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Pancreaticoduodenectomy (PD) is a complex surgery for the management of periampullary tumors. It is associated with significant morbidity and mortality of 20% and 3 to 5% respectively. While early complications like delayed gastric emptying, hemorrhage, and collections are common, late complications like biliary and pancreatic anastomotic stenosis are also known to occur. With the increase in cases of pancreatic and periampullary cancers, there is an upward trend seen even in the rates of surgery. Endoscopy has emerged over the years as a tool for both evaluation and management of various complications. In this narrative review, we aim to provide a primer for gastroenterologists who are likely to be called upon for endoscopic management of post-PD complications.

Objective: There is paucity of data on lower gastrointestinal bleed (LGIB) in the pediatric population. We aimed to retrospectively review the endoscopy findings in patients younger than 18 years, presenting with lower gastrointestinal (GI) bleed and undergoing colonoscopy.

Abstract Background The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow‐up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those. Methods A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatography with clearance, along with an analysis of risk factors. Results A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2–13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in‐situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement. Conclusion Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow‐up in high‐risk patients.

The current standard of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB) includes endoscopic hemostasis with either through-the-scope clips or thermal therapy. However, they may be associated with rebleeding, especially in high-risk ulcers. Over-the-scope clips (OTSC) have been demonstrated in multiple recent studies to be an effective measure for NVUGIB. We aimed to analyze the current literature on standard therapy with OTSC to manage NVUGIB. A meta-analysis was performed by pooling the data from randomized studies obtained from a comprehensive search of Medline, Embase, and Scopus from inception to February 2023. The outcomes analyzed included rates of persistent bleeding, rebleeding, mortality, and duration of hospitalization. A total of five studies were included in the final analysis. There was no significant difference in the risk of persistent bleeding between the groups, with a risk ratio (RR) of 0.29 (95% confidence interval [CI]: 0.07–1.27). The use of OTSC was associated with a significantly lower risk of 7-day and 30-day rebleeding compared with standard therapy with RR of 0.30 (95% CI: 0.16–0.59) and 0.42 (95% CI: 0.24–0.72), respectively. There was no difference in the risk of 30-day mortality or the duration of hospitalization. There was no change in the effect on subgroup analysis of studies using OTSC as first-line therapy. The use of OTSC can reduce the rebleeding rates after endoscopic hemostasis. However, they may not reduce the risk of persistent bleeding or mortality. Future studies are required on the cost-efficacy of this modality.

Endoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection have become the cornerstone for the management of early cancers of the gastrointestinal tract. Risks associated with endoscopic resection may be exacerbated by the presence of background cirrhosis with its attendant complications. With complex alterations in hemostasis in patients with cirrhosis, management of patients undergoing endoscopic resection is more challenging. In this article we discuss a case of early gastric cancer in a patient with background chronic liver disease and thrombocytopenia managed using endoscopic submucosal dissection.

Background/Aims The data on the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients with inflammatory bowel disease (IBD) are conflicting. The present systematic review was thus conducted to study the prevalence of HBV and HCV markers in patients with IBD. Methods A comprehensive literature search of 3 databases was conducted from 2000 to April 2022 for studies evaluating the prevalence of HBV or HCV in patients with IBD. Pooled prevalence rates across studies were expressed with summative statistics. Results A total of 34 studies were included in the final analysis. The pooled prevalence of hepatitis B surface antigen (HBsAg) and hepatitis B core antibodies were 3.3% and 14.2%, respectively. In HBsAg positive IBD patients, hepatitis B e antigen positivity and detectable HBV DNA were seen in 15.3% and 61.0% of patients, respectively. Only 35.6% of the IBD patients had effective HBV vaccination. The pooled prevalence of anti-HCV and detectable HCV RNA were 1.8% and 0.8%, respectively. The pooled prevalence of markers of HBV infection was higher in Asian studies, while the prevalence of markers of HCV infection was higher in European studies. The prevalence of viral hepatitis markers was similar between IBD patients and the general population and that between ulcerative colitis and Crohn’s disease. Conclusions The prevalence of markers of viral hepatitis remains same as the general population with significant regional variations, although the quality of evidence remains low due to publication bias. Only a small proportion of IBD patients had an effective HBV vaccination, requiring improvement in screening and vaccination practices.

