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Preoperative biliary drainage (PBT) may be warranted in patients with borderline resectable or locally advanced pancreatic carcinoma before neoadjuvant therapy (NAT) to relieve obstructive jaundice. However, it is unclear if the use of self-expanding metal stents (SEMS) has any benefit over plastic stents in this setting.We searched electronic databases from inception to February 11, 2022 to identify studies comparing SEMS and plastic stents for PBT in patients with pancreatic carcinoma undergoing NAT. Random effect models were used to determine pooled rates of recurrent biliary obstruction (RBO) and/or need for reintervention, stent-related complications and surgical outcome.A total of 10 studies (474 patients; metal group-37.1%) were included. Pooled risk ratio of RBO and/or need for reintervention was lower in the metal group (RR, 0.23 [95% CI: 0.11-0.45, IMetal stents are associated with reduced risk of RBO and/or need for reintervention, reduced risk of stent occlusion and cholangitis as compared to plastic stents in patients with pancreatic carcinoma undergoing NAT.

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has a potential risk of clinically significant adverse events including fatal complications. Learning from complications improves the results from interventional procedures especially the high-risk procedure like EUS-BD. The various complications that have been reported following EUS-BD include bile leak, bleeding, cholangitis, peritonitis, stent migration both internal and external as well as in the peritoneal cavity and fatal perforations. In this technical review, we discuss technical strategies to prevent serious adverse events during EUS-BD using a case based approach.

To investigate the performance of T2-weighted abbreviated magnetic resonance imaging (T2W-AMRI) protocol in evaluating patients with acute necrotizing pancreatitis (ANP).A retrospective analysis of consecutive hospitalized patients with ANP who underwent MRI (contrast-enhanced, CE or non-contrast, NC) between January 2017 and November 2020 was performed. The T2W-AMRI and complete MRI (cMRI) sequences were anonymized, and subsequently, two separate sets of data (AMRI and cMRI) were created for presentation to the radiologists involved in reading the data. The T2W-AMRI was based on a single-axial T2 half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence. The pancreatic and extrapancreatic findings were recorded and tabulated independently by two radiologists on T2W-AMRI and cMRI. In addition, the interobserver agreement and association of findings between T2W-AMRI and cMRI were analyzed.Twenty-eight patients (mean age 31.7 ± 12.2 years, 17 females) were included. Thirteen patients had CE-cMRI, while the rest underwent NC-cMRI. There was no significant difference in the identification of pancreatic necrosis on T2W-AMRI vs. cMRI (p = 1.00). However, T2W-AMRI underestimated necrosis in one patient. Collections were accurately detected in all patients on T2W-AMRI. The mean size of the collection was larger on cMRI (6.5 ± 3.7 cm) than T2W-AMRI (6 ± 3.7 cm) with p = 0.006. cMRI detected more patients with disrupted pancreatic duct (n = 9) than T2W-AMRI (n = 6). However, the difference was not statistically significant (p = 0.375). There was a good to an excellent interobserver agreement between the readers for T2W-AMRI (k = 0.62-1).T2W-AMRI may offer a suitable alternative to cMRI in ANP, especially severe disease, as it can be acquired rapidly without the need for contrast injection.

Perforations during endoscopic retrograde cholangiopancreatography (ERCP) is a rare but dreadful complication. Type I Stapfer's perforations tend to be large and can get easily complicated by peritonitis and collections if not recognized and managed in a timely manner. With advancement in endoscopic accessories, endoscopic closure is usually attempted first, and surgical interventions are reserved only in patients with a failed endoscopic attempt. Though over the scope clips (OTSC) are used in patients with defect up to 20 to 25 mm in gastric or duodenal perforation and up to 30 mm in colonic perforations, larger defects can be also closed with the right use of adjuvant accessories. Here, we report our experience of successful closure of a large duodenal perforation during ERCP, using a single OTSC clip with help of accessories.

