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The Gallbladder Reporting and Data System (GB-RADS) ultrasound (US) risk stratification is proposed to improve consistency in US interpretations, reporting, and assessment of risk of malignancy in gallbladder wall thickening in non-acute setting. It was developed based on a systematic review of the literature and the consensus of an international multidisciplinary committee comprising expert radiologists, gastroenterologists, gastrointestinal surgeons, surgical oncologists, medical oncologists, and pathologists using modified Delphi method. For risk stratification, the GB-RADS system recommends six categories (GB-RADS 0–5) of gallbladder wall thickening with gradually increasing risk of malignancy. GB-RADS is based on gallbladder wall features on US including symmetry and extent (focal vs. circumferential) of involvement, layered appearance, intramural features (including intramural cysts and echogenic foci), and interface with the liver. GB-RADS represents the first collaborative effort at risk stratifying the gallbladder wall thickening. This concept is in line with the other US-based risk stratification systems which have been shown to increase the accuracy of detection of malignant lesions and improve management. Graphical abstract: [Figure not available: see fulltext.].

Background: A point-of-care diagnostic test for acute pancreatitis could help in early triage and management of this condition. Materials & methods: Urine trypsinogen dipstick test (UTDT) was performed in consecutive cases suspected to have acute pancreatitis and diagnostic accuracy calculated. Results: Of 187 patients, 90 were have acute pancreatitis and UTDT was positive in 61 (67.7%). In the 97 non pancreatitis cases, UTDT was positive in nine (9.3%). The sensitivity and specificity of UTDT for acute pancreatitis was 67.8% and 90.7%, respectively. In patients presenting within 3 days of abdominal pain, sensitivity and specificity were 72.7% and 91.8%, respectively. Discussion: While offering the possibility of a point of care diagnosis, the low sensitivity of UTDT could be a concern with its routine use.

BACKGROUND Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.

Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma. This is a prospective comparative (January 2017–May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge. Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%). TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance. This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.

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

Background Majority of predictors of postoperative pancreatic fistula (POPF) use intraoperative variables. We aimed to study the role of preoperative ultrasound shear wave elastography (USWE) to predict POPF. Methods The consecutive patients who underwent pancreaticoduodenectomy (PD) between January 2019 to March 2020 were prospectively enrolled. All patients underwent USWE assessment at the pancreatic neck level. Intraoperative variables including pancreatic texture, pancreatic duct diameter, blood loss and histological grading of fibrosis were also recorded. Associations between USWE and intraoperative variables and histological grading with the development of POPF were analyzed. Results Of the 62 patients assessed, 50 patients (mean age: 53 ± 14 years; 31 males) were included. POPF and clinically relevant POPF (CRPOPF) were observed in 22 (44%) and 7 (14%) patients respectively. Soft pancreas was an independent predictor of CRPOPF (p = 0.04). The mean USWE valve was significantly lower in patients with CRPOPF as compared to no CRPOPF (9.7 Kpa vs. 12.8Kpa, p = 0.016). At receiver operating characteristic curve analysis, USWE value of 12.65Kpa yielded sensitivity and specificity of 100% and 47%, respectively, for prediction of CRPOPF. USWE showed significant correlation with intraoperative pancreatic texture (Spearman’s rank correlation coefficient (ρ) = 0.565, p = 0.001). Conclusion USWE helps in preoperative prediction of CRPOPF. This may further help to customize management strategy in high risk patients.

Background Surgical management is considered one of the effective treatment modality for liver hydatid. However the choice of surgery is debatable. This study aims to compare the outcome of radical surgery (RS) and conservative surgery (CS) in liver hydatid disease. Methods This is retrospective analysis of prospectively maintained institutional data of surgically treated liver hydatid from January 2012 to January 2019. The basis of diagnosis was typical imaging, confirmatory Hydatid serology and/or Intraoperative details. The clinical presentation, radiological data, operative detail, post-operative outcome, post-operative recurrence data was analysed. Results Sixty-four patients underwent surgery during the study period and were included. RS was done in 27 (42.2%) patients and CS in 37 (57.8%) patients. The mean age was 35.6 (13–72) years. The mean size of the cyst was 10.3 ± 2.9 cm. The cyst location was peripheral in 81.5% and 56.8% in RS and CS groups respectively. Intraoperative Cyst biliary communication was detected in 48.1% of RS & 35.1% in CS group of patients. The post-operative bile leak was significantly less in RS group (7.4% vs 27.0%, p = 0.047). Postoperative endoscopic stenting for persistent biliary fistula was necessitated in five of CS and only one patient from RS group. None of RS patients had recurrence while 3 patients of CS developed recurrence. Conclusion Radical surgery reduces post-operative bile leak and prevents recurrence and may be preferable to conservative surgery.