Background/Aims This meta-analysis analyzed the effect of an indwelling biliary stent on endoscopic ultrasound (EUS)–guided tissue acquisition from pancreatic lesions. Methods A literature search was performed to identify studies published between 2000 and July 2022 comparing the diagnostic outcomes of EUS-tissue acquisition (TA) in patients with or without biliary stents. For non-strict criteria, samples reported as malignant or suspicious for malignancy were included, whereas for strict criteria, only samples reported as malignant were included in the analysis. Results Nine studies were included in this analysis. The odds of an accurate diagnosis were significantly lower in patients with indwelling stents using both non-strict (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.52–0.90) and strict criteria (OR, 0.58; 95% CI, 0.46–0.74). The pooled sensitivity with and without stents were similar (87% vs. 91%) using non-strict criteria. However, patients with stents had a lower pooled sensitivity (79% vs. 88%) when using strict criteria. The sample inadequacy rate was comparable between groups (OR, 1.12; 95% CI, 0.76–1.65). The diagnostic accuracy and sample inadequacy were comparable between plastic and metal biliary stents. Conclusions The presence of a biliary stent may negatively affect the diagnostic outcome of EUS-TA for pancreatic lesions.

Introduction Colonic self-expanding metal stent (SEMS) placement is the preferred method for palliation of malignant colonic obstruction. We analyzed outcomes of patients who underwent colonic SEMS placement for palliation at a tertiary care oncology center in Western India. Methods Retrospective review of the endoscopy database was done for patients who underwent colonic SEMS placement at our center between January 2013 and September 2021. Demographic details, intent of stent placement, site of obstruction, length of stricture, technical success of stenting, clinical success, and complications (both immediate and long term) were noted. Results Sixty-one patients underwent colonic SEMS placement during the study period (mean age 53.6 years, 50.7% men). Obstruction was due to primary colonic malignancy in 43 (70.5%) patients and extracolonic malignancies in 18 (29.5%) patients. Most common extracolonic malignancy was gallbladder cancer in 8 (44.4%) patients. Most common site of obstruction was sigmoid colon in 18 (29.5%) patients. Proximal colonic obstruction was seen in 17 (27.9%) patients. Peritoneal metastases were seen in 26 (42.6%) patients. Colonoscopy revealed an impassable stenosis in 58 (95.1%) patients. Median length of stricture was 5 cm (range 2–9 cm). Technical success was achieved in 98.3% (60/61). Clinical success was achieved in 51 (86.4%) patients. Perforation during colonic SEMS placement was seen in 2 (3.4%) patients. Stent migration was seen in 3 (5.9%) patients, needing surgery for retrieval in all 3 patients. Over a median follow-up of 9 months (0–21 months), stent block was seen in 7 (13.7%) patients. Stent block developed after a median period of 6 months. Of these patients, three patients underwent SEMS placement within the SEMS and the other four patients underwent surgery. Conclusion Colonic SEMS placement achieves good palliation of malignant colonic obstruction in approximately 87% patients. Long-term complications like obstruction occur in a few patients after a median duration of 6 months.

