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Background There is limited literature on the role of percutaneous transhepatic biliary drainage (PTBD) as an adjunct to endoscopic retrograde cholangiopancreatography (ERCP). This study evaluates the role of PTBD in patients with failed ERCP or post-ERCP cholangitis. Methods Retrospective evaluation of clinical and intervention records of patients with biliary obstruction referred for PTBD following failed ERCP or post-ERCP cholangitis was performed. The cause of biliary obstruction, baseline serum bilirubin, white blood cell (WBC) count, serum creatinine, and procalcitonin were recorded. Technical success and clinical success (resolution of cholangitis, reduction in bilirubin levels, WBC count, creatinine, and procalcitonin) were assessed. Results Sixty-three patients (35 females, mean age 51.4 years) were included. Indications for ERCP included malignant causes in 47 (74.6%) cases and benign causes in 16 (25.4%) cases. Indications for PTBD were failed ERCP in 21 (33.3%) and post-ERCP cholangitis in 42 (66.7%). PTBD was technically successful in all patients. Clinical success rate was 68.2% in the overall group. Mild hemobilia was noted in five (7.9%) patients. There were no major complications or PTBD related mortality. Cholangitis and acute kidney injury resolved following PTBD in 63.1% and 80% of the patients, respectively. Total serum bilirubin reduced by 47.8% and 69.4% after one week and one month of the PTBD, respectively. The average fall in procalcitonin was 5.17 ng/mL after one week of the PTBD. Conclusion PTBD is an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis.

OBJECTIVES Organ failure (OF) and infected necrosis (IN) are the most important predictors of mortality in necrotizing acute pancreatitis (AP). We studied the relationship between timing (onset and duration) and patterns of OF with mortality and the impact of IN on mortality. METHODS Consecutive patients with necrotizing AP between January 2017 and February 2020 were analyzed retrospectively for OF and its impact on outcome. Organ failure was divided as single OF, simultaneous multiple OF (SiMOF) and sequential multiple OF (SeMOF). Mortality was compared for timing of onset, total duration and patterns of OF. RESULTS Among 300 patients with necrotizing AP, 174 (58%) had OF. Mortality was not associated with onset of OF (P = 0.683) but with duration of OF (P = 0.006). Mortalities for single OF, SiMOF, and SeMOF were 11.8%, 30.4%, and 69.2% respectively (P < 0.001). On Cox proportional hazard analysis, adjusted hazard ratio of risk of mortality for OF with IN versus IN, SiMOF versus single OF and SeMOF versus single OF was 3.183, 2.878, and 8.956, respectively (P = 0.023

Percutaneous catheter drainage (PCD) is an effective way of drainage in acute pancreatitis (AP) and its role in persistent organ failure (OF) has not been studied. This study assessed the outcome of severe AP managed with PCD.We retrospectively analysed outcome of AP patients undergoing PCD for persistent OF with respect to success of PCD, etiology, severity scores, OF, imaging features and PCD parameters. Success of PCD was defined as resolution of with PCD and survived without surgical necrosectomy.Between January 2016 and May 2018, 83 patients underwent PCD for persistent OF at a mean duration of 25.59 ± 21.2 days from pain onset with successful outcome in 47 (56.6%) patients. Among PCD failures, eleven (13.25%) patients underwent surgery. Overall mortality was 31 (37.3%). On multivariate analysis, pancreatic necrosis50% and absence of extrapancreatic infection (EPI) predicted the success of PCD. Presence of infected necrosis did not affect the outcome of PCD in organ failure.PCD improves the outcome in patients with OF even when done early irrespective of the status of infection of necrosis. Therefore, PCD may be considered early in the course of patients with OF.

Aim of the study This study aimed to evaluate the outcomes of patients with unresectable gallbladder cancer (GBC) with hilar involvement and cholangitis undergoing percutaneous transhepatic biliary drainage (PTBD). Material and methods This retrospective study comprised consecutive patients with unresectable GBC with cholangitis who underwent PTBD. The procedures were categorized as unilateral or bilateral. Bilateral PTBD was classified as simultaneous or sequential. The mean reduction in bilirubin at two weeks was recorded. Complications and mean overall survival were also recorded. Results Thirty-three patients (mean age 54.5 years, 12 males) were included. Thirty patients underwent unilateral drainage. Sequential drainage of the contralateral system was performed in 11 patients. Simultaneous bilateral PTBD was performed in 3 patients. PTBD was technically successful in all patients. Mean reduction in bilirubin was 41.5% in the unilateral group. The fall of bilirubin in the simultaneous bilateral PTBD group was 39%. The mean follow-up duration was 36.5 days. No major complications were encountered. At the last follow-up, 7 patients were alive. The mean overall survival was 34.6 days. Conclusions Patients with unresectable GBC and cholangitis frequently require bilateral drainage. However, prospective studies should be performed to evaluate whether a sequential or simultaneous PTBD should be performed.

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures and a first-line treatment for the establishment of enteral access in those with intolerance or contraindication to oral feedings. A small amount of pneumoperitoneum in the immediate postprocedure period is well reported after PEG tube placement. However, pneumoperitoneum resulting from displaced gastric bumper within 24 hours postprocedure is uncommon and rarely reported in the literature. Timely diagnosis and early endoscopic management can help tackle such an unusual complication.

Background There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms. Methods Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs). Results A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24–3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I2 83%). Clinical success rates at ≤3 months, 3–12 months, and >12 months were 82% (95% CI-70-90%, I2 42%), 86% (95% CI-75-92%, I2 44%), and 88% (95% CI-83-91%, I2 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35–13.53, I2 0%)). Splenic infarction was the most common complication (n = 47). Conclusion Endovascular embolization is associated with a high technical and clinical success.