The intestinal permeability (IP) of sugars and their derivatives has been widely used to assess mucosal damage in gastrointestinal diseases. Ulcerative colitis (UC) is a recurring and relapsing disease that causes inflammation of the gut. IP of sugars can be evaluated and correlated with the flare of UC.A prospective study was conducted on 91 patients with active UC at the tertiary care center in North India. Mayo grading system assessed disease activity, and IP was assessed by measuring sucrose, lactulose, mannitol, and sucralose in urine samples from UC patients. A high-performance liquid chromatography (HPLC) method to detect all of these sugars simultaneously using a refractive index detector was developed and further validated in patients with UC.The analytical recovery rate of the tested sugars ranged from 95% to 146% in the urine matrix. The limit of detection and limit of quantification were 78.838 mg/L and 262.79 mg/L for sucrose, 84.994 mg/L and 283.31 mg/L for lactulose, 74.789 mg/L and 249.30 mg/L for mannitol, and 50.908 mg/L and 169.69 mg/L for sucralose.The standardized HPLC method is sensitive and suitable for the simultaneous detection and determination of different sugar moieties in the urine sample. Patients with UC can be evaluated indirectly for the flare by estimating the recovery rate of sugars through gut permeability. The procedure is noninvasive and thus improves the quality of life of chronically ill patients.

Background and Aim Caustic ingestion is associated with long‐term sequelae in the form of esophageal and/or gastric cicatrization requiring endoscopic or surgical intervention. Quality of life (QoL) and disability in patients with caustic‐induced sequelae is less explored. Methods In this prospective study, we included consecutive patients with symptomatic caustic‐induced esophageal stricture undergoing endoscopic dilatation. QoL was measured using the World Health Organization Quality of Life questionnaire (WHOQoL‐BREF). Disability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Subjective dysphagia score was calculated by Likert scale. Results A total of 42 patients were included in the study; 25 (59.5%) patients were male. Patients had poor WHOQoL‐BREF and WHODAS scores compared to normality data in all domains of the scores among both the genders. A majority (66.7%) of patients had a current psychiatric diagnosis, with the most common being mood disorder (50%) followed by suicidality (45.2%). Males had a higher prevalence of a previous psychiatric diagnosis compared to females, while females had a higher prevalence of suicidality. Dysphagia score had strong correlation with the WHOQoL (r = −0.66; P, Caustic ingestion is associated with long‐term sequelae in the form of esophageal and/or gastric cicatrization requiring endoscopic or surgical intervention. We assessed quality of life, disability, and depression in a cohort of patients who ingested a caustic agent. These patients were found to have high levels of disability and depressive symptoms and poor quality of life.

Caustic ingestion can lead to structural changes in the upper gastrointestinal tract. However, there are limited data on the effect of caustic ingestion on gastric secretion. This study was planned to determine the changes in gastric acid output in patients with caustic ingestion. It was a prospective study done at a tertiary care center in northern India. Twenty consecutive patients in chronic phase of caustic ingestion were evaluated for the study. The gastric secretory function was estimated in the basal state and following pentagastrin stimulation. These results were compared with normal values for our laboratory. The mean age of the included patients (n = 20) was 27.35 ± 2.96 years and 14 patients were male. Sixteen (80%) patients had a history of acid ingestion. Patients with caustic ingestion had significantly lower mean gastric acid secretion (0.8 ± 0.4 mEq/h vs. 4 ± 0.4 mEq/h; p

Evaluation of a combination of antibiotics as an adjuvant therapy in acute severe ulcerative colitis (ASUC). Patients with ASUC were randomized to either infusions of placebo or intravenous ceftriaxone and metronidazole in addition to standard care. Primary outcome was response on day three according to Oxford���s criteria. Secondary outcome measures included changes in partial Mayo score, CRP levels, fecal calprotectin (day three), and need for second-line therapy, hospital stay, and mortality (day 28). Fifty patients (25 in each group, median age: 33 years, 23 males) were included. The number of patients with fulminant disease in the antibiotic group were 16 (64%) as compared to 7 (28%) in the standard of care group. Complete response on day three was attained by 7 (28%) in the antibiotic and 6 (24%) standard of care group (p = 1.00). Three patients from the antibiotic group underwent colectomy and three received intravenous cyclosporine whereas four patients in the standard of care group received cyclosporine (p = 0.725). There was no significant difference in change in CRP, Partial Mayo score, and fecal calprotectin between the two groups on day three. Combination of intravenous ceftriaxone and metronidazole did not improve outcomes in ASUC. Acronym: AAASUC trial Registration Number: CTRI/2019/03/018196 and NCT03794765

