensation, he was managed with intravenous liposomal amphotericin B (LAMB: 3 mg/kg), polymyxin, and tigecycline. Biopsy of skin lesions and mycological cultures was performed after a dermatology consult, which showed dermal panniculitis (HPE) and growth of aspergillus flavus sensitive to LAMB (Fig.1C-E). Despite LAMB treatment, he developed acute-on-chronic liver failure in next 7 days with coagulation and renal failure. Salvage treatment with anidulafungin was initiated but he further deteriorated with cerebral and circulatory failures in the next 3 days and succumbed to illness despite intensive care, ventilation, and hemodialysis support.

Conclusions OPAT should be cautiously advised with utmost hygiene in cirrhosis patients. Even cutaneous mycosis can be angio-invasive, precipitate ACLF, and deleterious in cirrhosis patients despite antifungal therapy.

Keywords ACLF, Acute-on-chronic liver failure, Aspergillosis, Cirrhosis, Fungal infection, Mortality, Mycosis

215

An interesting case of hepatic visceral larva migrans

Ravi Kishore , Praveer Rai

Correspondence – Ravi Kishore - rvk.medico@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareili Road, Lucknow 226 014, India,

Twenty-three-year-old female without any co-morbidities, presented with right upper quadrant abdominal pain, low grade fever, loss of appetite and malaise for 2 months. No jaundice, vomiting, GI bleed, no passage of worms in stools or urticaria. She was a vegetarian, with history of pets at home. On examination there was mild pallor. Vitals were stable. Abdominal examination revealed tender hepatomegaly (liver span:16 cm), splenomegaly (15 cm). Other systemic examination was unremarkable. Investigations Blood investigations revealed microcytic hypochromic anaemia (Hb=8.4 g/dL) and eosinophilia (eosinophil count being 18%, AEC:16200/mm³). ALP was raised (163 IU/L) other liver and renal parameters were normal. Serum α-fetoprotein was within normal limits (1.43 ng/mL), CA 19.9 2.41 U/mL. USG abdomen showed large solid cystic lesion (10.7 × 14.3 cm) in right lobe of liver. CTA : liver enlarged (17.5 cm), hypo attenuating lesion (15.3 × 8.5 × 8.6 cm) is noted in the right lobe involving segments V, VI, VIII. Without arterial enhancement. Heterogenous enhancement in porto venous phases. Ultrasound-guided biopsy from liver sol showed infiltrates comprises of predominantly eosinophils, lymphocytes, plasma cells and neutrophils along with multiple charcot-leydencrystals. Large areas of necrosis are identified. On special stains, no larva and hook lets are identified. The findings were suggestive of eosinophilic abscess, based on corroborating radiological and histopathological findings and a final diagnosis of hepatic visceral larva migrans was made. She was treated successfully with albendazole 400 mg BD for 4 weeks.

Discussion T canis and Toxocara cati are most important causes of VLM. The clinical triad of toxocariasis is unexplained eosinophilia, liver or lung nodules on imaging studies. Hepatic nodules due to visceral larva migrans (VLM) should be considered as one of the diagnostic possibilities in cases with multiple hepatic lesions. Eosinophilia is a useful clue but is not completely specific for VLM. Cytology/histology along with clinical correlation help exclude other causes like malignancies.

Keywords Charcot-leyden crystals, Eosinophilia, Visceral larva migrans

216

Spontaneous hepatogastric fistula in liver abscess: Case series of a rare complication

Sayan Malakar , Akash Mathur, Anshuman Elhence ^* , Uday C Ghoshal

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareili Road, Lucknow 226 014, India, and ^*All India Institute of Medical Sciences, Gate No, 1, Great Eastern Road, AIIMS Campus, Tatibandh, Raipur 492 099, India

Introduction Spontaneous hepatogastric fistula is a rare complication of liver abscess. It was previously reported in hepatocellular carcinoma following interventions. Most hepatogastric fistula cases complicating liver abscess can be managed conservatively. Here we present two cases of hepatogastric fistula.

Methods Two patients presented to us with a history of pain abdomen and fever. After initial workup and imaging, esophagogastroduodenoscopy (EGD) was performed to confirm hepatogastric fistula and they were managed accordingly.

Results Two patients with hepatogastric fistula were diagnosed using contrast-enhanced computed tomography of the abdomen and EGD. The first patient was a chronic alcoholic. He had three amebic liver abscesses, an abscess in the left lobe ruptured into the stomach. Another large abscess in the right lobe was managed with percutaneous drainage of the abscess. Later, on follow-up imaging left lobe liver abscess was resolved with conservative treatment. The second patient had choledocholithiasis with ascending cholangitis. Cholangitic liver abscess was complicated with intragastric rupture. He was managed successfully with emergency endoscopic retrograde cholangiopancreatography (ERCP) and stone removal. A percutaneous drainage was done for the ruptured abscess. Both patients were managed conservatively without surgery.

Conclusion Intragastric rupture of liver abscess can occur in amebic as well as bacterial cholangitis-related abscesses. They can be managed without surgery.

Keywords Cholangitis, Hepato-gastric fistula, Liver abscess, Percutaneous drainage

217

Hepatocellular carcinoma in young adults- An audit from a tertiary cancer center

Prachi Patil , Vaneet Jearth, Omkar Salvi, Sridhar Sundaram, Shaesta Mehta

Correspondence – Prachi Patil - prachipatil@gmail.com

Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Room No 1233, Homi Bhabha Block, Tata Memorial Hospital, Parel, Mumbai 400 012, India

Introduction Hepatocellular carcinoma (HCC) is uncommon in young adults. There is a dearth of literature evaluating clinical features of young patients with HCC (yHCC), especially from India. We compared the clinical characteristics of yHCC patients with older patients with HCC (oHCC).

Methods All consecutive untreated HCC patients who were recruited on another ongoing IEC approved project were evaluated. Patients aged ≤ 40 years at diagnosis of HCC were defined as yHCC. Their demography and clinical features were compared with that of oHCC (>40 years).

Results Of 508 HCC patients, 75 (14.8%) were yHCC. The mean age at diagnosis was 34.1 years for yHCC (range 20-40 yrs) as compared to 59.6 in oHCC (range 41-84 yrs). There was no significant difference in the male:female ratio in the 2 groups (yHCC 7.3:1 vs oHCC 6.9:1, p=0.866). yHCC patients had a higher rate of hepatitis B virus (HBV) infection (77.3% vs. 44.3%, p=<0.001) and higher mean albumin levels albumin (3.64 vs. 3.42 p=0.003). Although yHCC patients had a lesser incidence of cirrhosis (70.7% vs. 79.2%, p=0.099), and more patients with Child-Pugh class A cirrhosis (57.4% vs. 48.8%, p=0.242), the difference was not significant. There also was no significant difference in the two groups with respect to the alfa feto protein (AFP), bilirubin, ALT or INR levels. yHCC had more advanced disease with bigger lesions (size of largest lesion in cms:10.00 vs. 8.36, p=<0.001), and a higher incidence of extrahepatic metastasis (35.1% vs. 19.7%, p=0.003). The BCLC stage was as follows: yHCC- A-1, B-23, C-43, D-8; oHCC 0-3, A-31, B-139, C-189, and D-71).

Conclusion HBV infection was the predominant etiology in most yHCC. yHCC is often diagnosed at an advanced stage despite relatively preserved liver function. HCC surveillance may benefit young hepatitis B carriers, however further research is needed to understand who is at a higher risk.

Keywords HBV, Liver cancer, Young HCC

218

Rishyagandha induced possible autoimmune-like liver injury in an elderly couple with diabetes mellites

Sayan Malakar , Anshuman Elhence ^* , Uday C Ghoshal

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareili Road, Lucknow 226 014, India, and *All India Institute of Medical Sciences, Gate No, 1, Great Eastern Road, AIIMS Campus, Tatibandh, Raipur 492 099, India

Introduction Rishyagandha (Withania coagulans) is a well-known herbal remedy popularly sold as “paneer ka phool” in India. Rishyagandha fruit extract has a strong anti-hyperglycemic effect. This is the first case series reporting the hepatotoxicity of the herb.

Results A 65-year-old diabetic female presented to us with a history of progressive jaundice for four months without any cholestatic or prodromal features. Her 72-year-old diabetic husband also presented with similar history for three months. Before the onset of jaundice, they had started ingesting rishyagandha seed extract as a remedy for their diabetes for the last 11 months. Bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) of the wife at presentation and after three months of stopping the extract were 14.4 mg/dL, 1173 IU/L, 523 IU/L, 163 IU/L and 3.4 mg/dL, 257 IU/L, 321 IU/L, 149 IU/L, respectively. Her husband’s course was also similar. Their anti-nuclear antibodies were positive (2+, 1:100) and immunoglobulin-G levels were high. Liver biopsies were compatible with autoimmune injury without any evidence of cirrhosis in both. A Roussel Uclaf causality assessment method (RUCAM) score calculated for rishyagandha suggested it to be the “possible” culprit (RUCAM score of five for both). Jaundice resolved after four months of stopping the offending drugs.

Conclusion Rishyagandha, a popular herbal remedy for diabetes, can lead to autoimmune-like liver injury.

Keywords Autoimmune like-liver injury, Herb induced liver injury, Rishyagandha

219

Microbacterial spectrum of cirrhotic ascites in tertiary care hospital

Zahid Zubair, Arvind Kelkar, Kamal Chetri, Mukesh Aggarwala, Roshan Aggarwala, Mrinal Debbarma

Correspondence – Zahid Zubair - zahid.zubair2619@gmail.com

Department of Gastroenterology and Hepatology, Apollo Hospitals, Lotus Tower, International Hospitals, G S Road, Christian Basti, Guwahati 781 005, India

Background Spontaneous bacterial peritonitis (SBP) is the most common infection among patients with cirrhosis and ascites with an incidence of 10% to 30%. So this study was done to study the microbiological spectrum of ascites in North east Indian region and to determine the sensitivity pattern and prevalence of MDR organisms in this region.

Aims To determine the prevalence of ascitic fluid infection in cirrhotic ascites and to determine the prevalence of MDR organisms in ascitic fluid infections.

Methods One hundred and forty six patients with PHT related ascites were studied for microbiological spectrum and culture sensitivity pattern. The association of various parameters with ascitic fluid infection was also studied.

Results Majority of patients belonged to CTP class C (59.6%) and. Majority of patients had MELD Na > 15 (80.2%). Ascitic fluid infection was documented in 24% of cases, out of which SBP constituted 60% and CNNA 40%. Gram negative organisms were most commonly isolated, especially E. coli, Klebseilla. 33.3% of isolates were multidrug resistant organisms. Recent hospitalization and antibiotic usage predisposed to both ascitic fluid infections and MDROs. Recent paracentesis predisposed to both ascitic fluid infections and MDROs.

Conclusion MDR bacterial infections are common being isolated in 33.3% of isolates. Recent hospitalization, antibiotic usage, recent paracentesis increase the risk of ascitic fluid infections and drug resistant organisms. Patients with no risk factors for MDROs can be treated with third generation cephalosporins or floroquinolones, but patients with risk factors should receive broad spectrum antibiotics like piperacillin-tazobactum or carbapenems till results of culture and antibiotic sensitivity pattern are available. Our study doesn’t support the use of empirical gram-positive coverage as Gram positive organisms were less commonly isolated.

Keywords Multidrug resistant organisms, Spontaneous bacterial peritonitis

220

Efficacy and safety of saroglitazar in diabetic versus non-diabetic non-alcoholic fatty liver disease cohorts- A 24-week, real-world experience

Jayanta Mukherjee

Correspondence – Jayanta Mukherjee - jayanta40@yahoo.com

Department of Gastroenterology, ILS Hospitals, 2nd Floor, 3rd Ave, D D Block, Sector 1, Bidhan Nagar, Salt Lake, Kolkata 700 064, India

Introduction Type 2 diabetes (T2DM) is a well-known risk factor for non-alcoholic fatty liver disease (NAFLD). However, NAFLD is also very common in nondiabetic adults. The aim of this study was to evaluate the efficacy of saroglitazar 4 mg OD in diabetic vs. non-diabetic NAFLD cohorts, in routine clinical practice.

Methods A total of 123 NAFLD patients (males 75.6%, non-diabetics 63.4%) diagnosed either on Fibroscan or USG imaging or elevated LFT along with exclusion diagnosis and prescribed on saroglitazar 4 mg OD, were evaluated for changes in LSM, LFT, TG, and LDL along with the non-invasive NFS score. The overall improvement and improvements in diabetic (FBS median [IQR] 128 [75] mg/dL) vs. non-diabetic (median FBS 99 [17.5] mg/dL) NAFLD cohort, is measured at baseline and 24 weeks. The statistical significance was established using paired sample t-test.

Results The study shows significant improvements in all measured parameters from baseline in both diabetic and non-diabetic NAFLD cohorts. The LSM improved by 19.6% and 16.7%, ALT by 40.8% and 50.5%, AST by 40.9% and 38.2%, TG by 33.1% and 36.1% and LDL by 21.3% and 23.4% respectively in diabetic and non-diabetic NAFLD. The overall NFS score improved by 29.5% with 44% (n=54) patients in the intermediate or high NFS range at baseline reduced to 26.8% (n=33) patients after 24 weeks. All the improvements are statistically highly significant (p < 0.001).

Conclusions Saroglitazar 4 mg OD was found equally effective and safe in both diabetic and non-diabetic NAFLD. More studies, including well-designed clinical trials, will show further light on effect of saroglitazar 4mg in NAFLD with different underline co-morbidities.

Keywords LSM, NAFLD, NFS score, Saroglitazar, T2DM

221

Plasma proteomics unravels pathways driving acute-on-chronic liver failure phenotype in patients with acute decompensation of cirrhosis

Pratibha Garg , Nipun Verma, Maryada Sharma, Trayambak Basak ^* , Shreya Singh, Vivek Sarohi ^* , Sahaj Rathi, Arka De, Madhumita Premkumar, Sunil Taneja, Ajay Duseja, Virendra Singh

Correspondence – Nipun Verma - nipun29j@gmail.com

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, and ^*Indian Institute of Technology, Mandi, India

Background Progression from acute decompensation (AD) to acute-on-chronic liver failure (ACLF) associates with poor prognosis cirrhotic patients. We employed untargeted plasma proteomics to discern molecular determinants of AD and ACLF.

Methods Patients admitted with AD or ACLF (EF-CLIF criteria) and healthy controls (HC) were enrolled. Plasma samples bio-banked at baseline were subjected to LCMS based proteomics following top abundant protein depletion. Inferential statistics was performed to identify differentially expressed proteins (DEPs), while pathway analysis was performed using gene ontology (GO) and KEGG database.

Results Twenty-nine AD patients (93.1% males, median age: 40 years), 55 with ACLF (87.2%, 43 years) and 10 HC were enrolled. Alcoholic hepatitis was the predominant etiology of AD/ACLF (65.5% and 67.2%, respectively). ACLF patients had higher median WBC count (14.7 vs. 7.3 × 109/L), procalcitonin (1.3 vs. 0.42 ng/mL), SIRS (2 vs. 1), CLIF-C-OF (12 vs 7), and mortality (74.5% vs. 17.2%) than AD patients (p<0.001, each). Five hundred and twelve proteins were identified, 30 were DEPs (15 upregulated, 15 downregulated) between AD and ACLF (p<0.05); 85 exclusively expressed in ACLF. Pathways related to immune system activation, phagocytosis, chemotaxis, complement were upregulated in AD vs. HC, while plasma lipoprotein transfer, homeostasis and cell death regulation were underexpressed (Fig. 1A). Pathways of immune cell activation, cell motility, response to stress and stimuli were overexpressed, while positive regulation of protein processing, coagulation and phagocytosis were downregulated in ACLF vs. HC (Fig. 1C). Response to stress and infections, negative regulation of oxidative stress were over-activated, whereas carbohydrate and lipid metabolism were severely impaired in ACLF vs. AD, translating to immunometabolism failure in ACLF. Proteolysis increased significantly from HC, AD, to ACLF. ACLF patients had hypercoagulatory phenotype compared to AD (Fig.1B).

Conclusion Proteomics revealed in a novel single platform, a progressive aberration in immune system, metabolism, proteolysis, complement and coagulation system in ACLF patients.

Keywords ACLF, LCMS, Proteomics

222

Effect of saroglitazar on FIB4 index and metabolic parameters in non-alcoholic fatty liver disease/non-alcoholic steatohepatitis population - A 24-week, real-world experience from the eastern part of the country

R P Ray

Correspondence – R P Ray - dr.rpray@gmail.com Gastroenterology

Department of Gastroenterology, Anandaloke Multi Speciality Hospital, Paresh Nagar, Sevoke Road, Ward 44, Dasrath Pally, 2nd Mile, Siliguri 734 001, India

Background and Aims Non-alcoholic fatty liver disease (NAFLD) is a spectrum of liver damage and may progress to cirrhosis, liver failure, and hepatocellular carcinoma, if not managed well. It is strongly considered the hepatic manifestation of metabolic syndrome. Fibrosis-4 index (FIB-4) has been shown to be a prognostic marker of liver-related outcomes in patients with NAFLD. Saroglitazar 4 mg is the only approved therapy for NAFLD and non-alcoholic steatohepatitis (NASH). We tried to evaluate the efficacy and safety of saroglitazar 4 mg OD on non-invasive FIB-4 index and various metabolic parameters in NAFLD/NASH patients, in routine clinical practice.

Methods A total of 73 documented NAFLD patients (males 80.8%) prescribed saroglitazar 4 mg OD, were analyzed for changes in liver biochemical parameters and lipid profile at 24 weeks. The study population was of median age of 35 (10) years and a median BMI of 27.3 (6.1) kg/m². 32.9 % study population was diabetic, 35.6% are hypertensive and 61.6% are dyslipidemic. The median baseline FIB4 Index was 0.66 (1.2) with 38.4% of patients in the intermediate or high-risk group. The data at baseline and 24 weeks were analyzed and statistical significance was established using paired sample t-test.

Results The study shows statistically significant improvements in fat and liver-related parameters (LDL 13.5%, TC 23.8%, TG 37.6%, AST 35.5%, ALT 41.9%) from baseline. Also, there was a significant improvement in the overall FIB-4 index by 35.7%, with 38.4% (n=28) of patients in the high and intermediate risk category at baseline reduced to 9.6% (n=7), at 24 weeks. There was no single episode of any drug-related side effects and therapy discontinuation.

Conclusions The study shows saroglitazar 4 mg OD as a safe and effective treatment option for NAFLD/NASH, with significant improvement in all fat and liver-related parameters including the non-invasive FIB-4 index.

Keywords NAFLD, NFS score, Saroglitazar

223

Skin and soft tissue infections in decompensated chronic liver disease – A case series

Parag Papalkar, Ramakrishna B S, Babu Vinish D, Kayalvizhi J, Rohan Yewale, Naveenchand M, Muthukrishnan P

Correspondence – Parag Papalkar - paragpapalkar@gmail.com

Department of Gastroenterology, SIMS Hospital, Metro No.1 Jawaharlal Nehru Road, Vadapalani, Chennai 600 026, India

Introduction Skin and soft tissue infections (SSTI) are one of the most common types of infections seen in the hospitalized patients with decompensated chronic liver disease (DCLD) and account for significant morbidity and mortality. However, there is scarcity of focussed literature on this widely prevalent infectious complication in patients with DCLD. We aimed to retrospectively analyse SSTI in DCLD over the last four years in our hospital.

Methods The case records of patients with DCLD in our hospital were retrieved and the data analyzed.

Results Out of total 450 DCLD patients, 40 had cellulitis (mean age 59.1±13 years, M:F 2.63). Non-alcoholic steatohepatitis was the most common cause of cirrhosis (65%). Twenty-one patients (52%) had diabetes mellitus. Complications during admission included ascites (90%), renal dysfunction (62.5%), spontaneous bacterial peritonitis (22.5%) gastrointestinal bleed (12.5%) and hepatic encephalopathy (55%). Out of the 40 patients, 16 (40%) had cellulitis in the past and 30 (75%) patients had history of recent hospitalization for DCLD complications. Nine (22.5%) patients had history of trauma. Nine (22.5%) of the 40 patients were on Rifaximin prior to admission. Out of 40 patients 6 (15%) required surgical management while most patients were treated with Piperacillin Tazobactum. Length of hospital stay was 9.08±7.7 days and 12 (30%) of the patients required intensive care.

Conclusions Prevalence of cellulitis was 8.8% in hospitalized DCLD. Appropriate use of antibiotics resulted in a favorable outcome and lesser surgical intervention.

Keywords Cellulitis, Liver disease

224

Study of spectrum of upper gastrointestinal bleed in patients with cirrhosis of liver

Satish Shahu, Parimal Lawate

Correspondence – Satish Shahu - kumarsatishshahu@gmail.com

Department of Internal Medicine, Jehangir Hospital, 32, Sassoon Road, Sangamvadi, Pune 411 001, India

Objective Study the causes of upper gastrointestinal (UGI) bleed in liver cirrhotics, clinical presentation, endoscopic findings and outcomes during hospitalization including mortality.

Methodology Fifty-seven patients of UGI bleed were included comprising those diagnosed with liver cirrhosis. After initial stabilization each patient underwent gastroduodenal endoscopy by an expert Gastroenterologist and finding documented. If multiple lesions seen in endoscopy, then among them most possible cause of UGI bleed is identified. Treatment given, any complications and outcome including mortality at the time of discharge were noted.

Results Of 57 cases, 38 (66.7%) had variceal type of bleeding and 19 (33.3%) had non-variceal type of bleeding. Majority (34) had esophageal varices (59.6%), 5 (8.8%) had duodenal ulcer, 4 (7.0%) had gastric varices, 4 (7.0%) had portal hypertensive gastropathy, 3(5.3%) had gastric ulcer, 3 (5.3%) had erosive gastritis, 2 (3.5%) had esophagitis, 1 (1.8%) had esophageal ulcer and 1 (1.8%) had Mallory-Weiss tear. Peptic ulcer disease (duodenal ulcer+gastric ulcer) accounted for 8 (14% of total UGIB while 42.1% in nonvariceal causes). Distribution of incidence of mortality differs significantly between group of cases with different CTP classes (p-value<0.05). Of 13 cases with Class A, none expired; of 20 cases with class B, 3 (15.0%) expired and of 20 cases with class C, 8 (40.0%) expired. Incidence of mortality was higher in variceal group than in nonvariceal group (28.6% vs. 5.6%%).

Conclusion In cirrhotics, UGI bleed from ruptured varices is most common However, cirrhotic patients do not always bleed from varices. About one-third patients can also bleed from non-variceal causes of which most common is peptic ulcer; duodenal followed by gastric ulcers. Length of hospital stay and Incidence of mortality is higher in patients of variceal bleed group and patient having higher CTP class.

Keywords Upper gastrointestinal bleed, Liver cirrhotics, Variceal group

225

Rate of decline of HBsAg load among Indian patients with chronic hepatitis B virus infection

Pallavi Garg , Kaushal Madan, Richa Bhargava, Ayushi Singh, Muzafar Shawl, Vikas Singla, Amita Thakur, Abhaya Indrayan

Correspondence – Kaushal Madan - k_madan_2000@yahoo.com

Centre for Gastroenterology, Hepatology and Endoscopy, Max Institute of Liver and GI Sciences, 1 2, Press Enclave Marg, Saket Institutional Area, Saket, New Delhi 110 017, India

Introduction Functional cure in hepatitis B virus (HBV) infection involves clearance of HBsAg from the sera of infected individuals and reflects the intracellular ccc-DNA activity, but it is a rare event. Data on the dynamics of HBsAg load among patients with CHB is limited. Aim To measure the rate of decline of quantitative HBsAg among Indian patients with chronic HBV infection.

Methods Retrospective follow-up study. Patients of chronic HBV infection being followed up at our hospital and had at least two values of quantitative HBsAg were included.

Results Twenty-eight patients were included (67% males; median age 45.5 [33.5-70] years). The median HBsAg load available at the time of enrollment in the study was 2120 (552.5 to 42179) IU/mL. The HBsAg load declined from the baseline to the last available value in 12 (75%) patients, increased in 5 (17.9%) patients and remained the same in 2 (7.1%) patients. Among patients with a decline in HBsAg load, the median rate of decline was 581.9 IU/mL per year (based on the first and last available values), but was not linear.

Conclusion The rate of HBsAg decline among Indian patients with chronic HBV infection, is slow and non-linear.

Keywords HBV, India, Quantitative HBsAg

226

Association of GH and IGF1 levels with frailty, sarcopenia, bone health, and prognosis in decompensated cirrhosis patients

Parminder Kaur ¹ , Nipun Verma ¹ , Pratibha Garg, Sahaj Rathi, Arka De, Madhumita Premkumar, Sunil Taneja, Ajay Duseja, Virendra Singh

Correspondence – Nipun Verma - nipun29j@gmail.com

Department of ¹Hepatology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India

Background Impairment of GH-IGF1 axis and its association with frailty, sarcopenia and bone health is less well characterized in cirrhosis. We evaluated the association of GH and IGF1 levels with frailty, sarcopenia, bone health, prognosis in decompensated cirrhosis patients.

Methods Adult decompensated cirrhosis presenting to outpatient services at a tertiary care institute over 1 year were examined for frailty with liver frailty index (LFI), sarcopenia with DEXA (ASMI), anthropometry, plasma GH-IGF1 levels with ELISA, clinical decompensations and outcomes.

Results Patients (n=46) were male (42 [95.5%]) with mean age of 49.6±9.87 years. 93.2% (patients had ascites [Grade-I: 40.9%, Grade-II: 25%, Grade-III: 27.3%] and 4.5% patients had HE [grade-I]). Median MELD-Na was 15.5 (IQR:12.9-19.1) and CTP was 7.5 (7-9) [CTP A-18.2%, CTP B-65.9%, CTP C-15.9%]. Median GH (ng/mL) and IGF1(ng/mL) were 3.16 (1.62-5.25) and 35 (24.6-54.5). IGF1 levels were 0.53 times (IQR:0.38-0.90) the lower limit of age and gender matched reference. 75% patients were pre-frail and 25% patients were frail. Median ASMI (Kg/m²) was 6.59 (5.49-7.60), 66.7% patients were sarcopenic and 34.5% had osteodystrophy. IGF1 showed strong correlation with frailty (p=-0.419, p<.001) and moderate correlation with CTP (ρ=-0.32, p=0.034), and appendicular skeletal muscle mass (ρ=0.314, p=0.075). IGF-1 levels were reduced in patients with osteodystrophy (27 [IQR:16.4-38.4] vs. 45.4 [IQR:25.4-71.1], p=0.034). On regression, IGF-1 levels were associated with frailty (β= -0.63, SE=0.214, p=0.005) and ASMI (β=2.50, SE=1.21, p=0.047). AUROC of IGF-1 for 3-month mortality was 0.756 (p=0.094) showing a trend toward higher mortality. LFI had strong negative correlation with ASMI (ρ=-0.32, p= 0.034). Osteodystrophy had strong positive association with LFI (ρ=0.525, p=0.002). GH had no significant associations with ASMI, LFI and osteodystrophy.

Conclusion Reduced IGF-1 levels are associated with sarcopenia, frailty, osteodystrophy, increased severity in cirrhosis. Sarcopenia and frailty are interrelated, common, and associate with osteodystrophy in cirrhosis. Modulation of GH/IGF1 axis is a potential therapeutic target in cirrhosis.

Keywords Frailty, IGF1, Sarcopenia

227

Long-term outcome of patients with decompensated autoimmune liver diseases treated with steroids and azathioprine

Ashiesh Khandelwal

Correspondence – Ashiesh Khandelwal - drashieshk@gamil.com

Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India

There was a transplant free survival in 16/24 (66.6%) of patients over a median follow-up of 38.5 months. Sepsis, diabetes and cytopenia are common however drugs could be restarted or modified in all patients.

Keywords CLD

228

Minimal hepatic encephalopathy in patients with hepatic venous outflow tract obstruction: Evaluation of pre-intervention status and factors predicting outcome

Kashmira Datta, Amrit Gopan, Abhijeet Karad, Aditya Kale, Akash Shukla

Correspondence – Akash Shukla - drakashshukla@yahoo.com

Department of Gastroenterology, Seth G S Medical college and KEM Hospital, Multistoried Building, 9th Floor, Acharya Donde Marg, Parel. Mumbai 400 012, India

Introduction Prevalence of hepatic encephalopathy (HE) in hepatic venous outflow tract obstruction (HVOTO) is lesser than other chronic liver diseases due to lower prevalence of advanced cirrhosis. Minimal HE (mHE) is unexplored in HVOTO.

Aims and Methods To study prevalence of mHE in HVOTO and its outcome following endovascular intervention. One hundred and twenty-seven newly diagnosed un-intervened HVOTO patients (18-65y) between July 2017 to January 2020 screened. Patients with MMSE score ≥24 subjected to a pencil-paper based psychometric hepatic encephalopathy test (PHET), comprising number connection test A, figure connection test-A, digit symbol test, serial dotting test and line tracing test. PHET scores expressed as z scores (-3 to +1) (pre-intervention, post intervention days 1, 7, 30, 90 and 12 mo). Comparisons done based on severity of disease (MELD ≥/<15) and presence or absence of baseline mHE pre-intervention.

Results Thirty patients (27.5 [22,32] y,17 [56.7%] males) were compliant to complete follow-up regimen and were included. Median (IQR) symptom duration was 4.5 (1, 24) mo, jaundice (24,80%) and ascites (11,36.7%). Fifteen (50%) had mHE at baseline. Age (p=0.93), MELD score (p=0.30), CTP (p=0.27), Na (p=0.25) and total bilirubin (p=0.44), were not significantly different across groups with (bmHE+) or without (bmHE-) baseline mHE. In bmHE- group (n=15), PHET assessment showed development of new onset mHE significantly higher in those with MELD ≥15 at 3 (p=0.039) and 12 (p=0.039) mo but not at 7day (p=0.53) and 30-day (p=0.22) post intervention. In bmHE+(n=15), and overall (n=30) there was no such significant difference. In bmHE- group, those with improvement/normalization of total serum bilirubin at 30 days show a significantly lower 30-day mHE (p=0.039) with significant correlation between the two parameters (p=0.04, r=0.53). In the overall population, age at intervention predicted 30-day mHE with cut-off of 27.5y (AUROC 0.74, Sn 85.7%, Sp 60.9%, p=0.05, fig 1) and those with severe disease (MELD ≥15) show a significantly poor response in bilirubin improvement (p=0.004).

Conclusion Age at intervention, baseline disease severity, baseline mHE and trend of liver functions at 30 days influence development or persistence of mHE in HVOTO.

Keywords Minimal hepatic encephalopathy, Hepatic venous outflow tract obstruction, Outcome

229

Engaging, educating, enabling, and empowering the clinicians towards liver diseases: A comprehensive training program

Aayushi Rastogi , Akanksha Bansal, Ankur Jindal, Vinod Arora

Correspondence – Aayushi Rastogi - rastogiaayushi6@gmail.com

Department of Clinical Epidemiology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India

Objectives Chronic liver diseases (CLDs) account for significant morbidity and mortality throughout the world. It is important to empower clinicians for better management of liver disease patients. A comprehensive program on liver diseases was conceptualized under ILBS-ECHO (Institute of Liver and Biliary Sciences - Extension for Community Healthcare Outcomes). The present study aims at assessing the advancement in knowledge of the clinicians related to liver diseases after attending a 6-months virtual training program.

Methods A 6-month training program titled ‘Liver and Infections’ was designed for physicians practising across India. A total of 69 questions distributed across eight modules were shared with the registered participants before the start of each module using an online link. An online link consisting of similar questions was shared at the end of the sessions to assess change in knowledge after the session. One mark was allotted for each correct response. At the end of the program, an online exit exam consisting of 50 marks was conducted among participants who had attended 80% of the program. The data was analyzed using IBM-SPSS version-22.

Results A total of 84 clinicians across 16 states attended the virtual training on liver diseases with a mean age of 40.8±11.90 years, and approximately 76% were males. The mean pre-knowledge score of the participants was found to be 42.71±9.1, whereas the post-knowledge score was 54.02±10.6 out of 69. The overall pre- and post-knowledge scores were statistically significant (<0.001), as seen in Table 1. Approximately, 73% of the clinicians scored above 60% in the exit exam, indicative of learning from the comprehensive training program.

Conclusion Similar comprehensive training programs on liver diseases should be encouraged in developing countries as they play an important role in strengthening the clinicians for better management of liver disease patients.

Keywords Chronic liver diseases, Liver and infections, Training program

230

A comparison of factors influencing occurrence of acute and chronic portal vein thrombosis in a cohort of 502 patients with decompensated cirrhosis

Shivabrata Dhal Mohapatra, Minu Kumar, Srijaya Sreesh

Correspondence – Srijaya Sreesh - drsrijaya.sreesh@gmail.com

Department of Gastroenterology, Govt Medical College, 15 D Cordial Prabha Marappalam Pattom, Palace P O, Trivandrum 695 004, India

Background and Aims Portal vein thrombosis (PVT) due to portal flow stasis, complex thrombophilic disorders and factors leading to endothelial dysfunction, is an increasingly recognized complication in patients with cirrhosis. We assessed various parameters along with the stiffness of liver and spleen to study the risk factors associated with non-malignant PVT in patients with decompensated chronic liver disease (DCLD). We prospectively enrolled 502 patients with DCLD (CHILD B/C). All patients underwent detailed clinical evaluation, baseline investigation and ultrasonography of abdomen.

Results Thirty-nine patients were excluded. Of the 463 patients included, 51 had PVT (11%). It was observed that non-malignant PVT group patients had smaller liver size (11.8;1.8 vs. 12.4;1.5, p=0.032), higher spleen size (14.9;2.3 vs. 13.5;2.2, p;l;0.01), higher portal vein diameter (PVD, 14.4; 3.2 vs. 12.2; 1.7, 0.01), lower portal vein velocity (PVV, 11.5; plusmn;3.6 vs. 16.7;3.6, p 0.01), higher liver stiffness (61.3; 21.7 vs. 55.2;17.1, p=0.02), higher splenic stiffness (50.3;15.1 vs. 36.7;7.5, p; 01) as compared to non-PVT group. On plotting ROC; PVV;12.5 cm/sec (AUROC 0.86, sensitivity 74%, specificity 88%, NPV 95.9%), PVD;13.7 cm (AUROC 0.75), liver stiffness; 66.5 kPa (AUROC 0.72), liver size;11.95 cm (AUROC 0.63) were significantly associated with the development of non-malignant PVT (p 0.01). On multiple logistic analysis, PVD;13.75 cm (B=1.21, OR:95% CI 3.36 (1.05-10.7), p=0.04), PVV;12.5 cm/sec (B= -1.06, OR:95% CI 0.35 (0.13-0.09), p=0.03) were significant risk factors for PVT development in DCLD. Age, CHILD status, MELD Na score, presence of sarcopenia, Number of prior EVL banding, liver stiffness and splenic stiffness were comparable between the 2 groups of acute and chronic PVT patients, but the differences did not reach statistical significance.

Keywords Portal vein thrombosis

231

Rare cause of multuple liver abscess in an immunocompetent individual

Minu Kumar , Srijaya Sreesh

Correspondence – Minu Kumar - minusk7@gmail.com

Department of Gastroenterology, Kerala University, 15 D Cordial Prabha Marappalampattom Palace P O, Trivandrum 695 004, India

Tuberculosis (TB) is caused by Mycobacterium tuberculosis and still remains a major public health problem in developing countries. Mycobacterium tuberculosis is an aerobic, acid fast, non-motile, non-capsulated and non-sporing organism. It shows propensity to grow in oxygen rich environment, so demonstrates a predeliction for the lungs [1]. Though pulmonary TB is the most frequent presentation, extrapulmonary diseases involving the gastrointestinal tract especially terminal ileum, lymph nodes, peritoneum etc are not infrequent. Hepatobiliary Tuberculosis is uncommon and accounts for less than 1% of all tuberculous infections.

Keywords Liver abscess by TB

232

Impact of minimal hepatic encephalopathy on the health-related quality of life among patients with cirrhosis

Gaurav Kapur, Srijaya Sreesh, Ann Mary George, Minu Sajeev Kumar, Akhil N V, Aditya Verma, Jacob Raja, Krishnadas Devadas, Manoj Yadav

Correspondence – Gaurav Kapur - drgauravkapur85@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Introduction Minimal hepatic encephalopathy (MHE) is the mildest form in the spectrum of Hepatic Encephalopathy (HE), seen in 30% to 84% of patients with cirrhosis, that adversely affects their day-to-day activities. Identifying the factors associated with the Health-Related Quality of Life (HRQoL) will help improve patient care, limit complications and guide future research. Our aim was to evaluate the HRQoL in patients with cirrhosis and MHE.

Methods Cross-sectional study was performed in outpatient cirrhotics without overt HE and hepatocellular carcinoma. Malayalam version of chronic liver disease questionnaire (CLDQ) was developed and used for measuring HRQoL. Factors affecting HRQoL such as Child- Turcott Pugh (CTP) score, model for end stage liver disease (MELD) score, minimal hepatic encephalopathy (MHE) and others were studied. MHE was evaluated using number connectivity tests NCT A and NCT B. Univariate and multivariate regression analysis was performed.

Results Two hundred and eleven patients were included in the study. The mean age was 52 years and 79.6% were males. Alcohol remained the major etiology accounting for 49.8% cases. MHE was present in 51.2% of subjects. Mean CLDQ global was 5.27;1.05 for the study subjects. 28.9% of the patients had poor HRQoL with low global CLDQ (and lt;5). 45% of the patients fared poorly on emotional component of CLDQ. Among 61 patients with poor HRQoL, 86.9% had MHE. Viral etiology, presence of MHE, high CTP, MELD scores and BMI were found significant in multivariate analysis for predicting HRQoL.

Conclusion In this study, viral etiology, the severity of liver disease, presence of MHE and high BMI were the factors found to determine HRQoL. Majority of the patients with poor HRQoL had MHE. Hence patients with cirrhosis should be evaluated for MHE and treated to improve the HRQoL.

Keywords Cirrhosis, Health related quality of life, Minimal hepatic encephalopathy

233

The effect of Kirathathikthakadi yogam on hepatitis B virus DNA load in patients with chronic hepatitis B without advanced fibrosis: Pre-post analysis

Akhila Kurup ¹ , Sreejaya Sreesh ²

Correspondence – Sreejaya Sreesh - drsreejaya.sreesh@gmail.com

¹Department of Dravyaguna Vigyanam, Government Ayurveda College, Pulimoodu, Thiruvananthapuram 695 007, India, and ²Department of Gastroenterology, Govt. Medical College, Thiruvananthapuram 695 011, India

Background and Aim Chronic hepatitis B (CHB) is a global health burden. Many patients with this lifelong illness approach Ayurveda physicians seeking remedy. Kirathathikthakadi-yogam (KTY) is a polyherbal formulation described in Punaravarthaka jwara chikitsa of Caraka Samhita. In this study, the effect of KTY in reducing HBV DNA load was evaluated in CHB patients attending OPD, Govt. Ayurveda College Hospital, Thiruvananthapuram and CHB patients attending for follow up in Govt. Medical College, Thiruvananthapuram.

Method Fifty-seven CHB patients were screened by history and routine blood examination, Fibro scan/shear wave elastography and HBV DNA level by quantitative RT PCR. Twenty-three patients with HBV DNA level >500 IU/mL if there is no evidence of advanced fibrosis or cirrhosis and ALT is normal; or DNA 500-20,000 IU/mL with persistently high ALT were selected and provided with KTY Tablet 1000 mg twice daily for 90 days. Nineteen patients of external control was on follow-up at Govt. Medical College, Thiruvananthapuram. HBV DNA level at 91st day of treatment group was compared using Paired t test. Pharmacognostical and phytochemical evaluation of ingredients of KTY and itself were done as per standard procedures of Ayurveda Pharmacopeia of India.

Result KTY arm showed significant reduction in HBV DNA load in between day 0 and day 91 (p<0.05). There was significant increase in HBV DNA in external control arm. There was 82.6% reduction in viral load in KTY group (p<0.004). New SOP for standardization of KTY Tablet was developed.

Conclusion The KTY was found effective in reducing HBV DNA load (p <0.05) in CHB patients. There was 82.6% reduction in viral load in KTY arm.

Keywords Ayurveda, Chronic hepatitis B, HBV DNA load. Kirathathikthakadi yogam, Punaravarthaka jwara

234

Metabolic co-morbidities are common in patients with chronic viral-related hepatocellular carcinoma

Priya Singh, Ajay Duseja

Correspondence – Ajay Duseja - ajayduseja@yahoo.co.in

Department of Hepatology, Nehru Hospital Extension Block, Room No. 30, Sector 12, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background and Aim Metabolic risk factors including obesity and type 2 diabetes mellitus are common risk factors for hepatocellular carcinoma (HCC). The aim of the present study was to compare the presence of metabolic risk factors in chronic viral hepatitis (hepatitis B virus [HBV] and hepatitis C virus [HCV]) related HCC and non-alcoholic fatty liver disease (NAFLD) related HCC.

Methodology Among 119 patients with HCC diagnosed from August 2021 to May 2022, 96 patients with either NAFLD-HCC (38 [39.5%]), HBV-HCC (23 [23.9%]) or HCV-HCC (35 [36.4%]) were included in this ongoing prospective study. Baseline clinical and laboratory parameters at the time of diagnosis of HCC were compared among three groups of patients.

Results Age of patients with NAFLD-HCC (62.4±10 years) was significantly higher than that in HBV-HCC (56.8±10.3 years, p=0.03) but similar to HCV-HCC (58.6±11.2 years, p=0.74. BMI was significantly higher in NASH HCC in comparison to CHC HCC and CHB HCC. Metabolic risk factors (T2DM, obesity, hypertension and dyslipidemia) were compared among three groups (Table).

Conclusion Metabolic co-morbidities of type 2 diabetes mellitus, hypertension, and dyslipidemia are as common in viral hepatitis-related HCC as in NASH HCC. However, patients with NASH-HCC have a higher BMI and are more likely to be obese.

Keywords HCC, Hypertension, obesity

235

Serum fibrinogen VS INR in predicting rebleeding and mortality in cirrhotic patients

Rishikesh Malokar , Shubham Jain, Sanjay Chandanani, Pravin Rathi

Correspondence – Rishikesh Malokar - malokarr@gmail.com

Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India

Introduction Patients with cirrhosis develop unique changes in hemodynamic and hemostatic pathways that may result in life-threatening bleeding and thrombosis. At present no single parameter can accurately predict future bleeding risk and prognosis.

Aim To study the role of fibrinogen level and INR in patients with cirrhosis of the liver with bleeding to predict future bleeding risk, hospitalization, and mortality.

Methods It is an interim analysis of a prospective observational study involving 54 cirrhosis patients who presented with bleeding. At presentation, common coagulation parameters (INR, fibrinogen levels) and a complete hemogram were obtained in all patients, and patients were followed up for 1year for rebleeding episodes, future hospitalization, and mortality. Correlation of low fibrinogen (<120 mg/dL) and high INR (>1.5) with the first bleeding episode, rebleeding, repeat admission, and mortality were obtained.

Results The median age of the study population (n= 54) was 44 years (range 19-76 years). The mean fibrinogen value was 159.69±40.3 mg/dL, and the mean INR was 1.42±0.36. Out of 54 patients, 11 patients had low fibrinogen (<120 mg/dL), and 19 patients had an INR of more than 1.5. In the low fibrinogen group (n=11), 6 patients (54.54%) had rebleeding, 6 patients (54.54%) needed repeated admission, and 5 (45%) patients died. In the high INR group (n=19), 8 patients (42.1%) had rebleeding, 7 patients (36.84%) needed repeated hospitalization, and 9 patients (47.36%) died. The difference between both groups regarding the number of rebleeding episodes (p=0.09), number of repeat hospitalization (p=0.11), and mortality (p=0.91) at 1 year was not statistically significant.

