key: cord-0016152-ehahb030
authors: nan
title: 61st Annual Conference of Indian Society of Gastroenterology, Virtual Diamond Jubilee ISGCON 2020, 19-20th December 2020
date: 2021-03-19
journal: Indian J Gastroenterol
DOI: 10.1007/s12664-020-01133-9
sha: 8378add00b4af1f960b6543254dda5953b9e0229
doc_id: 16152
cord_uid: ehahb030

nan

Introduction Temporal shifts have been known to occur in antibiotic sensitivity patterns of organisms causing cholangitis. This study was conducted to study the common microorganisms cultured from bile during endoscopic retrograde cholangiography and their local sensitivity pattern. Methods This was a prospective study conducted between January 2016 and November 2017. Patients with extrahepatic biliary obstruction undergoing endoscopic retrograde cholangiography were included in the study. Bile was aspirated aseptically during endoscopic retrograde cholangiography and aspirated bile was transported to microbiology laboratory under all aseptic precautions. Bacteria were cultured, identified and antimicrobial susceptibility testing was performed by broth micro dilution method. Results Hundred patients (48% males, mean age 53.53±14.65 years) were included. Sixty-six patients had growth in bile culture, out of which 9 patients had dual growth and thus a total of 75 microbial growths were obtained. The maximum growths amongst all micro-organisms were of Escherichia coli (40.9%) and pseudomonas aeruginosa (40.9%). With regard to bacterobilia, there was no significant difference between patients with cholangitis and without cholangitis (61.36% vs. 69.64%, p = 0.288), patients who had underwent previous endoscopic retrograde cholangiography with stenting and those who had not undergone the same previously (60% vs. 67%, p=0.301), patients who were empirically administered antibiotics before intervention and not administered (67.92% vs. 63.83%, p = 0.599). Growth rates were significantly higher in patients with non-malignant causes of biliary obstruction vs. those with malignant causes (70.76% vs. 57.14%, p=0.03). Polymixins had the highest sensitivity to cultured bacteria followed by aminoglycosides and Imipenem. Conclusion Gram negative bacteria like Escherichia coli and Pseudomonas aeruginosa were the most common isolates from bile. Empirical antibiotic therapy in patients with cholangitis should be based on local sensitivity patterns.

Introduction Gluten intolerance or celiac disease is the most common genetically related food intolerance, worldwide. Celiac disease (CeD) is T-cell mediated small intestinal inflammation trigger by wheat gluten protein in genetically susceptible individual who carry HLA-DQ2/8 risk alleles. Lifelong elimination of gluten from diet is very challenging due to many reasons including availability of good quality gluten-free food items, cost, palatability. Thus, gluten and its's immunogenic peptides degradation approach is considered to be a novel therapy for CeD. Researchers have made adequate efforts for isolation of gluten-degrading bacteria (GDB) from human body and other environment. Oral supplementation of GDB and gluten digesting enzyme is emerging therapeutic approach for the CeD. Method Gluten agar plates assay for screening of gluten-degrading bacteria. Illumina Miseq was applied for whole genome sequencing of bacteria. Results Aerobic and facultative anerobic bacteria were isolated from human small intestine with gluten-degrading activity. Indeed, 70 bacterial strains belonging to 35 bacterial species were isolated; 12 strains were able to show gluten-degrading activity on gluten plates. Moreover, proline-glutamine specific endopeptidase genes were confirmed in gluten-degrading bacteria by whole genome sequencing approach. Additionally, a docking model was proposed of representative gliadin substrate in active side of endopeptidase enzyme. We cultivated and sequenced new gluten-degrading microorganisms from the human small intestine. Conclusion Study suggests that these bacteria or their gluten-degrading enzymes can be explored further for their application in treatment of celiac disease. Keywords Celiac disease, Gluten-degrading bacteria, Endopeptidase, HLA-DQ 2/8 008 HSP70 modulates immune response in pancreatic cancer through dendritic cells Background and Aim Gastroesophageal reflux disease (GERD) is common after per-oral endoscopic myotomy (POEM). Selective sparing of oblique fibers during POEM may reduce the incidence of reflux esophagitis after POEM. In this study, we aim to compare the incidence of GERD between conventional (CM) vs. oblique fiber sparing (OFS) techniques of endoscopic myotomy in cases with type I and II idiopathic achalasia. Methods Eligible patients with type I and II achalasia who underwent POEM from January 2020 to April 2020 were randomized into two groups (CM and OFS). Exclusion criteria were: type III achalasia, sigmoid esophagus and history of Heller's myotomy with fundoplication. The primary outcome of the study was comparison of reflux esophagitis at two months in the two groups. The secondary aims included reflux symptoms, esophageal acid exposure, and clinical success. Results Sixty patients were randomized in CM (30) and OFS (30) groups. Both the groups were similar with regards to the symptom scores, subtypes of achalasia and history of previous treatment. The mean operation time was similar in both the groups (CM 42.21±13.17 mins vs. OFS 48 ±29.12 mins). Mean length of total myotomies were comparable in the two groups (9.57±3.25 cm vs. 9.43 ±3.15 cm). Clinical success (Eckardt ≤3) was recorded in all the patients. Overall, reflux esophagitis was found in 30 (51.7%) patients. Grade B or higher esophagitis was similar in the two groups (34.6% vs. 41.4%, p=0.782). Symptoms of GERD were more frequent in the conventional group (35.7% vs. 16.7%, p=0.570). The mean number of reflux episodes (57.42±39.94 vs. 56.41±43.70), proportion of patients with increased esophageal acid exposure >6% (41.6% vs. 33.2%, p=0.574) and DeMeester scores (>14.7) (41.6% vs. 33.2%, p=0.574) were similar in both the groups. Conclusion Sparing of sling fibers has no significant impact on the incidence of GERD after POEM. (NCT04229342).

Combination of intravenous antibiotics in acute severe ulcerative colitis: A placebo controlled randomized trial Background Proton pump inhibitors (PPI) are commonly used drugs in management of reflux symptoms. These drugs are frequently abused and have side effects on long-term use. Aim To determine the feasibility of de prescription of PPI in patients with typical reflux symptoms in Indian setting. Moreover, symptom resolution and PPI requirement were assessed in patients with erosive and nonerosive reflux disease (NERD) . Methods This retrospective study recruited all patients, >18 years, with heartburn and/or regurgitation. Severity of reflux was assessed white light endoscopy and graded as per Los Angeles classification. All patients were advised lifestyle changes, aerobic exercises for > 30 min/day and dietary interventions. Follow-up details, including symptom resolution and drug requirement, were noted at 3 months after initial visit. Results A total of 106 patients formed the study cohort. Nearly three fifths of the cases were males and median age was 43 years. Reflux esophagitis was noted in 30% of cases. Of these patients, 25% had grade A esophagitis and the remaining had grade B or beyond. Three fourths of the patients were prescribed once a day dose of PPI. On follow-up at 3 months, PPI therapy could be stopped completely in 58 (54.7%) cases. Thirty-two (30.2%) and 16 (15.1%) patients were on on-demand PPI and continuous low dose therapy, respectively. Significantly higher proportion of patients with reflux esophagitis could stop PPI at the end of three months. The need for on demand PPI and continuous low dose therapy was higher in patients with NERD. Conclusion De prescription of PPI is attained in nearly 85% of patients at 3 months. PPI are effective in symptom resolution, more so in patients with erosive esophagitis.

Nutritional assessment and factors affecting dietary intake in patients with cirrhosis: A single center observational study Introduction Patients with suspected malignant biliary strictures frequently undergo endoscopic retrograde cholangiopancreatography (ERCP) based brush cytology and endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) for establishing the diagnosis. The outcomes of these tests aid in further management of the patient. A comparison of these two modalities in establishing the diagnosis is seldom reported. Aims To compare the diagnostic efficacy of ERCP based brush cytology and EUS FNA for tissue diagnosis in malignant biliary obstruction. It was obtained by performing a retrospective audit of all patients admitted in Vydehi Institute of Medical Sciences and Research Centre for EUS and ERCP from 2015-2019. Method Data were collected from 1 January 2015 to 31 December 2019. Majority of the patients were in the 5th decade with a slight female predominance. Most common CT finding was periampullary mass with 59.7% of the having common bile duct stricture. EUS-FNA was more sensitive than ERCP based tissue sampling. The overall sensitivity was 90.63% for EUS-FNA and 65.63% for ERCP sampling. EUS-FNA was found to have diagnostic accuracy of 92.63% in comparison to 71.43% for brush cytology.

Conclusions EUS -FNA is found to be superior to ERCP based tissue sampling with excellent sensitivity and diagnostic accuracy. Performing EUS before ERCP in all the patients with suspected malignant biliary obstruction would definitely improve the diagnostic accuracy and thereby help in the management of such cases.

Introduction Endoscopic variceal ligation (EVL) for high-grade varices (HGV) has reduced the morbidity and mortality of variceal bleed. Relook endoscopy is recommended after 2 weeks to confirm the eradication of varices. We tried to look at the changes in shear wave elastography (SWE) of spleen and liver following EVL and to identify the predictors for the eradication of varices at relook endoscopy. Methods Prospective observational study conducted in a university hospital in south India over one year. Cirrhotic patients undergoing EVL for primary prophylaxis (PP) and secondary prophylaxis (SP) with multiband ligator were included. Spleen stiffness (SS) and liver stiffness (LS) were measured by 2dSWE using Supersonic Aixplorer, before and 1-hour post banding. Endoscopy was repeated along with SWE of spleen and liver at 2 weeks. Results One hundred and fifty patients, 75 undergoing PP and 75 SP, were included. The Child status distribution was A: B: C = 40%: 44%: 16%. Splenic volume increased following variceal ligation in patients with CHILD C disease but difference was not significant. Mean increase in splenic volume in CHILD C was 177 cm3. Relook endoscopy showed HGV in 75 patients (42 -SP, 33 -PP). In the PP group, predictors of HGV were high baseline SS, increased serum creatinine and serial increase in LS at 2 weeks post EVL. ROC curve plotted for the new score (SLC score) devised using the above 3 parameters had an accuracy of 87% (p-value 0.001). In the SP subgroup, only ascites proved significant on regression analysis. Conclusion Variceal banding causes an increase in splenic volume and liver stiffness in patients with severe liver disease. Relook endoscopy after EVL may be avoided in patients undergoing EVL for primary prophylaxis using SWE of liver and spleen, and serum creatinine before banding. Using this score, we would be able to avoid 53% of unwanted endoscopies.

Real-world re-treatment outcomes of direct-acting antiviral therapy failure in patients with chronic hepatitis C Introduction Periampullary tumor is a clinical condition often encountered by gastroenterologist. There is limited data regarding clinical profile and endoscopic management of patients with periampullary tumor. Methods We retrospectively analyzed the ERCP (endoscopic retrograde cholangiopancreatography) records of periampullary tumor patients who were referred to Department of Gastroenterology for ERCP over a period of three years from January 2015 to January 2018. Demographic profile, clinical findings and ERCP management were taken into consideration. Statistics used were mean and standard deviation for continuous variables, frequencies and percentages were calculated for categorical variables were determined. Results We retrospectively analyzed 86 patients who had undergone ERCP for periampullary tumors from January 2015 to January 2018. Data interpretation revealed that majority of the cases were between 41 to 50 years (23.6%). There was a male preponderance (66.3%) . Maximum number of cases were of ampullary growth (46.5%), followed by lower CBD stricture (32.6%). The predominant presenting symptom was jaundice (77.9%), followed by abdominal pain (54.6%). Twelve patients (14%) had cholangitis at presentation. Mean bilirubin in the current study ranged from 11.76 to 23.72. CBD cannulation was achieved in 98.8% cases (selective cannulation 65.1%, pre-cut sphincterotomy 33.7%). Biliary drainage was done using plastic biliary stent (PC) in 84.7% and SEMS (self-expandable metallic stent) in 15.2% cases. Ampullary growth biopsy and biliary brush cytology revealed malignancy in 55% and 35.7% cases respectively. At 3 months, 4 patients with PC stent developed block. Conclusion In our study, ampullary growth was the most common type of periampullary tumor. Cholangitis was present in 14% cases at presentation. ERCP had good success for biliary drainage. Ampullary growth biopsy and biliary brush cytology has sensitivity rate of 50% and 35.7% respectively. Rate of PC stent block was low (< 5%).

Introduction Majority of patients with complicated CD including B2 and B3 require surgery and biologicals which have considerable morbidity and side effects. Hyperbaric oxygen therapy (HBOT) can alleviate the hypoxia driving chronic inflammation in CD. It has shown a beneficial effect in ASUC and perianal fistulising CD. Aim To assess the efficacy and tolerability of HBOT in small bowel B2 and B3 CD. Methods Selected patients of small bowel B2 and B3 active CD who were refractory to medical treatment were subjected to HBOT. Clinical disease activity was assessed using CDAI, patient-reported outcomes by SIBD questionnaire, baseline Hb, Alb and imaging findings (CTE or MRE) were noted. Patients were subjected to sessions of HBOT. Follow-up done at 2 months and 6 months by CDAI, SIBD questionnaire, MRE at 6 months. Results Fourteen patients (mean age 42.9 ± 15.67 years, 7 [50% males]) were subjected to HBOT. Thirteen (92.7%) patients had B2 and 1 had B3 phenotype. Mean CDAI at baseline 252 . Median sessions of , extended over an average of 4 weeks with duration of each session lasted for 60 mins with a pressure of 1.5-2.5 atm. One patient had hemotympanum. At 2 months of follow-up, 9 (64.2%) patients had a clinical response (reduction in CDAI >100), 7 (50%) had clinical remission, 8 (57.1%) had a steroid-free response. At 6 months of follow-up, 9 (64.2%) patients had clinical remission, 8 (57.1%) maintained steroid-free response. On MRE pre and post HBOT of patients having clinical response, 4 (50%) had no worsening, 2 (25%) had subtle improvement in enhancement scores and 2 (25%) had worsened. Significant improvement in SIBD scores at 2 months (p=0.03) and 6 months (p=0.07). Conclusion HBOT is effective and well-tolerated therapy in patients of B2 CD. Long-term follow-up needed in these patients whether HBOT can maintain this response.

Efficacy of antioxidants in relieving pain in chronic pancreatitis in children: A prospective observational study Introduction Early-stage diagnosis of pancreatic ductal adenocarcinoma (PDAC) is difficult due to non-specific symptoms. Circulating miRNAs in body fluids have been emerging as potential non-invasive biomarkers for diagnosis of many cancers. Thus, this study aimed to assess a panel of miRNAs for their ability to differentiate PDAC from chronic pancreatitis (CP), a benign inflammatory condition of the pancreas. Methods Next-generation sequencing was performed to identify miRNAs present in 60 FFPE tissue samples (27 PDAC, 23 CP and 10 normal pancreatic tissues). Four up-regulated miRNAs (miR-215-5p, miR-122-5p, miR-192-5p , and miR-181a-2-3p) and four down-regulated miRNAs (miR-30b-5p, miR-216b-5p, miR-320b, and miR-214-5p) in PDAC compared to CP were selected based on next-generation sequencing results. The levels of these 8 differentially expressed miRNAs were measured by qRT-PCR in 125 serum samples (50 PDAC, 50 CP, and 25 healthy controls [HC] ).

The results showed significant upregulation of miR-215-5p, miR-122-5p, and miR-192-5p in PDAC serum samples. In contrast, levels of miR-30b-5p and miR-320b were significantly lower in PDAC as compared to CP and HC. ROC analysis showed that these 5 miRNAs can distinguish PDAC from both CP and HC. Hence, this panel Aim Most research on human microbiota are done with molecular tools. Very few studies attempt to physically isolate gut bacteria due to various difficulties involved. Many studies use stool samples which provide only the transient passengers of the gut. Tissue samples (over stool samples) provide better expression of autochthonous gut bacterial population. This research focuses on challenges involved in isolation of "autochthonous" gut bacteria and how dietary constituents may influence their properties. Methods and Results Biopsy samples were collected from ileum and cecum of healthy volunteers who underwent routine colonoscopy. Pediococcus pentosaceus I44, isolated from ileum, was studied for acid and bile tolerance and surface properties. It was unable to survive in acidic conditions (pH 2 and pH 3) but could grow well in pH 6.5-8.0. It could withstand high bile stress of 0.5% w/v and 1% w/v for 24h. The cell surface was hydrophilic and showed good aggregation of 87%. The effect of tween-80, oleic acid, olive oil and sesame oil on properties of P. pentosaceus I44 was analyzed. These factors did not improve the acid tolerance. Tween-80 and oleic acid facilitated the growth of organism under bile stress. Conclusion P. pentosaceus I44 is a permanent inhabitant of gut and is deposited at National Centre for Microbial Resource, Pune. To our knowledge this is the first study on laboratory culturing of gut bacteria in Indian population. It is increasingly evident that dietary habits govern the gut microbiota, and hence what may benefit one ethnic human population may not be of use to another. Hence this study strives to provide the groundwork for the emerging concept of "personalized probiotics". Keywords Autochthonous, Biopsy, Pediococcus pentosaceus, Gut microbiota Esophagus 037 A rare cause of dysphagia post living donor liver transplantation in a child Introduction Post-transplant lymphoproliferative disorders (PTLD) is a life threatening disorder of the immunosuppressed state in transplanted patients. Common sites include lymph nodes, gastrointestinal tract and airways. Case A 12-year-old boy underwent a living donor liver transplantation for Budd-Chiari syndrome. Eighteen months later, he presented with progressive dysphagia. He was on Tacrolimus and Azathioprine with normal counts and liver function and a trough tacrolimus level of 10 ng/mL. His EGD scopy revealed two deep ulcers with overhanging edges in mid esophagus. Histopathology showed atypical small to medium sized lymphoid infiltrate in the esophageal mucosa, expressing CD79a, CD138 and MUM-1, EBERsBY ISH. He was immunonegative for CD20, CD3 CD5, Pax-5, CD2, CD7, CD4, CD8, CD30 and ALK-1. No light chain restriction was seen. Mib-1 proliferation index was 60% suggestive of polymorphic PTLD. PET-CT was unremarkable. EBV viral load was 12,50,00 copies/mL. Azathioprine was omitted and tacrolimus was reduced to maintain a trough level of 2-3 ng/mL. There was complete resolution of dysphagia and an endoscopy after 3 months showed complete healing of ulcers with mild hypertrophied mucosa with no evidence of any residual PTLD on histology. Currently he is well with normal liver function and an undetectable EBV infection. EBV-infected B cells cannot be controlled by EBV-specific cytotoxic T cells. Restoring recipient immunity helps control of EBV driven lymphoproliferation. Ours being the only one in a post liver transplant setting. Ours is the first esophageal PTLD reported in a post liver transplant setting; other being a renal transplant recipient treated with rituximab. Conclusion Esophageal PTLD should be considered in the DD of dysphagia in the post-transplant setting.

Introduction Esophageal stricture dilatation is a therapeutic procedure for the management of dysphagia secondary to structural or neuromuscular disorders of the esophagus that offers the benefits of temporary or permanent relief of dysphagia, with an improved quality of life and sometimes avoidance of surgery. Benign causes include peptic stricture, Schatzki's ring, esophageal web, corrosive ingestion, post-radiotherapy or post-surgical strictures. Malignant causes include adenocarcinoma, squamous cell carcinoma, pseudo-achalasia and metastases. In this study, we aimed to investigate the effectiveness of dilatation with Savary-Gilliard dilators (SGD) with respect to etiology. Methods We retrospectively analyzed the cases treated with esophageal dilatation with SGD in the Department of Gastroenterology at Sri Aurobindo Institute of Medical Sciences from January 2014 to August 2020. All the demographic and clinical data was recorded as well as endoscopic dilatation count and complications. Results A total of 108 patients (52 [48.14%] males and 56 [51.85%] females) were included in the study with mean age of 52.4±14.7 (17-80) years. A total of 1025 dilatations of 108 patients were done in 225 sessions. The most commonly seen etiologies were postradiotherapy strictures (n=46, 42.59%), peptic strictures (n=23, 21.29%), corrosive strictures (n=21, 19.44%) and esophageal web (n=11, 10.18%). Mean dilatation session count was 4.5 (1-10) in patients with post-radiotherapy strictures, 3.2 (1-8) in corrosive strictures, 2.1 (1-8) in peptic strictures, 1.3 (1-3) in esophageal web No major complications such as perforation, major bleeding were observed. Conclusion SGD for the treatment of esophageal strictures is a relatively safe, cheap, easily performed method. While esophageal web is usually treated in a single session, repeated endoscopic dilation sessions are required for the strictures caused by radiotherapy and corrosive ingestion as majority of them are long and complex strictures. laparoscopic Heller's cardiomyotomy. However, the optimal approach is still a matter of debate. Objectives To compare the clinical outcomes and overall quality of life in achalasia cardia patients undergoing pneumatic dilatation (PD) and laparoscopic Heller's cardiomyotomy (LH) . Methods A total of 30 patients with achalasia cardia were divided into two groups using computer-generated randomization in this prospective study conducted from July 2017 to July 2019 at Institute of Medical Sciences, Banaras Hindu University. The diagnosis was confirmed by timed barium swallow study/esophagoscopy and high-resolution manometry. Preprocedure data regarding demography, symptom duration and severity, and manometric pressure was collected. Group 1 and 2 underwent PD and LH respectively. The post-procedure evaluation was done on the basis of Eckardt score, manometric data and quality of life based on SF-36 questionnaire at 1 week and 3 months. Statistical analysis was done using SPSS 16.0 software. Results Both the study groups were similar. The mean age was 40.70 ± 13.42 in the PD group and 39.70 ± 9.71 in the LH group. The symptom severity as evaluated by Eckardt score was less in the PD group initially but at 3 months LH group had fewer scores (p<0.01). The decrease in lower esophageal sphincter pressure (PD: 9.20 ± 3.75, LH: 1.79 ± 8.98), integrated relaxation pressure and distal contractile integral was more in the LH group (p<0.01). Role limitation due to physical functioning and emotional problems were comparable in both groups. However, physical function, energy, general health, mental health, emotional well-being and social functioning were better in the LH group at 3 months (p<0.01). Conclusion Laparoscopic Heller's cardiomyotomy is a better treatment option with comparable safety as pneumatic dilatation.

Efficacy of POEM for achalasia cardia in a tertiary care center of Odisha Introduction Per oral endoscopic myotomy (POEM) is a highly effective and safe technique for treatment of achalasia cardia and has received worldwide acceptance for its promising results. The aim of this study is to evaluate the efficacy of POEM technique in patients with achalasia cardia. Methods Patients of achalasia cardia treated by POEM between January 2018 to March 2019 were retrospectively analyzed. These patients were followed up for a period of 1 year. All the patients had undergone timed barium swallow and high-resolution esophageal manometry before and after procedure. The outcomes of POEM procedures including Eckardt score, and occurrence of gastroesophageal reflux disease (GERD) and periprocedural complications were compared. Results A total 42 patients were performed POEM for achalasia cardia (Type I-9%, Type II-91%). POEM was successfully completed in all patients. Mean age was 37.12 ± 12.34 years, with males constitute 68% of all cases. Median duration of disease was 3 years. Dysphagia (81%), chest pain (62%), regurgitation (50%) were presenting symptoms, and mean pre-POEM Eckardt score was 8.51 ± 1.68 and mean post POEM Eckardt score was 1.63 ± 0.55 (p<0.001). The mean lower esophageal pressure before and after POEM procedure were 39.58 ± 7.82 and 15.86 ± 6.98 respectively (p<0.001). Technical success was 100 % and clinical success, defined as Eckardt score ≤?3 after POEM procedure, was achieved in 40 (95.2%) patients. Nine (21.4%) patients developed GERD, as documented by 24-hour pH-impedance study.

Conclusion POEM is a very effective, safe technique, and should be undertaken as a first treatment option in patients with achalasia cardia.

Esophageal stricture dilatation with Savary-Gilliard dilators-Etiological spectrum and response to treatment, a single centre experience from Central India Introduction Esophageal stricture dilatation is a therapeutic procedure for the management of dysphagia secondary to structural or neuromuscular disorders of the esophagus that offers the benefits of temporary or permanent relief of dysphagia, with an improved quality of life and sometimes avoidance of surgery. Benign causes include peptic stricture, Schatzki's ring, esophageal web, corrosive ingestion, post-radiotherapy or post-surgical strictures. Malignant causes include adenocarcinoma, squamous cell carcinoma, pseudoachalasia and metastases. In this study, we aimed to investigate the effectiveness of dilatation with Savary-Gilliard dilators (SGD) with respect to etiology. Methods We retrospectively analyzed the cases treated with esophageal dilatation with SGD in the Department of Gastroenterology at Sri Aurobindo Institute of Medical Sciences from January 2014 to August 2020. All the demographic and clinical data was recorded as well as endoscopic dilatation count and complications. Results A total of 108 patients (52 [48.14%] males and 56 [51.85%] females) were included in the study with mean age of 52.4±14.7 (17-80) years. A total of 1025 dilatations of 108 patients were done in 225 sessions. The most commonly seen etiologies were postradiotherapy strictures (n=46, 42.59%), peptic strictures (n=23, 21.29%), corrosive strictures (n=21, 19 .44%) and esophageal web (n=11, 10.18%). Mean dilatation session count was 4.5 (1-10) in patients with postradiotherapy strictures, 3.2 (1-8) in corrosive strictures, 2.1 (1-8) in peptic strictures, 1.3 (1-3) in esophageal web No major complications such as perforation, major bleeding were observed. Conclusion SGD for the treatment of esophageal strictures is a relatively safe, cheap, easily performed method. While esophageal web is usually treated in a single session, repeated endoscopic dilation sessions are required for the strictures caused by radiotherapy and corrosive ingestion as majority of them are long and complex strictures.

Fully covered stent in a case of endoleak for post aortic stenting in a case of primary aortoesphageal fistula Introduction Endoleak post aortic stenting for primary aortoesophageal fistula is a rare complication requiring reintervention, however with high risk of mortality. We hereby used a fully covered self-expanding covered esophageal metal stent (SEMS) in one such case to control the rebleeding. Case Seventy-eight-year-old gentleman with hypertension came with 2 episodes of hematemesis with hypotension, after resuscitation he underwent gastroscopy which showed a large non-occluding mass protruding from the posterior wall and occupying the esophageal lumen, biopsy taken which turned out to be inconclusive. CT scan thorax done S14 (December 2020) 39(Suppl 1):S1-S127 Indian J Gastroenterol showed a large aneurysm extending uptil the diaphragmatic opening and a large thrombus protruding into esophageal wall causing a large defect of 3.5 cm on the posteromedial wall in mid esophagus. Patient was immediately taken for aortic stenting which was successfully placed across the entire length of the aneurysm, patient was continued on ventilatory support overnight, however within 9 hours post-surgery patient had melena and a significant drop in hemoglobin. Patient underwent an urgent endoscopy which showed the clot at 20 cm insitu with active oozing of blood from the site, post-flushing the bleeding worsened and visibility reduced, hence initially a foleys balloon passed orally was inflated at 20 cm and a guidewire passed across into the gastric lumen and temporarily a rigiflex balloon placed along it, the bleeding was controlled for 24 hours, and patient underwent a CT scan which showed a type 2 endoleak. In view of high risk of surgery and no radiological intervention feasible we decided to use a covered esophageal stent for maintain hemostasis. Patient improved and was kept on RT feeds and was discharged after 7 days. Patient however readmitted and succumbed after 40 days due to persistent leak causing mediastinitis. Conclusion Fully covered SEMS can be used in endoleak management to control hemostasis.

Introduction Esophageal tuberculosis (ET) is rare in both immunocompetent and immunocompromised hosts with pulmonary tuberculosis, even in countries with high prevalence rates like India. Most reports of esophageal tuberculosis are secondary to direct extension from adjacent structures, such as mediastinal lymph nodes or pulmonary sites. Case Presentation We present two cases of esophageal tuberculosis in patients with initial complaints of dysphagia and epigastric pain, emphasizing the diversity of endoscopic presentation of TB. Upper gastrointestinal endoscopy was used in the diagnosis of esophageal tuberculosis following the biopsy of lesions of ulcerated mucosa in one case; other was based on confirming tuberculosis in adjacent strucrues. Pulmonary tuberculosis was detected in one patient. Anti-tuberculosis treatment (ATT) was curative in both patients. Conclusion Although rare ET has to be considered in the differential diagnosis of patients with dysphagia, especially in TB endemic areas, even in young immunocompetant patients. Detection of these cases by careful examination, biopsies and treatment with standard ATT appear effective. Keywords Esophageal tuberculosis, Dysphagia, Endoscopy, Pulmonary tuberculosis 044 Cerebellar metastasis as first presentation from undiagnosed esophageal carcinoma: A case report Introduction Esophageal strictures are a commonly encountered problem in daily practice and can occur from a variety of benign and malignant etiologies, which varies in developed and developing countries. This study was intended to describe the clinical profile of esophageal strictures and assess the outcome and complications associated with endoscopic dilatation. Methods A prospective study was conducted among 96 patients with esophageal stricture, attending Department of Gastroenterology in a tertiary care centre in Kerala from July 2019 to June 2020. The outcomes were to assess clinical and technical response to dilatation, procedure related complications and the factors predicting refractoriness to dilatation. Results Among the 96 patients studied, (M:F-1.46:1), mean age-54 years), corrosive and radiation induced strictures were the commonest contributing 20.8% each. Malignant, post-anastomotic, peptic, web and inflammatory strictures were 16.7%, 12.5%, 9.4%, 9.4% and 4.2% respectively. Esophageal dilatations were performed with bougie (91.5%), balloon or both with a clinical and technical success rates of 73% and 65%, and 22.9% remained refractory. Severe grades of dysphagia on presentation, poor nutritional status and long segment strictures involving multiple sites in corrosive induced and malignant strictures were found to predict refractoriness. A complication rate of 4.16% was noted during the periprocedural period. Conclusion Ingestion of corrosives and radiation therapy appear to be the most common causes of esophageal strictures. Endoscopic dilatation is usually successful and safe in achieving luminal patency, but corrosive and malignant strictures are mostly refractory, and the former tend to recur even after successful dilatation. of treatment refractory GERD helps in guiding the further course of treatment. We aim to study the physiological basis of patients with nonerosive refractory gastroesophageal reflux disease and classify these patients based on findings of high-resolution manometry (HRM) and 24hour ambulatory pH impedance monitoring. Methods This is a single centre prospective study from March 2019 to August 2020 in which clinical profile and data of HRM and pH impedance studies was analyzed in patients on PPI with refractory non erosive GERD. Refractory GERD was defined as persistence of heartburn or regurgitation at least once a week after receiving standard dose of PPI for at least 8 weeks. Patients on NSAIDs, pregnant females, patients with organic disease of the upper digestive tract or previous upper digestive tract surgery, significant comorbidities like decompensated chronic liver disease, chronic kidney disease, poorly controlled diabetes mellitus or any malignancy were excluded. Results One hundred and fifty-one patients with refractory GERD were analyzed of which, 48 had abnormal esophagogastroduodenoscopy and 103 were nonerosive GERD. Amongst, nonerosive disease, acid reflux disease was found in 29.1%, non-acidic reflux disease in 21.4%, 30.1% patients had reflux hypersensitivity whereas, 19.4% patients had functional heartburn. On HRM, 8.74% had esophageal motility disorders, most commonly being IEM in 5.82% patients followed by esophagogastric junction (EGJ) obstruction in 1.94% and absent contractility in 0.97%. 25.2% had hiatus hernia; 20.4% patients had type II EGJ morphology, 2.9% had type IIIa and 1.9% had type IIIb EGJ morphology. Conclusion True acid reflux disease was found in less than 1/3rd refractory non erosive GERD patients only and around 50% patients had functional esophageal disorder as found on pH impedance studies. Majority patients have normal esophageal motility but 1/4th have abnormal EGJ morphology. Keywords Refractory NERD, pH impedance studies, High resolution Background Perforation of esophagus secondary to bursting of tubercular mediastinal lymph nodes, presenting with hematemesis rare. Commonest site is mid-esophagus, due to proximity to mediastinal lymph nodes. Case A 50-year-old male, diagnosed case of sputum positive pulmonary tuberculosis, on first line ATT x 2 months, presented with multiple episode of massive hematemesis X 2 days. Clinical examination revealed mildgrade fever, tachycardia and tachypnoea. His hemoglobin was 5 gm%, managed by multiple units of blood transfusion. Patient shifted to ICU for close monitoring and intensive care. After stabilization endoscopy done which showed lymph node eroding in the esophagus at 30 cm from incisors with suspected bronchoesophageal fistula without active bleeding at eroded site. CECT chest showed enlarged subcarinal nodes with bronchoesophageal fistula. Bronchoscopy conformed bronchoesophageal fistula. He had another episode of hematemesis on next day so repeat endoscopy was done which showed there was active oozing through eroded site on which OTSC applied. He responded well to endotherapy and was discharged in stable condition on ATT. After one month, he again had hematemesis, endoscopy showed a small bleeding vessel at previously clipped site, another clip tried but not succussed. His CT angiography chest showed right bronchial artery pseudoaneurysm measuring 1.1 cm x 0.7 cm. Urgent interventional radiology team called and he underwent angiographic embolization of pseudoaneurysm. He responded well to the given treatment. Follow-up endoscopy showed no bleeding and clip in position. He was discharged in stable condition on ATT. He is doing well on 4 months follow-up without any further bleed. Conclusion It is important to consider esophageal perforation due to mediastinal lymph nodes in endemic areas of tuberculosis; the patient can be managed by simple clipping with anti-tubercular drug therapy and without removing the esophagus. Keywords Hematemesis, Tubercular lymphadenopathy, Perforation, OTSC clipping, Embolization 048

Ten-year study on management of corrosive esophageal stricture Neeraj Nagaich 1 , Radha Sharma 2 Correspondence-Neeraj Nagaich-drneerajn@gmail.com 1 Department of Gastroenterology, Fortis Hospital, Jawahar Lal Nehru Marg, Malviya Nagar, Jaipur 302 017, India, and 2 RUHS College of Medical Sciences, Kumbha Marg, Sector 11 Road, Pratap Nagar, Jaipur 302 033, India

Objective Analysis of outcome and safety of esophageal dilatation in caustic esophageal strictures. Methods This prospective and retrospective study was conducted to evaluate the safety and efficacy of endoscopic dilatation in corrosive esophageal stricture. All eligible patients with caustic esophageal strictures presenting between 2010 to 2020 and above 03 years of age were included. Patient with caustic stricture and fistulae or diverticulae, peptic stricture and malignant stricture were excluded. Barium swallow and meal was done if required Savary-Gilliard plastic dilators of increasing sizing were employed. Repeated sessions were performed fortnightly till a 15 mm (45 Fr) lumen size was achieved. Follow-up session were arranged whenever dysphagia developed after completing initial session of adequate dilatation. In patients with refractory stricture injection triamcinolone or topical mitomycin C application was done during dilatation session. Results Out of 320 patients, 192 patients (60%) were more than 12 years of age. Mean age is 20.25 ranging from 5 years to 64 years. There were 185 males (58%) and 135 females (42%). Total dilatations were 4822. Successful dilatation up to a lumen size of 15 mm could be achieved in 211 patients (66%) . In 48 patients (15%) with refractory stricture application of triamcinolone or mitomycin C lead to success. In 108 patients (34%) satisfactory dilatation could not be achieved and were referred for surgery. Nine patients (2.8%) had perforation with an incidence rate of 0.30%. Conclusion Caustic stricture is more common in adolescent and adults in our population. Endoscopic dilatation of esophageal strictures is a relatively safe procedure with good results and low rate of complications. Resection with esophagogastric anastomosis or colonic interposition is required in severe cases. Injection Triamcinolone and topical Mitomycin are safe and effective adjuvants in refractory stricture. Keywords Corrosive, Stricture Introduction H. pylori is world's most common bacterial infection affecting majority of population. Its incidence ranges between 7% to 97% in developed vs. less developed areas. Since incidence in our country is high eradication of the bacteria is necessary to prevent health disability due to its complications. The present study was undertaken to know the incidence and response to treatment. Methods Patients of different age groups and of either sexes presenting with symptoms of epigastric pain related to food of variable duration, from 2 weeks and above with no comorbidity were included in the study. All patients underwent UGIE, RUT, US abdomen and CBP, stool for occult blood. Those patients positive for H. pylori were given triple drug regimen of amoxycillin (750 mg BD), clarithromycin (500 mg BD) with esomeprazole 40 mg BD for 10 days with food precautions. After 10 days of treatment UGIE was repeated with RUT to know the clearance of H. pylori. Patients still positive were given tinidazole (500 mg 2 tablets OD), azithromycin (1 tablet OD) and rabeprazole 40 mg BD for a period of 10 days and subsequently underwent UGIE with RUT to know the response. Results Fifty patients of age groups 11-70 years were included in the study. Seventy-six percent of patients responded to the first line of treatment. Non responders were given second line of treatment who responded completely (100%). After treatment all were asymptomatic. Discussion H. pylori infection which is a worldwide problem can be corrected by good food habits, good sanitation, avoiding specific uncooked, unhygienic preserved food and water. Conclusion Screening of patients of APD is the first step followed by eradication with specific drug regimen to clear the infection and bringing good health in the community.

Is use of proton pump inhibitors associated with renal dysfunction? A prospective cohort study Introduction Long-term use of proton pump inhibitors (PPI) has been linked with infrequent but serious adverse events, including acute kidney injury (AKI), chronic kidney disease (CKD), and progression of CKD. Objective To determine whether use of PPI is associated with any shortor long-term renal dysfunction. Methods Patients taking PPI for 6 weeks had serum creatinine tested pre and post treatment; those with baseline eGFR <90 mL/min/1.73m2 were excluded. Patients taking PPI for at least 90 days in the next 6 months, and at least another 90 days in further 6 months, had serum creatinine tested at such follow-up. Renal dysfunction was classified as per the KDIGO criteria for AKI. Results At baseline, a majority of patients were aged 21-40 y (median 39; IQR 31-47); 98 (49%) had history of previous PPI use (median 6 mo; IQR 3-24). Serum creatinine was tested at baseline, 6 weeks, 6 mo and 1 y in 200, 180, 77 and 50 patients, respectively. Corresponding creatinine mean (SD) values were: 0.76 (0.14), 0.69 (0.16), 0.71 (0.15) and 0.76 (0.16) mg/dL. Although there was statistically significant difference (p<0.05) in creatinine at 6 weeks and 6 mo as compared to baseline, the difference was not clinically significant. Increase in creatinine was noted in 20 (11.1%), 11 (14.3%) and 6 (12%) patients at 6 weeks, 6 mo and 1 y, respectively; 14, 8 and 4 of these had less than Stage 1 dysfunction (i.e. less than 0.3 mg/dL increase), and 10, 5 and 5 had other risk factors for renal dysfunction. No patient developed CKD during the study period.

Conclusion Increase in serum creatinine occurred in 10% to 15% of patients on PPI but was mild (KDIGO Stage 1 or less) in a majority and not progressive. A majority of them had other risk factors for renal dysfunction.

Introduction There has been a tendency in recent years to delay endoscopy in dyspeptic patients younger than 45 years with no so-called "alarm symptoms." This study was conducted to test whether this policy might lead to an increased rate of delayed diagnosis of gastric cancer. Method A prospective study was carried out on dyspeptic patients < or = 45 years of age in our hospital from October 2019 to July 2020. Characteristics analyzed included duration and features of dyspeptic symptoms, presence of alarm symptoms, time interval from the onset of symptoms to diagnosis and pathological characteristics. Results In the study group we found 30 patients had gastric cancer (17 females, 13 males). Six patients (20%) presented with uncomplicated dyspepsia and 24 patients with (80%) alarm symptoms (persistent vomiting, anemia, weight loss, dysphagia). None had positive family history. In those with uncomplicated dyspepsia epigastric pain was the most common complaint (64.1%) followed by vomiting (30.4%). Weight loss was the most common alarm symptom (53.3%), followed by anemia (46.6%). Of the 6 patients without alarm features 3 were having adenocarcinoma, 2 lymphoma, 1 signetring cell carcinoma. Conclusion Significant proportion of young (<=45 yrs) gastric cancer patients present without alarm symptoms. We need to review the existing standard age criteria (>45 yrs) for endoscopy in dyspepsia without alarm features particularly in high gastric cancer prevalence areas.

Introduction Breast cancer accounts for 29% of newly diagnosed cancer in women and frequently, it metastasizes to liver, lungs, bones or brain and rarely is reported to metastasize to stomach. We report a rare case of Ca breast metastasizing to the stomach 12 years after the first diagnosis. Case Report Seventy-six-year-old female presented with pain in left hypochondriac region and backache which was continuous and dull aching without any radiation or aggravating or relieving factor and with no history of fever, vomiting or cough. Twelve years back, she was diagnosed with right side breast invasive ductal carcinoma grade 3, underwent surgery and subsequently chemo and hormonal therapy. For her persistent abdominal pain, upper gastrointestinal endoscopy was done which was s/ o diffuse thickening of gastric folds with poor distensibility with multiple ulcers extending beyond pylorus, biopsies s/o poorly differentiated tumor and IHC was consistent with metastasis from primary breast invasive ductal carcinoma. Discussion A high index of suspicion is required for metastatic breast cancer when patient develops gastric symptoms with prior history of breast cancer. Due to non-specific symptoms of anorexia, dyspepsia, dysphagia, nausea, vomiting, early satiety, abdominal pain and bleeding, it is difficult to distinguish between primary gastric cancer and gastric metastases from breast cancer. Moreover, gastric metastases may develop after many years following the first diagnosis of breast cancer as seen in our patient. Combinations of endoscopic, radiological, histological and IHC examination is the only reliable method to distinguish between metastatic and primary gastric cancer and the optimal treatment is chemotherapy or hormonal therapy. Conclusion Gastric metastasis from breast cancer is rare and it requires complete diagnosis by endoscopic, radiological and histological examination with IHC to differentiate from primary gastric cancer and hormonal or chemotherapy is the mainstay treatment modality.

Introduction Gastric outlet obstruction (GOO) is a partial or complete mechanical obstruction at antrum-pyloric region or first and second segment of duodenum. Earlier benign causes of GOO were more common than malignant causes. Now, recent studies suggests that 50% to 80% of cases are attributable to an underlying malignancy, in developed and developing countries. Methods This prospective study was conducted at Gastroenterology Department of SMS Hospital, Jaipur, India between June 2017 to June 2020. Consecutive patients having symptoms, and endoscopic or radiological evidence of gastric outlet obstruction were included in this study. Results A total of 451(288 male/163 female) patients with GOO were included. 248/451 (54.9 %) patients had malignant etiology and 203/451 (45.1 %) had benign etiology. In females, malignant etiology was present in 74.8 % and benign etiology in 25.2 % patients. In males, malignant etiology was present in 43.7 % and benign etiology in 56.3% patients. In malignant GOO, common causes were gallbladder carcinoma in 95 (37.5%); gastric carcinoma in 48 (31.8%) and carcinoma head of pancreas (HOP) in 49 (19.6%) . Other causes were periampullary carcinoma in 9 (3.5%); cholangiocarcinoma in 10 (4%); Duodenal carcinoma in 4(1.6%); gastrointestinal lymphoma in 3 (1.2%) and neuroendocrine tumor and retroperitoneal sarcoma in 1 patient each. In benign GOO, common causes were opioid abuse in 59 (29%); peptic ulcer disease in 44 (21.6%) corrosive ingestion in 41 (20.2%) and chronic pancreatitis in Background Primary gastric lymphoma (PGL) is less commonly reported in India. Since gastric cancer is a relatively less common malignancy in northern India, the possibility of PGL being less common in this region can't be excluded. However, another possibility could be under-reporting due to lack of adequate diagnostic workup and awareness. Methods During a 12-y period (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) , data of gastric neoplasm in a teaching institute were retrospectively analyzed with the aim to know (i) the frequency of PGL among patients with gastric neoplasm, (ii) their demographic and clinical profile, and (iii) the diagnostic procedures needed for the diagnosis.