Incidence and risk factors for the development of extremity deep vein thrombosis (eDVT) in admitted patients of acute pancreatitis have been rarely explored.To identify the incidence of eDVT and to explore role of clinical scores for predicting eDVT in admitted patients of acute pancreatitis.We prospectively enrolled admitted patients of acute pancreatitis and performed a weekly eDVT screen for the duration of their admission. Well's score and Padua's score were also calculated weekly. The incidence of venous thrombosis (eDVT and splanchnic thrombosis based on contrast-enhanced CT scan abdomen) was noted, and the risk factors were determined using multivariate analysis. The correlation between Well's score, Padua's score, and development of DVT was calculated using Pearson's correlation.Of the 102 patients of acute pancreatitis enrolled, 73.5% of patients had necrotizing pancreatitis. Total of 46 patients (45.1%) developed thrombosis: 43 patients had splanchnic vein thrombosis; 5 patients had eDVT; and 1 patient had pulmonary embolism. Patients with eDVT had higher BISAP score (2.6 ± 0.9 vs 1.7 ± 0.8; p = 0.039), requirement of mechanical ventilation (60% vs 8.2%; p = 0.008), and mortality (60% vs 12.4%; p = 0.022). Well's score of ≥ 2 had sensitivity and specificity of 80% and 96.9% for prediction of eDVT and it had better correlation with the development of eDVT compared to Pauda's score.Incidence of DVT is 5% in patients with acute pancreatitis requiring admission. It is associated with higher disease severity and mortality. The Well's score is useful to predict the development of eDVT in routine clinical practice.

Gastroduodenal tuberculosis is an uncommon form of abdominal tuberculosis.We report our experience with five cases of gastroduodenal tuberculosis and present results of a systematic review on gastroduodenal tuberculosis regarding clinical presentation, endoscopic, imaging findings, and the diagnostic and therapeutic approach.The presentation of gastroduodenal tuberculosis is diverse and may include nonspecific abdominal pain or dyspepsia like symptoms apart from gastric outlet obstruction. Endoscopy may show presence of growth, ulcer, narrowing, or fistula on endoscopy. Endoscopic biopsy, well-biopsy, or mucosal resection of an elevated lesion are helpful. On microscopy, granuloma with or without acid fast bacilli positivity can be found. For treatment, standard antitubercular therapy should be given for 6 months. In patients with tight stricture, endoscopic balloon dilatation can be helpful. Surgery is reserved for patient with diagnostic dilemma, refractory stricture, or complications like perforation or fistula. Future research should focus on improving diagnosis with use of modern microbiological techniques like PCR and Xpert MTB/RIF.

BACKGROUND Response to antitubercular therapy (ATT) is often used to differentiate intestinal tuberculosis (ITB) from Crohn's disease. Role of non-invasive biomarkers to predict mucosal response to ATT is unclear. MATERIALS AND METHODS A prospective study to compare faecal calprotectin and serum C-reactive protein (CRP) levels at diagnosis, 2 and 6 months of ATT in patients with suspected ITB started on ATT was done. The patients were eventually divided into two groups: ITB or alternative diagnosis (OTH). Decline of calprotectin and CRP levels was used to compute area under the receiver operating characteristic (AUROC) to predict mucosal healing at 2 months. RESULTS Thirty-seven patients (mean age: 34.95 ± 16.35 years, 23 males) were included and 28 (75.67%) were diagnosed as ITB while nine (24.32%) had alternative diagnosis (OTH). The median faecal calprotectin values of ITB and OTH groups at baseline, 2 months and 6 months were 216 and 282 µg/g (P = 0.466), 43 and 216 µg/g (P = 0.003), and 26 and 213 µg/g (P < 0.001), respectively. The median CRP values at baseline, 2 months and 6 months were 18 and 30 mg/L (P = 0.767), 4.7 and 15 mg/L (P = 0.025), and 3 and 10.85 mg/L (P = 0.068), respectively. The AUROC of percent decline in faecal calprotectin and serum CRP at 2 months for mucosal healing were 0.8287 [95% confidence inteval (CI) 0.6472-1] and 0.6018 (95% CI 0.4079-0.7957), respectively. CONCLUSION Faecal calprotectin can help in assessing response to therapy in suspected ITB patients started on empirical ATT.