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

Acute pancreatitis (AP) is a common disorder with high mortality in severe cases. Several markers have been studied to predict development of severe AP (SAP) including serum resistin with conflicting results. This study aimed at assessing the role of baseline serum resistin levels in predicting SAP.This prospective study collected data from 130 AP patients from July 2017 to Nov 2018. Parameters measured included demographic profile, serum resistin at admission, severity scores, hospital stay, surgery, and mortality. Patients were divided into two groups, severe and non-severe AP. The two groups were compared for baseline characteristics, serum resistin levels, hospital stay, surgery and mortality.Among 130 patients, 53 patients had SAP. SAP patients had higher BMI, baseline CRP, APACHE II and CTSI scores (We found that serum resistin is not a useful marker for predicting the severity of AP and does not correlate with increasing body weight.

Intra-abdominal hypertension (IAH) can adversely affect the outcome in patients of acute pancreatitis (AP). Effect of percutaneous drainage (PCD) on IAH has not been studied. We studied the effect of PCD on IAH in patients with acute fluid collections.Consecutive patients of AP undergoing PCD between Jan 2016 and May 2018 were evaluated for severity markers, clinical course, hospital and ICU stay, and mortality. Patients were divided into two groups: with IAH and with no IAH (NIAH). The two groups were compared for severity scores, organ failure, hospital and ICU stay, reduction in IAP and mortality.Of the 105 patients, IAH was present in 48 (45.7%) patients. Patients with IAH had more often severe disease, BISAP ≥2, higher APACHE II scores and computed tomography severity index (CTSI). IAH group had more often OF (87.5% vs. 70.2%, p = 0.033), prolonged ICU stay (12.5 vs. 6.75 days, p = 0.007) and higher mortality (52.1% vs. 15.8%, p 0.001). After PCD, IAP decreased significantly more in the IAH group (21.85 ± 4.53 mmHg to 12.5 ± 4.42 mmHg) than in the NIAH group (12.68 ± 2.72 mmHg to 8.32 ± 3.18 mmHg), p =0.001. Reduction of IAP in patients with IAH by40% at 48 h after PCD was associated with better survival (63.3% vs. 36.7%, p = 0.006).We observed that patients with IAH have poor outcome. PCD decreases IAP and a fall in IAP40% of baseline value predicts a better outcome after PCD in patients with acute fluid collections.

Background Prompt and accurate diagnosis of gastrointestinal tuberculosis (GITB) is highly challenging. Current conventional techniques lack sensitivity and are time-consuming. Multi targeted loop-mediated isothermal amplification (LAMP) using two targets (IS6110 and MPB64) is a promising technique for rapid diagnosis of TB. Methods LAMP test using IS6110 and MPB64 targets for M. tuberculosis complex was performed on ileocecal biopsy samples of 35 clinically suspected patients of GITB and 30 ileocecal biopsy samples of non-tuberculosis control subjects. Results of IS6110 LAMP and MPB64 LAMP were compared with IS6110 PCR and culture INFERENCE: Overall LAMP test (using any of the two targets) had a sensitivity and specificity of 100 and 100%, respectively, for confirmed GITB (five culture positive) cases and 85.71 and 100%, respectively, for clinically suspected 30 ileocecal biopsy samples of GITB. Sensitivity of IS6110 LAMP, MPB64 LAMP and IS6110 PCR for clinically suspected cases was 22 (73.33%), 24 (80%) and 21 (70%), respectively. In total 35 GITB patients, the overall sensitivity of microscopy, culture, IS6110 PCR, IS6110 LAMP, MPB64 LAMP and the multi-targeted LAMP assay (if any of the two targets were used) were 5.71, 14.28, 68.57, 74.28, 82.85 and 85.71%, respectively. Specificity of all the tests was 100%. There were three cases which were missed by IS6110 LAMP and two cases by MPB64 LAMP. Conclusion Multi-targeted LAMP is a promising technique for rapid and accurate diagnosis of GITB.

The world is witnessing a major public health crisis in the wake of the third coronavirus strain pandemic, a novel coronavirus (severe acute respiratory syndrome coronavirus 2). Although initially thought to be a pure respiratory pathogen, recent reports have highlighted not only the extrapulmonary effects of the virus but also, importantly, the gastrointestinal tract (GIT) effects. Various studies have looked into the effects of this novel coronavirus infection (coronavirus-19 disease [COVID-19]) on GIT involvement with reports of more frequent involvement than previously expected. With feco-oral transmission, debate being conclusively proven with fecal samples testing positive for COVID-19 and longer shedding time, it only underlines the importance of GIT involvement. Moreover, the presence of other GI diseases, such as inflammatory bowel disease, with COVID-19 infection might wreak havoc leading to poor patient outcomes.

The amount of intra-abdominal fat on CT correlates positively with the severity of acute pancreatitis (AP). The objective of the study was to evaluate a fat-modified CT severity index (FMCTSI) and compare its performance with MCTSI. For this retrospective study, 99 patients with AP who underwent contrast-enhanced CT between 3 and 7 days after pain onset were divided into a training cohort (n = 75) and a validation cohort (n = 24). MCTSI was calculated. The total adipose tissue (TAT), visceral adipose tissue (VAT), and total to visceral fat ratio (TVFR) were computed using semi-automatic software. These parameters were given a score of 1–3. FMCTSI was calculated by adding the fat score to MCTSI. Concordance for diagnosing the severity of AP was assessed. Areas under receiver operating characteristic curves (AUC) for predicting clinical outcomes were compared between FMCTSI and MCTSI. The diagnostic performance of the FMCTSI in the validation cohort was also evaluated. In the training cohort, our proposed FMCTSI performed better than MCTSI for all the outcome parameters. The highest concordance for the severity of AP was achieved for VAT-MCTSI. For all outcome parameters, the highest AUC was seen for TVFR-MCTSI. In the validation cohort, the FMCTSI achieved diagnostic performance similar to the training cohort with the highest AUC for TVFR-MCTSI. FMCTSI is a better CT index than MCTSI for predicting the severity and clinical outcomes of AP. Among the various FMCTSI parameters, TVFR-MCTSI is the best performer.