Results 30/324 (9.2%) patients (median age 56, range 25-72, 73.3% male) with gastric neoplasm had PGL. 40% of them had H. pylori infection (2/3 tests positive). Most presented with dyspepsia with or without weight loss (9, 30%); others presented with gastric outlet obstruction (n=7, 23.3%), upper gastrointestinal bleeding (n=5, 16.7%), dysphagia (n=4, 13.3%), malignant ascites (n=3, 10%) and other (n=2, 6.7%). In most (60%) diagnosis could be established on endoscopic biopsy while in 40%, surgical resection was required. The endoscopic and surgical diagnosis groups were comparable in age (53.4 vs. 52.7 years), sex (male 77.8% vs. 66.7%), H. pylori (38.9 vs. 16.7%), presentation with dyspepsia with or without weight loss (38.9 vs. 16.7%), presentation with organic symptoms (61.1 vs. 83.3%) and need for repeated endoscopic biopsies before conclusive diagnosis was established (12.5 vs. 33.3%). Conclusion The study demonstrates the comparatively high frequency of PGL in this population (9.2%) and confirms the intimate association of Introduction While celiac disease (CeD) is known to occur in many regions on the plane, there is a lack of data on its prevalence in high altitude area of India. Methods We screened serum samples of 332 participants of another population-based study in Lahaul and Spiti districts of (mean altitude >4000 meter) Himachal Pradesh, for estimation of prevalence of CeD in high altitude area. The screening of CeD was done using commercially available IgA human anti-tissue transglutaminase antibody (anti-tTG Ab). Results Of 332 samples (mean age 31.5±15.9) screened, two were found to have a positive anti-tTG Ab at low titre, suggesting a seroprevalence of 0.6%. Conclusions The seroprevalence of CeD in high altitude area is 0.6%, almost equal to the rest of the country. The physicians working in high altitude areas to be aware about CeD in their communities. Keywords Celiac disease, High altitude, Prevalence, Anti-tissue transglutaminase 059 Single balloon enteroscopy for small bowel evaluation in pediatric patients-A tertiary care experience utility of single balloon enteroscopy (SBE) in children with suspected small bowel diseases. Methods The data of all the children (≤ 18-years) who underwent SBE from November 2010 to July 2020, was analyzed retrospectively. The safety and diagnostic yield of SBE were assessed. Results One hundred and eighty-nine SBE procedures (males 117, mean age 15.1±2.76, range 3-18 years) were performed in 174 children. The most common indication for SBE was abdominal pain with or without additional symptoms in 119 (68.4%), followed by gastrointestinal bleed 17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%). Antegrade and retrograde enteroscopy procedures were performed in 98 (51.8%) and 77 (40.7%), respectively. Both (antegrade and retrograde) were performed in 7 (3.7%) cases. The mean length of small bowel intubation in antegrade and retrograde SBE groups were 168.9±58.6 cm and 120.7±52.1 cm, respectively. Overall, a positive finding was seen in 117 (67.2%) cases. The most common findings were ileal and jejunal ulcers with or without strictures found in 76 (64.9%). A final diagnosis could be established in 63.8% children. The diagnostic yield was higher in cases with additional symptoms besides pain abdomen as compared to pain abdomen alone (85.1% vs. 50%, p=0.001). A total of 17 therapeutic enteroscopic procedures were performed in 11 children including polypectomy in 7 children with Peutz-Jeghers syndrome and argon plasma coagulation therapy in 4 cases with vascular lesions. There were no major adverse events. Self-limiting bleeding not requiring blood transfusion was noticed in one patient after polypectomy. Conclusion SBE is a safe procedure for the evaluation of small bowel diseases in children and adolescents. SBE establishes a diagnosis in nearly two-thirds of the children.

Retrospective study of tissue transglutaminase antibody (ttgA) levels in celiac disease suspected patients at tertiary care hospital in Uttarakhand Background and Objective Celiac disease (CeD) is a chronic gastrointestinal disorder arising due to gluten sensitivity in susceptible individuals. In India, one person per 100 is suffering from this disease. CeD has been reported more in high wheat consuming areas like northern India. But the incidence of CeD in patients attending tertiary care hospital of Uttarakhand has not yet been reported. Therefore, this study was planned. Methods A retrospective study with 603 patients was done at AIIMS, Rishikesh in Biochemistry Department. These patients were screened for CeD by tissue transglutaminase antibodies (ttgA) levels using ELISA method. Percentage of levels of ttgA <4 U/mL (normal value) and >4 U/mL in male, female adults and children was calculated. Chisquare test was applied to compare results. Results Out of 603 patients, 23 (3.81%) had abnormally raised ttgA levels (>4 U/mL). Percentage (15.18%) of ttgA levels in male children was significantly (p=0.01) higher than 2.56 % in female children. Mean + SD of normal and abnormal ttgA levels in patients was 1.17 + 0.45 vs. 66.81+34.80 U/mL respectively. Mean+SD of abnormal ttgA levels in children and adults was 72.84+41.91 vs. 32.38+ 24.75 U/mL respectively. There was significant difference in abnormal ttgA levels among children and adults with children predominantly being higher (p value= 0.0235). Conclusion This study shows that the levels of ttgA suggestive of CeD in children is higher as compared to adults and more in males than females attending the tertiary care hospital of Uttarakhand.

Introduction Castleman disease, a variant of POEMS syndrome is a multisystem disorder of monoclonal plasma cell disorder. To reduce mortality and morbidity associated with POEMS syndrome proper diagnose and early treatment should be started. We report a case of POEMS syndrome who presented with diarrhea, skin hyperpigmentation, and edema and weight loss. Clinical presentation A 40-year-old male presented with chronic small bowel diarrhea, weight loss, swelling of feet, hyperpigmentation, and tingling sensation of both lower limbs. Examination revealed BMI of 15 kg/m 2 , pallor, papilledema, generalized lymphadenopathy, hyperpigmentation clubbing, hepatosplenomegaly, edema, decreased pain and temperature. Investigation showed anemia (Hb 10 gm%), thrombocytosis (6.5 lakh), raised ESR (42 mm in 1st hour), raised TSH (14 ng/mL). CECT revealed multiple sclerotic lesions, hepatosplenomegaly, and multiple subcentimetric lymphnodes. Lymph node biopsy showed reactive lymphadenitis with plasmacytosis and vascular proliferation. Gastric biopsy-pangastrtis with activity and lymphoid follicle formation and increased IEL. Bone marrow aspirate showed 7% plasma cells. NCVasymmetrical sensory motor demyelating polyneuropathy. Serum Introduction and Aims Acute mesentric ischemia (AMI) is a rare medical emergency and constitutes around 0.09% to 0.2% of all cases of acute abdomen. According to Western literature, AMI most commonly occurs in 7th-8th decade, with 50% mortality, and arterial occlusion being the most common cause. The clinical profile of patients of AMI in India may be different from Western patients, however, the data is lacking. We aimed to study clinical profile of patients of AMI at a tertiary care centre in northern India. Methods We retrospectively collected data of consecutive patients of AMI admitted our department from March 2015 to January 2019. Data regarding epidemiology, clinical presentation, etiology, imaging, treatment and outcome were studied. Results Our study included 59 patients (78% males, median age 47 years). The most common presentation was pain abdomen in 88%, obstipation 43%, gastrointestinal bleeding 17%, and peritonitis 0.5%. Mesenteric venous thrombosis was seen in 68% and mesenteric artery thrombosis in 32%. On imaging wall necrosis seen in 45 (65.2%) while additional 3 (4.34%) found during laparotomy. Most (68%) patients required surgical resection. The overall in-hospital mortality was 14%. Conclusions Unlike the Western literature, the AMI in North India is most commonly due to venous thrombosis, presenting in fifth decade, and has a lower mortality rate than West. Large prospective studies will be required to elucidate the cause of these differences from Western data.

Clinical outcomes in Crohn's patients newly initiated on azathioprine -A large single center cohort Alok Bansal, A J Joseph, Ebby George Simon, Amit Kumar Dutta, Sudipta Dhar Chowdhury, Reuben Thomas Kurien, Ratnaprabha Gupta Correspondence-A J Joseph-ajjoseph@cmcvellore.ac.in Department of Gastroenterology and Hepatology, Christian Medical College Hospital, Vellore 632 004, India

Background Azathioprine remain the first choice for maintenance therapy in Crohn's disease (CD) as biologicals are expensive. Response to treatment is commonly assessed by clinical and laboratory parameters rather than by endoscopy. The recent literature is limited regarding clinical outcomes and variables predicting response to thiopurines. Methods Crohn's disease patients started on azathioprine in the IBD clinic, Christian Medical College (CMC), Vellore between January 2016 to December 2019 were retrospectively reviewed. Outcomes were assessed using the Harvey-Bradshaw score (HBS). Patients were grouped as (i) remission = HBS < 5, (ii) response = reduction of 3 points and (iii) nonresponse. Results Among 318 patients who received azathioprine (AZA) for CD, 155 (48.7%) received higher doses (>1.5 mg/kg) and 163 (51.7%) received lower doses (<1.5 mg/kg). Among those who followed up at least once, 3 months from drug initiation, 188 (76%) patients had remission/ response on AZA, while 60 (24%) did not. A greater proportion of patients who had remission/response (116 [61.7%]) received higher doses (>1.5 mg/kg) of AZA compared to non-responders 26 (43.3%) (p<0.001). Among patients who initially achieved remission or response, 26 relapsed on follow-up. Nineteen (73%) of these patients were on a higher dose (>1.5 mg/kg) of AZA. The mean weight gain was significantly higher in the remission (5.3 kg) and response (6.8 kg) groups as compared to non-responders (1.3 kg) with p<0.001. Mean CRP improvement was significantly higher in remission (11 mg/L) and response (27.7 mg/L) groups as compared to non-responders (-1.3 mg/L). The drug was discontinued in 52 (16%) patients because of cytopenia, anemia, hepatitis, pancreatitis, tuberculosis and perianal abscess. Conclusion Patients on higher doses (>1.5 mg/kg/day) of AZA were more likely to achieve remission or response as compared to those on lower doses (<1.5 mg/kg/day). However, patients who required higher doses for disease control were more likely to relapse. Weight improvement was a useful parameter reflecting the response to AZA in CD patients. Background Gastrointestinal stromal tumor (GIST) comprises 1% to 3 % of all malignant GI tumors with up to 40% with acute hemorrhage following tumor rupture. Our patient presented with acute upper GI bleed with severe hypotension. A prompt and early diagnosis and multidisciplinary teamwork saved the patient. Case Presentation A 57-year-old male, engineer with no prior comorbidities presented to the ER at 5 pm with h/o 3 -4 episodes of hematemesis and melena since 1 day. Cinical examination revealed alert patient with pallor and severe hypotension (60 systolic) digital rectal examination revealed melena. He was admitted to the MICU and resuscitation done. He has severe anemia with relative neutrophilia and hypoalbuminemia. Urgent UGI scopy was done which showed only grade A GERD with erosive gastritis. However, there was altered blood in D2 with no active bleeding point. A possibility of small bowel bleed was considered. Emergency CT angiography revealed lobulated exophytic heterogeneously enhancing soft tissue lesion with coarse calcifications and small non enhancing areas in the proximal jejunum supplied by jejunal branches of superior mesenteric artery. We considered the possibility of jejunal GIST and angioembolization was done the same night by the interventional radiologist. With supportive care patient made a remarkable recovery.

Introduction Classically recognized for its gastrointestinal manifestations, celiac disease (CD) is now increasingly identified in patients with nonspecific manifestations like iron deficiency anemia (IDA), short stature, infertility, osteoporosis, asymptomatic transaminitis and cryptogenic cirrhosis. The aim of this study was to explore the spectrum of atypical presentation in CD patients and to highlight the differences in modes of presentation in adult and pediatric population.

Methods Case records of 42 diagnosed CD patients presenting to Gastroenterology OPD between January to June 2020 were retrospectively reviewed for their chief manifestation. The diagnosis of CD was made on the basis of serology and/or histology. Results The median age of the study group was 12 years (range 1-52 years). Majority of them (55%) belonged to pediatric population. Out of 42 patients, 38% were male and 62% were female. Our study showed typical gastrointestinal symptoms in 29% patients while 71% patients had atypical presentation. In adult group, chronic diarrhea (31.5%), IDA (31.5%) and cryptogenic cirrhosis (36.8%) were common modes of presentation. Pediatric group had short stature (43.5%), IDA (34.7%) and chronic diarrhea (17%) as dominant presentations. Transaminitis was present in 23.8% patients. The typical symptoms of diarrhea and vomiting were more frequent in adult as compared to paediatric patients. Conclusion Atypical Presentation is becoming dominant and typical for CD. More than half of the CD patients present with atypical manifestations and create a diagnostic dilemma. Paediatric patients tend to have a wider spectrum of presentation than adult patients. More awareness and a high index of suspicion is required for timely management.

Glasgow-Blatchford score and risk stratifications in acute upper gastrointestinal bleed: Our experience in tertiary care centre for extending this to 3 for urgent outpatient management Background Upper gastrointestinal bleeds are a common presentation to emergency departments. The Glasgow-Blatchford score (GBS) predicts the outcome of patients at presentation. NICE and ESGE recommend outpatient management for a GBS of 0. Aim Our aim was to assess whether extending the GBS allows for early discharge while maintaining patient safety. We also analyzed whether pathologies could be missed by discharging patients too early. Methods Data were prospectively collected and analyzed on patients admitted with upper GI bleed between 1 October 2019 and 31 December 2019. GBS calculated and gastroscopy reports were obtained for each patient. Patients were assessed for need for blood transfusion, endoscopic intervention during admission and for rebleeding, repeated endoscopic intervention, surgery or radiological intervention and mortality in 1month follow-up. Results Eighty patients were included in study between 16 and 85 years of age, 72.5% were male and 27.5% female. Most common endoscopic findings were duodenal ulcer in 27.5% patients followed by gastric ulcer in 22.5%. GBS score was between 1 to 3 in 58 patients, none of them needed blood transfusion or endoscopic intervention during admission, none had upper GI bleeding related events or mortality during 1 month. Six patients having GBS between 4 to 6, 2 out of 6 (33%) needed endoscopic intervention and blood transfusion, None reported any upper GI bleed related adverse event or mortality during 1 month. Sixteen had GBS more than 6. Twelve (75%) required blood transfusion, endoscopic intervention done in 10 (62.5%), during 1 month period, 8 patients (50%) had rebleeding, 4 managed by endoscopic management successfully, 2 required surgical intervention and 2 out of these 16 (12.5%) expired due to rebleed. Conclusion Study concluded, GBS may be extended to 3 for safe outpatient management, reducing the number of bed days in centres with high volume patient load with limited health care resources for better patient management.

Introduction Abdominal TB accounts for 11% of extrapulmonary tuberculosis. Intestinal TB accounts for 1% to 3% of TB worldwide. Any part of bowel may be involved and usually presents as multiple lesions. Most commonly distal ileum/ileocecal region is involved. Jejunal involvement is seen in terminal stages of extensive tuberculosis of bowel. It's rare, however, to find isolated tuberculosis of jejunum without tuberculosis elsewhere in bowel. Here, we present a rare case of isolated Jejunal tuberculosis. Case Sixty-year-old lady presented with complaints of upper abdominal pain, intermittent, colicky pain since 2 months, increasing with food intake and partly relieved by non-induced vomiting, associated with ball rolling movements with history of significant weight loss and loss of appetite. No history of loose stools, obstipation, constitutional symptoms, fever and cough. On examination Pallor present, no lymphadenopathy/edema. Per abdominal examination and per rectum examination-normal. Investigations Anemia+. Total count, platelets, RBS, RFT, LFT, amylase-normal. Viral markers-negative. Chest X-ray, erect abdomen X-ray-normal. USG abdomen-normal. UGI endoscopy-normal. Colonoscopy-normal. CT abdomen and CT enterography showed proximal jejunal thickening of 6 cm with sub-centimetric para aortic lymph nodes. Tumor marker CEA-normal. On day 4 of admission patient developed severe abdominal pain, abdominal distension with sluggish bowel sounds. X-ray erect abdomen showed features suggestive of small bowel obstruction. Surgical gastroenterology opinion was taken. Diagnostic laparoscopy was done, showed an obstructive jejunal mass and resection anastomosis was done. Surgical biopsysuggestive of tuberculosis, no evidence of malignancy or inflammatory bowel disease. Postoperative period was uneventful. Patient was started on ATT and is on follow-up. Conclusion Involvement of jejunum as part of abdominal tuberculosis is not uncommon. Isolated tuberculosis of jejunum can occur, though very rare. Hence abdominal TB should be considered in patients presenting with isolated jejunal mass lesions.

Introduction Classically recognized for its gastrointestinal manifestations, celiac disease (CeD) is now increasingly identified in patients with nonspecific manifestations like iron deficiency anemia (IDA), short stature, infertility, osteoporosis, asymptomatic transaminitis and cryptogenic cirrhosis. The aim of this study was to explore the spectrum of atypical presentation in CeD patients and to highlight the differences in modes of presentation in adult and pediatric population. Methods Case records of 42 diagnosed CeD patients presenting to Gastroenterology OPD were retrospectively reviewed for their chief manifestation. The diagnosis of CeD was made on the basis of serology and/or histology. Results The median age of the study group was 12 years (range 1-52 years). Majority of them (55%) belonged to pediatric population. Out of 42 patients, 38% were male and 62% were female. Our study showed typical gastrointestinal symptoms in 29% patients while 71% patients had atypical presentation. In adult group, chronic diarrhea (31.5%), IDA (31.5%) and cryptogenic cirrhosis (36.8%) were common modes of presentation. Pediatric group had short stature (43.5%), IDA (34.7%) and chronic diarrhea (17%) as dominant presentations. Transaminitis was present in 23.8% patients. The typical symptoms of diarrhea and vomiting were more frequent in adult as compared to paediatric patients. Conclusion Atypical presentation is becoming dominant and typical for CeD. More than half of the CeD patients present with atypical manifestations and create a diagnostic dilemma. Pediatric patients tend to have a wider spectrum of presentation than adult patients. More awareness and a high index of suspicion is required for timely management.

HLA haplotypes in patients with celiac disease in India: High frequency of non-DQ2/8 haplotypes Objectives HLA-DQ2 and/or DQ8 are believed to be essential for development of celiac disease (CeD). We conducted a case control study to determine HLA DQ haplotypes in patients with CeD and healthy adults using next generation sequencing. Methods HLA-DQA1 and DQB1 loci were amplified using long range PCR, from DNA of 400 patients with CeD (259 symptomatic, 45 asymptomatic, 96 potential) and 300 healthy adults. Amplicons were Illumina sequenced and HLA-DQ genotypes and haplotypes were assigned by matching against the HLA-IMGT database, while DQ serotypes were assigned on the basis of DQB1 genotype. Results Of 300 healthy controls, 80 expressed DQ2, and 33 expressed DQ8. DQ6 (170) and DQ7 (120) were the most common serotypes. Haplotypes DQ2.2, DQ2.5 and DQ8.1 were noted in 61, 32 and 33, respectively. Among 400 CeD patients, 221 had DQ2 serotype, 37 had DQ8 while 24 could express both. DQ6 and DQ7 serotypes were found in 53 and 29, respectively. DQ2.2, DQ2.5, and DQ8 haplotypes were found in 52, 147, and 36, respectively, while double heterozygote haplotypes were noted in 47. DQ2.5 haplotype was strongly associated with CeD (odds ratio 10.31, 95%CI 6.80-15.30), with a gradient in the strength of association between symptomatic, asymptomatic, and potential CeD phenotypes. In an overall analysis, DQ5.1 and 5.3 haplotypes showed protective associations with CeD. Conclusion Thirty three percent of healthy individuals expressed HLA DQ2 and/or DQ8, while thirty percent of CeD patients expressed neither.

Duodenoduodenal intussusception with invagination of the pancreatic head into the duodenum secondary to tubulovillous adenoma in the setting of duodenal malrotation: A case report Introduction Duodenoduodenal intussusception (DDI) is a rare entity due to the fixed position of the duodenum in the retroperitoneum. We report a rare case of documented DDI with invagination of the pancreatic head into the duodenum in a patient with a lead point (a tubulovillous adenoma) and duodenal malrotation with spontaneous resolution of the pancreatic invagination as noted intraoperatively. Methods/Presentation Our patient is a 31-year-old male presenting with a 2month history of vague epigastric pain, melena, anemia and weight loss. Results Esophagogastroduodenoscopy revealed a duodenal mass with adenomatous features. A triple contrast abdominal CT scan initially showed a duodenojejunal intussusception with invagination of the pancreatic head into the duodenum, causing dilatation of the pancreatic duct and the biliary tree. A follow-up MRI was then done which showed a duodenoduodenal intussusception, still with invagination of the pancreatic head. Patient underwent exploratory laparotomy where duodenal malrotation and intussusception at the second segment of the duodenum where the mass was also located with resolution of the pancreatic invagination were noted. Reduction of the intussusception and wedge resection of the mass was done. Patient was discharged with no complications. Conclusion Adult DDI is a rare entity that is challenging to diagnose due to its nonspecific symptoms and is possible in cases of malrotation and Introduction Encapsulating peritoneal sclerosis (EPS) is a rare benign cause of acute or subacute small bowel obstruction. It is also called as "abdominal cocoon" to describe total or partial encasement of the small bowel within a thick fibrocollagenous membrane. It is called as "icing gut" due to the intestinal surface appearing white from the membrane covering. EPS is classified as primary (idiopathic) or secondary based on the etiological factors. We report a case of EPS secondary to tuberculosis. Case report A 40-year-old male patient presented with abdominal pain, distension, altered bowel habits and significant weight loss since 3 months. No prior history of tuberculosis, dialysis, and abdominal surgery. On examination per abdomen is firm, tender, a fixed mass was felt extending from 2-3 cms above the umbilicus to the suprapubic area. CT abdomen showed clustering of small bowel loops encased in a sac like structure, diffuse omental thickening, mesenteric lymphadenopathy. Colonoscopy was normal up to the terminal ileum. USG guided FNAC from omentum revealed fibroblasts with epitheloid histiocytes suggestive of tuberculosis. Patient denied laparoscopy. He was started on ATT. On follow-up he improved symptomatically and clinically with decreased abdominal pain, distension and weight gain. Conclusion EPS is a rare clinical entity causing intestinal obstruction. The primary form is of unknown origin and has been classically described in young adolescent females. Secondary EPS has been reported in association with abdominal tuberculosis, peritoneal dialysis, sarcoidosis, systemic lupus erythematosus and prior abdominal surgeries. Peritoneal tuberculosis in the form of sclerosing variant is an unusual entity. Early recognition and initiation of ATT may prevent the need for operative intervention or bowel resection in these patients. Keywords Encapsulating Peritoneal Sclerosis,Tuberculosis, Intestinal obstruction 074 Enteroscopic management of life threatening obscure gastrointestinal bleeding due to jejunal leiomyoma Introduction Obscure gastrointestinal bleeding is a difficult medical emergency to manage. Benign small bowel tumors are rare cause of obscure gastrointestinal bleeding. Methods A 64-year-old male presented with massive gastrointestinal bleeding with hemorrhagic shock. The patient had severe comorbid conditions like diabetes mellitus, hypertension, ischemic heart disease with cardiomyopathy (Ejection Fraction-30%) and chronic kidney disease. After a non-conclusive upper GI scopy, colonoscopy and a plain CT scan, capsule endoscopy was done which showed proximal jejunal bleeding. Push enteroscopy was the done which showed a jejunal polyp measuring 3 x 2 cms. Result The polyp was successfully removed en-bloc by endoscopic mucosal resection (EMR) technique without any complications like bleeding or perforation. Histopathology examination and immunohistochemistry confirmed the polyp to be a leiomyoma. Patient was asymptomatic on follow-up at 6 months. Conclusion With adequate surgical back up, endoscopic resection of benign small bowel tumors can be done in selected high risk group of patients in whom surgery may be associated with increased morbidity and mortality. Keywords Gastrointestinal bleeding, Jejunal leiomyoma, Endoscopic mucosal resection, Capsule endoscopy, Push

Dental enamel defects and oral cavity manifestations in Asian patients with celiac disease Introduction Small intestine is the main site of celiac disease (CeD), affecting other organs also. Dental enamel defects are common indicators of CeD, in absence of other classical symptoms. Aims was to study dental and oral manifestations in Asian patients with CeD. Methods We recruited 118 patients with biopsy-confirmed CeD (36 treatment naïve and 82 follow-ups on at least one year of gluten-free diet) and 40 controls. Diagnosis was made as per standard criteria. Oral and dental manifestations were evaluated by a dental surgeon. The dental enamel defects (DED) were evaluated according to Aine's criteria. Results Overall higher number of patients with CeD (66.9%); both treatment naïve (69.4%) and those on GFD (65.8%) had DED in comparison to controls (20%) (Odds ratio, 8.1, 95% CI 3.4-19.2; p<0.001). Specific/ bilaterally symmetrical DED were present in significantly higher number of patients with CeD than controls. Recurrent aphthous ulcers were significantly higher in patients with CeD. Approximately 80.6% and 63.4% treatment naïve patients and those on GFD, respectively reported dry mouth sensation which was significantly higher than that in controls. Conclusions Almost two third of patients with CeD have DED. Physicians and dietitians caring for patients with CeD should train in identification of DED and other oral manifestations of CeD. Keywords Gluten; Teeth; Recurrent aphthous ulcers; Dry mouth

The proteome of the human small intestinal mucosa by SWATH-MS analysis Introduction Small intestinal mucosa, maintain and control a number of structural, functional, and regenerative activities in the human body. Understanding of diseases that damage small intestinal mucosae such as celiac disease or Crohn's disease necessitates understanding the normal human small intestinal mucosa proteome. However, an in-depth characterization of the normal small intestinal mucosal proteome is lacking. Therefore, we have carried out proteomics analysis of the small intestinal mucosa by obtaining small intestinal biopsies from twelve subjects with gastrointestinal reflux disease undergoing the routine endoscopic examination and having normal small intestinal morphology. Methods A spectral ion library representing the total proteome of small intestinal mucosa from 45 biopsies was generated in data-dependent acquisition mode. Small mucosal biopsies from 12 participants having GERD were included as representatives of normal human small intestinal tissue. Proteins extracted from the biopsies were subjected to tryptic digestion and SWATH-MS analysis. Results A total of 3369 proteins were identified with high confidence. Amino acid metabolism, endoplasmic reticulum-secretory pathway, spliceosome complex, and glycolysis were among the most prominent pathways as represented by the proteome. Proteins from various parts of the small intestinal mucosal structure mapping to enterocytes, goblet cells, Paneth cells, intestinal crypts were found in the dataset. Conclusions Cataloging the proteome in a healthy intestinal mucosa pro-Introduction Acute mesenteric ischemia (AMI) refers to sudden onset of intestinal hypoperfusion. Incidence of acute mesenteric ischemia appears to be rising-partly due to increased awareness among clinicians, ageing population with cardiovascular disease. Intestinal ischemia can be classified as acute or chronic and of venous or arterial origin. In young patients without cardiovascular disease, mesenteric venous thrombosis is the common cause of intestinal ischemia. Aims To evaluate and study the clinical profile of cases of AMI in our tertiary care centre. It was obtained by performing a audit of all patients presenting with Acute abdomen in Vydehi Institute of Medical Sciences and Research Centre from 2019-2020. Method Data were collected from 1 September 2019 to 31 August 2020. All relevant investigations including CECT abdomen-Mesenteric ischemia protocol, Procoagulant work up was done where indicated. Observations A total of 8 cases were enrolled in the study. Mean age of patients was 43.2 years (Range: 21-60 years). Majority of the patients were in the 4th and 5th decade. Male preponderance was noted. All patients presented with abdominal pain. Four patients (50%) had arterial thrombosis. Four patients (50%) had venous thrombosis. Seven cases were involving superior mesenteric territory. One case was involving inferior mesenteric artery territory. CECT abdomen was diagnostic in all cases. One patient had arterial thrombosis secondary to atrial fibrillation. Venous thrombosis was secondary to APLA in 2 cases, Protein S deficiency in 1 case. Evaluation for thrombosis could not be done in 4 cases. Keywords Mesenteric ischemia. Superior mesenteric vein thrombosis, Superior mesenteric artery thrombosis Introduction Celiac disease (CeD) is an autoimmune disorder diagnosed predominantly in pediatric population in western countries. With the advent of better awareness, CeD is being increasingly diagnosed in India across all regions. The aim of this study was to evaluate the clinical profile of CeD in western Indian population. Methods We retrospectively analyzed prospectively maintained data. Total 111 consecutive patients who were diagnosed with CeD as per the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria in a tertiary care center in Western India. Their clinical profile was studied. Result Of total 111 patients, 71 (63.96%) cases were females and 40 (36.03%) cases were males. Median age of presentation was 37 years. Diarrhea was the commonest symptom. Many patients presented with atypical symptoms like nausea, vomiting and bloating of abdomen. Extraintestinal symptoms are common in CeD and include weight loss, anemia, osteopenia, neurological abnormality and gynecological abnormality. CeD can present in adult as well as elderly age groups. Conclusion CeD is not an uncommon disease is Western India. High index of suspicion is required in patients with atypical presentation. Keywords Diarrhea, extraintestinal manifestations, hypertransaminasemia 079 Gluten content in labeled and unlabeled gluten-free food products used by patients with celiac disease Objective Gluten-free (GF) diet is the only reliable treatment for patients with celiac disease (CeD), but data on the extent of gluten contamination in GF-food available in India is scanty. We evaluated gluten content in labeled, imported and non-labeled GF-food products currently available in the Indian market. Methods Seven hundred and ninety-four processed and commercially available packaged GF products (labelled GF [n=360], imported GF [n=80] and non-labelled/naturally GF [n=354]) were collected from supermarkets of National Capital Region of India. Those unavailable in stores, were purchased from e-commerce sites or directly from the manufacturers. Gluten level in them was determined by Ridascreen Gliadin sandwich R5-enzyme-linked immunosorbent assay (R-Biopharm AG, Germany). As per Codex Alimentarius and Food Safety and Standard Authority of India, "gluten-free" labelled products must not contain >20 mg/kg of gluten. Results Overall, 10.1% of 794 GF products including 38 (10.8%) of 360 labelled and 42 (11.8%) of 354 non-labelled/naturally GFfood products had gluten content >20 mg/kg (range: 24.43-355 and 23.2-463.8 mg/kg, respectively). None of the imported GF products had gluten more than the recommended limits. The level of contamination was more in the labelled GF-food products manufactured using oats, amaranth, buckwheat and pearl millet than others which used Bengal gram dal, rice, maize, sorghum and multi-grains as ingredients. Contaminated products most commonly belonged to cereal and their products (flours, coarse grains, pasta/macaroni, snack foods) pulse flours, spices and bakery items. Conclusions A substantial proportion (10.1%) of GF-food products (both labelled and non-labelled) available in India have gluten content greater than the prescribed limits of <20 mg/kg. Physicians, dietitians, support group and patients with CeD should be made aware of this fact and regulatory bodies should ensure quality assurance. Keywords Labelled gluten-free, Naturally gluten-free, Contamination, Quality assurance, India

Falsely elevated anti-tissue transglutaminase antibodies in patients with immunoproliferative small intestinal diseases: A case series Introduction There is an overlap between clinical symptoms of celiac disease many other diseases including tropical sprue, parasitosis and immunoproliferative small intestine disease (IPSID). They are distinguished by presence of celiac specific antibodies and certain histological characteristics. We present a case series of 11 patients with IPSID, 8 of which were found to have falsely elevated anti-anti-tissue transglutaminase (anti-tTG Ab) in them. Methods We reviewed all patients who were diagnosed to have IPSID between 2016 and 2019. As part of evaluation, all patients had undergone complete work up including anti-tTG Ab, intestinal mucosal biopsies. Wherever feasible, anti-endomysial Ab, HLA haplotype, and serum IgA levels were estimated. A trial of gluten-free diet was also done in 4 patients before committing a diagnosis of IPSID. Results While diagnosis of IPSID was confirmed in all 11 patients, eight of them had persistent rise in IgA anti-tTG Ab; 6 of them had anti-tTG Ab more than 2 times upper limit of normal (ULN), 4 had values >5 times ULN and only one patient had a value 10 times ULN. EMA could be done in seven patients and it was negative in all of them. Haplotyping of HLA-DQ2 and -DQ8 could be done in five of them and only one of them had HLA-DQ2 haplotype. A gluten-free trial was given to 4 patients with a significantly raised anti-tTG Ab (>5x ULN), none demonstrated significant reduction symptoms and IgA-tTG Ab titre. Conclusion Patients with IPSID can have a false positive anti-tTG Ab. By making a diagnosis of celiac disease based only on anti-tTG Ab may lead to a false diagnosis of celiac disease. Keywords Anti tTG, IPSID, celiac disease Introduction Growth retardation and growth failure are important features of celiac disease (CeD) that lead to failure of attainment of full potential of adult height. Although there is data on the proportion of patients having short stature in CeD, there is a lack of data on the spectrum of height, with normal expected height at one end and short stature being the other end. Methods We performed a retrospective analysis of a prospectively maintained database at our center, including a total of 419 adults (183 [43.7%] males) and 164 adolescents (12-18 years) (72 [43.9%] males). The data from the National Family Health Survey 2015-16 (NFHS-4) from India was used as control group. Height and BMI Z-scores were defined according to the Indian Academy of Pediatrics (IAP) growth charts and compared with the control group. Results Overall, 19.6% of adult and 57.9% of adolescent patients with CeD had short stature. Mean height of male patients with CeD was similar whereas women were taller than the population controls. Higher proportion of men with CeD had short stature, as compared to population controls (32.2% vs. 20%, p<0.0001). In contrast, a lower proportion of women with CeD had short stature as compared to the controls (9.7% vs. 18.9%, p=0.0003). Higher proportion of adolescents with CeD had short stature compared to adults (57.9% vs. 19.6%, p<0.001). On multivariate analysis, adulthood was found to be independently associated with a lower prevalence of short stature. Conclusions The mean height of men with CeD was not significantly different from that of population controls, whereas females were taller than the population controls. Adolescent boys and girls with CeD are significantly shorter than their peers from the general population. Keywords Short stature, Enteropathy, Small intestine, Growth failure Introduction Association between inflammatory bowel disease (IBD) and neuroendocrine tumor (NET) is not well established till now. NETs are seen rarely in IBD patients but some new reports shows increased prevalence of NET in IBD patients compared to general population. Increased number of neuroendocrine cells along with other cells present in colonic mucosa which inflamed for long period in setting of IBD may be the triggering factor for NET along with IBD. NET is rare among colonic or small bowel neoplasms and its infrequently described along with IBD.

Here we report a case of distal ileal carcinoid arising in a UC patient. Case report A 47-year-old man with 9 years history of ulcerative colitis and diabetes mellitus was admitted due to intermittent bleeding per rectum and constipation. He was well maintained with mesalamine 1.2g/day and symptomatic treatment. Previous colonoscopy showed features of remission. Colonoscopy showed thickening in rectosigmoid region and exophytic intraluminal polypoidal lesion (12.7 x 10.5 mm) in distal ileum. Biopsy from rectal and sigmoid region showed features suggestive of mild colitis. Biopsy specimen from distal ileal polyp showed features suggestive of carcinoid. Laparoscopic resection was done, biopsy showed features consistent with carcinoid. Discussion Previous literature showed NET predominantly carcinoid tumors associated with IBD, most of them were clinically indolent and incidentally reported in surgical specimens of IBD patients. Siegel et al. suggested multipotential cells in dysplastic epithelium in IBD might be the prerunner for neuroendocrine differentiation leads to NET. Concept of cellular dysplasia involving neuroendocrine cells in inflamed mucosa of IBD patient leading to NET including carcinoids needs further validation. Background Genetic polymorphisms in TPMT and NUDT enzymes are implicated in thiopurine related cytopenia. The contribution of these polymorphisms in Indian population with inflammatory bowel disease (IBD) is uncertain. Methods Consecutive patients with the diagnosis of ulcerative colitis or Crohn disease initiated on thiopurines (azathioprine or 6mercaptopurine) were included in the study. Only those patients who developed an adverse event resulting in discontinuation or had at least three months of follow-up were included. Polymorphisms for TPMT and NUDT were detected. The patients with the genetic polymorphisms were compared to those without any detectable polymorphisms for frequency of cytopenia, maximal tolerated thiopurine dosage and occurrence of idiosyncratic reactions. Results Of the 119 patients (mean age was 36.8 ± 13.5 years) included, 61 (51.3%) were males. One hundred and five had ulcerative colitis while 14 had Crohn's disease. Of these 119, cytopenia were noted amongst 33 (27.7%), gastrointestinal tolerance in 5 (4.2%) and pancreatitis in 2 (1.6%). TPMT polymorphisms were noted amongst five patients while NUDT polymorphism was noted in 13 patients. One of these had both TPMT and NUDT polymorphism. The occurrence of cytopenia was more frequent in those with NUDT polymorphism than those with wild phenotype (53.8% vs. 24.5%) but was similar in those with TPMT polymorphism as compared to wild type (20% vs. 24.5%). Conclusion In Indian population with IBD, NUDT polymorphisms are more frequent than TPMT and are predictive of development of cytopenia. Keywords Ulcerative colitis, Crohn's disease, Azathioprine

A rare case of multiple jejunal diverticulosis with perforation T Ashokkumar, A Amudhan, R Kamalakannan, J Saravanan, M Thiruvarul, Satish Devakumar, S Jeswanth, T Selvaraj Correspondence-Ashok Kumar-asasupernova@gmail.com Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, Chennai 600 003, India Background Small bowel diverticular disease occurs in in 0.3 % to 20% of the population less common than large bowel diverticular disease .of these only 4% will develop symptoms. Three types of small bowel diverticula the duodenal, jejunoileal and Meckel diverticula, of these most frequently encountered diverticula are the duodenal 45%, jejunoileal 25% and Meckel diverticula 25%. Case report An 80-year-old women admitted in medical ward with complaints of abdominal pain vomiting and diarrhea patient underwent imaging after atypical presentations found to have small bowel thickening with mesenteric haziness patient underwent laparotomy for peritonitis and was discovered to have multiple jejunal diverticula with perforation and enterolith patient underwent resection anastomosis and her postoperative period was uneventful.

Conclusions Jejunal diverticula are the least common 60% to 70% patients are symptomatic peaks around 6th for 7th decade, these diverticula usually in the mesentric side of the bowel acquired diverticula result of smooth muscle dysfunction or defect in the myentric plexus resulting in irregular bowel contraction and increased intraluminal pressure these diverticula can present with or without perforation hemorrhage and after auction obstruction. Asymptomatic cases are left alone if there are signs of hemodynamic instability sepsis or peritonitis surgical resection is recommended. Keywords Small bowel diverticula, jejunal diverticula, perforation, enterolith Introduction Benign vascular lesions occur rarely in the gastrointestinal (GI) tract and are diagnosed by endoscopy or angiography. Rarely, these present with refractory bleed and a surgical resection is required to arrest the hemorrhage. Case Capsule Forty-eight-year-old female, presented with melaena and anemia for 2 years. She had undergone hemorrhoidectomy elsewhere 1 year back. Colonoscopy and upper GI scopy were normal. Abdominal CECT scan showed mesenteric lymph node enlargement. She had undergone diagnostic laparoscopy elsewhere and intraoperative enteroscopy was done. Intraoperatively she had mesenteric lymph node enlargement, nodular mucosa of the small bowel and Meckel's diverticulum. Meckel's diverticulum along with a segment of adjoining bowel was resected. Postoperatively she had recurrent melaena. CECT scan abdomen showed hemoperitoneum. She underwent exploratory laparotomy. Intraoperative enteroscopy showed highly vascular nodular lesion of the jejunum. Resection of 80 cm of small bowel was done. Histopathology report was suggestive of Hemangiolymphangioma. At follow-up, patient was symptom free. Discussion Hemangiolymphangioma is a benign disease, mainly found on the skin. Rarely, it is found in small bowel, spleen, colon, rectum and thorax. The incidence of hemangiolymphangiomas varies between 1.2 and 2.8 per 1000 live births. Most are asymptomatic, or show painless GI hemorrhage. Eighty percent of patients show intraluminal GI bleeding symptoms, and 50 % have chronic anemia. Most effective treatment is surgical resection, but other treatment modalities include sclerotherapy and angioembolization.

Introduction Gallstone ileus is a rare complication of cholelithiasis and is one of the rarest forms of all mechanical bowel obstructions. • It is caused by impaction of a gallstone in the gastrointestinal (GI) tract after passing through a biliary-enteric fistula. •Emergency laparotomy was done, impacted stone in jejunum measuring 4*4 cm seen with ?sealed perforation, removel of stone and resection anastamosis of bowel small bowel done post op period was uneventful. Conclusion Gallstone ileus occurs in 0.3% to 0.5% of all patients with gallstones. It is one of the rarest causes of gallstone ileus, occurring in about less than 0.1% of all mechanical obstruction cases and 1% to 4% of non-strangulating mechanical small bowel obstructions. Mortality remains high, ranging from 12% to 27%, because of non-specific symptoms, unremarkable biochemical investigations, high misdiagnosis rate, and delayed discovery. So

Introduction Gastrointestinal stromal tumors are rare. GISTs comprise 0.2% of gastrointestinal tumors and only 0.04% of small intestinal tumors. Jejunal GISTs are the rarest subtype. Only 10% to 30% progress to malignancy.