Background: Lumen apposing metal stents (LAMSs) have a higher clinical success rate for managing pancreatic fluid collections. But they are associated with adverse events (AEs) like bleeding, migration, buried stent, occlusion, and infection. It has been hypothesized that placing a double pigtail stent (DPS) within LAMS may mitigate these AEs. The present systematic review and meta-analysis were conducted to compare the outcome and AEs associated with LAMS with or without a coaxial DPS (LAMS-DPS). Methods: A comprehensive literature search of three databases from January 2010 to August 2022 was conducted for studies comparing the outcome and AEs of LAMS alone and LAMS-DPS. Pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for all the dichotomous outcomes. Results: Overall, eight studies ( n = 460) were included in the final analysis. The clinical success rate (RR 1.00, 95% CI: 0.87–1.14) and the risk of overall AEs (RR 1.60, 95% CI: 0.95–2.68) remained comparable between both groups. There was no difference in the risk of bleeding between LAMS alone and LAMS-DPS (RR 1.80, 95% CI: 0.83–3.88). Individual analysis of other AEs, including infection, stent migration, occlusion, and reintervention, showed no difference in the risk between both procedures. Conclusion: The present meta-analysis shows that coaxial DPS within LAMS may not reduce AE rates or improve clinical outcomes. Further larger studies, including patients with walled-off necrosis, are required to demonstrate the benefit of coaxial DPS within LAMS.

Background In clinical practice, decision about management of choledocholithiasis is driven by availability of resources and expertise, patients and healthcare professional preferences. This survey is aimed to describe the approach of physicians and surgeons for the management of choledocholithiasis. Method A 36-question online survey was conducted using Google Forms on various aspects of management of choledocholithiasis. Results The responses from 323 participants were included, of which 202 (62.54%) were physicians and 121 (37.46%) were surgeons. The proportion of responders who do not follow American or European Society of Gastrointestinal Endoscopy guidelines is associated with increasing age and experience of responders (p = 0.0001), while place of work (private vs. teaching) and broad specialty (physician vs surgeon) are not associated (p >0.05). For patients with high likelihood of choledocholithiasis, 123 (38.1%) participants prefer to do endoscopic ultrasound/magnetic resonance cholangiopancreatography (EUS/MRCP) rather than directly performing endoscopic retrograde cholangiopancreatography/intraoperative cholangiography (ERCP/IOC). For intermediate likelihood, MRCP is more commonly preferred compared with EUS, due to local availability (44%), expertise (39.6%), healthcare professionals preference (30.7%), and patients preference (17.3%). For difficult common bile duct (CBD) stones, short biliary sphincterotomy with large balloon sphincteroplasty (59.4%), followed by laparoscopic CBD exploration are commonly used approaches. Prophylactic CBD stent placement after ERCP and CBD clearance is common practice. Preoperative ERCP followed by cholecystectomy is more preferred approach than cholecystectomy and CBD exploration. Conclusion There is considerable variability in the management of choledocholithiasis. The practices such as use of EUS/MRCP for high likelihood group, use of prophylactic CBD stent placement after ERCP and CBD clearance, and use of single stage approach especially in patient with intermediate likelihood group should be addressed in future studies.

Background/Aims Cold snare polypectomy (CSP) is commonly used for the resection of colorectal polyps ≤10 mm. Data regarding the influence of snare type on CSP effectiveness are conflicting. Hence, this meta-analysis aimed to compare the outcomes and safety of thin- and thick-wire snares for CSP. Methods A comprehensive search of the literature published between 2000 and 2021 was performed of various databases for comparative studies evaluating the outcomes of thin- versus thick-wire snares for CSP. Results Five studies with data on 1,425 polyps were included in the analysis. The thick-wire snare was comparable to the thin-wire snare with respect to complete histological resection (risk ratio [RR], 1.03; 95% confidence interval [CI], 0.97–1.09), overall bleeding (RR, 0.98; 95% CI, 0.40–2.40), polyp retrieval (RR, 1.01; 95% CI, 0.97–1.04), and involvement of submucosa in the resection specimen (RR, 1.28; 95% CI, 0.72–2.28). There was no publication bias and a small study effect, and the relative effects remained the same in the sensitivity analysis. Conclusions CSP using a thin-wire snare has no additional benefit over thick-wire snares in small colorectal polyps. Factors other than snare design may play a role in improving CSP outcomes.