Percutaneous catheter drainage (PCD) performed pro-actively for collections in acute pancreatitis (AP) is associated with better outcomes. However, there are only a few studies describing this protocol. We aimed to evaluate an aggressive PCD protocol. Consecutive patients with AP who underwent PCD with an aggressive protocol between January 2018 and January 2019 were included. This protocol involved catheter upsizing at a pre-specified interval (every 4–6 days) as well as drainage of all the new collections. The indications and technical details of PCD and clinical outcomes were compared with patients who underwent standard PCD. Out of the 185 patients with AP evaluated during the study period, 110 (59.4%) underwent PCD, all with the aggressive protocol. The historical cohort of standard PCD comprised of 113 patients. There was no significant difference in the indication of PCD and interval from pain onset to PCD between the two groups. The mean number of catheters was significantly higher in the aggressive PCD group (1.86 ± 0.962 vs. 1.44 ± 0.667, p = 0.002). Additional catheters were inserted in 54.2% of patients in aggressive group vs. 36.2% in the standard group (p = 0.006). Length of hospital stay and intensive care unit (ICU) stay were significantly longer in the standard PCD group (34.3 ± 20.14 vs. 27.45 ± 14.2 days, p

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.

Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events. Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded. During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed. PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.

Esophageal diverticula (ED) are uncommon, mostly seen in elderly and can present with a multitude of symptoms. Of the three types of ED, epiphrenic and mid-esophageal diverticulum are still rare. These are often associated with esophageal motility disorder, which contributes to its development. The key step in the management of such symptomatic ED is the division of the septum and tackling the underlying motility dysfunction, if any. Traditional surgical options have high morbidity and mortality while flexible endoscopic septal division cannot adequately manage epiphrenic diverticulum with motility dysfunction. The technique of submucosal space creation and peroral endoscopic myotomy (POEM) has been used to treat a host of esophageal diseases such as achalasia. POEM has been recently described for the management of ED. Two different strategies have been described for tackling using POEM, namely, diverticular POEM (D-POEM) and salvage POEM (SPOEM). While D-POEM entails division of the septum and esophageal myotomy, S-POEM requires only esophageal myotomy without septum division. Multiple retrospective studies in the recent years have described use of POEM for the management of different types of ED with good safety and efficacy with low recurrence rate. This review encompasses a detailed account of the technical steps, pre- and post-procedure evaluation and literature review of safety, efficacy, adverse events, and recurrence rates of the use of POEM for ephiprenic and mid-esophageal diverticulum. We have also proposed a management algorithm based on the type of underlying motility dysfunction and the size of the diverticulum.

There is a paucity of evidence on the comparison between endoscopic ultrasound (EUS) fine-needle biopsy (FNB) and fine-needle aspiration (FNA) for lymph node (LNs) sampling. The aim of this study was to compare these two approaches in a multicenter series of patients with abdominal tumors. Out of 502 patients undergoing EUS sampling, two groups following propensity score matching were compared: 105 undergoing EUS-FNB and 105 undergoing EUS-FNA. The primary outcome was diagnostic accuracy. Secondary outcomes were diagnostic sensitivity, specificity, sample adequacy, optimal histological core procurement, number of passes, and adverse events. Median age was 64.6 years, and most patients were male in both groups. Final diagnosis was LN metastasis (mainly from colorectal cancer) in 70.4% of patients in the EUS-FNB group and 66.6% in the EUS-FNA group (p = 0.22). Diagnostic accuracy was significantly higher in the EUS-FNB group as compared to the EUS-FNA group (87.62% versus 75.24%, p = 0.02). EUS-FNB outperformed EUS-FNA also in terms of diagnostic sensitivity (84.71% vs. 70.11%, p = 0.01), whereas specificity was 100% in both groups (p = 0.6). Sample adequacy analysis showed a non-significant trend in favor of EUS-FNB (96.1% versus 89.5%, p = 0.06) whereas the histological core procurement rate was significantly higher with EUS-FNB (94.2% versus 51.4%, p &lt, 0.001). No procedure-related adverse events were observed. These findings show that EUS-FNB is superior to EUS-FNA in tissue sampling of abdominal LNs.

Background Polymorphisms in thiopurine methyltransferase (TPMT) and Nudix hydrolase-15 (NUDT15) have been implicated as the predominant cause of thiopurine induced leukopenia in the Western countries and East Asia respectively. Exact role of these polymorphisms in South Asian population with inflammatory bowel disease (IBD) is uncertain. Methods We included consecutive patients with IBD who were initiated on thiopurines at a center in North India. The dosage of thiopurines was titrated using regular monitoring of hemogram and liver function tests. Three TPMT polymorphisms (c.238 G > C, c.460 G > A, and c.719A > G) and one NUDT15 polymorphism (c.415 C > T) were assessed. Comparison regarding incidence of leukopenia and maximum tolerated thiopurine dosage was performed between those with wild polymorphism and those with TPMT and NUDT15 polymorphisms, respectively. Results Of the 119 patients (61 males, mean age 36.8 ± 13.5 years), 105 (88.2%) had ulcerative colitis and 14 (11.8%) had Crohn’s disease. Leukopenia was noted in 33 (27.7%), gastrointestinal intolerance in 5 (4.2%) and pancreatitis in 2 (1.6%). TPMT polymorphisms were detected amongst five patients of whom 1 developed leukopenia. NUDT15 polymorphism was noted in 13 patients of whom 7 had leukopenia. The odds of developing leukopenia in TPMT polymorphism were non-significant (0.77, 95% CI:0.0822 to 7.2134, P = 0.819) but were significantly higher in those with NUDT15 polymorphism (3.5933, 1.1041 to 11.6951, P value: = 0.0336). Conclusion NUDT15 polymorphism was more frequent than TPMT polymorphisms and was associated with thiopurine induced leukopenia. However, the tested polymorphisms account for only 24.2% of the risk of thiopurine induced leukopenia.