Introduction: The ICU in a hospital has a vital role to play in delivering prompt, appropriate and adequate care to critically ill patients. Patients in ICU are at greatest risk of acquiring device associated hospital acquired infection (DA-HAI). Infection control practices are the need of hour to control these infections. Objectives: Aim and objective of present study was to assess the role of preventive interventions in reducing the hospital acquired infection in ICU. Materials and Methods: The present study was conducted over a period of one year from November 2017 to August 2018 in the Department of Anesthesiology, Guru Nanak Dev Hospital, Amritsar. The study was conducted into pre and post interventional period to assess the role of preventive interventions in reducing the device associated acquired infections and results were statistically analysed. Results: During pre interventional study period 16/262 (6.1%) patients developed device associated infection and rate per 1000 device days was 6.25/1000. After interventions 3/132(2.27%) patients developed device associated infection and rate was significantly reduced to 2.92/1000. Conclusion: The implementation of various infection control measures to control DA-HAIs is found to be effective during study. Systematically collected data and findings of our study can be utilized in the ICU setting as a basic step toward a better infection control strategy for improving patient care practices. Keywords: ICU, DA-HAIs, Preventive interventions.

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.

Pancreatitis is one of the important medical conditions. Gastrointestinal (GI) complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require a strong clinical suspicion coupled with various imaging features. This review provides an extensive update of the whole spectrum of GI complication of pancreatitis, both acute and chronic, from inflammation, ischemia, and necrosis to obstruction, perforation, and GI fistulae. The focus is on the clinical and imaging features of this less commonly described aspect of pancreatitis., Gastrointestinal complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require strong clinical suspicion coupled with various imaging features.

Background:Solid Pseudopapillary neoplasm (SPN) is uncommon and constitutes to 1-2% of pancreatic tumors. Owing to its rarity, literature is spare on its clinicopathological characteristics and surgical outcomes.MethodsOur study is a retrospective analysis of prospectively maintained data of patients with histologically proven SPN between January,2012 and December,2019. Patients Demography, clinical presentation, preoperative imaging, operative details, perioperative outcomes and long term follow up were recorded and analyzed. ResultsA total of 14 patients were included in the study, all were females with a median age of 19.5 years (range 15 - 35 years). All presented with pain abdomen. Eight (57.1%) out of 14 patients were correctly diagnosed with Contrast enhanced computed tomography (CECT) abdomen. CECT revealed sloid cystic well encapsulated lesions in 12(85.7%) and homogenous mass lesions without cystic changes in 2(14.2%) patients. The most common tumor location was Head/uncinate process (57.1%). Eight (57.1%) underwent pancreaticoduodenectomy and 6 (42.8%) had undergone distal pancreatectomy. The mean size of tumour was 9.5cm(2.8-14cm). The median postoperative stay was 9 days(range 4-20 days). Seven patients (50%) developed post-operative pancreatic fistula (Grade-A-6/7,Grade-B-1/7) and delayed gastric emptying (DGE) were noted in two (14.2%).R0 resection could be achieved in 13 patients (92.8%). Median follow up period was 49.5 months. One patient had postoperative recurrence after 48 months of surgery.ConclusionSPN is a rare tumor of pancreas. Lack of preoperative predictors for malignant potential complete oncological resections is essential for potential cure.

Oligonucleotide-based therapies are advanced novel interventions used in the management of various respiratory diseases such as asthma and Chronic Obstructive Pulmonary Disease (COPD). These agents primarily act by gene silencing or RNA interference. Better methodologies and techniques are the need of the hour that can deliver these agents to tissues and cells in a target specific manner by which their maximum potential can be reached in the management of chronic inflammatory diseases. Nanoparticles play an important role in the target-specific delivery of drugs. In addition, oligonucleotides also are extensively used for gene transfer in the form of polymeric, liposomal and inorganic carrier materials. Therefore, the current review focuses on various novel dosage forms like nanoparticles, liposomes that can be used efficiently for the delivery of various oligonucleotides such as siRNA and miRNA. We also discuss the future perspectives and targets for oligonucleotides in the management of respiratory diseases., Highlights • Oligonucleotides are polynucleic acids consists of five base pairs. • They act by altering gene expression of an affected individual. • In respiratory diseases they are emerging as a newer therapy.

Background and aim Abdominal tuberculosis is an important form of extrapulmonary tuberculosis. Evidence from clinical trials suggests that 6 months of antitubercular therapy (ATT) is sufficient for abdominal tuberculosis. Methods We report real-world experience with 6 months of ATT based on a retrospective analysis of patients with abdominal tuberculosis seen at a large tertiary care hospital in India. Results Of 101 patients, 93 with complete records were included. The mean age was 35.90 ± 14.06 years, and 53 were males (56.98%). A total of 42 patients (45.16%) had intestinal involvement, 24 (25.08%) had peritoneal, 22 (23.65%) had combined involvement, and 5 patients (5.37%) had isolated lymph nodal involvement. Six patients received prolonged ATT. Six patients developed ATT-induced hepatitis. Of 64 patients with intestinal involvement, 45 had stricturing disease (70.3%), of whom 7 (15.5%) required surgery due to refractory symptoms. Overall, there was one death, and eight patients (including one with massive gastrointestinal bleeding) needed surgery. Conclusion Six months of ATT is associated with objective clinical response in most of the patients of abdominal tuberculosis.