Conclusion Neither low fibrinogen nor raised INR can predict the bleeding and rebleeding episodes and future hospitalization and mortality in patients with cirrhosis.

Keywords Chronic liver disease, Fibrinogen, PTINR

236

Impact of past decompensation, with or without acute-on-chronic liver failure (ACLF), on severity and outcomes of current ACLF

Akash Gandotra , Ajay Duseja, Madhumita Premkumar, Arka De

Correspondence – Ajay Duseja - ajayduseja@yahoo.co.in

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction Evidence suggests that past decompensation may impact the prognosis of acute- on-chronic liver failure (ACLF). However, the effect of past decompensation in Asian Pacific Association for the Study of the Liver (APASL). ACLF has not been explored. In this study, we aim to assess the impact of previous decompensations on the severity and outcomes of current ACLF (APASL and CANONIC).

Methods All adult patients with ACLF satisfying either or both Asia Pacific Association of Study of Liver (APASL) and European Association for the Study of the Liver (EASL) Chronic Liver Failure Consortium (CLIF-C) (CANONIC) definitions were followed-up for 6-months after informed consent. Detailed history regarding past decompensations and past ACLF episodes was taken. Baseline ACLF severity scores were assessed using CTP and MELD-Na, APASL ACLF Research Consortium (AARC) and CLIF-C ACLF scores.

Results Out of 103 ACLF patients, 23 (22.33%) were APASL-ACLF and 40 (38.83%) were CANONIC-ACLF. 40 (38.83%) patients fulfilled both the criteria. Nineteen (18.44%) patients had past history of ACLF. Mean age was 44±10.6 years with male sex predominance (89.32%). Commonest acute precipitant was alcohol (36.89%) and most common underlying aetiology for chronic liver disease was also alcohol (79.61%). Baseline liver severity scores (CTP and MELD-Na) were 12 and 32. Within ACLF with PD, only 1 (2.3%) patient was APASL ACLF, 43 (97.7%) were CANONIC and 6 (13.6%) fulfilled both criteria. Similarly, in ACLF without PD, 20 (33.9%) were APASL, 3 (5%) were CANONIC and 29 (49.2%) fulfilled both criteria. Presence of past decompensation in ACLF patients didn’t affect overall mortality in ACLF patients (70.45%, ACLF with PD; 55.93%, ACLF without PD; p=0.199).

Conclusion Past decompensation with or without ACLF doesn't affect outcomes in current ACLF.

Keywords Acute on chronic liver failure

237

Prediction of hepatocellular carcinoma by REACH-B score in patients with chronic B virus infection

Yeshika Bhatia, Ajay Duseja

Correspondence – Ajay Duseja - ajayduseja@yahoo.co.in

Department of Hepatology, Nehru Hospital Extension, Room No 30, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background Risk prediction models are available to calculate the risk of hepatocellular carcinoma (HCC) development in patients with chronic HBV infection. Aim of the present study was to predict HCC development by using REACH-B score in patients with chronic hepatitis B (CHB) and HBV related cirrhosis.

Methods The study included 100 patients with CHB with or without liver cirrhosis (mean age 43.4 years±13.9, 82 [82%] males) managed in a tertiary care hospital in last two years (January 2020 to January 2022). The diagnosis of CHB (HBeAg positive and HBeAg negative) and cirrhosis was made on the standard criteria. Seventeen point risk score called REACH-B was used to calculate the HCC risk using variables of age, gender, serum ALT levels, HBeAg status and HBV DNA level.

Results Of 100 patients, 21 patients had CHB-HBeAg positive disease, 45 had CHB-HBeAg negative disease and 34 had HBV cirrhosis. Three-year and 10-year risk of HCC in CHB-HBeAg positive group was 0.1% and 64.4%. In the CHB-HBeAg negative group 3-year and 10-year risk of HCC was 0.1% and 84% and in HBV cirrhosis it was 0.3% and 84%. (p=<0.05).

Conclusion Based on the REACH-B score, patients with CHB HBeAg negative disease and HBV related cirrhosis have similar 3-year and 10-year HCC risk and both have a higher 10-year HCC risk in comparison to CHB HBeAg positive disease.

Keywords CHB, HCC, Patients

238

Treatment outcome of Saroglitazar in improving the non-alcoholic fatty liver fibrosis score in the diabetic and non-diabetic group of patients Diagnosed with non-alcoholic fatty liver disease

Nisar A ¹ , Shashipal Sharma ² , Mohammad H Bhat ³ , Irfan Ali ² , Showkat A Kadla ¹ , Praveen Shah Gupta ⁴

Correspondence – Nisar A - gastronisar69@gmail.com

Departments of ¹Gastroenterology, ²Medicine, ³Endocrinology, Superspeciality Hospital, and ⁴Pharmacology, Government Medical College, Bemina, Srinagar 190 010, India

Introduction Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease (CLD) worldwide. It is a serious illness which have severe and widespread consequences due to the lack of a definite treatment. Other than lifestyle changes advice and Vitamin E we are still looking for a drug which can improve the prognosis and clinical outcomes in this group of patients. We aimed to see the treatment outcome of Saroglitazar 4 mg OD in the patient with and without diabetes, diagnosed to have NAFLD.

Methods In this prospective observational study of 48 weeks, Saroglitazar 4 mg OD was evaluated for its safety and efficacy in NAFLD patients with and without diabetes mellitus (DM). The primary efficacy point was the improvement of NAFLD fibrosis score (NFS). Total 292 patients with written informed consent, meeting inclusion-exclusion criteria were enrolled, out of which only 257 individuals completed the study. Eligible patients were put on Saroglitazar 4 mg per day for 24 weeks and followed on OPD basis up to 48th week for primary efficacy point in addition to secondary parameters like body mass index (BMI), glycalated hemoglobin A (HbA1c), lipid levels and liver biochemistry (transaminases). Statistical analysis used- repeated measures ANOVA on Statistical Package for the Social Sciences (SPSS) Version 20.0 (SPSS Inc., Chicago, Illinois, USA).

Results After 24 weeks therapy with Saroglitazar, there was a significant improvement in the NFS by 56.05 % in the Diabetic Group and 51.63% in non - Diabetic group of patients, the results were well sustained till the end of 48th week of follow-up.

Conclusions Saroglitazar 4 mg OD is an efficacious pharmcotherapy in improving NFS, liver and lipid parameters of NAFLD patients with or without Diabetes.

Keywords NAFLD fibrosis score, Peroxisome proliferator activated receptors, Saroglitazar

239

Efficacy and safety of Saroglitazar 4 mg OD in reducing the disease parameters in the non-alcoholic steatohepatitis patients with moderate to advance liver fibrosis- A 53 weeks prospective study analysis

Jatinder Pal Singh , Jahnvi Dhar

Correspondence – Jatinder Pal Singh - drsainige@gmail.com

Department of Gastroenterology, Sohana Hospital, Mohali Multi Super Specialty Hospital, SH12A, Sector 77, Sahibzada Ajit Singh Nagar 140 308, India

Introduction Recent studies suggest that a large percentage of south Asian population having non-alcoholic fatty liver disease (NAFLD) are in the progressive non-alcoholic steatohepatitis (NASH) stage.

Methods This single center 52 weeks prospective study aimed at evaluating the role of Saroglitazar 4 mg OD dose in improving the treatment outcome of moderate to advance fibrotic NASH patients. Total 178 patients were enrolled between December 2020 to March 2022 out of which only 112 patients continued for 01-year follow up. The patient diagnosed on the basis of disease history, biochemical parameters and transient elastography (TE) with their liver stiffness measure (LSM) ≥ 7.5 kpa were selected and put on Saroglitazar 4 mg OD therapy for an year. The disease parameters were checked at the end of 06 and 12 months. The primary efficacy point was the improvement of LSM, APRI and FIB 4, in addition to secondary parameters like body mass index (BMI), lipid levels and liver biochemistry (transaminases). Statistical analysis- The data was analyzed using paired T-Test on Statistical Package for the Social Sciences (SPSS) Version 1.0.0.1406.

Results

Table 1- Changes in liver stiffness measure, APRI and FIB-4 from baseline

Conclusion Saroglitazar 4 mg OD is an efficacious therapy in regressing the moderate to severe fibrosis in NASH patients as observed on transient elastography and non-invasive Scoring tests- FIB4 and APRI, however histological data is warranted to confirm the changes.

Keywords Liver Fibrosis, NASH, Saroglitazar

240

Efficacy of saroglitazar in improving liver steatosis and liver stiffness on transient elastography in diabetic versus non-diabetic patient population-A 52 weeks retrospective study

Varun Mehta , Yogesh Gupta

Correspondence – Varun Mehta - yogeshgupta22@gmail.com

Department of Gastroenterology, Dayanand Medical College and Hospital Tagore Nagar, Civil Lines, Ludhiana 141 001, India

Background and Aims Non-alcoholic fatty liver disease (NAFLD) has become one of the most prominent forms of chronic liver disease worldwide progressing to end-stage liver disease requiring liver transplantation. We tried to evaluate the effect of Saroglitazar 4 mg in diabetic and non-diabetic cohorts in terms of reduction in liver steatosis (CAP) and liver stiffness measure (LSM) on Fibroscan.

Methods A total 60 documented NAFLD patients (mean age 47.5+11.01 yrs, male 56.7%, non-diabetic 80%) prescribed on Saroglitazar 4 mg OD were analyzed for improvement in baseline mean CAP (324.9+39.6) and LSM (6.9+3.1) at 24 and 52 week interval. The improvements in primary endpoints were measured in diabetic vs. non-diabetic cohorts, along-with the overall study population. The statistical analysis was done using paired sample T- test.

Results The study shows significant improvements in CAP and LSM parameters along with all other secondary parameters (AST, ALT, and TG) from baseline in both diabetic and non-diabetic NAFLD cohort. The LSM improved by 15.3% and 25.9% in diabetic cohort compared to 15.2% and 23.4% in non-diabetics at 24% and 52 week respectively. The improvement in steatosis (CAP) was 8.13% and 14.7% in diabetics compared to 6.3% and 14.7% in non-diabetics at 24 and 52 week time interval respectively.

Conclusions Saroglitazar 4mg OD significantly improved Liver Stiffness Measure, and steatosis in both the diabetic and non-diabetic population and seems to be equally effective in these two cohorts. More studies, including well-designed randomised trials will show further light on the effect of Saroglitazar 4mg in NAFLD with different underline co morbidities.

Keywords Diabetes, Fibroscan, Saroglitazar

241

Efficacy and safety of different pharmacological strategies (Saroglitazar, vitamin E, ursodeoxycholic acid, and Saroglitazar with vitamin E) in non-alcoholic fatty liver disease/non-alcoholic steatohepatitis population - A 24-week, real-world evidence from a tertiary care specialty center of Northern India

V K Dixit

Correspondence – V K Dixit - drvkdixitbhu@gmail.com

Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Background and Aims Non-alcoholic fatty liver disease (NAFLD) is an umbrella term and is the most common chronic liver disease worldwide. Its prevalence is estimated to be around 32.4%. Saroglitazar is the only approved drug for the treatment of NAFLD/NASH in India, although there is certain evidence-based therapy also being used that had shown effectiveness. We tried to evaluate the effectiveness of 4 different pharmacological strategies for the management of NAFLD/non-alcoholic steatohepatitis (NASH) in routine clinical practice.

Methods The NAFLD/NASH patients (n=884, male 70.8%, non-diabetic 87.5%, obese 76.13%) visited in outpatient Gastroenterology Department of Banaras Hindu University (BHU), Varanasi, and were prescribed Saroglitazar 4 mg OD (n=254), or Vitamin E 400 IU BD (n=248), or ursodeoxycholic acid (UDCA) 300 mg BD (n=131) or Saroglitazar 4 mg along with Vitamin E 400 IU (n=251), were assessed for changes in LFT and NFS score in 24 weeks. The data at baseline and 24 weeks were analyzed and statistical significance was established using paired sample T-test.

Results Compared to baseline, after 24 weeks the % changes in ALT were 47.7, 27.1, 34.7, and 46.7%, in AST was 39.2, 17.2, 27.7, and 35.6% and in NFS score was 33.5, 8.9 (ns), 7.24 (ns), 38.1% respectively in Saroglitazar, Vitamin E, UDCA, and Saroglitazar along-with Vitamin E group. The improvement in LFT profile was significant in all the groups but NFS Score improvement was statistically significant in Saroglitazar or Saroglitazar with Vitamin E group only.

Conclusions The study shows that Saroglitazar 4mg OD alone is an effective treatment option compared to Vitamin E or UDCA or a combination of Saroglitazar with Vitamin E. In the future, more studies including a well-designed controlled comparative clinical trial will be needed to throw more light on the comparative effectiveness of these agents.

Keywords NAFLD, NFS score, Saroglitazar, UDCA, VIT. E

242

Correlation of serum zinc levels with hepatic encephalopathy and its severity

Rahul Sangwan, Ritesh Kumar Gupta, Lokesh Sharma

Correspondence  - Rahul Sangwan - drrahulsangwan323@gmail.com

Department of General Medicine, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Road, Type III, Connaught Place, New Delhi 110 001, India

Chronic liver disease (CLD) is a major public health disease. One of the most dreaded complications of chronic liver disease is hepatic encephalopathy. Unless the underlying hepatic disease is treated successfully, HE has a high recurrence chance and is associated with poor survival and prognosis. Zinc plays an important role in CLD as it is involved in hepatic urea cycle functioning and zinc deficiency will eventually lead to hyperammonemia due to impaired urea cycle. The present study aimed to determine the distribution of serum zinc levels and the prevalence of zinc deficiency in CLD patients and its association with hepatic encephalopathy (HE) and its severity.

The cross-sectional observational study was conducted for a period of 1 year and 6 months on 105 patients of the 18-65 years age group, who presented with chronic liver disease irrespective of severity and underlying etiology. All patients were evaluated for presence of HE and its grade. Also, serum zinc was collected, and its value was compared with the occurrence and severity of HE.

HE occurred in patients with lower zinc levels. Mean serum zinc values in patients with HE were 35.1 µg/dL as compared to 65.7 µg/dL in those who didn't have this complication.  Zinc deficiency was more pronounced in patients with increasing severity of HE.  Mean S. zinc values were 65.7 µg/dL, 40.6 µg/dL, 34.2 µg/dL, 30.3 µg/dL, 24.7 µg/dL in HE grade 0,1,2,3,4 respectively.

Zinc deficiency is commonly encountered in chronic liver disease. Zinc deficiency is aggravated with the severity of chronic liver disease. Zinc is required in the urea cycle and is a cofactor of ornithine transcarbamylase (OTC). Hence, zinc shall be measured routinely in patients of chronic liver disease as it may be a precipitating factor for hepatic encephalopathy.

Keywords Chronic liver disease, Hepatic encephalopathy, Zinc

Biliary Tract

243

Can esophagogastroduodenoscopy replace endoscopic retrograde cholangiopancreatography for stent removal?

Isha Bansal, Amol Dahale, Debabrata Banerjee

Correspondence - Amol Dahale - amolsd1986@gmail.com

Department of Medical Gastroenterology, Dr D Y Patil Hospital and Research Centre, Sant Tuka Ram Nagar, Pimpri, Pune 411 011, India

Endoscopic retrograde cholangiopancreatography (ERCP) is a modern and universally established modality in the evaluation and treatment of suspected biliary and pancreatic disease [1]. Follow-up ERCP procedures are routinely performed to remove biliary stents. Alternatively, the stents can be removed via upper endoscopy which appear to be more feasible, cost effective and are technically less challenging. There is no consensus or the guidelines on protocol to be followed for stent removal in post common bile ductstone clearance and after cholecystectomy.

We have collected data on stent removal approach by gastroenterologist in post-ERCP, post cholecystectomy patient. We formed a questionnaire of 11 questions and studied the responses among the gastroenterologists as to what they do in their institute or private practice. We have received 133 responses for the same. 66% responders were from private setup while rest are from government setup. 56.4% doctors responded are from academic institute. Maximum responded doctors (67%) are in practice for 5-10 years.

According to our survey 45% of doctors remove the stent via upper GI endoscopy and remaining 45% uses side view endoscopy +/- check cholangiogram +/- balloon sweep for stent removal. There is highly variable protocol followed by experts in gastroenterology among all over India. As per one previous abstract, follow-up ERCP was required in 90% of patient with choledocholithiasis, contrary to this what our survey showed.

Keywords CBD stent, ERCP, Upper GI endoscopy

244

Study of clinical profile of benign biliary strictures in a tertiary care centre: An observational study

Motij Dalai , Meghraj Ingle, Vikas Pandey, Shamshersingh Chauhan, Saiprasad Lad, Gaurav Singh

Correspondence – Meghraj Ingle - motij31@gmail.com

Department of Gastroenterology, College Building, 1st Floor, Room No. 2, LTMMC and MGH, Sion Hospital, Mumbai 400 022, India

Background Benign biliary strictures (BBSs) may from chronic inflammatory pancreaticobiliary pathologies, postoperative bile-duct injury, or at biliary anastomoses following liver transplantation. Endoscopic therapy, including stricture dilatation and stenting, is effective in most cases and the first-line treatment of BBS. We aim to study the different etiologies of benign biliary strictures and their clinical manifestations and observe their clinical progression over 1 year

Methods It’s an observational study in a tertiary care centre. We took 62 diagnosed patients of BBS and followed them over a period of 1 year. All baseline demographic details, routine blood workup were done tumor marker like CA 19.9 was also obtained and IgG-4 levels was done based on degree of suspicion. Transabdominal USG, MRCP and EUS (endoscopic ultrasound) was done to characterize the nature of lesion and to assess need for drainage procedure, ERCP (endoscopic retrograde cholangiopancreatography) was be performed and brush cytology was collected. All the patients were followed up prospectively for 1 year and their clinical profile was studied.

Results Common etiology in our study were post cholecystectomy and chronic pancreatitis related 25% (16), 16% (10) respectively while in majority cause could not be ascentained i.e. indeterminate 51% (32). 20% (12) Presented in cholangitis and all underwent ERCP; mean duration of stent use was 8.4 months and no. Stents used was 2.67 of which 33% (20) were on stent free trial by end of 1 year.

Conclusion This was a pragmatic approach to diagnosis and treatment of benign biliary stricture in a high-volume centre.

Keywords Benign biliary stricture, Clinical profile, Mangement

245

Opioid biliopathy with hepatitis B reactivation masquerading as perampullary carcinoma

Chhagan Lal Birda, Kaushal Singh Rathore, Subhash Soni, Ashish Agarwal

Correspondence - Ashish Agarwal - drashu123@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India

Introduction Opioid addiction is common in western Rajasthan [1, 2]. Opioid causes sphincter of Oddi dysfunction and results in double-duct sign [3, 4]. We hereby report a case of opioid biliopathy who also had hepatitis B reactivation mimicking as periampullary carcinoma.

Case Report A seventy-years-old gentleman, without previous comorbidities presented outside with history of jaundice for two-weeks duration. On evaluation he had abnormal liver function tests (LFT) and ultrasound abdomen revealed dilated common bile duct (CBD). Contrast enhanced computed tomography scan of abdomen and magnetic resonance cholangiopancreatography both revealed double-duct sign without any obstructing calculus/mass/bile duct thickening. A possibility of periampullary carcinoma was kept and endoscopic retrograde cholangiopancreatography (ERCP) was attempted but failed. He was referred to AIIMS, Jodhpur for further treatment.

At AIIMS Jodhpur, on reviewing history he complained of fever, anorexia and myalgia prior to onset of jaundice. Personal history revealed opioid addiction for last forty-years. His HBsAg was positive and HBV DNA titre was 1.2 × 106 IU/mL and coagulation profile was deranged. He was diagnosed as acute liver injury due to hepatitis B reactivation and started on Tenofovir. His side-viewing endoscopy and CA 19-9 both were normal. An endoscopic ultrasound was done which revealed dilated CBD (10.3 mm) and MPD (3.8 mm in the head) without any mass/filling defect All the relevant investigations are summarized in Table 1.

A diagnosis of opioid induced biliopathy with acute liver injury due to hepatitis B reactivation was made. Patient improved symptomatically with treatment and follow-up after four-weeks showed complete normalisation of LFT.

Conclusion Index case highlights concomitant hepatitis B and opioid biliopathy mimicking as periampullary carcinoma. Careful history and exclusion of malignancy (absence of mass on imaging and normal tumor markers) were key in making the diagnosis and avoided unnecessary endoscopic and surgical intervention.

Keywords Hepatitis B reactivation, Opioid biliopathy, Periampullary carcinoma

246

Long-term outcomes of endoscopic transpapillary gallbladder stenting in extrahepatic portal venous obstruction patients with calculous cholecystitis

Surinder Rana, Pankaj Kumar, Amit Yadav, Ravi Sharma, Rajesh Gupta^*

Correspondence - Surinder Rana - drsurinderrana@gmail.com

Departments of Gastroenterology, and ^*Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background Endoscopic transpapillary gallbladder stenting (ETGBS) has been advocated to prevent recurrence of acute cholecystitis in high-risk surgical patients. However, there is paucity of literature regarding the safety, efficacy, and long-term outcomes of ETGBS. Also, safety and efficacy of ETGBS has not been evaluated in patients with extrahepatic portal venous obstruction (EHPVO) where presence of venous collaterals may increase the risk of bleeding and cholangitis.

Methods A retrospective analysis of data base of patients with EHPVO and high surgical risk because of presence of extensive intraabdominal venous collaterals with acute calculous cholecystitis who were treated with long-term ETGBS between 2010 and 2022 was done. A single 7 Fr 5 cm double pigtail stent was used for gallbladder drainage in all patients. Patients were regularly followed up every 3-6 months and underwent routine laboratory investigations and abdominal X-ray. Recurrence of acute cholecystitis was treated with stent exchange along with antibiotics.

Results Seventeen patients (M13; age range: 19-48 years) with EHPVO and acute calculous cholecystitis were treated with attempted long term ETGBS. Ten patients had eradicated esophageal varices and two patients had gastric varices obliterated with cyanoacrylate glue. Transpapillary gallbladder stent could be successfully placed in 13/17 (76.4%) patients. Endoscopic sphincterotomy was done in all the patients with successful gallbladder stenting. Post ERCP pancreatitis developed in one patient. Thirteen patients with transpapillary gallbladder stenting were followed up for 2-144 months. Acute cholecystitis recurred in one patient at 118 months after the initial stenting and could be successfully managed with stent exchange and antibiotics. Asymptomatic external stent migration occurred in one patient 9 months after the initial stenting and was managed with stent replacement.

Conclusion Long-term ETGBS with double-pigtail plastic stent seems to be a safe and effective management strategy for patients with EHPVO and acute calculous cholecystitis.

Keywords Extrahepatic portal venous obstruction, Gallbladder, Stent, Varices

247

A case report of secondary bacterial peritonitis and pelvic abscess in a patient of recurrent pyogenic cholangitis

Tony Pious , Muma Devi, B Ramesh Kumar, L Sahitya Reddy

Correspondence - Tony Pious - tony.pious87@gmail.com

Department of Gastroenterology, Osmania Medical College, 5-1-876, Turrebaz Khan Road, Troop Bazaar, Koti, Hyderabad 500 095, India

Introduction Recurrent pyogenic cholangitis is a disease characterized by intrabiliary pigment stones, strictures in the biliary tree and recurrent episodes of cholangitis. Recurrent pyogenic cholangitis is also known as oriental cholangiohepatitis, hepatolithiasis, Hong Kong disease and biliary obstruction syndrome of the Chinese. It was first described by Digby in 1930.

This entity is almost exclusively seen in people living in Southeast Asia. The pathogenesis of this condition is incompletely understood even though bacterial and worm infections of the biliary tract are suggested. Patients usually present with recurrent bouts of cholangitis and its complications including multiorgan failure. Biliary strictures and recurrent cholangitis ultimately result in secondary sclerosing cholangitis, secondary biliary cirrhosis, portal hypertension and cholangiocarcinoma.

Management needs a multidisciplinary approach combining antibiotics, endoscopic therapy and surgical intervention.

Background A 44-year-old male presented with progressive abdominal distension and abdominal pain for 7 days, high grade fever with chills for 2 days. Patient had multiple similar episodes in the past. Abdominal examination revealed diffuse tenderness and shifting dullness.

Contrast-enhanced computed tomography (CECT) scan of abdomen showed multiple calculi in right and left hepatic ducts extending into second order biliary radicles. Portal cavernoma replacing portal vein at porta hepatis. 2 CBD stents noted in right and left ductal system. Moderate loculated fluid in the anterior aspect of the abdominal cavity and extending into the pelvis with thick enhancing walls.

Results Patient was treated with Meropenem, Amikacin, endoscopic retrograde cholangiopancreatography (ERCP) with CBD stenting and percutaneous drainage of pelvic abscess under ultrasound guidance. Patient was completely relieved of symptoms with treatment and doing well on follow-up.

Conclusion Recurrent pyogenic cholangitis is an uncommon entity requiring regular follow-up with timely biliary drainage, antibiotic treatment of cholangitis and appropriate surgical interventions including liver transplantation.

Keywords Biliary cirrhosis, Endoscopic therapy, Recurrent pyogenic cholangitis

248

To study the safety and efficacy of intraluminal brachytherapy via percutaneous transhepatic biliary drainage and subsequent endoluminal stenting as palliative treatment for unresectable malignant biliary obstruction

Shikha Sood , John V Alexander, Manish Gupta, Ashish Chauhan

Correspondence - Shikha Sood - vjohn989@gmail.com

Department of Radiodiagnosis, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India

Background Percutaneous, endoscopic or surgical biliary drainage forms the mainstay treatment for unresectable cases of malignant biliary obstruction (MBO) with endoluminal stenting providing a better quality of life. Intraluminal therapies like brachytherapy, photodynamic therapy and radiofrequency ablation can locally destroy the tumour and thus increase the catheter/stent patency.

Methods We prospectively analyzed the safety and efficacy of intraluminal brachytherapy (ILBT) with iridium-192 and its correlation with survival and stent patency periods. We enrolled 66 patients who underwent percutaneous transhepatic biliary drainage (PTBD) for unresectable causes of MBO from January 2021 to March 2022 who were unfit for any alternate treatment modalities including surgery, chemotherapy, or radiotherapy. Eleven consenting patients underwent PTBD with internalisation followed by subsequent ILBT once they met our inclusion criteria (ECOG status <4 and total bilirubin fall more than 50% of preprocedural bilirubin level). ILBT was given in two sessions (800 cGy each session– one week apart) with iridium-192 prescribed at 1.5 cm from the central axis of the catheter, via a percutaneous biliary catheter. 2nd session was followed up by endoluminal stenting in the same sitting. Data included biliary stent/catheter patency period (days), survival duration (days), the decline in mean bilirubin level (mg %) and response to treatment. Data were analyzed using Kaplan-Meir tests and multiple comparison tests. Alpha was set at 0.05.

Results The total bilirubin levels showed a median fall of 7.3 (4.75-11.875) mg% after PTBD. The median follow-up period (observation time for those event-free) of the ILBT group was 273.5 (172-430) days. The median survival period and stent/catheter patency period were 172 (84.5-273.5) days and 172 (83-273.5) days for the ILBT group. There was significant symptomatic relief. No major treatment-related complications were seen in any of the patients.

Conclusion ILBT with stenting is a safe and feasible option for improving stent patency and survival with minimal complications

Keywords Intraluminal brachytherapy (ILBT), MBO, Percutaneous transhepatic biliary drainage (PTBD)

249

Common bile duct calculi-break and then stent

Yeruva Deepthi Reddy , Avinash Balekuduru, Narendra Mandalapu

Correspondence - Avinash Balekuduru, - deepuy93@gmail.com

Department of Gastroenterology, M S Ramaiah Medical College, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India

Introduction Extraction of large common bile duct (CBD) calculus has challenged the therapeutic endoscopist. Extracorporeal shockwave lithotripsy (ESWL) is an excellent option for large CBD calculi followed by endoscopic retrograde cholangiopancreatography (ERCP) and CBD clearance. Here we present 2 successful cases of ESWL to large CBD stones followed by ERCP in our center.

Case Reports A 63-year-old male known case of status post ERCP and CBD stenting for choledocholithiasis, status post laproscopic cholecystectomy followed by CBD stent removal 1 year back presented with jaundice, fever and abdominal pain. On examination patient is icteric and investigations showed leucocytosis and obstructive jaundice. Magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis, stone size of 2 cms and CBD dilated to 15 mm with distal CBD stricture. Patient underwent ESWL and there is fragmentation of calculi. Post ESWL patient is taken up for ERCP, over the guide wire balloon sweep done, retrieved multiple pigmented calculi and saline flush given till clear. Later 10fr x10 cms, 7 frx10 cms Amsterdam stents was placed in CBD. Post procedure patient is stable.

A 55-year-old male known case of status post ERCP and CBD stenting in 2019 for choledocholithiasis, lost the follow-up and now presented with jaundice and abdominal pain. On examination patient is icteric and investigations showed leukocytosis and obstructive jaundice. MRCP done showed previously placed CBD stent in situ with CBD calculus of 1.8 cms just proximal to stent. patient underwent ESWL, followed by which patient is taken up for ERCP, old CBD stent removed, and clearance done. Later 10 fr x10 cms Amsterdam stent is placed in CBD. Post procedure patient is stable.

Conclusion In view of high efficiency, non-invasive nature and low complication rates, ESWL can be considered for selected patients with large CBD calculi.

Keywords Common bile duct, Endoscopic retrograde cholangiopancreatography, Extracorporeal shockwave lithotripsy

250

The plastic bridge

Shashank Devarasetty, Avinash Balekuduru

Correspondence – Avinash Balekuduru - avinashbalekuduru@gmail.com

Department of Medical Gastroenterology, M S Ramaiah Medical College, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India

Introduction Endoscopic ultrasound -guided biliary drainage (EUS-BD) has emerged as an alternative to percutaneous transhepatic biliary drainage (PTBD) in unsuccessful endoscopic retrograde cholangiopancreatography (ERCP), with a high clinical success rate and low risk of complications and morbidity. We present a case of malignant distal biliary obstruction successfully managed with EUS-guided choledochoduodenostomy (EUS - CDS).

Case Report A 62-year-old male known case of diabetes mellitus, now presented with abdominal pain and jaundice for a month and weight loss of 10 kgs in last 3 months, He had iron deficiency anemia with obstructive pattern liver function test. Ultrasonogram showed features of Intra and extrahepatic bile duct dilation. Endoscopy showed ulceroproliferative friable growth noted in the periampullary region and biopsy suggestive of moderately differentiated adenocarcinoma. Contrast-enhanced computed tomography (CECT) abdomen suggestive of ampullary stricture with biliary system dilation with no distant metastasis. Patient planned for Whipple surgery in view of cirrhotic liver and extensive collaterals on laparotomy procedure was abandoned. In view of obstructive jaundice patient was advised EUS guided choledochoduodenostomy. In which common bile duct (CBD) punctured using 22G needle, 0.021 guidewire passed till mid CBD, deep cannulation could not be achieved. Over the guidewire needle knife sphincterotomy done, sphincterotome exchanged over the guidewire and as deep CBD cannulation not achieved a 7Fr X 7 cms double pigtail stent (DPT) stent placed as bridge for placing metallic stent. Patient jaundice resolved and was started on chemotherapy (Gemcitabine), 8 weeks post procedure, Old DPT stent removed and later a 10 mm x 6 cms partially covered metallic stent placed in CBD and free bile flow noted.

Conclusion EUS-guided choledochoduodenostomy with a plastic stent has a high potential as a bridge to mettalic stent in cases of failed deep CBD cannulation.

Keywords Choledochoduodenostomy, Double pigtail stent, Endoscopic retrograde cholangiopancreatography, Endoscopic ultrasoun

251

Intrahepatic cholestasis of pregnancy and impaired health-related quality of life in pregnant women

Jasvinder Nain, Madhumita Premkumar, Anchal Sandhu, Shikha Guleria, Vanita Suri, Vanita Jain, Neelam Aggarwal, Ajay Duseja, Sunil Taneja, Rashmi Bagga, Surender Sehrawat, Vishesh Kumar

Correspondence – Madhumita Premkumar - drmadhumitap@gmail.com

Department of Hepatology, Sector 12, Kairon Block, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background Intrahepatic cholestasis of pregnancy (ICP) is associated with deranged liver function tests, elevated bile acids and pruritus, which affects the daily activities and emotional health of pregnant women. Utilizing the SF36, we evaluated the impact of ICP on health-related quality of life (HRQOL) of women with ICP compared with healthy pregnant women.

Methodology We screened consecutive pregnant women referred to the Liver Clinic/Antenatal Clinic with deranged liver function tests for ICP to estimate the prevalence in our population. The SF36 questionnaire includes social, emotional, general health and physical function of pregnant women with ICP and was compared with healthy controls.

Results A screening of 3900 pregnant women was done who attended the Liver Clinic /Antenatal Clinic at Postgraduate Institute of Medical Education and Research, Chandigarh. Prevalence of ICP was noted as 1.15%. The mean age of patients with ICP (n= 45) was 28.2 ±4.4 years with 11.1% having twin, and 8.8% having modified conception. Among the cases DM 17.7, preeclampsia 8.8, thyroid 11.1% of cases were reported. Mean HRQOL score was worse in ICP (45.8±5.8) vs. controls (64.9±3.9; (p<0.001) Physical function score (52.5 vs. 82.9), role limitation noted due to physical mean score (36.7 vs. 49.0), energy score (46.6 vs. 59.0), emotional well-being (50.4 vs. 59.0), social function (47.8 vs. 62.5), general health (48.0 vs. 62.5) were noted indicating worse functioning in all domains in women with ICP as compared with controls.

Conclusion Women with ICP have poor HRQOL as compared with healthy controls, which needs to be monitored and managed appropriately in addition to pharmacotherapy.

Keywords HRQOL, ICP, Pregnant

252

Predictors of effective drainage during biliary stenting of hilar strictures with liver volume assessment

Rishikesh Malokar , Prasanta Debnath, Shubham Jain, Sanjay Chandanani, Pravin Rathi

Correspondence - Rishikesh Malokar - malokarr@gmail.com

Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India

Introduction Hilar strictures can be both benign and malignant. The optimal strategies for drainage of hilar strictures are still controversial, mainly regarding the extent of drainage required and unilateral or bilateral stenting. The aim of this study was to identify predictors of successful biliary drainage mainly by liver volumetry.

Methods Prospective observational study was conducted. Total 14 patients with hilar strictures of Bismuth type II, III, or IV were studied who had either endoscopic or percutaneous biliary drainage. CT volumetry of 3 main hepatic sectors (left, right anterior, and right posterior) was calculated. The liver volume drained was estimated and classified into 2 classes: less than 50% (Group A) and more than 50% (Group B) of the total volume.

Main Outcome Measurements: Primary outcome was effective drainage which was defined as a more than 50% fall in bilirubin at day28 post-intervention. Secondary outcomes studied include complications, reintervention, and survival and mortality rates.

Results Mean age of study population was 55 years with 78.65% females. The commonest symptom other than jaundice was weight loss (85%). Most common type of block was type 2 (57.1%) followed by type 4 (35.7%) with commonest etiology being cholangiocarcinoma (57.1%), Ca gallbladder (35.7%). Nine patients (64.3%) had more than 50% drainage (Group A) and 5 patients (35.7%) (Group B) had lesser than 50%. Mean total bilirubin in Group A on day 0 was 16.43, Group B was 19.4, day 28 was 0.77 and 1.125 respectively. The difference in mean total bilirubin on day 28 was not statistically significant (p value 0.46). Group B patients had more complications and lesser survival.

Conclusion Draining more than 50% of the liver volume is not required for 50% fall in bilirubin but had better survival and lesser complications. Type 2 Hilar block is most common type and has best prognosis. A pre-ERCP assessment of hepatic volume distribution on cross-sectional imaging may optimize endoscopic procedures.

Keywords Biliary drainage, Hilar block, Liver volumetry

253

Spectrum of IgG4-related hepato-pancreato-biliary diseases- an experience from tertiary care center in Western India

Aditya Kale , Michael Kuruthukulangara

Correspondence - Michael Kuruthukulangara - michaelkr30@gmail.com

Department of Medical Gastroenterology, Seth G S Medical College and K E M Hospital, Ward 32A, 9th Floor, New Building, Parel, Mumbai 400 012, India

Introduction IgG4-related disease is systemic immune mediated sclerosing disease characterized by infiltration of organs with IgG4 positive plasma cells and elevated serum IgG4 levels.

Methods Medical records retrospectively reviewed from 2018-2021 to identify 13 patients with IgG4-related disease affecting liver, biliary system, and pancreas. Demography, clinical presentation, radiological, pathological investigations, therapy, and response were noted.

Results Median age was 55 years (interquartile range [IQR]=46-66 years). Nine male patients. Pancreatitis, biliary strictures, gallbladder thickening, and hepatic mass were presentation in 5, 4, 2 and 2 respectively. One patient had multisystem involvement affecting pancreas, lymph nodes and nasal polyp. Out of 8 patients with hepatobiliary disease 3 had obstructive jaundice, 5 abdominal pain, 2 abdominal lump. Computed tomography (CT) showed bile duct thickening in 4 cases, liver masses mimicking cholangiocarcinoma-2, gallbladder thickening mimicking malignancy-2, intrahepatic biliary dilatation-3, atrophy-hypertrophy complex-2, abdominal non-necrotic lymphadenopathy-2. Magnetic resonance cholangiopancreatography (MRCP) showed type II hilar stricture in 3 and type IV in 1. Three had obstructive jaundice, one each had recurrent pancreatitis and chronic pancreatitis respectively. CT showed diffuse involvement in 2 cases and 3 had pancreatic head mass. One had pancreatic duct stricture. Six cases required biliary drainage. All had elevated IgG4 levels. Histology showed lymphoplasmacytic infiltration with IgG4 positive cells in all, obliterative phlebitis (8,61.53%), storiform fibrosis (9,6923%). Six underwent biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP) and single (2) and multiple (4) plastic stents. Six patients (2-pancreatic mass, 2-liver lesions, 2 biliary strictures) underwent surgery with presumptive diagnosis of cancer. Others (7 patients) received steroids followed by azathioprine. At six months, patients showed response to therapy in the form of reduction in size of mass. Strictures were persistent despite therapy and required elective stent exchanges.

Conclusion IgG4-related diseases have varied clinical manifestations and mimic malignancy clinic-radiologically. IgG4 levels and histology differentiate from malignancy. It responds to steroids and/or immunosuppressors.

Keywords IgG4 related disease, Immunosuppression, Malignancy, Steroids

254

Bacteriological profile in patients with biliary obstruction in a tertiary care center

Neelakanth Parappanavar, P Shravan Kumar

Correspondence - Neelakanth Parappanavar - neelakanth26@gmail.com

Department of Medical Gastroenterology, Gandhi Medical College, Musheerabad, Padmarao Nagar, Secunderabad 500 003, India

Introduction The bacterobilia is common in patients presenting with biliary obstruction. Acute cholangitis carries mortality rate as high as 30% [1]. Choledocholithiasis is most common cause followed by neoplasm and benign biliary strictures for obstruction [2]. Because of widespread use of antibiotics over years lead to change in sensitivity pattern of organisms that requires change in empiric antibiotic usage [3].

Methods Study was conducted in Department of Gastroenterology, Gandhi Medical College, Secunderabad. We studied 45 patients with biliary obstruction who have undergone endoscopic retrograde cholangiopancreatography (ERCP). Study population included 27 females and 18 males. Thirty-three cases were of benign causes and 12 were malignant. After biliary cannulation bile was aspirated and sent for microbiological analysis.

Results Majority of patients were in age group of 40-65 yrs. Bile cultures were positive in 27 patients. 20 of them had benign etiology, gallstone being most common and 7 had malignant cause. Organisms grown are mainly gram negative, most common being E. coli and Klebsiella followed by pseudomonas species. Response to cephalosporins were good, resistance to fluroquinolones was observed in few patients. Higher grades of cholangitis seen in patients with pseudomonas bacterobilia and multidrug resistant bacteria.

Conclusions Study confirms the significance of obtaining routine bile sample during ERCP in obstructed biliary system to predict and prevent dreaded complications of cholangitis.

Keywords Bacterobilia, Biliary obstruction, Cholangitis, ERCP

255

Long-term patency rates of transmural and transpapillary endoscopic ultrasound guided biliary drainage – Time to choose transmural over transpapillary?

Mangesh Borkar, Harsh Bapaye^*, Jaseem Ansari, Ajay B R, Sanjana Bhagwat, Ashish Gandhi, Rajendra Pujari, Harshal Gadhikar, Amol Bapaye

Correspondence – Amol Bapaye - amolbapaye@gmail.com

Department of Gastroenterology, Deenanath Mangeshkar Hospital and Research Centre, Deenanath Mangeshkar Hospital Road, Erandwane, Pune 411 004, India, and *Department of Medicine, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Medicine, Jai Prakash Narayan Road, Railway Station Road, Pune 411 001, India

Introduction and Aim Endoscopic ultrasound guided biliary drainage (EUS-BD) is accepted treatment modality after failed endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant biliary obstruction (MBO). EUS–BD can be performed by transpapillary (TP) (antegrade [AG], rendezvous [RA]) or transmural (TM) (hepatogastrostomy [HG]), choledochoduodenostomy (CDS), choledochoantrostomy (CA) approach. This study compares long-term success rates of EUS-BD by transmural or transpapillary approach.

Methods Retrospective analysis of prospectively maintained database of patients undergoing EUS-BD for MBO and failed ERCP. Study duration–11 years (2011–2022). Patients underwent EUS BD by TP or TM approach using self-expandable metal stents (SEMS). Patients were followed up until stent occlusion or death, whichever was earlier. Stent patency, adverse events, reintervention rates and survival during follow-up were compared. P value<0.05 was considered significant. After initial clinical follow-up, later follow-up was taken telephonically.

Results Total n=163; TM–119 (73%), TP–44 (27%). Mean age=65.18 (±13.48) years, 92 (56.4%) were male. Follow-up–median 85 days (32-240) for cohort, TM–84 (35–267) days, TP–86 (24.75–171.25) days; (p=0.26). Lost to follow-up–10 (6.1%) for cohort, TM-8 (6.7%), TP-2 (4.5%); (p=1.0). Technical success of EUS-BD achieved-161/163 (98.8%) for cohort, TM-118 (99.2%), TP-43 (97.7%); (p=0.468). Clinical success was seen significantly more in TM group [TM–(101/119), 85.6%, TP–(31/44),72.1%, p=0.049]. Overall stent related adverse events were significantly more in TP group (TP–17/44, 38.6%, TM–17/119, 14.3%, p <0.001). Stent occlusion was significantly more frequent in TP than TM group [TM–6/119, (5%), TP–16/44, (36.4%); p<0.001]. Stent migration was more frequent in TM group but was not statistically significant (TM-7/119, [5.9%], TP-1/44, [2.3%]; p=0.684). Median stent patency after TM=68.5 days (32.75-238.5) and TP=54 days (18.5-134) (p=0.126). Re-intervention rates were more in TP group (TP-10/44, [22.7%], TM-6/119, [5.0%], p=0.002). Kaplan-Meier survival graph revealed superior survival for TM group (mean survival TM-221.09 days, TP-132.42 days, p=0.033).