Case capsule A 65-year-old male was admitted with abdominal pain for 6 hours. He was diagnosed to have hollow viscous perforation and on further evaluation found to be COVID-19 positive. Intra-operatively, he was found to have D1 perforation which was repaired by using Graham's patch repair. During exploratory laparotomy, the patient was found to have well circumscribed growth of size 3X3X2 cm which was 10 cm distal to duodenojejunal flexure. No mesenteric lymph nodes were found, no ascites was present, and liver was normal. Resection and anastomosis of the bowel was done with 2 cm margins on both ends. Histopathological examination revealed gastrointestinal stromal tumor which is of spindle cell type. Immunohistochemical analysis showed that the tumor is CD117 positive and S100 negative. During follow-up, patient was asymptomatic. Discussion GISTs are uncommon mesenchymal neoplasms of the alimentary tract. The incidence of GIST is very low (i.e. 2 in 1,00,000). Most common site of presentation is stomach, but it can crop up anywhere in the digestive tract. Two-thirds of GISTs occur in the stomach while about one-fourth develop in the small intestine, usually in the duodenum. while jejunal GIST is extremely rare accounting for 0.1% to 3% of all gastrointestinal (GI) tumors. Usually they are asymptomatic but can present as abdominal pain, bleeding, or mechanical obstruction. Surgery is the primary treatment of choice and imatinib mesylate is the first and only effective drug for the treatment of gastrointestinal stromal tumor at present. Keywords GIST, Jejunal, CD117, Imatinib, Perforation 088 Extraintestinal gastrointestinal tract involvement in patients with celiac disease: An early proof Introduction While celiac disease (CeD) is considered to affect mainly small intestine, a few of them also have lymphocytic infiltration of other parts of gastrointestinal tract. Whether these changes are due to CeD is not well-established. Deposits of IgA anti-tissue transglutaminase antibody (anti-tTG Ab) in the small intestinal mucosa has been used as an evidence of CeD. Methods Forty-two treatment naive patients with CeD (as cases) and 45 patients with irritable bowel syndrome (as controls) were recruited. They underwent esophagogastroduodenoscopy and sigmoidoscopy and multiple mucosal biopsies were collected from the esophagus (lower, mid and upper), stomach (multiple sites as per Sydney protocol), duodenum (bulb and post ampullary) and rectosigmoid, both at baseline and at 6-month post glutenfree diet (GFD). All biopsies were evaluated for histological characteristics and immunostaining, for co-localization of IgA anti-tTG deposits, using dual-colour immunohistochemistry, as an evidence of CeD at these sites. Results Significantly higher number of patients with CeD had evidence of lymphocytic esophagitis (9.7% vs. 0%, p<0.05), lymphocytic gastritis (35% vs. 8.8%, p<0.01), duodenal intraepithelial lymphocytosis (100% vs. 0%, p <0.001) and lymphocytic colitis (17.4% vs. 0%, p<0.05) than that in controls. Significantly higher number in patients with CeD had anti-tTG Ab deposits in esophagus (30.9% vs. 6%, p<0.001), stomach (62.2% vs. 9.3%, p<0.01), duodenum (88.5% vs. 0%, p<0.001) and rectum (17.4% vs. 0%, p<0.05) in comparison of controls. On follow-up on GFD, there was a decline not only in severity of intra-epithelial lymphocytosis but also in the intensity of anti-tTG deposits at all sites. Conclusion A significantly higher number of patients with CeD having intraepithelial lymphocytosis and anti-tTG Ab deposits in the esophagus, stomach and rectum in addition to small intestine suggests that other organs are also affected in CeD. Keywords Celiac disease, Immunohistochemistry, IgA tTG mucosal deposits 089 Colonic mucormycosis in fistulizing Crohn's disease: A case report Akash Mathur, Piyush Mishra, Neha Nigam, Uday C Ghoshal Correspondence-Uday C Ghoshal-udayghoshal@gmail.com Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India

Background Gastrointestinal mucormycosis, a rare fatal fungal infection in an immunocompromised host, commonly affects the stomach. Case Report A 46-year-old female with long-standing diabetes mellitus, hypothyroidism, and hypertension, presented with a 3month history of fecal discharge per vagina. She reported having intermittent loose stools, mixed with blood and mucus for 1.5 years. Based on the evaluation and unsuccessful treatment with antitubercular drugs elsewhere, Crohn's disease was diagnosed, and adalimumab biosimilar started; however, the response was partial. Examination revealed: pallor and large perianal tags. Investigations: Hb 9.4 g/dL, total serum protein, and albumin 5.5 and 2.8 g/dL, respectively. A computerized tomography (CT) scan with rectal contrast showed inflammatory involvement of the rectum and sigmoid along with a rectovaginal fistula. A magnetic resonance (MR) enterography showed a loss of haustrations in the transverse colon with a prominent vasa recta in the sigmoid colon. Colonoscopy showed loss of vascular pattern with pseudopolyps in the terminal ileum, IC valve, cecum, ascending, transverse, descending, sigmoid colon, and rectum; a fistulous opening was seen in the rectum ( Fig.  2A , B and C). Descending and sigmoid colon biopsies revealed crypt distortion, mononuclear cell infiltrates in lamina propria, exudate with broad aseptate fungal hyphae suggesting mucormycosis (Fig. 1A , B and C). The serology for the human immunodeficiency virus was negative. With a diagnosis of colonic mucormycosis with fistulising Crohn's disease, liposomal amphotericin B was started, but the patient succumbed. Conclusion This rare patient highlights the need for increasing awareness about fungal infestations as a cause of disease flare in patients with inflammatory bowel disease. Keywords IBD, Crohn's disease, Fistulizing Crohn's disease, Mucormycosis Introduction There are several conditions that mimic inflammatory bowel disease (IBD) because of location, symptoms, or appearance on endoscopy, imaging and histology. Consideration of alternative diagnosis is important when conventional therapy does not work or worsens the symptoms. The present study is a retrospective analysis of cases where IBD mimics were diagnosed. Methods Over a nine-year period, 104 cases with suspected IBD were seen by the author. Of these, 88 were suspected as ulcerative colitis (UC) and the remaining as Crohn's disease (CD). Diagnosis of IBD was suspected if 2 or more of the following symptoms were present-fever, weight loss, abdominal pain, chronic mucoid or bloody diarrhea, subacute intestinal obstruction with or without right iliac fossa mass. The diagnosis was confirmed using radiological investigations (ultrasound, computed tomography), colonoscopy evaluation and histopathology. Based on histology, and re-evaluation in cases with non-response, the eventual diagnosis was changed in 11 cases. Results Infections were commonest mimics and were noted in 6 cases (54.5%). Tuberculosis and amebic colitis were detected in 3 and 2 cases respectively. Five other cases (45.5%) were diagnosed with rarer diseases based on the clinical profile, histology and response to treatment. These included segmental colitis with diverticulosis (SCAD), solitary rectal ulcer syndrome, eosinophilic enteritis, Behcet's disease and NSAID enteropathy are rarer IBD mimics seen in India and reported mainly as case series. Conclusion IBD mimics are detected in nearly 10% of cases of suspected IBD. They are commoner in CD than UC. Infections are the commonest IBD mimics in Indian scenario.

Clinical and endoscopic profile of inflammatory bowel disease in a tertiary care hospital in South India

Introduction We aim to study the clinical profile of inflammatory bowel disease (IBD) patients in a tertiary care hospital of Karnataka. Methods We retrospectively analyzed the clinical profiles of IBD patients who had presented to Department of Gastroenterology over a period of four years from January 2015 to January 2019. Demographic profile, clinical and endoscopic findings along with management and complications were taken into consideration. Results Of the 143 patients, there were 126 (88.1%) patients with ulcerative colitis (UC), 6 (4.2%) with Crohn's disease (CD) and 11 (7.7%) with inflammatory bowel disease unclassified (IBDU). Chronic diarrhea (77.8%) and blood in stools (75.4%) were common in UC, whereas abdominal pain (50%) was common in CD. E2 (57.1%) was more common in UC, there were equal number of L2 (50%) and L3 (50%) in CD. Left sided colon involvement (81.8%) was common in IBDU. Extraintestinal manifestations were noted in CD (66.6%), IBDU (54.5%) and UC (53.3%). Most of the patients had moderate disease activity and responded well to pharmacotherapy. Conclusion In our study, we found that IBD was common in rural population of India and UC was more common than CD.

Introduction Data on the prevalence and distribution of colonic polyps in Indian/Asians is limited. To study this we conducted a retrospective study on 202 polyps out of 7936 colonoscopies. Method The objective was to analyse demographic, clinical, endoscopic and histopathological characteristics of polyps in patients undergoing colonoscopy from 2016 to 2019 at GIPMER, New Delhi. All polyps were removed colonoscopically by polypectomy and specimen were sent for histopathological examination. Parameters like age, gender, symptoms, site, gross morphology and histological subtypes of polyps were assessed. Result Total 7936 colonoscopies were performed in this period. Polyps were seen in 202 patients. Mean age was 23 years. Seventy-two percent were males. Eighty-two percent were below 40 years and 18% were above 40 years of age. 69% polyps were found in rectum. Sixty-three percent polyps were juvenile, 10% Peutz-Jegher, 17% adenomatous, 3% inflammatory and 7% others. Mean age of adenomatous polyp was 48 year. Sixty-six percent polyps were pedunculated. Fifty-one percent polyps were less than 1 cm. Eighty-one percent patients presented with bleeding P/R. Seventy-eight percent of adenomatous polyps were dysplastic. Out of adenomatous polyp 44% were tubular, 34% tubulovillous and 22% villous. Conclusion Frequency of polyps on colonoscopy at our centre was 2.5%. Most common type was juvenile polyp. Polyps were more common in younger age group. Adenomatous polyps were common in middle to old age group. Most polyps were small, pedunculated and located in rectum. Tubular was most common type of adenomatous polyp. Dysplasia was more common in villous type.

Introduction Solitary rectal ulcer syndrome (SRUS) was first identified as clinical identity in 1969. But the etiology is not known. Anal fissure, inflammatory bowel disease (IBD), proctagia fugax and malignancy, rectal polyps, hemorrhoids, and infections. Rarely ischemia, trauma and cystic profunda colitis and stercoral ulcers have to be excluded. Hence a careful history is important. Methods Patients presenting with C/O constipation or straining at stools with difficulty in passing motion with associated minimal bleeding per rectum on and off period less than a month were included in the study. All patients were investigated for stool for occult blood, US abdomen, BMFT, CBP and flexible sigmoidoscopy Results 1. Patients presenting with constipation and bleeding PR were investigated. Flexible sigmoidoscopy showed multiple pinpoint superficial ulcers on the anterior rectal wall without involvement of sigmoid colon. The incidence age group wise was seen very high between 20 to 60 years. M: F ratio 47:53. All were positive for stool for occult blood, negative for IBD and malignancy by biopsy. They responded to dietary changes i. e. veg, non-spicy, non-fried diet with antibiotic, mesalamine (400 mg BD) and lactulose 15 mL at bed time. Ten days after the test follow-up sigmoidoscopy was found normal and patient asymptomatic even after 3 months. Discussion The incidence of SRUS has become common irrespective of age and sex. The type of food used by all these patients was found to be more or less similar with majority of them using fast food, fried food, and spicy food. Stoppage of the above-mentioned food with specific treatment for 10 days resulted in recovery with normal sigmoidoscopy. Conclusion SRUS incidence is high in general population due to specific food type and evacuation behavior.

Introduction Steroids along with amino salicylates are classically used for induction of remission but the side effects of steroids are many and cause multiple problems to patients receiving it. A result many non-inflammatory bowel disease (IBD) immune suppressants are being tried for induction of remission and include methotrexate, cyclosporine, infliximab, azathioprine, 6-mercaptopurine, adalimumab, vadalizumab, tafacitimabb, golimumab, and tacrolimus. The major problem in its use is development of adverse side effects, increase hospital stay and high cost. Aim To compare and evaluate the efficacy and safely of tacrolimus with aminosalicylates vs. use of aminosalicylates with corticosteroid therapy in active phase of inflammatory bowel disease (IBD). Methods Fifty patients of acute IBD were evolved in this study based on inclusion and exclusion criteria. Group -I:(25 patients) received corticosteroid (prednisolone 10 mg BD) along with aminosalicylates 1.3 gms/ day Group -II: (25 patients) received tacrolimus in a dose of 0.1 mg/kg body weight per day (2 tablets of 1 mg twice daily) along with aminosalicylates 1.3 gms/day along with maintenance drugs required for patients for a period of 10 days. Colonoscopic evaluation was done before starting the drugs and after 10 days of completion of treatment and the efficacy assessed using Mao endoscopic scoring system. Follow-up of these patients was done at the end of 2 months with repeat colonoscopy to assess the effectiveness of the treatment. Results After initial therapy of 10 days clinical remission was observed in both groups of patients. Follow-up at 2 months no patient of group -II was admitted for exacerbation whereas in group -I 5/25 patients were re hospitalized following exacerbation (20%). Conclusion Tacrolimus has prolonged period of remission compared to corticosteroid with better efficacy, safety profile and cost effective which was well tolerated by patients.

Microbiological spectrum, endoscopic and histological characteristics and outcomes of enteric infection associated flare of ulcerative colitis -A retrospective analysis Introduction Enteric infections in ulcerative colitis (UC) can cause adverse outcomes in terms of increased severity, failure to attain remission, refractoriness to medical treatment and increased colectomy rates. Hence, this study was conducted to find the frequency, microbiological spectrum, endoscopic and histological characteristics, and outcomes of enteric infection associated flare of UC. Methods This retrospective study included patients hospitalized for moderate or severe UC between January 2019 and June 2020. The baseline characteristics, laboratory values, clinical severity, endoscopic and histological grading of disease severity, stool culture and sensitivity, stool microscopy, Cytomegalovirus (CMV) cytopathic changes in colonic biopsy, were collected.

Results A total of 17 (n=75, cases 22.7%) enteric infection associated moderate or severe flare of UC was seen during the study period. Their median age was 36 years (22-48 years), with a male preponderance (M:F=12:5). Stool culture was positive in 12 patients (70.6%), Salmonella species was the commonest organism isolated in 5 patients (41.7%), followed by Aeromonas punctate, Aeromonas caviae, Vibrio cholera, Vibrio vulnificus, Edwardsiella tarda, Pleisomonas shigelloides, and Shigella dysenteriae, in each of the remaining 7 patients (each 5.9%). Stool microscopy for parasites was positive in 3 patients (17.6%). The parasites include Ankylostoma duodenale, Blastocystis hominis, and Entameba histolytica. Cytopathic changes of CMV were seen in histology in 2 patients (11.8%). Mayo Endoscopic score was 1, in 4 patients (23.5%) and Geboes histological activity score was less than 3, in 10 patients (58.8%). All patients showed significant clinical improvement with appropriate dose and duration of antimicrobial treatment. None of them required colectomy or change in their maintenance therapy during this period. Conclusions In conclusion, clinically severe enteric infection associated flare of UC may have milder histological disease activity. Their symptoms and endoscopic findings improve with antimicrobial treatment and rarely warrant newer or change in immunosuppression or immunomodulation. Ulcerative colitis (UC) is autoimmune disease with varied extraintestinal manifestation. Acquired TTP is associated with autoimmune diseases but very rare with ulcerative colitis (only 4 cases reported in literature). We had a case of 31-year-old male who was a known case of UC since 5 years but not on regular treatment. Patient presented with history of index episode of focal seizures with secondary generalization with altered sensorium. Patient was having persistent seizures and altered sensorium after admission in spite adding of multiple antiepileptics and supportive care. No cause was found after blood investigations and brain imaging for seizures. His bowel habits were normal and there were no features of sepsis. His investigations revealed high serum creatinine, falling hemoglobin (8.3 gm%) and thrombocytopenia. Peripheral smear showed evidence of Schistocytes, high serum LDH, low serum haptoglobulin and negative coombs test suggestive of micorangiopathic hemolytic anemia (MAHA). In view of MAHA, thrombocytopenia, seizures and renal dysfunction diagnosis of acquired TTP was made and he was initiated immediately to plasmapheresis. After multiple sessions of plasmapheresis, patient improved clinically, his sensorium improved and also there was normalization of serum creatinine, steady Hb and platelet count. Hence, we concluded that acquired TTP can be an extra intestinal manifestation of UC which clinicians should keep in mind and initiate prompt management in the form of plasma exchange.

Incidence and anatomical distribution of colorectal cancer -A single centre retrospective study Background Colorectal cancer (CRC) is one of the major cancers in the developed world causing significant morbidity and mortality. Most colorectal cancers are due to old age and lifestyle factors, with only a small number of cases due to underlying genetic disorders. A recent study had shown a rising incidence of CRC in patients younger than 50 years of age. The incidence of CRC is low in India due to high dietary fiber intake. Aim of the study To determine the incidence and anatomical distribution of colorectal colorectal cancer at a tertiary care centre in south India. Methods Retrospective descriptive analysis of anatomical distribution, age at diagnosis and demography of 238 cases (149 [57.1%] men) of adenocarcinoma of the colon or rectum diagnosed by colonoscopy and biopsy over a period of five years (June 2014-May 2019) at Government Kilpauk Medical College, Chennai. Results Total numbers of patients presented with colorectal cancer were 238, with M: F 1.3:1. The mean age at diagnosis was 54.55 years (SD 14.12; . Thirty-five (14.7%) cases were below the age of 40 years. The majority (45.3%) cases were aged between 41-60 years. Most of the tumors (n=178, 78.5%) were located distal to the splenic flexure. Conclusion Almost half of the colorectal cancers in this series occurred in the fifth and sixth decades of life and most of them were located distal to the splenic flexure.

Introduction Data on the frequency and characteristics of colonic polyps from our country are limited. We aimed to study the frequency and profile of colonic polyps among our patients. Methods We conducted a retrospective study of patients who underwent colonoscopy from November 2019-June 2020. Clinical records including colonoscopic findings were evaluated. Patients with polyposis syndrome or incomplete colonoscopy were excluded. The demographic profile and indications for colonoscopy were assessed. The morphological and histological characteristics of polyps were recorded. In addition, the risk factors of adenomatous polyps were assessed. Results Among the consecutive 2000 patients who underwent colonoscopy during the study period, 135 (6.75%) had sporadic colonic polyps. These 135 patients had a total of 251 colonic polyps and histology report was available for 222 of them. Mean age of patients was 52+18.1 years and 71.1% were males. Majority (88,62.8%) of the patients had single polyp. Common indications for colonoscopy were altered bowel habits (25.2%), lower GI bleeding (21.5%) and surveillance in patients with prior polyps (20%). Most of the polyps were sessile (60.2%) and located in the left colon (60.2%). Majority were <1cm in size 189 (75.3%) and were adenomatous (56.3%) or inflammatory (25.7%). Other types included hyperplastic (9.9%), juvenile (4.1%), Peutz-Jeghers (0.9%), serrated (0.9%) and lipomatous polyps (0.9%). In adenomatous, tubular variety was more common (80.8%) and 12% showed features of high-grade dysplasia. Synchronous cancer was found in 8 patients. Risk factors for adenomatous polyps are shown in Table1. Introduction A gastrointestinal polyp is a discrete mass of tissue that protrudes into the lumen of the bowel wall. It is postulated that certain varieties of colonic polyps turn malignant over a period of time. The most common precursor of colorectal cancer is adenoma. The biggest concern is their ability to progress into carcinoma, through the adenoma-carcinoma sequence. In this retrospective study we analyzed clinical features, location, pattern of distribution, histopathological types of polyps and its association with severity of dysplasia.

Methods We retrospectively analyzed data of patients diagnosed to have polyps who had undergone colonoscopy between January 2016 to December 2019 in our hospital. We analyzed the association between age, sex, location of polyps, histopathological types and correlated size of polyps with degree of dysplasia.

Results Among the 2595 complete colonoscopies 140 (5.39%) patients were found to have colonic polyps. Mean age of the study population was 53.97 years and majority were men (69.2%). 48.69% polyps were located in rectum and 34.78% were seen in sigmoid colon. Commonest histopathological type was Adenomatous polyps in 64 (45.7%) followed by inflammatory in 41 (29.2%), hyperplastic in 23 (16.4%), juvenile in 10 (7.14%), hamartomatous and Peutz-Jeghers polyp in 1 each (0.71./.). 83% of polyps with size (>2 cms) and 57.1% of polyps with villous histology were associated with severe dysplasia. Conclusion Adenomatous polyps were the predominant histologic type similar to the west. Among the adenomatous polyps larger polyps (>2 cm) were more commonly associated with severe dysplasia. Polyps with villous histopathological variant were associated with severe dysplasia.

Demographic, etiological and histopathological profile of ileo-colonic ulcers from a tertiary care centre in North India

Background Data on ileocolonic ulcers due to inflammatory bowel diseases (IBD) is extensive. We retrospectively studied demographic profile and etiology of non IBD related ileocolonic ulcers over 6 months in patients undergoing colonoscopy for various reasons. Methods All patients undergoing colonoscopy from July 2019 to December 2019 and diagnosed as non IBD ulcers were included. The demographic, clinical, radiological data was extracted from patient case files. The endoscopic location of ulcers and their histopathological diagnosis were assessed. The data entry and analysis was done using SPSS version 23. Results A total of 101 patients of ileocolonic ulcers were included with median age of 38 (range 6-75) yrs. There were 61 males and 40 females. Abdominal pain (n=73) was the most common symptom followed by diarrhea (n=33), bleeding PR (n=28) and fever (n=17). Drug intake history was present in (n=22) patients. Ileocecal thickening with lymphadenopathy on computed tomography was the common radiological finding requiring colonoscopy. Cecum (n=29) was the most common location of ulcers followed by ileum and rectum (n=25) each. Ulcers were present at more than one location (n=13), with most common being combined ileocecal involvement (n=4). Histopathological examination revealed non-specific colitis/ileitis (n=60, 59.4%) as the most common cause followed by amebic as well as solitary rectal ulcer syndrome (SRUS) (n=12, 11.9%) each. Tubercular ulcers were present in 9 patients (8.8%). Infectious colitis and drug induced ulcers in 5 and 1 patient (NSAID related) respectively. Benign appearing ulcers were reported as malignant in 2 patients. Conclusion Abdominal pain, diarrhea and bleeding PR were the common symptoms. Most common non IBD related ileocolonic ulcers were nonspecific/idiopathic. Amebic and SRUS were the next common cause followed by tuberculosis. In 2 cases we had benign appearing ulcers which were histopathologically malignant.

Introduction Response to vaccine in Patients with inflammatory bowel disease (IBD) seems to be considerably lower than in general population, probably because of nature of disease and immunosuppressive regimens used. Aim Aim of this study was to evaluate the efficacy of hepatitis B (HBV) vaccination in patients with ulcerative colitis (UC) vs. controls. Method This is a prospective cohort study. One hundred IBD-UC cases and 100 healthy controls were taken. UC patients with no prior history of HBV vaccination between 18 to 60 years of age were included. HBV vaccination was given to all the cases and controls at 0/1/6 months. Anti-HBs titres were done 4 weeks after 1st and 3rd dose vaccination. Adequate immune response (AIR) was considered if anti-HBs titre was >10 IU/mL and effective immune response (EIR) if anti-HBs titre was >100 IU/mL. Result Total of 100 (59 male, 41 female) patients with IBD-UC and 100 (54 male, 46 female) healthy controls were included (p=0.47). Mean age for cases and controls was 33 ± 11 and 36 ± 10 respectively (p<0.05). AIR was significantly lower in cases than in controls (82% vs. 96%, p=0.003). EIR was also significantly lower in cases than in controls (41% vs. 66%, p=0.0007). Sixty-four percent IBD patients were on immunosuppressive therapy before vaccination. Among the IBD patients who were taking immunosuppressant AIR was 72% and EIR was 23%. Among the IBD patients who were not taking immunosuppressant AIR was 100% and EIR was 72%. Conclusion Response rate of IBD patients receiving HBV vaccinations were significantly lower compared to controls. Response rate of those receiving immunosuppressive therapy was also low.

Etiological spectrum of intestinal obstruction In North India in gastroenterology practice 

A retrospective single blinded study comparing efficacy of six months versus nine months antitubercular treatment in intestinal tuberculosis

Introduction The duration of treatment in intestinal tuberculosis, whether six months or more than six months, remains a dilemma. We conducted this study to assess efficacy of six months vs. nine months antitubercular treatment (ATT).

Methods Retrospective, single blinded, single center study was done in out patient department to evaluate efficacy of 6 months vs. 9 months of daily administered directly observed ATT. One hundred patients with intestinal tuberculosis who received ATT either for 6 months (n=55; 55%) or 9 months (n=45; 45%) were included and both pre-treatment as well as post-treatment details of clinical features, radiologic evaluation, endoscopic examination, histopathologic findings and special investigations like Gene Xpert and MGIT were noted. Patients from both the groups were observed for adverse drug events (nausea, vomiting, abdominal pain, ATT hepatotoxicity). Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE is a serious complication of IBD that carry significant cost, morbidity and mortality. Certain risk factors such as active disease, immobilization and drugs increases the risk. Thromboembolism in IBD is either overlooked or delayed as patients new symptoms are attributed to their disease severity or side effects of drugs. We present a case of 22 years old male patient presented in OPD with complains of chronic diarrhea and bilateral lower limbs swelling and breathlessness. On workup patient was diagnosed as a case of active Crohn's disease. Bilateral lower limb swelling is common in IBD patients due to malnutrition (anemia and hypoalbuminemia), in our case it was found to be due to extensive bilateral lower limb deep vein thrombosis also and breathlessness was due to pulmonary embolism. Bilateral deep vein thrombosis extending up to inferior vena cava (IVC) with pulmonary embolism is a rare finding which was seen in our patient. Balloon angioplasty of IVC was done with placement of a self expandable stent and IVC filter. In conclusion VTE has substantial morbidity and mortality and when IBD patients presents with a new symptom complex thromboembolic phemonenon needs to be considered.

Are all colonic thickening on CT worrisome -A tertiary care experience Background and Aim Increasing use of abdomino-pelvic CT for various indications has greatly increased the diagnosis of bowel wall thickenings. We aim to find out the correlation between bowel thickening with subsequent colonoscopic and histopathological findings. Methods Data of patients referred for colonoscopy on basis of Colonic thickening on CT were collected retrospectively between January 2019 and April 2020 and their histopathology reports were traced. Patients undergoing CT for known GI disease or known malignancy were excluded. Results A total of 320 patients were identified. Mean age of patients was 37.8 years (15-80) with male to female ratio of 0.7:1. The most common location of thickening was ileocecal (62.5%, n=200), followed by ascending colon (13%, n=42) and rectosigmoid (10.9%, n=35). Colonoscopy was normal in 29% cases. More than 75% patients under age group <40 yrs had ileocecal thickening and 42% of them had normal colonoscopy. The most common colonoscopic abnormality found was presence of ulcers and erosions (n=82, 25.6%), followed by stricture (n=67, 20.9%) and growth (n=52, 16.25%). Other less common findings included diverticulosis, telangiectasia, pseudomelanosis coli. Nonspecific colitis was most commonly reported in patients with ulcers (57.8%). Tuberculosis was diagnosed in 17.5% (n=56) mostly in pts with strictures (63%). The diagnosis of IBD was made in 23 patients (7.18%). Malignancy was found in 16.56% patients. Adenocarcinoma was most common (> 95%) followed by lymphoma, metastatic and NET in remainder Two patients had eosinophilic colitis. The diagnosis of malignancy was significantly more present in age group >40 yrs with only 5.3% cases less than 40 yrs had malignancy, most common site in them being rectosigmoid.

Conclusion Ileocecal thickening remain the most common reported site of thickening in CT. However, a significant proportion of patients may have normal colonoscopy and many have non-specific colitis on histopathology especially in younger age group patients.

Fecal calprotectin levels in patients with diarrhea at the tertiary care hospital of Uttarakhand On examination she was anemic and mild left iliac region tenderness. Initially upper GI scopy done which showed clean based duodenal ulcer. But as she continued to bleed and was on inotropic support, bedside colonoscopy was done which revealed large irregular ulcer 3 cm overlaid with exudates in rectum and multiple clean based ulcers in cecum. The distribution was unlikely to be ischemic in origin. Histopathological examination of colonic ulcers biopsies revealed invasive intestinal mucormycosis. Patient showed full clinical resolution after course of parenteral Amphotericin B followed by oral posaconazole. She had an uneventful recovery and on follow-up after 2 months, she was in good health. Mucormycosis is life threatening opportunistic invasive fungal infection caused by mucorales of class Zygomycetes. It's commonly seen in immunosuppressed cases like diabetes, organ transplantation, Human immunodeficiency virus infection and those on immunosuppressive medications. Gastrointestinal mucormycosis has high mortality rate. Conclusion Invasive Intestinal Mucormycosis is a rare cause of hematochezia in immunocompromised individuals. Timely diagnosis and treatment with antifungals plays a major role in reducing mortality. A good histopathological examination including IHC markers (if needed) for all colonic ulcers and to have high index of suspicion plays a crucial role for diagnosis Introduction Acute flare of ulcerative colitis is a life-threatening condition carrying high morbidity and mortality. We aim to find out the profile of patients presenting with ASUC and assess response to treatment. Methods A prospective study was conducted between January 2019 and May 2020. All patients admitted with acute flare of ulcerative colitis as defined by the truelove and Witts criteria were included in our study.

Patients were investigated and treated according to standard guidelines and were followed for 4 weeks. Results A total of 66 patients were evaluated. Baseline characteristics are listed in Table1. The average duration of disease was 4.6 years (2 months -18 yrs). Fifteen patients (22.7%) had recent onset disease symptoms with mean duration of 2.5±0.4 months. The most common cause of flare was treatment default in 30.3% (n=20) followed by Cl. difficle infection (15.15%, n=10) and CMV infection in 10.6% (n=7). Two patients had recent h/o NSAID intake and one patient had amoebiasis. In remaining cases no obvious cause was identified. About 50 patients (75.7%) achieved clinical remission with IV steroids. In remaining 16 patients rescue therapy was initiated of which 12 patients (75%) responded. Three patients required surgery and there was one mortality. Rescue therapy was needed more frequently in patients who had E3 disease, became steroid dependant early in their disease course with no obvious cause of flare (60%). Albumin < 2.4 g/dL and CRP level >77 mg/dL at D3 of steroids had significant association with steroid non responsiveness (p<0.05). Conclusion The most common cause of flare in our cohort of patients was treatment default followed by Clostridium difficle infection. Low albumin and high CRP at day 3 along with prior steroid dependence had significant association with failure to steroid response. Methods We analyzed data from randomized controlled trials (RCTs) evaluating induction of remission in adults with UC treated with anti-TNF (infliximab and adalimumab), anti-integrin (vedolizumab), anti-IL23 (ustekinumab), Janus kinase (JAK) inhibitors (tofacitinib), and FMT, compared with placebo or another active agent.

Results Overall nineteen studies were included, among which there was only one head to head RCT (adalimumab vs. vedolizumab). All interventions including FMT were superior to placebo in inducing clinical remission (except adalimumab-OR 1.66; 95%CI, 0.97-2.85), clinical response and endoscopic remission. FMT was comparable with other agents for all efficacy outcomes including clinical remission and response, and endoscopic remission. Infliximab was ranked highest in inducing clinical remission (SUCRA, 0.8), vedolizumab in clinical response (SUCRA, 0.9) and tofacitinib in endoscopic remission (SUCRA, 0.9). There was no difference in safety outcomes between FMT and other targeted therapies, among which ustekinumab ranked the safest.

Conclusions FMT is effective than placebo in inducing remission and appears to be as effective and safe as targeted therapies in inducing remission in patients with active ulcerative colitis. Further studies needed for definitive conclusion and the cost effectiveness of FMT with targeted therapies needs to be analyzed.

Utility of noninvasive markers in predicting mucosal healing in ulcerative colitis -A longitudnal follow-up study

Introduction 'Treat to target approach' is the current approach to management of ulcerative colitis (UC). Mucosal healing and histological remission are the targets associated with better long-term outcome but their assessment requires invasive tests. Hence, this study was conducted to determine the utility of noninvasive biomarkers in predicting mucosal healing in UC.

Methods It was a longitudinal follow-up study conducted on newly diagnosed acute UC or a relapse of pre-existing UC between September 2018 and February 2020. The disease activity was assessed using clinical, Mayo endoscopic sub-score (MES) and histological scores at baseline and at remission. Biomarkers such as ESR, CRP, fecal calprotectin, serum NGAL and 24-hour urinary potassium were estimated at baseline and at clinical remission. The correlation of biomarkers with mucosal healing (MES of 0 or 1) was analyzed using Chi-square or Fisher's exact test.

Results During the study period, 40 patients were recruited with a total of 43 episodes of flare. The mean age (SD) of study population was 35 (10) years. At baseline, majority had moderate or severe disease activity by clinical score (88%) as well as by MES (93%). At clinical remission, there was a significant reduction in fecal calprotectin (p=0.036), serum NGAL (p=0.002), ESR (p= < 0.001), and CRP (p= 0.002) and a significant increase in 24-hour urinary potassium (p=0.001) from baseline. The change in levels of all the biomarkers were also significantly associated with mucosal healing at clinical remission. Fecal calprotectin was the only biomarker that significantly correlated with mucosal healing (p=0.03). Delta calprotectin with cut off of 77μg/g had a significant AUC (0.738) for predicting mucosal healing with a sensitivity of 0.77 and specificity of 0.72. Conclusion Our study confirmed that changes in the level of biomarkers after treatment could predict remission in UC. Fecal calprotectin correlated well with mucosal healing.

Introduction Cronkhite-Canada syndrome (CCS) is a rare cause of gastrointestinal (GI) polyposis syndrome presenting with protein losing enteropathy and diarrhea. Here we report one such case.

Case presentation A 42-year-old female presented with abdominal pain, vomiting, frequent loose watery stools for the last six months and generalized body swelling, excessive fatigue, and decreased appetite for one month. She also noticed increasing hair fall, decreased taste sensation, nail changes and patchy skin darkening all over the body. Physical examination revealed anasarca, frontal alopecia, finger and toenails dystrophy, and diffuse hyperpigmentation of the skin. Laboratory investigations showed anemia with hemoglobin 9.5 g/dL (12-14 g/dL), hypoproteinemia with serum protein 3.4 g/dL (6-8 g/dL), hypoalbuminemia with serum albumin 1.2 g/ dL (3.5 -4.5 g/dL) and hypokalemia with serum potassium 2.8 mg/ dL (3.5-4.5 mg/dL). Ultrasound revealed mild ascites and mild bilateral pleural effusion. Esophagogastroduodenoscopy showed numerous nodular and polypoid lesions in stomach, first and second part of duodenum. Ileocolonoscopy also revealed numerous polyps throughout the colon and terminal ileum. Segmental biopsies from stomach, duodenum, ileum and colon were taken. Evaluating her for protein losing enteropathy, the characteristic ectodermal and endoscopic findings made us to think of a rare GI polyposis syndrome known as CCS. Our diagnosis was further confirmed on histopathology of GI polyps which revealed hamartomatous polyps with intervening mucosal biopsies remarkable for marked edema, mild lymphoplasmacytic infiltrates, and cystically dilated glands with inspissated mucin. She showed dramatic response to steroids (prednisone 40 mg daily for 1 month) followed by tapering over 2 months with overlap of azathioprine 50 mg. She is asymptomatic for last 18 months on azathioprine 50 mg.

Conclusions To the best of our knowledge, CCS is the only gastrointestinal polyposis syndrome which responds to steroids.

Introduction Nocardia is an emerging infection in the era of biological therapy with a fatal outcome without treatment. Risk of dissemination and multisystem involvement demands an early diagnosis from the treating physician. To the best of our knowledge, nine cases have been described in immunosuppressed inflammatory bowel disease (IBD). Case Description We are sharing our experience with such opportunistic infection (pulmonary nocardiosis) in a 23-year-old male with Crohn's disease on Inj. Adalimumab. He received anti tubercular therapy for six months without improvement before presenting to our center. For ileocolonic Crohn's disease, he initially received prednisolone (60 mg/day) and azathioprine (100 mg) for symptoms control. During tapering of steroid, relapse of the disease occurred so injection Adalimumab was initiated. There was overlapping period of two weeks when he was on inj. Adalimumab, steroid and azathioprine. After receiving two doses of inj. Adalimumab (160 mg, 80 mg), he again presented with fever for 2 days with dry cough. CECT revealed multiple loculated pleural space collections with well-defined abscess formation along mediastinal pleura in 9, 10 and 11th intercostal spaces invading muscles. Pleural fluid aspiration was purulent in infra-axillary pocket. Gram staining suggested bacilli with filamentous elements and on modified acid-fast staining branching bacilli were seen. MRI brain was normal.

Management Patient was managed with Inj. Meropenem and Inj Linezolid followed by Tab. Cotrimoxazole for 6 months. Inj. Adalimumab was reinitiated as he developed perianal disease with continued Cotrimoxazole prophylaxis without recurrence.

Conclusion Human nocardiosis is a rare opportunistic bacterial infection. The optimum duration of antibiotic therapy is uncertain but 1-year therapy seems to be advisable. The safety and timing of re-initiation of biological therapy remains unsettled. Results A total of 241 cases were studied. 58.9% of the patients were males and 41.1% were females. Significant 26.1% cases were reported in young adults less than 45 yrs. 71.4% of patients had bleeding PR as primary complaint in age group <45 yrs., 85% patients had left sided lesion and rectum as the most common site of primary lesion in age group <45 yrs, adenocarcinoma was most common accounting for 95.4%, 79% presented in advance stage in age group < 45 yrs.

Conclusions An increased incidence of colorectal carcinoma was seen amongst younger individuals in our study group. It is possible that CRC in our study is of a different phenotype as compared to the West. Moreover, in light of a significant number of young patients presenting with advanced CRC in our study, it is advisable to recommend for an early screening protocol for CRC in our population.

Objective assessment of the rectal effluent before colonoscopy gives fairly good idea about the quality of bowel preparation Multiple factors including color and consistency of the rectal effluent determine the quality of bowel preparation during colonoscopy. Patients verbal statement regarding color and consistency of the rectal effluent always does not give the idea of real picture. Our aim was to correlate the objective assessment of the color and consistency of rectal effluent with the quality of bowel preparation along with other factors such as preprocedural diagnosis, comorbid illnesses, amount of bowel preparatory agent consumed and runway time. 10 mL of the last rectal effluent was collected in plastic specican for visual inspection and grading for the color and consistency. Ottawa bowel preparation scale was used to assess the adequacy of bowel preparation. A pilot study involving 11 patients showed that objective assessment of color and consistency of the rectal effluent were good predictors of bowel preparation. This observation may help in improving the quality of bowel preparation and avoid hustle in colonoscopy room.

An unusual etiology of a left colon "tumor"

Rahul Deotale, Deepakkumar Gupta, Amey Sonavane, Aabha Nagral, Shankar Bhanushali Correspondence-Rahul Deotale-rahuldeotale23@gmail.com Department of Gastroenterology, Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India

Ameboma is a tumor-like mass involving whole thickness of the bowel wall and a rare manifestation of intestinal amoebiasis. We report an ameboma of left colon masquerading as an intra-abdominal mass.

A 72-year-old man presented with loose motions a month prior to presentation: 2-3 episodes/day, not associated with blood per rectum and lasted for 7 days, followed by fever with chills, breathlessness and pain in epigastric and left hypochondriac region. Physical examination of the abdomen revealed a 10 x 6 cm firm, tender, immobile lump in the left upper quadrant. Blood investigations showed Hb 9.4 g/dL, WBC of 29,450/μL, N 88%, platelet count of 551 x 103/μL. CECT of the abdomen showed circumferential wall thickening causing moderate luminal narrowing of colon (12-13 cm length) near splenic flexure with no leakage of contrast and no evidence of proximal dilatation, few subcentimetric sized enhancing lymph nodes in paracolic region. A possibility of neoplastic etiology was raised. Colonoscopy showed ulceroproliferative lumen occluding lesion suspicious of malignancy. Histopathology of the biopsy from the involved area revealed necrotic mass, fibrinous and granulation tissue. The patient was treated with left hemicolectomy with ileostomy and parenteral metronidazole. Colonic specimen showed necrotic mass, fibrinous and granulation tissue with multiple trophozoites of Entamoeba histolytica with small eccentric nucleus and cytoplasmic vacuole containing red blood cells. Patient is well on follow-up for 7 months. Amebomas are most commonly found in cecum and ascending colon. They are usually solitary with variable size and may measure up to 15 cm in diameter. Men, between 20 and 60 years of age, are most commonly affected. The exact incidence of ameboma is unknown with only isolated case reports.

Conclusion "Ameboma" should be considered in the differential diagnosis of colonic tumors presenting with fever and diarrhea, especially in countries with high prevalence of amebiasis. Introduction Inflammatory bowel disease (IBD) is caused by immune dysregulation of the digestive tract that results in chronic inflammation. Ulcerative colitis and Crohn's disease are the two major forms of idiopathic IBD. Endoscopy (and histology) remains the gold standard method for detecting and assessing bowel inflammation. Nevertheless, it has the disadvantage of being invasive, time consuming and not well tolerated by patients. Within the last years various laboratory markers have been investigated in search to provide non-invasive, cheap and rapid methods able to help in assessment of IBD activity. The most widely used laboratory parameters of inflammation, such as ESR and CRP resulted not sufficiently specific or sensitive and poorly correlated with symptoms and disease activity index. On the other hand, a series of studies indicate fecal calprotectin as the most useful marker able to quantify bowel acute inflammation. We propose to undertake a study to find out the correlation of fecal calprotectin levels with clinical, endoscopic and histological indices currently in use to classify the severity of IBD. Methods Total number of 60 patients with IBD were studied to find out correlation of fecal calprotectin levels with endoscopic index, clinical index, histological index currently in use to classify the severity of IBD.

Results Among total number of 60 patients of IBD 40 patients were of UC (57.5% patients were male) and 20 patients were of CD (65% patients were male).

Conclusions Fecal calprotectin levels correlate well with disease activity scores in ulcerative colitis and Crohn's disease.

Introduction Anorectal malignant melanoma (ARMM) is an uncommon and aggressive disease. It accounts for only 0.4% to 1.6% of all melanomas and less than 1% of anal canal tumors. They tend to occur more often in women than men with peak incidence in the sixth and seventh decade. We report a much rarer scenario of a young male presenting with bleeding per rectum treated as hemorrhoids found to have anal melanoma on further evaluation.

Case report A 32-year-old male patient presented with blood in stools and anal mass of one month duration. DRE -mass protruding from anus. Colonoscopy revealed polypoidal lesion in the anal canal just above the dentate line suggestive of hemorrhoid for which he underwent hemorrhoidectomy. The specimen sent for HPE revealed nests of epitheloid and spindle like cells with brisk mitosis -10% of cells showing melanin pigmentation. IHC with HMB45 and S100 found to be positive diagnostic of ARMM. MRI revealed circumferential wall thickening in anal canal with no evidence of nodal spread (AJCC stage 1). He further underwent Wide local excision and under follow-up.

Discussion Anorectum is the third most common location of malignant melanoma after skin and retina. The common initial symptoms are bleeding PR, anal mass, tenesmus, change in the bowel habits. ARMM most often misdiagnosed as hemorrhoids, polyp or adenocarcinoma. Confirmed by IHC panels S-100, Melan A, HMB-45. It is staged as stage I (local disease), stage II (local disease with regional lymph nodes), stage III (with distant metastasis) by CT, MRI, PET. Surgical approaches include Wide local excision and abdomino perineal resection. Conclusion Anorectal malignant melanoma though uncommon and described in elderly females, this case report suggests it can present in young males. Due to its polypoid appearance and lack of obvious pigmentation in majority of cases misdiagnosed as hemorrhoids/polyps. High index of suspicion is warranted in this innocuous looking lesion as it is an aggressive neoplasm with local invasion and distant metastasis.

Keywords Anorectal malignant melanoma, Misdiagnosed hemorrhoids, HMB45, S100.

Surgical technique to prevent redundancy after colon interposition for corrosive stricture of the esophagus Background In 1911, Vuillet and Kelling independently described the anatomical and surgical bases for the use of the colon for esophageal replacement and currently retrosternal coloplasty is the gold standard for post corrosive esophageal replacement. An important complication, in particular in later follow-up, is redundancy of the interposed colon, seen more after retrosternal interposition. The objective of this study is to share our experience of colon interposition for corrosive stricture of the esophagus in 150 patients within duration of 09 years and use of twopoint fixation technique in 25 patients to prevent redundancy of colon conduit.

Methods This was a retrospective study of colon interposition for corrosive stricture of esophagus in 150 patients from March 2011 to March 2020. Results There were 112 female and 38 male (3:1) patients; the mean age was 30.6 years (ranges from 21 to 47 years); 130 patients had suicidal and 20 patients had accidental ingestion; mean hospital stay was 14.5 days (range 10 to 25 days) and mean operative duration was 4.5 hours (range 2.5 to 7 hours). In our study, out of 150 patients with 10 deaths and 01 patient lost in follow-up, more than 80% patients (n=114) had 'good' result, 09 patients had 'fair' and 01 patient had 'poor' result. After using two-point fixation technique in 25 patients, we did not encounter any subjective or objective (barium swallow) evidence of redundancy in any patients during follow-up period of 2.5 years.

Conclusion Colon redundancy is the most common late morbidity and second most common complication that required surgical correction with inherent morbidity and mortality of revision surgeries. Our two-point fixation technique is refinement of already performed and tried fixation techniques to prevent redundancy of colon conduit considering kinetics, anatomical alignment and pathology. Keywords Redundancy, Colon interposition, Corrosive stricture, Twopoint fixation technique

Introduction Enteric fever is a systemic infection caused by gram negative bacillus salmonella typhi or paratyphi. It's a feco-orally transmissible disease endemic in southeast Asia. The most serious complications are intestinal ulceration, bleeding and perforation seen in 3rd week. We report a rare case of typhoid fever with atypical distribution of ulcers on colonoscopy.

Case report A 52-year-old man presented to us with high grade fever and loose stools since 10 days. On admission he was febrile and had relative bradycardia. Abdominal examination revealed mild periumbilical tenderness. Routine blood investigations showed a leukocytosis (11,900 cells/ cumm) with lymphopenia (12.5%), elevated alanine transaminase (79 IU/ L) and C-reactive protein (62.5 mg/L). Colonoscopy revealed variable sized ulcers with punched out margins throughout the colon including rectum and an ulcer with everted erythematous margins noted in terminal ileum extending up to ileocecal valve raising the possibility of Crohn's disease or intestinal tuberculosis. TB PCR was negative. Histological examination revealed features of active colitis with cryptitis and crypt abscess suggestive of infective etiology. Blood and stool cultures revealed growth of Salmonella typhi. He became asymptomatic after treatment with IV ceftriaxone 2 grams for 10 days and Tab. azithromycin 1 gram for a week.