Abdominal tuberculosis is a common problem for clinicians in the tropical world and may manifest with varying clinical scenarios. Intestinal tuberculosis could have intestinal ulcers, strictures, hypertrophic lesions like polyps and may be complicated by perforation, bleeding, and intestinal obstruction. Crohn’s disease is an important differential of intestinal tuberculosis which is closely mimics intestinal tuberculosis in clinical, endoscopic, radiological and histological presentation. Crohn’s disease is known to have a fistulising variant. We report the case of 23 year old lady who had disseminated tuberculosis with intestinal involvement and seemed to improve on anti-tubercular therapy (ATT) but present with intestinal obstruction in the third month of ATT. Surgical exploration revealed clumping of bowel loops with multiple ileo-ileal fistulae. The case is presented because of the presence of entero-enteric fistulae and also because it demonstrated that intestinal tuberculosis may need surgical intervention even after initial improvement because of complications like intestinal obstruction.

Background: The relationship between diabetes mellitus and tuberculosis (TB) has received increasing attention, and diabetes may be associated with poor outcomes in pulmonary TB. Clinical relevance of HbA1c measurement in abdominal TB is unknown. Methods: We did a retrospective study of consecutive patients diagnosed with abdominal TB and treated with antitubercular therapy for 6 months. Patients were categorized as those with normal HbA1c (

The topographic anatomy of the sternum is similar in a healthy population. However, in a clinical subset of patients with comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease, high body mass index, chronic renal disease, or age-related osteoporosis, there are significant changes in the normal physiology that may influence overall patient outcome following trans-sternal intrathoracic surgery. These changes can create technical difficulties in reconstructing the bisected sternum and adversely affect the biomechanics of the thoracic wall, forcing difficult surgical choices with regard to implant options and increasing the cost of an otherwise routine cardiac surgery. A thorough preoperative surgical and technical planning is essential to avert perioperative complications such as failure of wound healing, non-union of the sternum, and life-threatening mediastinitis. Patient expectations need to be explored and the patients should be well informed so that they can make knowledgeable choices regarding their illness and surgical interventions. They should also be given a probable prognosis to provide psychological support. Within the realm of clinical methodology, the concept of patient-appropriate medicine is introduced to direct attending team to become aware of overall health of its patient. The inclusion of a clinical biomechanical engineer as a surgical team member is recommended to perform patient-specific finite element analysis to select an optimal implant to fix the sternum. To help assess the overall benefit-risk profile objectively, an absolute therapeutic index has been proposed.

Introduction: Percutaneous Biliary drainage (PTBD) is required as palliation and optimization for surgery or chemotherapy in carcinoma gallbladder (GBC) but may be associated with complications. We aimed to study the outcomes, complications and changes in quality of life in patients with GBC undergoing PTBD. Methods: A prospective study from July 2018 to December 2019 in patients of GBC presenting with obstructive jaundice was done. Patients planned for PTBD were included in the study. The progression of disease, complications of PTBD, re-interventions, effects on initiation or completion of chemotherapy, surgical resection or intervention, overall survival was recorded. Quality of life (QoL) was assessed using SF–36 questionnaire before and after 4-6 weeks of intervention. Results: Of 160 patients assessed for inclusion, 60 (mean age: 53.7 ± 10.95 years, 27 (45 %) males) were eventually included. Eleven patients (18.3%) had metastatic disease at presentation. Of 60 patients undergoing PTBD, none had immediate procedure related complications, 41(68 %) patients had at-least one and 18 (30%) patients had more than one complication. The most common complication was peri-catheter bile leak (41.6%) followed by catheter dislodgement (30 %), blockage (23.3 %) and bleeding (10 %). Re-intervention was required in 32 (53 %) of patients. There was a significant decrease in QoL after PTBD (PConclusion: The high technical success of PTBD does not translate into the improvement of QoL, survival, and curative surgical treatment.

Oesophageal tuberculosis, an uncommon form of extrapulmonary tuberculosis, has been reported mainly as small case series and the literature is heterogeneous. A systematic review to characterize the clinical presentation, evaluation and management of oesophageal tuberculosis was performed. Electronic databases were searched with keywords: esophagus OR esophageal AND tuberculosis. We included original papers and case series (> 4 patients) with oesophageal tuberculosis. Twenty-two studies reporting 311 patients were included. Mean age in most of the studies was 31–51 years and male gender constituted 50.5% patients. Dysphagia (72.3%), odynophagia (22.4%) and chest pain (31.3%) were predominant symptoms. Mid-oesophagus was the commonest site of involvement (88%). Endoscopic findings included ulcers (59.9%), submucosal bulge (31.7%), extrinsic compression (24.8%) and pseudotumour (5.8%). On endoscopic ultrasound, presence of hypoechoic (69.5%), heteroechoic (47.6%) and matted (86.3%) mediastinal lymph nodes and oesophageal wall involvement (67.3%) were common findings. Computed tomography showed mediastinal lymphadenopathy (76.5%) and oesophageal thickening (52.1%). Diagnosis was confirmed by granuloma (72.3%) and acid fast bacilli positivity (32.5%) in mots patients. Response to antitubercular therapy was excellent; 97.7% patients recovered and 2.3% patients died. Surgery (14.5%) and oesophageal stenting (11.4%) were required infrequently. Oesophageal tuberculosis should be considered in endemic regions as a cause of dysphagia because early treatment is associated with excellent outcomes.

