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Overt hepatic encephalopathy (OHE) has high 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.In double blind RCT, we randomly assigned 150 patients with liver cirrhosis, with history of OHE in recent past to receive nutrition therapy (group I) or no nutrition therapy (group II) and followed up for 6 months. The primary efficacy end points were occurrence of breakthrough episodes and time to breakthrough episode of OHE. Secondary end points were OHE related hospitalizations and time to hospitalization involving OHE. Other parameters included anthropometry, changes in serum cytokines (IL-1,6,10TNF-α), endotoxin and myostatin.There was significant reduction in occurrence of breakthrough episodes of OHE in group I [10 vs 36, hazard ratio 0.20 P0.001], OHE related hospitalization [8 vs 24, hazard ratio 0.27 P0.001)]. Times to breakthrough episode of OHE and OHE related hospitalization were longer in group I. At end of 6 months, inflammatory and anthropometry parameters showed significant improvement in group I compared to worsening of serum albumin, anthropometric parameters, IL-6, IL -10 and TNF-α in group II. At end of 6 months, ascites (50 vs 66, p=0.01), gastrointestinal bleed (2 vs 11, p=0.007) and jaundice (16 vs 41, p0.001) were lower in group I.Treatment with nutrition therapy prevented recurrence of OHE and decreased OHE related hospitalizations as compared to no nutrition therapy.

Background/Aims: Response to vaccine in patients with inflammatory bowel disease is lower than in the general population. We aimed to evaluate the efficacy of hepatitis B virus (HBV) vaccination in patients with ulcerative colitis (UC) versus controls.Methods: We prospectively compared antibody response to HBV vaccination in 100 patients with UC versus controls. HBV vaccination was given to all the cases and controls at 0, 1 and 6 months. Anti-hepatitis B surface (anti-HBs) titers were then measured 4 weeks after the first and the third dose. Adequate immune response (AIR) was considered if the anti-HBs titer was >10 IU/L and effective immune response (EIR) if the anti-HBs titer was >100 IU/L.Results: Median anti-HBs titer was lower in patients with UC than controls (67 IU/L vs. 105 IU/L, P2 IU/L and non-exposure to corticosteroids, azathioprine and biologicals were predictors of AIR in patients with UC (P

Introduction The coronavirus disease 2019 (COVID-19) pandemic has affected the healthcare system. The residents who are at the frontline of this pandemic have suffered the most. The extent of the training loss due to the COVID-19 pandemic on gastroenterology (GE) training is not studied in India. Methods We designed a 36-question based google survey and distributed it to the GE residents all across India, via email. All the responses collected were analyzed using appropriate statistical methods. Results A total of 140 responses were received. No significant decrease in teaching sessions/ classes was reported. Most of the residents (83.5%) reported inability to complete the target thesis enrolment. The number of patients seen by the residents in outpatient department, patients managed in wards and endoscopic procedures done by residents have decreased significantly (p-valve Conclusion The COVID-19 pandemic has affected the training of GE residents in India immensely and an extension period of 3 months may be offered to them.

Objective Gastric foreign bodies are a common problem brought to an endoscopist. Prisoners are more prone to ingesting unusual foreign bodies for a secondary gain. The objective of this study was to study the profile of foreign body ingestion among the prisoners brought to a tertiary care center. Methods This is a retrospective case series. All the prisoners brought for endoscopic removal of foreign bodies between January 2018 to December 2019 were included in the analysis. Patients’ baseline characteristics, type of foreign body, management, and outcome were noted Results A total of eight inmates presented with ingestion of foreign body to our department. Most common foreign bodies ingested were drug packets and mobile phones. All ingestions were for secondary gain. Endoscopic removal was successful in all cases. Conclusion Endoscopic removal can be tried with all necessary precautions by an expert endoscopist.

Background Scope-induced duodenal perforation is a life-threatening complication and surgery remains the standard of care. With the advent of over-the-scope clip (OTSC), scope-induced perforations are increasingly managed conservatively, though there is no study comparing this form of non-surgical treatment with surgery. We aimed to compare OTSC and surgery in the management of scope-induced perforation of the duodenum. Methods We retrospectively collected data of scope-induced duodenal perforation patients. Perforations identified and treated within 24 h of procedure were analyzed. Factors analyzed were spectrum, etiology, baseline parameters, perforation size, outcome, comorbidities, and duration of hospital stay. Results A total of 25 patients had type I duodenal perforations, out of whom five were excluded due to delayed diagnosis and treatment. Of the twenty, eight were treated with OTSC placement while the rest underwent surgery. Age was comparable and the majority were females. Baseline parameters and comorbidities were similar in both the groups. The median size of perforation was 1.5 cm in both the OTSC group and the surgical group. All patients were treated with standard of care according to institutional protocols. Patients in the OTSC group were started orally after 48 h of OTSC placement, while in the surgery group median time to oral intake was 7 days. Two patients in the surgical group died while there was no mortality in the OTSC group (p = 0.48). Median hospital stay was shorter in the OTSC group (2 days vs. 22 days, p = 0.003). Conclusions OTSC is a feasible and better option in type I duodenal perforations with a shorter hospital stay.