Discussion The classical colonoscopic findings in Typhoid are multiple round and oval punched-out ulcers along the long axis of bowel with elevated margins. The most common site for typhoid ulcers is the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%) with sparing of left colon. Our patient had involvement of left colon along with rectum. Conclusion This case highlights the importance of considering Typhoid fever as a differential for diffuse colonic ulcers.

Keywords Typhoid fever, Colonic ulcers, Rectum

Non-invasive assessment of cardiovascular risk using carotid intimamedia thickness in patients with inflammatory bowel disease: Does non-alcoholic fatty liver disease add on to the risk?

Introduction We compared the carotid intima-media thickness test (CIMT) of patients with IBD and controls without IBD to know the association between subclinical atherosclerosis in IBD and the cardiovascular risk. We also looked at whether NAFLD is an important factor affecting CIMT in IBD. Methods Descriptive study on 80 patients with IBD and 80 subjects without IBD conducted in a tertiary care hospital. Subjects aged more than 55-years, obese individuals, patients already diagnosed with cardio/cerebrovascular disease and those with other chronic inflammatory conditions were excluded. CIMT was measured using B mode Doppler imaging. Presence of fatty liver and shear wave elastography of the liver were assessed. The quantitative data were compared using students t test and the qualitative data by Chi-square test. Pearson and Spearman correlation was done to find out the factors correlating with CIMT.

Results Age, sex distribution and traditional cardiovascular risks (hypertension, diabetes and dyslipidemia) were comparable in both groups. The CIMT was higher in patients with IBD as compared to controls (0.532±0.091 vs. 0.476±0.038, p=000). On analyzing the factors affecting CIMT in patients with IBD, those with NAFLD as an extra intestinal manifestation had increased CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP and ultrasound grades of fatty liver had positive correlations with CIMT. There was no change in CIMT with disease type (UC/ CD), extent of disease, disease activity or severity of disease. Multivariate regression analysis showed that age and ultrasound grading of fatty liver (R2=0.576, p=000) were independent predictors of CIMT.

Conclusion We found that CIMT was increased in patients with IBD as compared to controls. Age and NAFLD were independently associated with increased CIMT in IBD. Patients with IBD especially those with NAFLD may require enhanced monitoring for cardiovascular events. Introduction Colorectal cancer (CRC), the third major cause of mortality among various cancer types in United States, has been increasing in developing countries due to changing lifestyle and dietary habits. Colorectal cancer is largely asymptomatic until alarming features develop to advanced stages. The implementation of the screening program is very much essential to reduce cancer incidence and mortality rates. N-Myc downstream-regulated gene 4 (NDRG4) is a novel candidate tumor suppressor and related to carcinogenesis.

Aim To study the NDRG4 protein expression in neurons of myenteric plexus of colorectal tissues. Methods Samples collected from 22 patients undergoing surgery for colorectal adenocarcinoma in department of gastrointestinal surgery and 8 normal colon tissues from the department of forensic medicine, All India Institute of Medical Sciences, New Delhi, after obtaining ethical clearance. Tumor grading determined by pathologist and tissues were processed. Colonic tissues from the cancer site and normal specimens processed for paraffin blocks and 3μm thick sections used for H&E and immunohistochemistry (antibody used anti-NDRG4 antibody).

Results H&E stained sections showed infiltration of tumor cells in submucosa, inner circular muscle and in vicinity of myenteric plexus. Increase in the number of inflammatory cells in myenteric ganglia appeared with increasing grades of colorectal adenocarcinoma. Immunohistochemistry results showed the decreasing pattern of expression of anti-NDRG4 antibody in neurons with increasing grades of colorectal adenocarcinoma as compared to normal human colonic tissue.

Conclusion These results proved that NDRG4 could be a potential tumor suppressor and prognostic marker for colorectal cancer. Introduction Colorectal carcinoma (CRC) is one of the most common carcinoma of gastrointestinal tract in the. CRC develops from the epithelium of the colon or rectum and are mainly adenocarcinoma (≥ 90%). Nerve growth factor (NGF) is an essential neurotropic factor for the survival and maintenance of neurons. There is an important role for NGF in maintenance of gut integrity. The role of NGF in cancer development and progression has been reported in gastric mucosa and pancreatic cancers but in colorectal cancer is unknown.

Aim To study expression of nerve growth factor (NGF) in myenteric ganglia of the colorectal carcinoma in human.

Objectives To evaluate the expression of NGF in colorectal carcinoma tissue by haematoxylin and Eosin (H & E) and immunohistochemistry by anti-NGF antibody. Methods Samples collected from 22 patients undergoing surgery for colorectal adenocarcinoma in department of gastrointestinal surgery, All India Institute of Medical Sciences, New Delhi. Tumor grading determined by pathologist and tissues were processed. Sections processed for paraffin blocks and 3 μm thick sections used for H&E and immunohistochemistry (antibody used anti-NGF antibody: neuronal markar).

Results H&E stained sections showed myenteric plexus containing myenteric ganglia (MG) located between the inner circular muscle (CM) and outer longitudinal muscle (LM) layers of the muscularis externa in all grades of adenocarcinoma tissue sections and invasion of tumor cells and increase in the number of inflammatory cells in the myenteric ganglion appeared to increase with different grades of colorectal adenocarcinoma. Immunohistochemistry results showed the increase expression of anti-NGF antibody with in poorly differentiated adenocarcinoma.

Conclusion It is concluded that loss of neuron and neurodegeneration takes place in colorectal adenocarcinoma which is of supreme importance in understanding the problems of CRC patients who suffer from many GI symptoms. Expression of NGF in myenteric ganglion in different grades of adenocarcinoma.

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Hepatitis C treatment in the era of directly acting antivirals-An encouraging scenario!

Correspondence-Mayank Jain-mayank4670@rediffmail.com Department of Gastroenterology, Arihant Hospital and Research Centre, 283-A, Gumasta Nagar, Scheme 71, Indore 452 009, India

Introduction The availability of directly acting antivirals (DAA) has revolutionised the management of hepatitis C in developing countries like India.

Aim of the study To determine the spectrum of hepatitis C related liver disease and response to treatment using generic DAAs.

Methods The study is a retrospective analysis of prospectively collected data from a cohort of adult (>18 years) patients with hepatitis C infection. Patients with hepatocellular carcinoma, co infections with hepatitis B, HIV and those with incomplete data were excluded. The data analyzed included the severity of liver disease, treatment offered and response rates.

Results A total of 106 patients (84 males, median age 55 [22-80 years]) formed the study cohort. Eleven cases (10.4%) had received prior treatment with interferon based regimens but did not attain SVR. Twelve patients (11.3%) were on maintenance hemodialysis. Eight cases (7.5%) were patients with thalassemia major on regular blood transfusions. Genotype 3 (53.7%) and 1 (37.7%) were commonly noted. Sustained virological response was documented in 101 cases (95.3%) Conclusion DAA drugs are highly effective in management of hepatitis C infection across a wide spectrum of clinical presentations.

Acute HBV or chronic HBV with acute flare: Distinguishing clinical, biochemical, immunonological and virological parameters

Introduction Acute HBV infection and chronic HBV infection presenting as acute illness have differing prognosis. Differentiation between acute viral hepatitis B (AVH-B) and chronic hepatitis B with an acute exacerbation (CHB-AE) is difficult if prior HBsAg status is unknown. This prospective study was undertaken to screen various factors which could help with this differentiation. Methods All consecutive patients presenting with AVH-B like illness were enrolled in this study and were evaluated as per predefined study protocol. Patients were presumptively divided into AVH-B and CHB-AE groups based on HBsAg status at the end of 6 months. Results Significant differences in clinical and laboratory parameters were found between AVH-B and CHB-AE. No statistically significant difference in prodromal symptoms and jaundice was seen. Ascites (40%) and hepatic encephalopathy (10%) were seen only in patients with CHB-AE patients (p=0.002 and 0.244 respectively). IgM anti-HBc levels ≥10.15 (S/CO) had PPV and NPV of 90% for diagnosis of AVH-B. HBV DNA levels ≥25032 IU/ML has 62.5% PPV and 69% NPV for diagnosis of CHB-AE. Alpha-fetoprotein at > 22.5 ng/mL for diagnosing CHB-AE has PPV and NPV of 83% and 62% respectively. All six mortality were seen in CHB-AE group with median survival of two months.

Conclusions Differentiation of AVH-B and CHB-AE is important as management and prognosis differs. Low IgM anti-HBc levels (22.5 ng/ mL) favors CHB-AE over AVH-B.

Evaluation of pro-inflammatory markers IL-6 and TNF-a and their correlation with non-alcoholic fatty liver disease Background Non-alcoholic fatty liver disease (NAFLD) is a condition in which excess fat accumulates in the liver of a patient with no history of alcohol abuse or other causes for secondary hepatic steatosis. The pathogenesis of NAFLD and non-alcoholic steatohepatitis (NASH) has not been fully elucidated. NAFLD consists of a complex spectrum of diseases, ranging from asymptomatic steatosis with possible aminotransferase alterations to NASH, cirrhosis, and also hepatocellular carcinoma. Pro inflammatory cytokines like IL-1, IL-6 and TNF-α play a major role in the pathogenesis of NAFLD. These cytokines also play a crucial role in the development of insulin resistance, which is a key factor in the pathogenesis of NAFLD. There is limited data on the association of IL-6 and TNF-α with NAFLD from India. Hence, we aim to assess the correlation of IL-6 and TNF-α with NAFLD.

Methods It was a cross sectional observational study which was conducted on 40 cases of NAFLD and 40 healthy controls. All relevant investigations and serum levels of IL-6 and TNF-α were measured. Statistical analysis was done using Pearson Chi-square/fisher exact test, student ttest (un-paired). Pearson correlation test was used to see the relationship between the variables.

Result The serum levels of IL-6 and TNF-α correlated significantly with NAFLD with a p-value of <0.001. The serum levels of IL-6 showed a significant correlation with the severity of NAFLD (p<0.001), but the same was not seen with TNF-α.

Conclusion Our study showed significant correlation of TNF-α and IL-6 with NAFLD, which suggested a proven role of these pro-inflammatory markers in the pathogenesis of this disease as shown in past studies. In future target-based therapy is new field of research.

Introduction Thyroid storm and acute liver failure are both independently associated with high mortality. Hepatic dysfunction in a patient with thyroid storm presents a diagnostic and therapeutic challenge. Case A young male presented with symptoms suggestive of acute liver failure. Examination revealed bilaterally enlarged thyroid gland. Initial laboratory investigations showed suppressed thyroid stimulating hormone (0.0009 μIU/mL), high triiodothyronine (1.7 ng/mL), tetraiodothyronine (24 μg/dL), and positive anti-thyroid peroxidase. Liver function tests revealed total bilirubin (15.6 mg/dL), direct bilirubin (14.24 mg/dL), AST 1327 U/L, ALT 1186 U/L, ALP 1023 U/L, and serum ammonia (> 400 μmol/L). Furthermore, the patient was found to be IgM anti-hepatitis E virus (HEV) positive. Other viral, metabolic and autoimmune profile was negative. USG abdomen was normal. Working diagnosis of acute liver failure due to HEV and thyroid storm was made.

In view of hepatic dysfunction methimazole and propylthiouracil were avoided and the patient was stabilized with Lugol's iodine and lithium, after which the patient underwent total thyroidectomy. Post-surgery patient had significant clinical improvement and he was put on oral thyroxine. Histopathology of the removed thyroid gland showed congested blood vessels with colloid filled spaces suggestive of adenomatous goitre. He achieved normal liver function on subsequent follow-ups. The anti-thyroid drugs methimazole (MMZ) and its prodrugcarbimazole (CBZ) and propylthiouracil (PTU) are often used as firstline treatment for hyperthyroidism. Because of a higher risk of causing severe liver injury by PTU, as highlighted in the U S Food and Drug Administration's boxed warning, CBZ is more preferred except during the first trimester of pregnancy (can cause birth defects) and in patients with an adverse reaction to methimazole.

The following case report of 60-year-old female, known case of hyperthyroidism, admitted for urgent evaluation of new-onset jaundice, pruritus, nausea, fatigue, and clay-colored stool for 15 days. As per the patient history and investigations, a probable diagnosis of a cholestatic pattern of drug-induced liver injury was made. CBZ was stopped and with the advice of the endocrinology department, lithium carbonate and propranolol were started. Clinicians should be aware that hepatotoxicity though rare, can occur with CBZ and should swiftly consider an alternative treatment strategy. Patients who take anti-thyroid drugs should be informed about the risk of liver injury and be advised to avoid other possible susceptibility factors such as alcohol consumption, which might hasten liver damage induced by their anti-thyroid medications.

Psoas muscle index: A simple and reliable method of sarcopenia assessment on CT scan in chronic liver disease Background L3-Skeletal Muscle Index (SMI) is a CT based conventional method for sarcopenia assessment. However, recently psoas muscle parameters have been proposed as a simple and quick method without need of a special software. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle quantification on CT scan. Methods One hundred and fifty patients were assessed for the psoas muscle on CT scan and psoas muscle index (PMI) was calculated: PMI = total psoas muscle area (mm)/(height) 2 (m). The cut off values for diagnosis of sarcopenia were derived from the local control group (n=75) who did not have CLD/other causes of sarcopenia. The case group included consecutive CLD patients (n=75) who underwent CT scan of abdomen. Hand Grip (HG) dynamometer was used to assess the HG strength.

Results Sarcopenia assessed by PMI was seen in 36% (n=27) of CLD patients. Ascites, hepatic encephalopathy (HE) and gastrointestinal bleed was seen in 48%, 18.7% and 24% respectively, among the cases. The association of sarcopenia was statistically significant with ascites and HE (p value < 0.05). Sarcopenia was significantly higher in patients with CHILD C. HG weakness was seen in 41.3% (n=31) and mid-arm muscle circumference was low in 25.3% (n=19) of CLD patients. Fifty-three out of 75 patients completed the follow-up period of 1 year. Out of patients with sarcopenia, 77.8% (n=7) succumbed to liver related illness, while 22.2% (n=2) without sarcopenia expired during follow-up. The association of 1-year mortality and sarcopenia was statistically significant (p value = 0.01). The Kappa measure of agreement between HG and sarcopenia assessment was 0.608 (good strength of agreement). Conclusions In conclusion, PMI sarcopenia proved to be a reliable predictor of mortality and HG dynamometer seems to be a good alternative for sarcopenia assessment. Background Norfloxacin is the most commonly used agent for the prophylaxis against spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. Rifaximin, another broad-spectrum antibiotic, is used for the treatment of traveller's diarrhea and hepatic encephalopathy.

Objective We aimed to test the efficacy of rifaximin versus norfloxacin for prevention of SBP in patients with hepatitis C virus (HCV)-related liver cirrhosis.

Methods One hundred patients with HCV-related liver cirrhosis and ascites were included in study and divided into two groups of matching age, sex and Child-Pugh class. Group I patients were given norfloxacin 400 mg/day and group II patients were given total dose of rifaximin 1200 mg/day in three divided doses. The follow-up time was one year.

Results Patients on rifaximin developed fewer episodes of SBP than those on norfloxacin (8% vs. 16% respectively) although it was statistically insignificant (p=0.265). Also, the duration before developing a new attack of SBP was longer in patients treated with rifaximin as compared to those taking norfloxacin (9.0 vs. 5.5 months, respectively). Additionally, rifaximin significantly reduced the rate of new compared to past episodes of SBP by 24% (p while the rate reduction with norfloxacin was only by 18% and not statistically significant (p= 0.45). Overall survival was equal in both groups. Conclusion Rifaximin isat leastas good as norfloxacin. It seems to be an appropriate alternative for long-term primary and secondary prophylaxis of SBP in cirrhotic patients with ascites.

Daclatasvir and half-dose sofosbuvir is an effective and pangenotypic treatment for hepatitis C virus infection in patients with estimated glomerular filtration rate Aim Sofosbuvir, the backbone of hepatitis C virus (HCV) treatment, use is controversial in patients with estimated glomerular filtration rate (eGFR) <30 mL/min. We report here off label treatment with daclatasvir and half daily dose of sofosbuvir in patients with eGFR <30 mL/min on real life experience with increase in sample size and data in continuation with previous data reported.

Methods Adult patient with eGFR <30 mL/min and detectable HCV RNA were screened. We included those who (i) started treatment with direct acting antiviral drugs (DAAs) between July 2013 and January 2020 (ii) had taken DAAs at least for four weeks and (iii) had reached one of the end points either during HCV treatment or up to 12 weeks after stopping the treatment (death; lost to follow-up; quantitative HCV RNA assay at 12 weeks after stopping the treatment, SVR12; relapse). All the patients, regardless of HCV genotypes, were treated with daily doses of daclatasvir 60 mg and sofosbuvir 200 mg. Patients with or without cirrhosis were treated for 24 weeks or 12 weeks respectively. Results Eighty-seven participants (age mean±SD 44 ± 12.9 years; male 63 [72%]) were included in final analysis. Two had compensated cirrhosis. The genotypes were tested for 67 (77%) participants. The HCV genotype 1, 3, and 4 were identified in 31 (36%), 34 (39%), and 2 (2%) respectively. Serum HCV RNA (log10) was 5.73±1.24 IU/mL. Seventy-seven (89%) achieved SVR12, 6 (7%) lost to follow-up, 2 (2%) died during treatment and 2 (2%) relapsed.

Conclusion Daclatasvir and half-dose of sofosbuvir is effective against all the HCV genotypes in ESRD patients. Conclusions Increased TLC, low serum albumin, increased creatinine levels and low ascitic fluid protein are associated with poor prognosis. Once SBP is diagnosed, serial ascitic fluid cell count is helpful in predicting prognosis and should be used to monitor treatment.

Study of cytopenias and neutrophil lymphocyte ratio in rodenticidal hepatotoxicity patients C E Eapen, Ajith C Kuriakose, B Vijayalekshmi, Lalji Patel, Uday Zachariah, Sukesh Nair Correspondence-C E Eapen-eapen@cmcvellore.ac.in Department of Gastroenterology, Hepatology, Transfusion Medicine and Immunohematology, and Wellcome Trust Laboratory, Christian Medical College, Vellore 632 004, India Introduction As clinical significance of cytopenias in rodenticidal hepatotoxicity patients is unclear, we aimed to analyse incidence of cytopenias, any complications due to cytopenias and prognostic role of cytopenias and neutrophil lymphocyte ratio (NLR) in these patients.

Methods We retrospectively analyzed prospectively collected data on rodenticidal hepatotoxicity patients managed in our department from December 2017 to June 2020. Adverse outcome of hospital stay was defined as death/discharged against medical advice (DAMA). We looked for complications due to cytopenias (bacteremia in leucopenic patients, bleeding in thrombocytopenic patients). Introduction Acute liver failure (ALF) and acute on chronic liver failure (ACLF) due to idiosyncratic drug-induced liver injury (I-DILI) carry high short-term mortality without liver transplantation. We present our experience of plasma exchange to treat I-DILI patients.

Methods We retrospectively analyzed prospectively collected data on I-DILI patients treated with low volume plasma exchange (PLEX) and low dose steroid in our department from October 2016 to May 2020. Patients who met listing criteria were advised urgent liver transplantation, those not opting for transplantation were treated with PLEX. The disease severity parameters were measured at admission. Primary outcome was survival at 30 days from the date of admission.

Results Thirty-four I-DILI patients (17 males, age 35.8 (15-36) years, median (range) underwent plasma exchange for ALF (12 patients), subacute liver failure SAHF (9) and ACLF (13). Causative agents are native medication (44%), antimicrobial (21%), antiepileptics (11%), antitubercular drugs (9%), hormonal pills (5%) and others (10%). By RUCAM score, 29 patients had probable DILI and 5 had possible DILI. Twentytwo patients had hepatic encephalopathy. The 34 patients underwent 2 (1-7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma were exchanged per session. Twenty-one patients received prednisolone up to 20 mg per day for a duration of 32 (4-160) days median (range Introduction Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting around one third of global population. As there is paucity of reports on effects of dapaglifozine (SGLT2 inhibitor) in NAFLD cases with diabetes mellitus (DM) from this part, we aimed to evaluate the same.

Method Consecutive cases with Type 2 DM and NAFLD were included in the study and subjected to dapaglifozine 10 mg therapy for 3 months. Biochemical parameters, ultrasonographic fatty liver grading, fibroscan scoring, and non-invasive scoring for hepatic fibrosis (FIB4 and NAFLD fibrosis scores) of all the cases were evaluated at baseline and again after 3 months of completion of therapy and compared with each other. Introduction Liver abscess is a space-occupying lesion in liver associated with high morbidity and mortality. Our objective was to study the clinical characteristics and management outcomes in patients with liver abscess. Methods Prospective study was done from August 2019 to July 2020 on 52 patients with liver abscess at BGS Global Hospital, Bangalore. History, examination, laboratory investigations, imaging findings were recorded. Ultrasound guided aspiration was done and samples were investigated.

Results Out of 52 patients, 31 were male and 21 were female patients. Twelve of them were diabetic and 16 were alcoholics. Pain abdomen (96%) was predominant symptom. Hepatomegaly was found in 88%, jaundice in 23%. Elevated ESR was found in 65%, TLC was elevated in 88%, Total bilirubin was elevated in 28%, AST was elevated in 38%, ALT was elevated in 27% and serum albumin was reduced in 76%. On imaging liver abscess was found in right lobe in 65%, left lobe in 25%, bilateral in 10%; solitary in 79% and multiple in 21%. Segment VIII (46%) was predominantly involved. Pus culture was positive in 31% out of which K. Pneumonia was seen in 50%, E. coli in 31% and pseudomonas in 19%. Amebic serology was seen in 27%, AFB was positive in only 1 patient. Percutaneous abscess drainage was needed in 63% of patients and rest 37% were managed medically. No mortality was seen.

Conclusion Early diagnosis and treatment is necessary in management of liver abscess since the presentation may be subtle and nonspecific. Combined antibiotic therapy and percutaneous drainage will improve the patients prognosis.

A study on role of Lille's score in predicting response to granulocyte colony-stimulating factor therapy in patients with severe alcoholic hepatitis Introduction Alcohol-related liver disease is a broad spectrum of disease.

Severe alcoholic hepatitis has high short-term mortality up to 50%. The therapeutic options are limited. Glucocorticoids are recommended but have various limitation. A liver transplant is limited therapeutic option. G-CSF stimulates pluripotent stem cells which contribute to regeneration and repair of hepatocyte. In few RCTs, G-CSF therapy has improved liver function and survival. However, these studies lacked a prognostic guide for G-CSF. Thus, we hypothesized that G-CSF has better outcomes and Lille's score may be used in predicting response to G-CSF. .195 and >0.195 , showed at survival at 90days was 90% and 26.7% respectively. Lille's score also independently predicted mortality with cut-off 0.195 (p-value 0.009) and Odds ratio is 16.3. In survival group there was a significant improvement in CTPS, DF, bilirubin and transaminases on day 6 and day 30. MELD score improved on day6 and day 30, but was significant on day 30. Creatinine and serum albumin showed no significant change at day 6 and day 30. In non-survival group, no significant improvement in liver disease clinical score and biochemical parameters. G-CSF therapy was well tolerated in patients.

Conclusion G-CSF is appearing as a promising therapy in alcoholic hepatitis and Lille's score may be used as prognostic marker for survival. But, we need larger data and more similar studies to validate it as tool in G-CSF therapy.

Introduction Non-alcoholic fatty liver disease (NAFLD) is an emerging public health problem ultimately progressing to fibrosis, cirrhosis and hepatocellular carcinoma. The absence of specific symptom or sign warrants the need for identifying non-invasive tools for early identification of the disease and it's progression. Homocysteine is a sulfhydryl containing amino acid which can alter intracellular lipid metabolism thereby promoting hepatic fat accumulation. Thus, it is plausible that high homocysteine levels could be a marker for early identification, and an effective target for preventing the progression to NAFLD and it's related complications. Aim To determine if there is any association of serum homocysteine levels with NAFLD.

Methods Forty NAFLD patients along with 40 healthy volunteers underwent serum homocysteine level measurement along with a gamut of baseline investigations from August 1, 2019 to January 31, 2020 in this observational case control study conducted on an out-patient basis in the Gastroenterology Unit, Department of General Medicine, Safdarjung Hospital. USG and Fibroscan were done in 40 NAFLD patients.

Results 57.5% (23) of case cohort were males and rest were females. Mean age of case cohort was 43.08 years. 40% of patients were diabetic.

Mean homocysteine levels were 44.87 micromoles/L in cases as compared to 27.57 micromoles/L in controls. 47.50% of cases had Grade I fatty liver. Mean liver stiffness was 6.44 kPa on fibroscan. All cases with homocysteine levels in first quartile (<17.9) had Fibrosis score of F0-F1. On the other hand, only 33.3% cases with Homocysteine levels in fourth quartile (>51.5) had Fibrosis score of F0-F1. Conclusion Higher serum homocysteine levels were significantly associated (p value<0.0001) with progressive grades of hepatic fibrosis, as assessed by fibroscan, in NAFLD patients and holds the potential to be used as a tool for early identification of hepatic fibrosis in NAFLD. Introduction Melioidosis, caused by the gram-negative bacillus, Burkholderia pseudomallei is clinically indistinguishable to other causes of pyogenic liver abscess. A high index of suspicion is needs to diagnose early as it is poorly responsive to usual empiric antibiotics and is associated with significant mortality. Isolated liver abscess however is extremely rare.

Here we report two cases of hepatic meliodiosis who were previouly treated as liver abscess elsewhere and were not responsive to the treatment. Clinical presentation Case 1: A 39-years-old female with no known comorbid illness presented with history of pain right upper quadrant and fever of 3 months. On examination liver and spleen were enlarged. Patient was diagnosed elsewhere as liver abscess and had received multiple antibiotics (oral and intravenous) over last 2 to 3 months without any improvement in her symptoms. ultrasonography and CECT showed liver and splenic abscesses. USG guided aspiration was done and on culture Burkholderia pseudomallei was grown. She was started on IV meropenam for 2 weeks followed by oral trimethoprim and sulfamethoxazole for six months. She improved symptomatically after 48 hours of IV Meropenam. Case 2: A 42-years-male, diabetic with uncontrolled blood glucose presented with high grade fever and pain right upper quadrant. On examination there was rigidity and gaurding in the right hypochondrium. USG and CT showed multiple liver abscess in both the lobes. USG guided aspiration was done and on culture Burkholderia pseudomallei was grown. He was started on I.V Meropenam (as per sensitivity) and responded to the treatment.

Conclusion In clinical practice liver abscess is a commonly encountered problem and majority of which responds to standard antibiotic therapy. These reports highlights the specific problem of non-responsive to antibiotic therapy and stresses the need to be aware of Burkholderia pseudomallei as a potential cause of liver abscess.

A prospective study on profile of hepatic Wilson disease at a tertiary care centre

Introduction Wilson disease is a rare inherited disorder characterized by excess deposition of copper in liver, brain and other tissues. In this study Introduction Since the description of tuberculosis in literature, it has been always a challenge for the clinicians. Though endemic in developing nations, its atypical presentation makes it an enigmatic entity. Tuberculosis can mimic malignancy, exposing the patient to unnecessary investigations and sometimes even surgery. The hepatic involvement of tuberculosis is a rare entity with paucity of literature on the presentation. We are reporting our experience with four such cases seen over last 2 years. Case presentation Case 1, a 38-year-old male, presented with pyrexia of unknown origin (PUO) with jaundice which later turned to be granulomatous liver disease of tubercular origin with mediastinal lymphadenopathy. Case 2 is a 40 year old male, in whom portal vein thrombosis secondary to hepatic tuberculosis was the etiology of portal hypertension causing esophaegeal varices and long-term sequelae, including formation of portal cavernoma leading to portal cholangiopathy, who also had tubercular ascites and active pulmonary tuberculosis. Case 3 is a case of 59-year-old male with tuberculoma of the liver mimicking malignancy (hepatocellular carcinoma) on imaging, who responded to anti-tubercular therapy. Case 4 is a 65-year-female, an interesting case of paradoxical response to anti-tubercular therapy forming tubercular liver abscess which extended to involve the gallbladder fossa, leading to spontaneous perforation of the gallbladder.

Conclusion Even in modern era, tuberculosis still poses a great diagnostic challenge for gastroenterologists. Deviation from normal clinical presentation keeps the treating physician in diagnostic dilemma. Sometimes, response to anti-tubercular therapy is the only option left in endemic countries like India.

Introduction Decompensated Liver Disease (DCLD) has got a high mortality rate and prediction of mortality is important to prognosticate the patient and to channel high risk patients for liver transplantation.

Objectives To propose a new prognostic model for DCLD which is better than the existing scores.

Methods Retrospective study. Clinical and biochemical variables were assessed on the date of admission from the medical records and patient/ patient relatives were telephonically contacted regarding the date of death and mortality at 3 months from the date of admission. Logistic regression was done, coefficient of beta of independent variables were found out and a new score was proposed (New score/CHIBA score = Creatinine *0.6 + HE*0.4+ INR *0.8 + bilirubin *0.125 + INR *0.8 + ascites* 1.2) C stands for creatinine, H for hepatic encephalopathy, I for INR, B for bilirubin and A for ascites. Ascites was further divided into absent or mild with score of 0, moderate -1 and tense 2. Hepatic encephalopathy absent with score of 0, Grade I west heaven score of 1, Grade II score of 2 and Grade III and IV a score of 3.

Results CHIBA score has AUROC of 0.793 (at a cut off of >5.5 it has sensitivity of 66% and specificity of 76%) compared to MELD-Na of 0.735 (0.735, cut off >25 sensitivity 65% and specificity 72%), MELD of 0.727 (cut off >17 sensitivity of 80.37% and specificity of 55.14 %), i-MELD of 0.7223, MESO index of 0.727 and UKELD of 0.686. Conclusion CHIBA score is superior to MELD and MELD variants in predicting 3 month mortality. In short CHIBA score is better than all existing prognostic models for DCLD. CHIBA score needs to be validated in a different cohort to find out it's prognostic performance.

Analysis of effect of blood group on plasma von Willebrand factor levels, liver disease severity and survival in rodenticidal hepatotoxicity patients

Introduction In health, plasma von Willebrand factor (VWF) levels are significantly lower levels in group O compared to non -O group individuals. We have previously reported raised VWF levels correlate with liver disease severity and predict in-hospital survival in rodenticidal hepatotoxicity patients. The aim of this study was to analyse VWF levels, liver disease severity, and outcomes in rodenticidal hepatotoxicity patients as per their blood group.

Methods We retrospectively analyzed prospectively collected data on rodenticidal hepatotoxicity patients managed in our department from January 2016 to June 2020, in whom blood grouping data was available. Normal plasma VWF antigen level is 50% to 150%. Conclusion VWF levels tended to be higher in non -O blood group compared to O blood group in rat killer hepatotoxicity patients, however, 30 day survival was not different in these blood groups.

The triglyceride and glucose index (TyG) as screening biomarker to identify non-alcoholic fatty liver disease Introduction Hepatitis C virus (HCV) infection is known to cause cirrhosis. Advent of direct antiviral agents (DAA) have significantly altered the disease course of these patients. We describe our experience with HCV patients. Methods A prospective observational study was done over a one-year period (1st February 2019 to 31st January 2020) in patients of our department. Patients were evaluated and treated as per standard of care and followed up for 12 weeks after completion of DAA for sustained virological response (SVR12 We report a very rare presentation of angiosarcoma of liver as a simple hemorrhagic cyst. The patient is a 68-year-old male, who came with nonspecific right hypochondriac pain since 3 months. Contrast CT done showed a 10 X 10 cm cystic lesion in the right lobe of liver and MRI abdomen done showed T1 hyperintensities giving us a differentials of a hemorrhagic/ hydatid cyst. He then underwent laproscopic deroofing of the liver cyst and cyst fluid which was hemorrhagic was sent for analysis and tissure for histopathology. Cyst fluid analysis was negative for tumor markers and bilirubin levels. Histopathology showed clusters of atypical cells and pleomorphic nuclei and eosinophilic cytoplasm. However, IHC done was suggestive of angiosarcoma. Hepatic angiosarcoma presenting as a simple hemorrhagic cyst is a very rare presentation. The importance of keeping an open mind to the differentials even in a simple cyst is the highlight of this case report.

Introduction Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Risk factors involved in development of HCC include underlying cirrhosis, hepatitis B, hepatitis C, non-alcoholic fatty liver disease etc. This study aims to describe clinical profile, underlying risk factors, tumor characteristics and outcomes of therapy.

Methods One year prospective study on patients coming to our OPD with either imaging or biopsy proven HCC cases. Detailed history, examination and laboratory tests were performed. The statistical analysis of the data was performed. Results The mean age was 56.8 yrs. Presenting complaints included loss of appetite in 83%, abdominal distension in 71%, weight loss in 61%, abdominal pain in 60%, hemetemesis in 10%, jaundice in 18% and hepatic encephalopathy in 6% cases. The risk factors were hepatitis B virus (HBV) in 43.6%, hepatitis C virus (HCV) in 24.6%, non-alcoholic steatohepatitis (NASH) in 20.4%, alcohol in 13.6%, hepatitis B and alcohol in 35.5%, hepatitis C and alcohol in 13%. 86% of patients had underlying cirrhosis while 14% were non-cirrhotics. Most of the patients were in advanced stage BCLC-C 43.3%, followed by BCLC-D 28.3%, BCLC-B 26.6%, BCLC-A 28.3%. Most of the patients were CTP B 68.3%. Patients having ascites had significant greater mortality at 1 year (p=0.025). Portal vein thrombosis (PVT) increased the mortality at 1 month (p=0.002) and 1 year (p=0.001) follow-up. Higher mortality was found with higher BCLC class,1 month (0.05) and at 1 year (p=0.001). Conclusion Most patients diagnosed HCC belonged to 6th decade. Hepatitis B was the commonest etiology. Decreased appetite was the commonest complaint. Most patients were diagnosed at an advanced stage which narrows down the therapeutic options and this study further emphasizes the importance of periodic screening in patients with risk factors. Background Hepatic hydrothorax is known to occur in 5% to 15% of patients with cirrhosis and can lead to respiratory failure and also aggravate the clinical course of cirrhosis. The development of spontaneous bacterial empyema is also associated with significant mortality. We outline the clinical profile and initial management of 7 patients who were admitted to our centre over a duration of 14 months. (03/2019 -07/2020). Methods and Results Mean age was 60 yrs and 6 out of 7 patients were male and one was female. Five of the 7 patients had CHILD C Cirrhosis (CTP score > 10) and 2 patients belonged to CHILD Class B. All patients had MELD Na score of 15 or more with 4 patients having a Score > 21. All patients had ascites clinically. All patients had transudative effusion. 5 patients had right sided effusion, one had bilateral effusion and one had left sided effusion. All patients were treated with dietary sodium restriction, diuretics and albumin. All patients required thoracocentesis. 5/7 patients had recurrence of effusion during the initial follow-up within 2-4 weeks. All patients required a minimum of two pleural fluid aspirations during the initial admission. Indwelling Pleural Catheter (IPC)/ Pigtail was inserted in 6/7 patients including the two patients who did not have recurrence of Effusion on follow-up. One patient developed Empyema and died. Conclusion Hepatic hydrothorax is a relatively uncommon complication of cirrhosis. Temporary usage of an IPC/Pigtail for intermittent pleural aspiration obviated the need for repeated thoracocentesis. In our small case series, one patient developed empyema and succumbed and others did not have any procedure related complications. IPC/Pigtail catheter may be a good option to optimise the patient before transplant.

Introduction Transfusion of plasma containing blood products is associated with a small risk of breathing difficulty that can be broadly classified as TRALI and TACO. This study aimed to analyze the incidence of TRALI and TACO in patients undergoing plasma exchange (PLEX) to treat liver diseases. Methods We retrospectively analyzed prospectively collected data in consecutive patients undergoing PLEX to treat liver failure in our department who did not require respiratory support prior to initiation of PLEX. Cases who had onset of dyspnoea within 12 hours of a PLEX session were identified. TRALI and TACO were diagnosed as per Consensus Panel recommendations. The cases were categorized as TRALI, TACO, or any other cause using a predefined algorithm. The patients were treated with low volume PLEX (50% of plasma volume exchanged with equal volume of fresh frozen plasma) and low dose steroid. Results From October 2016 to April 2020, 180 liver disease patients underwent 563 PLEX sessions. Twenty-eight patients who were intubated prior to initiation of PLEX were excluded. A total of 152 patients (age -35.42 +/-15.15), (M -100, 65.7% and F -52, 34.2%) were identified who underwent 492 PLEX sessions and were transfused 4598 units of different blood products. Five patients who had new-onset dyspnoea within 12 hours of transfusion were identified. Among the 5 patients, 2 had TACO, and 3 had pneumonia (2 of these were aspiration pneumonitis). No patient fulfilled the diagnostic criteria for TRALI. The incidence of TRALI was 0%, and that of TACO was 1 in 2299 units of product transfusion in these patients. Conclusion We did not find TRALI in liver failure patients treated with low volume PLEX and low dose steroids. However, TACO seems a potential and life-threatening problem that needs careful monitoring, especially in those at risk of fluid overload.

Introduction Dengue fever is a common mosquito borne disease in India. Dengue fever in liver transplant recipient has rarely been described. We report here 2 cases of dengue fever in our liver transplant patients. Case Presentation We report 2 cases of dengue fever in our liver transplant patients. Case 1-presented 3 months after transplantation with history of febrile illness with myalgia, arthralgia, thrombocytopenia, leukopenia. His low platelet and WBC counts were initially attributed to hypersplenism. Dengue was diagnosed using NS1antigen test and he was managed conservatively as for dengue fever. He recovered well and his graft is functioning well till last follow-up. Case 2: Presented 2 years after transplantation with a history of fever, thrombocytopenia, mildly elevated liver enzymes. He had history of biliary stenting for post op anastomotic stricture. Initial diagnosis was suspected to be stent block cholangitis. Dengue IgM antibody test was negative but NS1 antigen test was positive. Final diagnosis of dengue fever was made. He improved well with conservative management. He is also doing well till last follow-up. Conclusion Reports of dengue fever in liver transplant recipients are limited. The presentation may be atypical. It should be suspected when patient present with febrile illness with thrombocytopenia, along with other possible causes. NS1 antigen has better sensitivity than IgM Elisa. Both should be included in diagnostic work up. Dengue fever usually follows a mild course in primary infection and most patients recover well. Dengue fever does not affect graft function in long-term. Introduction Non-alcoholic fatty liver disease (NAFLD) has progressively surpassed other etiologies in leading to the development of chronic liver disease. The clinical spectrum of NAFLD includes simple steatosis, non-alcoholic steatohepatitis (NASH) and fibrosis. Knowledge of the stage of NAFLD would greatly influence treatment and outcome. Numerous studies have outlined the association between visceral fat and fibrosis in NAFLD1. This study aimed at calculating visceral fat volume at the L3-L4 vertebral level which was then correlated with hepatic fibrosis as assessed by transient elastography. Methods All patients above 18 years undergoing CT abdomen who were incidentally detected to have NAFLD were included. Transient elastography was performed to assess hepatic fibrosis. Patients were categorized into advanced fibrosis (>10 kpa) and those without (<10 kpa). AUROC was plotted to determine the cut off for visceral fat volume in predicting advanced fibrosis. Pearson correlation was used to calculate the variables that correlated with visceral fat volume. Results Sixty-four patients which comprised 36 males and 28 females. Thirty-one (46%) were having advanced fibrosis (TE>10 kpA) and 34 (54%) patients without advanced fibrosis. Age, weight, BMI, visceral fat volume, ALP, HbA1c, FBS and ferritin were all found to be statistically significant between the 2 patient groups. AUROC curve for visceral fat in predicting advanced fibrosis was 0.733 and at a cut off of 167. 5cm3. Visceral fat had a sensitivity of 77.4% and a specificity of 51.5% in predicting advanced fibrosis. Subgroup analysis revealed visceral fat to be a predictor of advanced fibrosis in males with a BMI >25. Conclusion Visceral fat measured at L3-L4 level with a cut off of 167.5 cm3 had a sensitivity of 77.4% and specificity of 51.5% in predicting development of advanced fibrosis in NAFLD. In male patients with a BMI >25 kg/m2 visceral fat was a predictor of advanced fibrosis. Introduction Gastric variceal bleeding (GVB) compared to esophageal varices is rare but often massive and associated with a high mortality. Endoscopic cyanoacrylate glue injection is the first line treatment for GVB. Hence, we conducted this study to assess the efficacy and shortterm outcome of cyanoacrylate for gastric variceal bleed. Methods This was a prospective observational study of patients with endoscopic cyanoacrylate treatment for GVB between June 2019 to July 2020. Demographic characteristics, details regarding etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate and survival at three months were collected. Results A total of 39 patients underwent endoscopic cyanoacrylate injection for GVB. Their mean age was 48.2+-13.8 years with a male preponderance (n=23). 26 patients (66.7%) had cirrhosis, and half of them (n=13) were due to alcoholic liver disease. Gastric varices were GOV2 in 29 (74.4%), IGV1 in six (15.4%) and GOV1 in four (10.6%) patients. Varices were tortuous and medium sized in 21 (53.8%) and 16 (41%) patients respectively. Successful obliteration of gastric varices was achieved in 31 patients (79.5%). Median sessions required were 1 (1-4) and median volume of cyanoacrylate per session was 2 (1-6) mL. The procedure was associated with minor complications like transient abdominal pain in three (7.7%) and fever in one patient (2.6%). Rebleeding was observed in six (15.4%) patients, five of whom had a high MELD score. Cyanoacrylate failed in one patient (2.6%) who under-went emergency devascularization. Two patients (5.1%) died during follow-up due to advanced cirrhosis. Conclusion In conclusion, our study demonstrated endoscopic injection of cyanoacrylate to be very effective and safe for gastric variceal bleed. The technical success was high and can be achieved in fewer sessions and smaller volume of cyanoacrylate during each session.

Introduction Sarcopenia has been associated with poorer survival in patients with cirrhosis. Nutrition may very well have a direct influence on sarcopenia and functional status. There is no study on the nutritional management of patients with sarcopenia. We performed a randomized controlled trial to assess the effects of nutritional therapy on sarcopenia in patients of cirrhosis. Methods In a tertiary care setting in Jaipur, India, patients with cirrhosis with sarcopenia were randomly assigned to groups given nutritional therapy (30-35 kcal/kg/day, 1.0-1.5 g vegetable protein/kg/day; (n=49) or no nutritional therapy (patients continued on their same diet; (n=47) for 6 months. Sarcopenia was diagnosed based on computerized tomography psoas muscle index (PMI), handgrip strength, gait velocity. Primary Introduction Hepatic sinusoidal obstruction syndrome (SOS) is commonly recognized vascular pattern of drug-induced liver injury and has been frequently associated with oxaliplatin-based chemotherapy.

In this case report, we describe a case of 70years-old male who was diagnosed case of relapsed refractory diffuse large B cell lymphoma and received 3rd line chemotherapy R-GEMOX (Rituximab, Gemcitabine, Oxaliplatin, Ifosfamide. After receiving seven cycles of R-GEMOX, patient developed jaundice, abdominal distension, vomiting and 5 kg weight gain in one week duration. On examination he had tender right upper quadrant, icterus, pedal edema and gross ascites. Investigations revealed raised total bilirubin (13.1 mg/dL), elevated liver enzymes (SGOT 131U/L, SGPT 67U/L, ALP 114U/L, GGT 162U/L), total protein 4.8 gm/dL, albumin 2.6 gm/dL albumin: globulin 1.1, INR 1.45. Viral markers showed HBsAg positive, HBeAg and anti-Hbc IgM negative, HBV DNA viral load 69,56,53,574 IU/mL with HEV IgM positive. Ascitic fluid analysis showed high SAAG and low protein with fluid negative for malignant cells. CECT abdomen was showing multiple cystic lesions in liver in segment III, IVa, VI with moderate ascites. No splenomegaly, venous collaterals or changes of cirrhosis seen. Patient refused for liver biopsy. Repeat investigations revealed rising bilirubin (30.2 mg/dL) and SGPT-57 U/L so diagnosis of oxaliplatin induced HSOS, reactivation of hepatitis B, acute viral hepatitis E was made and treated with entecavir, therapeutic ascitic paracentesis, albumin and diuretics. He got better in initial two weeks but unfortunately after onemonth patient expired due to advanced lymphoma. Conclusion The incidence of oxaliplatin induced HSOS was 77.4%. Hepatic SOS should be included in the differential diagnosis of patients with rapid onset ascites, weight gain and jaundice following the administration of oxaliplatin based chemotherapy regimens.