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.

Background Antegrade approach myotomy is usually performed in peroral endoscopic myotomy (POEM) for achalasia cardia. This study assessed the feasibility of retrograde approach as an alternative. Methods This is a retrospective review of a prospectively maintained database of patients undergoing POEM, comparing the 2 techniques of antegrade myotomy (AM) and retrograde myotomy (RM). AM was performed by the conventional technique of proximal to distal myotomy while RM was from the distal end to proximal. The time required for myotomy, complications, and technical nuances were compared. Results Of the 24 cases of POEM, 6 were done by RM and 18 by AM approach. The baseline characteristics, symptomatology, type of achalasia, and preprocedure Eckardt score were similar between the 2 technique arms. The median myotomy time for AM was 21 minute while for RM was 25 minute (P=0.07). Complication rates were similar.Technical issues during RM included: (1) difficulty in visualizing the depth of myotomy; (2) incomplete myotomy requiring back and forth scope adjustment; (3) need for antegrade movement for completion of myotomy; (4) difficulty visualizing the axis of myotomy; (5) added arm strain during posterior myotomy. Conclusion Our study did not find any additional benefit of RM compared with AM approach for POEM.

BACKGROUND We performed a meta-analysis to determine diagnostic accuracy of Xpert MTB/RIF for diagnosis of abdominal (intestinal or peritoneal) tuberculosis (TB) in various tissues (intestinal, omental/peritoneal tissue or ascitic fluid). METHODS Electronic databases were searched for observational studies on use of Xpert MTB/RIF in ascitic fluid, peritoneal, or omental tissue for diagnosis of peritoneal and intestinal TB. We calculated the pooled sensitivity, specificity and diagnostic odds ratio of Xpert MTB/RIF for diagnosis of peritoneal TB in comparison to composite reference standard (CRS) and culture, and in comparison to CRS for intestinal TB. RESULTS Twenty-five observational studies were included. The pooled sensitivity and specificity as assessed with peritoneal culture from ascites as an Index test was 64% (95% Confidence Interval [C.I.] 49-76%) and 97% (95% C.I., 95-99%) respectively and with peritoneal CRS was 30% (95% C.I., 22-40%) and 100% (95% C.I., 98-100%) respectively. In the intestinal group, the pooled sensitivity and specificity of Xpert MTB/RIF was 23% (95% C.I., 16-32%) and 100% (95% C.I., 52-100%). The AUC of peritoneal culture and intestinal tissue was 0.935 and 0.499. CONCLUSION Xpert MTB/RIF has modest sensitivity for diagnosis of peritoneal and intestinal tuberculosis but has a good specificity. PROSPERO REGISTRATION CRD42020140545.

Autopsy practice has been an invaluable tool to understand the pathobiology of various disease processes. We herein have given the description of a case of malignant extra-hepatic biliary obstruction secondary to a diffuse large B-cell lymphoma. The patient disease could only be adequately characterized at autopsy in the form of exact origin and subtyping of lymphoma. The autopsy revealed certain unattended and exciting, yet significant pathological findings in the form of portal vein thrombosis, neurolymphomatosis, the exact track of the lymphomatous cells from abdominal to thoracic cavity, and the terminal events which led to the patient’s demise. The plausible clinical correlates of these pathological findings have been discussed. This can serve as a useful clue to the clinicians for managing such cases in the future.

With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker’s while two had epiphrenic diverticulum. The median symptom duration was 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280 days (range 98–330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.

Differentiation of malignant and benign pancreatic lesions on anatomical imaging is difficult in some cases with overlapping features. Prostate-specific membrane antigen (PSMA) is overexpressed during angioneogenesis in many tumors. We aimed to evaluate the PSMA expression in pancreatic lesions to differentiate these lesions and explore the performance of Ga-68 PSMA-PET/CT vis-a-vis F-18 FDG-PET/CT. Patients with pancreatic lesions on conventional imaging were prospectively recruited. All the patients underwent a whole-body F-18 FDG-PET/CT and a regional abdominal Ga-68 PSMA-PET/CT. Focal tracer uptake (FDG or PSMA) on PET images was considered positive. Histopathology and/or cytopathology were considered the reference standard. A total of forty patients (27 males, mean age 55.3 ± 9.8, range 37–71 years) were enrolled. Of these, 19 were diagnosed as malignant on histopathology/cytology. Patients with benign lesions showed no worsening of symptoms for at least 6 months on follow-up. FDG-PET/CT revealed 17 true-positive (TP), 9 false-positive (FP), 12 true-negative (TN), and 2 false-negative (FN) findings, whereas PSMA-PET/CT had 18 TP, 2 FP, 19 TN, and 1 FN finding. The sensitivity, specificity, PPV, NPV, and accuracy for FDG-PET/CT were 89.5%, 57.1%, 65.4%, 85.7%, and 72.5%, respectively, while for PSMA-PET/CT were 94.7%, 90.5%, 90%, 95%, and 92.5%, respectively. ROC curve analysis showed that the SUVmax value of 4.8 on PSMA-PET/CT could predict the malignant potential of a lesion with a specificity of 90.5% and a sensitivity of 84.2%. Ga-68 PSMA-PET/CT imaging helped in establishing a non-invasive pre-operative diagnosis of primary pancreatic malignancy with a higher degree of specificity and accuracy compared with FDG-PET/CT. • Conventional imaging such as CT and MRI are unable to reliably differentiate localized malignant pancreatic lesion from benign lesions mimicking malignancy such as mass-forming pancreatitis. • FDG PET/CT helps in detecting malignant foci in view of their increased glucose metabolism. However, it may be falsely positive in inflammatory lesions which may occasionally hinder its ability to differentiate between benign and malignant lesions. • Apart from prostatic malignancy, PSMA is overexpressed in neovasculature of many non-prostatic malignancies. The present study highlights that Ga68 PSMA PET/CT performed better in diagnosing malignancy non-invasively than FDG-PET/CT with a higher PPV (90.5% vs. 65.4%) and accuracy (92.5% vs. 72.5%).