Background and Aim Systemic inflammation and organ dysfunction/failure can complicate acute decompensation (AD) of cirrhosis with progression to acute‐on‐chronic liver failure (ACLF), leading to increased mortality. There are few studies on serum biomarkers predicting renal dysfunction (RD) or ACLF in AD. Serum cystatin C (CysC) and interleukin‐6 (IL‐6) were evaluated for predicting RD, ACLF, and mortality in AD patients. Methods Consecutive AD patients seen from January 2018 to June 2019 were included. IL‐6 and CysC were measured in serum at the time of index presentation. Patients were followed for 90 days or until primary (development of RD) or secondary outcomes (development of ACLF or mortality). Multivariate analysis was performed to find whether CysC and IL‐6 can independently predict primary and secondary outcomes. Results A total of 124 patients were screened; 88 patients were included. On follow up, 22 (27.3%) developed RD, 11 (11/57, 19.3%) developed ACLF, and 21 (24%) died. The CysC predicted RD (odds ratio [OR] 7.97, 95% confidence interval [CI] 2.70–23.53, P = 0.001) and ACLF (OR 5.486, 95% CI 1.456–20.6, P = 0.012) development. IL‐6 was not an independent predictor of RD (P = 0.315), ACLF (P = 0.168), and mortality (P = 0.225). Conclusion Serum CysC can predict the development of RD and ACLF in patients of cirrhosis with AD., Our study evaluates prognostic efficacy of biomarkers like cystatin C and Interlekin 6 in patients with acute decompensation of cirrhosis. We found cystatin C predicted renal dysfunction and Acute on chronic liver failure but mortality in cirrhotic patients presenting with new onset decompensation while Interlekin 6 did not predicte these events.

Background/Aims: The severe acute respiratory syndrome coronavirus 2 pandemic has affected the gastrointestinal (GI) endoscopy units globally owing to the risk of transmission. We present our data on the use of rapid antigen test (RAT) as a screening tool prior to endoscopy to prevent the transmission of coronavirus disease (COVID-19).Methods: This study was a retrospective analysis of patients who underwent any GI endoscopic procedure from July 2020 to October 2020 at a tertiary referral center in New Delhi, India. All patients underwent screening for COVID-19 using RAT, and endoscopy was performed only when the RAT was negative. The data are presented as numbers and percentages.Results: A total of 3,002 endoscopic procedures were performed during the study period. Only one endoscopic procedure was performed in a COVID-19 positive patient. A total of 53 healthcare workers were involved in conducting these procedures. Only 2 healthcare workers (3.8%) were diagnosed COVID-19 positive, presumably due to community-acquired infection, during this period.Conclusions: The COVID-19 RAT is easily usable as a simple screening tool prior to GI endoscopy during the COVID-19 pandemic.

Background and Aim Endoscopic biopsy is standard for the diagnosis of esophageal malignancy. However, few cases present with smooth stricture with repetitive negative biopsy results. We aimed to use linear endoscopic ultrasound (EUS) and fine‐needle aspiration (FNA) in the diagnosis of biopsy‐negative suspected malignant esophageal strictures. Methods We retrospectively analyzed the data from August 2017 to December 2018 of biopsy‐negative esophageal strictures. All adult patients with twice‐negative biopsies and with smooth overlying esophageal mucosa on endoscopy were included. Clinical, epidemiological, endoscopic, imaging, and EUS findings were noted and analyzed. Results Eighteen patients underwent EUS for suspicion of malignant esophageal stricture. Seven were excluded as they were submucosal tumors. Eleven patients showed the presence of malignancy on EUS FNA samples. Nine were males. Computed tomography showed esophageal wall thickening in eight (16–38 mm) and esophageal mass in three patients. EUS showed loss of a normal five‐layered wall structure of the esophagus in all patients. Fine‐needle aspiration cytology demonstrated squamous cell carcinoma (n = 4), adenocarcinoma (n = 4), poorly differentiated carcinoma (n = 2), and neuroendocrine carcinoma (n = 1). There were no complications. Conclusion EUS with FNA is effective and safe for the diagnosis of biopsy‐negative malignant esophageal strictures., Esophageal malignancy presenting as smooth esophageal stricture with a negative biopsy for malignancy is not uncommon. We retrospectively analyzed the data of 11 such patients who appeared to have malignant esophageal stricture otherwise but had negative repetitive biopsies. Linear endosonography provided a safe and effective modality for diagnosis in such patients.