Background/Aims: Endoscopic stenting is an evolving treatment for symptomatic Crohn's strictures. Several case series and small studies have reported its efficacy. Future studies can be designed based on a systematic review of the evaluation of efficacy. Hence, this meta-analysis was conducted to assess the critical role of stents in the management of intestinal strictures associated with Crohn's disease (CD). Methods: A literature search of various databases from 2000 to February 2022 was conducted for studies evaluating the outcome of stents in patients with CD-related stricture. The outcomes assessed included technical and clinical success, adverse events, symptom recurrence, and the need for a surgical resection. Pooled event rates across studies were expressed with summative statistics. Results: Ten studies with 170 patients were included in the present analysis. The pooled event rates for technical success, clinical success, stent migration, and post-procedural pain were 98.2% (95% CI, 95.8-100), 71.3% (95% CI, 57.4-85.1), 32% (95% CI, 0.0-65.3) and 20.2% (95% CI, 4.1-36.2), respectively. The cumulative recurrence rate and need for surgery were 40.1% (95% CI, 20.3-59.9) and 8.6% (95% CI, 1.7-15.5), respectively. Subgroup analysis showed that partially-covered (PC) self-expanding metallic stent (SEMS) was significantly better than fully-covered SEMS with a lower stent migration rate and symptom recurrence rate. Conclusions: Overall efficacy of stents in the management of CD-related stricture remains moderate with a low complication rate. Among the stents, PC-SEMS may be associated with a more favorable outcome. Future studies will be needed to determine the long-term benefits of endoscopic stenting.

Background/Aims Mucosal incision-assisted biopsy (MIAB) for tissue acquisition (TA) from subepithelial lesions (SELs) is emerging as an alternative to endoscopic ultrasound (EUS)-guided TA. Only a limited number of studies compared the diagnostic utility of MIAB and EUS for upper gastrointestinal (GI) SELs; therefore, we conducted this systematic review and meta-analysis. Methods A comprehensive literature search from January 2020 to January 2022 was performed to compare the diagnostic accuracy and safety of MIAB and EUS-guided TA for upper GI SELs. Results Seven studies were included in this meta-analysis. The pooled technical success rate (risk ratio [RR], 0.96; 95% confidence interval [CI], 0.89–1.04) and procedural time (mean difference=–4.53 seconds; 95% CI, –22.38 to 13.31] were comparable between both the groups. The overall chance of obtaining a positive diagnostic yield was lower with EUS than with MIAB for all lesions (RR, 0.83; 95% CI, 0.71–0.98) but comparable when using a fine-needle biopsy needle (RR, 0.93; 95% CI, 0.83–1.04). The positive diagnostic yield of MIAB was higher for lesions

Abstract Background and Aim The COVID pandemic and countrywide lockdown has had significant impact on patients with inflammatory bowel disease (IBD), with delay in diagnosis, difficulty in access to healthcare and unavailability of drugs. We conducted a telephonic survey to assess this impact. Methods Out of 350, 302 participated in the survey. Demographic data, disease severity at the time of survey, extent of disease, details of therapy, and adherence were noted. A validated questionnaire addressing information source, perception of COVID‐19 situation, contact with healthcare, and adherence to standard precautions was administered telephonically. Results Out of 350 contacted patients, 302 (86.28%) patients participated in the survey. Median age of cohort was 39 years. Ulcerative colitis (UC) constituted 79%, 16% Crohn's disease (CD), and 5% IBD‐unclassified. At the time of survey, 86.98% patients with UC were in clinical remission and 75.75% of CD patients were generally well. A total of 115 (38%) cases were nonadherent to therapy due to unavailability of medicines (66.38%), financial constraints (25.21%) and inability to reach healthcare facility (3.6%). Disease flare was seen in 14.2% and correlated well with nonadherence. Existing drug therapy was switched to alternative drug in 70 (23.17%) cases due to unavailability (74%). Social media (52.3%) and television (40.4%) were the common sources of information about the pandemic. Telemedicine platforms (WhatsApp and telephone) were used by 180 (59.6%) patients for consultation with good acceptance (81.6%). 87 (28.8%) patients failed to contact healthcare. Apprehension regarding severe COVID infection was noted in 80% while 29% thought that IBD therapy could increase infection risk. Adherence to wearing mask, hand washing, and social distancing was 100%. Conclusion Pandemic resulted in disruption of healthcare visits and medication supply. Majority were concerned about increased risk of COVID‐19 infection and adhered to standard precautions. Mobile phone‐based formats for patient care may be an alternative due to patient acceptance and convenience.