Ileocecal thickening (ICT) on imaging could result from diverse etiologies but may also be clinically insignificant. Evaluation of role of combined 2-deoxy-2-fluorine-18-fluoro-d-glucose(18F-FDG)-positron emission tomography and computed tomographic enterography (PET–CTE) for determination of clinical significance of suspected ICT. This prospective study enrolled consecutive patients with suspected ICT on ultrasound. Patients were evaluated with PET–CTE and colonoscopy. The patients were divided into: Group A (clinically significant diagnosis) or Group B (clinically insignificant diagnosis) and compared for various clinical and radiological findings. The two groups were compared for maximum standardized uptake values of terminal ileum, ileo-cecal valve, cecum and overall. Of 34 patients included (23 males, mean age: 40.44 ± 15.40 years), 12 (35.3%) had intestinal tuberculosis, 11 (32.4%) Crohn’s disease, 3 (8.8%) other infections, 1 (2.9%) malignancy, 4 (11.8%) non-specific terminal ileitis while 3 (8.8%) had normal colonoscopy and histology. The maximum standardized uptake value of the ileocecal area overall (SUVmax-ICT-overall) was significantly higher in Group A (7.16 ± 4.38) when compared to Group B (3.62 ± 9.50, P = 0.003). A cut-off of 4.50 for SUVmax-ICT-overall had a sensitivity of 70.37% and a specificity of 100% for prediction of clinically significant diagnosis. Using decision tree model, the SUVmax-ICT with a cut-off of 4.75 was considered appropriate for initial decision followed by the presence of mural thickening in the next node. PET–CTE can help in discrimination of clinically significant and insignificant diagnosis. It may help guide the need for colonoscopy in patients suspected to have ICT on CT.

Scalloping of visceral organs like liver and spleen can cause certain peritoneal diseases. It has usually been described with pseudomyxoma peritonei and peritoneal carcinomatosis. Occasionally, it has also been described with certain benign conditions like peritoneal tuberculosis. We describe visceral scalloping in setting of pancreatic diseases. We believe that pancreatic fluid collections exert significant pressure on the visceral organs to result in scalloping of the visceral surfaces.

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.

Objective: To compare risk of hepatotoxicity between various regimens for reintroduction of antitubercular therapy (ATT) in patients with previous episode of ATT hepatitis. Methods: We searched various databases (PubMed, Embase, CENTRAL, Scopus, WoS and LILACS) for studies comparing ATT reintroduction regimens using terms ‘drug-induced liver injury’ and ‘antitubercular drugs’ AND ‘reintroduction’. The reintroduction regimens i.e concomitant (all drugs introduced together), sequential (reintroduction of one drug in full dose followed by another) or incremental (one drug in a low dose and then higher dose followed by next drug) were compared using Bayesian approach for network meta-analysis with random-effect model. Cochrane revised tool was used to assess risk of bias in included studies (RoB 2.0). Results: Four randomized studies with 577 patients were eligible for analysis. Compared with concomitant regimen (baseline comparator), incremental regimen appeared to have lower risk of ATT hepatitis (odds ratio [OR] 0.24; 95% CrI 0.017, 1.2) as also the sequential regimen (OR 0.33; 95% CrI 0.033, 1.7). Rifampicin first and isoniazid first reintroduction regimens were similar via-a-vis recurrence of hepatotoxicity. Conclusion: The sequential and incremental regimen may be better than concomitant regimen in reducing risk of ATT hepatitis although the odds did not achieve statistical significance.

AIDS restriction genes (ARGs) like APOBEC3, TRIM5α, and BST2 can act as immunological detectors of the innate protective mechanism of the body. ARGs influence the course of viral pathogenesis and progression of the disease. The infection caused by different viruses including HIV activates the innate immune receptors leading to production of proinflammatory cytokines, interferons and signals that recruit and activate cells involved in the process of inflammation following induction of adaptive immunity. Differential expression of genes involved in viral infection decide the fate and subsequent susceptibility to infection and its clinical outcome. Nevertheless, comprehensive reports on the incidence of genetic polymorphism of APOBEC3s, TRIM5α, and BST-2 in the general population and its association with pathological conditions have not been described well. Therefore, the occurrence of APOBEC3, TRIM5α, and BST2 polymorphism in healthy individuals and its impact on HIV transmission was analyzed. We conducted an extensive search using the several databases including, EMBASE, PubMed (Medline), and Google Scholar. APOBEC3-D, -F, -G, and -H out of the seven human APOBEC3s, help in the control of viral infection. Amongst various restriction factors, TRIM5α and BST-2 also restrict the viral infection followed by the development of the disease. In the current review, a brief account of the polymorphism in the APOBEC3G, TRIM5α, and BST2 genes are explored among different populations along with the interaction of APOBEC3G with Vif protein. Furthermore, this review specifically focus on ARGs polymorphism (APOBEC3G, TRIM5α, and BST2) associated with HIV transmission.