Endoscopic retrograde cholangiopancreaticography (ERCP) is an essential therapeutic procedure with a significant risk of complications. Data regarding the complications and predictors of adverse outcomes such as mortality are scarce, especially from India and Asia. We aimed to look at the incidence and outcome of complications in ERCP patients.This study is a retrospective analysis of prospectively collected data of all the patients who underwent ERCP and had a complication from January 2012 to December 2018. Data were recorded in predesigned pro forma. The data analysis was done by appropriate statistical tests.: A total of 17,163 ERCP were done. A total of 570 patients (3.3%) had complications; perforation (n = 275, 1.6%) was most common followed by pancreatitis (n = 177, 1.03%) and bleeding (n = 60, 0.35%). The majorities of perforations were managed conservatively (n = 205, 74.5%), and 53 (19%) required surgery. Overall, 69 (0.4%) patients died. Of these, 30 (10.9%) patients died with perforation. Age (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.005-1.07) and need of surgery (OR: 5.11, 95% CI: 1.66-15.77) were the predictors of mortality in patients with perforation. The majority pancreatitis were mild (n = 125, 70.6%) and overall mortality was 5.6% (n = 10).ERCP complications have been remained static over the years, with perforation and pancreatitis contributing the most. Most perforations can be managed conservatively with good clinical outcomes.

The assessment of liver fibrosis is important in patients with chronic hepatitis C (CHC). In recent years, non-invasive tests like enhanced liver fibrosis (ELF) have been developed as an alternative to liver biopsy for estimating the severity of liver fibrosis. Therefore, we aimed to assess whether the ELF score can be used for fibrosis severity estimation using liver biopsy as the gold standard.Forty-nine patients with CHC were enrolled in this study. Liver biopsy, ELF assessment, and transient elastography (TE) were performed in all patients, and severity of fibrosis on histopathology was assessed by meta-analysis of histological data in viral hepatitis (METAVIR) score. In addition, the diagnostic performance of ELF was evaluated by receiver operator characteristic curve (ROC) analyses, and liver biopsy histopathology was taken as the gold standard for the severity of liver fibrosis.The area under receiver operator characteristic curve (AUROC) for significant fibrosis of ELF score was 0.64 (95% confidence interval {CI}, 0.48-0.79) and of TE was 0.85 (95% CI, 0.73-0.96). The AUROC for advance fibrosis of ELF was 0.77 (95% CI, 0.57-0.97) and TE was 0.98 (95% CI, 0.94-1.0). The calculated cut-offs of ELF overestimated fibrosis in 53.06% (26/49) of patients and underestimated fibrosis in 6.12% (3/49) patients. AUROC of TE was significantly better than ELF for diagnosis of significant fibrosis (p=0.004) and advanced fibrosis (p=0.034).The ELF score can be used for estimating the severity of fibrosis but it is inferior to TE in estimating liver fibrosis severity.

AIMS Data on the use of intravenous L ornithine L aspartate (LOLA) in the treatment of overt hepatic encephalopathy (OHE) is limited. We evaluated the role of intravenous LOLA in cirrhotics with OHE grade III-IV. METHODS In a double-blind randomized placebo-controlled trial, 140 patients were randomized to a combination of LOLA, lactulose, and rifaximin (n=70) or placebo, lactulose, and rifaximin (n=70). LOLA was given as continuous intravenous infusion at a dose of 30 grams over 24 hours for 5 days. Ammonia levels, serum tumor necrosis factor α, interleukins, and endotoxins were measured on days 0 and 5. The primary outcome was the improvement in the grade of HE at day 5. RESULTS Higher rates of improvement in grade of HE (92.5% vs 66%, p