Purpose Intraabdominal hypertension (IAH) in acute pancreatitis (AP) may reduce tissue perfusion and impair organ function and has been shown to portend poor prognosis. We investigated the computed tomography (CT) findings in patients with AP with IAH. Methods This retrospective study comprised of consecutive patients with AP from June 2016 to June 2018 in whom intraabdominal pressure (IAP) was measured. The patients who underwent a contrast-enhanced CT within 7 days of IAP measurement were included. Using a cutoff of 12 mm Hg for IAP, the patients were divided into IAH and non-IAH groups. Measures of severity and clinical outcome were evaluated. CT parameters were compared between the groups. Results The IAH group comprised of 41 patients, while there were 20 patients in the non-IAH group. The IAH group was characterized by severe disease, increased incidence of organ failure, increased requirement for drainage and surgery, prolonged hospital and intensive care unit stay. The mortality was not significantly different between the two groups. On univariate analysis, the CT features that were found to be significantly different between the two groups were the presence of collection (p = 0.036), the maximum dimension of collection (p = 0.004), volume of collection (p = 0.019), biliary dilatation (p = 0.011), and the presence of moderate-to-severe pleural effusion (p = 0.009). On multivariate analysis, all these parameters except biliary dilatation were found to be statistically significant. Conclusion CT findings in patients with AP may suggest IAH. This can be used as an additional marker for severity of AP.

Peritoneal lymphomatosis (PL) is a rare presentation of extranodal precursor leukemia/lymphoma. The presentation is often non-specific, leading to delayed diagnosis and treatment. In this case, though the preliminary diagnosis was established on ascitic fluid cytology, the disease progressed rapidly, leading to demise before initiating chemotherapy. Immunophenotyping and molecular studies, performed later, established a diagnosis of de novo B-cell precursor leukemia/lymphoma with MYC, BCL2 rearrangements (Double-hit lymphoma). MYC, BCL2 rearrangements are rarely reported in precursor B-lymphoma/leukemia which carry dismal prognosis. In this report, we illustrate autopsy findings of PL in an elderly gentleman who presented with ascites for evaluation.

Background Percutaneous catheter drainage (PCD) is effective initial strategy in the step-up approach of management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD and develop a predictive model. Method and materials In a prospective observational study between July 2016 and Nov 2017, 101 consecutive AP patients were treated using a “step-up approach” in which PCD was used as the first step. We evaluated the association between success of PCD (survival without necrosectomy) and baseline parameters viz. etiology, demography, severity scores, C-reactive protein (CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography (CT) [percentage of necrosis, CT severity index (CTSI), characteristics of collection prior to PCD (volume, site and solid component of the collection), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion (fall in IAP, reduction in volume of collection). Results Among 101 patients, 51 required PCD. The success rate of PCD was 66.66% (34/51). Four patients required additional surgical necrosectomy after PCD. Overall mortality was 29.4% (15/51). Multivariate analysis showed percentage of volume reduction of fluid collection (p = 0.016) and organ failure (OF) resolution (p = 0.023) after one week of PCD to be independent predictors of success of PCD. A predictive model based on these two factors resulted in area under curve (AUROC) of 0.915. Nomogram was developed with these two factors to predict the probability of success of PCD. Conclusion Organ failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD outcomes in patients with fluid collection following AP

Background and Aim The two most common etiologies of acute pancreatitis (AP) are alcohol and gallstone. Whether etiology contributes to the outcome in patients with AP is an unresolved issue, more so in the severe form of the disease. The aim is to study the effects of the etiological factors of alcohol and gallstone on the disease course and the role of etiology in the subgroup of severe AP. Methods Consecutive patients of AP with alcohol or gallstone etiology were included. Various severity parameters and various outcome measures, such as need for organ support, intensive care, surgical or radiological intervention, hospital stay, and mortality, were evaluated between the two groups. Results Of the 759 patients, alcoholic pancreatitis was seen in 368 (48.5%), while gallstone disease was observed in 246 (32.4%). Gallstone pancreatitis occurred in older age (P

Background Percutaneous catheter drainage (PCD) is used as the first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). There are limited data on the effect of PCD on inflammatory markers. Aim To study the effects of PCD on serum levels of C‐reactive protein (CRP), IL‐6, and IL‐10 and its correlation with the outcome. Methods Consecutive patients of AP with symptomatic fluid collections undergoing PCD were evaluated for serum levels of CRP, IL‐6, and IL‐10 before PCD and at 3 and 7 days after PCD. Resolution of organ failure (OF), sepsis, and pressure symptoms was considered to demonstrate the success of PCD. Changes in levels following PCD were correlated with outcome. Results Indications of PCD in 59 patients (age 38.9 ± 13.17 years, 49 male) were suspected/documented infected pancreatic necrosis (n = 45), persistent OF (n = 40), and pressure symptoms (n = 7). A total of 49 (83.1%) patients improved with PCD, five patients required surgery, and six died. A significant difference was noted between baseline levels of CRP (P = 0.026) and IL‐6 (P = 0.013) among patients who improved compared to those who worsened following PCD. Significant decrease (P

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.

Objective: Overall, a handful of studies are available on the outcomes of acute-on-chronic pancreatitis (ACP). We aimed to provide a more complete and updated picture of ACP. Methods: We evaluated consecutive patients of acute exacerbation of chronic pancreatitis (CP) in a tertiary care center located in north India and studied their epidemiological profiles, etiological factors as well as outcomes. Results: Forty-five patients of ACP with a mean age of 37±13 years were evaluated. The majority of the patients were male (75%) and alcohol was the most common detectable etiology while no etiology could be identified in 35% of patients after extensive laboratory investigations and imaging. Moderately severe pancreatitis was noted in 73% of patients and 49% of patients had necrotizing pancreatitis out of which the majority (33%) had both pancreatic as well as extra-pancreatic necrosis (EPN). Five patients (11%) were subjected to percutaneous catheter drainage. Persistent organ failure was noted in 9% of patients and two (4.5%) patients had died from organ failure. Conclusion: To conclude, this study has demonstrated that ACP has a milder disease course and low morbidity and mortality. Early elimination of the etiological factor is essential for optimal outcome.