Chylous ascites is an uncommon entity and infectious etiology is the most common cause in developing countries. However, recently, whether there is any change in trend of etiologies in developing countries is not known. In this study, a retrospective analysis of the data of cases of atraumatic chylous ascites was conducted. Twelve patients of atraumatic chylous ascites with a mean age of 35 years were studied and 6 of them were males. The mean duration of symptoms was 9.6 months and the clinical presentation was abdominal distension (12 cases), pain abdomen (10 cases), loss of appetite and weight (9 cases), peripheral lymphadenopathy (4 cases) and fever (3 cases). Etiologies were tuberculosis (3 cases), malignancy (2 cases), radiotherapy related (2 cases), pancreatitis related (2 cases), lymphatic malformation (2 cases) and multifactorial (1 case). Eight improved with conservative measures, 2 were lost to follow up and 2 died. Our outcomes found infectious etiology still as the most common cause of atraumatic chylous ascites. Benign treatable causes could be managed successfully with conservative measures while malignant etiology had a poor prognosis. Underlying etiology determines the outcome in atraumatic chylous ascites.

Small bowel is an uncommon site for primary neoplasm in the gastrointestinal tract. Traditionally, duodenum has been combined with jejunum and ileum in analysing the presentation and management of these tumors. Given the different presentation pattern, diagnostic difficulties and anatomical considerations, jejunal tumors may differ from duodenal tumors. Retrospective analysis of a prospectively maintained database of patients with histology proven jejunal tumors was done. Clinico-radiological characters, histological findings, surgical procedures and the outcomes in these patients were studied. Sixteen patients were included in the study. Median age at presentation was 42 years (26–76 years) and majority were males (n = 11, 68.8%). Seven (43.7%) patients presented with emergencies. Endoscopic tissue diagnosis could be obtained in 5 (31.3%) patients. Histology of tumors were adenocarcinoma, gastrointestinal stromal tumor and lymphoma in 6 (37.5%), 5 (31.3%) and 3 (18.8%) respectively. Sarcoma (myxofibroma) and metastasis (urothelial origin) were present in one patient each. Two patients with adenocarcinoma had neoadjuvant chemotherapy. Curative resection was feasible in 14 patients. Resection of tumor-bearing segment with anastomosis was performed in 9 patients. Among these, 5 had duodenojejunostomy. One patient had resection and double-barrel jejunostomy. One patient with jejunal GIST had sleeve resection. Multi-visceral resection was performed in 3 patients. There were no mortality and median postoperative hospital stay was 11 days (range 7–33 days). Histology spectrum of jejunal tumors are distinct. Difficulty in obtaining preoperative tissue diagnosis of these lesions need to be addressed by improved endoscopic and image-directed biopsy techniques.

Background Literature on the diagnosis of abdominal cocoon using computed tomography (CT) outside the setting of continuous ambulatory peritoneal dialysis is sparse. Methods We did a retrospective analysis of contrast enhanced CT done for patients treated for abdominal cocoon. The clinical features, radiological findings, underlying etiology and outcomes were recorded. Results Of the 22 patients analyzed, 19 had tuberculosis, 2 had malignancy and 1 was idiopathic. The basis of diagnosis of cocoon was CT in 18 and CT and surgery in 4. Types 1, 2 and 3 cocoon were found in 3 (13.63%), 6 (27.27%) and 13 (59.09%) respectively. The bowel findings were clumped loops in 21 (95%), inter-bowel fluid in 13 (59%), bowel wall thickening/enhancement in 6 (27%) and stricture in 1 (5%). Peritoneal thickening and nodularity were seen in 14 (64%) and 2 (9%) while omental thickening, nodularity and mass in 9 (41%), 5 (21%) and 1 (5%). Cauliflower sign was seen in 14 (64%), concertina pattern in 5 (23%) and Bottle Gourd sign in 6 (23%) patients. Of 12 with imaging done during episode of IO, 11 (92%) had cauliflower sign, 4 (80%) had concertina appearance and 6 (100%) had bottle gourd sign. Post treatment weight gain with anti-tubercular therapy was seen in 14 (63.63%), resolution of ascites in 12 (54.54%) and 2 patients had complete resolution of cocoon on repeat imaging. Conclusion CT is a valuable tool for pre-operative diagnosis of abdominal cocoon. The classical described signs are seen more frequently in patients with IO.