Conclusions For patients undergoing EUS-BD for MBO, using either transmural or transpapillary approach stent occlusion and reintervention rates were significantly low and survival was significantly higher in transmural group as compared to transpapillary group. Further randomized studies are recommended to confirm these findings.

Keywords Stent patency, Transmural, Transpapillary

256

Jaundice with double duct sign: Not always periampullary malignancy

Chhagan Lal Birda , Kaushal Singh Rathore, Subhash Soni, Ashish Agarwal

Correspondence – Ashish Agarwal - drashu123@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India

Introduction Jaundice with double duct sign is usually raise suspicion for periampullary malignancy. We report a case of opioid biliopathy with hepatitis B reactivation mimicking as periampullary malignancy.

Case Report A 70-year-old gentleman, without previous comorbidities presented outside with history of jaundice associated with fatigue and pruritus. On evaluation he had jaundice (total bilirubin/direct bilirubin–15/10.4 mg/dL), SGOT/SGPT/ALP–885/956/332. USG abdomen revealed dilated common bile duct (CBD). He underwent contrast enhanced computerised tomography (CECT) scan of abdomen and magnetic resonance cholangiopancreatography (MRCP) both revealed double duct sign without any obstructing calculus/mass/bile duct thickening. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted but CBD cannulation could not be achieved and was referred to All India Institute of Medical Sciences (AIIMS), Jodhpur for further treatment.

History was reviewed, he was smoker and opioid addict for last 40 years and he gave history of fever, anorexia, and myalgia prior to onset of jaundice. His HBsAg was positive and hepatitis B virus DNA titre was 1.2 × 106 copies and there was no evidence of cirrhosis. He was started on Tenofovir. His outside imaging was reviewed and reported same as dilated CBD and main pancreatic duct (MPD) without any mass lesion/calculus. An endoscopic ultrasound (EUS) was done which revealed dilated CBD (9.5 mm) and MPD (4 mm in head of the pancreas) without any mass/filling defect and CA 19-9 was normal. A diagnosis of opioid induced biliopathy with acute liver injury due to hepatitis B reactivation was made. Patient improved symptomatically and discharged. Follow-up after 4 weeks showed complete normalisation of liver biochemical tests.

Conclusion Index case highlights concomitant hepatitis B and opioid biliopathy mimicking as periampullary carcinoma. Careful history and exclusion of malignancy (absence of mass and normal tumor markers) was key in making the diagnosis and avoided unnecessary endoscopic and surgical intervention.

Keywords Opioid biliopathy double duct sign periampullary malignancy

257

A rare case of placing a metal stent in stent and successful dilatation of malignant biliary stricture and a review of literature on biliary self-expanding metal stents

Prithvipriyadarshini Shivalingaiah

Correspondence – Prithvipriyadarshini Shivalingaiah - drprithvipriya@gmail.com

Department of Clemenceau Medical Center, Healthcare city Dubai, United Arab Emirates

For patients presenting with biliary obstruction in an unresectable pancreatic malignancy, endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement is the treatment of choice. Except one case report, there are no further studies reported installing a metal stent into an already existing bare metal stent in the common bile duct (CBD). We describe a rare case of a stent-in-stent dilatation of the CBD for the patient presenting with jaundice and recurrent cholangitis in setting of biliary obstruction from pancreatic adenocarcinoma with previously inserted biliary metal stent in situ. The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting with no post procedure complications and rapid improvement in general condition.

Self-expanding metal stents (SEMS) - both covered and uncovered are used for palliation of patients with malignant biliary obstruction. There have been previous studies showing plastic biliary stents that were combined with biliary metal stenting. SEMS in the management of malignant biliary obstruction is associated with significantly longer stent patency, fewer ERCPs, and longer patient survival according to recent meta-analysis.

To our knowledge there are no existing guidelines for treatment of recurrent biliary obstruction with metal stent in situ. In this case, even though the patient had an existent biliary stent, accessing the CBD was difficult due to tumor invasion and bloody debris and extremely narrow channel in the common bile duct making it technically challenging. Despite the difficulties, the outcome was excellent with no complications.

Keywords Biliary SEMS, Malignant biliary obstruction, Pancreatic cancer, Stent in stent

258

Case of cholecystoduodenal fistula complicated with upper gastrointestinal bleeding and gallstone ileus

Vijay Rampally, Ravi Shankar Bagepally

Correspondence – Ravi Shankar Bagepally - b_ravishankar@yahoo.com

Department of Gastroenterology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India

Introduction Gallstone ileus is a rare complication of gallstone disease. It occurs mostly after the formation of a biliary enteric fistula, especially with the duodenum, causing small bowel obstruction [1]. Bleeding due to biliary-enteric fistula is rare.

Case Report A 79-year-old male k/c/o HTN, T2DM, CAD, recurrent biliary colic, was brought to casuality with history of 3 bouts of hematemesis. No history of malena. Physical examination normal, except tachycardia. Lab work revealed hemoglobin 13 g/dL. On endoscopy showed large deep duodenal ulcer with adherent clot, with suspicion of fistula. Patient was shifted to ICU, CT abdomen was reported intraluminal calculus of 2.2 × 1.8 cm in proximal jejunum and cholecystoduodenal fistula. On day 2 patient had abdominal pain and distension, contrast-enhanced computed tomography (CECT) abdomen showed distended small bowel loops max diameter 35 mm, intraluminal calculus of 27 × 22 mm at distal jejunal loop and cholecystoduodenal fistula. In view of intestinal obstruction, surgery was done. Laparoscopy assisted enterotomy and removal of gallstone+enterotomy closure was done.

Discussion Gallstone may cause biliary-enteric fistula and complicated by gallstone ileus. The most common fistulas are cholecystoduodenal. The most common site of obstruction is at the ileocecal valve, especially when the stone size is > 2.5 cm [2]. Gallstone ileus mostly presents in the form of small bowel obstruction. Only roughly 50% of gallstone ileus were noted with a history of previous biliary symptoms [3]. Cholecystoduodenal fistula rarely causes gastrointestinal bleeding, which occurs mostly from a branch of cystic artery due to duodenal ulcer or erosion by a gallstone (4). The best management of gallstone ileus remains controversial. Although the recurrence rate for gallstone ileus is approximately 5%, enterolithotomy alone is the treatment of choice in gallstone ileus, especially in patients with hemodynamically unstable or significant comorbidities [5].

Conclusion Gallstone ileus and gastrointestinal bleeding are rare but important complications of cholelithiasis with cholecystoduodenal fistula. Good judgment in selecting the surgical procedure is required, especially in elderly patients with a high incidence of comorbidities

Keywords Cholecystoduodenal fistula, Enterotomy, Gall stone, Gallstone ileus, Hematemesis

259

Profile of choledocholithiasis patients undergoing endoscopic retrograde cholangiopancreatography: An eight-year single-centre experience from eastern India

Haribhakti Seba Das, Chittaranjan Panda. Prasanta Kumar Parida, Sambit Kumar Behera, Kaibalya Ranjan Dash, Prajna Anirvan, Pankaj Bharali, Mrinal Gogoi, Buddhi Prakash Meena, Padma Lochan Prusty, Samir Hota, Sananda Kumar Sethi, Rakesh Mohanty, Pravin Kumar Mishra

Correspondence - Haribhakti Seba Das - hbsrho@yahoo.co.in

Department of Gastroenterology, Sriram Chandra Bhanj Medical College and Hospital, Behera Colony, Mangalabag, Cuttack 753 001, India

Background Choledocholithiasis is one of the most prevalent gastroenterological diseases with considerable geographical variation. The profile of patients presenting with choledocholithiasis and the procedural outcomes in this part of India has not been explored. We evaluated patients with choledocholithiasis undergoing endoscopic retrograde cholangiopancreatography (ERCP) in the Department of Gastroenterology and the procedural outcomes.

Methods This was a prospective study which was done at SCB Medical College and Hospital, Cuttack, Odisha from January 2014 to March 2022. ERCP was performed by different gastroenterologists using the standard technique. Data were expressed as percentages and mean ± SD.

Results Seven hundred and nine patients underwent ERCP for choledocholithiasis over the eight-year study period. The mean age of patients was 48.3±15.29 years. 45% patients were males while 55% patients were females. Cholangitis was present in 11.1% patients. Only 12 (1.7%) patients had a palpable gallbladder on abdominal examination. 36.6% patients had associated cholelithiasis with choledocholithiasis. 51.2% patients had single CBD calculus. 4.6% patients had associated stricture. Precut papillotomy was done in 52.3% cases while direct cannulation and sphincterotomy was done in 47.7% cases. Sphincteroplasty was done in 32.7% cases. Repeat ERCP was required in 21.2% cases. While complete stone clearance was achieved in 74.3% cases, in 17.5% patients, stenting and clearance were done. ERCP failed or was abandoned in 8.2% patients. The reasons for failure were: cannulation failure (52.5%), duodenal deformity (38.98%), impacted stone (3.38) and failure of positioning (5%). Post ERCP pancreatitis occurred in 10.4% patients. Bleeding occurred in 9 (1.3%) patients while perforation occurred in 5 (0.7%) patients.

Discussion In our series, female patients predominated. One-tenth of the patients had cholangitis. Half of the patients required precut papillotomy. Repeat ERCP was required in one-fifth cases while rates of bleeding and perforation were low.

Keywords Bile duct stone, ERCP, Patient profile

260

Opioid pancreatobiliopathy: A mimicker of periampullary malignancy in opioid addicts

Chhagan Lal Birda , Pranav S Kumar, Taruna Yadav, Binit Sureka, Ashish Agarwal

Correspondence – Ashish Agarwal - drashu123@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India

Introduction Opium use disorder is common in western Rajasthan. Chronic opioid use has multitude of gastrointestinal effects including dyspepsia, slow transit constipation and narcotic bowel syndrome. Chronic opium use can also result in gastrointestinal ulcers and strictures and these patients presents with recurrent partial bowel obstruction, anemia and malabsorption syndrome. Opioids increase the tone of the sphincter of Oddi, thus resulting in biliary stasis. There is sparse literature on opioid induced pancreatobiliopathy.

Results We hereby report prospectively maintained and retrospectively analyzed case series of seven patients of opioid pancreatobiliopathy presented to Gastroenterology OPD during July 2021 to June 2022. Median age of the patients was 60 (IQR -56-61) years and all were male. Majority were consuming opium in form of afeem (85.7%). The median duration of opium addiction was 25 (IQR-24.5-29) years. The median amount of opium consumption was 50 gms (IQR 45-50 gms) per month and money spent was 7000 rupees (IQR – 5500-7250) per month. Most common presentation were- pain abdomen (85.7%), constipation (71.4%), anorexia (57%) and weight loss (57%). Baseline investigation revealed mild anemia (median Hb 10.9 gm/dL, IQR 10.1-12.4) and hypoalbuminemia (median albumin 3.2 gm/dL, IQR – 2.6-3.4). Liver biochemical tests and tumor markers like CEA and CA19-9 were negative in all of the patients. Endoscopic ultrasound and contrast-enhanced computed tomography (CECT) abdomen revealed dilated common bile duct (median 12 mm, IQR 8.7-16.5) and main pancreatic duct (median 4 mm, IQR 4-5 mm) without any mass/obstructing calculus/stricture. All the patients were managed conservatively, and psychiatry consultation was taken for opioid deaddiction.

Conclusion Opioid pancreatobiliopathy is a common cause of double duct sign in opioid addicts and often mimic periampullary malignancy. High index of suspicion is required as clinical presentation is variable. Diagnosis should be considered in patients with chronic opioid use after carefully excluding ampullary obstructing lesions and pancreatic pathologies.

Keywords Double duct sign, Opioid pancreatobiliopathy, Periampullary malignancy

261

Comparison between endoscopic retrograde cholangiopancreatography guided brush cytology and single operator cholangioscopy guided biopsy in diagnosis of intraductal biliary strictures

Aeshal Parmar

Correspondence – Aeshal Parmar - aeshal.6@gmail.com

Department of Gastroenterology, Sri Balaji Action Medical Institute, Paschim Vihar, New Delhi 110 063, India

Introduction Biliary strictures are defined as abnormal narrowing of bile duct. Biliary strictures are caused by various benign and malignant conditions. However, differentiating malignant from benign stricture is challenging. The most convenient and widely used method for tissue sampling from biliary stricture is endoscopic retrograde cholangiopancreatography (ERCP) guided brush cytology. ERCP brush cytology has low sensitivity and low negative predictive value. Single operator cholangioscopy (SOC) is a new modality and can be easily performed during ERCP. Advantage of SOC over other modalities is that it provides direct visualization of biliary epithelium and gives opportunity to take direct visual guided biopsy of the target lesion. However, limited data is available on comparison between ERCP guided brush cytology and SOC guided biopsy in diagnosing etiology of intraductal biliary strictures.

Methods We conducted a prospective observational study over the duration of one year and collected data of 25 patients who fulfilled the inclusion criteria of the study. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy of ERCP brush cytology and SOC biopsy were calculated.

Results In our study out of 25 patients, nine patients had final diagnosis of malignant biliary stricture and 16 patients had final diagnosis of benign biliary stricture. The SOC biopsy had better sensitivity (77.8% vs. 55.6%), NPV (88.8% vs. 80%) and accuracy (92% vs. 84%) compared to ERCP brush cytology. However, specificity (100% for both) and PPV (100% for both) were comparable between two modalities.

Conclusion In our study we found that SOC biopsy had higher sensitivity, NPV and accuracy compared to ERCP brush cytology to diagnose malignancy in intraductal biliary strictures. Furthermore, direct visualization of intraductal lesion also had additional benefit in diagnosing malignancy. However, multicentre large study is required for further evaluation and conclusion.

Keywords Biliary stricture, Biopsy, Brush cytology, ERCP, SOC

262

Bacteriological evaluation of bile in patients with malignant biliary obstruction

Siva Sankar Reddy Gangireddy , Tarun Joseph

Correspondence – Siva Sankar Reddy Gangireddy - gangi97@gmail.com

Department of Digestive Diseases, Tata Medical Center, 14, MAR (E-W), D H Block (Newtown), Action Area I, Newtown, Kolkata 700 160, India

Introduction Cholangitis is a life-threatening complication in extrahepatic biliary obstruction. Malignant biliary obstruction is one of the predisposing factors for cholangitis. Most of the patients with bactibilia are asymptomatic. If incomplete biliary drainage is anticipated, prophylactic antibiotic treatment is advocated even in asymptomatic patients. Bacteriological evaluation of bile helps in choosing prophylactic antibiotic in such patients.

Methods Bile was aspirated immediately after cannulating the CBD in native papilla during endoscopic retrograde cholangiopancreatography (ERCP) in malignant biliary obstruction and sent for culture sensitivity testing in patients presented with obstructive jaundice from February 2017 to June, 2022 at Tata Medical Center, Kolkata.

Results ERCP was perfomed in 381 patients with malignant obstructive jaundice with native papilla. Bactibilia was seen in 128 patients (33%). E. coli is the major bacterium isolated (35%), followed by Enterobacter species (20%) and Klebsiella species (17%). Of the 128 patients with bactibilia only 27 patients (21%) had features of cholangitis and 19 patients (14%) had bacteremia.

Conclusion Asymptomatic bactibilia is common. E. coli is the commonly isolated bacterium.

Keywords Bactibilia, ERCP, Malignant biliary obstruction

263

Microbial profile of biliary infection in patients who underwent therapeutic endoscopic retrograde cholangiopancreatography at a tertiary care center in Western India

Apurva Shah , Aastha Shah, Alok Sahu, Shravan Bohra

Correspondence – Apurva Shah - apurvashah411@gmail.com

Department of Gastroenterology, Apollo Hospital International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Ahmedabad 382 428, India

Background Bile ducts are usually sterile under physiologic conditions. Bacteria could remain, colonize and replicate in a relatively stagnant bile environment if a biliary obstruction exists, resulting in increase of pressure, eventually spreading to blood and causing systemic complications.

Aim To identify the microbial profile from bile samples aspirated during endoscopic retrograde cholangiopancreatography (ERCP), the antibiotic susceptibility profile of the bacteria and the risk factors for bacterial colonization of biliary tree.

Method Our study is a retrospective study where all patients, who underwent therapeutic ERCP for various indications from June 2020 to June 2022 at a tertiary care hospital in Western India were included. Approximately 2-10 mL of bile was collected in sterile containers and sent for culture. Statistical analysis was performed using Chi-square test.

Results Total 61 patients were included, 62.2% were males and mean age was 58 +/- 18 years. Most common presentation was abdominal pain (63.9%). Six patients had a history of biliary intervention. Bile culture was found positive in 45 patients (73.8%) with 60% had monomicrobial and 40% had multimicrobial growth. Culture positivity was 83.4% with previous biliary intervention. Meropenem had highest susceptibility (82.3%), while Cefotaxime had worst susceptibility (28.9%). Most common organism was E. coli followed by Klebsiella pneumonie. Multi drug resistant (MDR) strains found in 17.5% of the ERCP naïve patients and in 60% with previous biliary interventions with significant p value.

Conclusion In conclusion, our results show that 70% to 75 % of patients who underwent ERCP had bacteriobilia. The most commonly isolated bacteria were Gram-negative bacteria including Escherichia coli and Klebsiella pneumoniae. Monomicrobial infection was more prevalent compared with multimicrobial infection and high MDR rates among patients with previous biliary interventions. The identified risk factors associated with positive bile culture included old age, previous history of ERCP and larger common bile duct diameter (>12 mm). Keywords Microbiology bile ERCP western India

264

An interesting case of obscure gastrointestinal bleed

Pratik Chhabra

Correspondence – Pratik Chhabra - kitu.pratik@gmail.com

Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Introduction Angiodysplasia of common bile duct is extremely rare. It has been reported in patients with hereditary hemorrhagic telangiectasia.

Case Report A 67-year-old male with hypertension presented with progressive dyspnea on exertion, and easy fatigability for 3 weeks. He also noticed passing black tarry stools intermittently for last 2 months along with mild abdominal pain. Physical examination was unremarkable except for pallor. There was no mucocutaneous telangiectasia. Initial laboratory parameters were significant for an iron deficiency anemia with a hemoglobin of 4.0 g/dL (baseline, 12 g/dL). Patient’s clinical presentation and laboratory parameters were suggesting subacute upper gastrointestinal bleeding. Esophagogastroduodenoscopy demonstrated altered blood around the major ampulla on limited tangential views. Side-viewing scopy showed major ampulla emanating dark blood-stained bile, concerning for hemobilia or hemosuccus pancreaticus (Fig. 1). A follow-up CT abdominal angiography and even conventional angiography did not show any contrast extravasation or pseudoaneurysm (Fig. 2). Magnetic resonance cholangiopancreatography (MRCP) showed pancreas divisum without any mass lesion or intraductal filling defect in bile duct (Fig. 3). Endoscopic retrograde cholangiopancreatography and SpyGlass® (Boston Scientific, Marlborough, MA) cholangioscopy was done, which showed jet of dark blood-stained bile (Fig. 4) and post irrigation and suction, clear visualization of common bile duct and common hepatic duct showed multiple ectatic blood vessels throughout with intermittent oozing of blood, consistent with angiodysplasia (Fig. 5). The size of the lesion was estimated to be less than 3.3 mm. Endotherapy using argon plasma coagulation was not performed due to nonavailability of compatible probe with SpyGlass® cholangioscopy. This case highlights importance of having dedicated therapeutic accessories compatible with SpyGlass® cholangioscopy. He was initiated on systemic thalidomide with hematinics expecting resolution of biliary angiodysplasia. He was passing normal stools with stable hemoglobin at 1month follow-up.

Conclusion This case highlights importance of having dedicated therapeutic accessories compatible with SpyGlass® cholangioscopy for hemostasis.

Keywords Biliary angiodysplasia and GI bleed

Pancreas

265

Pancreatic steatosis: Knowledge about its emerging spectrum and clinical implications

Manoj Yadav, Sudhir Maharshi, Shyam Sunder Sharma

Correspondence – Manoj Yadav - yadavmanoj49508@gmail.com

Department of Gastroenterology, Sawai Man Singh Medical College, New SMS Campus Road, Gangawal Park, Adarsh Nagar, Jaipur 302 004, India

Background Pancreatic steatosis (PS) is the accumulation of fat in pancreas and when there is presence of obesity or metabolic syndrome; it is called non-alcoholic fatty pancreas disease (NAFPD). Fatty liver is associated with insulin resistance, dyslipidemia, and obesity and is therefore considered a phenotype of metabolic syndrome. However, less is known regarding the metabolic abnormalities associated with NAFPD.

Methods Patients with diabetes mellitus (DM)/non-alcoholic fatty liver disease (NAFLD)/metabolic syndrome/obesity with PS were prospectively enrolled in the study. PS was diagnosed with trans-abdominal ultrasonographic findings and grading was also done.

Results Total 42 patients enrolled in the study with mean age of 45.2 ±10.2 years, out of them 27 (64.3%) were males and 15 (35.7%) were females. Out of total, 14 (33.3%) patients were diabetic and 12 (28.5%) had metabolic syndrome. Mean body mass index (BMI) and waist circumference of the study population was 25±2.7 kg/m² and 89.9±8.2 cm respectively. Mean amylase and lipase levels were 52.5±19 U/L and 57.4±35.3 U/L respectively. Mean triglyceride and cholesterol level in study population were 168.2±50.7 mg/dL and 193±33.2 mg/dL respectively. Four patients (9.5%) had grade IV PS, while grade III and grade II PS were seen in 17 (40.4%) and 15 (35.7%) patients respectively and only 6 (14.2%) patients had grade I PS. Fatty liver on ultrasonography were seen in 40 (95.2%) patients and 30 (71.4%) patients had transaminitis on biochemical investigations.

Conclusion PS was associated with higher BMI, DM, metabolic syndrome and NAFLD in our study. PS and NAFPD were not associated with elevation of pancreatic enzymes, however further studies with large sample size needed to draw definite conclusion.

Keywords Diabetes mellitus, Metabolic syndrome, Steatosis

266

Undiagnosed sarcoidosis presenting as acute pancreatitis – A case report

Matta Rakesh

Correspondence - Matta Rakesh - rakeshkumar.matta@gmail.com

Department of Gastroenterology, M S Ramaiah Medical College, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India

Introduction Sarcoidosis is a systemic non-caseating granulomatous disease involving many organs. Pancreatic involvement is unusual and hypercalcemic pancreatitis as initial presentation is very rare.

Case Report A 37-year-old female, k/c/o hypothyroidism, came with chief complaints of acute upper abdominal pain, associated with non-bilious vomiting since 2 days. There were no history of addictions. On examination, patient had epigastric tenderness and splenomegaly. On routine blood work up, patient had leukocytosis, elevated serum amylase and lipase levels; infiltrative pattern LFT and thrombocytopenia was noted. Ultrasonography revealed bulky and heterogenous pancreas with peripancreatic stranding (pancreatitis), moderate ascites, splenomegaly and mesenteric lymphadenopathy. On etiological work up of pancreatitis, serum calcium levels were elevated (14 mg/dL) and triglyceride levels were normal. On further work up for hypercalcemia, she had normal PTH, low vitamin D3 (16.03 ng/mL) and elevated serum ACE levels (176.58 U/L, normal 12-68 U/L). Endoscopy done in the view of ascites and splenomegaly revealed grade 3 esophageal varices; henceforth, diagnosis of presinusoidal portal hypertension was made. In view of infiltrative pattern of LFT and signs of portal hypertension, liver biopsy was done; which showed non caseating granulomas. The patient underwent whole body PET-CT scan to rule out pulmonary sarcoidosis and to evaluate extent of extrapulmonary sarcoidosis. The PET-CT revealed multiple enlarged abdominal lymph nodes (mesenteric, retroperitoneal, suprapancreatic, left gastric); multiple bilateral lung nodules, hepatosplenomegaly with splenic hilar lymph nodes. Patient was managed conservatively with IV fluids, IV analgesics.

Conclusion Acute pancreatitis can be a presenting symptom of sarcoidosis, although it appears to be extremely rare. Therefore, sarcoidosis should be considered a cause of acute pancreatitis, even in the absence of more common organic involvement such as pulmonary sarcoidosis, and especially when there is evidence of hypercalcemia.

Keywords Hypercalcemia, Pancreatitis, Sarcoidosis

267

Etiology, clinical profile and outcome of acute pancreatitis in a tertiary care centre

Ishan Mittal, Shishirendu Parihar, Aakash Shah, Nitesh Bassi, V K Dixit, S K Shukla, D P Yadav, Anurag Tiwari, Vinod Kumar Yadav

Correspondence – Ishan Mittal - ishanmittal29@gmail.com

Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Background Acute pancreatitis is an inflammatory condition of the pancreas with wide clinical variation. Acute pancreatitis may vary in severity ranging from mild self-limiting disease to pancreatic necrosis which may lead to life-threatening sequelae.

Aim and Objectives The present study was aimed to assess the etiology, clinical profile and outcome of acute pancreatitis in a tertiary care teaching hospital in eastern UP.

Methodology All patients admitted with a diagnosis of acute pancreatitis in Medical Gastroenterology Department, IMS, BHU between April 2021 to July 2022 were included in this retrospective study. Clinical history, examination, laboratory investigations and outcome was noted. Severity of AP was assessed using the modified Atlanta classification.

Results A total of 134 subjects were included in the study. The mean age was 40.9, ranging between 15 to 75 years. Among the study population, 88 (65.6%) were male and 46 (34.4%) were female. Epigastric pain with pain radiation to the back (90%) was the most common clinical presentation. The most common etiology was alcohol 48 (35.8%) followed by gallstone 40 (29.8%) then idiopathic 24 (17.9%). Mild, moderately severe, and severe pancreatitis was present in 40 (29.9%), 54 (40.2%) and 40 (29.9%) patients respectively. Acute fluid collection was the most common local complication seen in 18 (13.4%) cases whereas respiratory system involvement was the most common organ involvement seen in 28 (20.9%) of cases. Mortality was seen in 4 (2.9%) patients, all of which had severe pancreatitis.

Conclusion Alcohol intake is the predominant etiological risk factor for acute pancreatitis in Eastern UP followed by biliary etiology. Most of severe pancreatitis patients are due to alcohol related. Patients with body mass index ≥25 kg/m2, C-reactive protein (CRP) ≥150 mg/L and Hematocrit (HCT) ≥44% had an increased risk of developing severe AP.

Keywords Acute pancreatitis, Clinical profile, Etiology, Outcome

268

Pancreaticopleural fistula- An unusual complication of pancreatitis

Sharathchandra Khanappanavar, Nandeesh H P, Ganesh Koppad, Deepak Suvarna, Vijaykumar T R, Majaradya H V

Correspondence – Sharathchandra Khanappanavar - khanappanavar.sharathchandra@gmail.com

Department of Gastroenterology, J S S Hospital, Mahatma Gandhi Road, Fort Mohalla, Mysuru 570 004, India

Background and Aim Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis. It has been reported to occur in about 0.4% cases of pancreatitis mainly in chronic cases. It's defined as an abnormal connection between the pancreas and the adjacent pleural cavity. It's difficult to demonstrate the fistula tract on imaging like CT or MRCP but amylase-rich pleural fluid (greater than the upper limits of normal for serum amylase) is highly suggestive of the diagnosis. There's no guidelines for treatment and we are presenting a case of PPF that was treated endoscopically.

Methods and Results Twenty-seven-year-old male alcoholic who presented with worsening dyspnea, orthopnea, left-sided chest pain and pain abdomen. Patient was found to be tachypneic, tachycardic and with no breath sounds on the left side of the chest. Labs were notable for a leukocytosis of 18,810 and lipase 3000. CXR showed a white-out of the left hemithorax. MRCP abdomen showed acute on chronic pancreatitis with left pancreatico-pleural fistula and effusion. 1 liter of pleural fluid was drained, and fluid analysis showed an amylase of 4721. PPF diagnosis was made and he was started on octreotide drip and kept NPO. Patient had rapid reaccumulation of fluid in left pleural cavity, hence he was advised for pancreatic endotherapy. ERCP was performed and pancreatogram showed contrast leak from the tail of the pancreas extending into the left pleural cavity, PD stent was placed. Serial chest X-rays showed resolution of left sided pleural effusion.

Conclusion Pancreaticopleural fistula is a serious complication of acute or chronic pancreatitis. Modalities of treatment are conservative management with octreotide and chest tube drainage for extended period, endoscopic stenting of the disrupted PD or surgical intervention. We present a case who has been successfully treated with endoscopic PD stenting in case of PD disruption.

Keywords ERCP, Fistula, Stenting

269

Forward viewing echoendoscope guided combined coil and glue injection in bleeding gastric varices secondary to splenic vein thrombosis in chronic pancreatitis

Surinder Rana, Pankaj Kumar, Nikhil Bush, Ravi Sharma, Rajesh Gupta^*

Correspondence - Surinder Rana - drsurinderrana@gmail.com

Departments of Gastroenterology and ^*Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background and Aims Gastric variceal (GV) bleeding secondary to splenic vein thrombosis (SVT) in pancreatitis is rare and surgery has been the conventional treatment. The role of endoscopic ultrasound (EUS) guided combined coil and glue injection in bleeding GV in chronic pancreatitis (CP) has not been evaluated. We conducted this study to evaluate safety and efficacy of EUS guided combined coil and glue injection in bleeding GV due to CP induced SVT.

Methods A retrospective analysis of data base of 6 patients (all males; mean age: 36.1 ± 6.7 years) with bleeding GV with underlying CP was done. The details about clinical presentation, laboratory data, radiological studies, details of EUS guided intervention and long-term outcomes were retrieved. Patients were treated with EUS guided injection using a forward viewing echoendoscope (FVE).

Results Endoscopy revealed isolated fundal GV in all patients with one patient having active bleeding at time of endoscopy and remaining 5 patients having stigmata of recent GV bleed. EUS guided combined injection was technically successful in all patients with no instrument related technical difficulty in any patient. A single coil was placed in 4 (66%) patients and two coils in two (34%) patients and median volume of glue injected was 1 mL (range 1-2 mL). GV were obliterated in all patients and none of the treated patients had either early or delayed re-bleeding.

Conclusion EUS guided combined coil and glue injection using a FVE seems to be safe and effective treatment for bleeding GV due to SVT in patients with CP.

Keywords Chronic pancreatitis, Coil, Endosonography, Gastric varices, Glue

270

Role of per-rectal diclofenac with IV ringer lactate infusion in prevention of pancreatitis after endoscopic ultrasound-guided fine needle aspiration cytology and biopsy from pancreatic lesions

Bharat Nandaniya, G S Lamba, Monika Jain

Correspondence - Bharat Nandaniya - bharatnandaniya97@gmail.com

Department of Gastroenterology, Sri Balaji Action Medical Institute A 4 Block, A 6 Block, Paschim Vihar, New Delhi 110 063, India

Introduction Endoscopic ultrasound-guided fine needle aspiration cytology (EUS-FNAC) and fine needle biopsy (FNB) are currently the most commonly used procedure for obtaining tissue specimens of pancreas lesions. It is accurate, minimally invasive, safe, and cost-effective. Procedure-related acute pancreatitis is one of the serious complications. Its reported incidence is up to 2.5% to 3%. Studies for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis have shown the significant benefit of per-rectal diclofenac plus iv ringer lactate infusion. However, the use of these in the prevention of acute pancreatitis in post-EUS-guided pancreatic FNAC/FNB is not well studied.

Methods This prospective study includes 238 EUS-guided pancreatic FNAC and biopsy cases over the period from January 2018 to July 2022. Among 238 cases, 205 cases (86%) were solid lesions and 33 (14 %) were cystic lesions. All patients were administered per-rectal diclofenac (100 mg 30 minutes before the procedure) with IV ringer lactate solution (20 ml/kg 30 minutes before the start of the procedure and continue during a procedure, followed by 3 mL/kg/h for 6 hours after the procedure). The primary endpoint was the incidence of post-EUS -guided FNAC/FNB pancreatitis.

Results A total of 238 consecutive patients with a pancreatic mass underwent EUS- FNAC and biopsy. No major complications were encountered in any patient. Mild acute pancreatitis occurred in 1 of 238 (0.4%), who had mild epigastric pain, and enzymes were mildly raised (amylase/lipase: 268/372). He was managed conservatively by IV fluids and analgesics without any complications.

Conclusion Per-rectal diclofenac with IV ringer lactate infusion can be an important tool to prevent pancreatitis after EUS-guided FNAC/FNB from pancreatic lesions. However, to conclude it, further large RCT (Randomized control trails) are required.

Keywords Acute pancreatitis, Endoscopic ultrasound, Fine needle aspiration cytology

271

Study to evaluate red cell distribution width and its ratio to total serum calcium and platelet count as a major predictor of severity in acute pancreatitis

Jayanth Peddu , Gaurav Gupta

Correspondence - Jayanth Peddu - jayanthpeddu@gmail.com

Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India

Background Cases of acute pancreatitis are on the rise and now it is one of the most common reason for hospitalization with gastrointestinal conditions. The present study was undertaken for evaluating red cell distribution width and its ratio to total serum calcium and platelet count as a major predictor of severity in acute pancreatitis.

Methods Thirty-five cases of mild acute pancreatitis and 35 of severe acute pancreatitis were enrolled in this study. Diagnosis of acute pancreatitis was done according to the Revised Atlanta Classification. Assessment of red cell distribution width (RDW) at 0h (RDW0h) and RDW at 24H (RDW24h) was done. Additionally, RDW0h-to-total serum calcium ratio and RDW0h-to-platelets ratio was evaluated. RDW and other parameters were compared with validated and widely used acute pancreatitis prognostic scores, including Ranson, BISAP and Modified Marshall scores.

Results Mean RDW0hr levels and RDW24hr levels among the patients of mild acute pancreatitis was 12.32 and 12.26 respectively, while among the patients of severe acute pancreatitis was 14.11 and 14.26 respectively. Mean RDW0hr to calcium ratio and RDW0hr to platelet ratio among the patients of the mild acute pancreatitis group was 1.35 and 0.059 respectively while among the patients of severe acute pancreatitis was 1.78 and 0.067 respectively. While analysing statistically, it was seen that RDW0hr, RDW24hr, RDW0hr to calcium ratio and RDW0hr to platelet ratio were significantly higher with p values of 0.001, 0.023, 0.017, 0.011 respectively in patients of the severe acute pancreatitis group in comparison to mild pancreatitis group.

Conclusion RDW and its associated parameters have better prognostic value for severe acute pancreatitis patients than the Ranson, BISHAP or Modified Marshall score. Clinicians could use RDW as a valuable indicator for early recognition of SAP patients as it is cheap and easily available, and promptly provide more active therapies.

Keywords Acute pancreatitis, RDW, SAP

272

Tuberculous pancreatic abscess: A rare case presentation

Yash Gangadia, G S Lamba, Monika Jain

Correspondence - Yash Gangadia - yash_g2511@yahoo.com

Department of Gastroenterology, Sri Balaji Action Medical Institute, A3/281 A, 2nd Floor, Goel Niwas, Paschim Vihar, New Delhi 110 063, India

Introduction Primary pancreatic tuberculosis (TB) is a rare, reported condition. It can present as pancreatic SOL. Being a curable disease, distinguishing it from malignancy is very important. endoscopic ultrasound (EUS) guided fine needle aspiration cytology (FNAC)/ fine needle biopsy (FNB) can be useful tool for this differentiation.

Methods A, 33-year-old Indian female with no significant past history, was admitted with complaints of epigastric pain, vomiting and anorexia since 2 months. She had a history of weight loss of about 10 kg. Physical examination was unremarkable. Computed tomography (CT) scan of thorax was unremarkable. Contrast-enhanced computed tomography (CECT) whole abdomen showed well defined mass lesions in body and tail of pancreas with peripancreatic lymph nodes. Endoscopic ultrasound guided biopsy from pancreatic mass showed necrotizing granulomatous inflammation suggestive of tuberculous abscess. FNAC from peripancreatic lymph nodes showed granulomatous lymphadenitis. Gene xpert from pancreatic mass was positive. A diagnosis of tubercular pancreatic abscess was made. Patient was started with standard 4 drugs anti tubercular therapy (ATT), following which she showed a good clinical and radiological response.

Conclusion This case highlights the unusual presentation of extrapulmonary TB as well as the importance of EUS-guided FNA in diagnosing pancreatic TB which was presumed to be a malignant mass and excellent response to standard ATT.

Keywords Abscess, Endoscopic ultrasound, Pancreas, Tuberculosis

273

A case report on acute necrotizing pancreatitis with collections after organophosphates poisoning

Rajendran Santhosh , Shubha Immineni, Muthukumar K, Aravind A, Caroline Selvi, Premkumar K

Correspondence - Rajendran Santhosh - santhosh12@gmail.com

Department of Medical Gastroenterology, Rajiv Gandhi General Government Hospital, Poonamallee High Road, 3, Grand Southern Trunk Road, Near Park Town, Park Town, Chennai 600 003, India

Introduction Organophosphates widely used as agricultural chemicals are highly toxic to humans. Accumulation of large amounts of acetylcholine results in excessive cholinergic stimulation of many organ systems. Cholinergic stimulation can cause pancreatic hypersecretion and edema. The course of pancreatitis is usually subclinical and mild.

Case Discussion A 21-year-old male was admitted with alleged ingestion of unknown amount of dichlorvos. He presented with complaints of altered sensorium, profuse sweating, abdominal pain and increased oral secretions. As patients’ respiratory effort was high he was intubated. Gastric lavage was done immediately. Loading doe of atropine given and kept on maintenance dose. Injection pralidoxime was given as loading dose followed by continuous infusion. CT abdomen done on admission showed mild acute pancreatitis.

Patient complained of worsening abdominal pain, fever and abdominal distension. Serum amylase was 1832. Repeat CT abdomen was suggestive of acute necrotizing pancreatitis with multiple peripancreatic necrotic collections. Percutaneous drainage was done to remove the necrotic material. Culture of the necrotic material showed growth of Klebsiella susceptible to imipenem. Patient improved after drainage and started on appropriate antibiotics. Patient was weaned off ventilator support. Subsequent imaging revealed improvement in collection. Patients drain was removed. Patient was discharged after 35 days of admission.

Keywords Atropine, CT abdomen, Klebsiella, Necrotic collection

274

Pseudocyst-Portal vein fistula manifesting with hepatic pseudo cysts as rare manifestation of pancreatitis: A case series

Pritam Das, Dhruv Thakur, Gaurav Pande, Samir Mohindra

Correspondence - Pritam Das - pritamqwertyqw@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Introduction Acute pancreatitis may have a varied presentation ranging from symptomatic enzyme elevation, mild abdominal pain, pseudocyst formation, multiple organ failures. Pseudo cyst fistulising to portal vein is a rare phenomenon, however with a high mortality.

Case Series We describe a case series of 3 patients which presented with acute pancreatitis or acute exacerbation of chronic calcific pancreatitis. A 42-yer-old male, chronic alcoholic, presented with chief complaints of pain in epigastric region since 11 months. Triple phase CT abdomen was suggestive of pancreatic head replaced by well-defined peripherally enhancing collection measuring 32 × 28 mm suggesting of walled off necrosis. The collection in the pancreatic head was seen communicating with the lumen of main portal vein and extending to involve its right and left branches with no post contrast enhancement suggesting fistulous communication. The patient improved on endotherapy with controlled monitoring with repeated endoscopic retrograde cholangiopancreatography (ERCP) and drainage of collections. The second patient 52-year-old male, chronic alcoholic came with chief complaints of pancreatic type of upper abdominal pain since 6 months, planned for endotherapy. The third patient, 36-year-old male presented with chief complaints of epigastric pain since 3 months, succumbed to illness.

Discussion Pseudocyst fistulizing portal vein is a rare and morbid phenomenon with a high mortality rate. In our case series, the patient 1 responded to step up decompression therapy, initially the patient was subjected to major duct drainage followed by minor duct drainage. The hepatic pseudocyst resolved gradually and portal vein thrombosis and collateral formation. 18 cases were reported in literature till 2015, around 5 more cases were reported in literature till now.

Keywords Hepatic pseudocyst, Portal vein thrombosis, Pseudocyst, Pseudocyst-portal vein fistula

275

Thrombotic microangiopathy: A rare complication of acute pancreatitis

Aradya H V, Ganesh Koppad, Nandeesh H P, Deepak Suvarna, Vijaykumar T R, Sharathchandra K K, Devansh Bajaj, Abhishek Kabra

Correspondence – Ganesh Koppad - gkoppad@gmail.com

Department of Medical Gastroenterology, J S S Hospital, Mahatma Gandhi Road, Fort Mohalla, Mysuru 570 004, India

Introduction Thrombotic microangiopathy is characterized by thrombocytopenia, hemolytic anemia and end organ dysfunction. We report a case of thrombotic microangiopathy secondary to pancreatitis.

Methods and Results The patient was a 28-year-old male presented with abdominal pain and vomiting since 1 day, he was previously treated for acute pancreatitis (etiology : ethanol) a month ago, O/E abdomen was tender, HR 107 bpm, BP 150/90 mmHg, USG abdomen revealed bulky and hypoechoic head and body of pancreas with adjacent inflammatory changes, serum amylase was 1130 U/L, serum lipase was 3000 U/L, On day 3 patient developed jaundice. Total bilirubin was 24.7 mg/dL, Hb dropped to 5 g/dL from 16 g/dL, platelet counts were 53,000 and peripheral smear showed decreased RBCs, shistocytes, polychromatophils and occasional nucleated RBCs with thrombocytopenia suggestive of microangiopathic hemolytic anemia, Serum LDH was 722 U/L, reticulocyte count 10.4%, Coombs test (DCT/ICT) was negative, serum creatinine was 1.83 and urea 106 mg/dL, urine examination was normal.

Conclusion In view of acute pancreatitis leading to MAHA- T, therapeutic plasma exchange (TPE) and methylprednisolone infusion was initiated after consultation with nephrology team. He also received 2 units of packed RBCs, our patient showed significant response to TPE with rise in platelets, Hb and LDH optimization. TMA is rare complication of acute pancreatitis, the temporal association between pancreatitis and TMA is unclear but it is hypothesized that cytokines (IL-1 and TNF-alpha) cause vascular endothelial damage, ADAMTS13 is inhibited by inflammation leading to platelet aggregation and thrombus formation, Early initiation of TPE yielded a good outcome in this case.

Keywords Acute pancreatitis, Plasma exchange, Thrombotic microangiopathy

276

Diagnostic performance of KRAS and GNAS testing in pancreatic cystic lesions: Experience from a tertiary care centre

Ravi Kumar Sharma, Surinder Rana, Nikhil Bush, Radhika Srinivasan, Ritambhra Nada. Rajesh Gupta, Tarundeep Singh

Correspondence – Surinder Rana - surinderrana@gmail.com

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India

Objective To prospectively study the diagnostic performance of molecular (KRAS, GNAS) markers in diagnosis of PCLs.

Methods Eighty-five consecutive patients (mean age 49.15±15.9 years, 49 F) with PCLs were prospectively enrolled. All patients underwent EUS-guided cyst fluid aspiration. The cyst fluid was sent for cytological evaluation, amylase, lipase, CEA, VEGF and KRAS (exon 2, codon 12 and 13) and GNAS (exon 8, codon 201) mutation analysis. The final diagnosis was based on histopathology or cytological confirmation in aspirated cyst fluid, or clinical diagnosis with no significant growth on follow-up of >6 months.