Background Splenic abscess has been an uncommon entity which is now being encountered more frequently due to increased prevalence of immunodeficiency disorders and chronic illnesses. This study was aimed to audit our experience with splenic abscesses at a tertiary care centre in India highlighting usefulness of an algorithmic approach. Methods Retrospective analysis of data of patients (January 2014 to December 2019) with splenic abscess was done. Data were retrieved for clinical characteristics, radiological findings, organism spectra, abscess characteristics, therapeutic measures and clinical outcome. Results The mean age of the study population (n = 36) was 41.3 ± 19.0 years with 50% males. Comorbidities were identified in 17 (47.2%) patients, with diabetes mellitus being the commonest. Fever and abdominal pain were the most common presenting features. Multiple splenic abscesses were present in 21 (58.3%) patients. Extra-splenic abscesses in liver were seen in five (13.9%) patients while nine (25%) patients had ruptured splenic abscess. Microorganisms were identified in 24 (66.7%) patients, with Salmonella typhi being the commonest (n = 9, 25%) followed by Escherichia coli (n = 7, 19.4%) and Staphylococcus aureus (n = 4, 11.1%). Six patients received only antimicrobials, 24 were managed with percutaneous aspiration or catheter drainage and six required surgery. Five (13.9%) patients died, with highest mortality being seen in those who received only antimicrobial (50%), compared to percutaneous aspiration or catheter drainage (8.3%) and surgery (0%), P = 0.017. Conclusion Using percutaneous aspiration or drainage in conjunction with antibiotics, followed by surgery in non-responder, patients with splenic abscesses can be managed successfully with acceptable mortality.

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.

The world is witnessing a serious public health threat in the wake of the third corona virus pandemic, a novel corona virus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]). The Corona Virus Disease-19 (COVID-19) is not limited to the respiratory system but has widespread involvement including the gastrointestinal (GI) tract and liver, with evidence of prolonged fecal shedding and feco-oral transmission. This finding has stirred up a hornet's nest of not only a newer modality of the spread of the virus but also a risk of the unpredictable duration of the infective potential of the shedders. We reviewed the literature on fecal shedding and possible implications on prevention and surveillance strategies. The pandemic is changing the management of underlying chronic diseases such as inflammatory bowel disease (IBD) and other diseases. Moreover, for the gastroenterologist, doing endoscopic procedures in this COVID-19 era poses a high risk of contamination, as it is an aerosol-generating procedure. There is a daily influx of data on this disease, and multiple societies are coming up with various recommendations. We provide a comprehensive review of all the reported GI manifestations of COVID-19 infection and the side effects of confounding drugs. We have summarized the management recommendations for diseases such as IBD with COVID-19 and nutritional recommendations and provided a concise review of the endoscopy guidelines by the various societies. This review provides a comprehensive account and a lucid guide covering various aspects of gastroenterology practice during this COVID-19 pandemic.

To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP). This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated. One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3–267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively. Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics. • Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.

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.

The existing CT indices do not allow quantitative prediction of clinical outcomes in acute pancreatitis (AP). The aim of this study was to develop and validate a revised CT index using a nomogram-based approach. This retrospective study comprised consecutive patients with AP who underwent contrast-enhanced CT between June 2017 and March 2019. 123 CT scans were randomly divided into training (n = 103) and validation groups (n = 20). Two radiologists analyzed CT scans for findings described in modified CT severity index and additional exploratory items (13 items). Seven items (pancreatic necrosis, number of collections, size of collections, ascites, pleural effusion, celiac artery involvement, and liver steatosis) found to be statistically significant were used for development of index. Synthetic minority oversampling technique (SMOTE) was employed to balance representation of minority classes and hence this index was named “SMOTE Application for Reading CT in AcuTe Pancreatitis (SMART-CT index)”. Binomial logistic regression was used for development of prediction algorithm. Nomograms were then created and validated for each outcome. The new CT index had area under the curve (AUC) of 0.79 [95% CI 0.65–0.93], 0.66 (95% CI 0.54–0.77), 0.75 (95% CI 0.65–0.85), 0.83 (95% CI 0.69–0.96), 0.70 (95% CI 0.60–0.81), and 0.64 (95% CI 0.53–0.75) for mortality, intensive care unit (ICU) stay, length of hospitalization, length of ICU stay, number of admissions, and severity, respectively. The AUC of validation cohort was comparable to the training cohort. The novel nomogram-based index predicts occurrence of clinical outcome with moderate accuracy.

To study the natural course of patients with acute pancreatitis (AP) with acute kidney injury (AKI) and their cytokine profile.Natural course of patients with AP and AKI was studied in 97 individuals. Levels of TNFα, IL-6, IL-10, IL-8 and IL-1β were measured at presentation and at 72 h in patients who developed AKI.Amongst the entire cohort, 16.4% patients developed AKI (persistent AKI - 11 patients, transient AKI - 5 patients). Mortality rate was 25% amongst patients with AKI. Levels of IL-6 (p = 0.035) and IL-8 (p = 0.002) were found to be significantly higher in the AKI group. On multivariate analysis, IL-8 levels at baseline were found to be an independent predictor of AKI. AKI group had significant rise of TNF-α (P 0.001), IL-6 (P 0.001) and IL- 1β (P 0.001) on day 3 whereas persistent-AKI group had significant rise of TNF-α (p = 0.031), IL-6 (p = 0.001) and IL-1β on day 3 and significant decline of IL-10 (p = 0.015). Using a cut-off of 105 pg/ml, IL-8 levels at baseline could predict AKI with a sensitivity of 87.5% and specificity of 59.2%, with area under the curve being 0.744 (p = 0.002).AP patients developing AKI have poor prognosis. IL-8 levels can predict AKI in patients with AP.