Background/Aims Pancreatic strictures in chronic pancreatitis are treated using endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. The management of recalcitrant strictures remains a challenge, with the use of a Soehendra stent retriever or a needle knife described in case reports. Here, we discuss our experience with dilation of dominant pancreatic strictures with a 6-Fr cystotome. Methods A retrospective review of an endoscopy database was performed to search for patients with pancreatic strictures recalcitrant to conventional methods of dilation in which a cystotome was used. Technical success was defined as the successful dilation of the stricture with plastic stent placement. Functional success was defined as substantial pain relief or resolution of pancreatic fistulae. Results Ten patients (mean age, 30.8 years) underwent dilation of a dominant pancreatic stricture secondary to chronic pancreatitis, with a 6-Fr cystotome. Seven patients presented with pain. Three patients had pancreatic fistulae (two had pancreatic ascites and one had a pancreaticopleural fistula). The median stricture length was 10 mm (range, 5–25 mm). The head of the pancreas was the most common location of the stricture (60%). Technical and functional success was achieved in all patients. One patient had self-limiting bleeding, whereas another patient developed mild post-ERCP pancreatitis. Conclusions The use of a 6-Fr cystotome (diathermy catheter) can be an alternative method for dilation of recalcitrant pancreatic strictures after the failure of conventional modalities.

Combined biliary and duodenal stent placement has been reported previously in multiple series. Rarely, colonic obstruction may present simultaneously with duodenal and biliary obstruction in advanced pancreaticobiliary cancers. Biliary, duodenal and colonic obstruction managed simultaneously using endoscopic modalities have been reported in only one case report previously. Here we report outcomes of a case of carcinoma of the gall bladder with biliary, gastric outlet and colonic obstruction managed by endoscopic placement of biliary, gastroduodenal and colonic self-expanding metal stents.

Abstract Background Wilson’s disease is a multisystem disorder with predominant clinical symptoms depending on the site of copper deposition in the body. Hepatic presentation is usually seen in the younger age group. And pancreatitis is rarely associated with Wilson’s disease. To the best of our knowledge, recurrent acute pancreatitis as a presenting manifestation in a WD patient has not been mentioned before in the literature. Case presentation We report a 17-year-old boy who presented with recurrent acute pancreatitis and subsequently developed deranged liver enzymes and ascites. Work up for the cause of recurrent acute pancreatitis was normal. Low ceruloplasmin (0.07 mg/dL), high 24-h urinary copper excretion (576 μg/day), and dry copper content in the liver (270 μg/g) clinched the diagnosis of Wilson’s disease. The patient was started on a low-copper diet and D-penicillamine therapy resulting in an improvement in symptoms and no further recurrence of pancreatitis. Conclusion The possibility of Wilson’s disease should be considered in young patients with recurrent acute pancreatitis, who have a protracted and obscure disease course.

Background and study aims Clinical practice patterns for image-enhanced endoscopy (IEE) and colonic endoscopic resection practices vary among endoscopists. We conducted a survey to understand the differences in IEE and colonoscopic resection practices among endoscopists from India. Methods An online cross-sectional survey comprising 40 questions regarding quality control of colonoscopy, IEE, and colonic endoscopic resection practices was circulated through the registry of the Indian Society of Gastroenterology and Association of Colon and Rectal Surgeons of India. Participation was voluntary and response to all questions was compulsory. Results There were 205 respondents to the survey (93.2 % gastroenterologists, 90.2 % male, 54.6 % aged 30 to 40 years, 36.1 % working in academic institution, 36.1 % working in corporate hospitals). Of the endoscopists, 50.7 % had no training in IEE and 10.7 % performed endoscopy on systems without any IEE modalities. Endoscopists with more experience were more likely to use IEE modalities in practice routinely (P = 0.007). Twenty percent never used IEE to classify polyps. Sixty percent of respondents did not use dye-chromoendoscopy. Less experienced endoscopists used viscous solutions as submucosal injectate (P = 0.036) more often. Of the respondents, 44 % never tattooed the site of endoscopic resection. Ablation of edges post-endoscopic mucosal resection was not done by 25.5 % respondents. Most respondents used electronic chromoendoscopy (36.1 %) or random four-quadrant sampling (35.6 %) for surveillance in inflammatory bowel disease. Surveillance post-endoscopic resection was done arbitrarily by 24 % respondents at 6 months to 1 year. Conclusions There are several lacunae in the practice of IEE and colonic endoscopic resection among endoscopists, with need for programs for privileging, credentialing and proctoring these endoscopic skills.