Results Of 85 enrolled patients, 28 (33%) patients had mucinous (15 malignant) and 57 (67%) patients had non-mucinous PCL. The final diagnosis was: Mucinous adenocarcinoma in 9, IPMN in 7, mucinous cystadenoma in 12, serous cystadenoma in 20, simple cyst in 9, pseudocyst in 20, and SPEN in 8 patients. The mean cyst size was 4.2±2.8 cm with 42 (49.4%) patients having cyst size >3 cm. The string sign was positive in 12 (14%) patients and all had mucinous tumours. The mean PCL fluid CEA was 504±176.9 ng/μl with 17 patients having CEA >192 ng/μl. The mean VEGF was 2061±291.2 nmol/l and was elevated in 11/20 patients with serous cystadenoma. KRAS point mutation was positive in 13 patients (11 malignant and 2 premalignant). It was negative in 4 patients with malignant PCL. In all 13 patients KRAS mutation was in codon 12 (GGT to GAT) 35G>A. GNAS mutation was negative in all patients. For identifying mucinous lesions, elevated CEA levels performed best and cytology performed best for identifying malignant PCL. The mutational diagnosis changed diagnosis in 1 patient only.

Conclusions KRAS and GNAS mutational analysis did not improve diagnostic ability of conventional testing in PCL’s. The GNAS (exon 8, codon 201) mutation was not found in our patients with IPMN.

Keywords Cyst Fluid analysis, GNAS, IPMN, KRAS, Mucinous cyst, Pancreatic cystic lesion

277

Unusual presentations of autoimmune pancreatitis

Isha Bansal, Girish Muppa, Amol Dahale, Debabrata Banerjee, Abhijeet Karad

Correspondence – Girish Muppa - indrakeela.girish@gmail.com

Department of Medical Gastroenterology, D Y Patil Medical College, Hospital and Research Centre, Pune 411 018, India

Introduction Autoimmune pancreatitis (AIP) cases was first reported in 1960 by Sarles et al. and the term AIP was first introduced in 1995 by Yoshida et al. as a form of chronic pancreatitis with autoimmune etiology [1, 2]. AIP was classified into 2 types. Type 1 AIP was associated with extrapancreatic manifestations and IgG4 related disease. AIP accounted for 5% to 6% of all patients with chronic pancreatitis [3].We report two cases of AIP type 1 presenting with pseudocyst and second case with pain in abdomen and obstructive jaundice, both of which responded with steroid therapy. On H&E sections a dense lymphoplasmacytic infiltrate was seen in the pancreatic tissue.

Case 1 A 36-year-old male was referred to our department in 2020 with clinical symptoms of painless obstructive jaundice and fever. Patient came to our hospital with clinical symptoms of abdominal pain, lump at the epigastric region and left >right peri orbital edema. Computed tomography showed pseudocyst of approx. size 100 × 66 mm with enhancing wall of thickness 3 mm seen in lesser sac anteroinferior to proximal body of pancreas and multiple intrapancreatic fluid collections seen in body of pancreas.

Case 2 A 66-year-old non-alcoholic male gave a history of diffuse abdominal pain since 1 year. His blood sugar and liver function tests were all under normal limits. A contrast-enhanced computed tomography (CECT) scan was done which showed bulky head and obstructive jaundice findings. Endoscopic ultrasound-guided fine needle aspiration biopsy was done showed storiform fibrosis and lymphoplasmacytic infiltration with IgG4 positive plasma cells 18/HPF.

Conclusion Autoimmune pancreatitis is an increasingly recognized clinical condition. Even though a large number of reports on increased serum IgG4 levels and IgG4-positive cells in bile duct biopsy specimens are related the disease, established diagnostic criteria of autoimmune pancreatitis do not reflect the entire spectrum of the disease. Autoimmune pancreatitis is steroid-responsive, but maintaining remission continues to remain challenging.

Keywords Autoimmune pancreatitis, IgG4, Obstructive jaundice, Pseudocyst

278

Characterization of pancreatic head mass in patients with chronic pancreatitis

Randeep Rana , Soumya Jagannath Mahapatra, Shallu Middha, Tanmay Vajpai, Gadella Varun Teja, Anugrah Dhooria, Ashish Dutta Upadhyay, Pramod Kumar Garg

Correspondence – Pramod Kumar Garg - pgarg10@gmail.com

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Introduction Patients with chronic pancreatitis (CP) are at risk of developing pancreatic malignancy. It is often difficult to differentiate between malignant and inflammatory head mass in CP.

Methods Consecutive patients with CP presenting with a head mass on imaging (either CT and/or MRI) were included from January 2004 till December 2020. To differentiate inflammation from malignancy, patients underwent endoscopic ultrasound (EUS) and PET-CT. The gold standard was fine needle cytology or resected specimen histopathology. At-least 1 year post diagnosis follow-up was done in those considered having benign mass. A multivariate analysis was done to determine predictors of malignancy and a prediction model was developed.

Results A total of 167 patients with CP and head mass were included. The median age was 45 (38-50) years and 158 (88.6%) were male. Etiology of CP was alcohol in 110 (65.8%) and idiopathic in 56 (33.5%). Of these, 18 patients had pancreatic malignancy and 2 ampullary malignancy of whom 3 had alcoholic, 16 had idiopathic and one had hereditary pancreatitis. On multivariate analysis, idiopathic etiology, alkaline phosphatase (ALP) value >2.5 times ULN and EUS features of malignancy (presence of definite mass with absence of duct penetrating sign) were predictors of malignancy. A prediction model (10*a+12.1*b+14*c, where ‘a’ is idiopathic etiology, ‘b’ alkaline phosphatase >2.5 times and ‘c' is EUS features of malignancy) was developed with a score of ≥24 having sensitivity of 81.8%, specificity of 87.6% and negative predictive value of 97.5% for predicting malignancy with area under ROC of 0.92.

Conclusion Patients with CP and head mass having idiopathic etiology and biliary obstruction as evidenced by raised serum ALP level had higher chances of having malignancy. A prediction model incorporating EUS features in addition to these two parameters could predict malignancy with a high accuracy.

Keywords CA 19.9, Carcinoma pancreas, Chronic pancreatitis, EUS, Inflammatory head mass

279

Pancreatic endotherapy in painful chronic pancreatitis: Predictors and response to therapy

Ankit Agarwal , Soumya Jagannath Mahapatra, Tanmay Vajpai, Shallu Midha, Anshuman Elhence, Shivam Pandey, Pramod Garg

Correspondence – Pramod Garg - pkgarg10@gmail.com

Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029. India

Introduction Patients with painful chronic pancreatitis (CP) are initially managed with optimal medical therapy followed by endotherapy and subsequently surgery in a step-up protocol. The aim of our study was to study the predictors of the need for endotherapy, and short- and long-term response to endotherapy in painful CP.

Methods Medical records of consecutive patients with CP were reviewed from a prospectively maintained database from January 2000 till December 2020. The indications for endotherapy (which included extracorporeal shock wave lithotripsy [ESWL] for large stones) were: non-response to optimized medical therapy, dilated pancreatic duct and ductal obstruction due to either stones/stricture. Patients with painful CP with a follow-up of ≥18 months were included. Primary outcome was predictors of need for endotherapy and co-primary outcome was long-term response to endotherapy as compared to no endotherapy patients. Secondary outcome was short-term response to endotherapy.

Results Of 1574 patients, 541 patients had painful CP with a follow-up of at-least 18 months. There was no difference in baseline characteristics of patients who required endotherapy (n=131, 24.2%) as compared to patients who did not. On multivariate logistic regression analysis, female sex (odds ratio [OR] 2.03, 95% CI 1.25-3.28) and a higher baseline pain score ≥8 (OR 2.02, 95% CI 1.30-3.13) were significant predictors for the need of endotherapy while diabetes predicted a lower need for endotherapy (OR 0.63, 95% CI 0.48-0.82). Significant pain-relief occurred after endotherapy (pain score: pre-endotherapy 8 [7-10], vs. 0 [0-2] post endotherapy; p<0.001). The long-term response was not significantly different between the endotherapy and no-endotherapy group over a mean of 60 (32-108) months (complete response in 98 [74.8%] vs. 289 [70.4%]; p=0.64).

Conclusion Female sex and high baseline pain score predicted the need for endotherapy which provided excellent short-term pain relief. Long-term pain relief was similar as for no-endotherapy group despite aggressive initial course.

Keywords Chronic pancreatitis, Endotherapy

280

Accelerated combined catheter plus endoscopic percutaneous treatment for enhanced recovery in patients with infected pancreatic necrosis

Soumya Jagannath Mahapatra, Pramod Garg

Correspondence – Pramod Garg - pkgarg10@gmail.com

Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Introduction Building on our previously reported percutaneous endoscopic necrosectomy step-up approach, we developed an accelerated combined catheter plus endoscopic percutaneous treatment protocol for enhanced recovery (ACCEPTER) for predominantly laterally placed infected necrotic collections.

Methods Patients with predominantly laterally placed infected necrotic collections were included in the study. In case of no response to antibiotics and percutaneous catheter drainage (PCD) within 48-72 hours, rapid tract upgradation was done every alternate day by replacing with bigger catheter to reach 30 F or by placing a fully covered self-expanding metal stent (SEMS, 54F diameter). Thereafter, percutaneous endoscopic necrosectomy (PEN) was done using a flexible endoscope (8.8 mm dia.) through the percutaneous tract or the SEMS. Technical success was defined as clearance of the cavity and clinical success as resolution of sepsis.

Results From March 2019 to April 2020, 19 patients underwent PEN as per ACCEPTER protocol. The baseline CTSI score was 9 (8-10) and the modified Marshall organ failure score was 2 (IQR 0-4). Eleven patients had organ failure at inclusion. The median number of sessions to reach the desired catheter size was 2 (IQR 1-3) over 8 (6-10) days after a median of 32 (23- 42) days from the onset of pancreatitis. SEMS was placed in 15 (78.9%) for rapid tract upgradation. Necrosectomy was completed in a median of 3 (IQR 1-4) sessions done every alternate day. Four patients had bleeding: two due to pseudoaneurysm and two due to ooze during necrosectomy. Five patients needed salvage surgery (3 for sepsis, 2 for bowel fistula); 4 patients died. Technical success was achieved in 18 (94.8%) patients and clinical success in 14 (73.7%) patients. Median comprehensive complication index (CCI) was 8.7 (IQR 0-45.2).

Conclusion The technique of rapid catheter upgradation and PEN as per the ACCEPTER protocol was safe and effective for infected necrotic collections.

Keywords Acute Pancreatitis, Infected necrotising pancreatitis, Percutaneous endoscopic necrosectomy

281

Clinical profile and management of chronic pancreatitis in a tertiary care centr e

Nishanth Paturi, Venkatakrishnan Leelakrishnan, Mukundan Swaminathan, Thirumal P, Kartikayan R K, Arun P, Ravindra K, Swaapnika V, Dhanush T

Correspondence – Nishanth Paturi - nish_492@hotmail.co.uk

Department of Medical Gastroenterology, P S G Institute of Medical Sciences and Research, Avinashi Road, Peelamedu, Coimbatore 641 004, India

Introduction Chronic pancreatitis is a multifactorial disease best defined as a syndrome characterized by chronic inflammation, fibrosis, and eventual destruction of ductal, exocrine (acinar cell), and endocrine (islets of Langerhans) tissue producing varying degrees of symptoms (abdominal pain, nausea/vomiting), functional (exocrine insufficiency [steatorrhea], or endocrine insufficiency [diabetes mellitus]) and structural derangements of the gland based on imaging techniques including US, CT, EUS, MRI, and MRCP.

Aim To study the clinical profile and management of chronic pancreatitis with respect to clinical findings, lab parameters, imaging and management modalities.

Methods A cross-sectional observational study was conducted which included the patients admitted to a tertiary care center presenting with a clinical diagnosis of chronic pancreatitis. The study was conducted over a period of 3 years from August 2019 to July 2022. A total sample size of 200 patients was included.

Results In the study, it was observed that the majority of patients in the age group 50-58 years were male (75%). Alcoholism (42%) was the most common etiology and presented with pain in the abdomen (83%). The most common CT findings were pancreatic calcifications (72%) with the most common complication being pancreatic pseudocyst (30%). In the present study, the majority of patients were managed conservatively (44%) followed by pancreatic endotherapy (32%) and surgery (24%). The distribution of patients according to pain relief by various management showed that the majority were getting pain relief by surgery (68%) followed by endotherapy (44%).

Conclusion Chronic pancreatitis is a progressive inflammatory disease. Conservative management followed by endotherapy is frequently performed at our center with surgery giving relief of pain in most cases. However, surgery is indicated only when medical treatment fails and/or complication arises. The selection of an appropriate method of management for a particular patient varies based on underlying clinical features, imaging, and complications.

Keywords Chronic pancreatits, Clinical profile, Management

282

Internal pancreatic fistulae – A case series from tertiary care center

Amarnath A , Gayathri Gopalakrishnan, Nandish H K, Kiran R, Rangarajan Kasturi

Correspondence – Amarnath A - amar.ashwath@gmail.com

Department of Medical Gastroenterology, Narayana Hrudalaya, Electronic City, Bangalore 560 100, India

Pancreatic fistula is an abnormal connection between the pancreatic ductal epithelium and another epithelial surface containing pancreas-derived, enzyme-rich fluid [1]. Disruption of the pancreatic duct leads to leak of pancreatic fluid producing erosion and forming different pathways resulting in internal and external pancreatic fistulae [2]. Internal fistulae usually result as a complication of acute and chronic pancreatitis. External pancreatic fistulae are commonly seen post pancreatic surgery or trauma [2]. If duct disruption is anterior, fluid drains into peritoneal cavity, leading to pancreatic ascites [3]. If disruption is posterior, it leads to development of pleural effusions, commonly on left side [3]. However right pleural effusion, bilateral effusions and pericardial effusions have also been rarely reported [4, 5]. Diagnosis is made by fluid amylase levels, usually more than 3 times serum amylase levels [6]. Computerized tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) are useful to identify the fistulous communications, but are not always diagnostic [7].

We report 5 cases of internal pancreatic fistulae managed at our center. All patients were males, aged 18 years to 53 years. Two patients had underlying chronic pancreatitis and three patients presented as sequalae of acute pancreatitis. One patient had right pleural effusion. Two patients had bilateral pleural effusions and the other two had left sided pleural effusion. One patient who had bilateral pleural effusion, presented with pericardial effusion with impending tamponade requiring emergency pericardiocentesis. One of the patients with left side pleural effusion, initially presented with large pseudocysts (drained via EUS guided cysto-gastrostomy) and pancreatic ascites needing multiple large volume paracentesis. All the patients were managed with octreotide, pancreatic endotherapy and were discharged after symptomatic improvement.

Early recognition of fistulae and prompt pancreatic endotherapy results in good outcome. Clinical suspicion along with fluid analysis and cross-sectional imaging (MRI preferred over CT) would aid quick diagnosis and response.

Keywords Acute pancreatitis, Chronic pancreatitis, Pancreatic endotherapy, Pancreatic-pleural fistula, Pleural effusion

283

Percutaneous endoscopic necrosectomy: A safe and effective alternate to surgical necrosectomy - A single-center experience

Pankaj Singh, Vikas Singla, Sawan Bopanna

Correspondence – Pankai Singh - pankajdoc06@gmail.com

Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, 1 2, Press Enclave Marg, Saket Institutional Area, Saket, New Delhi 110 017, India

Background Traditionally infected/symptomatic walled off necrotic collection that fails to respond to transluminal endoscopic or percutaneous drainage requires necrosectomy. We aimed to evaluated the outcome of percutaneous endoscopic necrosectomy (PEN) as an adjunct to percutaneous catheter lavage for laterally placed WON in para-colic gutters.

Method Retrospective data of 110 consecutive patients with AP was reviewed. Data of 25 patients with ANC/WON±IPN were assessed. EUS guided transluminal drainage (n=15) followed by DEN (n=10) and percutaneous catheter drainage/lavage in combination with PEN for 7 laterally placed WON]. Both DEN and PEN in 3 patients. The primary endpoint was control of sepsis with resolution of necrosis/collections, and removal of drain catheters. The secondary endpoint was mortality, periprocedural complications, overall length of ICU and hospital stays.

Results Out of 25 patients (mean age 37.36 years, M:F=5.25:1, ANC=11, WON=14, IPN=19; twenty underwent endoscopic necrosectomy (PEN=7, DEN=10, both=3), 5 patients were managed either conservatively or with per-cutaneous catheter lavage. The etiology of pancreatitis varied: 6 biliary, 8 alcohol, 9 (idiopathic, 3 post-ERCP) with median size of necrosis of PEN=15.16 cm, DEN=12.5 cm, median number of necrosectomy sessions PEN=5 sessions, DEN=2 sessions. Median procedure time of 50 minutes per procedure for PEN, 35 min for DEN. Necrosis completely resolved in 77.77% following PEN and 92.30% following DEN. Drains removed at an average of 45 days. Peri-procedural complication: 5 intracavitary bleed, 2 colonic fistula, 3 pancreatic fistula. VARD (Videoscopic Assisted Retroperitoneal Debridement) was required in one patient, however none required open necrosectomy. 2 (8%) in hospital mortality. Predictor of mortality was >70% necrosis with abdomen compartment syndrome.

Conclusion Percutaneous endoscopic necrosectomy minimally invasive step-up treatment approach for laterally placed infected necrosis inaccessible to transluminal endoscopic treatment is a safe and effective alternate to Surgical necrosectomy.

Keywords Direct endoscopic necrosectomy, Infected pancreatic necrosis, Necrotizing pancreatitis, Percutaneous catheter drainage, Percutaneous endoscopic necrosectomy

284

Retrospective analysis of moderately severe pancreatitis with visceral aneurysm manifesting as intra-cystic or gastrointestinal bleed: A tertiary centre experience

Pritam Das , Dhruv Thakur, S Rakesh Kumar, Malla V A Gangadhar, Gaurav Pande, Samir Mohindra

Correspondence – Samir Mohindra - mohindrasamir@yahoo.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India

Introduction Visceral aneurysm comprises of major vascular complications in acute moderate severe pancreatitis. Visceral aneurysm manifesting as intra-cystic bleed may lead to delayed diagnosis and lead to poor prognosis. Aneurysmal bleed may also present in a varied manner, ranging from hemosuccus pancreaticus to occult gastrointestinal (GI) bleeding.

Case Review We retrospectively analyzed the patients presenting to Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow with moderate severe pancreatitis in the time period between July 2017 and July 2022. A total of twenty-nine patients had visceral aneurysm complicating the course of pancreatitis. The most common site of aneurysm was splenic artery aneurysm (13 cases, 44.8%), followed by gastroduodenal artery (8 cases, 27.5%), pancreaticoduodenal artery (3 cases, 10.3%), right gastroepiploic artery (2 cases, 6.9%). Coil embolization was done in 18 patients (62.06%) whereas arterial graft was placed in 2 patients. Of them 2 patients had rebleeding, one of them within 6 weeks, with source being a different artery, and the other patient had re-bleeding after 6 months and the patient succumbed to death. 24 (82.75%) patients had peripancreatic collection, predominantly lesser sac collection. Among the total patients, 11 (37.9%) patients had chronic pancreatitis, whereas 6 (20.6%) had recurrent acute pancreatitis. Sixteen out of 24 (66.67%) patients had history of active alcohol abuse.

Conclusion Anatomical location of the collection, nature of collection and active alcohol abuse may be independent risk factor for visceral aneurysm formation in cases of pancreatitis. However, chronicity of pancreatitis and relation with visceral aneurysm needs further studies.

Keywords Aneurysm, GI bleed, Moderate severe pancreatitis, Visceral aneurysm

285

An unusual cause of abdominal pain following extracorporeal shock wave lithotripsy in a young patient of chronic calcific pancreatitis

Animesh Shah , Vikas Bharti, Prabha Sawant, Ankit Dalal, Gaurav Patil, Amit Maydeo

Correspondence – Animesh Shah- animesh92@gmail.com

Department of Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Dr E Borges Road, Opp Shirodkar School, Parel. Mumbai 400 012, India

Background Extracorporeal shock wave lithotripsy (ESWL) is the preferred modality for pancreatic calculi measuring >5 mm. Although safe, major complications have been reported in less than 1% of patients.

The Case A 25-year-old female suffering from chronic calcific pancreatitis presented with recurrent left-sided upper abdominal pain with weight loss. Physical examination was unremarkable. She had prior history of ESWL followed by endoscopic retrograde cholangiopancreatography (ERCP) four years ago for pancreatic duct calculi. On present evaluation, a plain abdominal X-ray showed a large radiopaque calculus near the head of pancreas and subsequent computed tomography (CT) scan revealed a dilated and tortuous pancreatic duct with multiple intraductal calculi. So, planned for ESWL followed by ERCP. The first session of ESWL was performed with a total of 7,000 shocks. The patient tolerated the procedure well. On the next day, she had severe abdominal pain with persistent vomiting and a tender abdomen. Laboratory investigations showed increased pancreatic enzymes leukocytosis and raised C-reactive protein levels. She was managed with intravenous (IV) fluids and IV analgesics, and a CT was performed which revealed diffuse atrophy of the pancreas with changes of chronic pancreatitis. Bulky appearing head and uncinate process with multiple ill-defining hypoenhancing areas within the uncinate process was suggestive of early necrosis without vascular involvement. She received nasojejunal tube feeding and recovered gradually hence was discharged on liquid diet. She had an uneventful recovery.

Conclusions Development of acute necrotizing pancreatitis after ESWL is an extremely rare complication. Early detection and timely intervention can safely treat this condition. Clinicians should be aware of this rare entity.

Keywords Abdominal pain, Complication, ESWL, Necrotizing pancreatitis, Outcome

286

A curious case of jaundice

Nitish Ashok Gurav, Sundeep Lakhtakia, P Bharath Kumar Reddy

Correspondence – Nitish Ashok Gurav - niti0102@gmail.com

Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

A 54-year-old male patient presented with painless progressive jaundice, generalized itching and clay-colored stools, weight loss of around 3-4 kgs over 2 months. He was incidentally found to have right renal mass in 2007 for which he underwent right nephrectomy (renal cell carcinoma-clear cell variant). One month later, he developed gait abnormality and slurring of speech - right cerebellar space occupying lesion. He underwent posterior fossa craniotomy and lesion removal (multiple dilated capillary network in the background of astrocytes and purkinje cells). Follow-up abdominal imaging 5 years later revealed multiple non enhancing cystic lesions in pancreas, likely benign. Serial imaging showed an increase in number and size of pancreatic cystic lesions.

Patient is born to a non-consanguineously married couple. Two of his younger brothers have developed RCC in the recent past for which they underwent nephrectomy.

Liver function test (LFT) showed cholestatic pattern. Magnetic resonance imaging (MRI) abdomen - large complex cystic lesion (41×36 mm in head and uncinate process of pancreas, ?serous cystadenoma. Distal CBD compression causing upstream dilatation noted.

Endoscopic ultrasonography-multiple pancreatic cysts? serous cystadenoma, largest in pancreatic head compressing CBD. Multiple cysts noted in left kidney. Patient underwent endoscopic retrograde cholangiopancreatography (ERCP), biliary sphincterotomy and plastic stent placement. Follow-up LFT showed improvement.

Patient was suspected to have syndromic association and genetic analysis was done. Custom variant sequencing showed positive for VHL gene rs5030825 (C>T) variant, heterozygous genotype. His siblings too tested positive for the same variant.

As the serial abdominal imaging showed increase in size and number of pancreatic cystic lesions, he was counseled regarding need for total pancreatectomy. His children were advised to undergo genetic surveillance.

Conclusion Patient was diagnosed to have Von Hippel Lindau syndrome. This report emphasizes on the need to evaluate pancreatic cysts which are multiple, progressive, especially in those patients with multisystem involvement.

Keywords Jaundice, Pancreatic cysts, Von Hippel Lindau syndrome

287

Acute pancreatitis complicating dengue fever – A retrospective observational study

Vijay Rampally, Ravi Shankar Bagepally

Correspondence – Ravi Shankar Bagepally - b_ravishankar@yahoo.com

Department of Gastroenterology. Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India

Background and Objectives Acute pancreatitis is believed to be a rare complication of dengue fever [1, 2]. This retrospective, observational, South Indian study was undertaken to assess the incidence of acute pancreatitis in dengue patients [3], to determine the mortality rate and risk factors in patients who developed acute pancreatitis.

Methods The clinical, laboratory, and other relevant patient data were collected from the medical records of the patients with confirmed diagnosis of dengue admitted to Yashoda Hospital, Secunderabad. The diagnosis of acute pancreatitis was based on revised Atlanta criteria. The association between acute pancreatitis and mortality in dengue was evaluated using Chi-square test and Fisher’s exact test and a probability (p) value of less than 0.05 was considered as the level of significance.

Results A total of 702 dengue patients (mean age 28.7 years) were included in the study. The severity of infection was recorded as dengue fever, dengue hemorrhagic fever, and dengue shock syndrome in 42.16%, 55.55% and 2.28% of the patients, respectively. Fever, chills, weakness, vomiting, and body pain were the most common presenting features, while thrombocytopenia, leukopenia, raised transaminase levels (SGPT, SGOT) and low serum albumin levels were the important laboratory markers of complications. Acute pancreatitis was diagnosed in 41 (5.8%) patients. Mortality rate in this study population was 1.7%, while mortality rate in patients who developed acute pancreatitis was 7.31%. Increasing age (≥51 years) was a risk factor for acute pancreatitis in dengue patients.

Conclusion In this retrospective, observational study involving 702 Indian patients with dengue, the incidence of acute pancreatitis was found to be 5.8%. Acute pancreatitis may not be a rare complication but may be under-reported in clinical practice. It was significantly associated with mortality. Table 1 Summary

Keywords Dengue, DHF, DSS, Leucopenia, Mortality, Serum amylase, Serum lipase, Thrombocytopenia

288

Fecal Elastase-1 in acute and chronic pancreatitis: A preliminary study

Arun Kumar Sharma , V Sharma, K K Prasad, Anupam Singh, S K Sinha, U Dutta

Correspondence – Arun Kumar Sharma - arunsharma792001@yahoo.co.in

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Background Pancreatic Elastase-1 is an anionic endoprotease secreted from pancreas and it remains undegraded during intestinal transit. The stool concentration of pancreatic Elastase-1 reflects the exocrine pancreatic function. This study was done to estimate fecal Elastase-1 level in patients of acute and chronic pancreatitis admitted at this centre. Pancreatic elastase were also tested in patients other than that of pancreatic involvement namely patients of dyspepsia in order to know the level of pancreatic elastase in their stool using the same kit. Method Patients of acute pancreatitis, chronic pancreatitis and dyspepsia attending Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh between January 2020 to May 2022 were included in the study. Stool samples were collected and stored at -20°C. The quantitative estimation of pancreatic Elastase-1 in stool was done by using IDK Pancreatic Elastase ELISA kit (Immunodiagnostik AG, Germany).

Results The level of fecal elastase in 23 patients of acute pancreatitis (median age 36.5 years, M:F-13:9) was 325.43 μg/gm±78.14 (Mean±S.D). The fecal elastase level in 27 chronic pacreatitis (Median age 38.6 years, M:F-22:5) was 154.81 μg/gm±123.01 (Mean±S.D). Pancreatic elastase in 55 dyspeptic patients (Median age 41.5 years, M:F-37:18) was 525.21μg/gm ± 205.06 (Mean ± S.D).

Conclusion Fecal Elastase-1 is considerably reduced in chronic pancreatitis patients compared to acute pancreatitis patients. However more patient studies are needed to know the levels of fecal elastase in patients of chronic pancreatitis in our population.

Keywords Acute pancreatitis, Chronic pancreatitis, Fecal Elastase-1

289

Natural history of asymptomatic walled off necrosis in patients with acute pancreatitis

Manish Kumar ^* , Siddharth Srivastava, Sanjeev Sachdeva, Poonam Narang, Ashok Dalal, Bhawna Mahajan, Ujjwal Sonika

Correspondence – Manish Kumar - drtomarmanish@gmail.com

^*Department of Gastroenterology, Kailash Hospital, H-33, Shaheed Arjun Sardana Marg, H Block, Pocket H, Sector 27, Noida 201 301, India, and Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Background and Objectives Studies on natural history of asymptomatic walled-off necrosis (WON) in acute pancreatitis (AP) are scarce. We conducted a prospective observational study to look for incidence of infection in WON.

Methods Thirty consecutive AP patients with asymptomatic WON were included. Their baseline clinical, laboratory and radiological parameters were recorded and were followed-up for 3 months. Mann-Whitney ‘U’/Unpaired t-test was used for quantitative data and Chi- square/Fisher’s exact was used for qualitative data-analysis. “P” value <0.05 was considered significant. Receiver operating characteristic (ROC) analysis was done to identify the appropriate cut-offs for the significant variables.

Results Thirty patients were enrolled, 25 (83.3%) were males. Alcohol was the commonest etiology. Eight patients (26.6%) developed infection on follow-up. All were managed by drainage either percutaneously (n=4, 50%) or endoscopically (n=3, 37.5%). One patient required both. No patient required surgery and there was no mortality. Median baseline C-Reactive protein (CRP) was higher in infection group 76 (IQR 34.8) mg/L vs. asymptomatic group, 9.5 mg/dL (IQR 13.6), p<0.001. IL-6 and TNF-alpha were also higher in infection group. Size of largest collection (157.50±33.59 mm vs. 81.95±26.22 mm, p<0.001) and CT severity index (CTSI) (9.50±0.93 vs. 7.82±1.37, p<0.01) were also higher in infection group as compared to asymptomatic group. ROC curve analysis of baseline CRP (cut-off 49.5 mg/dL), size of WON (cut-off 127 mm) and CTSI (cut-off 9) showed AUROC (Area Under ROC) of 1, 0.97 and 0.81 respectively for the future development of infection in WON.

Conclusion Around one-fourth of asymptomatic WON patients develop infection on 3 months follow-up. Most patients with infected WON can be managed conservatively. Keywords Acute pancreatitis, Asymptomatic, Infection, Walled-off necrosis

290

Neutrophil-lymphocyte ratio as prognostic marker in assessing acute pancreatitis outcome

Rakesh Garlapati, Venkata Ranga Reddy, Mohan Reddy

Correspondence – Rakesh Garlapati - rakeshreddy117@gmail.com

Department of Gastroenterology, Kurnool Medical College, Near, Bhudawarapet Bharath Petroleum, Kisan Ghat Road, Kurnool 518 003, India

Introduction Acute pancreatitis is one of the most common cause of emergency hospital admissions in India. The neutrophil–lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process and helpful categorising the patients.

Aim To determine an optimal ratio of NLR for severity prediction.

Methods Prospective cross-sectional study was done in Department of Gastroenterology, Kurnool Medical College in 100 consecutive acute pancreatitis (according revised Atlanta criteria) patients visiting gastroenterology OPD. Blood samples were collected immediately on admission and end of 48 hours. Relevant radiological investigations were done.

Results and Discussion Alcohol etiology was common cause of pancreatitis. The mean NLR on admission in mild group was 6.2±1.2 and the moderate group was 9.1±1.6. The mean NLR of severe group was 13.6±2.5. The differences between the severity were statistically significant (p<0.001). The mean NLR at end of 48 hours in Mild was 4.7±0.7, The moderate group was 8.3±1.2 and the mean NLR of severe group was 14.8±1.6. The differences between the severity were statistically very highly significant (p<0.001).

Conclusion NLR can be done at the time of admission and can be serially monitored which can act as a guide to detect those patients progressing to severe pancreatitis. NLR is a cost effective, simple tool which can be calculated in any level care of hospital be it a secondary care or a tertiary care hospital.

Keywords Acute pancreatitis, NLR, Severity

291

Role of C-reactive protein in predicting severity of acute pancreatitis

Bilal Sheik , Venkata Ranga Reddy, Mohan Reddy

Correspondence – Bilal Sheik - shannu.ashique@gmail.com

Department of Gastroenterology, Kurnool Medical College, Budhwarpet Road, Budhawarapeta, Kurnool 518 002, India

Introduction Acute pancreatitis is a major debilitating disease of the gastrointestinal tract, having high morbidity and creating a huge physical, financial, and emotional stress to the affected individual. C-reactive protein (CRP) is probably the most studied serum biomarker and considered a marker of severity in pancreatitis.

Aim To determine the role of CRP in predicting severity of acute pancreatitis.

Methods Prospective observational study was done in Department of Gastroenterology, Kurnool Medical College in 70 patients admitted to the gastroenterology ward with acute pancreatitis (according to revised Atlanta criteria). Blood samples were collected immediately at the time of admission. Relevant investigations were done

Results and Discussion Alcohol is the common etiological factor for acute pancreatitis. The CRP had good predictive validity in predicting severe acute pancreatitis at a cut-off value of ≥ 174 mg/L. CRP had a sensitivity of 83.33%, specificity of 82.69%, PPV of 62.50%, and NPV of 93.48% with a total diagnostic accuracy of 82.86% making it a good marker for the prediction of severe acute pancreatitis. There was a statistically significant relationship between CRP and severe acute pancreatitis (p-value <0.001).

Conclusion The use of CRP as a way of predicting the severity of acute pancreatitis is a viable alternative to existing prediction methods and is feasible for use in emergency departments.

Keywords Acute pancreatitis, CRP, Severity

292

Infected pancreatic necrosis–Prospective evaluation of interventions and outcomes

Gauri Nayak , Jahangeer Basha

Correspondence – Gauri Nayak - gauri.nayak.17@gmail.com

Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Background Infected pancreatic necrosis represents a diagnostic and therapeutic challenge. Some form of intervention becomes necessary in such groups of patients to reduce the burden of their morbidity and mortality. Hence, we aim to study the interventions in infected pancreatic necrosis, the timing of the interventions, complications thereof, and the final outcome.

Methodology All patients of infected pancreatic necrosis with clinical suspicion of infection (fever, raised TLC) or evidence of infection on imaging studies and/or persistent organ failure despite conservative treatment were prospectively evaluated in our study. Interventions in patients not responding to conservative management were studied along with the day of pancreatitis on which they were performed. Outcomes were analyzed in the form of mortality, nature, and timing of interventions, need for reinterventions, microbial pattern of infection, etc.

Results One hundred patients qualified the inclusion criteria. 66% were males and majority were in the age group of 18–30 years. The most common cause of pancreatitis was alcohol induced followed by idiopathic cause, hypertriglyceridemia, gallstone induced and traumatic pancreatitis. Forty-three percent of patients had organ failure on Index contact. Seventy-four percent patients had a CT severity score of >5. Twenty patients had pancreatic ascites and 37 patients had abdominal venous thrombosis. Seventy patients underwent percutaneous drainage, 36 underwent endoscopic ultrasound guided drainage and 24 patients underwent both. Forty-three patients underwent necrosectomies (38 percutaneous and 30 endoscopic). Eleven patients had to undergo surgical necrosectomies. Forty-four patients underwent interventions within 28 days (11 endoscopic and 33 percutaneous drainages). Mortality in the early drainages (< 28 days) was 13% and 9% in the late drainage patients.

Conclusion Infected pancreatic necrosis still poses a challenge to treat. selection and performance of an appropriate intervention in the proper clinical setting will decrease the burden of morbidity and mortality.

Keywords Infected pancreatic necrosis, Interventions

293

Factors affecting pain relief in patients undergoing extracorporeal shock wave lithotripsy in chronic calcific pancreatitis

Nitish Ashok Gurav, Chandragiri Praneeth, Nitin Jagtap, Manu Tandon, D Nageshwar Reddy

Correspondence – Nitish Ashok Gurav - niti0102@gmail.com

Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Introduction Paradigm shift in the management of chronic calcific pancreatitis (CCP) with large ductal calculi includes extracorporeal shock wave lithotripsy (ESWL) followed by pancreatic ductal clearance by endotherapy. The safety and efficacy of ESWL for painful CCP is well established. However, independent predictors of persistent pain are not defined yet. Prior knowledge regarding the presence of these factors helps in predicting pain relief response and therapy towards treating these additional factors.

Method A total of 187 consecutive adult patients of CCP, who underwent successful ESWL and ERCP and PD stent placement were prospectively followed for 6 months. The pain was assessed at baseline and at 6 month using Izbicki pain score. The independent predictors of complete pain relief were derived from logistic regression analysis.

Results Of 187 patients, 177 (94.65%) had complete or partial pain relief while remaining 10 had no pain relief. On univariate analysis, older age, male gender, active smoking and alcohol intake, main pancreatic duct (MPD) stricture, stone density, absence of diabetes were associated persistent pain at 6 month after ESWL (p<0.05). While the presence of parenchymal calcification, CBD stricture, small fluid collection, portal vein thrombosis were not associated with persistent pain (p>0.05). On logistic regression analysis; active alcohol abuse (OR 9.36; 95% CI 3.9–22.2), active smoking (OR 3.41; 95% CI 1.1–10.7), MPD stricture (OR 15.5; 95% CI 4.6-51.7), higher stone density (OR 1.002; 95 CI 1.001–1.003); absence of diabetes (OR 2.75, 95% CI 1.2–6.1) were independent predictors of absence of complete pain relief at 6 months.

Conclusion Active alcohol abuse, smoking, MPD stricture, higher stone density and absence of diabetes are independent predictors of persistent pain after ESWL. Response to therapy in CCP patients should be explained considering the above factors as few of these factors are modifiable.

Keywords Chronic calcific pancreatitis, Extracorporeal shock wave lithotripsy, pain

294

Inter-observer agreement on ‘assessment of debris’ during endoscopic ultrasound guided drainage of walled off pancreatic necrosis

Partha Pal , Sandeep Lakhtakia, Nitin Jagtap, Shujaath Asif, Krithi Krishna Koduri, Rajesh Gupta, Jahangeer Basha, Azimudin Haja, Aniruddha Pratap Singh, Ashirwad Pasumarthy, Jagdeesh Rampal Singh, Rakesh Kalpala, Mohan Ramchandani, D Nageshwar Reddy

Correspondence – Sundeep Lakhtakia - drsundeeplakhtakia@gmail.com

Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-662, Somajiguda, Hyderabad 500 082, India

Introduction Estimation of solid component in a walled off pancreatic necrosis (WOPN) during endoscopic ultrasound (EUS) is important to guide stent selection WOPN drainage but often not objectively quantified. We studied inter-observer agreement (IOA) among endosonographers assessing debris in pancreatic fluid collection (PFC) and their choice of stent.

Methods EUS videos of 15 patients having PFC with concurrent magnetic resonance imaging (MRI) assessment of debris were independently reviewed by 40 endosonographers for percentage of debris (10% increments) and their choice of stent (plastic or metal). The Fleiss’ Kappa (κ) coefficient was used to assess IOA. Post-hoc analysis was done using wider debris intervals (20% increments).

Results A poor agreement was observed for the percentage of debris (κ-0.188) which did not improve (κ-0.196) even after including only expert endosonographers having >10 years experience (n=33). There was fair agreement (κ-0.266) with reference MRI on percentage of debris. On post-hoc analysis, the IOA (κ-0.293, fair agreement) and agreement with MRI (κ-0.456, moderate agreement) improved as the debris intervals widened from 10% to 20%. The agreement for stent selection (plastic vs. metal) was poor (κ-0.174) that did not improve with case volume (κ 0.153 among respondents with >25 EUS guided drainage/year, n=21) or years of experience (κ 0.195 for >10-year experience, n=33).

Conclusions IOA between endosonographers regarding estimation of debris in WOPN and subsequent stent choice for drainage is poor. Experience of endosonographers did not improve IOA. Studies to standardize the EUS criteria for debris assessment in WOPN and subsequent therapeutic approach are warranted.

Keywords Endoscopic ultrasonography (EUS), Interventional EUS, Pancreatic fluid collection (PFC), Training. Walled of pancreatic necrosis (WOPN)

295

Rare complication of acute pancreatitis with an unusual presenting symptom

Digvijaysinha Hodgar , Sandip Pal

Correspondence – Digvijaysinha Hodgar - doc.digvijayhodgar@gmail.com

Department of Gastroenterology, R N Tagore Hospital, Premises No: 1489, Mukundapur Main Road, 124, Eastern Metropolitan Bypass, Mukundapur, Kolkata 700 099, India

Acute severe pancreatitis is associated with many early and late complications involving multiorgan system. Thoracic complications of pancreatitis are rare. Commonly seen thoracic complications are ARDS, pleural effusion. Here, we will be presenting a case of acute pancreatitis with very rare complications viz pancreatico-bronchial fistula along with pancreatic duct disruption.

Keywords Pancreatico-bronchial fistula

Endoscopy

296

Endoscopic ultrasound features of upper gastrointestinal tract and pancreaticobiliary system in the opium addicts: A prospective longitudinal observation study

Amandeep Sidhu, Sudhir Maharshi, Shyam Sunder Sharma

Correspondence – Amandeep Sidhu - amansidhu4104@gmail.com

Department of Medical Gastroenterology, Sawai Man Singh Medical College, New SMS Campus Road, Gangawal Park, Adarsh Nagar, Jaipur 302 004, India

Objective Asymptomatic dilatation of bile duct and symptomatic sphincter of Oddi dysfunction have been reported in opium addicts. So far, only one study and 2 case reports had been published in the literature. Aim of this study to evaluate various parameters of upper gastrointestinal tract (UGI) and pancreaticobiliary system by using endoscopic ultrasound (EUS) in opium addicts.

Methods A total of 20 opium addicts presenting with upper abdominal pain and fulfilling all the inclusions and exclusion criteria were included in this study. EUS findings of upper GI tract and pancreaticobiliary system were analyzed in these patients.

Results All the 20 patients were males (median age 53.3 years; range 35-70) presented with upper abdominal pain. Median duration of opium addiction was 20.1 years. On EUS common bile duct (CBD) was dilated in all the patients (median 9.3 mm; range 7-12 mm) while PD was dilated in 8 (40%) patients (median 3.7 mm). CBD wall thickening was seen two (10%) patients. Aspartate transaminase, alanine transaminase and alkaline phosphatase were above the normal range in five (25%) and two (10%) patients respectively. Gallbladder (GB) wall was thickened in 3 (15%) patients (median 3.5 mm). EUS findings of esophagus, duodenum, stomach, liver, and pancreatic parenchyma were normal. Surface area of papilla of Vater (SPV= >25 mm²) was increased in 12 (60%) patients.

Conclusion Opium addiction causes obstruction at ampulla. CBD was dilatation in all while PD dilatation was seen in 40% patients. GB wall thickening and increased SPV was a peculiar finding as a result of direct effect of opium on GB and ampulla respectively.

Keywords Common bile duct, Endoscopic ultrasound, Pancreatic duct

297

Challenges faced in endoscopic management of proximal esophageal perforations: Surgery, FCSEMS, clips, combinations- thinking out of the box to achieve good patient outcomes with multidisciplinary management

Sushant Sethi, Rajat Khandelwal

Correspondence – Rajat Khandelwal - rajat87md@gmail.com

Department of Gastroenterology, Apollo Hospitals, Plot No. 15, Sainik School Road, Bhubaneshwar 751 005, India

Upper esophageal perforations/fistulae present a unique challenge to the endoscopist. We present three such cases seen over four months, with varying scenarios.

Case discussion A female aged 55 developed a cervical esophageal perforation on swallowing her denture. Endoscopic removal of the impacted foreign body, done with great patience, revealed a gaping defect in cervical esophagus postero-laterally at 25 cm from incisor teeth. Weighing options of surgery vs. endotherapy, jointly decided to deploy FCSEMS to cover the perforation after a tracheostomy, knowing that the proximal flange would remain in the pharynx. Proximal stent migration occurred despite clip fixation of distal flange, and endoscopic repositioning was required. After 5 weeks stent was removed, and video fluoroscopy showed no leakage of contrast extraluminally. Imaging revealed a minute defect in posterior aspect of esophagus at C7 level which healed in three weeks on continuing NJ feeds. Patient is doing well at one year follow-up.