Background and study aims Gastroduodenal tuberculosis (GDTB) is an uncommon disease. Surgery has been standard of care both for diagnosis and management of GDTB. The aim of this study was to evaluate the efficacy of non-surgical management of GDTB using a combination of anti-tuberculous therapy (ATT) along with endoscopic dilatation of the tuberculous stricture. Patients and methods Patients suspected to have gastroduodenal TB were evaluated: clinical, endoscopic, radiological, and histopathological data were recorded. Patients in whom a definite diagnosis of tuberculosis could not be confirmed on mucosal biopsies underwent endoscopic mucosal resection (EMR). Patients were treated with ATT and endoscopic dilatation was done if indicated. Patients were followed up to evaluate clinical, radiological and endoscopic response. Results Over a 9-year period from 2009 to 2017, 52 patients (mean age 28.5yrs) were diagnosed with GDTB. The most common presenting symptoms were vomiting (n = 51, 98 %) and weight loss (n = 52,100 %). The most common anatomical site of involvement was D1–D2 junction (n = 22, 42 %). Histopathological diagnosis could be made in 43 patients (82.6 %); 36 (69 %) on mucosal biopsies and in 7 of 10 patients (70 %) who underwent snare biopsy/EMR. Endoscopic dilatation was done in 37 patients (71 %) and median dilatation sessions were two. Failure of endotherapy occurred in four patients (7.6 %). All responders had complete amelioration of symptoms after 4 to 6 weeks of combination therapy. Median period of follow-up was 23.5 months and none of the patients reported any recurrence of symptoms. Conclusion ATT and endoscopic dilatation combined has a high success rate in management of GDTB and should be considered the standard of care.

Colonic self-expandable metal stents (SEMS) are widely used as palliation for malignant obstruction. The conventional method involves using a forward-viewing endoscope as part of the procedure. Sometimes, however, the sharp angle of the stricture poses difficulty in evaluating the stricture, so a guidewire is placed across the stricture. Here, we present a case where a side-viewing endoscope was employed for colonic stent placement and propose its use in patients with sharp bends to increase success.

A 42-year-old man presented with a history of episodic painless lower gastrointestinal (GI) bleed since 10 days. He passed approximately 200–300 mL maroon coloured blood in each episode. There was no history of fever, anorexia, weight loss or abdominal lump. History of use of Non Steroidal Anti

Introduction Peritoneal tuberculosis (PTB) is a paucibacillary disease with poor mycobacterial yield in ascitic fluid. The Xpert® MTB/RIF assay (Gene Xpert) is a new tool for the diagnosis of tuberculosis (TB) and has not yet been studied on peritoneal tissue. The present study aimed to investigate the yield of the Xpert® MTB/RIF assay on peritoneal tissue obtained at peritoneoscopy. Methods This is a retrospective study and the data were collected from hospital records. The patients who underwent peritoneoscopy along with Xpert® MTB/RIF assay on peritoneal tissue were included in this study. Those with proven PTB were considered as cases while those with other diagnoses as controls. Using the reference standard of TB diagnosis, sensitivity, specificity, and accuracy of Xpert® MTB/RIF assay were calculated. Results Total of 36 patients was analyzed in this study: 28 as cases and eight as controls. Peritoneoscopy was carried out for diagnosis and biopsy. Histopathology in cases revealed caseating granulomas in 16 while 11 had non-caseating granulomas. Nine patients showed acid-fast bacillus positivity on peritoneal tissue. The most common finding on peritoneoscopy was tubercles with adhesions (n = 14, 50%), followed by tubercles only (n = 12, 42.9%). Xpert® MTB/RIF assay was positive in 17 (60.7%) patients with a sensitivity of 60.71%, specificity of 100%, and an accuracy of 69.44%. Two patients expressed rifampicin resistance. Conclusion Xpert® MTB/RIF assay on peritoneal tissue has fair sensitivity and excellent specificity. The multidrug resistance and the ability to provide results rapidly make it clinically useful.

Background Endoscopic biopsy is standard for diagnosis of esophageal malignancy. However, few cases present with smooth stricture with repetitive negative biopsy results. We aimed to use linear endoscopic ultrasound (EUS) and fine needle aspiration (FNA) in diagnosis of biopsy negative suspected malignant esophageal strictures. Methods We retrospectively analyzed the data from August 2017 to December 2018 of biopsy negative esophageal strictures. All adult patients with twice negative biopsies and having smooth overlying esophageal mucosa on endoscopy were included. Clinical, epidemiological, endoscopic, imaging and EUS findings were noted and analyzed. Results Eighteen patients underwent EUS for suspicion of malignant esophageal stricture. Seven were excluded as they were submucosal tumors in which the role of EUS is already established. Eleven patients showed the presence of malignancy on EUS FNA samples. Nine were males. Computed tomography showed esophageal wall thickening in 8 (16–38 mm) and esophageal mass in 3 patients. EUS showed loss of normal five layered wall structure of esophagus in all patients. FNAC revealed squamous cell carcinoma (n=4), adenocarcinoma (n=4), poorly differentiated carcinoma (n=2) and neuroendocrine carcinoma (n=1).There were no complications. Conclusions EUS with FNA is effective and safe for diagnosis of biopsy negative malignant esophageal strictures.