Introduction Hepatic sarcoidosis covers a broad spectrum from asymptomatic and slightly deranged liver function tests to clinically evident cholestasis or, in advanced cases, cirrhosis, portal hypertension.

We report a case of 30-year-old male without comorbidity presented with painless progressive jaundice without itching followed by abdominal distension, pedal edema and weight loss of 20 kilograms since three months. No history of hepatotoxic/alternative medicine present. On examination, pallor, icterus, pedal oedema, moderate ascites and right axillary lymphadenopathy. Investigations showed pancytopenia, cholestatic liver pattern with raised total bilirubin (13.5 mg/dL) with direct 12 mg/dL, albumin: globulin ratio 0.9, PT-INR 1.3, raised ACE level 97 U/L (Reference range 8-53U/L), IgM hepatitis E virus (HEV) positive with negative HBsAg and HCV antibody. antimitochondrial antibody was negative. Diagnostic ascitic fluid analysis showed high SAAG, low protein, ADA 29 U/L and fluid negative for malignant cell. Contrast enhanced CT abdomen showed mild hepatosplenomegaly with poorly enhancing ill-defined hypodense lesions in liver and spleen of granulomatous etiology with moderate ascites. HRCT thorax showed mild bilateral pleural effusion with normal lungs, axillary lymphadenopathy largest measuring 3.9*1.6 cm, no hilar lymphadenopathy. Axillary lymph node excision biopsy was inconclusive, so USG guided percutaneous liver biopsy was done and it showed non caseating epithelioid granulomatous disease likely sarcoidosis. Gene Xpert for M. tuberculosis was negative on both liver, axillary lymph node biopsy. Patient treated with oral steroid, got better symptomatically and biochemically at one week but lost to follow-up. This patent had hepatic sarcoidosis with cholestasis as a primary disease complicated by acute viral hepatitis E. He responded to oral steroids. Conclusion Sarcoidosis should be kept in differential diagnosis of patient presenting with cholestatic liver pattern with lymphadenopathy and significant weight loss. Introduction Terlipressin is used in treatment of acute variceal bleeding due to its selective splanchnic and extrarenal vasoconstrictor effect by stimulation of V1 receptors. Due to its partial agonist effect on V2 receptors, it can also increase water reabsorption in the renal collecting ducts and cause hyponatremia. We planned a retrospective study to evaluate Terlipressin induced hyponatremia in patients with hepatocellular carcinoma (HCC). Methods From August 2017 till August 2020, 32 patients with HCC presenting to our centre with variceal bleeding who were treated with Terlipressin were analyzed. Results Among 32 patients, there were 29 males. Mean age was 53 years (range 27-75 years). Most patients had advanced BCLC stage (B-1, C-25 and D-6). All patient underwent endoscopic variceal ligation (EVL) at admission and were started on Terlipressin 1 mg 6 hourly for 3-5 days. Serum sodium decreased from a mean of 132.8 ± 3.6 mEq/L (126-139 mEq/L) to 128.2 ± 6.0 mEq/L (113-138 mEq/L) (p< 0.001) in 29 patients over 3 days. It decreased by ≤ 5 mEq/L in 16 patients (50%), by 5-10 mEq/L in 8 patients (25%) and >10 mEq/L in 5 patients (16%). In this latter group, serum sodium decreased from mean of 130.2 ± 2.1 to 117.2 ± 2.7 mEq/L and 2/5 patients developed neurological manifestations in the form of nausea, headache and mental confusion. Risk of hyponatremia decreased with increasing MELD score (p=0.037). Serum sodium returned to baseline values in most patients after stopping therapy. Four patients (all BCLC D with poor performance status) died during hospitalization due to other complications.

Conclusion Terlipressin can cause an acute reduction in serum sodium concentration in most patients with HCC during treatment for portalhypertensive bleeding. It develops rapidly after starting therapy, may be severe in some patients where it can cause neurological manifestations, but is usually reversible.

Comparison of visceral and subcutaneous adipose tissue in lean and obese non-alcoholic fatty liver disease patients: An observational study Manoj Kolhe, Anil Arora, Ashish Kumar, Praveen Sharma Correspondence-Manoj Kolhe-manojck008@gmail.com Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India Non-alcoholic fatty liver disease (NAFLD) is major cause of cirrhosis in India and around the world. Asians are more predisposed to NAFLD at lower BMI rates as compared to west. Although lean NAFLD population has been shown to share metabolic features and hepatic pathology as the classical obese NAFLD, there is lack of linear correlation with adiposity. As per Framingham heart study the distribution of adipose tissue in the body has more relevance in the pathogenesis of lean NAFLD. Abdominal fat is compartmentalized into two parts, visceral and subcutaneous adiposity. Lean NAFLD patients also have visceral adiposity as obese populations. Visceral fat is a driving factor for insulin resistance, activation of innate immunity, hepatic inflammation and finally fibrosis. So it is a necessity of time to quantify subcutaneous and visceral adipose tissue in patients. It will help to understand the pathogenesis of lean NAFLD. We studied 52 patients, 25 were lean (BMI =< 23 kg/m2) and 27 were obese (BMI >23 kg/m2). We evaluated biochemical and imaging profile in both groups. We quantified the visceral and subcutaneous adipose tissue at 5th lumbar vertebra by non-contrast computed tomography scan. Thirty-six out of 52 patients had insulin resistance (HBA1c ≥5.7 gm%). This study showed that obese NAFLD group has higher visceral fat, subcutaneous fat and lower visceral to subcutaneous fat ratio (VSR). On subgroup analysis, non-diabetic lean NAFLD group had lower subcutaneous fat and VSR as compared to obese NAFLD group. In conclusion, lean NAFLD group had lower visceral and subcutaneous fat and higher VSR. Subcutaneous fat is more in obese NAFLD group. Visceral fat may be more associated with NAFLD than subcutaneous fat.

Introduction In this study, we aimed to explore the clinical and epidemiological profile of all patients with hepatitis E virus (HEV) who were admitted to a tertiary care hospital in Chennai, India and to further assess various factors that influence the prognosis of these patients.

Methods Hospital records of patients who presented with features of acute hepatitis taking into consideration inclusion and exclusion criteria were taken from medical records from 2018-2020. History and clinical examination including the presence of signs of organ failure were obtained. Investigations collected included routine parameters with viral markers for HBV, HAV, HCV, HEV. Outcomes are recorded in the form of discharge or death.

Results Based on the inclusion and exclusion criteria, 43 patients were analyzed. Males had a higher (81.39% n=35) incidence of HEV infection. Yellowish discoloration of urine was the most common symptom (n=19, 44.19%) followed by fever (n=16, 37.21%), and icterus was the most common sign at presentation (n=28, 65.11%). Hepatomegaly was the most common finding on abdominal examination (n=10, 22.72%). Overall, mortality observed was 13.90% (n=6), including 2 patients presented as ACLF and 3 patients developed sepsis. Higher mean prothrombin time-international normalised ratio (PT-INR) (2.08 vs 1.41), total bilirubin (11.94 vs. 11.01 mg/dL), and direct bilirubin (7.35 vs. 6.43mg/dL) was associated with higher mortality, whereas lower mean serum albumin (2.86 vs. 3.06 gm/dL) was associated with higher mortality. Increase in renal parameters (i.e, BUN [44.17 vs. 14.46 mg/dL] and creatinine (1.98 vs. [1.08 mg/dL]) and electrolyte imbalances (i.e. hyponatremia [128.5 vs. 132 mmol/L]) were associated with higher mortality. Conclusions Higher mean age, duration of hospital stay, PT-INR, total bilirubin, direct bilirubin, blood urea, serum creatinine, lower mean serum albumin, and sodium values were associated with higher mortality along with co-morbidities especially chronic liver disease which can result in ACLF and cause higher mortality.

Circulating tumor cells assessment in patients with hepatocellular carcinoma by imaging flowcytometry and it`s relationship with staging -An interim analysis Introduction Circulating tumor cells are considered as potential biomarkers for the detection of hepatocellular carcinoma. It is expected to play an important role in early diagnosis and dynamic monitoring. This study aimed to evaluate the relationship of circulating tumor cells with hepatocellular carcinoma Barcelona clinic liver cancer (BCLC) staging. Methods An imaging flow cytometry method, using immunofluorescence of cytokeratin, EpCAM, AFP together with the analysis of size, morphology and DNA content for detection of circulating tumor cells was developed and applied to 20 hepatocellular carcinoma patients and 10 patients with cirrhosis of liver without any evidence of hepatic or extrahepatic malignancy. Results Among 20 hepatocellular carcinoma patients 17 (85%) were male. Two patients were BCLC stage A, 5 were BCLC stage B and 13 were BCLC stage C. Out of 10 cirrhotic patients 7 were CTP B and 3 were CTP C. Circulating tumor cells were detected in 20 of 20 patients of HCC and none among cirrhosis of liver patients. The mean number of circulating tumor cells was 9.9 (range 1-20). Circulating tumor cells positive for EpCAM were detected in 18 patients with a mean value of 4.6. Circulating tumor cells positive for cytokeratin were detected in 16 patients with a mean value of 1.8. Circulating tumor cells positive for AFP were detected in all patients with a mean value of 3.5. The number of circulating tumor cells was significantly associated with BCLC stage (p<0.0005) and portal vein thrombosis (p=0.025). Conclusion This study shows the potential role of circulating tumor cells as a biomarker of hepatocellular carcinoma and also a significant association between the number of circulating tumor cells with BCLC staging and portal vein thrombosis.

Introduction Hepatorenal syndrome-acute kidney injury (HRS-AKI) or HRS -1 carries high short-term mortality in patients with advanced cirrhosis. Recently International club of ascites (ICA) has proposed new definition criteria for HRS and at present we lack literature on the predictors of response of terlipressin according to this new definition. So, we aimed to evaluate the response rate of terlipressin and factors affecting the response rate according to this new HRS-AKI definition.

Methods We performed a prospective study on 114 cirrhotic patients with HRS-AKI diagnosed according to ICA definition 2015 from August 2018 to April 2020 using terlipressin and albumin. Baseline clinical and biochemical details were noted. Response was defined as improvement in serum creatinine within 0.3 mg/dL of baseline (if baseline s. cr <1.5 mg/ dL) or < 1.5 mg/dL (if baseline s. cr >1.5 mg/dL). Further responder and non-responder were followed up to 90 days or death. Results Among 114 HRS-AKI patients the median age was 52.5 years and 83.3% were male. Response to terlipressin was seen in 70 (61.4%) patients. On subgroup analysis, response rate in acute decompensation (AD) was seen in 37 (78.7%) patients and in acute on chronic failure (ACLF) was seen in 32 (47.7%) patients. Independent predictive factors of response to therapy were serum creatinine before start of terlipressin and baseline Child-Pugh score (CTP). Response to therapy was associated with improved 90 days survival compare to patients with non-response (69.56 % vs. 10%, p<0.00001). The best cut off for serum creatinine that best predicted response to treatment was 2.3 mg/dL (AUROC, 0.79; p<0.0001; sensitivity, 87%; specificity, 64%). and for CTP was 12 (AUROC, 0.72; p<0.0001; sensitivity, 84%; specificity, 58%). Conclusions Serum creatinine before start of terlipressin and CTP predicts response to terlipressin in HRS-AKI. Early transplantation should be considered in patients of HRS low likelihood of response.

Abhishek Mahajan, Shiran Shetty, Ganesh Bhat, Ananth Pai Correspondence-Abhishek Mahajan-abhi141191@yahoo.co.in Department of Gastroenterology, Kasturba Medical College, Manipal 576 104, India Carcinoid tumors are neuroendocrine origin neoplasms producing serotonin and other functional peptide hormones. 74% carcinoid tumors arise from GI tract of which 75% metastasize to liver. We present 2 patients with features of HCC on CT abdomen but were later diagnosed with NET after histology analysis. 1st case: 43-year-old female presented with low grade fever and loss of appetite since 1 month. Ultrasound abdomen showed multiple hyperechoic lesions in liver. CECT abdomen suggested multifocal hepatocellular carcinoma involving both lobes, largest lesion measuring 10.8 x 9.2 x 14.2 cm. Biopsy revealed neuroendocrine tumor grade-1, IHC positive for synaptophysin and Ki 67 index 2%. Ga-68 DOTANOC PET CT showed multiple somatostatin receptors avid retroperitoneal lymph node and liver metastasis. Arterial phase Portovenous phase Delayed phase 2nd case: 60-year-old female presented with loss of appetite and mild right hypochondriac pain since 1 month. CECT abdomen showed few lesions in liver suggesting multifocal HCC. Biopsy revealed NETgrade 1 with IHC positive for synaptophysin and chromogranin. Ga-68 DOTANOC PETCT showed multiple somatostatin receptor avid hepatic nodules and para aortic lymphadenopathy. Arterial phase Porto venous phase Delayed phase Hence, it's important to know conditions mimicking imaging appearance of HCC to avoid false-positive diagnosis of HCC and subsequent management. A multimodality imaging approach along with a careful review of clinical and laboratory findings can be helpful when in doubt for these potential tumor mimicking lesions.

Introduction Alcoholic steatohepatitis (ASH) and non-alcoholic steatohepatitis (NASH) are known to possess increased atherosclerotic cardiovascular disease (ASCVD) risk. Although, there are studies correlating severity of liver injury with future cardiovascular risks in ASH and NASH, in cases of BASH there is very little data on future ASCVD risks. Aim To assess and compare future ASCVD risks for ASH, BASH, and NASH patients. Methods We studied 934 patients with fatty liver during 2010-2019. They were classified into 3 groups: ASH, BASH, and NASH on the basis of obesity (BMI ≥25) and alcohol intake. After appropriate matching, 551 included for statistical analysis. Future cardiovascular risk was assessed using American College of Cardiology (ACC)/American Heart Association (AHA) guideline of 2013. Results Of 551 patients, 73 had ASH, 185 had BASH and 253 had NASH. Using calculator provided by ACC/AHA, median 10-years ASCVD risk for ASH, BASH and NASH was 4.2%, 2.5% and 1.8% whereas for control groups (similar characteristics and optimal risk factors), the median values were 1.7%, 1.3% and 1.2% respectively with significant differences among them (p<0.0001, 0.0001 and 0.004 respectively). Similarly, the median lifetime ASCVD risk for each groups was 36%, whereas for control groups (50 year-old persons with optimal risk factors), it was 5% (p<0.0001) in each. When inter group comparison was made among the three groups, median 10 years ASCVD risk was higher in ASH group while median lifetime risk was same across all 3 groups. Conclusion Our study shows that in ASH, BASH and NASH, the 10-year and lifetime ASCVD risk are higher compared to normal healthy individuals of same age and optimal risk factors. Among the three groups, 10year median ASCVD risk was highest in ASH although the median lifetime risk was same across all three groups.

Transjugular intrahepatic portosystemic shunt for refractory ascites in Gaucher's disease: First case report in literature Kunal Adhyaru, Pratik Jaydeokar, Aabha Nagral, Shaji Marar * Correspondence-Kunal Adhyaru-getkunal12@yahoo.com Departments of Gastroenterology and Hepatology, and * Interventional Radiology, Jaslok Hospital and Research Centre, 15, Pedder Road, Mumbai 400 026, India Gaucher's disease is a rare disease, but the most common amongst the lysosomal storage disorders in India. Patients present with cytopenias and massive splenohepatomegaly arising from deficiency of beta glucosidase enzyme. Splenectomised patients may develop portal hypertension and its complications. The main stay of treatment is enzyme replacement therapy (ERT). We report a case of 30-year-old man diagnosed at the age of 8 years with Gaucher's disease (L444P variation) when he was splenectomised for a massive splenomegaly. He also had recurrent bone crisis and underwent bilateral hip joint replacement for avascular necrosis of the femoral head. He had variceal bleeding two years back followed by development of ascites which had become refractory in the past 6 months. He was referred to us for liver transplantation. On examination, he was sarcopenic, had tense ascites, with hugely dilated veins on the abdominal wall. Investigations revealed pancytopenia and liver function tests revealed mildly elevated transaminases and an albumin of 1.5g/dL. He had a high SAAG ascites. He underwent a transjugular study and was found to have an HVPG of 22 mm Hg. Transjugular intrahepatic portosystemic shunt (TIPS) was performed with post TIPS pressures fell to 2 mmHg. The ascites and the dilated abdominal veins resolved significantly after the TIPS procedure over a period of 2months. He also been started on ERT (imiglucerase). Few cases of Gaucher disease needing liver transplantation for end-stage liver disease have been reported in literature with one of these patients needing TIPS for variceal bleeding. However, ours is the first Gaucher disease patient in literature to have received a TIPS for management for refractory ascites Conclusion TIPS can be used to successfully treat refractory ascites secondary to severe Gaucher related liver disease.

Profile of liver abscess patients in a tertiary care hospital Ashutosh Gupta, Vinod Kumar Dixit, S K Shukla, D P Yadav, Anurag Tiwary Correspondence-Vinod Kumar Dixit-drvkdixit@gmail.com Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction Liver abscess is a common disease entity and early diagnosis and prompt intervention improve the survival and outcome of the disease. The objective of the study is to assess the clinical profile and management of liver abscess in the patients attending tertiary care hospital. Methods This is a retrospective cross-sectional study carried out from January 2019 to February 2020. A total of 138 patients presenting with signs and symptoms of liver abscess were accessed. Confirmation of diagnosis was made by abdominal ultrasound and examination of aspirates. Results The mean age of patients was 43.54 years and majority of them (86.7 %) were males. There was a strong correlation of the occurrence of liver abscess with addiction to alcohol and history of diabetes mellitus. Most common presenting complaint was pain abdomen (91.3%) followed by fever (85.5%), vomiting (27.5%) and abdominal distension (10.1%). Clinical examination revealed tender hepatomegaly in (70.5%) of cases while ascites, pleural effusion and icterus were present in (23.6%), (26.8%) and (13.04%) cases respectively. On evaluation, mean TLC was 15860/cumm, serum albumin was (2.78 gm/dL) while serum creatinine was raised in (8.69%) of patients. The abscess were predominantly in right lobe (73.9%) and solitary (53.62%) with mean volume of 363.8 mL. Left lobe abscess were present in (10.1%) while both lobes were involved in (17.39%) of patients. Etiological analysis revealed that 79% were amebic, 18% pyogenic and 1.4% were tubercular in origin. Percutaneous needle aspiration was done in 73.9%, pigtail drainage in 23.1% and surgical intervention for rupture in 2.8% patients. Mortality rate was 1.4%. Conclusion The commonest presentation was in the middle aged males with history of alcohol intake having right lobe solitary amebic liver abscess. Minimally invasive drainage techniques reduced mortality.

Neutrophil lymphocyte ratio and platelet lymphocyte ratio are excellent markers for predicting survival and severity of hepatocellular carcinoma Sagar Walinjkar, Ashish Kumar, Praveen Sharma, Naresh Bansal, Vikas Singla Correspondence-Anil Arora-dranilarora50@gmail.com Department of Gastroenterology, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India

Background and Aims Hepatocellular carcinoma (HCC) is the 5th most common malignancy worldwide. Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are the markers which have been proven useful in prognostication of many malignancies. We aimed to evaluate the predictive value of NLR and PLR in prognosticating patients with HCC and to study its association with severity of HCC. Methods Patients with newly diagnosed HCC getting admitted at our centre were included in the study. The imaging features, ECOG status and liver functional status were analyzed and BCLC staging was done. Patients were given treatment according to the BCLC stage. Pre-treatment NLR and PLR were calculated from differential leukocyte count. Repeat imaging was done at 1-and 3-months post treatment. Patients were followed up for 6 months for survival. Optimum cut off values of NLR and PLR were calculated by ROC curve analysis. The OS at 6 months was compared on Kaplan-Meier curve using high and low NLR, PLR values. Association between NLR and PLR was also tested with BCLC stages. Results The optimum cut off for high NLR and PLR were >= 3 and >= 102 respectively. OS rates at 6 months in patients with NLR >= 3 and < 3 were 41% and 93.5% (p< 0.01) and with PLR >= 102 and < 102 were 34% and 88% respectively (p< 0.00). 90.47 % and 96% of BCLC stage C and D had NLR >= 3 (p 0.000) whereas 71.42% and 84% of BCLC Stage C and D had PLR >= 102 (p 0.000). Conclusion NLR and PLR are strong markers for predicting survival and severity in patients with HCC.

Introduction Patients with non-alcoholic fatty liver disease (NAFLD) and T2DM have up to 20% advanced fibrosis. Clinicians treating the diabetic population are underestimating the covert hepatic injury which account for future complications. This study was conceived to assess the fibrosis in Type 2 DM without overt liver disease by comparison of various non-invasive fibrosis scores with Fibroscan and acoustic radiation force impuse (ARFI) and risk factor determination for advanced fibrosis. Methods This was a cross-sectional study including Type 2 DM patients attending Endocrinology OPD of AMC between March 2019 to April 2020 with steatosis on ultrasound. BMI >35 kg/m2, alcohol intake (men >20 g/d and women >10 g/d), drugs causing steatosis, hepatitis viral markers were excluded. Introduction Sarcoidosis is a chronic multisystem disease with different clinical presentations. Asymptomatic presentation (75%) is the commonest, but others include jaundice with chronic cholestasis, cirrhosis, portal hypertension, hepatic venous outflow tract obstruction and extrahepatic biliary obstruction. Cirrhosis and portal hypertension are the rarest manifestation of hepatic sarcoid and represent less than 1% of all cases. Acute liver failure as a presentation of sarcoidosis has never been reported before. Here we present a patient of sarcoidosis presenting with acute liver failure. Case A 60-year-old man was admitted to the Indraprastha Apollo Hospital, New Delhi with complaints of fever, jaundice, altered mental status for 2 days. He had history of pulmonary sarcoidosis 20 years back for which he took medication for around 10 years after that he stopped medication. Based on history, clinical and investigational analysis, the patient was diagnosed as a case of acute liver failure (ALF) with acute insult being probable sarcoid flare secondary to pulmonary sarcoidosis. Management He was started on weight based corticosteroid therapy, with other anti-hepatic coma measures. The patient did not recover clinically and manifestations of hepatic encephalopathy, worsened substantially. He was kept on ventilatory, inotropic, CRRT and other supportive treatment. Patient's relatives were explained for liver biopsy (transjugular approach) and liver transplant repeatedly but they refused for the same due to some financial constraints and we lost the patient. Conclusion The patient of sarcoidosis may present as acute liver failure. Conservative management of acute liver failure in sarcoidosis associated with an increased risk of mortality.

Association of lifestyle and metabolic risk factors with grades of fatty liver Background and Aim Non-alcoholic fatty liver (NAFL) is a public health problem in India. We aimed to study association of lifestyle and metabolic risk factors with grades of fatty liver (FL). Methodology NAFL (n=160) cases constituted the study group, FL was diagnosed by ultrasound of abdomen. Anthropometric and biochemical parameters were recorded. Lifestyle risk factors (physical activity, diet, nutrient, snacks and alcohol intake) and metabolic risk factors as per standard cut-offs were compared in different grades of FL. Results Grade 1 FL was present in 69% and grade 2 in 31% of subjects. The prevalence of lifestyle risk factors were higher in grade 2 FL vs. grade 1 FL but were non-significant: Low physical activity ( Conclusions The worsening grades of fatty liver are associated with metabolic risk factors and should initiate workup of patients to avoid progression of NAFL to severe forms.

The triglyceride and glucose index (TyG) as screening biomarker to identify non-alcoholic fatty liver disease Hozefa Runderawala, Nutan Desai Correspondence-Hozefa Runderawala-hozaaee@gmail.com Department of Gastroenterology, Fortis Hospital Mumbai, India

Introduction Non-alcoholic fatty liver disease (NAFLD) is associated with insulin resistance. The triglyceride and glucose index (TyG), which is defined as the product of an individual's serum levels of triglycerides (TG) and fasting plasma glucose (FPG), has been recommended as a reliable and simple surrogate index for insulin resistance. NASH is diagnosed on basis of ultrasound and biochemical tests and exclusion of other etiologies for liver disease. We compare the ability of triglyceride and glucose index (TyG), compared with alanine aminotransferase (ALT), to identify individuals at risk for NAFLD. Methods Patients more than 18 yrs of age attending our institution health check-up OPD were screened as per inclusion and exclusion criteria between December 2019-March 2020. Pregnant women and those with significant alcohol intake, history of diabetes mellitus, hypertension, dyslipidemia, viral hepatitis or any known liver disease were excluded. Routine blood parameters were noted and fatty liver assessed as the presence or absence of hepatic steatosis by abdominal USG. The TyG is calculated with established formula: TyG= Ln (Tg [mg/dL] X FBS [mg/dL]/2). Results A total of 95 people were enrolled, among which 53 were (56%) found to have fatty liver by abdominal USG. TyG index was calculated by using above mentioned formula and taking cut off value of 8.6, and that for ALT of 40 IU/L, Sensitivity of TyG index is 72% and for ALT is 27.08%, also negative predictive value (NPV) for TyG index is 82.35% and for ALT is 54.5%. By using McNemar Chi-square Test, p value is found to be significant with p <0.01. Conclusion TyG index is found to have higher sensitivity in comparison with ALT for an effective screening biomarker to identify NAFLD.

Non-alcoholic fatty liver disease as independent risk factor for coronary artery disease Background Non-alcoholic fatty liver disease (NAFLD) is currently the most common cause of chronic liver disease. The leading cause of mortality in NAFLD patients is coronary artery disease (CAD). Our study attempts to evaluate whether NAFLD is an independent risk factor for CAD and to study the correlation between hepatic steatosis and fibrosis with subclinical atherosclerosis. Methods Case control study.125 cases with angiographic proven CAD and 125 controls with normal angiogram were enrolled after informed consent and subjected to sonography and blood investigations. Carotid intima media thickness (CIMT) measurement was also done to assess subclinical atherosclerosis. Hepatic steatosis was measured by sonographic grading of fatty liver. Liver stiffness measurement was done to assess fibrosis. Results 65.6% (82/125) of cases were found to have NAFLD and it was found to be an independent risk factor for CAD (adjusted OR= 2.6955, p=0.0079). On multivariate analysis, the other independent risk factors for CAD were male gender (adjusted OR=52.8314 (17.6521 -158.1206 Mean CIMT did not differ between the two groups. Subgroup analysis of NAFLD patients showed that mean CIMT differ significantly between NAFLD with and without CAD patients. A mean CIMT value of 0.55 mm had a sensitivity of 81% and specificity of 68% (AUROC=0.696, p=0.0001) in predicting CAD in NAFLD patients. Hepatic steatosis measured by sonographic grading of fatty liver correlated with CIMT (r=0.423, p<0.001). Liver fibrosis measured by liver stiffness measurement did not correlate with CIMT (r=0.09, p=0.117). Conclusions NAFLD is a risk factor for CAD independent of other traditional risk factors. In NAFLD patients hepatic steatosis not fibrosis correlated with subclinical atherosclerosis.

Clinico-biochemical risk factors for non-alcoholic steatohepatitis and significant fibrosis in patients with non-alcoholic fatty liver disease Introduction and Aim In patients with non-alcoholic fatty liver disease (NAFLD) presence of non-alcoholic steatohepatitis (NASH) and/or significant fibrosis (stage 2 to 4) is a key driver of liver disease-related morbidity and mortality. Our aim is to identify the clinical and biochemical risk factors associated with the presence of NASH and significant fibrosis. Methods Two hundred and forty-three consecutive biopsy-proven NAFLD patients with clinical, anthropometric, biochemical, and liver biopsy data (from 2013 to 2020) were included in the study. Appropriate statistical analysis was done. P-value <0.05 was considered significant. Results The mean age of patients was 40.14 ± 9.36 years (range: 17 to 64 years) with a male to female ratio of 5.5:1. On liver biopsy 75 (37.28%) patients had definite NASH and among them, 11 (15.1%) had significant liver fibrosis (stage 2 or 3). Patients with concomitant NASH and significant fibrosis had significantly higher BMI, waist circumference, fasting blood sugar, and serum aspartate aminotransferase levels. On univariate analysis high AST/ALT ratio, TC/HDL ratio >3.5, insulin resistance (IR) (HOMA IR >2) were the risk factors for concomitant NASH and significant fibrosis. On multivariate logistic regression analysis, the only risk factors significantly associated with concomitant NASH and significant fibrosis were high TC/ HDL ratio (OR= 1.524, 95% CI= 0.591-2.821, p=0.001) and IR (OR=1.224, 95% CI= 0.360-2.684, p=0.047). Conclusion Insulin resistance and TC/HDL ratio >3.5 were the independent risk factors for the presence of concomitant NASH and significant fibrosis. Patients with fibrotic NASH are at higher risk of disease progression. So a high TC/HDL ratio >3.5 and insulin resistance could identify the cohort of patients who are at risk of progression of NAFLD and need timely intervention with lifestyle modification and drugs.

A comparative study of non-A-E hepatitis with acute viral hepatitis and autoimmune hepatitis -An interim analysis Introduction The objective was to compare clinical/laboratory features (and histopathology as needed) of non-A-E hepatitis with acute viral and autoimmune hepatitis (AIH) and determine whether etiology is likely to be viral or autoimmune. Methods Cases of acute hepatitis were evaluated to segregate acute viral, autoimmune and non-A-E hepatitis. Viral hepatitis was diagnosed by viral serology. All the patients with negative viral serology and revised AIH score between 10-14 (probable AIH) underwent liver biopsy. Patients with negative conventional serology for AIH were tested for other liver-defined autoantibodies. Those with post-biopsy revised AIH score > 15 were diagnosed as AIH and rest were considered as non-A-E hepatitis. Patients were followed up for 3 months. Results Of 107 patients presenting with acute hepatitis, 8 (7%) had non-A-E hepatitis, 10 (10%) AIH (acute presentations), 13 (12%) acute viral hepatitis (hepatitis A, B, E). Jaundice, anorexia and nausea were the most common presentations (100%) of non-A-E hepatitis followed by fatigue (87.5%). Three out of 8 (37.5%) patients with non-A-E hepatitis were males. Median age was 44 years (range 15-55). Total bilirubin was 11 mg/dL (range 4.5-16.1), aspartate and alanine aminotransferases were 575 and 717 U/L (range 273-1665 and 445-2245 U/L, respectively). Two (25%) patients had anti-nuclear antibody and 1 (12.5%) had Introduction Frailty is characterized by low physiologic reserve and decreased functional status. Whether frailty status in patient with cirrhosis reduces with nutritional intervention is not well studied. Aim was to assess the effects of nutritional therapy on change in frailty status in cirrhotic patients. Methods In a tertiary care centre in Jaipur, India, patients with cirrhosis were randomly assigned to groups received nutritional therapy (30-35 kcal/kg/day, 1.0-1.5 g vegetable protein/kg/day; (n= 47) or no nutritional therapy (patients continued on their same diet (n = 47) for 6 months. Frailty status was assessed by liver frailty index (LFI) and gait velocity. Primary endpoints were improvement or worsening in frailty status at the end of 6 months. Results Till date total 104 patients were enrolled. Forty patients were analyzed in each group. Alcohol (70%) was most common etiology. Baseline characteristics like age, body mass index (BMI), hemoglobin, MELD score, mid arm circumference (MAC), hand grip, gait velocity and LFI were comparable in both the groups. At the end of 6 months there were significant improvement in hand grip strength (30.02 ± 3.01 vs. 26.17 ± 3.14, p= <0.001), MAC (24.59 ± 2.5 vs. 21.16 ± 2.27, p= < 0.001), gait velocity (0.91 ± 0.25 vs. 0.69 ± 0.32, p= <0.002) and LFI (3.84± 0.34 vs, 4.14 ± 0.32, p= <0.001) in nutritional therapy group compare to no nutritional therapy group. Conclusion Based on a randomized controlled trial performed, nutritional therapy is effective in the improving the frailty status. Background The pathogenesis of non-alcoholic fatty liver disease (NAFLD) is multifactorial. The gut microbiota has been suspected to contribute to the pathogenesis of NAFLD through several mechanisms. We evaluated the prevalence of small intestinal bacterial overgrowth (SIBO) in NAFLD and its association with various lab parameters and anthropometric measurements. Methods One hundred patients with NAFLD (63 males)-diagnosed by imaging, were enrolled. They were subjected to glucose hydrogen breath test (GHBT). Anthropometric parameters and lab parameters (liver function tests, lipid profile, platelet count) were noted. Results Of 100 NAFLD patients, 43/100 (43%) had SIBO. A significantly higher number of patients with SIBO had elevations in transaminases: AST (55.56% vs. 44.44%, p=0.029), ALT (60.61% vs. 39.39%, p<0.006). There was also a significant relative risk of increase in transaminases with SIBO -positive status: AST -1.657 (95% CI, IQ range 0.985-2.788), and ALT-2.039 (95% CI, IQ range 1.165-3.568). Both these findings were more pronounced in females. The mean AST (38.58 ± 16.66 IU/L vs. 32.28 ± 15 IU/L, p = 0.025) and mean ALT (41.12 ± 21.28 IU/L vs. 33.96 ± 19.65, p= 0.043) values were also higher in patients with SIBO. Majority of patients enrolled in our study had high BMI (32.05 + 3.07 kg/m2), increased waist circumference (36.29 + 4.88 inches) and high mean cholesterol (167.4 ±30.22 mg/dL). There was no significant relation of SIBO with grade of obesity, increased waist circumference, lipid profile (including serum triglyceride levels) or aspartate aminotransferase to platelet ratio index (APRI) score in our patients. Conclusion SIBO is prevalent in NAFLD patients and is associated with significant derangement in aminotransferases. Patients with SIBO may benefit from aggressive control of risk factors for NAFLD. Background The underlying mechanism for the development and progression of non-alcoholic fatty liver disease (NAFLD) is complex and multifactorial. Studies have suggested the role of gut microbiota and, association of small intestinal bacterial overgrowth (SIBO) with NAFLD. We investigated the frequency of a SIBO in NAFLD. Methods One hundred patients with NAFLD-diagnosed by imaging, and 20 healthy volunteers were enrolled. They were subjected to glucose hydrogen breath test (GHBT) for detection of SIBO. Anthropometric parameters were noted and compared in both groups. Lab parameters were noted in NAFLD patients. Results Of 100 patients of NAFLD 43/100 (43%) tested positive for SIBO, and 6/20 (30%) tested positive in control group. This was not a statistically significant difference (p=0.140). Obesity parameter remained associated with NAFLD-healthy volunteers had a significantly lower BMI (27.09 + 4.03 kg/m2 vs. 32.05 + 3.07 kg/m2, p=<0.001), waist circumference (32.05 + 3.07 inches vs 36.29 + 4.88 inches , p=<0.001) than NAFLD patients. In NAFLD patients-elevation in transaminases was significantly more prevalent in patients with SIBO: AST (increased in 55.56% vs. 44.44%, p=0.029), ALT (increased in 60.61% vs. 39.39%, p< 0.006). Also, among those testing positive for SIBO in NAFLD-the relative risk of increase in transaminases was significant: AST -1.657 (95% CI, IQ range 0.985-2.788), and ALT-2.039 (95% CI, IQ range 1.165-3.568).

Conclusion SIBO is more prevalent in NAFLD, than healthy population. Obesity parameters remain associated with NAFLD. SIBO may contribute to progression of liver disease. Keywords SIBO, Hydrogen Breath Test, Gut microbiota, NAFLD Background Langerhans cell histiocytosis (LCH) is an abnormal accumulation of Langerhans cells in various organs that sometimes induces organ dysfunction. LCH can affect the liver, resulting in sclerosing cholangitis and biliary cirrhosis. However, liver and bile duct involvement is usually observed in the disseminated form of LCH. We here in report a rare case of LCH presented to us with cholestatic jaundice with skin manifestations. Case Presentation A 1-year-old girl with elevated liver enzymes, obstructive jaundice with crusted lesions on scalp and pruritic skin lesions on hands and feet presented to our OPD TORCH panel was negative. CECT abdomen and MRCP where normal except for borderline hepatomegaly. Sections of liver biopsy showed histiocytic cell proliferation with sclerosing fibrosis of portal tracts and IHC revealed histiocytoses that were positive for Langerin, S-100 protein, and CD1a. histiocytic cell proliferation was noted in the liver tissue and correlated with skin biopsy findings. The definitive diagnosis was LCH with skin and hepatic involvement. The patient was initiated on prednisolone and vinblastine as bridge therapy prior to liver transplantation with good response under follow-up. Conclusions LCH can affect the liver rarely. LCH should be considered as a differential diagnosis if pediatric patients show the presence of cholestatic jaundice with skin lesions. sclerosing cholangitis is unusual complication and eventually progress to cause cirrhosis and may require liver transplantation.

Introduction Cirrhosis is frequent cause of death mostly as a result of complication predominantly including sepsis and/or renal failure. Acute kidney injury (AKI) is a common complication in cirrhotic estimated as 19% of hospitalization and mortality of 55% to 91%. Methods A total 94 patient (74 (M) and 23 (F)) with either newly diagnosed or known case of cirrhosis of liver, admitted with AKI or developed AKI during hospital stay with no documented renal parenchymal disease were studied with AKI diagnosed by International club of ascites criteria followed by history, medical evacuation and testing including creatinine, LFT, lactate, uNGAL and then classified into types, stages of AKI and followed till either death or discharge from hospital. Results Mean age (56.79 +11.74 yrs) CTP score (10.41 + 1.75) and MELD score of (24.84 + 7.97). NASH (41.5%) and alcoholism (28.7%) were cause of cirrhosis. Cause and stage of AKI were prerenal AKI (52.1%), HRS (28.7%) and ATN (19.1%) with Stage 1 (38.3%), Stage 3 (31.9%) and Stage 2 (29.8%) AKI respectively. Majority of prerenal AKI shows complete response with minority of ATN shows response. 25.53% expired (predominantly male) with death classified seen in ATN (37.5%), HRS (33.33%) and prerenal (29.1%), 41.66% (Stage3) 37.5% (stage 2) and 21% (Stage1). Hemodialysis is required in 27.7% as modality of treatment majority in ATN and Stage3 AKI with 38.5 % of these patients didn't recovered from HD. Urinary NGAL was tested in 43 patients with 60.5% patients having level > 121 ng/mL with level 1340.91 (ATN) and 727.49 (death). uNGAL is 84.2% sensitive and 54.2% specific for predicting mortality (cut-off 111.7ng/mL) and 100% sensitive and specific for detecting ATN (cut-off value 771.9 ng/mL). Conclusion Prerenal AKI is most common cause of AKI but having better prognosis with ATN having highest mortality and mostly requiring HD. uNGAL is sensitive method to detect ATN leading to early diagnosis, improve prognosis and henceforth predicting mortality. Introduction The use of liver transient elastography (TE) to assess liver fibrosis is attractive for its non-invasiveness, but reference values in Indian paediatric population has not been established.

Objectives We aimed to determine the liver stiffness (LS) and controlled attenuation parameter (CAP) for healthy children in the age group 5-12 years, and to determine whether liver fibrosis is age dependent in children.

Methodology We conducted a school based cross-sectional study in Kerala, India for healthy children of age 5-12 years. Fatty liver screening was done with ultrasound. TE and CAP were measured using Fibroscan 502 Touch using M probe. Children were grouped in to 2 groups, 5-8 years and 9-12 years. Student t test was used to compare the mean for TE and CAP. Results Total 110 children were screened. 60.9% (67) were male and 39.1% (43) female. 47.2% (52) belonged to 5-8 years age group and 52.8% (58) in 9-12 years group. 3.6% (4) children had fatty liver by ultrasound. Pooled mean TE was 4.496±0.29 KPa (95%CI). For 5-8 years group mean was 4.19±0.43 and for 9-12 years group 4.77±0.38 KPa. Mean difference of TE was statistically significant (p value=0.027). Mean difference was significant (4.19 vs. 4.73 KPa, p=0.036) even after excluding children with fatty liver. Pooled mean for CAP was 180.01 ±2.99dB. Mean difference between the 2 groups (5-8 years 178.1 ±3.8dB vs. 9-12 years 181.7±4.4dB) was not statistically significant. In the 4 children with fatty liver, the mean CAP was 198.5dB. None of the children with fatty liver had steatosis according to CAP adult standards of 241dB.

Conclusion TE values in children increases with age. However, values in children may be much less than in adults. CAP is age independent. However, CAP value standards of 24dB to diagnose fatty liver may not be applicable to Indian children. Keywords Pediatric NAFLD, Transient elastography, Liver stiffness measurement, Controlled attenuation parameter

Hepatitis B and C viral infections in chronic liver disease: Experience from a resource constrained region of Asia Introduction Chronic liver disease (CLD) is associated with serious complications and increased mortality, and is caused by different etiologies like alcohol use, chronic viral hepatitis B (CHB), chronic viral hepatitis C, and other etiologies. However, the prevalence of chronic hepatitis B, hepatitis C infection in CLD patients has not been assessed in this region of Asia. Hence, we performed this prospective study to evaluate the prevalence and spectrum of hepatitis B, and hepatitis C related CLD and its outcome. Method A prospective study was carried out in consecutive CLD patients hospitalized in the Gastroenterology Department, SCB Medical College between December 2016 and October 2018. On admission all CLD patients were screened to identify the underlying etiologies. Further the demographic, clinical, and laboratory parameters were recorded and survival during hospitalization was recorded. Results Out of 708 CLD patients, alcohol was the underlying etiology in 59.7% (n=423) patients, CHB in 16.4% (n=116) patients, both alcohol and CHB in 2.4% (n=17) patients, chronic viral hepatitis C in 0.8% (n=6) patients and other etiologies in in 20.6% (n=164) patients. Among the patients with chronic viral hepatitis B and C, 78.4% (n=109) were male, mean age was 53.39±12.42, BMI was 20.85±3.09, MELD UNOS score was 18.39±10.84, MELD Na+ score was 20.09±2.50, and CTP score was 10.01±3.33. More no of patients were admitted with severe liver disease (5% [n=7]) had Child A, 37.4% (n=52) had Child B, and 57.6% (n=80) had Child cirrhosis], and more importantly 5% of patients died during hospitalization. Conclusion In our institution chronic viral hepatitis B or C were found to be the underlying etiologies of CLD in one fifth of patients. 95% of the patients were hospitalized with either Child B or Child C cirrhosis and were associated with mortality during hospitalization. Keywords Chronic liver disease, Hepatitis B, Hepatitis C Background Skin and soft tissue infections (SSTI) are among the common bacterial infections noted in patients with cirrhosis and are related to hypoalbuminemia and edema. Aims This study aimed to determine the clinical profile, bacteriology and in-hospital mortality in patients with cirrhosis with SSTI. Methods In this retrospective study, we analyzed patients with cirrhosis presenting to our department with soft tissue infections (SSTI) between March 2019 and June 2020. Clinical and laboratory data were retrieved from hospital records. Data retrieved included demographics, etiology, comorbidity, cirrhosis related complications, site of Cellulitis, baseline investigations, wound culture, blood, urine, and ascitic fluid culture and clinical outcome. Results During the study period, 387 patients with cirrhosis were admitted, of whom 29 (7.5%) had skin and soft tissue infections (median [IQR]) age 44.5 [16) years; 75.9% w]ere males, model for end-stage liver disease score (MELD) score 27 (14), Child-Pugh (CTP) score 12 (3). Etiology of cirrhosis was alcohol in 45%, hepatitis C virus in 27.6 %. 20.7% (6/29) had diabetes mellitus. Lower limbs were most commonly involved. Of the 29 patients, cellulitis was noted in 15 (52%), ulcers in 10 (34.5%). Cultures were positive in 58.6% (17/29) patients. The majority of cultures showed monomicrobial growth with predominant gram-negative bacteria 64.7% (11/17). E coli 35.2% (6/17) was the commonest isolate, followed by Klebsiella 10.3% (3/17). 11 (34.4%) patients died during the hospital stay. Compared to non-survivors, survivors had higher CTP score (13 [2] vs. 12 [4], p < 0.05).