Objective To evaluate the relationship of mucosa-associated candida (MAC) and disease severity in patients with ulcerative colitis (UC). Methods We prospectively investigated the presence, nature, and quantification of MAC in patients with UC and its relationship with disease severity. Consecutive patients with UC were assessed for clinical, endoscopic, histological features and serum markers of disease severity. All patients underwent mucosal brushing cytology, brushing culture, and biopsy culture for candida growth. MAC was considered present if mucosal biopsy culture grew candida. Candida spp. identification was performed by matrix-assisted laser desorption/ionization. Serum β-D-glucan was measured with a Fungitell assay. Patients with irritable bowel syndrome who had undergone similar investigations were included as controls. Results Ninety-six patients with UC showed evidence of MAC more often than the controls (n = 20) based on biopsy culture (33.3% vs 5.0%, P = 0.011), brush cytology (30.2% vs 5.0%, P = 0.019), and brush culture (36.5% vs 10.0%, P = 0.021). Patients with UC had higher candida colony counts (≥103 CFU/mL) than controls (34.4% vs 5.0%, P = 0.007). Median β-D-glucan values were higher in patients with UC than in controls (103.26 pg/mL vs 66.51 pg/mL, P = 0.011). The UC group with MAC had a higher median total Mayo score, C-reactive protein, fecal calprotectin, β-D-glucan, and histological activity than those without MAC. Conclusions Patients with UC more often show evidence of MAC and a higher candida colony count than controls. The presence of MAC is associated with high disease severity in patients with UC.

Quantitative analysis as a technique of rendering market conditions using an arithmetic value has been employed by several investors for identifying trading opportunities. Quantitative Trading (QT) Strategies are further aggrandized by the victorious amalgamation of finance with AI technologies. However, existing studies fail to leverage elementary finance notions for devising a portfolio optimization algorithm using rudimentary QT strategies to generate maximum profits. Such a portfolio optimization algorithm can be further optimized to require a minimum upfront investment, by exploiting the process of initially going SHORT on a financial asset, and using the generated profit to subsequently enter a LONG on another financial asset. In this paper, we propose Kairos, a computationally-inexpensive, flexible framework for exploiting LONG and SHORT QT strategies for portfolio optimization which minimizes required investment and maximizes returns.

With increasing use of cross-sectional imaging in diagnosis of various diseases, incidence of asymptomatic pancreatic cyst has increased dramatically in last decade. In management of such asymptomatic pancreatic cyst differentiation of pre-malignant cyst and benign cyst remains an utmost important parameter. Though various endoscopic ultrasound (EUS) criteria have been developed, differentiation between these two entities still remains a challenge in many patients. Confocal laser endomicroscopy (CLE) has shown promising results in diagnosis of various gastrointestinal cancers and colonic polyps. However, CLE criteria have not been prospectively validated in asymptomatic pancreatic cyst to differentiate premalignant vs benign cysts. Similarly, CLE criteria are also not defined for diagnosis of various gastric sub-epithelial lesions. In this news and views we have discussed two important articles regarding role of needle based CLE (nCLE) in these lesions. While one is a multicentric trial which prospectively validates previously defined nCLE criteria for characterizing pancreatic cystic lesion, second developed criteria for diagnosis of various gastric subepithelial lesions based on nCLE findings.

Background There is an emerging role of fungal dysbiosis in the pathogenesis of inflammatory bowel disease. Prevalence of Candida in patients with active ulcerative colitis (UC) and the effect of fluconazole therapy in reducing disease activity of UC are not known. Patients and methods All consecutive consenting patients with active UC defined as Mayo score ≥3 were evaluated for presence of Candida by stool culture and predictors for presence of Candida were identified. Those who had evidence of Candida in the stool were randomized to receive oral fluconazole 200 mg daily or placebo for 3 weeks along with standard medical therapy. Patients were assessed by clinical, sigmoidoscopy, and laboratory parameters at baseline and at 4 weeks. The primary outcome was clinical and endoscopic response at 4 weeks defined by a 3-point reduction in Mayo score. Secondary outcomes were reduction in fecal calprotectin, histologic response, and adverse events. Results Of the 242 patients with active UC, 68 (28%) patients had Candida in stool culture. Independent predictors for presence of Candida in patients with active UC were partial Mayo score of ≥3 and steroid exposure. Among those with Candida on stool culture (n=68), 61 patients fulfilled eligibility criteria and were randomized to receive fluconazole (n=31) or placebo (n=30). Three-point reduction in Mayo score though was numerically higher in the fluconazole group than the placebo group but was not statistically significant [5 (16.1%) vs. 1 (3.33%); P=0.19]. Postintervention median Mayo score was lower in fluconazole than placebo group [4 (3, 5) vs. 5 (4, 6); P=0.034]. Patients in fluconazole group had more often reduction in fecal calprotectin [26 (83.9%) vs. 11 (36.7%); P=0.001] and histologic scores [23 (74.1%) vs. 10 (33.3%); P=0.001] compared with placebo. All patients were compliant and did not report any serious adverse event. Conclusion Candida colonization is found in 28% of patients with UC. Steroid exposure and active disease were independent predictors for the presence of Candida. There was no statistically significant difference in the number of patients who achieved 3-point reduction in Mayo score between 2 groups. However, clinical, histologic, and calprotectin levels showed significant improvement in fluconazole group.