Kaposiform haemangioendothelioma, an endothelial borderline tumour, is typically seen in childhood involving extremities. It has been closely associated with a consumptive coagulopathy state, Kasabach-Merritt phenomenon (KMP). Extracutaneous involvement is uncommon. Intestinal involvement is quite uncommon and can masquerade as an acute abdomen. A 24-day-old neonate presented with bilious vomiting and fever for 5 days. Sections from the resected gangrenous duodenum contained a submucosal tumour composed of infiltrating nodules of slit-like or crescentic CD34-positive spindled-to-flattened endothelial-lined vascular spaces along with zones of fibrosis. No nuclear pleomorphism or necrosis identified. The findings were classic example of kaposiform haemangioendothelioma with an absence of any deranged coagulation profile. The index case raises interest given its congenital incidental presentation at an uncommon site, like duodenum, and absence of coexistent KMP.

Intraductal papillary mucinous neoplasms (IPMNs) are mucin-secreting cystic neoplasm of pancreas. They have a malignant potential. They are usually localised to the pancreas but occasionally can involve surrounding structures (1.9%–6.6%), like bile duct and duodenum, and are labelled as IPMN with invasion. Jaundice as a manifestation of IPMN is not common (4.5%). It can present as jaundice as a result of invasion of common bile duct (CBD) resulting in stricture formation or uncommonly as a result of fistulising to CBD with resultant obstruction of CBD by thick mucin secreted by this tumour. As only few cases (around 23) of mucin-filled CBD are reported in the literature. We are presenting our experience in dealing a rare case of obstructive jaundice caused by IPMN fistulising into CBD, highlighting the difficulties faced in managing such case, especially with regards to biliary drainage and what can be the optimum management in such cases.

Annular pancreas is a rare entity. It clinically presents with intestinal obstruction. We present a case of a young female with incomplete annular pancreas presented with recurrent acute pancreatitis.

OBJECTIVE The present study demonstrates and investigates the involvement of differences in human leukocyte antigens (HLA) class I and class II genes in the risk of hypersensitive reaction to nevirapine and efavirenz among Indian HIV- 1 infected patients. METHODS Thirty-three HIV-positive patients treated with efavirenz and nevirapine were studied. The HLA class I and II molecular typing in both Non-tolerant and tolerant patients were performed using the sequence-specific primers (SSP), the Olerup HLA-A-B-C and DQ-DR SSP Combi Tray. Odds ratios (OR) with 95 % confidence intervals (CI) were calculated to assess patients’ increased risk of developing hypersensitivity in comparison with Tolerant. RESULTS Thirteen patients (39.39%), developed a hypersensitive reaction thus requiring the drug to be discontinued. AnHLA-B*40 and HLA-C*15 allelesrevealed a significant association in 8/13 (61.53%) p = 0.028, OR= 9.6; 95% CI=1.04–222.49 and 7/13 (53.84%)p = 0.05, odds ratio (OR)= 8.75; 95% CI= 0.92–205.44 of hypersensitivity reaction in HIV patients compared with only 4% in Tolerant group, respectively. MHC class I genes, HLA-A*24 allele and MHC class II genes, DRB1*10:01:01:01 allele showed significant association with skin rash in 5/13 (38.46%) and 4/13 (30.76%) respectively (p CONCLUSION A strong significant associations were seen between the MHC genes alleles (HLA-B*40 and HLA-C*15) and cART drug (nevirapine and efavirenz) induced skin rash in the Indian population. It can be utilized to avoid a subset of hypersensitivity reaction in HIV infected patients in Indian population.

There is a paucity of data on the spectrum of benign gastric outlet obstruction in India. Our aim was to evaluate its spectrum and to identify the subgroup which would be most amenable to endoscopic therapy. We studied 64 patients whose aetiology revealed in approximately equal proportions: corrosive injury; gastroduodenal tuberculosis (TB); and peptic ulcer disease. The median number of endoscopic dilations required was two for TB, four for peptic ulcer disease and five for corrosive injury. Gastroduodenal TB and corrosive injury appear now to be more, or at least as, common as peptic ulcer disease as causes of benign gastric outlet obstruction in India. Gastroduodenal TB responds best to endoscopic therapy.