Chronic pancreatitis (CP) is a known risk factor for pancreatic cancer. CP may present with an inflammatory mass, and differentiation from pancreatic cancer is often difficult. Clinical suspicion of malignancy dictates a need for further evaluation for underlying pancreatic cancer. Imaging modalities remain the mainstay of evaluation for a mass in background CP; however, they have their shortcomings. Endoscopic ultrasound (EUS) has become the go-to investigation. Adjunct modalities such as contrast-harmonic EUS and EUS elastography, as well as EUS-guided sampling using newer-generation needles are useful in differentiating inflammatory from malignant masses in the pancreas. Paraduodenal pancreatitis and autoimmune pancreatitis often masquerade as pancreatic cancer. In this narrative review, we discuss the various modalities used to differentiate inflammatory from malignant masses of the pancreas.

Summary of event: Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) with the placement of a fully covered self-expandable metal stent (SEMS) is an alternative method to percutaneous transhepatic biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction. We report the case of a 64-year-old female who underwent EUS-CD with placement of a fully covered SEMS for obstructive jaundice due to distal bile duct obstruction by a pancreatic head mass and failed ERCP. Five months after the procedure, she presented with spontaneous expulsion of the stent in vomitus. She did not have bile leak and jaundice due to the formation of an epithelialized fistulous tract between the bile duct and duodenum (choledocho-duodenal fistula). Teaching point: Delayed distal migration of a fully covered SEMS after EUS-CD can occur. The formation of an epithelialized choledochoduodenal fistula prevented the occurrence of bile leak, pneumoperitoneum and perforation. Re-stenting through the same tract is possible. Stents with antimigration flanges or lumen-apposing metal stents may prevent migration.

Background/Aims Bile leak is a common complication of cholecystectomy, and it is also observed in other conditions such as ruptured liver abscess, hydatid cyst, and trauma. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management for such conditions. However, studies on the outcomes of endoscopic management for bile leaks with etiologies other than post-cholecystectomy injury are extremely limited. Methods We conducted a retrospective review of patients with symptomatic bile leak who were referred to a tertiary care center and who underwent ERCP between April 2016 and April 2019. The primary outcome was complete symptomatic resolution without extravasation of the contrast medium during the second ERCP conducted after 6 weeks. Results In total, 71 patients presented with symptomatic bile leak. The etiologies of bile leak were post-cholecystectomy injury in 34 (47.8%), liver abscess in 20 (28.1%), and post-hydatid cyst surgery in 11 (15.4%) patients. All patients were managed with ERCP, sphincterotomy, and stent placement for 6 weeks, except for one who underwent surgery. The primary outcome was achieved in 65 (91.5%) of 71 patients. There was no significant difference in terms of outcome in relation to the interval between the diagnosis of bile leak and ERCP. Conclusions Most patients with bile leak can be successfully managed with ERCP even when performed on an elective basis.

In patients undergoing ambulatory laparoscopic surgeries, Ryles tubes are required only for the purpose of intraoperative gastric decompression. Insertion of nasogastric tubes can lead to nasal trauma, and hence, oral tubes provide a feasible alternative. In contrast to the nasopharyngeal cavity, whose anatomical orientation allows ease of insertion into the esophagus, oral insertion of Ryles tube is difficult on account of a larger cavity and potential for coiling. Various aids are often used to ease the insertion of these orogastric tubes. One such aid is the use of an oral endotracheal tube (ETT). This case report aims to bring to light, and the inadvertent complications may occur with the improper use of these aids, which in our case, was the misplacement of the said oral ETT.