Introduction The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy. Areas covered This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.

Background Some studies have suggested that targeted combination therapy with antibiotics could improve response in active ulcerative colitis, but similar data is not available in acute severe UC (ASUC). Methods We randomised consecutive patients diagnosed with ASUC ( modified Truelove and Witt’s classification) to receive placebo infusions or combination antibiotics (intravenous ceftriaxone and metronidazole) groups. Response as defined by oxford criteria was used to assess response on day three. We also assessed changes in partial Mayo score, CRP levels and reduction in fecal calprotectin at day three. Also, we assessed the need for second line drug therapy, colectomy, length of hospital stay and mortality by day 28. Results Fifty patients were randomised: 25 in each arm (Median age: 33, IQR 25–45, 23(46%) males). Twenty-two patients had extensive disease, while the median disease duration was 24 months. Sixteen patients (64%)in antibiotic arm responded (complete and partial response) at day three while 18 (72%) in the placebo arm responded. Three patients from the antibiotic group underwent colectomy. Three patients in the antibiotic arm received intravenous cyclosporine, whereas four patients in the placebo group received cyclosporine (p=0.725). There was no significant difference in change in CRP, Partial Mayo and fecal calprotectin between the two groups on day three. Conclusions Combination of intravenous ceftriaxone and metronidazole in patients with ASUC neither improved the day 3 response nor reduced the need for second line therapy.

Hepatic involvement is an infrequent manifestation of abdominal tuberculosis and could occur in form of granulomatous hepatitis, nodular involvement or abscess formation. Tubercular liver abscess (TLA) is uncommon, and diagnosing this entity is a challenge. Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) assay has been widely used for diagnosing pulmonary tuberculosis (TB) and lymph nodal tuberculosis. Its utility in some forms of other extrapulmonary TB has also been studied. The role of Xpert MTB/RIF for diagnosis of tubercular liver abscess is not known. Here we present a series of four 4 cases of TLA, where the diagnosis was made on the basis of positive Xpert MTB/RIF assay tested on liver drained pus.

Caustic ingestion can lead to structural changes in the upper gastro-intestinal tract. However, there is limited data on the effect of caustic ingestion on gastric secretion. This study was planned to determine changes in gastric acid output after sham feeding in patients with caustic induced esophageal stricture and to compare it with healthy controls. It was a prospective study done at tertiary care center in North India. Consecutive patients with caustic induced esophageal stricture were evaluated for the study. Gastric secretory function was estimated in the basal state and after modified sham feeding. These results were compared with age-matched controls. The mean age of the included patients (n = 18) was 30.11 ± 9.19 years and 13 patients were male. 16 (88%) patients had history of acid ingestion. Patients with caustic sequelae had significantly lower basal and stimulated acid secretion compared to controls (n = 10) (5.84 ± 2.44 mmol/hr; p

The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than the retroperitoneum has not been systematically studied. To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes. This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated. A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups. Mesenteric collections are frequent in ANP. The other non-retroperitoneal sites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.

Black oesophagus, also termed acute oesophageal necrosis or Gurvits syndrome, is an uncommon but well-characterised entity predominantly involving the lower oesophagus. Co-morbidity—such as diabetes mellitus, hypertension, chronic liver or kidney or pulmonary disease—predisposes to this condition. On endoscopy, it appears as a diffuse, circumferential, black discolouration. Though poorly understood, tissue hypoperfusion appears central to its pathogenesis. Tackling the underlying predisposing co-morbidity and supportive management are the mainstay of therapy. Despite early diagnosis and prompt treatment, the outcome may be unfavourable and is related to the underlying aetiology. We report a case series of three patients of acute oesophageal necrosis who presented to us with symptoms of acute upper gastrointestinal bleeding and improved with conservative management.