Abdominal cocoon is an uncommon entity manifesting as abdominal pain, lump and features of intestinal obstruction. The diagnosis is established by demonstrating a membranous sac covering the small bowel loops which can be seen at the time of surgery or demonstrated by imaging studies like computed tomography (CT) or magnetic resonance imaging. CT has been reported to be of utility in making a preoperative diagnosis. The features may include clumped bowel loops, loculated fluid, cauliflower sign or concertina arrangement of bowel loops. We report on three cases of abdominal cocoon who presented with intestinal obstruction due to three varied etiologies (idiopathic, tuberculosis, malignancy). We also describe a radiological sign, the bottle gourd sign, in these three cases. The sign possibly suggests jejunal obstruction due to formation of abdominal cocoon.

A 48-year-old male diagnosed with classical chronic mesenteric ischaemia along with features of hepatic ischaemia as revealed by low prothrombin time index and contrast computerised tomography (CT) showing small tiny ischaemic fibrotic nodules in liver parenchyma. Computerised tomography angiogram of the abdomen showed occluded celiac artery, superior mesenteric artery and inferior mesenteric artery. Patient required early treatment and the need was to restore blood flow to common hepatic artery and superior mesenteric artery. Open surgical revascularisation was planned considering his young age, longer patency of open bypasses with lesser reintervention rate in follow-up. Patient was optimised by infusion of fresh frozen plasma and injection vitamin K before being taken for surgery. Antegrade supraceliac aorta to common hepatic and superior mesenteric artery bypass was done successfully. Patient developed ascites and elevation of transaminases postoperatively which settled gradually over a week after management with diuretics and albumin infusion. Patient is doing fine at follow-up of more than 16 months.

Abdominal cocoon formation is an uncommon manifestation of abdominal tuberculosis that is characterized by the formation of a fibrous membrane-like sac around the small intestinal loops. Appropriate treatment and outcomes are uncertain Objectives: To review the clinical presentation, treatment, and outcomes for tubercular abdominal cocoon (TAC).We included studies published in the English language and listed in EMBASE or PubMed. All case series or reports that reported patients with TAC were considered for inclusion. Details regarding demographic, clinical presentation, and treatment received were tabulated.The clinical features included predominantly abdominal pain, abdominal distension and features of intestinal obstruction, loss of appetite, and weight loss. The diagnosis was usually established at surgery, however, computed tomography was a useful tool. In most patients the treatment reported was surgical, however, conservative therapy with anti-tubercular therapy (ATT) did succeed in a subset of patients. The published literature includes only case series and reports. The outcomes, especially long-term outcomes, have not been reported in most studies.Abdominal cocoon is an uncommon form of abdominal tuberculosis and conservative management with ATT may suffice in some patients whereas non-responsive cases require surgery.

Sclerosing encapsulating peritonitis (Abdominal cocoon) is an uncommon cause of intestinal obstruction and tuberculosis is an important etiology. Appropriate management of this entity is still uncertain. We did a retrospective analysis of patients with abdominal cocoon who were seen over a two year period at a tertiary care center in North India. We included patients with tubercular abdominal cocoon (TAC) who were managed primarily with antitubercular therapy in the present report. The diagnosis of TAC was made using combination of criteria (radiological or surgical findings of cocoon with evidence of tuberculosis in form of microbiological, histological or biochemical evidence). The clinical presentation, outcome and need for surgery for these patients were retrieved from the records of these cases maintained in a database. Of 18 patients with abdominal cocoon, 15 patients had underlying tuberculosis. The median age was 28 years (interquartile range 24) and 12 (80%) were males. Three patients had confirmed tuberculosis on basis of microbiological evidence. All had abdominal pain for 1–9 months, and 11 had intestinal obstruction. Twelve patients had positive Mantoux test, none had HIV. Pulmonary tuberculosis was noted in four patients, pleural in five, splenic and intestinal in two each, hepatic and mediastinal lymph-nodal in one each. Thirteen patients were started on usual 4-drug anti-tubercular therapy (ATT) while two cirrhotics needed modified ATT. Three patients were on steroids with ATT and all three improved. One patient was lost to follow up. Of the rest 14 patients, 2 underwent surgery, 1 at initial presentation while another after 4 months of ATT. Overall five patients developed intestinal obstruction while on ATT, one needed surgery and one died of liver failure while others improved with conservative means. TAC can be managed conservatively in a subset of patients.

Aortoenteric fistula (AEF) is an uncommon entity with high morbidity and mortality associated with it. Primary AEF can occur in the presence of aortic aneurysm but it is less common as compared to the secondary type, which is associated with the presence of prosthetic graft used for repair of aortic aneurysm or aortic bypass for occlusive disease. Multiple strategies have been described in the literature which needs to be individualized to each patient. This patient had undergone aortobifemoral bypass twice in the past, which makes anatomy hostile, followed by graft infection and graft enteric (jejunum) erosion leading to very challenging case to treat. The patient was managed in two stages, first axillobifemoral bypass followed by explantation of two grafts. He is doing fine at >12 months of follow-up.