A 45-year-old male, presented with dysphagia due to a TEF, caused by prolonged (3 months) intubation and ventilation due to severe corona virus disease – 19 (COVID-19) pneumonia. Endoscopic closure of the esophageal fistula was performed using two endoclips. Tracheostomy and TEF closure was performed by surgical colleagues. Endoscopic healing was confirmed at 4 weeks.

A 37-year-old male developed esophageal perforation in posterior surface at D8 vertebral level after ingestion of a chicken bone. Endoscopy showed fistulous opening at 33 cm from incisor teeth however no foreign body was found in the lumen. FCSEMS was deployed to cover the fistula and proximal end fixed with endoclips. Stent migrated distally once causing recurrent vomiting and was repositioned. Endoscopically fistulous opening healed at 4 weeks.

Conclusion A tailored approach with endoscopic tools, and timely surgical intervention may hold the key to improving outcome in management of proximal esophageal perforations.

Keywords Cervical esophagus perforation, FCSEMS

298

Comparison of serum lactic acid and urea-creatinine ratio with Rockall, Glasgow Blatchford and AIMS65 score in risk stratification of patients with acute upper gastrointestinal hemorrhage

Anto Gnana Delasallem, Bailuru Vishwanath Tantry, Sandeep Gopal, Suresh Shenoy, Anurag Shetty

Correspondence - Anto Gnana Delasallem - anto19893@gmail.com

Department of Medical Gastroenterology, Kasturba Medical College Hospital, Nandigudda Road, Attavar, Mangaluru 575 001, India

Introduction Upper gastrointestinal (UGI) bleeding is a common emergency requiring admission to the intensive care unit. A number of clinical scores have been developed to aid in the prediction of mortality risk. In this study we evaluated the role of serum lactic acid and urea-creatinine ratio (UCR) in risk stratification of patients.

Methods This was a prospective observational study conducted on 30 patients with UGI bleed over a period of 18 months. At admission, baseline blood investigations included measurement of serum lactate levels, and calculation of UCR, Glasgow Blatchford (GBS), Rockall and AIMS65 scores. These were correlated with the primary (inpatient and thirty-day mortality) and secondary outcomes (need for ICU stay, requirement of blood transfusion, re-bleeding and need for endoscopic/surgical/radiological interventions).

Results In this study the mortality rate was found to be 11.3% (8 patients). Mean lactate levels were significantly higher in the non-survivor group (86.48 mg/dL) in comparison to the survivors (32.09 mg/dL). Elevated lactate levels (>45 mg/dL) was found to be a better predictor of mortality (area under ROC curve 0.868, p<0.0.1), when compared to Rockall, GBS and AIMS 65 scores with a sensitivity of 90.9% and a specificity of 81%. However, UCR was a poor predictor of mortality. On analysis of secondary outcomes, a serum lactate of >40 mg/dL at admission was associated with increased length of ICU stay (3.06 days, p<0.01), increased requirement of blood transfusions (2.63 units, p–0.01), increased requirement of inotropic support and endoscopic interventions. UCR was not found to have any significant association.

Conclusion Our study shows that serum lactate levels is useful in predicting in-hospital and thirty-day mortality in patients with UGI bleed. However, UCR showed no similar benefit. Lactate levels can be incorporated into the existing risk stratification scores for better prediction and timely intervention, in patients with UGI bleed.

Keywords Lactate, Upper GI bleed, Urea creatinine ratio

299

Clinical profile, endoscopic finding and outcome of patients with upper gastrointestinal bleed attending a tertiary-care hospital: A retrospective cross-sectional study

Srija Sen , Bailuru Vishwanath Tantry, Sandeep Gopal, Suresh Shenoy, Anurag Shetty

Correspondence – Srija Sen- srijasen01@gmail.com

Department of Medical Gastroenterology, Kasturba Medical College Hospital, Nandigudda Road, Attavar, Mangaluru 575 001, India

Introduction Upper gastrointestinal bleed is a common acute medical emergency. Endoscopy is the gold standard diagnostic and therapeutic tool in the management of upper gastrointestinal bleed. This study was undertaken to look into the clinical profile, endoscopic finding and outcomes in patients with upper gastrointestinal bleed.

Methods A retrospective cross-sectional study was conducted in a tertiary care teaching hospital in Mangalore from June 2020 to November 2021. The sample size was calculated. Eighty patients with upper gastrointestinal bleed were included in the study. Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 22.

Results Variceal hemorrhage was the most common etiology of UGI bleed and was seen in 55% of patients, and the most common lesion within the group was found to be large esophageal varices (73.3%), followed by non-variceal bleed (45%), in which duodenal ulcer was found to be most common (44%). Almost one third of patients had a previous history of upper GI bleed (35.5%) and the most common presenting symptom was hemetemesis (78.57%) followed by melena (68.75%). The mortality at the time of discharge was found to be 11.25% (9 out of 80) and overall mortality at 30 days was 13.75% (11 out of 80). Eight of these patients had variceal hemorrhage and 3 had non-variceal hemorrhage. Mortality rate was higher in those with variceal hemorrhage (18.18%), as compared to non-variceal bleed (8.34%). The mean of the Rockall score, Glasgow Blatchford score and AIMS65 scores were higher in the non-survivors compared to the survivors. Bad prognostic factors were rebleeding, variceal etiology and Rockall score > 6.

Conclusion UGI bleed of variceal etiology presented with a higher Rockall score, had more rebleeding and higher mortality than those with non-variceal etiologies. Early gastroscopy within 24 hours is recommended for diagnosis and timely intervention in upper gastrointestinal bleed that helps in reducing morbidity and mortality.

Keywords Duodenal ulcer, Rockall score, Upper GI bleed, Variceal hemorrhage

300

Endoscopic removal of impacted coin from esophagus: A case report

Shatdal Chaudhary, Nagendra Chaudhary^*

Correspondence - Shatdal Chaudhary - shatdalchaudhary@yahoo.com

Departments of Internal Medicine, and ^*Paediatrics, Universal College of Medical Sciences, Siddhartha Nagar 32900, Nepal

Introduction Impacted foreign bodies are some of the most challenging emergencies encountered by endoscopists. The commonly ingested foreign bodies are coins, toys, and batteries in children whereas impaction of either bone or meat bolus during eating are common in adults. We have come across case of impacted coin in lower esophagus in a 5-year child.

Methods A 5-year-old boy presented in Pediatric OPD with ingestion of a coin of 13 hours duration. After a quick evaluation, chest X-ray posterior-anterior view and lateral view were performed which has shown an impacted coin in lower esophagus. Written informed consent was taken from child’s parents and upper GI endoscopy was performed under general anesthesia to remove the coin.

Results Coin was impacted in lower esophagus, just above lower esophageal sphincter with aberration of esophageal mucosa at impacted site. Coin slipped in stomach during the procedure. Coin was removed with Roth net. Child was kept for observation for 48 hrs and discharged uneventfully.

Conclusion Foreign body ingestion is commonly seen in children and young adults. Roth net is a safe and effective tool in removing coin from upper gastrointestinal tract.

Keywords Endoscopy, Foreign body, Roth net

301

Real time qualitative endoscopic ultrasound elastography assessment for evaluation of benign and malignant mediastinal and abdominal lymph nodes

S Rakesh Kumar, Ashiq Hussain Dar*, Malla V A Gangadhar Rao, Dhruv Thakur, Pritam Das, Gaurav Pandey, Samir Mohindra

Correspondence - S Rakesh Kumar - dr.srk2018@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India, and ^*Ganesh Shankar Vidyarthi Memorial Medical College, Swaroop Nagar, Kanpur 208 002, India

Background and Objectives Endoscopic ultrasound elastography (EUE) is a novel method of measuring tissue stiffness during endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). This prospective study was conducted to evaluate the diagnostic utility of endoscopic ultrasound guided elastography for diagnosing benign and malignant lymph nodes in the mediastinum and abdomen.

Methods A total of 70 patients were enrolled between June 2021 and February 2022 who had lymph node enlargement (mediastinal, abdominal) on computed tomography (CT) examination, and lymph nodes were evaluated by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). EUE of lymph nodes was performed prior to EUS-FNA. A linear probe EUS was used with processor to assess elastographic patterns that were classified based on color distribution as follows: Type 1, predominantly green (green, yellow and red); Type 2, part blue, part green (greenish blue); Type 3, predominantly blue. Pathologic assessment of lymph nodes was used as the gold standard. The elastographic patterns were compared with the final pathologic results from EUS-FNA. For tuberculosis, confirmation histopathology as well as polymerase chain reaction PCR (GeneXpert) method were correlated.

Results On pathological evaluation of the 70 lymph nodes, 26 were malignant and 43 were benign among which 8 were PCR (GeneXpert) positive for TB. Among Type 3 lymph nodes on EUE: malignant in 20/24 (83.3%) and benign in 4/24 (16.7%); for Type 2 lymph nodes, 13/17 (76.4%) were benign and 4/17 (23.6%) were malignant; Type 1 lymph nodes were benign in 27/29 (93.1%), malignant in 1/29 (3.4%). In classifying type 1 as benign and type 3 as malignant taking cut-off elasto score 2; the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were found to be 87%, 91.3%, 83.3% and 93.3% respectively.

Conclusion EUS elastography of mediastinal and abdominal lymph nodes is non-invasive technique that can be performed reliably for assessment and differentiation of benign and malignant lymph nodes.

Keywords EUS elastography, EUS FNA, Malignant lymph node

302

Endoscopic ultrasound-guided combined coil and glue injection for the primary prophylaxis of the gastric variceal bleed

Pankaj Kumar , Surinder Rana ^* , Rajesh Gupta ^* , Ravi Kumar Sharma ^**

Correspondence - Pankaj Kumar - pankdoct2@gmail.com

Department of Gastroenterology, Ojas Superspeciality Hospital, Sector 26, Panchkula 134 116, India, ^*Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India, and ^**Department of University Institute of Biotechnology, Chandigarh University, Mohali 140 413, India

Introduction Gastric varices attributes to 20% of all variceal bleeds and are associated with a high risk of uncontrolled bleeding, rebleeding, and death compared to esophageal varices. Endoscopic ultrasound (EUS)-guided combined coil and glue injection has been shown to be an effective therapy in acute bleeding and secondary prophylaxis of gastric variceal bleed, however, there is a paucity of data on primary prophylaxis.

Methods Single-center retrospective analysis of adult patients with age >18 years who underwent EUS guided combined coil and glue injection for the primary prophylaxis of high-risk gastric varices (gastric varices size >15 mm on EUS or cherry-red spot on endoscopy) between April 2018 and June 2022 was performed. The analysis included technical success, rate of adverse events and risk of bleeding.

Results Eighteen patients (77.2% males) with mean age of 43±11.4 years were included in the study. Fifteen (83.3%) patients had IGV1 varices, whereas GOV2 varices were seen in 3 (16.7%) patients. Mean variceal size was 2.5±0.55 cm. technical success was achieved in 100%, and 100% of patients had EUS confirmation of GV obliteration with EUS at 7 days and at 6 months. Only one EUS session was required in all the patients to obliterate the gastric varices. The mean number of coils used were 2 (1-3) and mean glue volume injected was 2.2 mL (1.5-2.5 mL). Mean follow-up period was 37.8±7.9 months and 2 patients had gastric variceal bleed which was managed successfully with repeat endoscopy sessions. No deaths related to gastric variceal bleed occurred.

Conclusion EUS guided combined coil and glue injection for primary prophylaxis of high risk gastric varices is technically feasible, safe and highly effective in preventing gastric variceal bleed.

Keywords EUS guided coil and glue injection, Gastric varices, Variceal bleeding

303

Predictors of inadequate bowel preparation in patients taking split dose preparation for diagnostic colonoscopy

Aditya Kale , Michael K, Love Garg, Mayur Satai, Nitish Patwardhan, Gautam Jain, Abu Ansari, Tanmay Laxane, Shashank Punjalwar, Akash Shukla

Correspondence – Aditya Kale - adityapkale@yahoo.com

Department of Gastroenterology, 9th Floor, Ward 32 A, Seth G S Medical College and K E M Hospital, Parel, Mumbai 400 012, India

Introduction Inadequate bowel preparation results in missing out critical findings like adenomas, increases procedure time, reappointment for procedure, diagnostic delay.

Methods Adult (age >18 years) patients undergoing diagnostic colonoscopy were prospectively included from July 2021-July 2022. Demography, indication of procedure, bowel movements at baseline and after preparation, stool colour, distance from hospital, time interval between preparation completion and procedure, amount of preparation taken, diet and water consumption in preceding 24 hours, history of poor preparation were noted. Boston bowel preparation score (BBPS) <6 was considered poor preparation. All patients received split dose bowel preparations (Polyethylene glycol based or Coloprep containing sodium sulphate+potassium sulphate+magnesium sulphate or sodium phosphate based – Exelyte solution).

Results Total 400 cases (male-217, 54.3%) were included. Median age was 42 years (interquartile range [IQR]-28-54 years). Diagnosis of bowel thickening (85, 21.3%), evaluation of gastrointestinal (GI) blood loss (87, 21.8%), chronic diarrhea (63, 15.8%), constipation (48, 11.5%) were the common indications for colonoscopy. Poor bowel preparation was seen in 43 (10.8%) cases. On univariate regression, number of bowel movements after bowel preparation (0.04), requirement add on T. Bisacodyl (0.001), turbid stool colour (0.024), amount of preparation consumed (0.003) were associated with poor preparation. On multivariate analysis, preparation without Tablet Bisacodyl (0.013), amount of bowel preparation consumed (0.027), amount of free water taken with preparation (0.036), turbid stool after bowel preparation (0.048) were associated with inadequate bowel preparation.

Conclusion Poor bowel preparation was noted in 10.8% cases. Amount of bowel preparation consumed, amount of free water consumed with bowel preparation, preparation without tablet Bisacodyl and turbid stool color after bowel preparation were associated with poor bowel preparation at diagnostic colonoscopy, after split dose bowel preparation regimens. Use of tablet Bisacodyl as add on to bowel preparation may improve the preparation.

Keywords Adenoma detection, Bisacodyl, Boston bowel preparation score, Bowel preparation

304

Forgotten common bile duct plastic stents: An experience from tertiary care referral center

Nitish Patwardhan, Aditya Kale, Shashank Pujalwar, Gautam Jain, Tanmay Laxane, Abu Asim Akhtar Ansari, Amrit Gopan, Arun Vaidya, Akash Shukla

Correspondence - Nitish Patwardhan - nitp_18@rediffmail.com

Department of Medical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, Multistoried Building, 9th Floor, Acharya Donde Marg, Parel. Mumbai 400 012, India

Background and Aims Plastic stents (PS) placed in common bile duct (CBD) mandates timely stent removal or replacement sessions. Despite appropriate counseling, retention of CBD PS for >3 months often occurs. We assessed the prevalence and impact of retained CBD stents and outcomes of endoscopic endotherapy.

Methods Prospectively maintained endoscopy database was reviewed from November 2019 - April 2022 to identify patients with retained CBD PS (Indwelling stent in CBD for >3 months).

Results Two hundred and fifty-two patients (median age-46 years [interquartile range - IQR-31-56 years], males 150 [61%]) had retained CBD stent of which 180 (71%). Median duration of PS in CBD was 5 months (IQR-4-6 months). Corona virus disease – 19 (COVID-19) pandemic related delay in procedure was reported by 84 (33.3%) patients of which 28 were symptomatic. Sixty-seven (26.6%) were symptomatic with abdominal pain (n=31[12.3%]), cholangitis (n=22 [8.7%]), jaundice (n=14 [5.6%]). Stent migration and stent fragmentation was noted in 5 (2%) patients each. All patients with stent migration were symptomatic (5 vs. 0, p-0.001). Multiplicity or duration beyond 3 months of stents was not associated with reduced risk of symptoms. Fifty-five (21.82%) patients had normal imaging findings while 197 (78.17%) had obstructive dilatation of biliary tree. All patients underwent CBD clearance or stent exchange, retrieval of migrated stent with 100% technical success. Three patients with cholangitis and septic shock died despite stent exchange.

Conclusion COVID pandemic resulted in delayed exchange/removal in one third cases. Retained CBD PS causes significant symptoms, complications, morbidity, and mortality.

Keywords CBD stent retention, Complications, COVID-19

305

Capsule endoscopy for obscure gastrointestinal bleed in tropics: A single center experience on 350 patients

Uday C Ghoshal, Piyush Mishra, Anshuman Elhence, Akash Mathur, Bushra Fatima, Anand Prakash Agrahari, Asha Misra

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Background Obscure gastrointestinal bleed (OGIB) comprises 5% to 10% of all gastrointestinal (GI) bleed episodes and capsule endoscopy (CE) is an indispensable tool for evaluation of such patients. There is paucity of literature on OGIB evaluation from the tropics with majority of previous studies having small sample size.

Methodology We did a retrospective analysis of patients presenting for OGIB evaluation to a tertiary care center from September 2003 till July 2021. CE was done using either PillCam SB or MiroCam capsule after overnight fasting and polyethylene glycol preparation. Clinical demographic data, type of bleed-overt vs. occult, spectrum of lesion and age-wise yield of CE was analyzed.

Results Of 350 patients (aged 52.39±17.36 years, 70.9% male), 107 (30.6%) and 243 (69.4%) had OGIB-occult and OGIB-overt, respectively. Lesions were picked up in 244 (69.7%) with multiple etiologies in 72 (20.6%) and single etiology in 172 (49.1%) patients. Amongst single etiology, lesions identified were vascular malformations in 52 (14.9%), ulcer in 47 (13.4%), tumor in 24 (6.9%), hookworm in 19 (5.4%) and stricture in 15 (4.3%) patients. Amongst multiple etiologies ulcer with stricture was the most common finding in 43 (12.3%) patients. There was no difference in rate of detection of lesions with respect to change in oro-cecal transit time and/or recording duration and lesions were detected in comparable frequency in both groups who underwent 8 (PillCam) or 11 hours (MiroCam) of recording. Young patients (0-39-y) more often had multiple etiologies detected on CE than the older (≥40-y) patients (26/76, 34.2% vs. 46/228, 20.2%, respectively; p=0.001). Lesions were detected in a comparable frequency among patients with obscure overt and occult bleed (173/243, 71.2% vs. 71/107, 66.3%, respectively; p=0.4).

Conclusion CE has a high diagnostic yield in OGIB in the tropics, regardless of the type of bleed or duration of CE procedure. Younger age group more often have multiple etiologies for OGIB as compared to elderly.

Keywords Lesions, Oro-cecal transit time, Tropics

306

Risk factors for early re-bleed following endoscopic variceal band ligation and assessing utility of dedicated score (BICAP score) to identify high risk groups

Ramu Krishnan, Kandasamy Kumar, Poppy Rejoice, A Shafique

Correspondence - Ramu Krishnan - drramukrishnan87@gmail.com

Department of Medical Gastroenterology, Tirunelveli Medical College, 3, High Ground Road, Palayamkottai, Tirunelveli 627 011, India

Background Endoscopic variceal band ligation (EVBL) is a universally accepted and approved treatment for bleeding esophageal varices. Re-bleed is the most common complication following EVBL. Ours is a prospective study analyzing risk factors for early re-bleed (ERB) and creating a laboratory-based score (BICAP) for detecting high-risk groups for re-bleed.

Methods The study period was between March 2021 to March 2022 when 111 patients underwent EVBL in our department. Patients were followed by telephone or direct visits weekly for 1 month. ERB was defined by active variceal hemorrhage presenting as hematemesis in a patient following EVBL within 1 month. Endoscopy was done for all patients after re-bleed to confirm.

Bedside Index for Severity in Acute Pancreatitis (BISAP) score

	0	1	2
Bilirubin	<3 mg/dL	3-5 mg/dL	>5 mg/dL
INR	<1.5	1.5- 2.0	>2.0
Creatinine	<1 mg/dL	1-1.5 mg/dL	>1.5 mg/dL
Albumin	>3.5 g/dL	2.8 – 3.5 g/dL	< 2.8 g/dL
Platelet count	>1.5 L	50,000 to 1.5 L	<50,000
	Max score is 10

Results Among 111 patients, 26 patients developed ERB with an incidence of 23.4%. ERB was higher in emergency EVBL than elective (29.3% vs. 6.9%, p=0.014). Platelet count of < 50,000 and INR >2.0 were associated with high ERB risk (52.4%, p–0.002) and (60%, p-0.001). Overt encephalopathy was associated with 42.3% risk of ERB (p - 0.009). Usage of high number of bands (>6) were associated with increased risk of ERB (56.3%, p–0.001). Child-Pugh C patients had high risk of ERB (37.5%, p-0.001). BICAP score >7 was associated with increased risk of ERB (80%, p-0.002)

Conclusion Child-Pugh score and BICAP score both can predict high risk groups for ERB, but BICAP score is a dedicated score and can be used even in non-cirrhotic patients. BICAP score is found to have high sensitivity in detecting patients with high risk for early re-bleed.

Keywords BICAP score, Early re-bleed, Endoscopic variceal band ligation

307

Pancreatic hydatid cyst: Expanding the therapeutic armamentarium of endoscopic retrograde cholangiopancreatography

Anupam Kumar Singh ¹ , Shreya Shruti², Chhagan Lal Birda¹, Anupam Lal³, Jayanta Samanta¹, Saroj Kanrt Sinha¹

Correspondence - Saroj Kant Sinha - sarojksinha@hotmail.com

Departments of ¹Gastroenterology, and ³Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India, and ²Government Medical College and Hospital, Sector 32, Chandigarh 160 030, India

A 14-year-old female presented with epigastric pain and recurrent vomiting for five days. She had multiple similar episodes over last 2 years. Physical examination showed mild hepatomegaly and upper abdominal tenderness. Serum amylase/lipase were elevated more than five-fold. Ultrasonography revealed a cystic lesion (suggestive of hydatid cyst) in liver and a solid cystic lesion (70 × 39 mm) in body of pancreas. Pancreatic duct was dilated and contained few tiny cystic lesions. Endoscopic ultrasound and contrast enhanced computed tomography confirmed these findings. Acute pancreatitis was treated conservatively and albendazole was advised (400 mg twice daily for 21 days). Endoscopic retrograde cholangiopancreatography was performed four weeks later. Pancreatic sphincterotomy, papillary balloon dilatation and extraction of membranes from pancreatic duct were done. 10 Fr pancreatic stent was placed into cyst cavity which was removed after six weeks. Histology confirmed the diagnosis of hydatid membranes. Liver cyst was managed by PAIR method. Patient received total 6 cycles of albendazole. Follow-up imaging at 12 and 24 months showed no residual pancreatic lesion.

Discussion Hydatid cysts commonly occur in liver and only rarely in pancreas. Its rupture into pancreatic duct is an extremely rare event and can result in acute pancreatitis. The parasite is known to die on coming in contact with bile or pancreatic juice. Pancreatic ductal rupture of hydatid cyst was exploited to treat it endoscopically and was successful.

Conclusion Hydatid cysts rarely occur in pancreas. Its rupture into pancreatic duct can result in acute pancreatitis but such lesions can be treated endoscopically.

Keywords Hydatid cyst, Pancreas, ERCP

308

Hepatic hydatid cyst with biliary rupture: Balloon dilatation of cystobiliary communication to achieve cure

Anupam Lal ¹ , Shreya Shruti², Anupam Kumar Singh³, Kaushal Kishore Prasad³, Jayanta Samanta³, Saroj Kant Sinha³

Correspondence - Saroj Kant Sinha - sarojksinha@hotmail.com

Departments of ¹Radiodiagnosis, and ³Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, and ²Government Medical College and Hospital, Sector 32, Chandigarh 160 030, India

A18-year-old male presented with fever, abdominal pain and obstructive jaundice for one month. Examination showed icterus and diffuse hepatomegaly. Liver function showed conjugated hyperbilirubinemia, ultrasonography showed 9 cm size single cystic lesion in liver with floating membranes and dilated common bile duct (CBD) (14 mm). Hydatid serology was suggestive. Magnetic resonance imaging (MRI) abdomen with magnetic resonance cholangiopancreatography (MRCP) confirmed the same. Endoscopic retrograde cholangiopancreatography (ERCP) showed grossly dilated bile duct with irregular filling defects and one large cavity opacified in liver. Endoscopic sphincterotomy was performed and CBD was cleared of membranes. Cystobiliary communication was dilated with biliary balloon (8 mm). 10 F double pigtail biliary stent was placed in CBD which was removed after 4 weeks. He was treated with Piperacillin+Tazobactum for 10 days and Albendazole 400 mg twice daily for 20 days (repeated twice at interval of 3 weeks). Patient improved rapidly. Follow-up ultrasonography at 6 months showed resolution of liver lesion and normal CBD.

Discussion Hepatic hydatid cyst with biliary rupture is traditionally treated surgically. Role of ERCP is limited to biliary drainage and treatment of cholangitis. Parasite dies on coming in direct contact with bile, thus hydatid cyst rarely if ever occur in biliary system. In the index patient, the cystobiliary communication was dilated to increase bile entry into the hepatic hydatid cyst. Cyst resolved without any surgery. Although this strategy was successful in the index patient, it may not be useful in patients with multiple cysts in liver.

Conclusion Solitary hepatic hydatid with biliary rupture can be treated with ERCP and dilation of cystobiliary communication.

Keywords ERCP, Hepatic rupture, Hydatid cyst

309

Significant bradycardias during unsedated diagnostic gastroscopy- An omnipresent risk

Alok Sahu, Aastha Jha, Maitrey Patel, Apurva Shah, Shravan Bohra

Correspondence – Apurva Shah - apurvashah411@gmail.com

Department of Gastroenterology, Apollo Hospital International Limited, Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Estate, Ahmedabad 382 428, India

Introduction Gastroscopy or an upper gastrointestinal (GI) endoscopy, is a relatively safe procedure. Serious complications are seen in 1 case out of 10000 procedures. Complications are most often noted in therapeutic procedures or when intravenous sedation is being used. We present two such cases, where during unsedated diagnostic upper GI endoscopy, patients developed significant bradycardia.

Case Report We present two cases, one 71-year-old female and another 73-year-old male, who underwent diagnostic gastroscopy and developed significant bradycardia (<45 beats per minute), which required immediate abandoning of the procedure. Both of them achieved their base-line heart rate within two minutes of pulling out the scope. Both patients were asymptomatic at routine activities. Both had controlled diabetes mellitus, one of them had coronary artery disease, had undergone bypass grafting 10 years back. Second patient had mild hypertension. Although both patients were on beta-blockers, but their base-line heart rate was more than 70 beats per minute. Both of them underwent electrocardiogram which was normal and echocardiography, which did not reveal any significant wall motion abnormality or low ejection fraction.

Conclusion The likely cause for such bradycardia, without any other obvious causes cause, would be activation of vaso-vagal reflex from esophageal intubation and gastric distention by sudden air insufflation in elderly individuals. Continuation of the procedure would have been risky. Although no such cases have been reported so far as per our knowledge, where patients developed significant bradycardia without administration of intravenous sedation. There are many centers in peripheral parts of our country, performing upper GI scopies without adequate vital monitoring of the patients. These two cases provide an insight as to the need for continuous patient monitoring even during simple diagnostic upper GI endoscopy, which can turn into a fiasco if taken lightly particularly in elderly patients.

Keywords Bradycardia unsedated upper GI scopy

310

Clinical audit of enbloc resection for large colorectal mucosal lesions using endoscopic submucosal dissection from a single centre from a region non endemic for colorectal cancer – Assessing the predictive factors for difficult endoscopic submucosal dissection (ESD) and learning curve for ESD

Jaseem Ansari, Harsh Bapaye^*, Hameed Raina, Mangesh Borkar, Ashish Gandhi, Pankaj Bharambe, Ajay B R, Jay Bapaye^**, Sanjana Gokhale, Yash Kanani, Rajendra Pujari, Harshal Gadhikar, Amol Bapaye

Correspondence – Amol Bapaye - amolbapaye@gmail.com

Department of Gastroenterology, Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital, Kothrud Pune, India, ^*Byramjee Jeejeebhoy Medical College, Jai Prakash Narayan Road, Railway Station Road, Pune 411 001, India, and ^**Rorchester General Hospital

Aims Endoscopic submucosal dissection (ESD) for enbloc resection (ER) of large colorectal mucosal lesions are technically difficult and is associated with steep learning curve. This study aimed to identify the factors predicting difficulty to perform colorectal ESD and those increasing the risk of failure of ER and calculate the learning curve to achieve competency to perform colorectal ESD.

Methods Single center retrospective study. Study duration 10 years (2012–2021). One hundred and forty-nine patients with >2 cm colorectal mucosal neoplasms undergoing ESD were abstracted. Primary outcome – Identify factors predicting difficulty while performing ESD. Secondary outcomes – Identify risk factors for failure of ER and to assess learning curve based on ER rate, Speed (S) and Adverse Events (AE).

Results N = 149; mean age – 61.36 years, 101 males (67.8%). Mean size of lesion –46.62 mm (±25.46). ER – 141/149 (94.6%), R0 – 132/142 (92.9%). Mean S (mm2/min) = 9.03 ± 7.94, fastest (rectum) = 10.9, slowest (right colon) = 4.22. Previous resection attempt associated with prolonged procedure time (mean 298.44 min±161.1) compared to naïve (209.77 min ±146.44) (p<0.009). Significant increase in procedure time (Min) as area (mm²) increased, strong positive correlation (rho = 0.64, p=<0.001). For each 100 mm² increase in area, procedure time increased by 3 min. ROC curve analysis estimated final size ≤68 mm as predictor for ER (positive predictive value [PPV] 95.8%, odds ratio [OR] 14.06, p<0.001). Univariate regression analysis for ER identified lesion size as single independent predictive factor (OR 0.96; 0.95–0.98; p<0.001). Cusum curve analysis showed approximately 47 resections required to achieve compentency in ESD.

Conclusion Increase in lesion size associated with higher risk of failure for ER. Right sided colonic lesions, anastamotic site lesions and previous resection attempts associated with longer procedure time. The learning curve to attain competency in ESD are approximately 47 procedures.

Keywords Enbloc resection, Endoscopic submucosal dissection

311

Frequency, pattern and severity of endoscopic features in patients with inflammatory bowel disease- A retrospective study

Akshatha K, Sandeep Gopal, Bailuru Vishwanath Tantry, Suresh Shenoy, Anurag Shetty

Correspondence – Akshatha K - akshathakattimani.ak@gmail.com

Department of Medical Gastroenterology, Kasturba Medical College Hospital, Ambedkar Circle, Mangalore 575 001, India, and Manipal Academy of Higher Education, Manipal 576 104, India

Background Inflammatory bowel disease (IBD) is a chronic inflammatory disease of gastrointestinal tract which encompasses ulcerative colitis (UC) and Crohn’s disease (CD). UC usually presents with confluent lesions, and can involve rectum, sigmoid, left sided colitis, entire colon and while CD presents with discontinuous inflammatory lesions and frequently involves the ileocecal region. Present study was undertaken to study endoscopic patterns of IBD.

Method and Results Among total of 1303 lower GI endoscopies, 94 (7.2%) patients found to have UC and 58 (4.4%) patients had CD for duration of one year (1/8/2021 to 30/7/2022) at a tertiary care centre. Among patients with UC, 56 (59.5%) were male and 38 (40.4%) were female. Mean age was 44.47 years. Out of 94 patients, 29 (30.8%) patients had mild disease, 38 (40.4%) had moderately active disease and 25 (26.5%) patients had severe disease. Disease pattern included proctitis in 25 (26.5) patients, proctosigmoiditis in 19 (20.2%) patients and left sided colitis in 14 (14.8%) patients. Pancolitis was observed in 22 (23.4%) patients. Pseudopolyps and malignancy were present in 11 (11.7%) and one patient respectively.

Fifty-eight patients with CD were included in study. Mean age was 27.7 years, Male were 37 and females were 21. CD in remission was seen in 8 (13.7%) and 28 (48.2%) patients had mild disease, 22 (37.9%) had moderately active disease. Disease pattern in endoscopy revealed ileocolitis in 30 (51%) patients, only ileal involvement seen in 6 (10.3%) and diffuse involvement was noticed in 4 cases (6.8%). longitudinal ulcers were present in 8 (13.7%) and 5 (8.6%) had serpigenous ulcers. Luminal narrowing was observed in 6 (10.34%) and 1 patient had ascending colon stricture. Pseudopolyps and cobblestone appearance were seen among 11 (18.96%) and in 3 (3.4%) patients respectively.

Conclusion In our study majority of patients with UC had pancolitis (one fourth) and moderate to severe disease was seen in two third of the patients. In CD almost fifty percent of patients had ileocolonic involvement and fibrostenotic lesions.

Keywords Inflammatory bowel disease, Simple endoscopic score for Crohn’s disease, Ulcerative colitis endoscopic index of severity

312

White light endoscopic findings of gastric and duodenal mucosa in Helicobacter pylori infected patients: Cross sectional observational study in a tertiary hospital of south India

Debapratim Routh Routh, Chezhian Annasamy

Correspondence – Debapratim Routh Routh - debapratimraja@gmail.com

Department of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India

Background and Aims H. pylori infection causes variety of upper gastrointestinal tract diseases and can be diagnosed by various non-invasive tests, but they have high false negative results. Endoscopy plays an important role for diagnosis of various gastric and duodenal lesions. This study provides an observation of various endoscopic findings in patients with H. pylori infection (biopsy proven).

Methods It is a cross sectional observational study conducted from April 2021 to September 2021 at Medical Gastroenterology Department of Madras Medical College. Endoscopy and biopsy done at same sitting for patients who met ROME IV criteria for dyspepsia. Endoscopic images of those patients were recorded whose biopsies were positive for H. pylori. Biopsy specimens were collected as per Sydney protocol, stained by H-E staining and examined using a light microscope.

Results Out of total 200 biopsy proven H. pylori infected patients (130 male and 70 female, and mean age 39.7 years), most common endoscopic finding was spotty redness (38.5%) followed by enlarged gastric mucosal fold (20.5%), diffuse redness, mucosal edema, gastric and duodenal ulcers and antral nodularity. Least common findings were erosions (2%) and multiple dots (1%).

Discussion Various related studies support our findings but there are other studies as well which demand more validation.

Conclusion Endoscopic findings can be used as an important diagnostic tool for H. pylori infection but additional studies with larger sample sizes and more diverse populations are required to establish the association of endoscopic features with H. pylori infection.

Keywords Biopsy, Endoscopy, H. pylori, ROME IV criteria

313

A man with innumerable colonic worms

Ashish Jha , Vishwa Mohan Dayal, Arya Suchismita

Correspondence – Ashish Jha - ashishjhabn@yahoo.co.in

Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Bailey Road, Sheikhpura, Patna 800 014, India

A 28-year-old man presented with a 3-months history of diarrhea, abdominal discomfort, mucoid stool, and rectal bleeding. Examination showed pallor. Blood tests revealed hemoglobin of 10.5 g/dL and serum albumin of 3.0 g/dL. Stool examination showed barrel-shaped ova of parasite. A colonoscopy showed carpeting of the entire mucosa (predominantly left colon) with innumerable whipworms (T. trichiura) (Fig. 1). The worms were embedded in the mucosa with their slender anterior end. Mucosa showed scattered hemorrhagic spots (Fig. 1). A diagnosis of trichuris dysentery syndrome (TDS) was made. The patient was successfully treated with a course of oral albendazole (400 mg once daily, X 7-days).

Persons with whipworm infection can present with anemia, abdominal pain, appendicitis, malnutrition, weight loss, perforation, obstruction, or dysentery. The heavy worm load can cause TDS, which is characterized by mucoid or bloody mucoid diarrhea, tenesmus, and iron-deficiency anemia. Growth retardation and rectal prolapse are also seen in children. Trichuriasis can be diagnosed with identification of barrel-shaped ova in stool. Diagnosis of trichuriasis is often missed on stool microscopy in patients with light infection. Alternatively, it can be diagnosed with colonoscopy. Whipworm infestations usually do not cause mucosal changes in the colon. Colonoscopic findings may include peri-appendicular ulcers or erosions, erythema, petechial hemorrhagic spots, mucosal edema, exudates and mucosal oozing.

Whipworm is usually treated with 3-days course of oral mebendazole (100 mg twice daily) or oral albendazole (400 mg once daily). Unlike other nematodes, cure rates for T. trichiura infections are low. Endoscopic retrieval of worms followed by 3-days course of anti-helminths are effective in patients with light infection. Longer duration therapy (5-7 days) have a higher cure rate in heavily infected (more than 1000 eggs/g) patients.

Keywords Colonoscopy,Trichuris dysentery syndrome, Trichuris trichiura, Whipworms

314

Comparison of endoscopic ultrasound guided fine needle aspiration cytology and endoscopic ultrasound guided needle core biopsy in the diagnosis of abdominal Masses

Mohd Rafiq Najar , Monika Jain, Gurwant Singh Lamba, Aeshal Parmar

Correspondence – Mohd Rafiq Najar - dmrfqn@gmail.com

Department of Gastroenterology, Sri Balaji Action Medical Institute, Paschim Vihar, New Delhi 110 063, India

Introduction The management of patients with solid abdominal masses is dependent on obtaining an accurate tissue diagnosis. Endoscopic ultrasound (EUS) guided FNAC and EUS-FNB are safe and preferred method for tissue acquisition from solid gastrointestinal and extraintestinal lesions. This technique enables precise visualization of the lesion and tissue acquisition.

Aim To compare the diagnostic accuracy of EUS-FNB and EUS-FNAC in the diagnosis of solid abdominal masses.

Methods This prospective observational study was conducted in 58 patients who underwent EUS-FNB and EUS-FNAC for diagnosis of solid abdominal masses on cross-sectional imaging. Needle size of 22 gauge were used for sample collection. Technical success and number of needle passes for tissue acquisition were noted for both the techniques. Histopathology and FNAC reports were followed.

Results Number of passes required for the tissue acquisition were less in EUS-FNB compared to EUS-FNAC, but the difference was not statistically significant. Diagnostic accuracy was higher in EUS-FNB (57/58, 98.30%) as compared to EUS- FNAC (54/58, 93.10%) but the difference was not significant statistically. The sensitivity of EUS-FNB was higher (52/53, 98.1%) compared to the sensitivity of EUS-FNAC (49/43, 92.4%) which was statistically significant (p value 0.04). Negative predictive value of EUS-FNB (5/6, 83.2%) was higher than the negative predictive value of EUS-FNAC (5/9, 55.5%) which was statistically significant (p value < 0.0001). Positive predictive value, specificity, technical success for tissue acquisition and complication rate were statistically comparable for both the methods of tissue acquisition.

Conclusion The EUS-FNAC and EUS-FNB are effective methods of tissue acquisition. EUS-FNB has better sensitivity and negative predictive value than EUS-FNAC. Diagnostic accuracy of EUS-FNB was higher compared to EUS-FNAC but not of statistical significance.

Keywords EUS, EUS-FNAC, EUS-FNB and abdominal masses.

315

The unexpected and unique balloon stuck complication during endoscopic retrograde cholangiopancreatography in a patient with choledocholithiasis

Bilal Mir , Brij Sharma, Rajesh Sharma, Vishal Bodh, Ashish Chauhan, Tahir Majeed, Rajesh Kumar

Correspondence – Bilal Mir - mir13bilal@gmail.com

Department of Gastroenterology, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India

Background Common bile duct (CBD) clearance for choledocholithiasis using balloon catheter is well established approach during endoscopic retrograde cholangiopancreatography (ERCP). The most common and well known ERCP related complications include pancreatitis, bleeding, perforation, and infection. We reported a unique complication of stuck balloon in CBD and is probably first ever case recorded in literature. Case presentation: A middle aged female underwent ERCP for symptomatic choledocholithiasis. During procedure, CBD balloon (biliary extraction balloon, Boston scientific) got stuck-in while doing balloon sweep and neither came out nor got deflate despite different and exhaustive manoeuvring. Given the uniqueness of complication and failure of endoscopic approach, we cut the balloon catheter distal to inflation and wire entry port and removed the duodenoscope leaving behind the stuck balloon with remaining catheter. Patient was taken up by surgery team and managed with open cholecystectomy with choledochotomy with T tube-drainage along with removal of stuck CBD balloon. While the stuck stone near proximal summit of balloon explains the failure of balloon coming out and complete extrinsic compression of air passage of catheter by surrounding stones probably explains the failure of balloon inflation-deflation process.

Conclusion It seems pertinent to provide patients prior information about unique complications such as balloon stuck and balloon burst in addition to well-known complications and we should have back-up to deal with such cases. Hereby we reported a unique case of ERCP related complication and its subsequent surgical management.

Keywords Balloon catheter, Choledocholithiasis, Endoscopic Retrograde Cholangiopancreatography

316

Plastic stents versus metal stents for endoscopic ultrasound-guided transmural drainage of walled-off necrosis with significant solid debris: A randomized controlled non-inferiority trial

Rinkalben Kakadiya , Gaurav Muktesh ^* , Jayanta Samanta, Jimil Shah, Harshal Mandavdhare, Pankaj Gupta, Vikas Gupta, Thakur Dindayal Yadav, Rakesh Kochhar

Correspondence – Gaurav Muktesh - gauravmuktesh@gmail.com

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India, and ^*Department of Gastroenterology, Al Zahra Hospital, Gastroenterology, Dubai, United Arab Emirates

Background Recently large-calibre metal stents are increasingly being used, assuming higher efficacy compared to the plastic stent. However, the better efficacy of metal stents is not proven by existing studies. Treatment success was not the primary outcome of the previous randomized controlled trial (RCT), which is the major endpoint. Hence, we conducted non-inferiority RCT (plastic stents are not inferior to metal stents).

Methods This single-centre, open-label, RCT enrolled 48 patients with symptomatic WON (>20% solid debris). The primary outcome was treatment success (symptom plus radiological resolution) of WON. Secondary outcomes were technical success rate, number of procedures required, adverse event, procedure duration, and treatment failure. We assessed all outcomes three weeks after drainage with cross sectional imaging. Patients were followed up for three months to determine recurrence.

Results Twenty-four patients were randomized in each arm. The treatment success was achieved in 21(p1=87.5%) and 20 (p2=83.3%) patients in metal stent and plastic stent groups, respectively, with P1/p2 being 1.05 (95% confidence interval [CI] is 0.81 to 1.39). Assuming a 10% noninferiority margin using the Gart Nam score method, the p-value was <0.001 for non-inferiority. As noninferiority p-value was below the threshold, we conclude that plastic stent is non-inferior to the metal stent. The secondary outcomes were comparable in both groups (Table). DPDS was present in 41/48 (87.5%) patients. One asymptomatic recurrence was seen in metal stent.

Variable	Metal stent (n=24)	Plastic stent (n=24)	P-value
Volume of WON (mL) Median, IQR (Range)	411,710 (125-2148)	370, 328 (73-1230)	0.174
Solid debris (%)	32.083 ±11.1	28.542 ±8.9	0.230
Technical success	100%	100%	1.000
Numbers of procedure	2.8±1	2.2±1	0.097
Procedure duration	12.95±5.3	29.77±6.6	0.001
Bleeding	1,4.1%	1,4.1%	1.000
Stent Migration	0	1,4.1%	1.000
Failure	1,4.1%	1,4.1%	1.000

Conclusion Plastic stents are not inferior to metal stent in terms of treatment success in transmural drainage of WON. However, a large study is needed to make definite conclusions.