Introduction: Intestinal tuberculosis (ITB) and Crohn's disease (CD) have similar clinical presentation, but require different treatment approaches. Despite advances in various endoscopic, imaging, microbiological, and histological techniques, the differentiation of these two entities is often difficult. Newer radiological and image acquisition modalities have now become indispensable tools for evaluation of these two diseases.Areas covered: This review summarizes the currently available literature on various radiological investigations to differentiate ITB from CD. This review also enumerates the newer modalities in image acquisition techniques and their potential role for differentiating these two diseases. At present abdominal computed tomography (CT) scan is used as a first line investigation for differentiating ITB from CD. Magnetic resonance imaging (MRI) is preferred in pediatric patients and for follow-up studies.Expert opinion: Role of newer modalities like contrast enhanced abdominal ultrasound, perfusion CT, advanced MRI and positron emission tomography (PET) is evolving and requires further exploration. Till further robust studies are available, differentiation between ITB and CD requires use of a combination of clinical, endoscopic, serological, histological, and radiological parameters rather than relying on a single test.

Giardia duodenalis is a common cause of chronic diarrhea especially in tropical countries. Diagnosis is based on microscopy (three stool samples) for trophozoites/cysts. Role of stool or duodenal biopsy PCR as a diagnostic method needs to be defined. We conducted a prospective study to determine the diagnostic characteristics of G. duodenalis stool and duodenal biopsy PCR in comparison to stool microscopy (reference standard). Later, we compared other techniques with stool PCR, considering it as new reference standard and characterized the type of Giardia assemblage. G. duodenalis stool nested PCR was first evaluated using 40 positive controls and 50 negative controls considering stool microscopy as reference standard. Patients with chronic diarrhea (n = 100) were evaluated by stool microscopy and nested PCR. In 30 patients in whom upper gastrointestinal endoscopy was performed, duodenal biopsy samples were obtained and evaluated by histopathology, imprint cytology, and nested PCR. The type of Giardia assemblage was detected by assemblage-specific PCR. Stool nested PCR was found to have sensitivity and specificity of 100% and 94%, respectively, compared to stool microscopy. In patients with chronic diarrhea, 48% had evidence of Giardia infection. Stool microscopy detected 65%, stool PCR detected an additional 27%, and duodenal biopsy PCR detected an additional 8% of cases. The commonest assemblage found was assemblage B. Clinical and demographic characteristics were similar in patients harboring either assemblage A or B. Stool PCR is more sensitive than stool microscopy. By utilizing stool microscopy, stool nested PCR, and duodenal biopsy PCR in sequential manner, diagnostic yield can be increased.

Development of organ failure is one of the major determinants of mortality in patients with acute pancreatitis (AP). Acute respiratory distress syndrome (ARDS) is an important cause of respiratory failure in AP and is associated with high mortality. Pathogenesis of ARDS in AP is incompletely understood. Release of various cytokines plays an important role in development of ARDS in AP. Increased gut permeability due to various toxins, inflammatory mediators, and pancreatic enzymes potentiates lung injury by gut-lymph-lung axis leading on to increased translocation of bacterial endotoxins. Various scoring systems, serum levels of various cytokines and lung ultrasound have been evaluated for prediction of development of ARDS in AP with varying results. Various drugs have shown encouraging results in prevention of ARDS in animal models but these encouraging results in animal models are yet to be confirmed in clinical studies. There is no specific effective treatment for ARDS. Treatment of sepsis and local complications of AP should be done according to the standard management strategies. Lung protective ventilatory strategies are of paramount importance to improve outcome of patients of AP with ARDS and therefore effective coordination between gastroenterologists and intensivists is needed for effective management of these patients.