Intestinal stomas have been performed for hundreds of years for both benign and malignant disorders of the large and small bowel. Complications of stomas like stomal prolapse, parastomal hernia, and retraction are well-known. The evisceration of intra-abdominal contents is a very rare occurrence, carrying a high burden of morbidity. The etiology, timing, and treatment of this complication are not adequately described in the literature. We report two patients who were operated and in whom ostomy was fashioned; parastomal evisceration occurred in the early postoperative period in both cases. Both of these patients were operated emergently, and reduction of eviscerated contents followed by stoma refashioning was performed. One patient survived; whereas, the other patient who presented with septic shock expired due to multiorgan dysfunction syndrome. This report describes a rare and possibly fatal complication of ostomy and highlights the importance of meticulous operative technique in ensuring safety in this procedure.

With an increasing number of long-term survivors of carcinoma esophagus, it is important to be vigilant about postoperative complications related to gastric tubes. Perforation of the gastric conduit has been rarely seen, with very few case reports in the literature. We report a rare case of perforation of the gastric tube conduit in a patient who had previously undergone esophagectomy for squamous cell carcinoma of esophagus five years ago. The patient presented with diffuse peritonitis in an emergency. On exploration, a large perforation was present on the anterior wall of the gastric conduit. This was closed with primary suture repair. Histopathology revealed nonspecific inflammatory changes. Unfortunately, the patient succumbed to severe sepsis and multiorgan dysfunction despite early surgical intervention and critical care management. Conduit perforation can be a major source of morbidity and mortality. Although gastric conduit is predisposed to ulcer formation due to multiple reasons, conduit perforation may occur only in rare cases. We recommend that surveillance endoscopy for conduit ulcer should be performed in long-term survivors after esophagectomy. Patients with conduit ulcers would benefit from long-term acid suppression with proton-pump inhibitors.

Background Various reintroduction regimens are used for reintroducing antitubercular therapy (ATT) in patients who had hepatitis previously related to use of ATT. Reintroduction of ATT in these patients has not been studied systematically. Methods We performed a systematic review and network meta-analysis of randomized trials to compare the safety of three different reintroduction regimens (Incremental, sequential and concomitant) of ATT using R software with ‘gemtc’ package. Articles were retrieved from various databases from inception to 28thDec 2018 with ‘chemical and drug-induced liver injury’, ‘ATT hepatotoxicity’, ‘drug-induced liver injury’ and ‘reintroduction of anti-tubercular drugs’ as search keywords. We excluded the articles published in languages other than English, case reports, case series and narrative reviews. Recurrence of hepatotoxicity after reintroduction of ATT was taken as the primary outcome. We also compared if the sequence of introduction of isoniazid or rifampin affected the risk of ATT hepatitis. The random effect network model was constructed taking logit likelihood function and heuristically imputed outcome scale assuming uniform standard deviation (0,2.615) as heterogeneity prior. The burn in, inference and thinning were kept at 20000, 100000 and 10 respectively. Results We found a total of 71 citations in our systematic search, out of which 4 randomized control trials were found eligible and included in the meta-analysis. The rank probability test of network meta-analysis demonstrated that incremental reintroduction therapy has a high chance of number one in all three regimens. Compared with concomitant regimen, incremental regimen was found better (odds ratio [OR] 0.24; 95% CI 0.017,1.2) then sequential regimen (OR 0.33; 95% CI 0.033,1.7). The point scale reduction factor of both consistency and node-split models was achieved less than 1.05. The deviance information criterion (DIC) and residual deviance of the consistency model were 17.3 and 9.8. Conclusions The sequential and incremental were better than concomitant. The order of reintroduction of rifampin and isoniazid does not seem to make any difference to the recurrence of ATT hepatitis.

© 2019 Elsevier B.V. Cancer is one of the major diseases that cause a high number of deaths globally. Of the major types of cancers, lung cancer is known to be the most chronic form of cancer in the world. The conventional management of lung cancer includes different medical interventions like chemotherapy, surgical removal, and radiation therapy. However, this type of approach lacks specificity and also harms the adjacent normal cells. Lately, nanotechnology has emerged as a promising intervention in the management and treatment of lung cancers. Nanotechnology has revolutionized the existing modalities and focuses primarily on reducing toxicity and improving the bioavailability of anticancer drugs to the target tumor cells. Nanocarrier systems are being currently used extensively to exploit and to overcome the obstructions induced by cancers in the lungs. The nano-carrier-loaded therapeutic drug delivery methods have shown promising potential in treating lung cancer as its target is to control the growth of tumor cells. In this review, various modes of nano drug delivery options like liposomes, dendrimers, quantum dots, carbon nanotubes and metallic nanoparticles have been discussed. Nano-carrier drug delivery systems emerge as a promising approach and thus is expected to provide newer and advanced avenues in cancer therapeutics.

Gall bladder tuberculosis (TB) is a rare entity and differentiation of gall bladder TB from gall bladder malignancy is difficult. We hereby present an unusual case of incidental diagnosis of gall bladder TB during the evaluation of a gall bladder with suspicion of gall bladder cancer in a 49-year-old woman. The diagnosis of gall bladder TB was made with fine needle aspiration cytology (FNAC) from the gall bladder mass as the disease was found unresectable after cross-sectional imaging. Even with the advancement of cross-sectional imaging, the differentiation of gall bladder TB from gall bladder malignancy is not possible without tissue diagnosis.