The aim was to study the outcomes of acute pancreatitis (AP) patients who were referred from other facilities to a tertiary care centre.Patients with AP were who were referred from other hospitals to a tertiary care centre between April 2013 and September 2019 were studied and their outcomes were analysed. Comparison was made between patients referred early (≤7 days) versus those referred late (7 days).Of the 838 patients seen by us, 650 patients (77.6%) were referred from other centres. Median (interquartile range) onset to admission interval was 5 (4-7) days for those who were referred ≤7 days and was 16 (11-30) for those who were referred7 days. Patients referred beyond 7 days of pain onset had higher rates of development of organ failure (P = 0.007), including acute lung injury (P = 0.008) and acute kidney injury (P = 0.026), infected necrosis (P 0.0001), requirement of endoscopic/percutaneous drainage (P 0.001) and need for surgery (P 0.02) compared to patients who were referred ≤7 days of pain onset. Mortality was however similar in the two groups.Patients with AP referred to a specialized centre with AP early (≤7 days) have better outcomes than those referred late (7 days) from other facilities.

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.

Objective: To evaluate the sensitivity, specificity, and diagnostic odds ratio (DOR) of Doppler ultrasound, CT, and MRI in the diagnosis of Budd Chiari syndrome (BCS). Methods: We performed a literature search in PubMed, Embase, and Scopus to identify articles reporting the diagnostic accuracy of Doppler ultrasound, CT, and MRI (either alone or in combination) for BCS using catheter venography or surgery as the reference standard. The quality of the included articles was assessed by using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results: 11 studies were found eligible for inclusion. Pooled sensitivities and specificities of Doppler ultrasound were 89% [95% confidence interval (CI), 81–94%, I2 = 24.7%] and 68% (95% CI, 3–99%, I2 = 95.2%), respectively. Regarding CT, the pooled sensitivities and specificities were 89% (95% CI, 77–95%, I2 = 78.6%) and 72% (95% CI, 21–96%, I2 = 91.4%), respectively. The pooled sensitivities and specificities of MRI were 93% (95% CI, 89–96%, I2 = 10.6%) and 55% (95% CI, 5–96%, I2 = 87.6%), respectively. The pooled DOR for Doppler ultrasound, CT, and MRI were 10.19 (95% CI: 1.5, 69.2), 14.57 (95% CI: 1.13, 187.37), and 20.42 (95% CI: 1.78, 234.65), respectively. The higher DOR of MRI than that of Doppler ultrasound and CT shows the better discriminatory power. The area under the curve for MRI was 90.8% compared with 88.4% for CT and 86.6% for Doppler ultrasound. Conclusion: Doppler ultrasound, CT and MRI had high overall diagnostic accuracy for diagnosis of BCS, but substantial heterogeneity was found. Prospective studies are needed to investigate diagnostic performance of these imaging modalities. Advances in knowledge: MRI and CT have the highest meta-analytic sensitivity and specificity, respectively for the diagnosis of BCS. Also, MRI has the highest area under curve for the diagnosis of BCS.

Background Doppler is the screening modality of choice for assessment of patients suspected of Budd Chiari syndrome (BCS). The aim of this study was to compare the diagnostic value of contrast enhanced ultrasound (CEUS) with Doppler in the initial evaluation of patients with BCS. Methods This was a retrospective study of patients with suspicion of BCS who underwent CEUS of the hepatic veins and inferior vena cava between July 2017 and April 2019. CEUS was performed using Sonovue. All patients underwent Doppler evaluation of the hepatic veins and inferior vena cava. The final diagnosis of BCS was based on transvenous or percutaneous digital subtraction venography. The diagnostic accuracy of CEUS was compared with Doppler. Results A total of 19 patients (median age, 30 years; 11 males) were evaluated with CEUS and Doppler. A final diagnosis of BCS was established on digital subtraction venography in 15 patients. CEUS was found to have a 100% sensitivity and 75% specificity. The sensitivity and specificity of Doppler was 100% and 25%. The diagnostic accuracies of CEUS and Doppler were 94.74% and 84.29%, respectively. Conclusion CEUS is a useful adjunct to the Doppler in the initial assessment of patients with BCS. However, further prospective studies must confirm our preliminary observations.

Objecives To compare the clinical outcome of patients with extrapancreatic necrosis (EXPN) alone with that of acute interstitial pancreatitis (AIP), pancreatic parenchymal necrosis (PPN) alone, and combined PPN and EXPN. Background There are only a few studies in the literature in which EXPN has been recently recognized as a subtype of acute necrotizing pancreatitis (ANP), with a better prognosis. Methods We analyzed clinical data and outcome variables of 411 consecutive acute pancreatitis (AP) patients between January 2012 and December 2014. Contrast-enhanced computed tomography (CECT) images of each patient were reviewed and characterized as AIP or ANP. Patients with ANP were divided into EXPN alone, PPN alone, and combined PPN and EXPN. Outcome variables were then compared between these groups. Results Of the 411 patients, 74 (18%) had AIP, and 337 (82%) had ANP. Patients with EXPN alone (n = 40; 11.8%) had similar outcomes as patients with PPN alone (n = 12; 3.5%); however, their outcome was worse than that of patients with AIP, with a higher frequency of persistent organ failure (POF), need for percutaneous catheter drainage (PCD), and longer length of hospitalization (LOH). Patients with combined PPN and EXPN (n = 285; 84.7%) had the worst clinical course, with higher frequency of POF, infected necrosis, intervention requirement, and longer LOH. Conclusion Patients with combined PPN and EXPN have a severe disease course with the worst clinical outcomes; patients with AIP patients have the most benign course, while patients with EXPN alone stand between the two extremes of disease course with an intermediate grade of severity.

One of the critical factors for predicting the success of percutaneous catheter drainage (PCD) is the mean CT density of collection. A higher CT density suggests more necrotic solid tissue within the collection. In the present study, a novel technique for PCD of the necrotic pancreatic collection with a higher mean CT density was evaluated. It was a retrospective study of patients with acute pancreatitis (AP) who underwent PCD of pancreatic collections between May 2018 and December 2018. Patients with pancreatic collections having a CT density of >30 Hounsfield Units (HU) were considered for PCD using the kissing catheter technique. This technique involved placing two catheters side-by-side through a single cutaneous entry site, as the conventional technique of PCD may not be effective. The technical details, outcomes and complications of this technique were recorded. A total of 10 patients with a mean age of 30 years underwent PCD using this technique. All patients had severe pancreatitis with a mean CT severity index of 9 (range, 8-10). The mean CT density was 37 HU (range, 32-56). Successful management with PCD alone was achieved in 8 patients. The other 2 patients underwent surgical necrosectomy. One patient who underwent surgical necrosectomy died. Minor complications occurred in 3 patients. The kissing catheter technique allows for a higher success rate of PCD compared with that of the conventional method of PCD, in collections with a higher mean CT density.