Conclusion SSTI was noted in 7.5% of patients with cirrhosis. Alcohol was the most common etiology of cirrhosis in these patients. Gramnegative bacteria (E. coli and Klebsiella) were the most common bacterial isolates. In-hospital mortality was noted in 34.3% of patients and was higher in patients with higher CTP and MELD score. Keywords Liver cirrhosis, Soft tissue infections, Bacteriology 189 Diffusion MRI in focal liver lesions and role of apparent diffusion coefficient (ADC) in Barcelona clinic liver cancer (BCLC) staging of hepatocellular carcinoma Introduction Diffusion weighted imaging has resulted in enhanced disease detection and characterization with easy implementation techniques. The quantitative apparent diffusion coefficient derived shows good measurement reproducibility, which can be applied for tissue characterization, assessment of tumor response and disease prognostication. We compared the diagnostic utility of diffusion weighted imaging with conventional MRI in benign and malignant focal liver lesions and compared the apparent diffusion coefficients with Barcelona clinic liver cancer (BCLC) stage of hepatocellular carcinomas. Methods Fifty patients of focal liver lesions were prospectively evaluated by Diffusion Weighted-MRI and conventional MRI after approval of Ethics Committee. ADC values of each benign and malignant lesion were calculated. Ten patients of HCC were staged as per the BCLC staging. The liver imaging in HCC patients was standardized with LI-RADS (Liver imaging Reporting and Data system). Results Of 210 focal liver lesions in 50 patients, 84 were benign lesions and 126 were malignant lesions. Most common lesion was metastasis (52.8%). There is significant difference between T2WI and DWI for detection of malignant lesions. There was no difference between the use of T2 weighted imaging and DWI for the detection of benign hepatic lesions in our study. The mean ADC values of malignant lesions were significantly lower than those of benign lesions (0.90 x 10-3 mm2/s vs. 2.52 x 10-3 mm2/s) (p<0.001). There was significant difference between the mean ADC values of HCC and metastasis (p-value<0.001). Lower the ADC values of the lesions, patients had a poorer outcome as per the BCLC staging. Conclusion DWI can be used as the imaging modality to differentiate malignant from benign liver lesions, thus avoiding unnecessary biopsies. Its utility in the assessment of diffuse hepatic parenchymal diseases is still at a research level. Further investigations are needed to increase the reliability of the technique for these indications. Background FIB 4 score is known to have a significant negative and positive predictive value in predicting lower and higher grades of liver fibrosis. Aim Correlate FIB-4 score with grades of fatty liver (FL) amongst men and women greater and less than 45 years. Methods Prospective data on hemogram, liver biochemistry, and ultrasound (USG) was collected in master health check. USG findings were classified as normal, Gr 1, 2, and 3 FL, FIB-4 was calculated. Patients with known liver disease were excluded. Cut-off of 45 years was taken for comparison between men and women. Statistical Analysis Appropriate non-parametric tests were used. AUROC was obtained for the FIB-4 cut-off. SPSS version 23.0 version was used. Results There were 741 subjects (474 men; 64%). 418 (56.4%) were > 45 years. Liver was normal in 297 (40.1%); grade 1, 2 and 3 FL in 293 (39.5%), 114 (15.4%) and 37 (5%) subjects respectively. The overall mean FIB-4 score was high in males (1.37 ± 1.06 vs 1.15±0.83, p value 0.009) and remained so, for > 45 years (1.69+ 1.09 vs. 1.33+ 0.88, p value 0.000) and < 45 years (1.01±0.90 vs. 0.87±0.66; p NS). Mean FIB-4 scores increased with grades of FL (p 0.126). AUROC was 0.538, 0.516 and 0.602 respectively for Gr 1, 2 and 3 respectively. Conclusion FIB-4 score in our study is lower than that reported in the west with a poor prediction for any grade of FL. Keywords Background and Aims Hepatocellular carcinoma (HCC) is a primary cause of liver cancer leading to death worldwide. Meanwhile, in a country like India where because of financial constraints for patients, liver transplantation is not popular in spite of being offered to patients. Thus, HCC is managed with the best available treatment options. Methods Prospective study was conducted in which a total of 21 diagnosed cases of HCC patients were managed and treatment strategy was planned according to Barcelona Clinic Liver Cancer staging over a period of 3 years. Results Study showed male predominance (85%). Mean age was 65+/-5 years. The etiology was mainly hepatitis B (70%), followed by hepatitis C (25%). 60 % patients were asymptomatic. Serum alpha fetoprotein was raised in 45% of patients. Unresectable cases underwent loco regional therapy. Trans arterial chemoembolization (TACE) was done in 9 patients, radiofrequency ablation (RFA) in 3 patients, TACE+RFA in 6 patients, TACE + ethanol ablation in 1 patient , TACE followed by curative partial hepatectomy in 1 patient and only sorafenib in 1 patient. Median survival of patients is 2 years after TACE + RFA with no recurrence; TACE patients had a median survival of 6-8 months in which 44% had recurrence. RFA patient's survival is around 1 year, after which the patient developed recurrence. TACE + ethanol and TACE + surgery patients are on follow-up with no recurrence. Conclusion HCC is potentially curable if discovered in its initial stages. Strategies for early diagnosis and treatment of HCC is a way to decrease mortality. Introduction Cavernous hemangioma is the most common benign tumor of the liver and is found in as many as 7% of autopsies. Women are predominantly affected (6:1) and often present at a younger age. Majority are small (<2cm), predominantly in right lobe of liver and are discovered incidentally during imaging of the liver for another reason. Those larger than 5 cm are called giant cavernous hemangiomas. Upper abdominal pain is the most common complaint. We report a case of elderly female with giant hemangioma occupying entire left lobe presenting as epigastric hernia. Case Report Sixty-two year-old female patient presented with pain abdomen and distension since 3 months. She had prior history of abdominal surgery 10 yrs back (no records). On examination she had swelling in midline in epigastric region becoming prominent while coughing. USG abdomen-midline defect noted at epigastric region with herniation of abdominal fat. To our surprise large heterogenous lesion noted in left lobe of liver. AFP-normal, viral markersnegative, LFT and CBP within normal range. CECT triphasic done revealed 15*12*17 cm hypodense lesion occupying entire left lobe showing intense enhancement in arterial phase with progressive centripetal enhancement in delayed phase suggestive of giant hemangioma. She is referred for surgical resection and hernia repair. Background Alcoholic liver disease is one of the commonest causes of advanced liver diseases. The prognosis of patients with alcoholic hepatitis (AH) can be established by different scoring systems. The prognostic role of neutrophil to lymphocyte ratio (NLR) has been documented in multiple diseases but the overall evidence of prognostic role of NLR in AH is relatively scarce. The aim of the study was to assess NLR as a prognostic marker in patients with AH and compare it with other prognostic scores.

Introduction Extrahepatic portal venous obstruction or cirrhosis is the cause of portal hypertension (PHT) in majority of Indian children (92%). Nodular regenerative hyperplasia (NRH) is a rare entity especially in children which is clinically dominated by PHT with splenomegaly. This condition is often associated with systemic diseases or drugs and is characterized by a widespread benign transformation of liver parenchyma into small regenerative nodules. We report a rare case of NRH with portal hypertension with a normal spleen in a girl child, as an isolated occurrence. Case Report A 7-year-old girl, pre-morbidly well, presented with multiple episodes of hematemesis. Clinically she had severe pallor without icterus and hepatosplenomegaly. Labs showed severe anemia (Hb-6.8 g/dL) and normal platelet count. Liver function tests were normal apart from mild transaminitis. Ultrasonography abdomen revealed heterogeneous liver echotexture without nodularity, portal vein measuring 4.2 mm at porta, with normal spleen and minimal ascites. Grade III esophageal varices were detected on gastroduodenoscopy. Liver biopsy showed early nodular regenerative hyperplasia with few porta showing obliterated portal vein. Endoscopic variceal banding was done as a secondary prophylaxis. Our patient had no drug exposure and further investigations did not reveal any autoimmune, metabolic, myeloproliferative or neoplastic disorders. Discussion NRH has rarely been described in children. It is important to consider NRH in the differential diagnosis of unexplained PHT owing to its relatively favorable prognosis. Though the largest pediatric series (16 cases) by Moran et al. emphasized the association of NRH with other diseases, we did not find any association, suggesting the possibility as an isolated occurrence. To the best of our knowledge this is the first case report of NRH with clinically significant portal hypertension with a normal spleen which is inconsistent with the previous case reports.

Introduction Hydatid cyst is endemic zoonotic diseases in India. Due to its different morphological presentation it has multiple treatment options like PAIR, surgical enucleation and antihelmintics. Methods This is retrospective cross-sectional observational study carried out in consecutive 48 patients of hepatic hydatid cyst presented to Department of Gastroenterology, SSH/BHU between January 2016 to December 2019. Observation Mean age of our patient group was 37.6 years (7 to 68 years). Most of the patients were female (70.8%). Most common presenting symptom was right hypochondrium pain (62.5%) followed by abdominal lump (25%). Fifty-two percent of hydatid cysts were of Gharbi I , 31% of Gharbi III. Mean cyst volume was 7.5*6.2*8.1cm. Hydatid serology was positive in 47% cases and protoscolex of echinococcus granulosus in aspirated fluid was present in 72% of the cases. Successful PAIR was done in 66% 0f cases (out of which in 20% cases repeated PAIR was required). PAIR was failed in 22% cases for which surgical referral was taken and in remaining 12% of cases only albendazole was sufficient. Conclusion For management of hepatic hydatid cysts of favo-rable morphology PAIR is still a conservative treatment option.

Introduction Ischemic hepatitis (IH) presents as significantly raised liver enzymes in ICU patients, who are more prone in view of co-existing illness. This study aimed to evaluate the profile of IH. Methods Patients admitted to ICU with cardiac/respiratory failure, hypotension, sepsis, or those resuscitated after cardiac-arrest were screened. LFT, INR, creatinine were measured on day 1. ALT, bilirubin (T), LDH were measured on day 3, 7 and 14. ABG (in hypoxia) and cultures (in sepsis) were done. Echocardiography and USG abdomen were done for all. Patients with ALT >800 IU/L, negative IgM antibodies (HAV and HEV) and with no history of drug-induced toxicity were followed. Results Of 3794 patients screened over a year, 75 had IH. Mean age was 67 years and 46 were male. 60% had ≥2 predisposing causes. Predisposing causes were bi-ventricular dysfunction (56%), leftventricular dysfunction (43%), hypotension (40%), sepsis (25%), cardiac-arrest and resuscitated (20%), respiratory failure (17%). 3 (6%) were cirrhotic, but none developed ACLF. Mortality was 46% but none were primary liver related. Mean ALT (IU/L) level on day 1 (54 IU/L), day 3 (4305 IU/L), day 7 (1915 IU/L), day 14 (523) and the ALT levels reduced by >50% (day 7) and >80% (day 14). Mean T. bilirubin (mg/dL) was 1.49 (day1), 3.2 (day7) and 2.6 (day 14). Mean AST (3711 IU/L) was higher than ALT (3683 IU/L), ALT/LDH ratio was 1.15 and ALT were higher in those who died (4305.17 ± 2465.0 and 3683.74 ± 2618.43 respectively). Peak ALT were on day 3 (non-cirrhotics) and on day 7 (in cirrhotics). Cirrhotics had higher mean bilirubin on day 7 and day 14. Conclusions Incidence of IH was 1.98% of ICU admissions. Their presentation closely mimics acute viral/toxin-induced hepatitis. It has no specific symptoms, is easily missed, unless looked for. Careful monitoring of LFTs in critical-care patients would identify IH. Early aggressive Introduction Patients with cirrhosis of liver are more prone to sepsis and sepsis related complication with poor prognosis. Recently the international task force proposed new criteria to define sepsis and septic shock which has been named as sepsis -3 criteria. The group also proposed qSOFA criteria for screening of sepsis. It is believed that based on these new criteria prognostication of patients of cirrhosis with sepsis will be more accurate, therefore we aimed this study "to compare sepsis -3 with sepsis -1 (old criteria for screening of sepsis) and qSOFA to predict 90-days mortality in patients with cirrhosis of liver and infection". Method All patients with cirrhosis and proven infection were prospectively included in our study. Demographic, clinical, laboratory and microbiological data were collected at time of admission. Base line qSOFA score was obtained from previous record. Sepsis 1, sepsis 3 and q SOFA were calculated at the time of admission. The primary outcome was 90-days survival. Result A total of 108 patients of cirrhosis with proven infection were recruited. Out of 108 patients, 60 patients (55.6%) fulfilled sepsis-1 criteria, 63 patients (58.3%) fulfilled sepsis -3 criteria and only 32 (29.6%) fulfilled positive qSOFA criteria. Overall 90-days mortality was observed in 21 (19.4%) patients, out of these 21 patients who died within 90 days, 13 patients (61.9%) fulfilled sepsis-1 criteria, 11 patients (52.4%) fulfilled q-SOFA criteria and all 21 patients (100%) fulfilled sepsis-3 criteria. Sepsis-3 showed good accuracy for 90-days mortality area under the receiver operating characteristic ( A U R O C ) = 0 . 8 3 8 , 9 5 % C I , 0 . 7 5 5 -0 . 9 0 2 t h a n q S O F A ( A U R O C = 0 . 7 6 0 , 9 5 % C I , 0 . 6 6 9 -0 . 8 3 7 ) a n d s e p s i s -1 (AUROC=0.658, 95% CI, 0.560-0.7) (Fig.1 ). Conclusion Present study shows that sepsis-3 criteria are more accurate than qSOFA and sepsis-1 in predicting 90-days mortality in patients of cirrhosis with infection. Keywords: Liver, Cirrhosis, Sepsis-3, qSOFA, Sepsis Fifty-six-year old lady, Asha worker was referred to MGE, OPD with complaints of bloating, belching and nausea with findings of hepatomegaly on USG abdomen done outside. She gave additional h/o DM and suspected CAD, on antiplatelets. LFTs done revealed an cholestatic pattern with elevated ALP, GGT and borderline raised OT/PT and hepatomegaly was confirmed with repeat USG abdomen. Subsequent serological and imaging investigation (CT scan abdomen), done to determine the etiology yielded no definitive results. A liver biopsy was planned to give a definitive diagnosis. A liver biopsy was planned to give a definitive diagnosis. Liver biopsy showed congophilic material with apple green birefringence which s/o hepatic amyloidosis. Once confirmed, SPE was performed as part of determining the type of amyloid. SPE showed band in gammaglobulin region and subsequent bone marrow showed biopsy confirmed multiple myeloma. Screening for other organ involvement showed involvement of heart (2Decho with bulls eye appearance on strain imaging and cardiac MRI confirming cardiac amyloidosis) and peripheral; nerves showing length dependent axonal polyneuropathy. MRI spine also showed multiple levels of degenerative vertebral bodies. Background India has the 2nd highest incidence of liver abscess in the world due to overcrowding, poor sanitation and inadequate nutrition and continue to be an important cause of morbidity and mortality. So identification of risk factors and early diagnosis are key issues for effective interventions. Most of the Indian data are from north and north east with sparse data from the south. The aim of this study is to evaluate the changing trends in clinical profile, microbiological etiology of patients diagnosed with liver abscess. Methods A retrospective data of the 108 patients who admitted with a liver abscess in a tertiary care center in south India from January 2018 to January 2020 was collected including presenting complaints, lab parameters including cultures and serology along with necessary imaging. Results Pyogenic liver abscess PLA (86.1%) is predominant over amebic liver abscess ALA (13.8%). The mean age of the patients with PLA is 52.5 vs. 44.8 years for amebic with male preponderance (94.4%). There was no significant difference in lab values between pyogenic and amebic liver abscess. Alcoholism (23.1%) and diabetes (43.5%) are main predisposing factors. Pain abdomen and fever was present in 91.7% and jaundice in 19.4% patients. The ALA were predominantly solitary and in right lobe. The most common pathogen in pyogenic was klebsiella pneumonia (36.8%) followed by E. coli (21%). More than 5 cm abscess required a pigtail insertion. Forty-nine patients (45.3%) underwent pigtail insertion. Mortality was 1.8% and was due to sepsis and multi organ dysfunction. Conclusion The commonest type of liver abscess was pyogenic in contrast to studies from north India. Liver abscess was predominant in males. Obstructive type of jaundice was more common in pyogenic abscess compared to amoebic. Most of the patients can be effectively managed with antibiotics covering gram negative spectrum and with proper selection of patients for drainage. Keywords Liver abscess, Pyogenic liver abscess, Amebic liver abscess Introduction Hepatocellular carcinoma (HCC) is fourth most deadly cancer. Majority of HCC patients have underlying chronic liver disease (CLD) that leads delayed HCC diagnosis. Surveillance of high risk CLD patients can led to early HCC diagnosis. Delay in diagnosis results in progression of HCC and metastasis. Routine screening for HCC is not cost effective. Liquid biopsy holds great promise for early detection, prognosis, and response to cancer treatment. The cell free DNA (cfDNA) concentration and its integrity index changes early during carcinogenesis. The DNA integrity index by real time PCR of repetitive genomic sequences (Alu, LINE1) and beta actin and GAPDH may predict early hepatocarcinogenesis for which propose study was undertaken. Objectives Cell free DII determination by real time PCR for the early prediction of hepatocarcinogenesis in CLD patients. Methods Consecutive HCC (n=100), CLD (n=55) and healthy (n=10) controls were included. CfDNA was isolated from serum using Qiagen kit. Genomic DNA from Huh7 cell line was used as control. Cf DNA concentration and purity was checked by scan-iT software. The primer pairs for large (>200 bp) and small (<200 bp) amplicon against Alu, LINE1, beta-Actin and GAPDH gene were designed. Real time PCR using SYBR was carried for both fragment. The DII by comparative Ct method was used for differential ability CLD vs HCC. Results More fragmentation was observed in DNA in cancer. Normalization was done with genomic DNA. Increased DII indicates lower integrity in HCC vs. CLD vs. healthy. ROC curve in CLD vs. HCC subjects are significant for ALU and GAPDH gene having AUC Introduction Hepatocellular carcinoma (HCC) is the third leading cause of cancer related death worldwide. Although hepatitis B (HBV) and hepatitis C (HCV) have been the main drivers of HCC, non-alcoholic steatohepatitis (NASH) is emerging as a leading cause of HCC. The aim of this study was to assess NASH as cause of HCC. Methods This retrospective observational study was carried out on diagnosed patients of HCC during last one year at tertiary care center in western India. Data included were clinical presentation, comorbid conditions, biochemical parameters with alfa fetoprotein levels, imaging (ultrasound/ computed tomography of abdomen). Data regarding etiology of cirrhosis and HCC were collected. Barcelona clinic liver cancer (BCLC) staging was used to stage and guide HCC therapy. Results Total 13 patients of HCC were included in analysis. Mean age of patients was 64.53 ± 8.43 years with male predilection (93.30%). Most common presentation was abdominal pain (61.53%) followed by ascites (46.15%) and constitutional symptoms like anorexia and weight loss (46.15%). Eleven patients had underlying cirrhosis and two patients were noncirrhotic. 69.23% patients of HCC had diabetes mellitus as co morbidity. NASH was the commonest etiology in cirrhotics with HCC (72.72%) followed by HBV (18.18%) and alcohol (9.1%). HBV and NASH was the etiology respectively in two noncirrhotics. Alfa fetoprotein was normal, between 40-400 ng/mL and >400 ng/mL in 54%, 23% and 23% respectively. Majority of patients had higher stages of HCC (BCLC-C and D) at diagnosis even on surveillance (62%) and received targeted therapy of sorafenib. Conclusion NASH is the most rapidly emerging cause of HCC paralleled with epidemic of metabolic syndrome components in India. Screening of HCC should be considered in all patients of NASH cirrhosis and advanced fibrosis.

Introduction Pasteurella multocida is pleiomorphic, facultatively anaerobic, a Gram-negative coccobacillus commonly isolated as commensals in the oral flora of a variety of animals. In dog and cat bite wounds, Pasteurella multocida, are isolated in 50% to 70% of the cases. Although direct inoculation of the skin through animal bite or scratch is the most common route of human disease, infection has been documented even in the absence of direct animal contact. Pasteurella multocida serves as an opportunistic pathogen in humans, especially in patients with depressed immune system. Few cases in the literature identify Pasteurella multocida as the causative agent of septic shock, especially in cirrhotic patients. Here, we present a rare case of Pasteurella multocida septic shock in an elderly woman with chronic liver disease. Case Report A 74-year-old female was admitted with abdominal distension, breathlessness and edema without any fever or gastrointestinal bleed. She also gives history of close contact with pet dog, but no history of any dog bite. She had past history of chronic obstructive pulmonary disease, hypertension and recently detected chronic liver disease. Physical examination showed drowsy, pallor, icterus, edema, cellulitis both legs, hypotension, tachycardia and ascites. Evaluation showed features of sepsis with probable source as cellulitis and blood cultures grew P. multocida which was managed with piperacillin/tazobactam with clinical improvement. Discussion Although cases of bacteremic P. multocida infections has been infrequently reported in the literature, clinicians should consider this organism as an important and potentially lethal pathogen in humans, where it can cause life-threatening infections. It should be included in the microbiologic differential diagnosis in patients with underlying chronic liver diseases who presents with possible infection, with history of exposure to domestic animals. Septic shock is an uncommon complication of P. multocida infection with a mortality rate of 15% to 30%.

Introduction Serum ferritin, a marker of hepatic necroinflammation has been studied to predict early mortality in patients with decompensated cirrhosis. But its significance when compared with serum CRP levels has not been studied. The aim of the study was to analyze serum ferritin and CRP levels as prognostic markers in patients with decompensated cirrhosis and compare it with MELD and CTP scores. Methods Two hundred and twenty consecutive patients with decompensated cirrhosis were included. Serum ferrtin and CRP levels at presentation and factors predicting mortality at 3 months were assessed. Results Patients with decompensated cirrhosis (n=220) (M:F 168:52, mean age 55.7 yrs +/-11 ) were followed up for a period of 3 months. At presentation, median serum ferritin level was 321.45 (7.4-750) ng/mL in survivors and 725 (275-3000) ng/mL in non-survivors, and median serum CRP level was 9 (2-60) mg/L in survivors and 18.5 (6-64) mg/L in non-survivors. Serum ferritin levels were significantly different between survivors and non-survivors (p<0.05) and showed significant correlation with CRP levels (p<0.01). Serum ferritin, CRP, total leukocyte count, MELD score, CTP score, presence of hepatorenal syndrome, spontaneous bacterial peritonitis, hepatic encephalopathy and ACLF were significant predictors of mortality on univariate analysis. Ferritin, MELD and presence of hepatorenal syndrome were significant predictors of mortality on multivariate analysis. Serum ferritin (AUROC 0.91, 95% CI 0.87-0.95) was comparable to MELD score (AUROC 0.92, 95% CI 0.891-0.961) and better than CRP (AUROC 0.74, 95% CI 0.67-0.80) and CTP score (AUROC 0.847, 95% CI 0.79-0.89), in predicting death at 3 months. Conclusion Elevated serum ferritin level is as an independent prognostic marker in decompensated cirrhosis. Elevated serum CRP levels did not show association with mortality at three months in decompensated cirrhosis.

Indu Grover, Namrata Singh, Deepak Gunjan, Anoop Saraya Correspondence-Anoop Saraya-ansaraya@yahoo.com Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Introduction Sarcopenia is common and camouflaged complication which adversely affects quality of life and outcomes in the patients with cirrhosis. The aim of this study is to describe the prevalence of sarcopenia and its relationship with nutritional status, disease severity and disease duration in patients with cirrhosis. Methods The appendicular skeletal muscle mass index (ASMI) was assessed by dual energy X-absorptiometry (DEXA). Cut off given by Asian working group for sarcopenia (AWGS) was used to define sarcopenia; for male (<7 kg/m 2 ) and female (<5.4 kg/m 2 ). Subjective global assessment (SGA) modified for liver disease was used to assess nutritional status. Patients were categorized in compensated and decompensated group and MELD score was calculated. Results A total 341 patients with cirrhosis (271 male, mean age 44.0±12.0 years) were included in this study. The prevalence of sarcopenia was 36.7% (male: 36.9% vs. female: 35.7%). The value of ASMI (kg/m 2 ) was for male (7.36±1.16), female (5.86±0.99), compensated (7.01 ±1.25) and decompensated cirrhosis (7.01±1.32), respectively. More results are shown below: Background and study aim Deranged LFT, commonly noted along with other abnormal blood parameters in ICU patients is both a consequence as well as a significant cause of patient's morbidity. In this observational study we aim to analyse the pattern of liver injury noted in patients being treated in ICU and suggest various precocious therapeutic measures for better clinical outcomes.

Method We conducted a prospective observational study in ICU patients irrespective of age and gender from October 2019 to July 2020. We analyzed the pattern of liver injury (hepatocellular/cholestatic) and also noted the derangement observed in specific liver parameters secondary to hepatic dysfunction.

Results Of the 184 patients in study group, 132 (72%) found to have abnormal LFT. Among them majority are found to have hepatocellular pattern, 103 of 132 (78%). Cholestatic pattern is noted in 12 patients (9%) and mixed pattern in 17 (13%) patients. The major causes for hepatocellular injury are hypoxic hepatitis (shock/congestion/respiratory failure) noted in 69 patients (77%) and ethanol related liver injury noted in 34 patients (33%). The major cause for cholestatic pattern and mixed pattern noted is sepsis related.

Conclusion Liver dysfunction is a major contributor for significant morbidity and mortality in ICU patients. Deranged LFT is seen in almost 2/3rd patients of our study group. Precocious therapeutic measures like early and aggressive treatment of sepsis, hemodynamic abnormalities and metabolic derangements can prevent or reduce the severity of liver dysfunction there by leading to improved clinical outcomes in measures of morbidity and mortality. (ALT), triglycerides (TG), gamma-glutamyl transferase (GGT), albumin (Alb) and HOMA-IR were significantly different between no fibrosis (F0), any fibrosis (F1-F4) and significant fibrosis (>F2-F4). A Pediatric NAFLD fibrosis predictor (PNFP) score was develo p e d . P N F P = 2 . 5 6 4 + ( 0 . 0 4 9 * W C ) + ( 0 . 0 0 5 * T G ) + (0.016*AST)-(0.578*ALB). PNFP score had an AUROC for any fibrosis, significant fibrosis and advanced fibrosis of 0.747, 0.864 and 0.909 respectively when compared to pediatric NAFLD index (PNFI) (0.604, 0.778 and 0.925). A PNFP score of 5.05 had a sensitivity of 71% and specificity of 53% for any fibrosis. A score of 5.94 had a sensitivity of 80% and specificity of 88.7% for significant fibrosis. Conclusion Significant fibrosis occurs in 15% to 20% of pediatric NAFLD. Age, obesity, insulin resistance, and dyslipidemia increase fibrosis. Inactivity in the form of increased screen time accelerates fibrosis. PNFP score, a simple score incorporating AST, Alb, WC, and TG can predict significant fibrosis with better accuracy than existing models in children.

Keywords Transient elastography, Fibrosis, Pediatric non-alcoholic fatty liver disease fibrosis predictor (PNFP)

Does undetected non-alcoholic fatty liver disease lead to poorer treatment outcomes in patients undergoing surgery for gastrointestinal malignancy?

may not be picked up on routine preoperative screening and may be incidentally detected intraoperatively. Suitable modifications in the treatment plan could be made if liver disease is detected preoperatively. The aim was to determine the prevalence of undetected non-alcoholic fatty liver disease (NAFLD) in patients undergoing surgery for gastrointestinal malignancy; to assess correlation between MRI, MR elastography and liver biopsy and determine if morbidity is increased in patients with undetected pre-existing liver disease. Methods Patients undergoing surgery for primary gastrointestinal malignancy without known liver disease between July 2018 and December 2019 were included. All patients underwent baseline LFT, MRI and MR elastography in the preoperative period. Intraoperative liver biopsy was done. Change in surgical or chemotherapeutic plan was noted. Any morbidity in the postoperative period was noted and patients were followed up during chemotherapy period to look for worsening in the liver function.

Results Sixty-two patients were included in our study. NAFLD was more common in elderly males (n-46). Twenty-four of 62 patients (38.7%) had NAFLD. Seven of 15 (44.6%) patients who were overweight and obese had NAFLD. The sensitivity and specificity of MRI in detecting steatosis was 62.5%, 94.7% respectively. The sensitivity and specificity of MR elastography in detecting fibrosis was 29.2%, 100% respectively. Treatment plan was modified in 7 patients due to pre-existing liver disease. On multivariate analysis presence of sinusoidal dilatation was associated with statistically increased morbidity. There was an increased trend of complications in patients with NAFLD, but the increase did not reach statistical significance (p-0.070).

Conclusion The prevalence of NAFLD in our population was less than Delhi and more than Eastern India. There was an increased incidence of complications among patients with NAFLD though it did not reach statistical significance.

Keywords Non-alcoholic fatty liver disease (NAFLD), Magnetic resonance imaging (MRI), Magnetic resonance elastography (MR elastography)

Variations in CD14 gene and severity of alcoholic liver disease Neelanjana Roy, Hem Kumar * , Hem Pandey, Yatan Pal Singh Balhara ** , Anoop Saraya * , Shalimar * , Baibaswata Nayak * Correspondence-Neelanjana Roy-neelanjanam@gmail.com Departments of Blood Transfusion Medicine, * Gastroenterology and Human Nutrition, and ** Psychiatry, National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India

Introduction Alcohol accounts for 60% of all injuries registered in emergency rooms in India. Alcohol consumption in excess resulting in leaky gut is attributed to liver injury due to portal translocation of bacterial endotoxin ultimately leading to alcoholic liver disease (ALD). Variations in genes for alcohol metabolism and inflammation also contribute to development of ALD. The gene CD14 is a key player of endotoxin-mediated inflammation and vulnerability to ALD. Association of CD14 polymorphisms and the mechanisms relevant to alter inflammatory responses leading to ALD was assessed in this study. Aims Associations of CD14 gene polymorphisms and mechanisms relevant to alcoholic liver disease.

Methods Alcoholics with (ALD, n=128) and without (ALCon, n=184) liver disease and controls without alcohol habit (HLC, n=152) from North India were enrolled. The CD14 SNP rs2569190 of all individuals (n=464) were genotyping by RFLP and confirmed bysequencing. Secretory CD14 (sCD14), LBP, TLR4, MD2, TNFa, IL1b, IFNg, IL6, IL10 and IL4 levels in serum were measured by ELISA. And circulatory bacterial DNA level was estimated by realtime PCR.

Results Sequencing of promoter and exonic regions for reported SNPs of CD14 gene was done and majority found to be monomorphic except rs2569190 in Indian population. The SNP rs2569190 (C/T) was genotyped and TT genotype showed significant association with risk of ALD (ALD vs. ALCon [p=0.014] or vs. HLC [p=0.043]). Significant increased sCD14 level was detected in ALD and ALCon as compared to HLC (p=0.010, 0.013). Enhanced levels pro-inflammatory cytokines, like LBP, TLR4, TNFa, IL1b, IFNg and IL6 and reduced levels of antiinflammatory cytokines, as MD2, IL10 and IL4 was observed among the ALD patients (especially, in TT genotype) than the other two groups.

Conclusion Enhanced CD14 expression associated with inflammatory responses increases susceptibility of ALD in risk TT genotype individual.

Keywords Alcoholic liver disease, CD14 gene, Polymorphism

Alterations in autophagy and mTOR pathways mediate sarcopenia in patients with cirrhosis

Introduction The pathophysiology of sarcopenia in cirrhosis is poorly understood. We aimed to evaluate the histological alterations in the muscle tissue of cirrhotic patients with sarcopenia and identify the regulators of muscle homeostasis.

Methods Computed tomography images at the third lumbar vertebral level were used to assess the skeletal muscle index (SMI) in 180 patients. Sarcopenia was diagnosed based on the SMI cut-offs from a population of similar ethnicity. Muscle biopsy was obtained from the vastus lateralis in 10 sarcopenic cirrhotics, and the external oblique in 5 controls (voluntary kidney donors during nephrectomy). The histological changes were assessed by hematoxylin and eosin staining and immunohistochemistry for phospho-FOXO3, phospho-AKT, phospho-mTOR, annexin V, and caspase 3. The mRNA expressions for MSTN, FoxO3, markers of ubiquitin-proteasome pathway (FBXO32, TRIM63), markers of autophagy (Beclin-1 and LC3-II) were also quantified.

Results The prevalence of sarcopenia was 14.4%. Muscle histology in sarcopenics showed abundant atrophic angulated fibers (p=0.002). Immunohistochemistry showed a significant loss of expression of phospho-mTOR (p=0.026) and a trend towards loss of phospho-AKT (p=0.089) in sarcopenic patients. There were no differences in the immunostaining for annexin-V, caspase-3, and phospho-FoxO3 between the two groups. The mRNA expressions of MSTN and Beclin-1 were higher in sarcopenics (p=0.04 and p=0.04, respectively). The two groups did not differ in the mRNA levels for TRIM63, FBXO32, and LC3-II. Conclusions Significant muscle atrophy, an increase in autophagy markers, MSTN gene expression and an impaired mTOR signalling were seen in cirrhotic patients with sarcopenia.

Background Etiology and clinical presentation of space occupying lesion SOL of liver are varied it can be solid cystic for heterogeneous and it can be very difficult for hepato-biliary-pancreatic surgeons to diagnose preoperatively.

Case report An 27-year-old lady came with complaints of abdominal pain for one month and fever of 1 episode. she was investigated outside, her vitals was stable and abdominal findings was insignificant. Sonogram showed a well-defined lesion in the left lobe of liver with no internal vascularity possibly abscess, tumor markers where within normal limits, CE CT suggested recurrent pyogenic cholangitis with abscess while MRI suggested intrahepatic duplication of gallbladder. initial diagnosis of SOL segment 4b of liver. patient underwent laparoscopic cholecystectomy with enucleation of the lesion postoperative period was uneventful and final histopathology came back as Caroli disease.

Conclusions Caroli disease has been broadly applied to describe any patient with intrahepatic bile duct cyst regardless of the presence of extrahepatic bile duct cyst or the shape of the intrahepatic cyst. This disease occur in less than 1% of all the patients with biliary cystic disease and isolated version is even more rare in medical literature. Routine diagnostic armamentarium can not always achieve an accurate preoperative diagnosis. Caroli disease in adults main present in a localized form limited to 1 hepatic lobe or segment or a diffuse form most often the left side.

Keywords liver SOL, Cystic, Caroli disease 214 FibroScan-aspartate aminotransferase score in an Asian cohort of non-alcoholic fatty liver disease and its utility in predicting histological resolution with bariatric surgery Background and Aim The FibroScan-aspartate aminotransferase (FAST) score was developed for identifying patients with non-alcoholic steatohepatitis (NASH), who also have an elevated non-alcoholic fatty liver disease (NAFLD) activity score (NAS) ≥4 and significant fibrosis (F≥2). We aimed to validate it in our NAFLD cohort and assess if it correlates with the histological changes post-bariatric surgery.

Methods Patients with NAFLD, including those undergoing bariatric surgery, were included. The FAST score was calculated using liver stiffness measure, controlled attenuation parameter, and AST. Calibration and discrimination of the model were assessed by calibration plots and area under the receiver operating curve (AUROC), respectively. Sensitivity and specificity were assessed at the rule-out and rule-in cut-offs (≤0.35 and ≥0.67), respectively. Changes in the NAS and FAST scores were compared in the bariatric cohort one-year after surgery.

Results The cohort comprised of 309 patients, of which 48 patients underwent repeat liver biopsy at 1-year. The model showed good discrimination with AUROC of 0.79 (0.74-0.84); however, it wasn't satisfactorily calibrated (Hosmer Lemeshow test p=0.008). The sensitivity and specificity at the ruleout and rule-in cut-offs were 0.90 and 0.84, respectively. A significant correlation was seen between the 1-year reduction in the NAS and FAST scores (r=0.38, p=0.009). A significant reduction in the median FAST score was seen in patients who had ≥2-point reduction in NAS post-bariatric surgery.

Conclusion FAST score demonstrated good discrimination for fibrotic NASH in our cohort. However, a miscalibration resulted in over prediction. The score correlated well with the histological response to interventions for NAFLD.

Introduction Decompensated liver disease (DCLD) has got a high mortality rate. Prediction of mortality is important to prognosticate the patient and to channel high risk patients for liver transplantation. Objective of the study was to propose a new prognostic model for DCLD which is better than the existing scores.

Methods It was a retrospective and prospective observational study. Clinical and biochemical variables were assessed on the date of admission from the medical records and patient relatives were telephonically contacted regarding the date of death and mortality at 3 months from the date of admission. Logistic regression was done, coefficient of beta of independent variables were found out and a new score (HAM score)

Introduction Even though enough literature exists regarding the prevalence of CAD in patients with NAFLD, the literature on the prevalence and severity of NAFLD in patients with CAD is sparse. Objective of the present study was to assess the prevalence of NAFLD and its severity in patients with CAD.

Methods In a prospective study, consecutive adult patients with CAD were screened for the presence and severity of NAFLD after an informed consent. The study had the approval of Institute's Ethics Committee. CAD was diagnosed on coronary angiography and severity assessed by number of vessels involved and SYNTAX score. Prevalence and severity of NAFLD was assessed on ultrasound (abdomen), transient elastography [measuring liver stiffness measurement (LSM) and controlled attenuation parameter (CAP)] and other non-invasive assessment.

Results Of 256 patients screened over one and half years, 100 patients (males 71, mean age 56.7 ± 9.6 yrs) meeting the criteria were included. Prevalence of NAFLD on USG and CAP was 48% and 42% respectively and 38 patients (38%) had evidence of steatosis on both modalities. Severity of hepatic steatosis as assessed on CAP (n=42) was S1 (248 to ≤ 268 dB/m) in 26%, S2 (268 to 288 dB/m) in 31% and S3 (>288 dB/m) in 43% patients respectively. Seven (18.4%) patients had abnormal ALT (>40 IU/L); significant hepatic fibrosis (LSM≥8 kPa) was observed in 6 (15.8%) among 38 patients with hepatic steatosis on both USG and CAP with none of the patients having evidence of cirrhosis (LSM ≥12.5 kPa). Severity of CAD did not affect the prevalence or severity of NAFLD; severity of NAFLD did not affect the severity of CAD. Conclusion NAFLD is common in patients with CAD; majority of them have mild disease without significant necro-inflammation and hepatic fibrosis.

Keywords Fatty liver, Steatosis, NAFLD, NASH, Cardiovascular disease, Metabolic syndrome 217 Therapeutic plasma exchange is safe and effective in the treatment of acute-on-chronic liver failure-A case-control, pilot study Introduction Decompensated HCV cirrhosis is a difficult-to-treat cohort, with an SVR rate of over 80%. DAAs are also associated with an improvement in overall liver function. MELD purgatory is used to describe patients, who experience viral eradication, have an improvement in the biochemical parameters-MELD score, yet remain decompensated, post-treatment. We conducted this study to look for improvement in MELD purgatory state posttreatment in decompensated HCV cirrhosis.

Methods A prospective analysis of data from decompensated HCV cirrhotics was done. MELD score was calculated for each patient and patients were stratified into Child-Pugh class B and C. clinical and biochemical parameters were noted at baseline and factors predicting persistent MELD purgatory state post-treatment were evaluated. In surgical portal decompression group 9 out of 11 survivors remain symptoms free and with normal liver function. In liver transplant group, 1 patient underwent DDLT. Three years follow-up is good, maintaining liver function and good quality of life. Remaining patients have undergone liver transplant work up. In radiological intervention group 5 patients died of liver failure and one patient lost follow-up. In Surgical shunt one patient died of postoperative liver failure, one due to pulmonary complication and 6 patients died of liver failure while awaiting liver transplant.

Conclusion Effective treatment of BCS requires multidisciplinary approach. Early diagnosis and decompression of porto-mesenteric venous system can provide excellent survival. Accurate assessments of duration of symptoms, extent of thrombosis and liver function are critical in determining the course of treatment.

Keywords Budd-Chiari syndrome management, Portocaval shunt Introduction A regional data on common causes for portal vein thrombosis and to know its prognosis and outcome helps in better understanding of disease and in management. This study was undertaken to determine etiological factors, clinical characteristics, complications, and outcome in patients with portal vein thrombosis.

Methods A cohort study of 40 patients with diagnosis of portal vein thrombosis was conducted. A pre structured proforma was used for collection of data. Patients were followed up for 6 months from the time of diagnosis.

Results Study population was grouped into three strata: C-PVT, nonmalignant cirrhotic PVT; N-PVT, non-malignant non-cirrhotic PVT and M-PVT, malignant PVT. N-PVT patients were younger at the time of diagnosis compared to patients with C-PVT or M-PVT (p<0.01). Most common cause of PVT was cirrhosis liver followed by malignancy. Abdominal pain was a common complaint in N-PVT and M-PVT but less frequent in C-PVT (p<0.05). Ascites (p<0.001), splenomegaly (p<0.05), esophageal varices (p<0.001) and jaundice (p<0.01) were more prevalent in C-PVT and M-PVT than in N-PVT. In 80% of patients diagnosis was established by means of Doppler ultrasound. Anticoagulation therapy was administered to 60% of patients and was more common in N-PVT patients (92.3%) than in those with C-PVT (52.9%) or M-PVT (30%) (p<0.01). Out of the 31 patients for whom results of recanalization were available 51.6 % had complete/partial recanalization during 6 month follow-up. Seventy-five percent of patients with recanalization had received anticoagulation. Recanalization was seen in 69.2% of patients in N-PVT group, 50% of patients in C-PVT group (p<0.05). Sixty percent of patients in the M-PVT group and 17.6% patients in the C-PVT group died during follow-up.

Conclusion Partial or complete recanalization was more frequent in patients treated with anticoagulation therapy. The prognosis is variable and highly dependent on underlying disease.

Introduction Spontaneous bacterial peritonitis (SBP) is a very common bacterial infection in patients with cirrhosis and ascites which requires prompt recognition and treatment. This study was carried out to identify and understand the clinical profile of SBP, about causative organisms and different mortality indicators in SBP in cirrhotic.

Methods Study was conducted at tertiary care center. All consecutive patients with cirrhosis with ascitic fluid TLC >250 cells /mm3 were included.