Background Long-term indwelling transmural stents in patients with walled-off pancreatic necrosis (WOPN) and disconnected pancreatic duct syndrome (DPDS) has been accepted as an effective strategy to decrease the risk of recurrence of pancreatic fluid collection (PFC). However, long term studies on the safety and efficacy of leaving permanent indwelling plastic prosthesis are lacking. Methods Retrospective analysis of the database of patients with WOPN treated with endoscopic transmural drainage over the last 8 years was done to identify patients with DPDS and permanently intended indwelling transmural stents. Patients with indwelling stents for more than 3 years were only included in this study. The follow-up database was analysed for any recurrence of symptoms or PFC or complications. Results During the last 8 years, 179 patients of WOPN were treated with endoscopic transmural drainage and 138 (77.09%) patients had DPDS. Of 138 patients, 56 patients (39 males; age range: 21–62 years) had an indwelling transmural stent/stents for >3 years (3–8 years). Amongst plastic prosthesis, 67.85% of patients had 10 Fr stents and 32.14% of patients had 7 Fr stents. Neck (n=28; 50%) was the most common site of disruption followed by proximal body (n=16; 28.57%) and distal body (n= 12; 21.43%). One patient (1.78%) developed recurrence of fluid collection 58 months later despite of in-situ stent which was successfully treated with repeat endoscopic transmural drainage. Two (3.5%) patients had asymptomatic spontaneous external migration of the transmural stent. Two (3.5%) patients developed complications 4 years later because of the indwelling stent. The transmural stent eroded into descending colon in one patient and the other patient had a recurrence of abdominal pain due to the development of pancreatic parenchymal calcification around the pigtail of the plastic stent. The transmural stent was removed in both patients and this led to the closure of colonic fistula as well cessation of abdominal pain. No other complication of long term indwelling transmural stents was observed. Conclusions Long term indwelling transmural stents in patients with WOPN and DPDS are safe as well as effective in preventing recurrence of PFC.

Introduction: Peritoneal tuberculosis is a common type of abdominal tuberculosis. The most commonly used classification divides peritoneal tuberculosis into wet-ascitic type, dry-plastic type, and fixed-fibrotic type. Areas covered: We performed a systematic literature search on the definitions of existing classification of peritoneal tuberculosis. The literature search identified confusion in the classification of peritoneal tuberculosis. The classification system also fails to classify some patterns of peritoneal tuberculosis like an abdominal cocoon and a substantial overlap in various categories was found. The impact of the present classification on clinical management is unclear. Lack of prospective studies and the presence of heterogeneity in reporting add to the confusion. Expert opinion: We suggest that a uniform system which better classifies peritoneal tuberculosis and helps in clinical management should be used in future studies. We propose a simple, clinico-radiological classification of peritoneal tuberculosis into two types: distension-dominant and/or pain-obstruction dominant based on the clinical presentation. This approach will be relevant to clinicians as patients with the pain-obstruction dominant presentation are more likely to receive surgical interventions and may benefit from additional measures aimed to reduce fibrosis-like addition of steroids to ATT. Future studies should aim to validate the proposed clinico-radiological classification in patients with peritoneal tuberculosis.

IgG4-related hepato-pancreato-biliary (IgG4 HPB) disease is a part of a multisystem disease called IgG4-related diseases (IgG4 RD). It may involve the liver, pancreas, or biliary tree in various combinations and termed as IgG4 hepatopathy, autoimmune pancreatitis type-1 (AIP-1), or IgG4 cholangiopathy, respectively. It is characterized by multi-organ fibroinflammatory condition with tumefactive lesions, dense lymphoplasmacytic infiltration, IgG4-rich plasma cells, storiform fibrosis, and elevated serum IgG4 levels. It can present with mass lesion, stricture, or features of end-organ damage. It mimics various malignancies, infectious etiologies, and vasculitis posing difficulties in diagnosis. Though the disease lacks any gold standard test for diagnosis, serum IgG4 levels, IgG4/IgG RNA ratio, and increased circulating plasmablast are helpful in diagnosing this disease. Steroid remains the main stay of therapy; however, some patients may require immunosuppressive treatment.

Background The Mayo endoscopic score (MES) remains the most commonly used index in clinical practice, as well as in various clinical trials. Recently, two validated histological indices (Nancy Index [NI] and Robert Histological Index [RHI]) have been developed for ulcerative colitis (UC). We aim to study the relationship between MES with NI, RHI, and the established Geboes Index (GI) in patients with UC. Methods This was a prospective single‐center study. MES was documented from the most involved area. Biopsy was taken from the same area and reported by a single gastrointestinal histopathologist who was blinded to the endoscopic score. Histological activity was reported using GI, NI, and RHI. Statistical analysis was performed using Spearman's correlation coefficient and Cohen's kappa coefficient using SPSS version 23. Results Median age of patients with UC (n = 96) was 36 years. Seventeen patients were in endoscopic remission (MES 0/1). Correlation coefficient between MES and GI/NI/RHI was only weak to moderate (rho = 0.381/0.389/0.442, respectively; P, In the era of mucosal and histological healing, it is of utmost importance to understand the relationship between endoscopic and histological scores. In our study, we have shown that the endoscopic score is only moderately correlated with histological scores. Agreement between endoscopic and histological remission is also weak. A better endoscopic scoring system is needed for defining endoscopic remission.