Background The majority of foreign bodies entering the small intestine are passed spontaneously. However, in case of a sharp object, its removal is an urgency due to a higher risk of intestinal perforation, and endoscopic intervention is an appropriate management strategy as surgery is associated with greater morbidity. Although enteroscopy is the standard practice for the removal of a foreign body in the small intestine, gastroduodenoscopy may be used for small intestinal foreign body removal. Case Presentation We describe here the case of a 21-month-old child in whom a 5-cm, sharp-pointed nail in the midjejunum was removed successfully by a gastroduodenoscopy. This case highlights the difficulties in the removal of a sharp foreign body in a pediatric patient and the use of push enteroscopy. Conclusion Gastroduodenoscopy can be used for the removal of a foreign body in the small intestine in pediatric population in a resource-limited setup by performing push enteroscopy.

Autoimmune pancreatitis (AIP) is a known autoimmune disorder of the pancreas, with a clinical presentation similar to that of carcinoma of the pancreas. CA19-9 levels can be the distinguishing feature between the two disorders. In rare instances, CA19-9 may be elevated in AIP. Elevation of levels of more than 1,000 U/mL has been reported in only one case series previously. Here we report a rare instance of CA19-9 more than 1,000 U/mL in a case of AIP and its subsequent management.

Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder of the liver, with strictures in the bile ducts leading to cirrhosis of the liver in a proportion of patients. PSC is commonly associated with inflammatory bowel disease and increased risk of cholangiocarcinoma, gall bladder cancer, colorectal cancer, and hepatocellular carcinoma. Medical therapies are primarily aimed at symptom management and disease-modifying therapies are limited. Endoscopic therapies are used in patients with dominant strictures and liver transplantation is a last resort. In this article, the authors aim to comprehensively review the epidemiology, diagnosis, and management of PSC with emphasis on risk of malignancies and management of PSC. The authors also survey the advances in pathogenesis understanding and novel medical therapies for PSC.

Colonic self‑expanding metal stent (SEMS), although associated with high technical and functional success in malignant colonic obstruction, may be associated with complications such as migration. Furthermore, fistulous tract formation with SEMS in situ has been reported only in few case reports previously. Here, we present a case of colonic SEMS migrating through a gastrocolic fistula into the stomach. There are no previous reports of migration of a colonic SEMS into a proximal segment of the gastrointestinal tract.

Dye decolorization with the help of a plant based enzyme was investigated. Crude peroxidase (35.58 U/ml) extracted from the pulp of Raphanus sativus (radish) was used for decolorization of a basic dye, safranin. The effect of the influencing parameters of pH, temperature, dye concentration, and enzyme concentration on safranin decolorization was primarily studied using the traditional One Factor At a Time method (OFAT). The optimal values of each influencing parameter for maximum decolorization were obtained via the OFAT approach which can be extended to study factorial interactions by applying range levels statistically. To obtain the optimal operating conditions for decolorization, the influencing process parameters were optimized further by applying Response Surface Methodology based on Box-Behnken Design. A three level four factor design was generated using the Design Expert software version 8.0.7.1. A quadratic model was fitted for the experimental data obtained, and the significance of the model predicted was analyzed through Analysis of Variance (ANOVA) at the 95 % confidence interval. The determination coefficient, R², of the model was found to be 0.8993. The optimal process conditions were found to be a temperature of 30 °C, a dye concentration of 200 mg/l, an incubation time of 60 min, and an enzyme concentration of 26.69 U/ml, producing 30.07 % decolorization at an optimum pH of 7, which is in accordance with the predicted value of 29.24 %. Confirmatory experiments verified the adequacy of the model. The study provides a foundation for further research on enzyme based decolourization of safranin.