Keywords Metal stents, Plastic stents, Walled off necrosis

317

Clinical profile and outcome of iatrogenic colonic perforations at a tertiary care centre in south India

Noble Mathews , Sudipta Dhar Chowdhury, Vijay Balaji, Anoop John, Ajith Thomas, Rajeeb Jaleel. Amit Dutta, Ebby Simon

Correspondence – Sudipta Dhar Chowdhury - sudipta@cmcvellore.ac.in

Department of Gastroenterology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Iatrogenic colonic perforations are a serious complication of colonoscopy. Although rare, identifying risk factors and optimizing treatment may reduce the occurrence of perforations and their severe complications. This study aimed to determine the frequency of iatrogenic colonic perforations and their management.

Methods A retrospective review of hospital electronic medical records of patients with iatrogenic colonic perforations following colonoscopy between April 2012 to April 2022. The demographic data, procedural information, site of perforation, and outcome were recorded.

Results A total of 42,825 endoscopic colonic procedures were performed. Sixteen colonic perforations occurred (0.037%). The most common site of perforation was at the rectosigmoid. Thirteen patients underwent laparotomy of which, the site of perforation was not localized in three patients and managed with peritoneal washout. Seven patients underwent laparotomy and primary closure, while 3 had a diversion procedure and secondary closure. Of the 3 patients managed non-surgically, one underwent needle decompression while the other 2 were handled with supportive care. Three deaths occurred among the colonic perforations, all three had a severe systemic illness and could not be salvaged following the perforation.

Conclusion Iatrogenic perforations are a rare but serious complication following colonoscopy. Early detection and management have good outcomes in otherwise well patients. Careful selection of patients for colonoscopy and preferably avoiding a full colonoscopy in patients with severe systemic illness may help reduce mortality associated with this routinely performed procedure.

Keywords Colonoscopy, Perforation

318

Rotational thrombo-elastometry reduces fresh frozen plasma transfusion in patients without liver disease undergoing therapeutic endoscopic procedures with deranged screening coagulation tests

Pegatraju Bharadwaj ¹ , Ebby George Simon¹, Tulasi Geevar², Rutvi Dave², Sukesh Chandran Nair², Aby Abraham³, Joseph A J¹, Amit Kumar Dutta¹, Sudipta Dhar Chaudhury¹, Rajeeb Jaleel¹, Anoop John¹, Ajith Thomas¹

Correspondence – Pegatraju Bharadwaj - Krishnabharadwaj004@gmail.com

Departments of ¹Gastroenterology, ²Transfusion Medicine, and ³Hematology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Rotational thrombo-elastometry (ROTEM) is a viscoelastic test used in patients with liver disease for guiding blood component use. We aimed to compare the amount of blood products transfused, bleeding and survival rates in patients with and without hypocoagulable ROTEM who underwent therapeutic endoscopic procedures with deranged standard coagulation tests (prothrombin time, PT; activated partial thromboplastin time, aPTT; and platelet count) without liver disease.

Methods Clinical details of patients with deranged parameters without liver disease and who underwent therapeutic endoscopic interventions between 1st January 2020 and 31st May 2022 were retrospectively analyzed. Baseline parameters, amount of blood products transfused and outcomes like 30-day bleeding and survival rates were compared between those with and without hypocoagulable ROTEM.

Results Of the 204 patients with deranged parameters, 180 patients with liver disease were excluded. Six patients (M: F=5:1; median age: 37 years) had hypocoagulable ROTEM and 18 patients (M:F=11:7; median age:56 years) were without hypocoagulable ROTEM. Both groups were comparable in baseline characteristics except platelets (p=0.04) and aPTT levels (p=0.04). There was significant difference in total amount of fresh frozen plasma (FFP) infused and FFP infused per patient between the groups (9000 mL vs. 4500 mL; p=0.001 and 1875 mL vs. 875 mL; p=0.04). Two patients with hypocoagulable ROTEM rebled within 30 days and none in another group (p=0.05). One patient in hypocoagulable group died and none in another group (p=0.25).

Conclusions Use of ROTEM reduces FFP use in those patients without liver disease who underwent therapeutic endoscopic procedures with deranged screening coagulation tests without any increased risks of 30-day re-bleeding risk and mortality.

Keywords Fresh frozen plasma, Rotational thromboelastometry, Therapeutic endoscopic procedures

319

Can a skin disorder cause sudden onset dysphagia and melena?

Arshiya Siddiqua , Raghu D K, Sarath Chanra G, K Soma Sekhar Rao, Naveen Polavarapu

Correspondence – Arshiya Siddiqua - arshiya.siddiqua@outlook.com

Department of Medical Gastroenterology, Apollo Hospitals, Road Number 72, Film Nagar, Hyderabad 500 033, India

Introduction Bullous pemphigoid (BP) is an autoimmune illness that primarily affects the elderly and the middle-aged. It manifests with varying degrees of mucosal involvement. However, gastrointestinal mucosal involvement is rare.

Case Report We report a 75-year-old female, recently diagnosed with BP and on treatment with steroids, presented to the hospital with a history of acute onset dysphagia and melena. After initial stabilization, endoscopy was performed, which showed hemorrhagic bullae throughout the esophagus. No other cause of bleed or dysphagia was identified. She was put on a high-dose steroid regimen along with proton pump inhibitors, as well as azathioprine. Monitored regularly, and her symptoms subsided. Steroids tapered and stopped with no recurrence of similar symptoms.

Conclusion Although GI mucosal involvement is rare in BP, it should be considered a differential of GI bleeding in patients affected by this disease. Esophageal involvement in BP usually manifests as hemorrhagic bullae involving the mucosa, which can cause esophageal luminal narrowing and dysphagia symptoms, and when ruptured manifests as GI bleed. Definitive management is with high doses of steroids along with immuno-suppression.

Keywords Bullous pemphigoid, Dysphagia, Esophageal involvement, Melena

320

Clinical spectrum of magnet ingestion in children: Experience from a single center in south India

Jayalakshmi K , Anupama Nagar, Amit G Yelsangikar, Kayal Vizhi, Raghu B M, Naresh Bhat

Correspondence – Jayalakshmi K - jaya.arundhathi74@gmail.com

Department of Medical Gastroenterology, Aster CMI Hospital, No. 43/2, New Airport Road, NH.7, Hebbal, Sahakara Nagar, Bengaluru 560 092, India

Introduction Majority of magnet ingestions occur in children. They are accidental/unintentional. High powered magnets with neodymium are used in toys because of impressive strength (5-10 times stronger than traditional magnets). When ingested as multiple or along with a metal, they attract each other across the wall of the GI tract causing high rate of complications (75%) such as ischemia, perforation, fistula formation, obstruction, peritonitis, or death.

Methods We report 4 children (up to 18 years of age) with magnet ingestion presenting to our emergency/outpatient department from June 2020 to October 2021 and their clinical presentation including complications, management, and outcomes.

Results Four children (3 years-7 years) with accidental history of ingestion of magnets were included in the study. The clinical features were vomiting in 2 (50%), pain abdomen in 2 (50%), constipation in 1 (25%), asymptomatic in 2 (50%). The number of magnets ingested were one in 1, three in 2, ten in 1 child. Child with single magnet ingestion was managed conservatively. 2 of 4 (50%) children underwent successful endoscopic removal. One child with a bead of three magnets in the jejunum was removed using single balloon enteroscope. Child with multiple (10) magnet balls required intraop endoscopy and removal of magnets from the stomach. Two children had complications - cecal perforation in one, jejunal perforation and colonic mesenteric defect and peritonitis in the other. They were managed surgically and did well post-operatively.

Conclusion Intervention is a must when more than one or single magnet with metallic objects are ingested. Aggressive and early removal to reduce potential morbidity and mortality. The observation period and the decision for removal should not exceed 6 hours

Keywords Endoscopy, Magnets, Perforation

321

Predictors of variceal rebleeding after endoscopic variceal ligation

Kamuni Abhishek

Correspondence – Kamuni Abhishek - abhisheksmrt6@gmail.com

Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India

Background/Aims Variceal rebleeding is a life-threatening complication in patients with cirrhosis and portal hypertension and occurs within first few weeks. Mortality associated with each bleeding episode ranges from 30% to 50%. Present aim of the study is to identify the factors associated with early rebleeding after band ligation.

Methods A total of 100 patients with variceal bleeding confirmed on endoscopy were included in this study. The patients were divided into rebleeding and non-rebleeding groups. Complete history, physical examination, laboratory investigations and abdominal ultrasound (US) were performed for all patients.

Results Incidence of rebleeding within 4 weeks was around 10%. Factors significantly associated with rebleed were Child-Pugh class C, MELD-Na >24, presence of PVT and HRS.

Conclusion Predicting factors of early rebleeding after EVL will help endoscopist to plan further sessions and to pursue further lines of management such as TIPS.

Keywords Band ligation, Rebleeding

322

Underwater endoscopic mucosal resection for large sessile colorectal polyps- A tertiary care oncology center experience

Aadish Jain , Sridhar Sundaram, Prachi Patil, Shaesta Mehta

Correspondence – Sridhar Sundaram - drsridharsundaram@gmail.com

Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), 1202 B Wing, Pariwar Saflya, Sewri, Mumbai 400 015, India

Background Underwater-endoscopic mucosal resection (uEMR) is a novel method for resection of sessile colorectal lesion without submucosal injection. The aim of our study was assessment of efficacy and safety of uEMR for resection of large (>10 mm) sessile colorectal lesions.

Methods Retrospective review of prospectively maintained endoscopy database was done for patients who underwent underwater endoscopic mucosal resection for colorectal polyps >10 mm, between January 2021 to July 2022. Size, location, number, morphologic appearance of the polyp were recorded. The polyp was completely inundated in water and resection was done using snare. Ablation of resection margin using snare-tip and clip application for defect closure was done as per endoscopist’s discretion. Study outcomes were complete resection (primary outcome), en-bloc resection, recurrence (on scar biopsy at 3 and 6 months), and adverse events.

Results Over 18 months, 33 patients underwent underwater EMR of whom 25 patients (mean age 53+12.1 years) were eligible for inclusion. uEMR was done for 27 lesions (mean size 21.3+8.5 mm, range 10–45 mm). Most common location was the left colon (15 [55.5%] lesions). The most common morphology was Paris type 0-Is in 18 (66.6 %) lesions, Paris IIa in 7 (25.9 %) lesions and Is+IIa in 2 (7.4%) lesions. All lesions were completely removed (100 %) by uEMR. En-bloc resection of the lesion could be done in 23 lesions (85.1%) and piecemeal in 4 (14.8%). Low grade dysplasia was seen in 16 lesions on histopathology (59.2%). Grade II deep mural injury was seen in 2 patients (7.4 %) and mild bleeding was seen in one patient (3.7%). All managed by applying haemostatic clips. Evidence of recurrence was not seen in 10 patients on follow-up.

Conclusion Underwater EMR is a safe and effective technique for resecting large sessile colorectal lesions.

Keywords Endoscopic resection, Sessile colorectal lesion, underwater EMR

323

Yoga for bowel preparation: A novel study

Manas Kumar Panigrahi , Harsh Prakash Jain, Mohd Imran Chouhan, Rajesh Manik, Ajaya Ghosh R U, Shivam Sethi, Madhav Sameer Makashir, Hemanta Kumar Nayak, Subash Chandra Samal, Mansi Chaudhary, Biswa Mohan Padhy

Correspondence – Manas Kumar Panigrahi - manaskumarpanigrahi@gmail.com

Department of Gastroenterology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India

Introduction Diagnostic accuracy of colonoscopy depends on the quality of bowel preparation. Despite being the most used method of bowel cleaning, polyethylene glycol (PEG) electrolyte solution is far from being the ideal agent. Shankhaprakshalana is a yogic method to cleanse the bowel. It involves the use of warm saline water and a combination of five asanas. This study was designed to assess the quality of bowel preparation by Shankhaprakshalana.

Methods A prospective observational study was conducted in the Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar. Patients planned for colonoscopy were screened and enrolled to undergo bowel preparation by Shakhaprakshalan (SP) on the day of colonoscopy. A low fiber diet (<10 g/day) for one day before colonoscopy. SP was done under supervision of a yoga trainer. In each cycle patients were advised to drink 400 ml of lukewarm saline water followed by five asanas (exercises) of SP (Tadasana, Tiryaka tadasana, Katichakrasana, Tiryaka bhujangasana and Udarakarshanasana), each done eight times. After completing six such cycles patients underwent colonoscopy. Boston bowel preparation score (BBPS) was used to assess the quality of bowel preparation.

Results A total of 109 patients were included. Mean age was 38 years (range 15 - 70) with a higher proportion of men (male-86, female-23). Mean BBPS was 7.87 (SD±1.24). BBPS was <6 in only two patients. Mean segmental BBPS for the 3 segments of colon (right, transverse and left) was 2.59 (SD±0.49), 2.68 (SD±0.52), 2.57 (SD±0.70), respectively. Segmental BBPS was <2 (inadequate) in 5 patients (4.5%). Adverse events in the form of nausea (n=2, 1.8%), vomiting (n=1,0.9%), abdominal pain (n=2,1.8%) and dizziness (n=1, 0.9%) were seen in a few patients.

Conclusion Findings from this study have given encouraging results on use of Shankhaprakshalana with adequate bowel preparation achieved in >95% patients with low incidence of adverse events.

Keywords Boston bowel preparation scale (BBPS), Bowel preparation, Colonoscopy, Yoga

324

Diagnostic yield and technical performance of novel motorized spiral enteroscopy compared to single-balloon enteroscopy in suspected Crohn's disease: Interim analysis of a randomized controlled study (The MOTOR-CD trial)

Partha Pal, Piyush Viswakarma, Mohan Ramchandani, Aniruddha Singh, Palle Manohar Reddy, Hardik Rughwani, Rupa Banerjee, Rajendra Patel, Anuradha Sekaran, Swathi Kanaganti, Polina Vijayalaxmi, Santosh Darisetty, Jagdeesh Rampal Singh, Pradeep Rebala, Guduru Venkat Rao, D Nageshwar Reddy, Manu Tandon

Correspondence – Partha Pal - partha0123456789@gmail.com

Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-662, Somajiguda, Hyderabad 500 082, India

Introduction Both single balloon enteroscopy (SBE) and novel motorized spiral enteroscopy (NMSE) are effective techniques for device assisted enteroscopy (DAE). To date, no study has compared both modalities in suspected Crohn’s disease (CD) in a randomized controlled manner.

Methods Patients with suspected CD requiring DAE between May 2022 to August 2022 in a high volume tertiary center were prospectively randomized into NMSe or SBE group which were compared with regard to diagnostic yield, depth of maximal insertion (DMI), procedure time and total enteroscopy rates.

Results In this interim analysis, 77 (total target 124) suspected CD patients (25.6% female,18-73 years) underwent DAE (9-bidirectional). The diagnostic yield was 94.2% with SBE and 100% with NMSE (p=0.2). DMI was higher with antegrade NMSE (DMI [cm]: median [range]: NMSE: 500 [80-600], SBE: 150 [50-350], p<0.0001). Procedure time was not significantly different between NMSE and SBE [duration (min): median (range): NMSE: 50 (7-180), SBE: 35 (10-170), p<0.0001; retrograde: NMSE: 25 (20-60), SBE: 60 (20-180), p<0.088). To adjust for variable location of lesions, depth to time ratio was compared between NMSE and SBE which was significantly higher with NMSE (median [range], NMSE: 9.2 [2 - 27.5]; SBE: 4.1 [1-13.6], p<0.0001). Total enteroscopy rate was higher with NMSE (42.8% vs. 0% with SBE, p<0.0001). All adverse events were mild.

Conclusions Both NMSE and SBE are safe and effective for small bowel evaluation in suspected CD. NMSE scores over SBE with regards to deeper small bowel evaluation with complete small bowel coverage and shorter procedure time (NCT05363930).

Keywords Crohn’s disease, Device-assisted enteroscopy, Novel motorized spiral enteroscopy, Single-balloon enteroscopy, total enteroscopy

325

Endoscopic retrograde cholangiopancreatography related perforations:10-year experience from a tertiary care centre in south India

Ajith C Kuriak Ose, Sudipta Dhar Chaudhary

Correspondence – Sudipta Dhar Chaudhary - sudiptadharchaudhary@gmail.com

Department of Gastroenterology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Perforation is one of the most dreaded complications of endoscopic retrograde cholangiopancreatography (ERCP). Since it is uncommon, there has been little study of incidence and outcomes of management. We aimed to study the incidence, characteristics, and outcomes of ERCP-related perforations over a 10-year period at our centre.

Methods We retrospectively analyzed prospectively collected data of patients who underwent ERCP from April 2012-June 2022. The demographic profile, indication, time of diagnosis of perforation, clinical and radiological presentation were assessed. The management, complications, length of hospital stay, and patient outcomes were also recorded.

Results A total of 6552 ERCPs were performed during the study period. Twenty-seven perforations were identified yielding a cumulative incidence of 0.41%. Majority of the procedures were done by trainee endoscopists. The mean age of patients was 53.2 years and majority (63%) were females. Most common indication was choledocholithiasis (66.7%) and others were malignant extrahepatic biliary obstruction (18.5%), biliary stricture (11.1%). Precut papillotomy was done in 7 (25%) patients. Majority of perforations were identified intraprocedure (59%). Commonest type was Stapfer type II (12,44%) followed by type I (10, 37%), type IV (3, 11%) and type III (2, 7%). Majority of patients (14, 51.8%) were managed conservatively. Seven (25.9%) were managed surgically, 4 (14.8%) endoscopically and 2 (7%) underwent percutaneous drainage. Mean hospital stay was 11.2 days (range 5–43 days). Majority (24, 88%) of the patients improved and were discharged. Three (11%) patients were sent discharge against medical advise (DAMA). There were no deaths recorded.

Conclusion We report a low incidence (0.41%) of ERCP related perforations. Majority of the patients had a good outcome with conservative management alone. Early recognition of perforation during the procedure, can help to institute appropriate therapy.

Keywords ERCP related perforations, Post ERCP complication, Stapfer classification

Motility Disorders

326

Comparison of Indian cut offs with Chicago classification v4.0-Is it really needed?

Mayank Jain

Correspondence – Mayank Jain - mayank4670@rediffmail.com

Department of Gastroenterology, Arihant Hospital and Research Centre, 297 Indrapuri, Near Bhanwarkuan, Indore 452 017, India

Background Chicago classification v 4.0 (CCv4.0) has used a database of 469 healthy volunteers (55% women, median age of 28 years, age range of 18-79 years) across 4 continents using the 3 available commercial high-resolution manometry (HREM) systems. Recent Indian data has suggested that normative data for water perfusion manometry system in Indians is different from the West.

Aim of the study To determine the change in manometry diagnosis in patients with esophageal motility disorders using CC v4.0 and Indian cut offs.

Methods This retrospective study included all patients referred for HREM study to our centre between 2019 and 2021. The analysis was done using Indian cut offs and CCv4.0 for all cases. Correlation between the two sets of final reports for concordance was done. A p value of <0.05 was considered significant.

Results A total of 105 cases were recruited. There was 100% concordance between reports using both reporting systems for normal motility and disorders of esophagogastric junction (Table 1). Ten cases (30.3%) labelled as ineffective esophageal motility were classified as normal as per Indian cut-offs. There was excellent correlation between the two reporting systems.

Conclusion CCv4.0 reporting is adequate for Indian patients with normal motility and disorders of esophagogastric junction. One third of patients with ineffective motility are classified as normal as per Indian cut offs.

Keywords Chicago, Esophageal, Indian, Motility

327

Misnomer rectal motility disorder: High volume center case series of solitary rectal ulcer syndrome

Jasmeet Singh Dhingra, Nirmaljit Singh Malhi, Rajiv Grover, Achal Garg

Correspondence – Jasmeet Singh Dhingra - doctorjasmeet@gmail.com

Department of Gastroenterology, Advanced Gastroenterology Institute-The Gastrociti, Ludhiana Road Vth Floor Orison Hospital, Barewal Road, Ludhiana 141 008, India

Introduction Solitary rectal ulcer syndrome (SRUS) is an outcome of defecatory disorder with multiple presentations. This retrospective study from a high-volume center aims to identify the clinical presentation, risk factors, colonoscopic findings, pathological features and therapeutic interventions in patients presenting with SRUS.

Methods This is a retrospective study of all patients diagnosed with SRUS at Advanced Gastroenterology Institute: AGI The GASTROCITI in Ludhiana for a 30 month period from February 2020 to July 2022. Cases were identified using the Department of Endoscopy database. Data were obtained from medical records that included clinical manifestation, endoscopic findings, and histopathological features.

Results Out of total diagnostic colonoscopic procedures (Approx. 4800), 30 patients were identified. The mean age was 52.5 years (±18.5) and 70% (21) were males. 80% (24) patients had bleeding per rectum, 70% (21) had constipation and 50% (15) had straining with a mean symptom duration of 16.7 months. The most common associated factors identified were constipation (70%), digital rectal manipulation (40%), history of high-pressure water jet use to clean after defecation in 20 %, history of rectal surgery (10%), and rectal prolapse (10%). Endoscopic findings included a large single ulcer (50%) and multiple ulcers (30%); 40% had a polypoidal appearance. One patient had a proliferative mass like appearance with rectal stricture. Endoscopic finding of difficulty to obtain a good biopsy specimen had a high PPV of >90% to diagnose SRUS. On histopathology, there was surface ulceration (90%), fibrosis of the lamina propria (70%), distorted architecture (60%), and muscle hypertrophy with increased mucin production (50%). Patients were treated conservatively, and none required surgery.

Conclusion SRUS is a rare disorder with multiple presentations. High dose laxatives, counselling against digital evacuation and waterjet use, high fiber diet in addition to topical mesalamine/ sucralfate, and biofeedback are useful in treatment.

Keywords Rectal dysmotility, Rectal ulcer, SRUS

328

Efficacy of biofeedback therapy on management of functional defecatory disorder

Stephan Benny

Correspondence - Stephan Benny - Stenny2.0@gmail.com

Department of Gastroenterology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Management of functional defecatory disorder is very challenging. We are aiming to find out the efficacy of biofeedback therapy in management of functional defecation disorder.

Method This is an interim analysis of an observational study. Adult patients who are diagnosed with functional defecation disorder by ROME IV criteria were recruited for the study. The demographic, clinical and laboratory data were documented in predesigned forms. They underwent standard biofeedback therapy of 3 sessions. Symptom severity before biofeedback therapy and after 3 months of biofeedback therapy were documented using a standard questionnaire (PAC-SYM questionnaire).

Results There were 31 patients included in the study. Twenty-four out of 31 patients were males (80.6%). The median age of the patients were 48 years with range of 16 years to 59 years. The mean duration of disease was 8.8±7.1 years. Twenty-nine out of 31 patients had type 1 anorectal dyssynergia (93.5%). Only 2 patients had type 3 anorectal dyssyneria (6.5%) and none of the patients had type 2 or type 4 anorectal dyssynergia. Among patients with type 1 anorectal dyssynergia, 16 out of 29 patients (66.8%) showed improvement after biofeedback therapy, where among the two patients with type 3 anorectal dyssynergia, only one patient showed improvement after biofeedback therapy (50%). The mean score in PAC SYM questionnaire before and after biofeedback therapy were 16.3±4.7 and 11.4±5.56 respectively which was statistically significant (p<0.05). Seventeen out of 31 patients (54.8%) had symptomatic improvement at 3 months after biofeedback therapy.

Conclusion Result from the interim analysis suggests that there is significant improvement in anorectal dyssynergia at three months with biofeedback therapy.

Keywords Anorectal dyssynergia, Biofeedback therapy, Functional defecatory disorder,

329

An observational study of esophageal manometry in patients of gastroesophageal reflux disease

Dinesh Kumar , Anil Khatri, Rajiv Baijal, Nripen Saikia

Correspondence - Dinesh Kumar - dineshgadhveer@gmail.com

Department of Gastroenterology, Pushpawati Singhania Hospital and Research Institute, Press Enclave Marg, Sheikh Sarai, Phase-II, New Delhi 110 017, India

Introduction Abnormal esophageal motility and low lower esophageal pressure (LES) play an integral role among various etiologies implicated in pathogenesis and severity of gastroesophageal reflux disease (GERD). EGJ-CI in segregating GERD populations, with general agreement that this metric identifies a subset of patients with severe barrier dysfunction prone to either endoscopic oesophagitis or unequivocally abnormal reflux testing. In view of this, the Lyon Consensus concluded that the esophagogastric junction contractility integral (EGJ-CI) is a promising metric but needs further research before widespread adoption.: An observational study done in a tertiary medical care center in New Delhi from December 2019 to November 2020.

Methods An observational study was carried out among patients presenting with symptoms of GERD (heart burn and regurgitation), at least twice per week for past three months. Based on their endoscopy findings patients with GERD are grouped into two having erosive and nonerosive reflux disease. High resolution manometry was performed. Statistical methods. Chi-square test was used to analyze categorical variables and independent ’t’ test was used for continuous variables. (ROC) was used to find out cut off of EGJ-CI for predicting erosive esophasitis and. sensitivity, specificity, positive predictive value and negative predictive value of EGJ-CI for predicting erosive esophasitis.

Results Out of 76 Individuals, 56.58% individuals were male and age of patients ranged from 20 to 80 years. On esophagogastroduodenoscopy (EGD) out of 76 individuals, 60.53% had erosive esophasitis (erosive reflux disease) and 39.47% had non erosive reflux disease (normal appearing esophagus). Among 76 individuals, 31.58% shows ineffective esophageal motility and 10.53% individuals showed reduced basal lower esophageal sphincter (LES) pressure. out of 46 individuals with erosive reflux disease, 13.04% shows low basal LES pressure and ineffective esophageal motility (IEM) in 32.6%. The association of EGJ-CI with endoscopic results had low mean value for erosive reflux disease in comparison to non-erosive reflux disease; the association was not statistically significant.

Conclusions Ineffective esophageal motility, low LES pressure, low EGJ-CI and hiatus hernia were associated with GERD, but do not predict the disease with sufficient accuracy. No significant association was observed for IEM or low LES pressure to predict endoscopic esophagitis. EGJ-CI showed low sensitivity and low diagnostic accuracy with high specificity and high Positive Predictive Value (PPV) for predicting endoscopic esophagitis.

Keywords Endoscopy, Ineffective esophageal motility, Manometry

330

Epidemiology, predictors and agreement between various irritable bowel syndrome criteria among medical students in a Government Medical College in South India

Manoj Yadav, Akhil N V, Srijaya Sreesh, Ann Mary George, Minu Sajeev Kumar, Aditya Verma, Jacob Raja, Shivabrata Dhal Mohapatra, Krishnadas Devadas

Correspondence – Srijaya Sreesh - drsrijaya.sreesh@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India

Background Irritable bowel syndrome (IBS) is found to be the most common functional gastrointestinal disorder. The prevalence of IBS among various Asian countries (ROME III) is 5% to 10%. There have been no previous studies on the epidemiology of IBS using ROME IV criteria among medical students.

Aims (1) To determine the prevalence and predictors (sociodemographic and lifestyle risk factors) of IBS by ROME IV, ROME III and Asian criteria among medical students. (2) The degree of agreement between Rome IV, ROME III, and Asian criteria.

Methods It was a cross-sectional questionnaire-based study performed on 552 medical students (138 students per batch x 4 batches) who consented for the study. Filled up questionnaires were collected, and appropriate statistical analysis was applied.

Results IBS prevalence using ROME IV, ROME III, and Asian criteria were 5.8%, 19%, 30.4% respectively. Among IBS subtypes, mixed type was the predominant one. The prevalence increases with increasing age and higher medical batch. IBS was found to have an association with lack of physical activity, high body mass index (BMI), lack of sleep, coffee, analgesic use, antibiotic intake, Caesarian birth etc. Cohen's kappa coefficient (κ) was highest (0.699) between Rome III and Asian criteria.

Conclusion The low prevalence of IBS based on Rome IV criteria was due to its stringent nature. This study demonstrated that lifestyle factors are significantly associated with IBS among medical students in a Medical College in South India. In view of its high prevalence, medical students need to be aware of IBS and stress management should be incorporated into the lifestyle.

Keywords Epidemiology, Irritable bowel syndrome, Medical. Students

331

Diagnostic yield of high-resolution esophageal manometry and its correlation with clinical presentation and impacts on management

Vikas Pemmada, Balaji Musunuri, Shiran Shetty, Ganesh Pai, Ganesh Bhat

Correspondence – Balaji Musunuri - balajim.bmc@gmail.com

Department of Gastroenterology, Kasturba Hospital Manipal, MAHE, Tiger Circle Road, Madhav Nagar, Manipal 576 104, India

Introduction High-resolution esophageal manometry (HREM) is an important test in evaluation of esophageal motility disorder. We analyzed HREM data and its correlation with symptoms and impact on management.

Methods In a single center retrospective observational study, all the patients who underwent HREM from 2017 to May 2022 were included. HREM was performed using 16 channel water perfusion system and classified according to Chicago classification v3.0. Patients were divided into Group A (with dysphagia) and Group B (without dysphagia). Groups were compared for spectrum of manometric findings.

Results Total of 422 patients (271 patients in Group A and 151 in Group B) were included, with a mean age of 43±15 years and male to female ratio was 1.63. Group B had patients with reflux symptoms (136, 32.2%) and chest pain (15, 3.55%). IRP was higher among Group A compared to Group B (19.62±7.92, 8.92±13.63, <0.001). Most common type of esophagogastric junction (EGJ) morphology was type I (A:71.6%, B:43.3%) followed by type II (A:23.5%, B:37.7%) among both the groups. Mean EGJ CI was higher among Group A compared to Group B (67.02±42.34, 46.12±29.34, <0.001). EGJ outflow obstruction was seen in 153 (56.45%) and 14 (9.27%) patients, while major peristaltic disorders were seen in 37 (13.65%) and 5 (3.31%) among Group A and B respectively. In Group A, achalasia cardia was the most common diagnosis (51.2%), followed by DES (7.3%), IEM (7%) and esophagogastric junction outflow obstruction (EGJOO) (14, 5.1%). Among group B, most of the patients (104, 68.8%) had normal study. The most common abnormality being IEM in 26 (17.2%) and EGJOO in 7(4.6%). Achalasia was seen in 7(4.6%) patients among group B.

Conclusion Achalasia cardia is the commonest finding in patient with dysphagia. Diagnostic yield of HREM in patient without dysphagia is very low and should be used only in selected patients.

Keywords Achalasia, Diagnostic yield, Dysphagia, HREM

332

Disorders of gut-brain interaction following Coronavirus disease-19: A systematic review and meta-analysis

Akash Mathur , Shikha Sahu, Uday C Ghoshal

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Background Persistent gastrointestinal (GI) symptoms and disorders of gut-brain interaction (DGBIs) are increasingly being recognised after Coronavirus disease-19 (COVID-19). While some studies report GI symptoms and DGBIs after COVID-19, their prevalence is highly variable.

Methods A comprehensive literature search was performed for studies reporting GI symptoms and DGBIs after COVID-19. After applying prospectively decided exclusion criteria, the eligible papers were examined using a meta-analysis approach for the prevalence of GI symptoms and irritable bowel syndrome (IBS) after COVID-19. The relative risk of development of IBS using Rome IV criteria among subjects with COVID-19 compared to healthy controls was calculated.

Results Of the available studies, 13 (5 case-control) reporting persistent GI symptoms after COVID-19 met the inclusion criteria. Among 112,674 subjects, 19.85% had persistent GI symptoms after COVID-19. Of the four studies reporting IBS using Rome IV criteria (2 case-control), patients with COVID-19 were 3.33 (95% confidence interval [CI] 0.226 to 49.061) times more likely to have post-COVID IBS as compared to healthy controls.

Conclusions A significant proportion of patients develop long-term GI consequences following COVID-19. Patients with COVID-19 are more likely to develop post-COVID IBS than healthy controls.

333

Study of subtypes of constipation and its correlation with clinical features

Ajay Jain, Sudhanshu Yadav, Shohini Sircar, Suchita Jain

Correspondence – Ajay Jain - ajayvjain@yahoo.com

Department of Gastroenterology, Choithram Hospital and Research Centre. 14, Manik Bagh Road, Indore 452 014, India

Background Chronic constipation is prevalent, with a prevalence of 12% to 17% in India. Identifying the subtypes of chronic constipation and treating them accordingly is essential to improve the patient's quality of life and decrease the economic burden.

Aims To study chronic constipation subtypes and assess their clinical characteristics in central India.

Methods This was a prospective and observational study. All patients of 18 years and above with chronic constipation as per ROME IV criteria were included in the study. All were evaluated with colonic transit study, anorectal manometry & balloon expulsion test.

Results The mean age of the patient was 50.60±15.61 years. 70.2% of patients with constipation had 7-14 bowel movements per week, with only 3.1% having bowel movements of less than 3 per week, while 2.5% had bowel movements >21/week. The most typical symptom is a sense of incomplete evacuation seen in 93.8% of patients, followed by straining in 88.8%, anorectal blockage in 13%, and manual evacuation in 14.3%. Normal transit constipation is the most common type observed in 64.0%, followed by dyssynergic defecation (DD) in 19.9% and slow transit in 14.3%. The mixed (slow transit + DD type) was seen in only 1.9%. This study suggests a significant association between type of constipation and stool frequency (p-value <.001) and time spent in the toilet (p-value < .001). There was a good correlation between digital rectal examination with manometry and balloon expulsion test (68.5% sensitivity and 96.8% specificity). The use of complementary alternative medicine (CAM) was seen in 80%.

Conclusion A sense of incomplete evacuation and not the number of bowel movements per week is the predominant symptom described by most patients with constipation in India. The use of CAM for constipation is widespread. Chronic constipation should be subclassified into its subtypes for individualized treatment.

Keywords Constipation, Dyssynergic defecation, Normal transit constipation, Slow transit constipation

334

High prevalence of sexual dysfunction among patients with irritable bowel syndrome: Data from a tertiary care center in south India

John George, Rajeeb Jaleel, Asisha Janeela, Ajith Thomas, Anoop John, A J Joseph, Amit Dutta, Ebby Simon, Sudipta Chowdhury

Correspondence – John George - johntgeorg@gmail.com

Department of Clinical Gastroenterology and Hepatology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Sexual dysfunction is an extraintestinal manifestation of irritable bowel syndrome (IBS) which is often neglected despite its implications on the quality of life of such patients.

Methods In this prospective observational study, we estimated the prevalence of sexual dysfunction among consecutive patients, newly diagnosed to have IBS, who were married, between the age group of 18 and 50. We used validated questionnaires -The International Index of Erectile Function-5 (IIEF-5) for erectile dysfunction (ED); the Chinese Index of premature ejaculation – 5 (CIPE-5) questionnaire for premature ejaculation (PE) in males and the Female Sexual Function Index (FSFI) for females.

Results Ninety-seven patients were recruited, of which 90 (93%) were men and 7 (7%) were women. The mean age was 37.8±6.4 years. Among men, 36 (40%) of the patients reported sexual dysfunction, while 39 (43.3%) fulfilled criteria for ED, PE, or both. Among women, 1 (14.3%) reported sexual dysfunction and 2 (28.6%) fulfilled criteria for female sexual dysfunction. Among men, a higher prevalence of sexual dysfunction- 30 (57.7%) was noted in those with moderate or severe IBS when compared with those with mild IBS - 9 (23.7%) according to IBS-Symptom Severity Score, which was statistically significant p value – 0.001, OR- 4.39 (1.74 – 11.12)

Conclusion A high prevalence of sexual dysfunction is noted among patient with IBS and addressing it may play a major role in improving the quality of life of such patients.

Keywords Female sexual dysfunction, Irritable bowel syndrome, Male sexual dysfunction

335

Unexplained vomiting in a patient with joint hypermobility syndrome

Sayan Malakar , Akash Mathur, Anshuman Elhence ^* , Uday C Ghoshal

Correspondence – Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India, and ^*All India Institute of Medical Sciences, Gate No.1, Great Eastern Road, AIIMS Campus, Tatibandh, Raipur 492 099, India

Introduction Joint hypermobility syndrome is a common disorder as it involves four to 13% of the population. Increased incidence and prevalence of functional as well as structural gastrointestinal disorders have been reported in the literature. Here we present an interesting case of chronic nausea and vomiting in a patient with joint hypermobility syndrome.

Case Presentation A 19-year-old boy presented to us with a history of nausea, vomiting, anorexia and postprandial abdominal fullness for two years. On further questioning, he revealed that he had polyarthralgia since his childhood. An examination of the musculoskeletal system revealed joint laxity involving various small and large joints. After defining joint laxity using the Beighton score, a diagnosis of benign joint hypermobility (BJHS) was made after calculating the Brighton score. As his esophagogastroduodenoscopy was normal we kept the possibility of gastroparesis. He was already on pantoprazole, domperidone and acotiamide. After stopping the prokinetics he underwent a solid-phase gastric emptying test. After four hours, his gastric retention was 25%, which was suggestive of delayed gastric emptying (normally gastric retention should be less than 10% after four hours). As his symptoms were refractory, he was managed with an endoscopic intra-pyloric botulinum toxin-A injection. A total of 100 units of intra-pyloric botulinum toxin A was injected (25 units each quadrant). The patient’s symptoms improved following the intervention.

Conclusion BJHS is associated with gastroparesis. It can be successfully managed with intra-pyloric botulinum toxin-A injection.

Keywords Botulinum, Gastric emptying, Gastroparesis, Joint hypermobility syndrome, Vomiting

336

An observational study of pH impedance monitoring and high-resolution manometry in patients with gastroesophageal reflux diseases

Rohit Mathur, Neeraj Singla, D Nageshwar Reddy

Correspondence – Rohit Mathur - rohitmathur2021@gmail.com

Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Background Gastroesophageal reflux disease (GERD) is one of the most common disorders in the west and has a negative impact on millions of people's quality of life. Now that high-resolution manometry (HRM), 24-hour ambulatory pH impedance studies, and additional novel measures are available, it is possible to assess motility disorders more accurately.

Methods Prospective observational study done at a single tertiary care hospital from November 2019 to November 2021 with classical symptoms of GERD based on Montreal classification 1.

Results Of the 79 patients, 68.4% were male, had a BMI of 25.3 kg/m², with a mean age of 38.4 years. The most common symptoms were regurgitation (n=72, 91.2%) and heartburn (n=73, 92.4%). 89.5% of those who ate fatty foods, 34.8% alcohol user and 47.5% aerated drinks user, reported exaggeration of symptoms 4. According to the ROME and Lyon consensus 2, people were divided into four groups: those with functional heartburn (n=29, 36.7%), reflux hypersensitivity (n=11, 13.9%), and those with erosive esophagitis (n=22, 27.8%). Esophagogastroduodenoscopy (EGD) revealed grade A esophagitis in 16 (20.3%), grade B esophagitis in 6 (7.6%), and no esophagitis in 57 (72.2%) cases. A total of 30.4% of patients showed hypotensive LES pressure (HLES), while 11.3% of patients had inadequate esophageal motility (IEM) 5. The degree of esophagitis did not significantly correlate with the individual's HLES and IEM. Additionally, the degree of esophagitis and the duration of acid exposure were not correlated (AET). However, there was an inverse relationship between DCI, HLES pressure, AET, and the overall number of refluxes. AET and the contractile integral of the oesophageal junction were significantly correlated with GERD QQL (EGJ-CI).

Conclusion In individuals with GERD, lower DCI was discovered to be substantially more correlated with acid exposure time. Patients with longer acid exposure times and lower EGJ-CI had higher GERD QQL scores.

Keywords Acid exposure time, Gastroesophageal reflux disease, Motility

337

Faster small bowel transit time leads to poorer diagnostic yield in patients undergoing capsule endoscopy study

Ashiesh Khandelwal

Correspondence – Ashiesh Khandelwal - drashieshk@gamil.com

Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India

Shorter SBTT during VCE (<300 minutes) is associated with a poorer diagnostic yield. This may be due to a negative effect on image quality due to a faster small bowel transit. Thus, use of prokinetic agents during VCE might adversely impact the diagnostic yield and should be discouraged

Keywords Capsule endoscopy

338

Risk factors for submucosal fibrosis during per-oral endoscopic myotomy: A prospective study

Pradev Inavolu , Zaheer Nabi, Rajesh Goud, Mohan Ramchandani, Santosh Darisetty ^* , Nageshwar Reddy Duvvur

Correspondence – Zaheer Nabi - zaheernabi1978@gmail.com

Department of Medical Gastroenterology, and ^*Anasthesiologist, AIG Hospitals, No 136, Plot No 2/3/4/5 Survey, 1, Mindspace Road, Gachibowli, Hyderabad 500 032, India

Background and Aim Per-oral endoscopic myotomy (POEM) is an established treatment modality for achalasia cardia. Submucosal fibrosis (SMF) is rare, but the most important reason for technical failure during POEM. Prediction of SMF may be crucial to improve technical outcomes with POEM. In this study we aim to evaluate the predictors for SMF in cases with achalasia cardia.

Methods Consecutive patients with achalasia cardia who underwent POEM (August 2021 to February 2022) were included in the study, prospectively. Various factors were analyzed for prediction of SMF including age, gender, stasis esophagitis, type of achalasia, duration of disease, lower esophageal sphincter pressure (LESP), height of barium column on barium esophagogram and severity of symptoms (Eckardt score). Esophageal mucosa was graded for the severity of stasis esophagitis (grade I to grade III) based on vascular pattern, mucosal thickening, ulceration, and nodularity. SMF was graded (I minimal, II moderate, III severe) according to mucosal lift, difficulty in entry, density of SM fibers, separation of mucosa and muscle.

Results One hundred and four patients (males 59, mean age 41.9±15.7 years) underwent POEM during the study period. Median symptom duration was 24 (2-240) months and mean pre-POEM Eckardt score was 6.9±1.7. POEM was performed via posterior route in majority of patients (95.2%). Stasis esophagitis was evident in 70 (67%) patients and majority had mild (grade I, 51.9%) stasis esophagitis. Mean duration of disease was significantly longer in those with stasis esophagitis (56.6 vs. 20.9, p=0.001). SMF and severe SMF were detected in 29 (28.2%) and 1 (1%) case, respectively. On multivariate analysis, the presence of stasis esophagitis was the only factor that predicted the presence of SMF (p=0.014). Other were not significantly associated with SMF.

Conclusion Severe SMF is rare in cases with achalasia cardia. The presence of stasis esophagitis is the only predictor for SMF during POEM.

Keywords Achalasia cardia, POEM, Submucosal fibrosis

339

Spectra and psychological profile of Rome IV disorders of gut–brain interaction among out-patients in northern India

Omesh Goyal , Arshdeep Singh, Akash Aggarwal, Prerna Goyal, Yogesh Gupta, Ajit Sood

Correspondence – Omesh Goyal - goyalomesh@yahoo.co.in

Department of Gastroenterology, Dayanand Medical College and Hospital, Tagore Nagar, Civil Lines, Ludhiana 141 001, India

Background Disorders of gut brain interaction (DGBI) are the most prevalent disorders in gastroenterology. They are commonly associated with psychological co-morbidities and impairment in health-related quality of life. Indian data on the prevalence of DGBIs, the overlap, and the associated psychological co-morbidities is scarce.

Aim To study the spectra and psychological profile of Rome IV DGBIs among out-patients in northern India.

Methods Consecutive patients presenting to gastroenterology out-patient department of a tertiary care institute between May 2019 to October 2019 were enrolled. Rome IV Diagnostic Questionnaire (English/Hindi) was used to diagnose DGBIs. DASS questionnaire (English/Hindi) was used to assess depression, anxiety, and stress.