AIM To quantify the components in biofilms and analyze the predisposing factors involved in occlusion of biliary stents. METHODS In a prospective study conducted from April 2011 to March 2014 at a tertiary care hospital, all consecutive patients who required endoscopic biliary stent exchange/removal were included. Etiology of the biliary disease was diagnosed by imaging, cytology and on follow-up. Clinical details of patients with biliary stent retrieval were noted. All extracted stents were collected in sterile containers and immediately processed for quantification of biofilm proteins and polysaccharides. Molecular identification of commonly known and unknown bacteria was performed by polymerase chain reaction and density gradient gel electrophoresis methods. RESULTS Eighty one patients (41 males) with age range of 20-86 years were studied. The underlying causes for stent insertion were bile duct stones (n = 46; 56.8%) benign stricture (n = 29; 35.8%) and malignancy (n = 6; 7.4%) with cholangitis in 50 (61.7%) patients. The retrieved stent sizes were 7 Fr (n = 62; 76.5%) and 10 Fr (n = 19; 23.5%) with 65 days median insertion duration. Polybacterial consortia were detected in 90.1% of the stents. The most common bacteria identified by polymerase chain reaction alone and/or sequencing were Pseudomonas (n = 38), Citrobacter (n = 23), Klebsiella (n = 22), Staphylococcus (n = 20), Serratia (n = 16), Escherichia coli (n = 14), Streptococcus (n = 13), Enterococcus (n = 13), Aeromonas (n = 12), Proteus (n = 10) and Enterobacter (n = 9). Protein concentration according to gender (0.547 ± 0.242 mg/mL vs 0.458 ± 0.259 mg/mL; P = 0.115) as well as age > 60 years and < 60 years (0.468 ± 0.295 mg/mL vs 0.386 ± 0.238 mg/mL; P = 0.205) was non-significant. However, polysaccharide concentration was significant both according to gender (0.052 ± 0.021 mg/mL vs 0.049 ± 0.016 mg/mL; P < 0.0001) and age (0.051 ± 0.026 mg/mL vs 0.038 ± 0.016 mg/mL; P < 0.011). Protein concentration in the biofilm was significantly higher (0.555 ± 0.225 mg/mL vs 0.419 ± 0.276 mg/mL; P = 0.018) in patients with cholangitis, lower (0.356 ± 0.252 mg/mL vs 0.541 ± 0.238 mg/mL; P = 0.005) in the 10 Fr group than the 7 Fr group, and significantly higher (0.609 ± 0.240 mg/mL vs 0.476 ± 0.251 mg/mL; P = 0.060) in stents of ≥ 6 mo of indwelling time. However presence/absence of cholangitis, size of stent, indication of stent insertion and indwelling time did not affect the quantity of polysaccharide concentration. CONCLUSION Plastic stents retrieved from patients with biliary tract disease showed polymicrobial organisms with higher protein content among patients with cholangitis and those with smaller diameter stents. Longer indwelling duration had more biofilm formation.

Biodegradable (BD) stents have been used for the management of various esophageal strictures (ES) but the experience of its use in caustic strictures is limited. The present study, aimed at evaluating efficacy of BD stents for the treatment of refractory caustic-induced ES, was a retrospective multi-center study conducted at three tertiary care centers in India wherein adult patients with refractory caustic induced strictures underwent placement of a BD stent. Patients were followed up for immediate complications and long term outcome. All 13 patients (39.3 ± 15.1 years) underwent successful BD stent placement. Retrosternal chest pain occurred in 2 patients and stent migration in 1 (7.6%) patient. At 3 months, restenosis with recurrence of dysphagia was seen in nine (69.2%) patients, at 6 months, 10 (77%) patients had dysphagia of whom three underwent surgery and the remaining seven patients required dilatations. At 1 year, one patient remained asymptomatic while nine had dysphagia. The requirement for dilatation was once in 3 months in seven patients & once in a month in two patients. At 2 years, the requirement of dilatations was further reduced to once in 4–6 months in all patients. Over a 3 year follow up three (23%) patients had undergone surgery, one was free of symptoms while nine patients continued to be on periodic dilatation although the requirement had reduced to once in 4–6 months. Efficacy of BD stents in patients with caustic-induced ES is limited and the short term radial force applied by the currently available BD stents is inadequate to provide long term relief in such patients.

Background The site and size of extrapancreatic necrosis (EPN) as assessed on computed tomography may influence the severity of acute necrotizing pancreatitis (ANP). The objective of the study was to evaluate the impact of site and size of EPN on the clinical outcomes in patients with acute necrotizing pancreatitis (ANP). Method and materials This retrospective study comprised of consecutive patients with ANP who were admitted between January 2017 and March 2019. Patients in whom the initial contrast enhanced CT showed EPN were eligible for inclusion. The site, volume and maximum dimension of EPN were recorded. The severity of AP and modified CT severity index (MCTSI) was calculated. Clinical outcomes were recorded. Results A total of 119 patients (mean age, 37.56 years, 91 males) were included. There was a significant association between the location of EPN and the outcome parameters. The left posterior pararenal collections were significantly associated with mortality (P = 0.041), left paracolic gutter collections with the length of hospitalisation (LOH) (P = 0.014), and right paracolic gutter and mesenteric collections with the intensive care unit (ICU) stay (P = 0.024, and P = 0.021, respectively). There was a significant correlation between the volume and the maximum dimension of collection with LOH and ICU stay. The area under the receiver operating characteristic curve for volume, maximum dimension and MCTSI for predicting death was 0.724 (95% CI, 0.612–0.837), 0.644 (95% CI, 0.516–0.772) and 0.574 (95% CI, 0.452–0.696), respectively. Conclusion The site and size of EPN provide reliable and objective information for assessing clinical outcomes in patients with ANP.