Results Forty population were enrolled with 20% were female. Majority of patients were in age group 40-50 years. Mortality was more in males (25%) than female (7.5%). Alcohol was predominant etiology for cirrhosis (85%). Most common presenting complaint was abdominal pain (82.5%) followed by abdominal distention (60%) but both were not significantly associated with mortality. Altered sensorium and reduce urinary output on admission was associated with increase mortality (p<0.05). On examination presence of jaundice, grade 3 ascites and WHC >2 was associated with increase mortality (p<0.05). There was significant association between the degree of hyperbilirubinemia and mortality (p=0.017). Though ascitic fluid albumin < 1 gm is strongly associated with SBP, its association with mortality was not significant. Association of ascitic fluid TLC, sugar and SAAG were also not significant with mortality. Most common organism isolated was E coli. Etiology of cirrhosis didn't affect mortality. There was less mortality in patients responding to the treatment on day 3 (p=0.001). Most of patients belongs to Child-Pugh class C. Mean MELD score was 24.57 ± 8.45. A highly significant association was found between MELD score and Child-Pugh score with mortality. Conclusion Spontaneous bacterial peritonitis is often a fatal complication of cirrhosis. Early diagnosis is critical for successful treatment. With use of various mortality indicator response can be predicted. Key word Cirrhosis, SBP

A study of frailty in patients with liver cirrhosis and impact of nutritional intervention on frailty Introduction It has been seen that commonly used scores to predict prognosis in cirrhosis are CTP and MELD, however these scores failed to capture the effects of muscle wasting, malnutrition, and functional decline that are present in most decompensated cirrhotic patients, and contribute to excess mortality in this population. Recent Studies have shown that frailty index does have an added role in prognostication of these patients. So, we aim to determine prevalence of frailty in patients of chronic liver disease and to assess the effects of nutritional intervention at 8 and 12 weeks in this patient population. Methodology This is a prospective non-randomized interventional study for 18 months in patients of cirrhosis. All patients did balance, chair stands and gait speed (SPPB-short physical performance battery) at baseline, 8 and 12 weeks respectively. All patient underwent nutritional assessment at baseline and specific dietary advice was given to achieve protein intake of 1 gm/kg body weight and 30 Background Non-alcoholic fatty liver disease (NAFLD) is an overlooked complication of type 2 diabetes mellitus (T2DM) one of the most common cause of chronic liver disease worldwide. Aim To study the proportion of NAFLD in T2DM patients. To measure the grade of liver fibrosis using fibroscan and to calculate Bazick's and NAFLD fibrosis score (NFS) and compare both the scores for advanced liver fibrosis vis a vis fibroscan. Method One hundred diagnosed between 35-65 yrs of age were included and patients with alcohol intake in past 2 years >140 gm and >70 gm in male and female respectively per week, known liver disease, history of hepatotoxic drug intake, on insulin therapy, ascites and pregnancy were excluded. NAFLD was diagnosed as; fatty liver grade 1, 2, 3 using ultrasonography, transamniitis (AST, ALT >35 IU/L), and fibrosis by fibroscan (F0-F4) and advanced fibrosis was considered as F3 (8.7-10.2) and F4 (≥10.3). Bazick's score and NAFLD score were calculated and compared vis-a-vis fibroscan for advanced fibrosis.

Results One hundred T2DM patients (69 female/31 male) in age group of 35-65 years enrolled in LHMC, 84 (84%) T2DM patients were identified as having NAFLD. 61% patients had fatty liver, 43% had transamniitis and 60% patient had fibrosis, 23% patient had advanced fibrosis by fibroscan. As per prevalence of advanced fibrosis was 41% and by NFS score it was 50%. The diagnostic accuracy for advanced fibrosis was found to be 61% and 55% in our study for Bazick's and NFS score respectively. The specificity, sensitivity, NPV and PPV for Bazicks score was 90%, 56.8%, 47.7% and 93.2% respectively, for NAFLD score it was 98%, 51%, 85% and 95% respectively. Objectives Prospective and retrospective study of 451 patients with alcohol use disorders was done with an intent to assess various factors affecting remission and relapse and improve outcome for individuals with alcohol dependence and liver disease.

Methods Patients with ethanol related liver disease and alcohol dependence were enrolled after their presentation in gastroenterology clinic and followed thereafter at 1, 3, 6, and 12 months. Patient assessment and relevant investigations were done. Semi structured clinical interviews, the symptom checklist 90-revised (SCL90-R), addiction severity index (ASI), the Beck Depression inventory (BDI) were recorded. High-risk alcoholism relapse scale-based score was calculated. 2 Patients were reassessed at six and twelve months to determine treatment outcome (abstinence status and duration of continuous abstinence). Data were coded, validated and analyzed using descriptive statistics.

Results A majority of the sample 70 percent (n=315) had significant psychiatric symptoms at intake: 22 percent (n=70) presented with depressive symptoms, 17 percent (n=15) with anxiety symptoms, and 41 percent (n=192) with combined depressive and anxiety symptoms. Forty percent of patients who presented with combined depression and anxiety symptoms were abstinent at six months. These patients had worse prognosis than less symptomatic cohort at intake, including those who presented with depression symptoms alone; in the latter group, 60 percent were abstinent at six months.

Conclusions Concurrent depression or anxiety symptoms low education, lack of motivation for abstinence had a significant negative predictive effect on treatment outcome. Craving was noted as most common cause for relapse in alcohol dependent patients. Higher relapse rate was seen in concomitant opioid dependence, high risk' situations, previous relapses positive predictors were more number of coping strategies, principally adaptive ones. There is significant association between age at first drink, age at dependence, duration of dependence, other co-morbid diagnosis of patients and relapse.

Osteodystrophy in non-cholestatic liver cirrhosis Background There is scant data about serious adverse events with d-Penicillamine (DPN) resulting in discontinuation of the drug. We aimed to audit penicillamine related severe adverse effects in patients with Wilson's disease requiring drug withdrawal.

Methods A retrospective audit of prospectively maintained database of patients diagnosed with Wilson's disease registered in the Liver Clinic at a tertiary care center between December 2006-January 2020 was done. Demographic parameters and details of treatment were noted. We analyzed side effects related to DPN treatment, subsequent therapies following the discontinuation of medication and the reasons for discontinuation.

Results A total of 118 patients with Wilson's disease, were included in the study. 101/118 (85.6 %) patients were started on DPN and 11 patients (9.3 %) on combination therapy of DPN and zinc, while another six patients (5.0%) received only zinc. Serious side effects were seen in 28/112 patients (25.0%) over a study duration of 860 person years. The most common side effect was bone marrow suppression seen in 16/28 (57.1%) and proteinuria in 7/28 (25%). Two patients developed paradoxical neurological deterioration following DPN administration. Elastosis perforans serpingosa was seen in one patient. DPN was discontinued temporarily in 25/28 patients. In three patients, side effects improved with reduction of dose. Fifteen out of 25 patients were switched to zinc monotherapy, and two to trientine. Reintroduction of DPN with lower dose was attempted in 8 patients out of which 4 tolerated without reappearance of adverse effects. Conclusion DPN treatment is associated with significant adverse effects mainly related to blood, kidney, and skin, with 1 per 30 person-years. Temporary stoppage of drug with reintroduction at lower dose is an effective and safe option.

Keywords Wilsons, Penicillamine, Intolerance

Performance of non-invasive tools to stratify patients with chronic liver disease for risk of future variceal bleeding

Introduction Multiple non-invasive tools (NITs) are validated in compensated advanced chronic liver disease (cACLD) for identifying those at low-risk of varices needing treatment (VNTs) but their role in stratifying risk of variceal bleeding (VB) is unclear. The present study assessed the performance of NITs to stratify risk of VB in cACLD, and their utility for initiating primary prophylaxis.

Methods In this retrospective multicentre analysis, patients with cACLD were classified at baseline using endoscopy (high-risk vs low-risk/no varices) and different NITs (high-risk vs. low-risk for VNTs) like Baveno-VI, expanded Baveno-VI, platelet-MELD, platelet-albumin and ANTICIPATE platelet criteria. Follow-up data for future VB was collected. Rates of VB in different risk subgroups of endoscopic classification and NITs were calculated. Decision curve analysis was conducted to assess net benefit of initiating primary prophylaxis for VB based on different NITs versus endoscopic classification.

Results One thousand two hundred and eighty-four patients of cACLD of different etiologies were included. All NITs predicted VNTs with good accuracy at baseline. Ninety-eight (7.6%) patients developed VB over 20 (9-35) months with 22% events in those with low-risk/no varices at baseline endoscopy. All NITs adequately risk-stratified future VB risk. Background Chylous ascites results from blockage of abdominal lymphatics by malignancy, trauma, surgery, and infections. A patient presenting with chylous ascites due to histoplasmosis is presented.

Case report A 53-year-old female with undifferentiated connective tissue disorder and hypothyroidism presented with a 3-month history of anasarca initially responding transiently to prednisolone and diuretics. However, ascites and anasarca recurred along with breathlessness. 25-year-old ago, she received anti-tubercular drugs (ATD) for tubercular lymphadenitis. Examination revealed cervical lymphadenopathy, right-sided pleural effusion (confirmed on chest radiography) and ascites. Echocardiography did not reveal pericardial effusion. Investigations: Hb 14.7 gm/dL, serum total protein and albumin 4.1 and 2.3 g, respectively; 24-h urinary protein: 118 mg. Endoscopic duodenal biopsy (for possible protein-losing enteropathy) was unremarkable. Pleural and ascitic fluids were milky white, had low serum ascitic fluid albumin gradient with high triglyceride (437 mg/dL). A contrast-enhanced CT showed bilateral pleural effusion, ascites, and subcutaneous edema (1 A, B). Cervical lymph node aspiration cytology showed necrosis, no granuloma but acidfast bacilli (Ziehl-Neelsen stain). As she did not respond to 1-mo ATD, histopathology of an excisional biopsy of the cervical lymph node was done, which showed necrosis, effaced nodal architecture and capsulated fungal elements in histiocytes suggesting histoplasmosis (1 C). A rectal biopsy also showed histoplasmosis (1 D . Other assessments included quantitative androgen deficiency in the aging male (qADAM) questionnaire; generalized anxiety disorder 7 (GAD-7) questionnaire; patient health questionnaire (PHQ-9); Karnofsky performance score (KPS) and hepatic vein pressure gradient (HVPG) measurement. Primary outcome was proportion of patients having an increase in more than 5 points in EF score.

Results Increase in more than 5 points in EF score was seen in 62.82% in Tadalafil arm (n=44/70), vs. 30% cases in placebo arm (n=21/70) (p<0.001). As compared to placebo, patients taking Tadalafil had significant improvements in orgasmic function domain, intercourse satisfaction domain, overall satisfaction domain, anxiety (GAD 7) score, depression (PHQ 9) score, functional impairment (KPS) score and HVPG. There were no significant differences in side effect profile between groups (2.7% in Tadalafil Background Refractory ascites is associated with poor survival outcome. Transjugular intrahepatic portosystemic shunt (TIPS) decompresses portal system, reduces ascitic refilling, but with complications. Poor outcome is likely due to delayed intervention. We investigated whether early TIPS (eTIPS, before ascites becomes refractory) would help in better control of ascites, reduced development of new complications and improved survival.

Methods Total 47 patients (M: F-41:6) with recurrent ascites (2 LVPs in last 3 months) were randomized to receive LVP (Gr. A, n=24) or eTIPS (Gr. B, n=23) satisfying inclusion criteria and followed up at month 1, 3, 6 and 12. Primary endpoint of the study i. e. transplant-free survival at 12 months and secondary endpoints like overall survival, and complications analyzed.

Results Among the patients who were randomized, all baseline characteristics were comparable (mean CTP -8.3 ± 1.49 and 8.9±1.19, MELD score of 13.6±3.5 and 14.9±2.82 respectively). The mean portal pressure gradient reduction was 15.7±3.8 in the Gr. B. Significantly more patients

Introduction Functional exhaustion of monocyte phagocytic function has been shown to be associated with increased susceptibility to infection and sepsis in acute-on-chronic liver failure (ACLF). We investigated the pathobiology of compromised phagocytic functions of monocytes in ACLF.

Method Monocytes were isolated from peripheral blood mononuclear cells of ACLF (n=34) patients at hospitalization and of healthy controls (HC, n=6). Energy metabolism of freshly isolated monocytes was determined.

Results Compared to HC, monocytes of ACLF patients (mean age 43 years, M: F 16:1, MELD 30, 61.76% alcohol) showed significant decrease in oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) at baseline, indicating significant defect in both glycolysis (p<0.001) and OXPHOS (p<0.001) in ACLF (Fig. 1A) . Real time measurement of change in OCR during sequential treatment of cells with oligomycin, the FCCP (H+ ionophore), and Antimycin-A/rotenone showed significant decrease in ATP linked (p<0.01), proton leak (p<0.01), maximum (p<0.0001) and spare reserve respiration capacity (p<0.0001), suggesting multilevel defects in mitochondrial energy metabolism of monocytes. Compared to HC, ACLF monocytes showed decreased phagocytic capacity (p<0.0001 (Fig. 1B) . Inhibition of mitochondrial ATP production by oligomycin, but not glycolysis showed significant (p<0.001) decrease in the phagocytic capacity of healthy monocytes (Fig. 1C ). This indicates that mitochondrial ATP fuels the phagocytic function of monocytes and its compromised production severely impairs phagocytic potential of monocytes in ACLF. Among the ACLF group, patients with sepsis at the time of presentation had a significant (p<0.0001) decrease in maximum respiration and ATP linked respiration (p<0.0001) in monocytes as compared to ACLF without sepsis (Fig. 1D ). ACLF patients with significantly low maximum (p<0.001) and ATP linked cellular respiration (p=0.01) showed increased 28 day mortality.

Conclusions Defects in mitochondrial energy metabolism compromise the phagocytic capacity of monocytes, which contributes to development of sepsis and increased short-term mortality in ACLF patients.

Keywords ACLF, Monocyte energetics, Sepsis, Cellular respiration, Functional exhaustion

A randomized controlled trial (RCT) of efficacy and safety of hemoperfusion or plasma exchange compared to standard medical therapy in patients with acute-on-chronic liver failure

Introduction Acute-on-chronic liver failure (ACLF) has high 28-day mortality of 30% to 40%. Exaggerated hepatic necrosis, inflammation and immune response lead to early organ failure and mortality. We aimed to remove high levels of toxic bile acids, bilirubin, and metabolites from circulation and to modulate the immune mechanisms. Methods Total of 32 ACLF patients with ACLF with bilirubin >12 mg/dL and INR > 1.5 without any infection or extrahepatic organ failure, were randomized into 3 groups; standard treatment SMT (Gr A, n=11), SMT with hemoperfusion (Gr B, n=11) and SMT with plasma-exchange (Gr C, n=10). Results The baseline characteristics were comparable (mean age 50.2± 11.5, 44 ± 12 and 47±12.3 yr., male 10:9:8, baseline bilirubin 21.7±7, 26.9±6.1 and 27.6±8.8 mg/dL, bile acid levels 131±7, 126.8±11 and 138 ±10.8 mg/dL, MELD score 29±4.2, 28±3.5 and 31.4±3.4, AARC score 9.5 ±1.8, 8.9±1, 10±0.92). There was no statistical difference in survival SMT vs. HA vs. PE (89%, 0, 89% and 63.3 %, 90%, 72%, respectively) at day 7 and 28 (p=0.12). In comparison with Gr. A, Gr. B had significantly lower incidence at day 7 and 28 of new onset sepsis (27%, 10%, 20% and 45.5%, 20%, 36%) and AKI (27%, 0%, 11% and 45%, 10%, 27%) respectively. In comparison with Gr A, B and C, there was (3.5 and 2.5-fold, p=0.03) and (1.64 and 1.4-fold, p=0.18) reduction in bilirubin and bile acids which were associated with improved survival. Further, bile acid profiling identified persistent increase in cholic acid, glycocholic acid, chenodeoxycholic acid, taurochenodeoxycholic acid, tauroursodeoxy cholate and lithocholic acid (p<0.05), amongst the survivors specially in Gr. B. In comparison to SMT, intervention arms showed significant change in the metabolites of energy metabolism (p<0.05).

Conclusion Artificial liver support in the form of hemoperfusion and plasma exchange, can safely be used and improve the bile acid and metabolic profile of ACLF patients.

Keywords Acute-on-chronic liver failure (ACLF), Bile acids, Metabolites

Comparison of efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) and SX-Ella Danis metal stent (SEMS) in the management of refractory variceal bleed in cirrhotics-A randomized controlled trial (NCT-03827681)

Introduction Refractory variceal bleed carries a high morbidity and mortality in cirrhosis. TIPS (decompresses the high portal pressure) and. esophageal SEMS (compresses varices locally) are used for managing such bleeds; though the efficacy of the two has not been compared.

Aim We compared efficacy and safety of SEMS and TIPS in management of refractory variceal bleed. Background Sarcopenia has been shown to be a marker of poor long-term outcomes in advanced cirrhosis. Nutrition supplementation and exercise are the only current approaches for such patients. Aims and Objectives We compared nutrition and structured exercise (NEx) to NEx with addition of testosterone (NExT) in improvement of sarcopenia. Methods Altogether, 102 cirrhotic patients with sarcopenia were randomized to receive either nutrition and structured exercise with addition of intramuscular testosterone undeconate 1000 mg every 4 weeks with (NExT, group A, n=50) or only structured exercise and nutrition (NEx, group B, n=52). The primary end-point was increase in appendicular lean mass index (APLMI) by 10%, using dual-energy X-ray absorptiometry (DEXA) and bio-electrical impedance. Conclusions Administering testosterone to men with cirrhosis, irrespective of baseline serum testosterone levels, significantly increases their muscle mass, bone mass and improves fraility, with reduction in fat mass and need and duration of hospitalization. Keywords Sarcopenia, Cirrhosis, Testosterone

Incidence and clinical outcome of hyponatremia in patients with acute-on-chronic liver failure

Manasa Alla, Vinod Arora, Guresh Kumar, Shiv Kumar Sarin Correspondence-Vinod Arora-vinod_ucms@yahoo.com Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India

Background Hyponatremia is an important predictor for mortality and outcome in patients with cirrhosis. Incidence of severe hyponatremia (serum sodium <125 meq/l) and its correlation with various clinical outcomes has not been studied in (ACLF) patients.

Methods A retrospective analysis of the electronic data 3,880 patients with APASL ACLF was taken from 2009-2020. Hyponatremia categorized as moderate (125-130), severe (< 125 meq/l). Patients with serum sodium <125 mEq/L were evaluated at baseline, 7, 14 and 28 days. 20% albumin was given to such patients, but no diuretics or vaptan were given. The incidence of acute kidney injury (AKI), hepatic encephalopathy (HE), GI bleed was evaluated at baseline and day 7, 28 day survival determined. Conclusion Serum sodium < 125 meq/L at baseline may be an independent predictor for mortality in ACLF and associated with various adverse clinical outcomes and treatment options remain an important therapeutic option in improving outcomes.

Keywords Hyponatremia ACLF study aims to characterize clinical and autoimmune features of DILI by complementary and alternative medicine (CAM). Methods Data from 31 DILI patients was analyzed. Patients were investigated for levels of immunoglobulin G (IgG), antibodies to nuclear antigen (ANA), anti-smooth muscle (ASMA), and anti-liver-kidney microsomal antibody (anti-LKM). We calculate autoimmune score based on increase in levels of IgG, ANA, SMA, and anti-LKM (assigned values of 0, 1+, or 2+). We categorize patients based on type of injury.

Results Of the 31 cases 12 were males and 19 were females with a median age of 50 years (range 20-75 years). All patients had jaundice on presentation. Fever, rash, itching, and eosinophilia was present in 29%, 7%, 32%, and 26% patients. Mode of presentation was acute hepatitis in 71% (22/31) and ACLF in remaining 29% (9/31). In majority of patients (80%) cause of DILI was CAM. The median duration of drug intake was 90 days (range 15-730 days). Of the 31 cases, 65% had hepatocellular injury and 19% had severe injury, of which 37% were males and 63% were females. On presentation 29% of cases had increased levels of IgG, 29% had increased levels of ANA, 22% had increased levels of SMA. A phenotype of autoimmunity (autoimmune score ≥2) was seen in 48% of cases, of which 33% were males and 66% were females. Mean RUCAM score was (4.6±1.6). Liver biopsy was available in 6 patients. 4/6 (66%) patients had marked interface activity and remaining 2/6 (33%) had mild activity.

Conclusion We found that most cases of DILI due to CAM had hepatocellular injury. Almost half of cases had features of autoimmunity. Females were more affected than males.

Introduction Approximately 10% to 30% of patients with acute pancreatitis do not have an established etiology after routine investigations and are labelled as having idiopathic acute pancreatitis (IAP). Establishing the etiology in such patients will prevent recurrences and evolution to chronic pancreatitis. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) typically are used to diagnose IAP when conventional methods fail but their exact role has not been determined.

Methods A prospective study of patients admitted initially with diagnosis of IAP to department of gastroenterology in a tertiary care centre was done. These patients underwent MRCP and EUS at least 4 weeks after an episode of acute pancreatitis. The etiological results of EUS and MRCP were compared and analyzed with various clinical variables using suitable statistical tests. Results A total of 31 patients with IAP were included. EUS and/or MRCP were able to establish at least one etiology in 17 of our patients (54.8%). The diagnoses revealed were gallbladder (GB) microlithiasis, GB sludge, choledocholithiasis, pancreas divisum, pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm and anomalous pancreatobiliary union. Comparing the diagnostic accuracy of both the modalities, EUS (14/31) was able to diagnose more cases than MRCP (8/31). The EUS yield was lower in patients who had a previous cholecystectomy (12.5% vs. 56.5%; p=0.03).

Conclusion EUS and MRCP are useful techniques in the etiological diagnosis of IAP and should be considered complimentary rather than competitive investigations. EUS is better for establishing a possible biliary etiology and MRCP for an anatomical alteration in pancreatobiliary ducts.

Pancreatic tuberculosis with obstructive jaundice masquerading as malignancy Pancreatic tuberculosis (TB) is rare form of extra-pulmonary TB even in endemic countries like India with literature only reported as case reports or very small case series. Also pancreatic TB has varied clinical presentation from incidental pancreatic mass detected on imaging to abdominal pain mimicking pancreatitis. We report a case of pancreatic TB who presented to us with jaundice, abdominal discomfort, weight loss and palpable gallbladder. He had long history of loss of weight, abdominal discomfort for 1 year and hence there was low suspicious of malignancy. On USG abdomen he had pancreatic mass lesion compressing distal CBD with upstream biliary system dilatation. He underwent whole body PET-CT which revealed FDG avid heterogenous enhancing mass lesion involving neck and body of pancreas with enlarged necrotic lymph nodes in paratracheal, hilar, peripancreatic, periportal, paraaortic, aortocaval lymph nodes. The findings of PET-CT were more in favor of infective or lymphoproliferative disease. Patient underwent endoscopic ultrasound guided FNA from pancreatic mass and lymph node which were positive for mycobacterium tuberculosis by NAAT (nucleic acid amplification test). Patient underwent ERCP and plastic stent was placed in CBD. Patient was started on antitubercular drugs once LFT improved. Patient was symptomatically better after receiving ATT. Hence clinicians must keep in mind pancreatic TB in patients with obstructive jaundice due to pancreatic mass lesion.

SPINK 1 genetic mutation in chronic pancreatitis 'a single center survey'

Introduction Chronic pancreatitis is known to be a complex problem occurring due to several genetic and clinical risk factors. There are already several studies revealing the genetic mutation and their association with clinical risk factors in chronic pancreatitis in different geographic regions, but unfortunately there are no genetic studies on chronic pancreatitis from this part of coastal India. Aim This study was carried out with an aim to find out the genetic defect of Serine protease inhibitor Kazal-type 1 (SPINK1) gene in chronic pancreatitis patients from this part of coastal eastern India and also their demography and presentations to be evaluated. Method Consecutive 20 chronic pancreatitis patients attending the Dept. of Gastroenterology of IMS and SUM Hospital, Bhubaneswar were enrolled in this study and evaluated. Two mL of venous blood was collected from each of the patients and the DNA was isolated by salting out method. The genetic defect was evaluated by polymerase chain reactionrestriction fragment length polymorphism (PCR-RFLP) method. Demography and clinical presentations of all the cases were also evaluated.

Result The mean age of presentations of study participants was 33.9±1.089 years. Most of the cases were female i.e. 55% were female. The RFLP result showed that 60% of the patients were genetically heterozygote, whereas 40% patients were genetically mutants for SPINK1. Most of the cases presented with abdominal pain. Most of the cases in this study were nonalcoholic and nonsmoker.

Conclusion This study is unique of its kind as it is the first genetic pilot study from this part of coastal eastern India which evaluated the genetic defects in chronic pancreatitis patients. Further genetic studies with larger number of sample size may be carried out in future to validate our findings.

Clinical profile, management and outcomes associated with pancreatic ascites -Our experience from Western India

Introduction Pancreatic ascites is a well-recognized sequelae of pancreatitis and is associated with significant morbidity and mortality. We studied the clinical profile, management and outcomes of patients with pancreatic ascites.

Methods This retrospective study investigated 35 patients seen over a period of 5 years with pancreatic ascites who underwent magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP). Management strategies included conservative therapy, endotherapy and surgery.

Results Thirty-five patients (male=29; 82.9%) were included. Associated pancreatic fluid collections (PFC) were documented in 31/35 (88.6%) patients. MRCP demonstrated a leak in 18/35 patients (51.4%) and ERCP did it in 21/30 patients (70%). Most common leak site on ERCP was in body in 13/30 (43.3%) patients followed by head in 5/30 (16.7%) and tail in 3/30 (10%) patients. Stent was placed beyond the leak in 18/21 (85.7%) patients. In 9/30 patients (30%) no leak was found, thus stent was placed empirically. Sphincterotomy was done in 23/30 (76.7%) patients. Endotherapy was successful in 25/30 patients (83.3%) amongst which 8 % had recurrence. Only conservative therapy was successful in three patients amongst which two had recurrence. Site of ductal leak (p=0.008), sphincterotomy (p=0.033) and stent bridging the leak site (p=0.004) were the factors significant for success of endotherapy. Extensive necrosis >30% (p=0.022) and presence of intraductal calculi (p=0.049) were associated with failed endotherapy. Mortality was seen in 1/35 (2.8%) patients.

Conclusions In this study, clinical profile of pancreatic ascites usually involved more severity of pancreatitis and associated PFC. Success rate in management and outcome of pancreatic ascites is high for endotherapy and low for conservative therapy. Combining pancreatic sphincterotomy with transpapillary stenting and stent bridging the leak site increases efficacy of endotherapy.

Is plasma osteopontin a novel biomarker in prognostication of acute pancreatitis?

Introduction Osteopontin (OPN) is an important mediator of inflammation. Its role has not been established for prediction of mortality and complications in acute pancreatitis (AP). Aim To assess the utility of plasma OPN level on day of admission as early predictor of severity and mortality in AP and compare it with admission C-reactive protein (CRP), procalcitonin (PCT) and prognostic scores like Ranson's, APACHE II, BISAP and mCTSI. Methods Sixty-one consecutive patients of AP presenting within 5 days of symptom onset and 20 age and sex matched healthy controls were prospectively enrolled. Admission OPN, CRP and PCT levels were estimated and prognostic scores of AP calculated. These patients were followed till discharge or death. The association of biomarker levels and prognostic scores with severity and mortality was analyzed and utility compared by receiver operator characteristics (ROC) curve analysis.

Results Sixty-one patients (M:F=48:13), age (mean±SD=34.47±13.62 years) were studied. Larger studies are required to assess its utility in AP.

Diabetes is frequent after an episode of acute pancreatitis: A prospective, tertiary care centre study Wahid Akbar, Zaheer Nabi, Jahangeer Basha, Rupjyoti Talukdar, Manu Tandan, Sundeep Lakhtakia, Radhika Chavan, Chandrakant Koutarapu, D Nageshwar Reddy Correspondence-Zaheer Nabi-zaheernabi1978@gmail.com Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Background Acute pancreatitis (AP) is a known risk factor for the development of new onset diabetes and prediabetes (NODAP). The severity of AP may correlate with the development of NODAP. However, the results in published studies are conflicting. In this study, we aim to determine the incidence and risk factors for the development of NODAP after AP. Methods In this prospective study, patients diagnosed with AP between March 2019 to May 2019 were followed at 3 months, 6 months and 12 months. Patients with pre-existing diabetes or prediabetes were excluded from the study. The primary outcome of the study was the incidence of NODAP at 1-year which was evaluated using fasting blood glucose, oral glucose tolerance test and HbA1c. The secondary outcomes included risk factors for the development of NODAP.

Results A total of 86 confirmed cases (males 66, mean age 35.5±11.7 years) with AP were enrolled during the study period. The etiologies of AP included alcohol 31 (36%), gallstones 17 (19.8%), post ERCP (3.5%), others (40.7%). The proportion of patients with necrotizing pancreatitis, moderately severe and severe AP were 67.4%, 59.3% and 15.1%, respectively. Overall, diabetes and pre-diabetes developed in 10.46% and 23.25% patients, respectively. NODAP was more common in patients with necrotizing pancreatitis (>30% necrosis) as compared to interstitial pancreatitis (42.9% vs. 17.9%, p=0.044). NODAP was significantly more frequent in patients with moderately severe and severe pancreatitis as Introduction Primary sclerosing cholangitis (PSC) is a rare disease associated with IBD with an incidence of 0.4-2 per 100,000. Acute pancreatitis may occur secondary to drug intake in the treatment of IBD. Here we present a very rare case of probably idiopathic acute pancreatitis in a patient of PSC and ulcerative colitis in remission. Conclusion Acute pancreatitis in the absence of PD abnormality or incriminating drugs is extremely rare in the setting of IBD with PSC and needs an extensive genetic and familial work up of the disease and also follow-up for development of chronic pancreatitis or pancreatic malignancy apart from the routine surveillance of IBD and PSC.

A study of pancreatic exocrine insufficiency in early onset idiopathic chronic pancreatitis

Introduction Early onset idiopathic chronic pancreatitis (EOICP) is a common form of chronic pancreatitis in India. The present study was done with an aim to identify the prevalence of pancreatic exocrine insufficiency (PEI) in EOICP.

Methods This is an ongoing prospective study in a tertiary care hospital initiated in August 2018. Baseline data as regards demographic variables, duration of disease, pain, diabetes mellitus, steatorrhea, body mass index (BMI), medication use, CT parameters were recorded. PEI was evaluated by faecal elastase-1 assay (FE-1). Patients with FE-1 <100 μg/gm were labelled as having PEI. Results A total of 100 patients with EOICP were included. Mean age of onset was 24.5 (SD 6.03) years and 46% were females. The average disease duration was 6 (SD 4.8) years. Pain abdomen was present in 98%. The mean BMI was 21.04 (SD 3.61) kg/m2. Calcifications were noted in 61 (75%) patients, mean main pancreatic duct (MPD) diameter was 7.59 (SD 5.01) mm, mean pancreatic thickness was 13.97 (SD 5.53) mm. PEI was identified in 75% of patients. Except for duration of disease, there was no correlation between PEI and sex, age of onset, and diabetes mellitus. We evaluated the association between morphological parameters identified at CT scan with PEI. There was a significant association between MPD diameter, parenchymal width and PEI. However, there was no association between presence of calcification and PEI. Fifty percent patients were on enzyme supplements. Background Hereditary angioedema due to C1-esterase inhibitor (C1-INH) is a rare cause of pain abdomen. We present a patient with recurrent acute pancreatitis (RAP) due to C1-INH deficiency. Case Report Sixteen-years female was hospitalized with epigastric pain with back radiation for one day. Pain was severe, band-like, associated with vomiting and relieved partially on stooping forward. There was history of similar episodes for last 4 years requiring repeated hospitalization. BP was 100/60 mmHg, pulse 100/minute and epigastric tenderness present. Blood counts and LFT were normal, amylase/lipase 2300 U/L/1825 U/L. CECT scan abdomen showed haziness of margins of pancreas with mild peripancreatic stranding and no calcification. Evaluation over last 4 years at various centers for RAP including serum calcium and trigylerides, ultrasound abdomen (x4), CT scan, MRI with MRCP and EUS (x 3) were normal. On direct questioning there was history of angioedema of lips, hands, and limbs since early childhood, forcing her to skip school due to swollen lips and colicky pain abdomen. There was no such family history. Side-viewing endoscopy revealed edema and boginess of ampulla of Vater. She was discharged after 48 hours following improvement with IV fluids and symptomatic treatment. C1-INH level was 164 mg/L (range 275-400), C4 8 mg/dL (range 10-40) and C1q 7.2 mg/dL (range 5-8.6). She was diagnosed as C1-esterase inhibitor deficiency, Type 1 and managed with oral Danazol built up to 400 mg daily. There was reduction in number and severity of episodes of angioedema and pain abdomen, but she developed mild hirsutism, weight gain and acne and Danazol was reduced to 100 mg daily and she continues to do well at one year.

Introduction Infected pancreatic necrosis (IPN) is associated with high mortality. Information is limited about bacterial infections in IPN managed exclusively with percutaneous catheter drainage (PCD). This study aimed to determine the spectrum and antibiotic sensitivity patterns of bacterial isolates from IPN exclusively managed by PCD.

Methods The database of 156 consecutive acute pancreatitbs patients, hospitalized between May 2018 to April 2020, was analyzed for culture results and antibiotic sensitivities of bacterial isolates from IPN patients exclusively managed by PCD. Other isolated organisms were MRCoNS, Acinetobacter (8.6% each); Serratia, Morganella, Burkholderia, Citrobacter, Enterococcus faecalis, Proteus (4.3% each). On antibiotic sensitivity, most bacteria were sensitive to beta-lactams and carbapenems; Escherichia coli -meropenem (76.9%), piperacillin-tazobactam (69.2%); Klebsiella -colistin (50%); Pseudomonasgentamicin (88.8%), cefepime (77.7%), piperacillin-tazobactam (77.7). Panresistant organisms grew from six (14%) PCD fluid samples (Klebsiella, Escherichia coli -2 each; Pseudomonas, Acinetobacter-1 each) and two (22.2%) extra pancreatic sites (blood-Klebsiella, urine-Pseudomonas). IPN patients had higher organ failures (43.5% vs. 28.6%) and mortality (17.4% vs. 14.3%) than sterile pancreatic necrosis. Conclusion Bacterial infections were common (76.6%) in pancreatic necrosis exclusively managed by PCD. Escherichia coli, Klebsiella, and Pseudomonas were the most common isolates. Most bacteria were sensitive to beta-lactams and carbapenems. IPN was associated with an increased probability of organ failure and mortality. Background Objective and aims: Malnutrition and changes in the body composition are common complications of chronic pancreatitis. We measured the prevalence of sarcopenia and it's impact on chronic pancreatitis patients. The aims of the study were 1) to determine the prevalence of sarcopenia in chronic pancreatitis 2) to determine risk factors associated sarcopenia 3) to determine the association between sarcopenia and quality of life and 4) to determine the association between sarcopenia and hospitalization in chronic pancreatitis.

Methods This was a cross sectional study conducted on 100 patients diagnosed with chronic pancreatitis from October 2019 to August 2020. Quality of life was measured by the Brazilian version of the short form-36. Patients were classified according to conventional anthropometrics, hand grip strength, timed up and timed go test, body mass index (BMI) and biceps, triceps, suprailiac and subscapular skinfold thickness using the appropriate methods. The primary outcome of sarcopenia was defined according to EWGSOP criteria. Several parameters including alcohol, smoking, exocrine pancreatic insufficiency and pain related symptoms were analyzed for their association with sarcopenia. Statistical tests included the Chi-square, Mann-Whitney and spearman correlation tests with the significance level set at p value less than .05. Results Amongst 100 patients enrolled in the study, median age was 55.5 years; 68 % were men; 72 % had alcoholic etiology.

Smokers were 67%. Prevalence of sarcopenia was 31%. An abnormal low BMI (<18.5 kg/m2) was seen in 30.2% and 57.6% had normal BMI (18.5-25 kg/m2) and 9.6% had BMI in over weight/obese range (>25 kg/m2). Sarcopenia was significantly associated with exocrine pancreatic insufficiency, alcoholic, smoking and pain related symptoms on univariate analysis. Four skin fold thicknesses were also positively correlated with multiple domains of scale used to asses quality of life. Recurrent hospitalization and complications related to chronic pancreatitis were also higher in sarcopenic group compared with their counterparts.

Conclusion Sarcopenia is common complication in chronic pancreatitis patients and associated with adverse health related outcomes.

Introduction Changes in glycemia status over time have never been investigated comprehensively in patients after acute pancreatitis. The primary aim was to determine the incidence of new-onset prediabetes and new-onset diabetes after acute pancreatitis over 9 months of follow-up in a prospective cohort study. The secondary aim was to identify fluctuations of glycemia levels during follow-up. Methods This was a prospective cohort study conducted on patients with a prospective diagnosis of acute pancreatitis and non-diabetic based on the American Diabetes Association criteria were followed up every 3 months up to 9 months after hospital discharge from October 2019 to August 2020 at Madras Medical College. Incidence of new-onset prediabetes and diabetes over each follow-up period was calculated. Multinomial regression analyses were conducted to investigate the associations between a wide array of routinely available demographic, anthropometric, laboratory and clinical factors. Results A total of 100 patients without diabetes were followed up. The cumulative incidence of new-onset prediabetes and diabetes was 20% at 6 months after hospitalization and 28% over 9 months of follow-up. Three discrete groups were identified based on HbA1c levels: normal-stable glycemia (40%), moderate stable glycemia (54%), and high-increasing glycemia (6%). Conclusion This study of changes in glycemia showed that at least one out of five patients develops new-onset prediabetes or diabetes at 6 months of follow-up and more than two out of ten patients in 9 months. Early detection of changes in blood glucose metabolism following an attack of acute pancreatitis will help to reduce the burden of new-onset diabetes after acute pancreatitis.

Introduction There are several causes of acute pancreatitis (AP). In clinical practice, AP is diagnosed by presence of acute pain abdomen, elevated serum amylase and lipase value (> 3 times of upper limit of normal) and ultrasonographic (USG) findings of acute pancreatitis but in only 25% to 50% of patients with acute pancreatitis, pancreas is visualized in ultrasonography. Abdominal pain is the cardinal symptom which occurs in about 95% of cases of AP. Few studies showed that prevalence of alcohol induced pancreatitis is higher than gallstone induced pancreatitis but other study showed opposite result.

In this case, 44 years gentleman was presented with acute pain abdomen, normal serum amylase and lipase value and no pancreatic abnormality in abdominal USG. After diagnosis of elevated serum triglyceride, computed tomography (CT scan) of abdomen was done to exclude hypertriglyceridemia induced AP. CT scan abdomen showed features of acute pancreatitis. Background Closure of the abdomen has always been a challenging task especially in the emergency setting with presence of bowel edema, hemoperitoneum, peritonitis, fecal contamination or intra-abdominal infection. So following infection or due to tension give away of midline laparotomy wound sutures and formation of laparostoma is not uncommon. We here report a case of such laparostoma formed following the give away of midline laparotomy wound suture following intraabdominal infection and tension over suture and successful management of laparostoma conservatively leading to spontaneous closure of laparostoma.

Case presentation A 22-year-old male patient underwent the exploratory laparotomy with right hemicolectomy with pancreatic necrosectomy with end ileostomy formation for necrotising pancreatitis with necrotizing enterocolitis with two ascending colon perforation. There was wound gap in midline laparotomy wound with gross pyoperitoneum with pus coming out through abdominal drains. There was evident sheath gap and laparostoma formation. We managed the patient conservatively. Continuous draining of pyoperitoneum through laparostoma for around a month was done leading to epithelialization and spontaneous closure of laparostoma. Patient was discharged. Eleven months after discharge patient was operated for stoma closure through laparotomy and out of a surprise bowels were healthy without adhesions to each other or to abdominal wall.

Conclusion Conservative management of laparostoma wound with regular dressings involving betadine and metronidazole wash prior to every dressing to drain pyoperitoneum not only prevented suspected mortality from immediate 2nd hit in the form of re-operation but also took care of intra-abdominal infection prevented the inter-bowel adhesions. A wide spectrum of benign and malignant diseases can produce a mass in the head of the pancreas. It can be solid (ductal adenocarcinoma, chronic pancreatitis, endocrine tumor) or a cystic lesion (cystic neoplasm, true cyst or pseudocyst). We present two cases of pancreatic actinomycosis and one case of pancreatic tuberculosis.

Case 1 A 79-year-old lady known case of diabetes mellitus, systemic hypertension, chronic kidney disease and chronic calcific pancreatitis presented with history of fever for 2 weeks. There was history of EUS FNAC of pancreatic abscess in 2016. Ultrasound guided FNAC pancreas showed dense inflammatory cell infiltrate and actinomycotic colonies with Splendore Hoeppli phenomenon.

Case 2 A 67-year-old male known case of chronic calcific pancreatitis presented with recurrent episodes of abdominal pain. EUS FNAC done from pancreatic head mass showed occasional clumps of basophilic filamentous bacteria surrounded by Splendor-Hoeppli and a background of acute inflammatory cells suggestive of actinomycosis.

Case 3 A 75-year-old male presented with loss of appetite and weight loss since 1 month. CT abdomen showed a well defined multiloculated cystic lesion abutting the neck of pancreas with multiple rim enhancing lesions in the splenic parenchyma. He underwent EUS which showed a cystic SOL in the pancreas with thick contents and splenic abscess. FNB was done which showed large size caseating granulomas composed of epitheloid cells and Langhans's giant cells with occasional acid fast bacilli. He was initiated on ATT.

Conclusion There are only thirteen reported cases of pancreatic actinomycosis to the best of our knowledge. A history of previous pancreatic surgery or stenting was frequently reported. Both our patients had previ-Introduction Chronic pancreatitis is an irreversible disease with increased oxidative stress. The therapeutic role of antioxidants for pain reduction in chronic pancreatitis (CP) however is debatable. We conducted a systematic review and meta-analysis to ascertain their role in pain relief, their effect on quality of life in CP and associated adverse events.

Methods On literature review, we found 668 articles, seven of which were included. Only randomized controlled trials (RCT) were included. Two reviewers extracted the data and assessed the risk of bias. Pain was analyzed by visual analogue scale (VAS) and pain free participants. Results are expressed as standardized mean difference (SMD) or risk ratio (RR) with accompanying 95% confidence intervals and analysis was performed with fixed or random effects model according to heterogeneity.

Adverse events and quality of life (QoL) were also assessed.

Results Twelve articles and four articles were eligible for qualitative and quantitative analysis respectively. The four included studies had a total of 352 participants. Pain reduction as measured by visual analogue scale was not significantly different in the antioxidant group compared to placebo (SMD=-0.14 [95% CI=-0.44-0.17]; p=0.38). Number of pain free participants were also similar (OR= 1.59 [0.97-2.59]; p=0.06). Antioxidants were not associated with increased adverse events (OR=2.59 [CI=0.77-8.69]; p=0.12). Qualitative analysis for effect on quality of life did not suggest any significant improvement with antioxidants. Conclusion There was no significant pain reduction or change in quality of life in patients of CP with use of antioxidants. This makes their routine use in management of CP questionable.

Introduction Patients with chronic pancreatitis (CP) are at an increased risk of sarcopenia and was associated with increased hospitalization rates and mortality. CT is considered a valuable tool for the assessment of skeletal muscle mass and sarcopenia. We aim to determine the prevalence of sarcopenia using segmented skeletal muscle area, investigate risk factors associated with sarcopenia, and to derive the cut-off value of psoas muscle cross-sectional area (CSA) and muscle thickness for the diagnosis of sarcopenia using segmented skeletal muscle area as the reference method.

Methods Retrospective data on patients' demographic and disease characteristics were collected from medical records during the last 5 years. CT from the archives was taken and CSA of the psoas muscle was determined by manual encircling the outer surface of the muscle and muscle thickness as 2 points transverse diameter, normalized to stature, taking skeletal muscle index as a reference of sarcopenia (defined as SMI < 41.3 cm2/m2 for males and <34.cm2/m2 for females , similar results were seen for IL-6 (0.0665). Percentage of energy from macro nutrients was similar in both groups. There was no difference in frequency of diabetics/nondiabetics (p=0.970) and patients with steatorrhea/no steatorrhea (p=0.951) in group 1 and 2.

Conclusion Two third patients with CP are 1/4th daily energy deficient in their diet. Also patients with higher inflammation and continuous pain are more likely to have low calorie intake.