Results Of the total 2547 patients screened, 1044 (40.9%) had DGBIs. Mean age was 41.8 ± 12.6 years and 51.9% were males. Most common DGBIs were functional dyspepsia (FD) (44.3%), esophageal disorders (ED) (34.9%), irritable bowel syndrome (IBS) (16.1%), functional constipation (15.6%), functional abdominal bloating/abdominal distension (7.5%), nausea and vomiting (6.3%), centrally mediated abdominal pain syndrome (4.6%), and functional diarrhea (2.8%). Co-existing DGBIs were present in 394 (37.7%) patients. Out of total FD patients (n=463), 52 (11.2%) had co-existing IBS, while 103 (22.4%) had co-existing ED. Prevalence of anxiety, depression and stress were 74.5% (n=778), 42.4% (n=443) and 31.3% (n=327) respectively.

Conclusion Rome IV DGBIs are common among out-patients in northern India, most common being functional dyspepsia, esophageal disorders, irritable bowel syndrome and functional constipation. More than one-third patients have co-existing DGBIs. Anxiety, depression, and stress are reported by majority of the patients.

Keywords Dyspepsia, Functional, Irritable bowel syndrome

Pediatric Gastroenterology

340

Microscopic colitis in adolescent population: A case series

Jasmeet Singh Dhingra, Rajiv Grover, Nirmaljit Singh Malhi, Achal Garg

Correspondence - Rajiv Grover - drgrover@rediffmail.com

Department of Gastroenterology, Advanced Gastroenterology Institute-The Gastrociti, Opposite Grandwalk Mall, Barewal Road, BRS Nagar, Ludhiana 141 008, India

Introduction Microscopic colitis (MC) is characterized by chronic watery diarrhea, normal colonoscopy and abnormal histology. While mostly encountered in adults, pediatric or adolescent cases are rare and may show varying presentations.

Methods This is a retrospective study of all adolescent patients diagnosed with microscopic colitis at Advanced Gastroenterology Institute: AGI The GASTROCITI in Ludhiana for a 30-month period from February 2020 to July 2022. Cases were identified using the Department of Endoscopy database. Data were obtained from medical records that included clinical manifestations and histopathological features.

Results Three patients (2 females and 1 male, median age: 15 years, ranging from 14 to 16) were included. Two patients presented with non-bloody watery diarrhea and one with diarrhea associated with alternating constipation and rectal prolapse. Abdominal pain and weight loss were manifested in all patients. Two patients had celiac disease in remission and were on gluten-free diet (GFD). All patients had normal colonoscopy, but had typical histologic features of MC in colon biopsies. Two patients had clinical follow-up (12 months and 14 months duration), and both patients on follow-up had no gastrointestinal (GI) symptoms, but one patient had continued symptoms at 1 month of therapy and was lost to follow-up.

Conclusion Although rare in children and adolescents, the clinical presentation is similar to adults, with a female preponderance, presentation with diarrhea and abdominal pain, and an association with celiac disease. Adolescents are more likely to have weight loss and irritable bowel syndrome (IBS) like presentation. Active celiac disease should be ruled out and adherence to GFD is essential. Treatment is less standardized in children and adolescents with MC.

Keywords Collagenous colitis, Lymphocytic colitis, Microscopic colitis, Pediatric colitis,

341

Rectal prolapse as an unusual presentation of cystic fibrosis

Sumit Kumar Suman, Prafulla K Singh, Snehitha Nalluri, Sai Krishna Katepally, P Shravan Kumar

Correspondence – Sumit Kumar Suman - sumitsuman511vmmc@gmail.com

Department of Medical Gastroenterology, Gandhi Medical College and Hospital, Musheerabad, Padmarao Nagar, Secunderabad 500 003, India

Introduction Rectal prolapse is a common and self-limited condition in children less than 5 years of age. Various anatomical variants and medical conditions predispose a child to developing rectal prolapse .It is an unusual presentation with cystic fibrosis, accounting for only 3.6 % [1].

Case Presentation Herein we present a case of 2-year-old female child presented with complaints of increased frequency of stool since 2 months and mass per rectum since 1 month with past history of recurrent lower respiratory tract infections. Upper gastrointestinal endoscopy and colonoscopy was normal. Stool routine examination revealed presence of fat globules. Fecal elastase level was less than 15 microgram per gram of stool. Sweat chloride was 88 milliequivalent per liter and cystic fibrosis transmembrane conductance regulator (CFTR) mutation analysis revealed homozygous DF508 mutation. Patient was started on pancreatic enzyme replacement therapy. Over a follow-up of 2 months patient gained weight of 2 kg and her rectal prolapse also got resolved.

Conclusion Historical data suggests that approximately 23% of patients with cystic fibrosis experience rectal prolapse [2]. With wide spread use of new born screening for cystic fibrosis, rectal prolapse as a manifestation of disease has decreased in incidence and estimated to be as low as 3.5%. Prolapse frequently ceases with pancreatic enzyme replacement therapy and rarely surgery is required [3].

References

1. El-Chammas KI, Rumman N, Goh VL, Quintero D, Goday PS. Rectal prolapse and cystic fibrosis. J Pediatr Gastroenterol Nutr. 2015;60:110-2.

2. Kulczycki LL, Shwachman H. Studies in cystic fibrosis of the pancreas: Occurrence of rectal prolapse. N Engl J Med. 1958;259:409-12.

3. Stern RC, Izant Jr RJ, Boat TF, Wood RE, Matthews LW, Doershuk CF. Treatment and prognosis of rectal prolapse in cystic fibrosis. Gastroenterology. 1982;82:707-10.

Keywords Cystic fibrosis, Rectal prolapse

342

Pediatric gastrointestinal endoscopy by adult gastroenterologists: A retrospective study addressing the outcome and safety of performing endoscopies in resource-poor setting

Arya Suchismita , Ashish Jha, Vishwa Mohan Dayal, Jayant Prakash, Rizwan Ahmer, Anand Gupta, Rakesh Kumar

Correspondence – Ashish Jha - ashishjhabn@yahoo.co.in

Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Bailey Road, Sheikhpura, Patna 800 014, India

Background Pediatric endoscopic procedures are mostly performed by the pediatric gastroenterologist with pediatric endoscopes under GA or, under deep sedation in a carefully monitored unit. Data regarding the outcome and safety of pediatric endoscopy performed by an adult gastroenterologist are limited.

Methods We aimed to investigate indications, the use of sedation, endoscopic findings, and outcomes of pediatric endoscopic procedures performed by the adult gastroenterologist. We also analyzed the success rate of upper gastrointestinal endoscopy (UGIE) performed with adult gastroscopes in children weighing 7 to 10 kg. In a retrospective study, case record of pediatric patients (age up to 15 years) who underwent UGIE and lower GI endoscopy (LGIE) were reviewed.

Result Out of 391, UGIE was successfully completed in 383 (98%) patients. The mean (SD) age was 7.7 (3.3) years. 28% of the children were required mild sedation or GA for the procedure. Successful UGIE with adult gastroscopes was possible in 23 (82%) of 28 young children (weighing 7-10 kg). The endoscopic yield was 65.54%. Therapeutic UGIE were done in 39.16% patients. Out of 123, LGIE was successfully completed in 120 (97.95%) patients (sigmoidoscopy: 81.66%; colonoscopy: 18.33%). The mean (SD) age was 7.9 (3.3) years. 27% of the children were given mild sedation or GA for the procedure. The endoscopic yield was 75%. Therapeutic LGIE were performed in 44% patients.

Conclusions Pediatric GI endoscopy can be safely performed by an experienced adult gastroenterologist. Unsedated UGIE and sigmoidoscopy can be well-tolerated by children when performed by appropriate monitoring.

Keywords Colonoscopy, Lower gastrointestinal endoscopy, Pediatric endoscopic procedures, Pediatric endoscopy, Sigmoidoscopy, Upper gastrointestinal endoscopy

343

Etiology, referral pattern and role of genetics in children with neonatal cholestasis-Experience of a tertiary care centre from India

Ankit Agrawal , Anshu Srivastava

Correspondence – Anshu Srivastava - avanianshu@yahoo.com

Department of Pediatrics Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014. India

Introduction Timely and correct etiological diagnosis is the most important determinant of outcome in neonatal cholestasis (NC). This allows for administration of specific therapy including surgery in biliary atresia (BA). We determined the aetiology, age at referral and role of exome sequencing in infants with NC.

Method Retrospective observational study of infants (age <6 months) with NC admitted from 2017 to 2021. Etiological diagnosis was based on clinical profile and investigations (biochemical, radiological, histological and genetics). Clinical features and investigations were noted and analyzed.

Result Three hundred and eighty infants (66.8% boys) were analyzed. The mean age at onset of jaundice was 18.2±23.8 days and at admission was 84.2±39.2 days. The most common etiology was BA (235, 61.8%) followed by metabolic causes (62, 16.24%), idiopathic neonatal hepatitis (37, 9.7%), multifactorial (29, 7.7%), cryptogenic (12, 3.2%) and TORCH (1, 0.27%). Metabolic disorders included galactossemia, tyrosinemia, mitochondrial hepatopathy, progressive familial intrahepatic cholestasis, bile acid synthetic defect, alagille syndrome, cystic fibrosis, HNF-1B mutation and storage disorders. Among the multifactorial group, majority had a single risk factor (24, 82.6%) with sepsis (19, 65.5%) and prematurity (6, 20.7%) being most common. In BA group, the age at admission has remained at >60 days (88.7±37.3 days) over last 5 years with average delay of 75.4±36.7 days between development of jaundice and admission. One-third BA patients couldn’t be offered surgery due to advanced age (>4 months). Interval between the age of presentation and referral was longer in BA vs non-BA (88.7 vs. 76.7days; p=0.005). Among the non-BA group, yield of liver biopsy for a definitive diagnosis was lower than exome sequencing (12/43 [28%] vs. 25/33[75.7%]; p<0.0001).

Conclusion BA is the most common cause of NC followed by metabolic and multifactorial etiology. There is an urgent need for early referral of BA. Exome sequencing has better yield than liver biopsy in the non-BA group.

Keywords Biliary atresia, Genetics, Neonatal cholestasis

Surgical Gastroenterology

344

Comparative analysis of heller myotomy with dor versus toupet fundoplication for achalasia cardia

Sunita Suman ¹ , Vaibhav Varshney¹, Subhash Soni¹, Sanjeev Sachdev², Sabir Hussain³, Narendra Bhargava³

Correspondence – Vaibhav Varshney - drvarshney09@gmail.com

¹Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India, ²Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India, and ³Department of Gastroenterology, Dr. S. N. Medical College, Residency Road, Sector-D, Shastri Nagar, Jodhpur 342 003, India

Background Heller myotomy with partial fundoplication is the standard of care for achalasia cardia. However, the choice of partial fundoplication is still controversial. We compared both types of fundoplication concerning subjective and objective parameters.

Methods A total of 30 consecutive patients underwent laparoscopic/robotic Heller myotomy (LHM/RHM) with either DF (n=15) or TF (n=15). Preoperative baseline characteristics, intraoperative details, and post-operative complications were recorded. Patients were followed with Eckardt score, quality of life-related scores, and 24-hour pH study and high-resolution manometry (HRM) at one year of follow-up.

Results There was no significant difference between the two groups regarding preoperative baseline parameters, length of hospital stay, and post-operative complications. The HM+DF group had 4 (27%) patients with recurrence/failure with none in the HM+TF, but it was not significant (p= 0.79). Symptom scores were similar between the groups at 6 and 12 months of follow-up. One patient in the HM+DF group and two in the HM+TF group had significant pathological acid reflux (p=0.483). On HRM, HM+TF showed a trend towards significance in terms of esophagogastric junction (EGJ) relaxation (p=0.058) with a non-significant difference in median integrated relaxation pressure (IRP) (p=0.081).

Conclusion The study showed a trend towards lower failure rates and improved EGJ relaxation with similar reflux rates in patients who underwent HM+TF compared to HM+DF. However, long-term follow-up is required to validate our findings with well-defined subjective and objective criteria.

Keywords Achalasia, Disease-specific quality, Fundoplication, Heller myotomy, pH monitoring

345

Gastrointestinal perforations during corona virus disease - 19 pandemic

Ritambhra Duseja , Ridhi Sood, Aravind Sekar, Ashwani Kumar, Rajesh Gupta

Correspondence – Ritambhra Duseja - ritamduseja@yahoo.com

Department of Histopathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Introduction Gastrointestinal perforations and thromboembolic acute limb ischemia were the most common surgical specimens received during corona virus disease – 19 (COVID-19) pandemic in addition to specimens from ENT departments.

Materials There were total of 19 GIT resections from February 2020-December 2021 which were analyzed by two GIT pathologists.

Results They were mostly hemicolectomies (n-13), small intestines (5) and gastrectomy (n-1). Prevalence of GIT resections for perforations remained same as in past 10 years though general perception of increased number was due to cessation of all other non-emergency surgeries. Histopathology showed predominantly ischemic perforations with secondary infective vasculitis in 3 patients. Ischemia was mainly due venous thrombi with venulitis along with arteritis in one fourth. In addition, neo-angiogenesis not supported by any stroma was prominent finding, which generally was not seen in pre-covid perforations. Thrombotic microangiopathy was present in 3 patients. Tissue invasive candida was present in caecal perforation and gastrectomy and mucormycoses in 1 hemicholectomy.

Conclusion COVID-19 associated coagulopathy resulted vascular thrombo-emboli with compensatory neo-angiogenesis. Fungal infections were observed in some of these patients.

Keywords Ischaemia, Perforation, Thrombosis

Nutrition

346

A questionnaire survey to determine challenges in implementing practice of low FODMAP dietary intervention in India

Mayank Jain

Correspondence – Mayank Jain - mayank4670@rediffmail.com

Department of Gastroenterology, Arihant Hospital and Research Centre, 297 Indrapuri, Near Bhanwarkuan, Indore 452 017, India

Background Restriction of Fermentable Oligosaccharide, Disaccharide, Monosaccharide, and Polyols in the diet (low FODMAP diet) has been found to be effective in management of irritable bowel syndrome (IBS) and functional dyspepsia (FD). Despite good evidence regarding its benefits in Indian patients, regular use of this intervention is limited.

Aim To determine the challenges faced by gastroenterologists in implementing low FODMAP diet in daily practice.

Methods A questionnaire was circulated using Google forms. It sought information regarding place of practice, cases of FD/IBS seen per month and use of low FODMAP dietary intervention for patients at their respective centres. The data obtained were entered in Microsoft excel sheet and interpreted using number and percentages.

Results The questionnaire was circulated among 100 gastroenterologists predominantly practicing in Madhya Pradesh, Maharashtra, and Gujarat. Response rate was 51%. Nearly all (87.5%) were in private hospital setups. Majority saw >20 cases of FD (76.5%) and IBS (70.6%) per month. Rome IV criteria were used by 70.6% (36) regularly and nearly all (48, 94.1%) considered dietary intervention as necessary for management of these disorders. Dietician facility was available full time with 64.7% (33) and on call with 9 (17.6%). However, none used dietician assessment regularly for FD and IBS patients. Twenty-seven reported that dieticians at their centres were trained in administering low FODMAP diet and proper follow-up of patients. Only 9 (17.6%) used low FODMAP diet regularly. Majority (82.4%, 41) noted that patients are unable to follow low FODMAP diet due to logistic reasons (62.5%) or being too restrictive (37.5%). Use of mobile apps (100%) was considered as the best option to promote low FODMAP diet among patients.

Conclusion Low FODMAP diet is seldom used in daily practice. Lack of trained dieticians and poor acceptability by patients are the limiting factors.

Keywords Diet, Dyspepsia, Functional, Intervention, Irritable Bowel

347

Dietary intake of patients with inflammatory bowel disease: A comparison with disease phenotype subgroups and ulcerative colitis disease activity subgroups

Moni Chaudhary , Shikha Sahu, Uday C Ghoshal

Correspondence - Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Background The pathogenesis of chronic and relapsing inflammatory bowel diseases (IBDs) is not fully understood. Diet is likely to play an important role in modification of the gut microbiota. The unguided dietary habits lead to nutritional deficiencies and severity of disease course. Therefore, we aimed to compare the dietary intake of IBD patients.

Methods Dietary intake of IBD patients was recorded for consecutive 3 days.

Results One hundred patients (71 ulcerative colitis [UC], 29 Crohn’s disease [CD]) were enrolled. UC patients differed in anthropometric measurement from CD patients in total body fat % (24.3±7.6% vs. 20.1±7.6%, p=0.017), and total body fluid (51.2±6.2% vs. 55.2±6.2%, p=0.005). The recommended protein and fat intake of UC disease activity subgroups (45 in remission and 26 with active disease) differed significantly (protein: 76.1±5.3 g vs. 79.8±7.3 g, p=0.017; fat 55.5±3.7 g vs. 57.7±5.3 g, p=0.05). No significant difference in fat, protein and carbohydrate intake between UC and CD patients was found (fat: 232.2 [212.4-279] kcal vs. 250.2 [215.1-283.5] kcal, p=0.494; protein: 0.5 [0.4-0.7] g vs. 0.6 [0.4-0.7]g, p=0.535; carbohydrate: 60.7 [54.6-66.7] g vs. 59.9 [53.6,63.8] g, p=0.397). No difference was seen in micronutrient intake when comparing UC and CD (potassium: 25.4 [21.7-32.3] mg vs. 24.8 [20.3-29.9] mg, p=0.646; sodium: 61.9±14.5 mg vs. 62.9±12.1 mg; p=0.772; iron: 51 [42.5-81] vs. 53.9 [38.6-94.8] mg; p=0.797; calcium: 27.3 [21.8-46.9] mg vs. 27.6 [19.3-47.5] mg, p=0.886). 91.1% (41/45) of patients in remission had protein intake below the recommended 0.8 g/kg and 92.3% (24/26) with active disease below the recommended 1.2 g/kg.

Conclusion Our study confirms recommended macronutrient differences in habitual dietary intake of UC disease activity subgroups. To be able to propose better dietary guidelines for IBD patients, more research into dietary effects on IBD disease course is needed.

Keywords Inflammatory bowel disease, Macronutrient, Micronutrient

348

Nutritional deficiencies in patients with ulcerative colitis: Prevalence… Predictors… and effect on quality of life

Anurag Sachan, Usha Dutta, Vishal Sharma, Jayanta Samanta, Arun Sharma, Kaushal Kishore

Correspondence - Anurag Sachan - anuragsachan223@gmail.com

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Introduction Malnutrition is common in patients with ulcerative colitis (UC). To study the prevalence and predictors of nutritional deficiencies and their effect on quality of life (QOL) in patients with UC.

Subjects One hundred and twenty-six patients with UC and 57 healthy controls were analyzed.

Methods It was a cross-sectional prospective study done on patients with UC over one year (Fig. 1). Cases were defined as enrolled patients with UC and controls were healthy relatives of the cases. Short inflammatory bowel disease questionnaire (SIBDQ) score <50 denoted poor QOL.1

Results The controls and cases were well matched in their demographics. Cases as compared to controls had increased prevalence of being nutritionally poor as shown in (Table 1). Serum albumin and iron deficiency emerged as independent predictors of serum calcium-deficiency with odds ratio (OR) of 6.8 and 13.4 respectively. Serum folate-deficiency emerged as independent predictor of magnesium-deficiency with OR of 3.93. Serum calcium emerged as independent predictor of serum iron-deficiency with OR of 11.56. Serum albumin-deficiency emerged as independent predictor of vitamin D-deficiency with OR of 4.43.

Eighty-five (67.46%) of cases had poor QOL. Vitamin D (r=0.275), and albumin levels (r=0.399) positively correlated with quality of life. Vitamin D-insufficiency (<32 ng/mL) and histologically active disease by Robarts score >3 emerged as independent predictors of poor quality of life with OR of 6.0 and 4.0 respectively.2

Conclusions Micro and macro-nutrient deficiencies are more prevalent in patients with UC than healthy controls. Albumin levels correlated well with micronutrient deficiencies and QOL. Vitamin D-insufficiency and histologically active disease predict the poor QOL.

Keywords Nutrition, Quality of life, Ulcerative colitis

349

Reproductive functions and pregnancy outcome in female patients with celiac disease

Shubham Prasad ¹ , Priyanka Singh ² , Alka Singh ¹ , Wajiha Mehtab ¹ , Simple Rajput ¹ , Sana Dang ³ , Aditya V Pasichia ¹ , Shubham Mehta ¹ , Ashish Chauhan ¹ , Mahendra S. Rajput ¹ , Garima Kachhawa ⁴ , Soumya Jagannath ¹ , Vineet Ahuja ¹ , Govind K Makharia ¹

Correspondence – Shubham Prasad - shubham769@gmail.com

Departments of ¹Gastroenterology, and ²Obstetrics and Gynaecology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, ²Department of Medicine, Lady Harding Medical College, Shaheed Bhagat Singh Marg, Lady Hardinge Medical College, DIZ Area, Connaught Place, New Delhi 110 001, India, and ³Department of Medicine, Vardhaman Mahavir Medical College and Safdarjung Hospital, NH 48, Near AIIMS Hospital, Ansari Nagar West, New Delhi 110 029, India

Objectives: Abnormalities in the reproductive functions are often ignored while evaluating a patient with celiac disease (CeD). We evaluated the reproductive functions in female patients with CeD and effect of gluten-free diet (GFD) on them.

Methods In a case control study between 2020-2021 using detailed questionnaire, we evaluated reproductive functions (age at menarche, menstrual pattern, fertility, pregnancy outcome and menopause) in biopsy-proven female patients with CeD with age >10 years. The questionnaire was administered either in person or telephonically. Age-matched healthy female controls (twice the number) were also recruited.

Result Of 1086 CeD patients, 480 were females and 288 were included. As compared to controls (n=586), females with CeD had higher age at menarche (14.6±2.0 vs. 13.6±1.5 years; p=0.001), delayed menarche (30.8% vs. 11.4%; p=0.001), abnormal menstrual pattern (39.7% vs. 25.8%; p<0.001), involuntary delay in conception at >1 year (33.8% vs. 11.8%; p=0.01), current infertility rate (10.5% vs/ 5.2%; p=0.028) and poorer overall pregnancy outcomes (abortion (23.5% vs. 12.8%; p=0.001), pre-term birth (16.3% vs. 3.7%; p=0.001). With GFD, 69.2% patients with delayed menarche attained menarche within 0.5 to 2 years, 70.1% patients with abnormal menstruation had improvement in menstruation pattern within 6 months, 25% patients with involuntary delay in conception at >1year conceived within 1-2 years and 75% patients with poor pregnancy outcomes had improvement in pregnancy outcomes in subsequent pregnancies.

Conclusion Either one or more aspect of reproductive functions and pregnancy outcome is affected adversely in two-third female patients with CeD, and many of them do reverse with GFD.

Keywords Celiac disease, Gluten-free diet, Pregnancy outcomes, Reproductive functions

350

Comprehensive assessment of macronutrient and micronutrient deficiency in patients with ulcerative colitis: Prevalence and its effect on quality of life

Anurag Sachan ¹ , M Thungapathra², Harmandeep Kaur¹, Kaushal Kishor Prasad¹, Ravjeet Singh Jassal², Vishal Sharma¹, Anurag Jena¹, Anupam Kumar Singh¹, Kim Vaiphei³, Jayanta Samanta¹, Arun Kumar Sharma¹, Sanjay Bhadada⁴, Usha Dutta¹

Correspondence – Usha Dutta - ushadutta@gmail.com

Departments of ¹Gastroenterology, ²Biochemistry, ³Histopathology, and ⁴Endocrinology, Nehru Hospital, Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India

Introduction Patients with ulcerative colitis (UC) have poor nutritional intake and increased gut losses. Micronutrient and macronutrient deficiency are likely to be prevalent and may impact quality of life. Our study was designed to prospectively study the prevalence and predictors of nutritional deficiencies and their effect on quality of life (QOL) in patients with UC.

Methods A prospective study was conducted among patients with UC visiting a university teaching hospital. Cases were defined as patients with diagnosed UC and controls were healthy relatives of the cases. They were then assessed for clinical, demographic and socioeconomic characteristics. They were evaluated systematically for presence of macronutrient and micronutrient deficiency after informed consent. Further, we assessed their anthropometry, functional performance and quality of life using the Short inflammatory bowel disease questionnaire (SIBDQ) score.

Results Cases (n=126) and healthy controls (n=57) were included. Cases had poorer anthropometric parameters as compared to controls: being underweight (27.8% vs. 3.5%; p=0.000) and had lower mid-arm-circumference (45.2% vs. 12.3%; p=0.000). Cases had poorer functional status: weaker hand grip strength (66.7% vs. 45.6%; p=0.007) and weaker lower limb strength (80.2% vs. 42.1%; p=0.000). Cases had significantly higher macronutrient deficiencies than controls: protein deficiency (30.95% vs. 3.50%; p<0.000), albumin deficiency (25.39% vs. 0.00%; p=0.000) and cholesterol deficiency (62.69% vs. 28.07%; p<0.000). Micronutrient deficiencies were common in UC: Calcium deficiency (44.44%), phosphate deficiency (20.63%), magnesium deficiency (11.11%), `zinc deficiency (76.19%), iron-deficiency (87.3%), folate-deficiency (15.9%), vitamin B₁₂ deficiency (10.3%) and vitamin D-deficiency (19.8%). Over two-thirds of cases (n=85) had poor quality of life (SIBDQ score ≤ 50). Vitamin D-insufficiency (<32 ng/mL) (OR = 6.1; 95% CI:1.9-19.7) and histologically active disease (Robarts histological score >3) (OR=4.0; 95% CI:1.6-9.9) emerged as independent predictors of poor QOL.

Conclusion Patients with UC have higher prevalence of poor functional status and macronutrient deficiencies. Patients with UC have high prevalence of poor QOL. Low serum Vitamin D levels and histologically disease are predictors of poor QOL.

Keywords Nutrition, Quality of life, Ulcerative colitis,

351

Barriers and facilitators in the adherence to gluten-free diet in adult patients with celiac disease

Wajiha Mehtab ¹ , Alka Singh², Anam Ahmed², Ashish Chauhan³, Mahendra Singh Rajput², Lalita Mehra², Vikas Banyal², Shubham Prasad², Namrata Singh², Vineet Ahuja², Anita Malhotra⁴, Govind K Makharia²

Correspondence – Govind K Makharia - govindmakharia@gmail.com

¹Department of Home Science, University of Delhi, Ashok Vihar III – Ashok Vihar, Delhi 110 052, India, ²Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029. India ³Department of Gastroenterology, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India, and ⁴Department of Home Science, Lakshmibai College, University of Delhi, Ashok Vihar III – Ashok Vihar, Delhi 110 052, India

Objectives Lifelong and strict adherence to gluten-free diet (GFD) is essential for the successful treatment of celiac disease (CeD). We determined factors influencing adherence to GFD at various ecological levels of human-development and decision-making, including intra-personal, inter-personal, organizational, community and system-based levels in adult patients with CeD.

Methods A questionnaire was developed based on review of literature, group discussions and expert group meetings. The questionnaire was administered to patients with CeD attending Celiac Clinic and following GFD for >1 year.

Results Overall, 978 patients (median age 29 years, inter-quartile range: 22-46 years; females: 592) were included. We observed many barriers including intra-personal such as lack of a separate gluten-free flour mill at home in 441 (45.1%) patients and intake of gluten-containing food items due to frustration in 108 (11.1%) patients; inter-personal barrier such as inadvertent intake of gluten-containing food products either during dining-out with family/friends in 324 (33.1%) patients or due to non-supportive in-laws in 68 (9.1%) patients; organizational barrier such as non-availability and high cost of packaged GF-food products in 475 (48.6%) and 461 (47.1%) patients respectively and non-membership of celiac support group in 322 (32.9%) patients; community-based barriers such as non-awareness of complexity of eating gluten among relatives in 419 (42.8%) patients and forceful intake of gluten-containing foods due to relatives’ pressure in 78 (7.9%) patients; system-based barriers including lack of appropriate infrastructure and strategy for maintaining GF lifestyle e.g. inappropriate counselling by dietician in almost one-third of patients and irregular follow-up visit with doctor in 560 (57.2%) patients.

Conclusions In India, there are multiple barriers to the adherence of GF lifestyle at all ecological layers of human development. There is a need to create infrastructure and removal of these barriers at various levels of ecosystem.

Keywords Adherence, Barriers, Celiac disease, Facilitators, Gluten-free diet

352

Cost and nutrient comparison of gluten-free foods with their gluten containing counterparts

Wajiha Mehtab ¹ , Samagra Agarwal ² , Tamoghna Ghosh ² , Harsh Agarwal ² , Alka Singh ² , Anam Ahmed ² , Shubham Prasad ² , Ashish Chauhan ³ , Namrata Singh ² , Vineet Ahuja ² , Anita Malhotra ⁴ , Govind K Makharia ²

Correspondence – Govind K Makharia - govindmakharia@gmail.com

¹Department of Home Science, University of Delhi, Ashok Vihar III – Ashok Vihar, Delhi 110 052, India, ²Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, ³Department of Gastroenterology, Indira Gandhi Medical College, Ridge Sanjauli Road, Lakkar Bazar, Shimla 171 001, India, and ⁴Department of Home Science, Lakshmibai College, University of Delhi, Ashok Vihar III – Ashok Vihar, Delhi 110 052, India

Background A lifelong gluten-free diet (GFD) is the only available treatment for patients with celiac disease. There is paucity of data on the nutritional content and cost of gluten-free (GF) food products compared with their gluten-containing (GC) counterparts from India and Asia.

Methods After a detailed market survey, the packaged and labeled GF-food products (n=485) and their packaged gluten containing counterparts (n=790) from the supermarkets of Delhi (India) and e-commerce websites were included. Nutritional content and cost per 100-gram food (in US dollars) were calculated using the nutritional contents and prices mentioned on food label.

Results Gluten-free food products were 232% (Range: 118%-376%) more expensive than their gluten-containing counterparts. Energy content of all GF-food products was similar to their gluten-containing counterparts, except cereal-based snacks (GF:445 kcal vs. GC:510 kcal, p<0.001). The protein content was significantly lower in GF pasta and macaroni products (single-grain:GF:6.5 g vs. GC:11.5 g, p-0.002; multigrain:GF:7.6 g vs. GC:11.5 g, p-0.027), cereal flours (single-grain:GF:7.6 g vs. GC:12.3 g, p<0.001; multigrain:GF:10.9 g vs. GC:14.1 g, p-0.009) and nutritional bars (GF:21.81 g vs. GC:26 g, p-0.028) than their gluten containing counterparts. Similarly, the dietary fiber content of GF pasta and macaroni products, cereal flours, cereal premix and nutritional bars of GF-foods was significantly lower than their gluten-containing counterparts. Gluten-free bread and confectionary items, biscuits and cookies and snacks had higher total-fats and trans-fat content than their gluten-containing counterparts. Gluten-free cereal-based snack foods had higher sodium content than their gluten containing counterparts (GF:820 mg vs. GC:670 mg, p<0.001). Seventy-three percent of GF-food products were classified as ultra-processed foods.

Conclusion Gluten-free food products are significantly more expensive than their gluten containing counterparts, thus increasing the economic burden to patients and potentially acting as a barrier to adherence to GFD. Majority of packaged GF-food products are highly processed and contain less protein and dietary fiber and higher fat, trans-fat and sodium.

Keywords Celiac disease, Cost, Gluten-containing food, Gluten-free foods, Nutritional quality

Miscellaneous

353

Randomized trial of ‘Roll-over’ technique of abdominal paracentesis versus standard technique in suspected malignant ascites

Daya K Jha, Manish Rohilla, Chandan Das, Santhosh Irrinki, Harjeet Singh, Aashima Arora, Subhas C Saha, Pankaj Gupta, Harshal Mandavdhare, Usha Dutta, Aman Sharma, Vishal Sharma

Correspondence – Vishal Sharma - docvishalsharma@gmail.com

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

Background Single abdominal paracentesis for peritoneal carcinomatosis has a variable but low sensitivity (40% to 70%). We thought that rolling over the patient before paracentesis might improve the cytological yield because the tumor cells may settle down in the peritoneum while lying supine.

Methods We conducted a pilot, randomized cross-over study at a single center. We compared the cytological yield of fluid obtained by roll-over technique (ROG) with standard paracentesis (SPG) in suspected peritoneal carcinomatosis. In the ROG group, patients rolled side-to-side thrice, and the paracentesis was done within 1 minute. Each patient served as their own control, and the outcome assessor (cytopathologist) was blinded. The primary objective was to compare the tumor cell positivity between SPG and ROG groups.

Results Of 71 patients, 62 were analyzed. Of 53 patients with malignancy-related ascites, 39 had peritoneal carcinomatosis. Most of the tumor cells were adenocarcinoma (30, 94%) with one patient each having suspicious cytology and one having lymphoma. The sensitivity for diagnosis of peritoneal carcinomatosis was (31/39) 79.49% in SPG group and (32/39) 82.05% in ROG group (p=1.00). The cellularity was similar between both the groups (good cellularity in 58% of SPG and 60% of ROG).

Conclusion Rollover paracentesis did not improve the cytological yield of abdominal paracentesis.

Keywords Cytology, Malignant ascites, Peritoeum, Peritoneal carcinomatosis, Peritoneal tuberculosis, Tuberculous peritonitis

354

The perioperative outcome in geriatric patients undergoing major gastrointestinal surgery-A prospective observational study

Anantha Krishna V R

Correspondence - Anantha Krishna V R - akvrkrsna@gmail.com

Department of Surgical Gastroenterology, 1, Vinod Nagar Road, Anayara, Thiruvananthapuram 695 029, India

Background The surgical impact on the perioperative outcome in geriatric patients is a scarcely studied topic. The objective of this study was to identify the 30-day morbidity and mortality in geriatric patients undergoing major elective gastrointestinal (GI) surgery and the risk factors associated with the same.

Methodology Ninety-three patients above or equal to 65 years constituted this study conducted in the Department of Surgical Gastroenterology, KIMS Health, Thiruvananthapuram. The 30-day morbidity comprised of grade 2 and above Clavien Dindo complications. The preoperative risk factors for the above were analyzed. The basic ADLs i.e. skills required to manage one’s basic physical needs and the Instrumental Activities of Daily Living (IADLs) which includes more complex activities related to the ability to live independently in the community was documented preoperatively. The preoperative functional status was also assessed using the clinical frailty scale, gait speed, timed up and go test and Carlson’s comorbidity index.

Results The 30-day mortality and the 30-day overall morbidity was 3.2% and 58.06% respectively. 26.9% had grade 2 and above Clavien Dindo complications. This was more in those with prior history of falls, timed up and go test >14 seconds, significant weight loss, malignancy, and open surgeries. Age had no association with adverse postoperative outcomes.

Conclusion Age is not an independent variable in predicting postoperative outcomes. Grade 2 and above Clavien Dindo surgical complications were more in those with poor preoperative functional and nutritional status, those who were operated for malignancy and in open surgeries.

Keywords Age, Gastrointestinal, Geriatric

355

Trends and clinico-epidemological profile of patients with Giardiasis: Five-year experience from a tertiary care centre

Ujjala Ghoshal ¹ , Nidhi Tejan ¹ , Tasneem Siddiqui ² , Pooja Kumari ³ , Uday C Ghoshal ⁴

Correspondence - Ujjala Ghoshal - ujjalaghoshal@yahoo.co.in

Departments of ¹Microbiology, and ⁴Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, India, ²Department of Microbiology, Integral University, Kursi Road, Lucknow 226 026, India, and ³Department of Medical Microbiology, Chaudhary Charan Singh University (CCSU), Ramgarhi, Meerut 250 001, India

Introduction Giardiasis is an important cause of diarrheal disease and is associated with morbidity in children and adults worldwide [1, 2]. We aimed to study the frequency of Giardiasis, its clinical presentations, seasonal trends in detection and coinfection with other intestinal parasites. We also compared the fecal antigen and microscopy for detection of Giardia.

Methods It is a retrospective study conducted from January 2017 to December 2021 at our tertiary care center. Patients of all age groups referred to Parasitology laboratory for stool examination were included. Iodine and normal saline mounts and enzyme-linked immunosorbent assay (ELISA) were used for detection of Giardiasis in stool samples. Fisher exact test was used for analysis. Sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of tests were computed.

Results Of 8364 patients, 432 (5.2%) had Giardiasis by microscopy and/or ELISA. Giardiasis was more common in males compared to females (318/5613 [5.6%] vs. 114/2751 [4.1%]; p = 0.003) and among those ≤10-y compared to older individuals (102/560 [18.2%] vs. 330/7804 [4.2%]; 𝑃<0.0001). Most cases were detected in the month of May to October. The most common clinical presentation was diarrhea (80.1%) and abdominal pain (72.9%) followed by malnutrition (60.2%) and loss of appetite (46.8%). Stool microscopy and ELISA were comparably positive (393/864 [45.5%] and 413/864 [47.8%]; p=NS). Using microscopy as gold standard, sensitivity, specificity, positive, negative predictive values, and diagnostic accuracy of ELISA were 95%, 91%, 91%, 95% and 93%, respectively.

Conclusion 5.2% of the studied population had Giardiasis; it was commoner among male and younger individual. We observed a seasonal variation with peak during May to October. Fecal antigen was comparable to microscopy for detection of Giardiasis.

Keywords Diarrheal disease, Enzyme linked immunosorbent assay, Epidemiology, Giardiasis

References

1. Einarsson E, Maayeh S, Svärd SG. An up-date on Giardia and giardiasis. Curr Opin Microbiol. 2016; 34:47–52.

2. Painter JE, Gargano JW, Collier SA, et al . Giardiasis surveillance- united states, 2011- 2012. MMWR Surveill Summ. 2015; 64:15-25.

356

Fecal calprotectin can differentiate gastrointestinal graft versus host disease from other diarrhea in post-hematopoietic stem cell transplant patients

Santhosh Kumar ¹ , Shreyas Hanmantgad², Tintu Varghese³, A J Joseph⁴, Amit Kumar Dutta⁴, Biju George²

Correspondence – Santhosh Kumar - santhoshkumare@gmail.com

Departments of ¹Hepatology, ²Hematology, ³Wellcome Research Unit, Division of GI Sciences, and ⁴Gastroeneterology, Christian Medical College, William Building, Ida Scudder Road, Vellore 632 004, India

Background Large number (40% to 50%) of hematopoietic stem transplant (HSCT) patients experience diarrhea in the initial post-transplant period. Gastrointestinal graft vs. host disease (GI-GVHD) has to be distinguished early from other diarrheal causes and treated. Fecal calprotectin (FC) is sensitive agent to identify bowel inflammation.

Methods We prospectively studied consecutive HSCT patients and FC levels were measured pretransplant, post-transplant day 14, day 1 of diarrhea and serially (day 3 and day 5) on treatment for GI-GVHD. We aimed to measure ability of FC to predict development of GI-GVHD and differentiate GI-GVHD from other diarrhea. Informed consent was taken and the study was Institute Review Board approved.

Results One hundred and three patients (age 18 [±14.9 years], mean [SD]) were studied, pre-transplant FC was similar among patients; GI-GVHD (11.6 ug/g [2.6-34.4] median [IQR]), no-GI-GVHD (11.3 ug/g [2.3-28.3]), p-0.93. Post-transplant day 14, FC was similar among patients; GI-GVHD (25.13 ug/g (9.9-45.2]) no-GI-GVHD (15.01 ug/g [10.4-34.1]), p-0.49. Thirty-nine patients had diarrhea (post BMT day 17 [11-26]) in the post-transplant setting, 17 patients diagnosed with GI-GVHD and 22 patients had other diarrheal illness. Day 1 of diarrhea FC levels among GI- GVHD was significantly higher (62.97 ug/g [28.3-296.7]) compared to other diarrheal illness (23.9 ug/g [19.4-48.7]), p-0.042. AUROC for day 1 diarrheal sample in a post HSCT to predict GI-GVHD was 0.7 (0.56-0.87) and FC cut-off > 50 ug/g had sensitivity (77.3%), specificity (58.8%), PPV (66.7%), NPV (70.8%) and diagnostic accuracy (69.2%). Our study numbers were small to correlate FC levels with grade of GI-GVHD and assess treatment response.

Conclusion In post HSCT patient day 1 of diarrhea FC level > 50 ug/g has good accuracy (69.2%) for diagnosing GI-GVHD. Larger post HSCT diarrhea patients need to be studied to assess correlation between FC with grade of GI-GVHD and treatment response.

Keywords Calprotectin, Graft versus host disease, Hematopoietic stem cell transplant

357

The role of fibroscan in predicting the risk of variceal bleed in patients with cirrhosis

Harinder Chhabra , Sandeep Gopal, Bailuru Vishwanath Tantry, Suresh Shenoy, Anurag Shetty

Correspondence - Harinder Chhabra - harinder.singh.chhabra@gmail.com

Department of Medical Gastroenterology, Kasturba Medical College, Mangalore MAHE, 203, Light House Hill Road, Hampankatta, Mangaluru 575 001, India

Background and Study Aim Variceal bleeding is a life-threatening event that has an incidence of 5% and 15% in patients with small and large esophageal varices respectively. Endoscopic screening for esophageal varices in cirrhotic patients is mandatory. The aim was to study the role of LSM and spleen stiffness measurement (SSM) in predicting the risk of variceal bleed in patients with cirrhosis.

Methods This is a single centre case control study conducted on chronic liver disease patients (CLD) who will undergo fibroscan over a period of 18 months from October 2020 to March 2022. A total of 70 patients have been included in this study. LSM and SSM values of cirrhotics with history of UGI bleed (cases) were compared to those without any history of UGI bleed (controls).

Results Spleen stiffness cut-off level of 47.65 kPa had 82.9% sensitivity and 74.3% specificity in determining the risk of bleeding, with a negative predictive value (NPV) of 0.81. LSM cut-off level of 25.85 kPa had 85.7% sensitivity, 65.7% specificity and NPV of 0.82 for detecting variceal bleeding. Combining the two cut-offs NPV was 0.96 (sensitivity, 97.1%; specificity, 62.85%). Only one patient had a history of variceal hemorrhage when their LSM and SSM were below their respective cut-off values.

Conclusions Our study suggests that in patients with CLD, SSM and LSM values could aid in identifying those with high risk of variceal bleed and the grades of esophageal varices. Hence majority of the patients who may never experience variceal hemorrhage, transient elastography (Fibroscan) will help to avoid invasive methods of assessment and prophylactic therapies.

Keywords CLD, Fibroscan, Liver stiffness, LSM, Spleen stiffness, SSM, Variceal bleed

358

Melioidosis presenting as splenic abscess: Case report and review of literature

Pranav Kumar ¹ , Chhagan Lal Birda ² , Yadav Suresh Chand ¹ , Taruna Yadav ³ , Ashish Agarwal

Correspondence – Ashish Agarwal - drashu123@gmail.com

Departments of ¹Medicine, ²Gastroenterology, and ³Radiology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A. 1st Phase, Basni, Basni, Jodhpur 342 005, India

Introduction Melioidosis is an infectious caused by gram-negative bacilli Burkholderia pseudomallei. It has a wide variety of clinical presentations. Presentation as a splenic abscess is relatively rare and a high index of suspicion is needed for the diagnosis. In this case report, we report an interesting case of recurrent splenic abscess which was eventually diagnosed to be due to melioidosis.

Methods Melioidosis is an emerging infectious disease resulting from infection with a gram-negative bacterium. It is endemic in India but is rarely suspected and diagnosed. It has a varied presentation and is aptly called the “great mimicker”. In this case report, we have presented a case of recurrent splenic abscess which was diagnosed as Melioidosis. Although the presentation was typical, due to limited awareness and suspicion, the diagnosis was delayed.