Background Opioids and non steroidal anti inflammatory drugs (NSAIDs) are commonly used for pain relief in acute pancreatitis (AP). Opioids carry risk of sphincter of oddi constriction. Although diclofenac prevents post endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis, few reports of diclofenac associated AP are also present. Although, both tramadol and diclofenac are commonly used for pain relief in AP, no study has evaluated their comparative efficacy and safety. Materials and methods Forty-six eligible participants were randomized to either diclofenac or tramadol. Primary objectives of our study were improvement in pain intensity on visual analogue scale (VAS pain score after 1 hr of drug administration) and number of patients requiring supplementary analgesia. The secondary objectives were total number of times of supplementary analgesia requirement, time to significant decrease (33%) in VAS pain score from baseline, number of painful days (VAS pain score >5), VAS pain score on 7th day, side effects, all cause death and complications of pancreatitis between the two groups. Results Although 46 patients were randomized, the final analysis included 41 participants. Five patients were withdrawn from the study (intubation = 3, altered sensorium = 2). No significant difference was seen in terms of VAS score after 1 hr of drug administration, number of patients requiring supplementary analgesic and number of painful days. However, time taken to significant reduction of pain was lower in the diclofenac group (p = .028). Both the agents were comparable in terms of safety. Although complications were less in the diclofenac group, the difference was not statistically significant. Conclusion Both diclofenac and tramadol are equally effective in controlling pain in AP with similar safety profile. Significance There are no studies that have compared the safety and efficacy of two commonly used analgesics for pain relief in patients with AP. We found that both diclofenac and tramadol are equally effective in decreasing the pain associated with AP. There is also no significant difference in the incidence of side effects between both the groups. Hence both diclofenac and tramadol can be used safely and effectively for pain control in AP. Trial registration The trial was registered with clinical trials registry India (Number- CTRI/2018/05/014309).

Background Percutaneous catheter drainage (PCD) is an effective initial strategy of step-up approach for the management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD Methods This prospective observational study was conducted from July 2016 - Nov 2017. A total of 101 consecutive AP patients were recruited. Step up approach was followed for the management of patients. We evaluated the association between success of PCD ( survival without necrosectomy) and baseline parameters (aetiology, demography, severity scores(SIRS,APACHE II, organ failure),total leucocyte count, C-reactive protein(CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography, percentage of necrosis , CT severity index (CTSI), characteristics of collection before PCD (timing, nature of collection, volume, site, solid component), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion ( fall in IAP, reduction in volume of collection). Results Among 101 patients of AP, 51patients required PCD. The success of PCD 66.66% (34/51). Four patients required surgical necrosectomy after PCD. Mortality was 29.4% (15/51, including 2 deaths after necrosectomy). Multivariate analysis(6 factors included after univariate analysis) showed the percentage of volume reduction of fluid collection (p=0.016) and organ failure (OF) resolution(p=0.023) after one week of PCD predicted success of PCD. A predictive model based two factors resulted in AUROC- 0.915. Internal validation by bootstrapping of 5000 resamples showed AUROC 0.906 & is similar to the original model. Nomogram was developed with above factors to predict the probability of success of PCD((figure 1. Nomogram for predictor of PCD success in managing fluid collection in patients with necrotizing pancreatitis total points line indicates total points obtained from predictors and which is synchronized w) figure 1: Total points line indicates total points obtained from predictors and which is synchronized with probability of PCD success line which indicates probability of PCD success). (table 1). Conclusions Organ failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD in patients with pancreatic fluid collection.

Background Ascites in patients of acute pancreatitis (AP) is understudied although recent literature hints at its evident role on the final outcome. This study was planned to study the characteristics of ascites in patients of AP and its effect on the disease course and outcome. Methods Consecutive patients of AP were included and patients with or without ascites were evaluated for the baseline parameters and severity assessment. Ascites was quantified and fluid analyzed for its characteristics. Intraabdominal pressure (IAP) was monitored. The various outcome parameters were compared between the two groups of patients with and without ascites. Results Of the cohort of 213 patients, 82 (38.5%) developed ascites. Ascites group had significantly higher rates of organ failure (p=0.001), necrosis (p= 1000U/L) and low ( Conclusions AP patients with ascites have a more severe disease course with a poorer outcome as compared to those who do not have ascites. A higher degree of ascites and IAH grades are significant predictors of mortality.

Ascites in patients with acute pancreatitis (AP) is understudied although recent literature hints at its evident role in the final outcome. This study was planned to study the characteristics of ascites in patients of AP and its effect on the disease course and outcome.Consecutive patients of AP were studied and patients with or without ascites were evaluated for the baseline parameters and severity assessment. Ascites was quantified and fluid analyzed for its characteristics. Intraabdominal pressure (IAP) was monitored. The various outcome parameters were compared between the two groups of patients with and without ascites.Of the cohort of 213 patients, 82 (38.5%) developed ascites. Ascites group had significantly higher rates of organ failure (p = 0.001), necrosis (p=0.001) and higher severity assessment scores. The ascites group had significantly longer hospital and ICU stay and higher ventilator days compared to the non-ascites group. Mortality was also higher in the ascites group (34.1% vs 8.45; p = 0.001). Majority of patients with ascites had moderate to gross ascites (75.6%), low serum ascites albumin gradient (87.8%) with low amylase levels (71.9%). Sub-group analysis in ascites group showed that patients with fatal outcome had higher rates of moderate to gross ascites, higher baseline IAP and lower reduction in IAP after 48 h. Moderate to gross ascites and grades of intra-abdominal hypertension (IAH) were significant predictors of mortality (AUC - 0.76).AP patients with ascites have a more severe disease with poorer outcome. Higher degrees of ascites and IAH grades are significant predictors of mortality.