Results Thirty-seven-year-old male patient, chronic alcoholic, presented with fever and left hypochondriac severe pain for last 3 days. He had a history of similar presentation four times in the last 1 year when he was managed with empirical antibiotics. He had also received empirical ATT 2 years back when he had presented with fever with imaging suggestive of enlarged mediastinal lymph nodes. A contrast-enhanced computed tomography (CECT) abdomen was suggestive of ruptured splenic abscess, which showed growth of B. pseudomallei on culture. A review of previous imaging showed hypoechoic lesions in the spleen in the CT done 2 years back and a ruptured splenic abscess 6 months back. The patient was treated with a prolonged course of antimicrobials specific for B. pseudomallei, with which the patient has improved.

Conclusion B. pseudomallei should be suspected in patients with deep-seated abscesses. Increased awareness and suspicion and prolonged treatment with specific antibiotics if curative in this otherwise fatal infection.

Keywords Burkholderia, Diabetes, Tuberculosis

359

Carotid intima-media thickness as a surrogate marker of cardiovascular disease in patients with inflammatory bowel disease

Jithin John, Anju Krishna K, Ravindra Pal, Avisek Chakraborty, Rushil Solanki, Devika Madhu, Vijay Narayanan, Shivabrata Dhal Mohapatra, Swetha Sattanathan, Aditya Verma, Srijaya Sreesh, Sandesh K*, Krishnadas Devadas

Correspondence- Jithin John - jithin4john@gmail.com

Department of Medical Gastroenterology, Government Medical College, Ulloor - Akkulam Rpad, Chalakkuzhi, Thiruvananthapuram 695 011, India and ^*Department of Medical Gastroenterology, Government Medical College, Gandhi Nagar, Kottayam 686 008, India

Background and Objectives There is an increased risk of cardiovascular disease in patients with inflammatory bowel disease (IBD), even without conventional risk factors. We compared the carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis, of subjects with and without IBD to study the cardiovascular risk. We also studied other factors affecting CIMT in IBD.

Methods A descriptive study on 280 subjects with and without IBD. Subjects aged more than 55 years, obese individuals, patients already diagnosed with cardio/cerebrovascular disease, and those with other chronic inflammatory conditions were excluded. Baseline data including CIMT was recorded. The quantitative data were compared using the Student’s t-test and the qualitative data by Chi-square test. Pearson and Spearman’s correlation was done to find out the factors correlating with CIMT.

Results Both groups were comparable in terms of age, sex distribution, and traditional cardiovascular risks (hypertension, diabetes, and dyslipidemia). The IBD group had 55.71% patients with ulcerative colitis (UC) and 44.28% with Crohn’s disease (CD). The CIMT was higher in patients with IBD as compared to controls (0.532±0.091 vs. 0.476±0.038, p=.000). In patients with IBD, those with n. on-alcoholic fatty liver disease (NAFLD) had an increased CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP, and ultrasound grades of the fatty liver had positive correlations with CIMT. There was no change in CIMT with disease type (UC/CD), the extent of disease, disease activity, or severity of the disease. Multivariate regression analysis showed that age and ultrasound grading of fatty liver (R2 =0.576, p=.000) were independent predictors of higher CIMT. Fibrosis score by 2D-SWE was significantly higher in the IBD group (6.6±1.8 vs. 5.6±1.3, p=.000).

Conclusion As compared to the control group, CIMT was increased in patients with IBD. Age and NAFLD were independently associated with increased CIMT in IBD. Enhanced monitoring for cardiovascular events may be required in patients with IBD especially those with NAFLD.

Keywords Carotid intima-media thickness, Inflammatory bowel disease, Non-alcoholic fatty liver disease

360

Irritable bowel syndrome complicating asymptomatic nonrotation of midgut

Vikas Reddy, Bhashyakarla Ramesh Kumar, Malladi Uma Devi, Sahitya Reddy, Suraj Kumar, Rahul Vijay Vargiya

Correspondence - Vikas Reddy- vikas.venkannagari@gmail.com

Department of Medical Gastroenterology, Osmania Medical College, 5-1-876, Turrebaz Khan Road, Troop Bazaar, Koti, Hyderabad 500 095, India

Introduction Nonrotation is a part of spectrum of anatomic anomalies comprising malrotation. Most cases are symptomatic and managed surgically with a Ladd's procedure. However, incidental discovery of asymptomatic patients has also been reported. In these cases, role of surgery is debated. Malrotation is a collection of several distinct anatomic anomalies, which can be described based on the location of duodenal-jejunal junction and cecum. Most common anomaly is nonrotation of duodenum and cecum, in which both pre-arterial and post arterial midgut are mispositioned. Despite the heterogeneity of anomalies grouped under heading of malrotation, treatment is rather homogeneous as patients with all types are treated with Ladd's procedures. While the role of surgery is clear in the setting of symptomatic disease, its role in asymptomatic malrotation has been challenged by a series of publications.

Methods Twenty-one-year-old male presented with complaints of cramping abdominal pain and constipation since 3 years. Pain is in periumbilical and suprapubic regions and is non radiating. No tenderness. Computed tomography scan of abdomen showed duodenal-jejunal junction is in right side of abdomen, as is entire small bowel. Large bowel is in left side of abdomen. Cecum is in left lower quadrant. Superior mesenteric vein is left and anterior to superior mesenteric artery.

Results Patient initially treated with polyethylene glycol 3350 and fiber supplementation which resulted in daily soft bowel movements. Patient has been without abdominal complaints for more than 6 months and a Ladd's procedure has not been recommended.

Conclusion Asymptomatic nonrotation of midgut can be considered for observation alone and does not necessarily require operative intervention. Functional bowel disorders can complicate evaluation and management of patients with otherwise benign anatomy and lead to unnecessary and ultimately ineffective operations. Thorough history and physical and radiographic evaluations are critical to appropriate treatment of stable patient.

Keywords Constipation, IBS, Nonrotation

361

RS3PE and pseudo-achalasia: A rare combination and an unusual presentation of metastatic cancer

Rishi Raman, Raya Venkatesh Reddy, Shiran Shetty, Balaji Musunuri

Correspondence - Rishi Raman - rishiraman89@gmail.com

Department of Gastroenterology and Hepatology, Kasturba Medical College, Tiger Circle Road, Madhav Nagar, Manipal 576 104, India

Introduction Although Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE) syndrome has been reported in malignancies including lung cancer, prostatic carcinoma, bladder cancer, myelodysplastic syndrome and adenosquamous lung carcinoma literature is sparse related to hepatic and luminal cancers. To our knowledge, pseudo-achalasia and RS3PE both occurring together in a patient with metastatic cancer is a rare occurrence.

Case Report A 60-year-old lady presented to us with history of progressive dysphagia since 4 months associated with progressive weight loss, symmetrical joint swelling involving both upper limbs for one month duration. She had bilateral pitting pedal edema. Evaluation revealed anemia (Hb of 9 g/dL), elevation of inflammatory markers (CRP 63 mg/L). The inflammatory polyarthritis was seronegative with rheumatoid factor and anti-CCP being normal. Upper GI endoscopy revealed a significantly dilated tortuous esophagus with food residue, with significant narrowing at GE junction, normal mucosa, with suspicion of achalasia. Esophageal manometry revealed findings of Achalasia (high IRP and aperistalsis in all the swallows). CT scan revealed a 3 cms lymph nodal lesion compressing the gastroesophageal (GE) junction, with multiple liver metastatic lesions. Biopsy done from the liver lesion was confirmative of malignancy. She was diagnosed as RS3PE with metastatic malignancy with lymph nodal compression at GE junction causing pseudoachalasia.

Discussion RS3PE is a distinct clinical syndrome, initially by McCarty et al. (1985), which was described as a distinct form of late-onset rheumatoid arthritis. It has been found to coexist with various rheumatic diseases, such as Sjogren's syndrome, polyarteritis nodosa, ankylosing spondylitis, sarcoidosis, amyloidosis, relapsing polychondritis and bronchiolitis obliterans organizing pneumonia. It is also found to be associated with various malignancies including hematological and solid tumors and represents a form of paraneoplastic syndrome. Pathogenesis is unknown but it has been hypothesised that VEGF promotes synovial inflammation and vascular permeability in patients with RS3PE syndrome causing pitting edema and synovitis.

Conclusion Pseudoachalasia and RS3PE presenting together as a first presentation of metastatic cancer is a rare occurrence.

Keywords Metastatic carcinoma, Pseudoachalasia, RS3PE

362

Serological response to vaccination against coronavirus disease-19 in patients with inflammatory bowel disease

Akash Mathur, Shikha Sahu, Uday C Ghoshal

Correspondence - Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014, India

Background Vaccination against coronavirus disease-19 (COVID-19) is effective to prevent the occurrence or reduction in the severity of the infection. Patients with inflammatory bowel disease (IBD) are on long-term immunomodulator therapy, which may alter the serological response to vaccination against COVID-19. Accordingly, we studied, (i) serological response to vaccination against COVID-19 in IBD patients, and (ii) comparison of serological response in IBD patients with that in healthy controls.

Method A prospective study was undertaken during a 6-month period (July 2021 to January 2022). Blood samples were collected from vaccinated, unvaccinated IBD patients and vaccinated healthy controls. Seroconversion was assessed using COVID Kawachanti-SARS-CoV-2 IgG antibody detection ELISA kit (J. Mitra and Co. Pvt. Ltd., New Delhi, India) and optical density (OD) was measured at 450 nm. OD is directly proportional to the antibody concentration.

Result One hundred and thirty-two blood samples were collected from 97 IBD patients (85 [87.6%] ulcerative colitis and 12 [12.4%] Crohn’s disease). 41/71 (57.7%) unvaccinated and 60/61 (98.4%) vaccinated IBD patients tested positive (OD >0.3) for SARS-CoV-2 IgG antibodies. OD values were significantly higher in vaccinated IBD patients than unvaccinated IBD patients (1.31 [1.09-1.70] vs. 0.53 [0.19-1.32], p<0.001) and 16 vaccinated healthy controls (1.31 [1.09-1.70] vs. 0.64 [0.43-0.78], p<0.001). OD values of vaccinated healthy controls and unvaccinated IBD patients were comparable (0.64 [0.43-0.78] vs. 0.53 [0.19-1.32], p=0.882). 3/71 (4.22%) of the unvaccinated IBD patients reported to have recovered from COVID-19.

Conclusion Most IBD patients seroconvert after vaccination against SARS-CoV-2, similar to a healthy population in spite of being on drugs used to treat IBD. A large proportion of IBD patients had anti-SARS-CoV-2 antibodies even before vaccination despite a low frequency of occurrence of clinically recognized COVID-19 in the past suggesting occurrence of herd immunity.

Keywords Coronavirus disease-19, Inflammatory bowel disease, Vaccination

363

Hyperammonemic encephalopathy following sleeve gastrectomy: First report from India

Jitendra Mohan Jha , Avnish Kumar Seth

Correspondence - Jitendra Mohan Jha - akseth2003@yahoo.com

Department of Medical Gastroenterology, Manipal Hospital, Sector 6, Dwarka, Delhi 110 075, India

Introduction Hyperammonemic encephalopathy (HAE) related to liver disease or shunt surgery is frequent. Rarely, HAE may occur in the absence of liver disease due to inborn errors of metabolism, drugs, parenteral nutrition, or infections by urease producing bacteria. We present a patient with HAE following bariatric surgery.

Case Report Forty-nine—year-old female who underwent sleeve gastrectomy for morbid obesity eight years ago, presented with insidious onset of altered sensorium over three days. There was no history of fever or seizure. She was on Thyroxine 100 mcg daily for primary hypothyroidism. On examination GCS was E2V3M5, weight 82 Kg with BMI of 28 Kg/m². She was afebrile, BP 134/80, pulse 88/minute. There was no focal neurological deficit or signs of meningeal irritation. Investigations revealed Hb 9.1G/dL, WBC 5500 and platelets 1,52,00/c.mm. INR 1.3, sodium 140 mEq/L, creatinine 0.5 mg/dL, random blood sugar 110 mg/dL, bilirubin 1.3.g/dL, AST 42 and ALT 27 U/L. albumin 2.9 G/dL. X-ray chest was normal and NCCT head was normal. Plasma ammonia level was 345 mcg/dL. Ultrasound abdomen showed grade two fatty liver. Fibroscan showed F0-F1 fibrosis. She was started on L-Ornithine L-Aspartate, Lactulose and Rifaximin but sensorium continued to deteriorate, requiring intubation. Peak ammonia was 649 mcg/dL. CECT head showed marked cerebral edema with loss of demarcation of grey and white matter, loss of sulci and compression of lateral ventricles. She developed evidence of sepsis and multiorgan failure and died after six days.

Discussion Previous reports of HAE following Bariatric surgery describe the syndrome in females, up to 28 years following surgery, usually Roux-en-Y gastric bypass. Mechanism remains obscure but nutritional deficiency of Arginine and Zinc leading to unmasking of subclinical urea cycle defects and bacterial overgrowth have been proposed.

Conclusion HAE is a rare but potentially fatal complication of bariatric surgery.

Keywords Bariatric surgery, Hyperammonemic encephalopathy

364

Irritable bowel syndrome patients diagnosed by Rome IV criteria have greater symptom severity, worse quality of life and sleep disorder compared to those diagnosed by Rome III criteria

Anshika Varshney , Moni Chaudhary, Vamika Mansi Saigal, Uday C Ghoshal

Correspondence - Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014. India

Background The changes in the diagnostic criteria for irritable bowel syndrome (IBS) from Rome III to Rome IV might have led to the selection of a group of patients with more severe symptoms and higher level of psychological co-morbidity. The relative paucity of data with some conflicting findings, demands further studies to examine the impact of change in IBS diagnostic criteria on symptom severity, sleep quality and quality of life.

Methods A total of 57 IBS patients were categorized as having IBS using Rome III and Rome IV questionnaires. The symptom severity was assessed using IBS-symptom severity score (SSS), quality of life by world health organization quality of life-BREF (WHOQOL-BREF) and sleep quality by Pittsburgh sleep quality index score (PSQI).

Results Of 57 IBS patients, 51 (89.5%) fulfilled the Rome III IBS criteria and 40 (70.2%) fulfilled the Rome IV criteria. Overall, 59.6% of Rome III IBS patients fulfilled the Rome IV criteria for IBS, but 40.4% did not. Rome IV-positive subjects were significantly more likely to have greater pain severity (4 [10%] vs. 0 [0%], p=0.041) and pain frequency (12 [30%] vs. 0 [0%], p<0.001); higher IBS-SSS score (median scores, 260 [187.5, 306.2] vs. 190 [150,215], p=0.005), and symptom severity than Rome IV-negative subjects. For the psychosocial alarm status, work impairment and abuse were higher in Rome IV-positive than the other patients.

Conclusion IBS patients positive by Rome IV criteria have more severe symptoms, pain frequency, work impairment and history of abuse than the Rome IV negative patients. Forty percent of Rome III-positive IBS patients fulfilled the Rome IV IBS criteria.

Keywords Irritable bowel syndrome, Sleeps disorders, symptom severity

365

Comparing the psychosocial health and quality of life in patients with ulcerative colitis and functional gastrointestinal disorders

Shikha Sahu, Moni Chaudhary, Sushmita Rai, Uday C Ghoshal

Correspondence - Uday C Ghoshal - udayghoshal@gmail.com

Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareli Road, Lucknow 226 014. India

Background Inflammatory bowel disease (IBD) patients after control of their disease activity may continue to have symptoms of functional gastrointestinal disorders (FGID), which may be associated with poorer quality of life. Moreover, patients with active IBD may have poor quality of life (QOL) because of their severe symptoms. Accordingly, we studied the psychological issues and QOL of patients with ulcerative colitis, those with FGID and healthy control.

Method Quality of life and psychological issues were assessed using World Health Organization quality of life-BREF (WHOQOL-BREF) and Rome III psychosocial alarm questionnaire, respectively. Data were obtained from 225 participants (100 UC patients, 100 FGID patients and 25 healthy controls). Severity of UC was assessed using ulcerative colitis disease activity index (UCDAI) and Truelove and Witt’s severity index.

Result Of 225 subjects, 100 UC patients (median age 36 years, range [28.0-48.7]; 47 [47%] male), 100 FGID patients (median age 38 years [range 29.0-51.0]; 44 [44%] male), and 25 controls (median age 29 years, [range 27-41], 15 [60%] male) had significant differences in all the four domains of WHOQOL-BREF: physical domain score (53.57 [42.85-53.57] vs. 53.57 [43.7-64.2] vs. 53.75 [50.0-62.5]; p=0.026), psychological domain score (54.16 [45.8-54.1] vs. 50.0 [37.5-62.5] vs. 66.87 [64.6-70.6]; p<0.001), social relationship domain score (66.6 [58.3-75.0] vs. 75.0 [66.0-75.0] vs. 75.0 [50.0-87.5]; p<0.001) and environment scores (median scores and range, 50.0 [46.8-59.3] vs. 59.37 [56.2-65.6] vs. 65.6 (53.1-78.1); p<0.001). The psychological QOL scores of FGID and IBD patients were comparable, whereas the parameters of Rome III psychosocial alarm questionnaire: depression, severity of body pain, impairment and impaired coping were lower in FGID patients. Suicidal tendency was higher in FGID as compared to IBD.

Conclusion UC patients in relapse have poorer social relationship and environment domain of QOL than FGID. Psychosocial alarm parameters are also greater in UC patients than FGID.

Keywords Functional gastrointestinal disorders, Quality of life, Ulcerative colitis

366

Case of primary disseminated intraabdominal hydatidosis

Sumit Suman, Harish Kulkarni, Prafulla K Singh, Sai Krishna Katepally, P Shravan Kumar

Correspondence - Sumit Suman - sumitsuman511vmmc@gmail.com

Department of Medical Gastroenterology, Gandhi Medical College and Hospital, Musheerabad, Padmarao Nagar, Secunderabad 500 003, India

Introduction Hydatidosis, a zoonotic disease caused by echinococcus granulosus sensu lato, can be primary or secondary. However primary disseminated intraabdominal hydatidosis is a rare form of the disease accounting for 2% of all intraabdominal cysts [1].

Case Presentation We report a case of primary disseminated intraabdominal hydatidosis with multiple organ involvement in a 40 year old man presenting with abdominal pain with abdominal distension for 2 weeks. Ultrasound and computed tomography revealed one cystic lesion of size 4.9*4.2*6.2 cm in segment VII of liver and a 10*9.7*12 cm sized cystic lesion in spleen, two cystic lesions adjacent to gallbladder fossa, one cystic lesion posterolateral to left kidney. Endoscopic ultrasound revealed a daughter cyst in hepatic cystic lesion. Enzyme linked immunosorbent assay for IgG Echinococcus was also positive. The patient was started on albendazole 400 mg twice daily and praziquantel 600 mg thrice daily. There was regression in cyst size at 2 months of follow-up.

Conclusion Although hydatidosis usually affect liver and lung, it can involve other organs, albeit less frequently. The cystic lesion of the disease can be primary or secondary [2], while a rare form of primary hydatidosis, Disseminated intraabdominal hydatidosis accounts for 2%. Such dissemination occurs through lymphatic or systemic circulation.

While surgical excision is the mainstay of treatment for localized hydatid cysts or cysts with infection and multiple septae, management of disseminated disease is medical therapy in the form of albendazole [3].

References

1. Anandpara KM, Aswani Y, Hira P. Disseminated hydatidosis. BMJ Case Rep. 2015;2015: bcr2014208839.

2. Meera M, Vrushali T, Tanaya LK. Primary multiple intraventricular hydatid cysts in a child. Trop Parasitol. 2018; 8:47–9.

3.Brunetti E, Kern P, Vuitton DA; Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop 2010; 114:1-16.

Keywords Echinococcus granulosus sensu lato, Hydatidosis

367

Strongyloides hyperinfection causing refractory gastrointestinal bleed in an immunocompromised patient - A rare presentation

Chitikeshwarapu Sai Kumar , Chandragiri Praneeth

Correspondence – Chandragiri Praneeth - praneethkumar.chandragiri1@gmail.com

Department of Gastroenterology, Asian Institute of Gastroeneterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

A 34-year-old male with diffuse motor and sensory demyelinating poly radiculoneuropathy (post rabies vaccine) on azathioprine and steroids presented with fever, abdominal pain, bilious vomiting and black, tarry stools since 15 days. On examination abdomen showed mild epigastric tenderness. His hemoglobin was 7 gm%. Contrast-enhanced computed tomography (CECT) abdomen revealed circumferential wall thickening of the pylorus and D1, D2 segments with active bleed in duodenum. Upper GI endoscopy showed multiple large deep ulcerations with nodular and edematous mucosa with active bleeding in stomach, D1, D2 duodenum and proximal jejunum.

Biopsies revealed active gastritis and chronic active duodenitis, with associated strongyloides infection. Steroids were stopped and the patient was started on oral ivermectin and albendazole. With a continued drop in hemoglobin, empirically underwent coil embolization of GDA and SPDA initially and later Whipple’s pancreaticoduodenectomy procedure after a multidisciplinary meet. Histopathology showed numerous eggs, rhabditiform larvae and adult worms of strongyloides in the glands, crypts and the muscularis propria from gastric and duodenal sections. Ivermectin and albendazole were continued.

Conclusion This rare diagnosis displays the importance of screening patients at a high risk of Strongyloides infection before starting glucocorticoids.

Keywords Immunocompromised, Strongyloides hyperinfection, upper gastrointestinal bleed

368

Interesting case of ascites

Nitin Pai , Sahil Rasane, Chaitanya Lodha

Correspondence – Sahil Rasane - sahilrasane@gmail.com

Department of Gastroenterology, Ruby Hall Clinics, 40, Sasoon Road, Sangamvadi, Pune 411 001, India

Introduction Eosinophilic gastroenteritis is a rare and heterogeneous gastrointestinal disorder. Definitive diagnoses requires histological demonstrations of eosinophilic infiltration of the gastrointestinal wall or high eosinophil count in ascitic fluid, absence of extragastrointestinal eosinophilic infiltration and exclusion of other diseases. The Klein classification, where patients are arbitrarily divided into those with predominantly mucosal, muscle layer or subserosal disease, is widely used. We report a case of eosinophilic ascites and how we managed our patient.

Case Report A 35-year-old gentleman came with complaints of insidious onset abdominal distension for 3 weeks which was progressively increasing. Abdominal examination revealed free fluid in abdomen. On evaluation, complete blood count showed eiosinophilia, gastroscopy and ileocolonoscopic mucosal biopsies were normal, ascitic fluid analysis showed low SAAG high protein ascites with 55% eosinophils which led to the diagnosis of eosinophilic ascites. The patient was treated with dietary modifications and oral steroids. Ascites was resolved within 1 week of starting treatment.

Conclusion Eosinophilic gastroenteritis is a rare cause of ascites. The pathogenesis of this disease remains obscure, but the diagnosis should not be missed. Steroids remain the mainstay of therapy for eosinophilic gastroenteritis with good symptomatic response as also seen in our case.

Keywords Ascites, Eosiniphilic ascites, Eosinophilic gastroenteritis, Steroids, Unexplained ascites

369

Chronic recurrent multifocal osteomyelitis of the ribs associated with ulcerative colitis : A case report

Aradya H V, Ganesh Koppad, Nandeesh H P, Deepak Suvarna, Vijaykumar T R, Sharathchandra K K, Devansh Bajaj, Abhishek Kabra

Correspondence - Ganesh Koppad - gkoppad@gmail.com

Department of Medical Gastroenterology, J S S Hospital, Mahatma Gandhi Road, Fort Mohalla, Mysuru 570 004, India

Introduction Chronic recurrent multifocal osteomyelitis (CRMO) is a condition characterized by sterile bone inflammation of unknown etiology. Most cases of CRMO are associated with Crohn’s disease; very few are associated with ulcerative colitis; We report a case of CRMO associated with inflammatory bowel disease-ulcerative (IBD-UC).

Methods and Results A 31-year-old male patient known case of IBD–UC on tab mesalamine presented with fever, right sided chest wall pain and swelling, melena since 3 days, O/e multiple subcutaneous swellings were seen over the right chest wall which were tender and there was local rise of temperature. Hb was 6.1 g%, platelets 10.02 lacs, TLC 20410 cells/cumm, CRP 58.13 mg/L, ESR 60 mm, serum procalcitonin 6.83. There was no growth on blood culture, USG thorax showed an ill-defined hetroechoic collection/phlegmon measuring 7.4 × 5.2 × 4.4 cms encasing right 5th and 6th ribs with its destruction and cortical irregularity. CECT thorax confirmed the same, aspiration of the pus was done, grams stain was negative, pus culture was negative, AFB staining and CBNAAT from pus sample was negative. He was treated empirically with IV antibiotics and supportive treatment, However, pain and fever persisted till day 10. UGI endoscopy showed multiple clean based ulcers in D1, colonoscopy revealed multiple pseudopolyps.

Conclusion On the basis of patient’s clinical course, diagnosis of CRMO associated with UC was confirmed, Treatment with mesalamine was continued and Tab Prednisolone /Azathioprine were initiated, there was improvement in the symptoms and resolution in the chest wall abscess after intensifying immunosuppression in the form of steroids / Azathioprine, To conclude the association of IBD–UC with CRMO is rare, physicians should be aware of the possibility of CRMO associated with UC when bone related symptoms are encountered in cases of IBD.

Keywords Azathioprine, CRMO, Osteomyelitis, Steroids, Ulcerative colitis

370

Eosinophilic disorders of gastrointestinal tract - A case series

Dandi Kranthi, Suhas Udgirkar, Amol Dahale

Correspondence – Amol Dahale - amolsd1986@gmail.com

Department of Medical Gastroenterology, Dr D Y Patil Medical College, Hospital and Research Centre, Pune 411 018, India

Introduction Eosinophilic gastrointestinal (GI) disorders are chronic, immune mediated disorders characterized histologically by a pathological increase in eosinophilic predominant tissue inflammation and clinically by GI symptoms Primary eosinophilic GI diseases include five variants according to their localization on their GI tract : Esophagitis, gastritis, gastroenteritis, enteritis, colitis. Eosinophilic gastroenteritis is classified according to the most infiltrated layer of intestinal wall in the form of mucosal, muscular and serosal involvement.

Methods Twelve patients in the study of which 8 patient had eosinophilic eosophagitis, 4 patient had eosinophilic gastroenteritis were analyzed from June 2021 to May 2022 based on review of biopsy results from previous endoscopies and colonscopies. All the patients with eosinophilic esophagitis defined as 15 eosinophils/HPF. Biopsy sample were taken from mid and distal esophagus, stomach, duodenum and jejunum.

Results The mean age in the study population was 32 yrs, males effected were 91.63%, females were 8.37%. Most common presentation was dysphagia (50%), intermittent food impaction was seen in 16.6%, abdominal pain in 33.3%. Mean duration of follow-up was 6months, 1 patient was treated with elimination diet, 3 patients with local (inhalational steroids) and 8 patients with systemic steroids. All patients responded well and on regular follow-up.

Conclusion Eosinophilic disorders of GI tract were uncommon but not rare, high degree of suspicion is required and are easily treatable.

Keywords Elimination diet, Eosinophilic esophagitis, Eosinophilic gastroenteritis, Steroids

371

An interesting case of celiac crisis in adulthood

Nitin Pai, Sahil Rasane, Chaitanya Lodha

Correspondence – Sahil Rasane - sahilrasane@gmail.com

Department of Gastroenterology, Ruby Hall Clinics, 40, Sasoon Road, Sangamvadi, Pune 411 001, India

Introduction Celiac crisis is rare in adults. It is life threatening syndrome with high mortality thus the need to identify early. The prevalence of celiac crisis is adults is less than 1% in India and only 12 reported cases in literature. Here we present a case of celiac crisis in an adult female and how we managed our patient.

Case Report Thirty-two-year-old female came with diarrhea of large volume, watery stools since more than 2 weeks with no blood, 8 to 10 per day with nocturnal episodes as well associated with colicky abdominal pain, nausea and vomiting for 7 days, myalgia and generalized weakness. She was initially treated by a local physician with IV antibiotics, IV fluid and supportive care. Patient then developed hypotension and was shifted to our centre. Her routine workup revealed anemia, deranged electrolytes, metabolic acidosis and hypoproteinemia. contrast-enhanced computed tomography (CECT) abdomen was suggestive of mild hepatomegaly. Patient was admitted to the intensive care unit (ICU) and started with supportive management, IV empirical antibiotics and IV fluids. Even after 4 days there was no improvement in the patient’s overall condition and hence endoscopy was performed which was suggestive of celiac crisis, confirmed on histopathology. Patient was managed with steroids, strict gluten-free diet, and supportive correction nutritional deficiencies, with good response to therapy and discharged on day 10 of steroids.

Conclusion The need for early identification is crucial in patient with celiac crisis because of high mortality index, but the management remain conservative with control of immune system activation and bowel inflammation.

Keywords Celiac crisis, Celiac disease in adults, Uncontrolled dirrhea

372

Lead as an unusual cause of acute pain abdomen: Case report

Manish Kak, Charu Agarwal, Rajesh Bhardwaj, Vinca Kaulkak

Correspondence – Manish Kak - manishkak@yahoo.com

Department of Gastroenterology, Manipal Hospital, Ghaziabad, NH-24, Hapur Road, Pandav Nagar, Ghaziabad 201 002, India

Acute pain abdomen is a common day to day symptom in GI practice; usual diagnosis is achieved by history taking, blood tests, imaging, and endoscopy; however, at times we have a patient who does not fit in any clinical syndrome; usually such patients are labelled as IBS; we present once such case that presented with acute, unrelenting pain abdomen, his routine workup was negative, finally diagnosed as lead toxicity.

Keywords Acute abdomen, Blood lead levels, Lead toxicity

373

Role of tofacitinib as an adjunct to intravenous corticosteroids in the management of acute severe ulcerative colitis: An interim analysis

Manjeet Goyal , Arshdeep Singh, Shivam Kalra, Ajit Sood

Correspondence – Manjeet Goyal - manjeetgoyal@gmail.com

Department of Medical Gastroenterology, Dayanand Medical College and Hospital Tagore Nagar Civil Lines, Ludhiana 141 001, India

Acute severe ulcerative colitis (ASUC) is a medical emergency and a potentially life-threatening condition requiring hospitalization. Intravenous steroids are the mainstay of therapy, but 30; 40% of patients will fail to respond to steroids and require progression to rescue therapy. The current study aimed to evaluate the role of tofacitinib in reducing steroid refractoriness when used as an adjunct to intravenous corticosteroids.

Keywords Inflammatory bowel disease, Tofacitinib, Ulcerative collitis

374

Etiological spectrum of mediastinal and intra-abdominal lymphadenopathy diagnosed by endoscopic ultrasound guided fine needle aspiration

Sagar G

Correspondence – Sagar G - sg718191@gmail.com

Department of Medical Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India

Introduction Evaluation of mediastinal and abdominal lymphadenopathy is a great diagnostic challenge considering the myriad of causes. Tuberculosis is reported as the commonest etiology but the diagnosis still remains a challenge due to inaccessibility to these sites. In recent years, the role of endoscopic ultrasound (EUS) has been greatly extended in evaluation of lymphadenopathy due to its safety, and accuracy. There is a scarcity of data from India about the etiology of intra-abdominal and mediastinal lymphadenopathy and hence the present study was conducted.

Methods A retrospective study was conducted after reviewing hospital records from July 2021 to July 2022 who underwent EUS-guided fine needle aspiration (FNA). A total of 80 patients with mediastinal and/or intra-abdominal lymphadenopathy detected by cross-sectional imaging were examined for clinical features, EUS, and histopathology records.

Results A total of 70 patients (68% male, n=47) were identified with mean age of 43.5 years. Fifty-four patients (77.1%) had mediastinal lymphadenopathy and 16 (22.8%) had abdominal lymphadenopathy. The median number of needle passes was 2 (range: 1–4). The majority of patients in the mediastinal EUS group had tubercular etiology 31% (n=17) followed by metastases 24% (n=13). Other etiologies were reactive-12% (n=7), lymphoma-5% (n=3), sarcoidosis-1 and Aspergillosis-1. The diagnosis was inconclusive in 22% (n=12) of patients.

In the abdominal group, metastasis 43% (n=7) was the most common etiology followed by TB (n=3), lymphoma (n=1) and reactive (n=1). 25% (n=4) had inconclusive report. There was no significant difference between the two groups with respect to the proportion of patients with tubercular and malignant etiology. Seven patients underwent repeat procedure. There were no complications related directly to the procedure.

Conclusion Tuberculosis was the most common cause of mediastinal lymphadenopathy and metastasis was the most common etiology of abdominal lymphadenopathy. EUS FNA is an important modality for the diagnosis of mediastinal and intra-abdominal lymphadenopathy.

Keywords Abdominal lymphadenopathy, EUS-FNA, Mediastinal lymphadenopathy

375

Mastocytic enterocolitis as a rare cause of recurrent abdominal pain

Vamshi A, Adarsh C K, Bhuvan Shetty, Pooja K

Correspondence – Vamshi A - drvamshi21@gmail.com

Department of Medical Gastroenterology, B G S Gleneagles Global Hospitals, 67, Uttarahalli Main Road, Sunkalpalya, Bengaluru 560 060, India

Introduction Abdominal pain is a frequent complaint that causes patients to visit an emergency department. In most cases, a cause can be identified during initial work-up, however there are few cases where the diagnosis may not be straight forward. Mastocytic enterocolitis is a rare disorder characterized by an increased number of gut mucosal mast cells (>20 per high power field) that are revealed by immunohistochemical demonstration of mast cell tryptase. This disorder can be easily missed if immunohistochemical staining for mast cells is not done.

Case Report A 26-year-old female patient presented with complaints of recurrent pain abdomen since 20 days in the epigastric and periumbilical region, severe in intensity, associated with multiple episodes of non-bilious vomitings. No history of radiation of pain, no aggravating or relieving factors. On examination HR-120 bpm, BP-110/70 mmHg. Mild epigastric tenderness was present. Baseline investigations done were normal. Amylase, lipase were normal. CRP was 12. Contrast-enhanced computed tomography (CECT) abdomen showed few prominent mesenteric lymph nodes in the epigastric region. On day 2, she had severe abdominal pain and tachycardia. She was shifted to ICU and managed with analgesic infusions. Urine porphobilinogen and serum lead levels were normal. Upper GI endoscopy showed few superficial gastroduodenal erosions. and colonoscopy was normal. Duodenal, ileal and colonic biopsies showed increased cellularity of lamina propria composed of lymphocytes and plasma cells and also spindle to plasmacytoid cells with fine granular cytoplasm, mast cells (30/HPF) . Immunohistochemistry staining with CD117 showed increased mast cells.

Conclusion It is important to consider mastocytic enterocolitis in the differential diagnosis when evaluating patients with unexplained abdominal pain as these patients typically respond well to histamine receptor antagonists, antileukotrienes and inhibitor of mast cell degradation.

Keywords Abdominal pain, Mast cells, Mastocytic enterocolitis

376

Acute intermittent porphyria- Commonly missed well known entity: Case series report

Ajay Jain, Amber Mittal, Shohini Sircar

Correspondence – Amber Mittal - ambermittal1011@gmail.com

Department of Gastroenterology, Choithram Hospital and Research Centre. 14, Manik Bagh Road, Indore 452 014, India

Introduction Acute intermittent porphyria (AIP) is an autosomal dominant disorder resulting from partial deficiency of porphobilinogen deaminase enzyme in haem biosynthetic pathway. The presentation of AIP as an acute abdomen is well known but a short duration of gastrointestinal symptoms followed by rapidly progressive neuropsychiatric manifestations may also occur thereby misleading the diagnosis.

Report of the Cases A 14-year-old female presented in emergency with sudden onset diffuse, severe excruciating abdominal pain for 5 days, vomiting multiple episodes since 4 days. There was no history of fever, weight loss, altered bowel habit, abdominal distension. She had similar episode 4 months back requiring hospitalization. Family history for AIP was positive. On examination vitals were stable. Abdominal examination revealed non distended diffusely tender abdomen with sluggish bowel sounds. Blood investigations revealed anaemia, sodium-116 mEQ/L, urine PBG: Positive. Next day patient developed generalized tonic clonic seizures with vision loss. Magnetic resonance imaging (MRI) brain s/o posterior reversible encephalopathy (PRES).

Another case of 15-year-old female presented to emergency with severe excruciating diffuse abdominal pain since 7 days with absolute constipation since 3 days. On examination vitals were stable, on per abdomen examination abdomen was diffusely tender. Investigations revealed hyponatremia and urine for PBG: Positive. During hospital stay she had a episode of generalized tonic clonic seizure. MRI brain s/o PRES. Both patients were managed conservatively with IV fluids, antiepileptics along with correction of hyponatremia.

Conclusion Diagnosis of AIP requires high degree of clinical suspicion. Diagnosis of AIP is difficult due to constellation of diverse symptoms involving multiple systems AIP is a life threatening disease, so correct diagnosis and proper management plan regarding abortive and preventive therapies, treatment of acute crisis are crucial to save life of the patient. The patient should be referred to genetic specialist for family screening.

Keywords Acute abdomen, Hyponatremia, Seizures

377

Gastrointestinal and hepatic manifestations in Corona virus disease-19 - A data from western India

Dhaval Gupta, Nilesh Pandav, Palak Shah

Correspondence – Dhaval Gupta - drdhavalgupta@gmail.com

Department of Medical Gastroenterology, G C S Medical College, Hospital and Research Center, Naroda Road, Ahmedabad 380 025, India

Background An increasing number of studies have reported gastrointestinal (GI) symptoms and liver injury in patients with Corona virus disease-18 (COVID-19). Early identification of GI manifestations is not only crucial in management but also of public health importance.

Aims and Objectives. We aim to study relationship between COVID-19 and GI and hepatic manifestations focusing on both clinical findings and their impact on outcomes.

Methods We retrospectively analyzed the data from 630 patients admitted in GCS Medical College, Hospital and Research Center, Ahmedabad during May 2020 till December 2021.

Results and Discussion Among patients with GI manifestations 30.8% had vomiting and 29% had diarrhea. In patients with GI manifestations 64.4% of cases had mild covid infection, 15.5%, 12.8% and 7.3% of cases had moderate, severe and critical covid respectively (p value < 0.005). Among patients with mild COVID, 38 % had exclusive GI manifestation, 30 % had both GI and respiratory, 24% had only respiratory manifestations, 8% had neither of them (p<0.005). Sixteen percent of cases with GI manifestations required oxygen support compared to that of patients with respiratory manifestations who required oxygen support in 48.6% of the cases. Twelve percent of patients with GI manifestations required ventilatory support. Patients with exclusive GI manifestations had 1.2% mortality whereas those with combined GI and respiratory manifestations had a mortality of 18.6%. 23.5% of the patients had deranged liver function tests. Amongst patients with deranged LFTs, bilirubin, AST, ALT, ALP and GGT were elevated in 37.5%, 32.1%, 22.2%, 3% and 12% of cases respectively. Abnormal LFTs were associated with higher mortality.

Conclusion COVID patients with GI manifestations has favorable outcomes with reduced severity, shorter hospital stay, reduced need for O2 support, lesser mortality whereas abnormal LFT favoured severe covid, longer hospital stay, increased need for O2 support and higher mortality.

Keywords COVID-19, Gastrointestinal, Hepatic

378

A rare case of drug induced badycardia in inflammatory bowel disease

Devamsh G N, Mallikarjun

Correspondence – Devamsh G N - chdev1990@gmail.com

Department of Medical Gastroenterology, St. John's Medical College, Sarjapur - Marathahalli Road, John Nagar, Koramangala, Bengaluru 560 034, India

A 45-year-old female presented to the hospital with bloody diarrhea and weight loss since 1 month. On evaluation, patient was diagnosed to have acute flare of ulcerative colitis. She was started on prednisone and mesalamine. Within 24 hours of initiation of mesalamine, patient developed giddiness and chest discomfort. She was found to have sinus bradycardia on ECG. After withdrawing mesalamine, the heart rate returned to normal within 24 hours. This is a rare case report of severe symptomatic sinus bradycardia due to mesalamine therapy. To our knowledge, only four cases of mesalamine induced bradycardia have been reported so far in literature. Clinicians should be aware of this serious adverse effect of mesalamine and keep a look out for bradycardia in patients on mesalamine. Further research is required to establish the mechanism, natural history and prognosis of bradycardia in patients receiving mesalamine.

Keywords Bradycardia, IBD, Mesalamine

379

Utility of MGIT culture and Xpert MTB RIF assay in diagnosing extraintestinal intraabdominal tuberculosis

Polavarapu Jagadish ¹ , Hemanth Chinthala¹, Joy Sarojini Michael², Lalji Patel¹, Shaleen Dass¹, Ajith Thomas¹, Anoop John¹, Reuben Thomas Kurian¹, Rajeeb Jaleel¹, Sudipta Dhar Chaudhury¹, Ebby George Simon¹, Joseph A J¹, Anna Pulimood³, Amit Kumar Dutta¹

Correspondence – Polavarapu Jagadish - bobby.pol69@gmail.com

Departments of ¹Gastroenterology, ²Microbiology, and ³Pathology, Christian Medical College, Ida Scudder Road, Vellore 632 004, India

Introduction Diagnosis of abdominal tuberculosis relies on microbiological tests to detect M tuberculosis and histopathology. Newer microbiological tests like MGIT (culture test for M tb) and Xpert (PCR test for M tb) have an established role in diagnosing pulmonary TB. This study aimed at assessing the diagnostic accuracy of these tests in extra-intestinal intraabdominal tuberculosis (EIATB).

Methods We conducted a retrospective study among patients diagnosed with EIATB. The clinical and investigation details were recorded on a data sheet. This included nature and duration of symptoms and site of lesion. The sample was acquired under radiological guidance and sent for histopathology, MGIT culture and Xpert test. Final diagnosis of EIATB was based on the presence of histopathology findings suggestive of tuberculosis or positive microbiological test for tuberculosis or response to ATT. Yield of MGIT and Xpert tests were calculated for diagnosis of EIATB.

Results We included twenty-eight patients with EIATB. Their mean age was 47.8+13.6 years and 16 (57.1%) were males. Fever was present in 60.7% and abdominal pain in 35.7% cases. Tissue sample for diagnosis of TB was obtained from omentum in 16 (57.1%), intraabdominal lymph node in 7 (25%) and other sites in 5 (17.9%) patients. Histopathology supported a diagnosis of TB in 67.9% cases. Xpert test was positive in eight (28.6%) cases. MGIT culture was positive in 3 (10.7%) of whom two also had a positive Xpert test. The combined sensitivity of the two tests together was 32.1%. Six of the seven intra-abdominal lymph node tissue had a positive Xpert test while none of the omental tissue sample showed a positive result for this test.

Conclusion Microbiological tests can help in the diagnosis of EIATB in about one-third of cases, especially when the tissue is obtained from intra-abdominal lymph nodes.

Keywords Intraabdominal tuberculosis, MGIT culture, Xpert TB

380

Kikuchi fujimoto disease rare presentation

Dattatray Patki

Correspondence – Dattatray Patki - dattatraypatki@gmail.com

Department of Medicine, Poona Hospital, Sadashiv Peth, Pune 400 030, India

Patients with Kikuchi disease have been misdiagnosed as having lymphoma and treated with cytotoxic agents. Other conditions that have been confused with Kikuchi disease are tuberculous adenitis, lymphogranuloma venereum, and Kawasaki disease. Neurologic symptoms are increasingly reported, including aseptic meningitis, meningoencephalitis, acute cerebellar symptoms with tremor and ataxia, and optic neuritis. Aseptic meningitis is the most common neurological complication, usually at the time of the lymphadenopathy. Given that lymphadenopathy is a common presentation, it is important for physicians to be cognizant of Kikuchi disease in the differential diagnosis of lymphadenopathy to prevent misdiagnoses and unnecessary treatments.

Keywords Kikuchis disease