Keywords Energy deficit, Inflamation and energy deficieny, CP and energy intake

Introduction Parenchymal fibrosis in chronic pancreatitis is mediated by various inflammatory cytokines and growth factors. It is characterized by activation of pancreatic stellate cells and start expressing smooth muscle actin (α-SMA). Normal pancreas has predominantly quiescent stellate cells in periductal and perivascular locations and does not express α-SMA. So, we wanted to study the immunohistochemistry (IHC) expression pattern of α-SMA, platelet derived growth factor (PDGF-BB) and transforming growth factor (TGF-β) in the resected specimen of chronic pancreatitis. Methods A total of 20 biopsies from resected specimen of chronic pancreatitis were included. The expression was measured as compared to control biopsies (breast carcinoma as a positive control for PDGF-BB and TGF-β, and appendicular tissue for α-SMA), and scored based on a semi-quantitative system based on staining intensity and percentage of positive cells was used for objective scoring, which value varies from 0-15. This scoring was done separately for acini, ducts, stroma and islet cells.

Results (Table 1 and Fig. 1 ) All the patients had undergone surgery for refractory pain and median duration of symptoms was 48 months (IQR). On IHC, α-SMA was not expressed in the acini, ducts or islets but had high expression in the stromal regions (vs. acini, ducts and islet, p<0.01). PDGF-BB was expressed in the acini, ducts and stroma but has highest expression in islet cells (vs. stroma, p<0.01). TGF-β1 was also expressed maximally in islet cells; however, the distribution amongst all locations was statistically similar.

Conclusion α-SMA expression in the pancreatic stroma is an indicator of concentration of activated stellate cells in the stroma, a site Introduction Acute pancreatitis is thought to be a local inflammatory process involving premature intracellular activation of digestive enzymes within acinar cells leading to auto digestion of the tissue that can progress to involve distant organs. AP was one of the most common diseases in gastroenterology. Practical understanding of etiology and severity will accommodate in advocate the appropriate treatment. Background Asymptomatic pancreatic cystic lesion (PCLs) are now being increasingly diagnosed because of widespread use of cross-sectional imaging modalities. There is a clinical dilemma to diagnose it correctly as PCLs are complex group of lesions from benign, premalignant to malignant and data from India on these tumors is scarce.

Methods Consecutive with PCLs seen in our unit from July 2015-September 2019 were prospectively enrolled and underwent endoscopic ultrasound (EUS) and EUS guided cyst fluid aspiration. Air dried slides were sent for cytological evaluation. Cyst fluid CEA, CA19.9, CA72.4, CA125, VEGF were performed by using ELISA and KRAS (exon 2, codon 12 and 13) and GNAS (exon 8, codon 201) mutation analysis were performed by using Sanger sequencing. The final diagnosis was based on histopathology of resected specimen or confirmation in aspirated cyst Background Pancreatic divisum (PD) is the likely cause of abdominal pain in 5% to 10% of patients with recurrent acute pancreatitis (RAP). The outcomes for endotherapy in these patients remains currently unexplored in India.

Methods This is a prospective observational study of RAP patients who underwent endotherapy for PD from June 2018 -May 2020. RAP was defined as >2 episodes of acute pancreatitis (AP) without underlying chronic pancreatitis (CP). PD was diagnosed based on MRCP and/ or EUS. At ERCP, minor papilla guidewire cannulation followed by over the wire sphincterotomy was done. A dorsal duct stent (5-Fr) was placed short-term for 1 month. All patients were followed up at 1, 6, and 12 months' post sphincterotomy. Pain was assessed by visual analogue score (VAS). The outcomes included technical and clinical success, pain relief and complications.

Results A total of forty-one patients, male = 34 (82.9%); with a mean (SD) age of 29 (11) years were analyzed. Median episodes of RAP prior to endotherapy were 3 (range 3-6). All patients underwent minor papilla sphincterotomy with placement of 5Fr stent and PD stenting (technical success 100% Background miRNAs are known to skew the immune responses towards development of pancreatic cancer. Upregulation of receptor interacting protein (RIP-140) exacerbates inflammatory events and facilitates the tumorigenesis of pancreatic ductal adenocarcinoma. In this report, we evaluated whether any down regulated microRNA 30b in pancreatic cancer patients orchestrates RIP-140 mediated inflammation with the progression of the disease.

Methods Target scan and PicTar algorithm was used to predict the miRNAs target in RIP-140. N=50 PDAC patient and healthy volunteers were accrued in this study. Taqman assay and SYBR green based qRT PCR was done to validate the expression of miRNAs and their target, respectively, in pancreatic patient tissues and their serum samples. Inflammatory markers (TNF-α, IL-1β and IL-6) levels in serum was detected by ELISA. Infiltration of M1 (CD80+ and CD86+) and M2 macrophage markers (CD204+ and CD163+) in tumor samples was elucidated by flow cytometry. In Invitro setting, CD45+ cells were co cultured with panc-01 cells in transwell system and miR-30b was over expressed in panc-01 to see the effect of miR30b on inflammatory response.

Results miRNA-30b was remarkably found to be down regulated in PDAC samples and pancreatic cancer human cell lines showing upregulation of RIP-40. Low levels of miRNA-30b enhanced the expression of inflammatory markers in serum samples. In addition to that we also found more infiltration of M2 macrophages in tumor samples. Invitro over expression of miRNA-30b in panc-01 reversed these effects when co cultured with CD45+ cells.

Conclusion Our data suggested miR-30b as a plausible target for RIP-140. Low levels of miR-30b and high RIP-140 expression levels both predicts dismal prognosis via increasing inflammation in PDAC patients. Taken together, these findings implicated that over expression of miR-30b may suppress inflammation through suppressing RIP-140 expression highlighting that miR-30b may serve as therapeutic agent in the treatment of PDAC.

Keywords miRNA, RIP-140 (receptor interacting protein), inflammation, M1/M2 macrophages, pancreatic cancer

Introduction Abdominal pain is most frequent presenting symptoms in emergency medicine department. Diagnosis can be as subtle as acute gastritis to mesenteric insufficiency a life-threatening condition. Acute pancreatitis is one of the diseases presenting with symptom of severe abdominal pain. Here in this study we will assess diagnostic accuracy of newly introduced urine trypsinogen dip stick, point of care test for early diagnosis of acute pancreatitis. Method This diagnostic accuracy study was performed in emergency unit of one of tertiary care hospital of north India. Consecutive patient with abdominal pain duration of less than and equal to seven days and fulfilling inclusion criteria were recruited in this study. Urine trypsinogen dip stick test was performed in all patient and diagnostic accuracy (sensitivity and specificity) were calculated.

Result Total 187 patient were recruited, out of which 90 were cases (acute pancreatitis) while 97 were control (non-pancreatitic cause of abdominal pain). Sensitivity and specificity of urine trypsinogen dip stick test for diagnosis of acute pancreatitis 67.8% and 90.7% respectively, further subgroup analysis in patient of duration of pain less than and equal to 3 days, sensitivity and specificity approach to 72.7% and 91.8% respectively. Positive and negative likelihood ratio is 6.10 and 0.36 (≤ 7 days), 8.9 and 0.3 (≤3 days) respectively. In patient with acute severe pancreatitis diagnostic sensitivity of UTDT is 82%. Objective Proximal migration of pancreatic stents is an uncommon, but significant problem that poses risk of pain and pancreatitis. It is a challenging situation to the endoscopist, necessitating surgical retrieval in 10% of cases. We describe our experience with endoscopic removal of different stents with different methods (namely use of grasping forceps, Spy-glass, EUS guided extrusion), complications, and outcome.

Methods A retrospective review of the last 10 years for pancreatic duct stent removal procedures done at our unit was done. The size, type, status (intact or fragmented) and position of migrated stents, the status of PD (pancreatic duct), the method utilized, and the number of sessions needed for extraction, success, complications, and need for surgical retrieval were studied. Introduction Sarcopenia is associated with increasing morbidity and mortality in various chronic disease. Chronic pancreatitis (CP) is a chronic inflammatory disease with various complications and sarcopenia is not well studied in these patients. We aimed to study the prevalence of sarcopenia in chronic pancreatitis and its association with pain severity, complications, dietary intake, exocrine and endocrine insufficiencies.

Methods A prospective observational single center study was conducted from February 2019 to August 2020. All consecutive chronic pancreatitis patients were included, and exclusion criteria was age <18 or >60 years, associated other co-morbidities and history of pancreatic surgery. The sarcopenia was assessed by measuring skeletal muscle index at L3 level and gender specific skeletal muscle index cut offs were taken (<37.3 cm2/ m2 for males and <26.7 cm2/m2 for females). All these patients were assessed for clinical details, anthropometry, body composition by bioimpedance analysis, hand-grip strength, 6-meter gait speed and dietary intake. He had gastrostomy tube placed for nutrition. Endoscopy with balloon dilation was done for posterior pharyngeal wall ulceration, and hypopharyngeal stricture (Fig. 1A, C) . He had an inspiratory stridor. On image enhanced endoscopy intrapapillary capillary loops type III-IV were noted on pharyngeal wall (Fig.1A, B) . Biopsies were obtained which showed non-specific granulomatous tissue. Immunohistochemistry staining revealed positivity for CD-20, CD-3 and LCA and was negative for CD-56 (Fig.1D ). He underwent tracheostomy for stridor. There was no apparent evidence of either tuberculosis or Crohn's disease. Other causes of granulomatous pharyngitis such as syphilis, sarcoidosis, autoimmune diseases, Wegener's granulomatosis, viral serology or Klebsiella rhinoscleromatis were excluded. Chest radiograph and computed tomography of neck did not reveal any abnormality. Diagnosis of midline granulomatous disease was made. He was treated with mycofenalate mofetil, hydroxychloroquine and tapering dose of prednisolone. He had speech and swallowing physiotherapy. He was able to resume to oral feeds. He is on follow-up for 3 months and his disease has not progressed.

Conclusion Isolated midline granulomatous disease is rarely reported and should be considered in the differential diagnosis of pharyngeal diseases.

Introduction Foreign body ingestion is common in pediatric age group. This study was conducted with the aim to identify the most common age group, types and locations of foreign bodies. Methods A retrospective study was conducted in G B Pant Hospital, Delhi from October 2015 to December 2019. All patients presented to the hospital with a history of foreign body ingestion during this time period were included. The data were analyzed using descriptive statistics.

Results Total 170 cases of foreign body ingestion were encountered. These included 68.8% males and 31.1% females with a median age of 5 yrs. Though foreign body ingestion was accidental in all children of less than 15 yrs of age, it was either intentional (5.2%) or secondary to esophageal stricture (4.1%) or denture (3.5%) in adults. In majority of the cases, foreign bodies were located in the stomach, 55.8% followed by esophagus, 25.2%. The most common type of foreign body was a coin, 58.2%. Foreign bodies passed spontaneously in 7%. In rest of the patients endoscopic removal was attempted and was successful in 97.4%. Complications were seen in 10% cases. Ulceration at the foreign body site being the most common, 7.6%.

Introduction Incidence of gastrointestinal perforations are increasing due to increase in number of therapeutic procedures (EMR, ESD, POEM, NOTES).

We report a similar case of iatrogenic gastric perforation after partial splenectomy which is closed with endoscopic clips. Case Report A 48-year-old female presented with complaints of high grade fever, left upper quadrant pain and loss of appetite for 2 weeks. After laboratory and imaging studies patient was diagnosed to have splenic abscess for which she underwent partial splenectomy. Post operatively after 4 days when patient is allowed to take orally, food particles are noted in drain. 10 mL methylene blue was given through NG tube, dye was seen draining through drains. Gastroenterology reference was given for upper gastrointestinal endoscopy which revealed small 2 cm full thickness defect in stomach wall on the greater curvature at the junction of body and fundus thus diagnosis of gastric fistula is made.

As repeat surgery carries greater risk and morbidity endoscopic closure of gastric defect was planned. After taking consent ovesco clip was applied with suction technique and patient was stable post procedure. Patient improved subsequently tolerated oral feeds and discharged after 4 days.

Conclusion Endoscopic closure is preferred in acute small perforations which are <2 to 3 cm due to high success rate (90%), minimally invasive procedure and short hospital stay. OTSC (over the scope clips) is a new device for the closure of GI defects so it should be an essential component of endoscopic arsenal.

Comparison of endoscopic ultrasound guided fine needle aspiration with endoscopic ultrasound guided fine needle biopsy for solid gastrointestinal lesions: A randomized crossover single centre study Introduction Endoscopic removal of ingested foreign bodies is well documented. But removal of FBs in colonoscopy not well documented. We present 3 cases of FBs which were managed by colonoscopy. Case Report -Case 1 A 52-year-male presented to us with constipation for 3 days. He used to have anal eroticism with traditional sex toys. But he tried an infant feeding bottle on a tinder date, which he pushed it in too far and could not remove the bottle. The bottle was noted at recto-sigmoid junction on fluoroscopic spot image. Colon-fluoroscopic trans-anal retrieval attempts with snare forceps were futile. A CT followed by minilaparatomy and sigmoid incision were made for FB removal. He was referred to psychiatry for perversion disorder and to prevent recurrences. Case 2 A 27-year-old female presented with pelvic pain for 18 months duration. Computed tomography (CT) abdomen and pelvis showed an intrauterine device (IUD) perforating the sigmoid colon without pelvic collections. Sigmoidoscopy revealed displaced IUD at 30 cms from anal verge. Using foreign body forceps and gentle manipulation, IUD was removed under fluoroscopic guidance. Fistulous opening was closed using through the scope clips. Postoperative period was uneventful Case 3 A 14-year-old male, presented to us after 5 days of accidental history of nail ingestion. He had serial abdominal radiographs which revealed a stuck nail in the left lumbar region without any pneumoperitoneum. Colonoscopy was done in fluoroscopic room without bowel preparation. Nail was noted to be embedded in the stool near the hepatic flexure without any pneumoperitoneum. It was removed using foreign body forceps under colon-fluoroscopic guidance. Follow-up spot image on fluoroscopy did not reveal any complication.

Conclusion Colonoscopy with unprepared bowel, grasped FB maintained in the center of the visual field with close monitoring on fluoroscopy can be effective in FB removal in colon.

A retrospective single blinded study comparing efficacy of prucalopride when used as an adjunct with polyethylene glycol in bowel preparation in patients of constipation

Background Colonoscopy is currently gold standard for visualizing colonic mucosa. Presence of constipation is generally associated with poor bowel preparation. We compared effect on colonic cleansing when prucalopride was used as adjunct with polyethylene glycol in patients of constipation.

Methods A retrospective, single blinded controlled study was conducted in outpatient of a tertiary care centre. One seventy patients with constipation were enrolled in two groups of who took only polyethylene glycol (PEG) and other of prucalopride (2 mg one day prior to endoscopy) plus polyethylene glycol (PEG+) for bowel preparation. They underwent colonoscopy by a single blinded experienced endoscopist. Bowel preparation quality was reported by Boston bowel preparation scale (BSS) prior to washing or suctioning. The groups were analyzed for bowel preparation quality and side effects in either groups based on preformed questionnaire.

Results Both groups were comparable in view of mean age and male female ratio. Diabetes was comparable in either group (14-PEG, 13 in PEG+) with 70 patient having functional constipation in both groups. Mean BSS IN PEG group (5.33+/-1.43) was slightly higher than peg+ GROUP (5.16 + 1.37) although not statistically significant (p value=.44). The side effects of preparation used like nausea, vomiting, abdominal discomfort, headache was higher in peg+ group than peg group although not statistically significant. Post procedure questionnaire suggested patient preferring peg more than the peg plus prucalopride combination (21 vs. 8) (p value <.001).

Conclusion We conclude addition of prucalopride has no additional benefit when used in combination with polyethyleneglycol in bowel preparation in patients of constipation. It may rather lead to noncompliance and inferior bowel preparation in view of increased side effect of nausea, vomiting, bloating, abdominal discomfort and headache. Background Heterotopic gastric mucosa (HGM) in esophagus is commonly noted as an inlet patch at endoscopy. We describe a rare patient with symptomatic distal esophageal HGM. Case Report Forty-year-male presented with retrosternal pain, heartburn and marked odynophagia for 4 weeks. There was no history of ingestion of antibiotics, foreign body or corrosive. There was no history of fever or weight loss. Clinical examination was unremarkable. Endoscopy showed abrupt circumferential transition to salmon pink mucosa at 35 cm from incisors. From 35 cm to 41 cm there were areas of polypoid edematous thickening with few superficial ulcers of 1-3 mm. Squamous epithelium was visualized at NBI from 41 cm to the Z-Line at 43 cm with no hiatus hernia. Biopsy from 35 to 41 cm showed gastric mucosa with parietal cells without dysplasia. Blood counts and biochemistry were normal and serology for CMV and HIV were negative. Contrast enhanced CT scan showed circumferential mural thickening of 7 mm involving distal esophagus with associated polypoid thickening of 26 mm x 6 mm along right lateral wall. He was managed with proton pump inhibitors (PPI) and prokinetics and improved over two weeks. Follow-up endoscopy at 3 months demonstrated healing of ulcers. There was no resolution of polypoid lesion. He remains well on maintenance PPI. Conclusion Symptomatic heterotopic gastric mucosa in distal esophaguscan be differentiated from Barrett's esophagus by presence of squamous epithelium distally. Inflammatory mass lesions may develop and mimic esophageal malignancy. Symptoms due to acid production may be prominent and respond to PPI.

Lockdown due to COVID-19 and its impact on endoscopy and upper gastrointestinal bleeding -A single centre study

Introduction and Aim COVID-19 pandemic was declared on 11/03/2020 and required Indian government to implement intermittent lockdown to contain the disease from 24/03/2020. Aim of the study was to investigate the effects of lockdown on acute upper gastrointestinal bleeding (UGIB) at our centre.

Methods Records of all the UGIB patients who had undergone endoscopy at our institution during the 3 months-April, May and June in years 2019 (n =1175) and 2020 (n = 554) were retrospectively reviewed and compared. All the procedures were performed by enhanced personal protective equipment.

Results Of the 1729 patients (mean age + SD :61.7±12.7 years, 85 % males) during the two study periods, 64 (3.7 %) had UGIB. Hemetemesis was the most common presenting symptom in 60% of patients. The proportion UGIB among the total endoscopies done was significantly higher during the lockdown period compared to the previous year 5.4% to 2.8% (p value = 0.009). The frequencies of UGIB variceal and nonvariceal showed the decline in variceal and increase in non-variceal bleeding due to lock down from 38% to 20% and 62% to 80% respectively but this was not statistically significant. The decline was more marked for need for endotherapy-as 70% to 30% in nonvariceal bleeding (p value 0.010). There was no mortality among the subjects.

Conclusions National lockdown resulted in a decrease in the total number of endoscopies as well as the number of UGIB. The proportion of endoscopies done for UGIB during the lockdown was significantly. Establishing standard safety protocol for endoscopy during the pandemic will ensure safety of patients and health care workers. Background Fecaloma is organized hardened stool, usually impacted in rectum and sigmoid colon. Cola, with a pH of 2.5 due to carbonic acid and bubbles of carbon dioxide has been effective in dissolving gastric phytobezoars. We describe colonoscopic instillation of Cola for clearance of fecaloma in a patient with megarectum and sigmoid megacolon.

Case report Seventy-two-year-old lady, bed-ridden with co-morbidities, presented with constipation and progressive abdominal distension for six months. There was history of infrequent passage of small amount of liquid stool without blood or mucus. Physical examination revealed illdefined, firm, non-tender pitting mass occupying the hypogastrium, left iliac, left lumbar, umbilical and epigastric regions of abdomen. Rectal examination revealed normal anal tone and impacted stool, some of which was removed manually. X-ray abdomen revealed fecal loaded and grossly dilated rectum and sigmoid colon. CT scan showed grossly distended sigmoid colon (12.7 cm) and rectum, loaded with stool. Repeated sodium phosphate enemas and oral polyethylene glycol were unsuccessful in clearing the stool. Colonoscopy revealed grossly dilated rectum and sigmoid colon with large amount of solid fecal matter few superficial sterocoral ulcers. The option of surgery was refused by the family. Following informed consent, 1000 mL of Cola was instilled into the sigmoid colon during colonoscopy. Over the next three hours she passed explosive stool with expulsion of more than 3 litres of fecal matter. The abdominal distension decreased and repeat plain CT scan showed remarkable decrease in the fecal loading. She refused further evaluation and was discharged. A few weeks later, she was subjected to ileostomy with a possibility of idiopathic megarectum with sigmoid megacolon and remains lost to follow-up.

Conclusion Colonoscopic instillation of Cola may be used for clearance of large fecaloma refractory to oral and rectal medication.

Life threatening gastrointestinal bleeding due to thrombocytopenia and megakaryocytic blast crisis as presenting symptom of myeloproliferative disorder -A case report Introduction Myeloproliferative disorders commonly present as unexplained anemia or cytopenias. Overt gastrointestinal (GI) bleeding as an index presentation for underlying hematological malignancy is unusual.

Recently we encountered a case of GI bleeding which turned out to have underlying chronic myeloproliferative disorder.

Case summary A 57-year-old male, presented with chief complaints of generalised weakness, decreased appetite and loss of weight for last 6 months along with evening rise of temperature for 1 month. Clinical examination revealed pallor, generalized lymphadenopathy and an enlarged firm spleen. Investigation showed low hemoglobin, high reticulocyte count, raised TLC and low platelet count with peripheral smear showing promyelocytes and metamyelocytes. Stool occult blood was positive. Imaging showed hepatosplenomegaly with multiple enlarged intraabdominal lymph nodes. UGI endoscopy showed a bleeding gastric polyp which was removed by snare polypectomy. Colonoscopy revealed internal hemorrhoids to which sclerosant polidocanol was injected. Patient was doing well when he developed painless hematochezia 6 to 7 times a day. Sigmoidoscopy showed rectal oozing, APC was done, hemostasis achieved. After lymph node and bone marrow biopsy, cytogenetic tests, hematopathologist diagnosed chronic myeloproliferative disorder with megakaryocytic blast crisis. During admission patient developed malena and UGI endoscopy showed diffuse mucosal oozing to which hemoseal application was done to achieve hemostasis. Despite management with multiple transfusions, IV immunoglobulins and IV steroids, patient developed bilateral frontotemporal subdural hemorrhage and succumbed.

Conclusion The reported incidence of hemorrhagic complications in hematological malignancies ranged from 3% to 53%, and resulting deaths ranged from 14% to 24%. In another similiar study it was found that 16 % of patient deaths occur due to major bleeding from gastrointestinal or intracranial hemorrhage. In autopsy finding of MDS patients, it was found that 25 % had evidence of major gastrointestinal bleeding and so must be foreseen when clinical signs are suggestive.

Introduction Diagnosis of intestinal tuberculosis is challenging with conventional methods due to the paucibacillary nature of the disease and the close similarity it shares with IBD-Crohn's. Introduction There is significant decrease in gastrointestinal (GI) endoscopies during the COVID-19 pandemic due to travel restrictions and concerns of infection amongst doctor, staff and patients. Even emergency endoscopies have been deferred due to fear of SARS-CoV-2 infection. Aim Aim of this study is to analyse the indications and safety of GI endoscopy during lockdown period.

Methods We did retrospective analysis of the prospectively maintained data of endoscopic procedures performed from 24/03/2020 to 29/08/ 2020. The data was analyzed for indication of procedure in terms of urgency (emergent, urgent and routine) and de-novo development of SARS-CoV-2 infection in endoscopy department staff, doctors and patients. Pre-procedural COVID testing was not mandatory in our department. Thorough history of exposure was taken and triage was done before the procedure. All the procedures were done wearing level three personal protective equipment. Standard scope cleaning process was followed after each procedure and a gap of 15 minutes was maintained in between procedures. Post procedure, patients were followed up telephonically on every third day and inquired about development of symptoms of SARS-CoV2 infection. Patients who tested negative before the procedures were excluded from the study.

Results A total 274 of various GI endoscopic procedures were performed over a period of 159 days. Indication wise 48% were emergency procedures, 31% were urgent and 21% were routine. Seven emergency bedside procedures were performed in COVID positive patients. Throughout the study period none of the endoscopy staff, consultants and residents were tested COVID-19 positive, or exhibited any signs or symptoms of the disease. None of the patients developed symptoms of SARS-CoV-2 infection till 14 days post procedure.

Conclusion GI endoscopy in lockdown, is not a daunting task. It can be safely performed without pre-procedural COVID testing and should not be delayed because of non-availability of the test. Background Gastric variceal bleed is a complication of liver cirrhosis that causes significant morbidity and mortality. there is substantial variability in prevalence due to the differences in patient characteristics. With advancement of endoscopic techniques, cyanoacrylate injection has become the most accepted intervention. Aim To identify the clinical profile of gastric variceal bleeding and also determined the outcomes of cyanoacrylate glue injection in relation to primary hemostasis and rebleeding. Methods This is a prospective observational study of 42 patients who were diagnosed with bleeding gastric varices from October 2018 to January 2020 at SRMC. Patients who underwent glue injection were included and were followed up for 3months for complications.

Results Patients has mean age of 55 years with male predominance of 76.2%. The main etiology is alcohol related cirrhosis in 15 patients (35.7%), melena is main presenting symptom 35.7%. Sarin classification of gastric varcies GOV1 seen in 14 patients (33.3%), GOV2 seen in 18 patients (42.9%), IGV1 seen 7 patients (16.7%) and size of varix ranges from 5 mm-10 mm in 71.4% and >10 mm in 28.5% of patients. 64.3% of patients requiring ICU admissions and 61.9% were requiring blood transfusion. All 42 patients underwent Glue injection and 100% achieved primary hemostasis. 45.2% patients required both glue and EVL banding. The volume of glue required varied among patients 0.5ml in 30.9%, 1 mL in 40.4%, 1.5 mL in 21.4% and 2 mL in 7.14%. The incidence of rebleeding is seen in 5 patients (11.9%), of which 4 patients (9.5%) required Re-Glue injection and 2 patients (4.8%) required BRTO. complications like gastric ulceration, sepsis and embolism were not seen.

Conclusion Bleeding gastric varices were mainly seen among in 5th and 6th decade. Melena is the most common presentation. Cyanoacrylate injection is an effective modality in achieving primary hemostasis however there is still remains a significant of rebleeding.

Introduction In benign non stricturing esophageal disease for example leak, fistula or perforation the use of fully covered stent is a modality of treatment. However, its use is limited due to its high rate of migration and embedment. We use a novel technique of using a proximal release stent and using a silk thread anchored to the proximal end of the stent tied to it before release and then moved through the nose and attached to ear lobe with tape (Shim technique). Aim To determine the risk of migration and efficacy in using Shim technique in benign non stricturing esophageal disease.

Methods Patient undergoing fully covered stenting for benign non structuring disease over last 24 months were included in this study. Success of deployment and duration of procedure was collected from records. Migration was identified by serial X-ray and also dislodgement of the silk thread tied to the ear lobe. Stent embedment, difficulty in removal of stent and successful closure of leak/fistula was retrieved from records. Results Fully covered esophageal stent with Shim technique was used in total five cases. 2 Boerhaves syndrome, 1 Post Esophagectomy cervical leak, 1 aortoesophageal fistula, and 1 post balloon dilatation perforation were managed. Stent were placed by experienced endoscopist under guidance of fluoroscopy. Stent deployment were successful in all 5 cases and anchored by Shim technique. Migration happened only in one case of Boerhaves syndrome within 72hours and patient succumbed post-surgery to mediastinitis. In aortoesophageal fistula the patient succumbed to mediastinitis 4 weeks post stent placement. The stent was removed at 4-6 weeks in other cases with complete healing of leak or perforation seen. Conclusion Fully covered SEMS using Shim technique in benign esophageal nonstricturing disease has good efficacy with minimal migration rate.

Effectiveness of low volume split-dose versus same day morning polyethylene glycol regimen for adequacy of bowel preparation in patients undergoing colonoscopy: A single blinded randomized controlled trial Introduction EUS-guided tissue acquisition has been widely used to obtain tissue for the diagnosis of gastrointestinal (GI) lesions with good accuracy and safety, but the diagnostic yield remains highly variable. Hence, we intend to study these outcomes in the absence of on-site cytopathologist.

Methods A retrospective analysis of patients who underwent EUS-FNA for upper GI lesions from September 2018 to March 2020. EUS-FNA had been performed by 2 experienced endosonographers, using the fanning technique with 22-G franseen design needle from Boston Scientific without on-site cytopathologist. Specimens were analyzed through cell blocks and thread biopsies by an experienced pathologist and were categorized into adequate and diagnostic or non-diagnostic. Results A total of 176 patients were taken into study; male 108 (61.4%) with mean age of 53.6 ± 15.5 years. The lesions were grouped into those arising from pancreas in 110 (62.5%), lymph nodal lesions in 28 (15.9%), bile duct lesions in 16 (9.1%), and the rest in 22 (12.5%) of patients. The mean size of the lesions was 2.8±1.5 cms. The average number of passes was 2.35 ± 0.9. There were no complications observed during or post procedure. The overall adequacy rate of the tissue specimen was 92% for both smears and/or biopsy specimen. The adequacy rate was highest for pancreatic lesions at 95.5%, followed by bile duct lesions (93.7%), lymph nodal lesions (89.3%) and lowest among submucosal epithelial lesions at 77.7%. Among the adequate samples, malignancy was confirmed in 60.49% and benign pathology was seen in 39.5%.

Conclusion EUS guided tissue acquisition by experienced endosonographer yields high adequacy rates and is safe and cost effective in the absence of on-site pathologist at resource limited settings.

Background Role of pre-cut fistulotomy in reducing fluoroscopy time and radiation dose in difficult selective biliary cannulation is unknown. Methods This is a prospective randomized controlled trial where patients with difficult biliary cannulation were randomized into 2 groups, viz, Group I -Early pre-cut fistulotomy after difficult biliary cannulation at 5 minutes and Group II-Late pre-cut fistulotomy after failure of conventional methods of selective biliary cannulation for 15 minutes. We compared the success rates of selective biliary cannulation along with fluoroscopy time and radiation dose, the complication rates, need for repeat Endoscopic retrograde cholangiography (ERC) and need for other interventions in early and late pre-cut fistulotomy. . Layer of origin (EUS)-GIST (18) and leiomyoma (5) arising MP, NET (7) -SM and MP. Mean EFTR procedure time -162 min (range 20 -424). Mean resection specimen size -3.0 cm. R0 resection 28/33, margin positive 5/33, morcellation 6/33. Mean defect closure time -17.9 mins (2-50 mins). Closer methods-TTSC 19, endoloop+TTSC-6 Padlock-3, padlock+TTSC -2, padlock+ endoloop + TTSC-1, Padlock + Apollo overstitchendosuture-1, Omental patch + TTSC-2, Ovesco clip -2, Apollo overstitch endosuture -2. Histology GIST -18 (46.1%, low grade -17, high grade -1), NET-7 (17.9%, WHO grade-grade 1-4 , grade 2 -3), leiomyoma-5 (12.8%), Schwannoma-3 (7.6%), gastric duplication cyst -1 (2.5%), ectopic pancreas 1 (2.5%), neurofibroma -1 (2.5%), parietal cell hyperplasia-1 (2.5%), adenomatous proliferation with high grade dysplasia-1 (2.5%), hyperplastic granulation tissue-1 (2.5%).Two adverse events-laceration and perforation. Follow-up -3 months -100% no residual lesions,1-3 yrs -60-80% no residual lesions, after 3 yrs 56% asymptomatic and no residual lesions. Background Per-oral endoscopic myotomy (POEM) is an established modality of treatment in achalasia and non-achalasia spastic motility disorders of esophagus. However, there is limited data on the long-term outcomes of POEM. In this study, we aim to evaluate the efficacy of POEM in patients with a minimum follow-up of five-years.

Methods The data of patients who successfully underwent POEM and completed at least five-years follow-up were analyzed from a prospectively maintained database. The primary outcome of the study was clinical success (Eckardt&le;3) at age; 5-years after POEM. The secondary outcomes included the prevalence of dysphagia and symptoms of gastroesophageal reflux disease (GERD). Multivariate analysis was performed to analyze the predictors of dysphagia and symptomatic and GERD on long-term follow-up. Introduction Functional dyspepsia is a commonly encountered entity worldwide and is difficult to treat. Most of the treatment modalities have low quality evidence for use, except for proton pump inhibitors. Aerobic exercise has been shown to improve the symptoms but its direct effect on symptoms has never been studied. Objective was to study the effects of moderate aerobic exercise on symptoms of functional dyspepsia and to compare the effect of conventional treatment alone vs. exercise plus conventional treatment.

Methods Out of 112 patients, 72 were randomly divided into controls (conventional treatment) (n=36) and experimental (aerobic exercise for 30 minutes per session, 5 times a week for 6 weeks with conventional treatment) group (n=36). Both groups were assessed on day 1 and at the end of 6 weeks, using Glasgow dyspepsia severity score (GDSS), Depression anxiety stress scales-42 (DASS 42) and Visual analogue scale (VAS).

Results Pre-treatment GDSS, DASS 42 and VAS in the experimental group were significantly different as compared to the post-treatment scores (p=0.00019, p=0.0002, p=0.00019 respectively). Even in the control group, pre-and post-treatment GDSS, DASS 42 and VAS scores were significantly different (p=0.00019, p=0.0002, p=0.00019 respectively). However, on head-to-head comparison of the 2 groups, scores at the end of 6 weeks were significantly different (p< 0.05), in favor of the experimental group.

Conclusion Aerobic exercise with conventional treatment is more effective than conventional treatment alone for functional dyspepsia.

Incidence and risk factors associated with development of post infection irritable bowel syndrome (PI-IBS) -A one-year prospective longitudinal study Chronic constipation is a common complaint in the general population worldwide as well as in India. It may be idiopathic or secondary. Idiopathic constipation is classified as functional constipation (FC) and IBS-C. Proportion of FC among patients of idiopathic chronic constipation is higher than IBS-C. We studied 100 patients of FC. Majority were male (70%). Colonic transit time (CTT) was measured by using radioopaque markers and anorectal manometry by high resolution water perfusion system. Mean age of patient was 41y ±14.7, maximum were in 21-30 years and 31-40 years of age group. Introduction Psyllium husk is bowel regulator and could work very effectively in irritable bowel syndrome (IBS) provided it is taken in proper quantity and with adequate water. This and other physiologic steps (FEED) were studied.

Methods IBS patients (Rome IV criteria) were prescribed FEED regimen, (F) -Fiber (Psyllium-Ispaghulla husk), 5 tsf (25 grams) with 500 mL water/day (E) -Elevation of feet by small bench (12-16" height) while on toiletcommode, (E) -Exercises of abdominal muscles (D)-Drinking (500 mL) water in morning. Earlier 5-10 grams of soluble fiber (psyllium) has been studied which provide only partial relief. Daily fiber requirement is 35-40 grams/day whereas the intake is <15 grams/day. So, this deficiency of 20-25 grams fiber needs to be supplemented daily to maximise the relief in IBS patients. Second aspect is the amount of water taken along with the fiber. Psyllium absorbs water, takes water to the rectum, thereby making stools softer and bulkier. However, for this to happen optimally, adequate water must be taken along with the fiber intake (@25 mL water/gram fiber, 500 mL water with 25 grams fiber/ day). These aspects which markedly increases the efficacy of fiber supplement was ignored by previous studies. Elevating the feet while sitting on toilet commode straightens the rectoanal canal which by relieving functional obstruction makes defecation process easier and less strainful. Drinking water in morning and doing abdominal wall exercises while sitting on toilet-commode activate gastrocolic reflex and help in bowel regulation. All these physiological steps (FEED) when implemented together, helps to regulate bowel and provide substantial relief in IBS.

In the pilot study, FEED was recommended to 7 patients of IBS (4-IBS with constipation, 2-IBS with diarrhea, IBS mixed). After 6 weeks, all patients responded well to this physiological treatment and reported a major relief (>90%) in their symptoms. To study normal values on high-resolution anorectal manometry in healthy volunteers in India

Introduction High-resolution anorectal manometry (HRAM) is used for determination of anorectal disorder. There are differences in data on effects of gender and age on anorectal function. The data on normal anorectal pressure and sensation are sparse. Our hypothesis is that values in Indian population might be different from others. This study aims: (1) To obtain normal data sets of anorectal function using HRAM and (2) Influence of gender and age on anorectal functions in healthy volunteers in India.

Methods In our population healthy volunteers underwent HRAM using a 24-channel water perfused catheter. We determined anorectal pressures, recal sensation and balloon expulsion time. Measurements were recorded during rest, squeeze, and push with and without balloon inflation. Informed consent was taken.

Results HRAM was performed in 93 healthy volunteers of which 29 were females. Median age was 38 years (ranges: female 18-65 years; male 18-decided to reduce the size of the mass by embolization in the interim. Two sittings of selective embolization of tumor branches of right hepatic artery was done, with 6 months interval. Post embolization syndrome following first sitting was medically managed, second embolization uneventful. Tumor significantly reduced to 12.1 cm x 9.8 cm and left lobe enlargement was noted. Then she underwent surgical excision of the hepatic adenoma along with right hepatectomy. She recovered well postoperatively and remained clinically well at 12 months follow-up. Discussion Hepatocellular adenomas (HCAs) are extremely rare during childhood with varying histopathological features. HCA can be sporadic but is more frequently associated with oral contraceptive use and metabolic liver disease. In our patient there was no history of oral contraceptive use, underlying liver disease or genetic predilection. In view of risk of rupture/bleed we intervened. Conclusion Hepatic adenoma, particularly large one is extremely rare in childhood and needs MDT management. Huge adenoma can be successfully reduced by selective embolization technique before high risk surgery to achieve optimal postoperative outcome.

Introduction The role of endoscopic retrograde cholangiopancreatography (ERCP) both as a diagnostic and therapeutic tool is well established in adults, while there is a paucity of data regarding its safety and efficacy in the pediatric population. The aim of our study was to evaluate the outcomes of ERCP in the management of pancreaticobiliary diseases in children (<18 years) by adult gastroenterologists using standard duodenoscopes.

Methods Consecutive patients aged 18 years or less who underwent ERCP from January 2010 to December 2019 were identified from our endoscopy database. Data pertaining to patient demographics, indications, success at cannulation of the desired duct, findings on cholangiopancreatogram, and adverse events if any were recorded.

Results A> total of 175 ERCP procedures were performed on 159 children, aged between 3 years to 18 years with 93 (58.5%) males and 66 (41.5%) females. The most common indications for ERCP were chronic pancreatitis (CP) with pancreatic duct disruption and/or acute exacerbations (n=93) followed by choledocholithiasis with biliary pancreatitis (n=41) and with cholangitis (n=4), choledochal cyst (n=12), and traumatic pancreatic duct disruption (n=10). Less common indications included pancreas divisum (n=6), PCC (n=3), hepatic hydatic cyst with biliary communication (n=2), traumatic liver laceration (n=1), progressive familial intrahepatic cholestasis with intractable pruritus (n=1), primary sclerosing cholangitis (n=1) CBD stricture status post-surgery for rhabdomyosarcoma (n=1). Cannulation was successful in 95% of the patients. Adverse events were noted in 4 patients (2.2%), post-ERCP pancreatitis in 3 patients and one had post-sphincterotomy bleed, all of whom were managed conservatively. There was no procedure or anesthesia related mortality. Conclusions ERCP when performed by expert endoscopists is a relatively safe and effective procedure in children. Introduction Extrapulmonary involvement occurs in one fifth of all TB cases and out of them, 60% have no evidence of pulmonary infection in chest radiograph or in sputum. Tuberculosis can present as a obstructive jaundice but it is a very rare entity with only a few cases reported. We are reporting unusual case of multiple enlarged tuberculous lymph nodes compressing the common bile duct in the retro pancreatic region and causing obstructive jaundice.

Background Acute cholangitis is the infection of the biliary tree with life threatening outcomes. The aim was to analyze the clinical profile, microbial spectrum and outcome of patients with cholangitis at our centre. Methods A prospective observational study of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis (as per Tokyo guidelines) due to any biliopancreatic disorder from July 2019 to December 2019. Bile samples collected during ERCP were sent for culture and sensitivity. The demographic profile, clinical and biochemical profile, microbial spectrum along with their sensitivity patterns and patient outcome were studied. The data analysis was done with SPSS 23. Results A total of 92 patients were included with median age of 49 (Range 15-85 years). Females comprised 73.9% (n=68). Etiology of cholangitis was mainly benign, most common being choledocholithiasis (n=42,45.6%). Cholangitis with underlying malignancy was less common (n=17,18.5%). Charcot's triad (n=44,47.8%) was more common than Reynod's pentad (n= 3,3.3%). Renal failure was the predominant organ failure (n=14,15.2%) and 12 cases had hypotension at admission (8 patients required inotropic support). Mean leukocyte count was 16876 ±6496/mm3, bilirubin and alkaline phosphatase (ALP) levels were 9.60 ± 7.18 mg/dL and 596±471 U/L, respectively. Mean serum procalcitonin levels were 3.19 ± 1.8 ng/mL. Most frequent organism identified on bile culture was E. coli (n=35,38%) followed by pseudomonas (n=20, 21.7%) and Klebsiella (n=7, 7.6%) and was sterile in (n=28, 30.4%) cases. Most sensitive antibiotic was imipenem followed by tigecycline and piperacillin/tazobactum. Multidrug resistant organisms (n=25, 27.2%) were also identified. Mean hospital stay was 8 ± 7.6 days, with most cases being discharged (n=80, 87%) and with mortality in 12 patients. Conclusion Gram negative organisms were the most frequent cause of cholangitis with E. coli and pseudomonas being the most common.

Emergence of multidrug resistant organism mandates judicious use of antibiotics in hospital settings. Cholangitis was more frequent due to benign etiologies. Background Simultaneous dilatation of common bile duct and pancreatic duct, the double-duct sign, is considered an ominous finding at imaging and usually suggestive of peri-ampullary malignancy.

Case Report 32-year-old male presented with pain epigastrium and right upper abdomen with jaundice for 3 days. The pain was severe, exacerbated with meals and was radiating to the back. There was history of episodes of similar pain without jaundice for last 3 years. There was no history of fever, weight loss, alcohol intake, steatorrhea or diabetes. On examination there was icterus and marked epigastric tenderness. Bilirubin was 6.5 mg/dL, ALT 1450 U/L, GGT 760 U/L, lipase 90 U/L, CA-19.9 58 U/mL. MRCP showed dilated entire MPD of up to 8 mm with clubbing of side branches and possible impacted stone at distal end. Bile duct dilated 9 mm with no filling defect. EUS confirmed double duct sign with changes of chronic pancreratitis with impacted distal MPD stone and dilated CBD till distal end with no filling defect. ERCP showed bulky ampulla and of 7 mm diameter impacted stone was removed from distal PD with needle-knife pre-cut and manipulation. 10F X 8 cm plastic tannenbaum stent was placed in CBD and 7F X 8 cm percuflex plastic stent was placed in PD. Pain abdomen and LFT improved rapidly. Both stents were removed at 3 months and he continues to do well on medical treatment for chronic pancreatitis.

Conclusion Impacted distal pancreatic duct stone can present with obstructive jaundice and double duct sign.

Introduction IgG4-related sclerosing cholangitis (IgG4 SC) is the biliary manifestation of IgG4 related disease often in association with autoimmune pancreatitis. Here we report two patients of IgG4 SC mimicking primary sclerosing cholangitis and carcinoma head of pancreas, respectively. Case 1 A 16-year-old boy presented with history of recurrent self-limiting episodes of jaundice and pruritus for last 4 years. liver function tests (LFT) suggested cholestatic jaundice. Ultrasound abdomen was non-contributory. Magnetic resonance cholangiopancreatography (MRCP) was characteristic for multiple intrahepatic biliary strictures with beaded appearance and long segment narrowing in distal segment of common bile duct (CBD). Serum IgG4 level was raised 227 mg/dL (80-120 mg/dL). Contrast enhanced computed tomography (CECT) of abdomen revealed bulky pancreas. After receiving prednisone 40 mg daily for 2 months, jaundice settled and biliary strictures resolved on repeat MRCP. He is on maintenance azathioprine 50 mg without any relapse in last 8 months.

Case 2 A 54-years-old woman presented with abdominal pain, weight loss and anorexia for 2 months. Her physical examination revealed marked pallor, mild icterus, and left axillary lymphadenopathy. Introduction Bronchobiliary fistula is a rare condition consisting of communication between biliary tract and bronchial tree presenting with bilioptysis and suspicious pneumonia. The management of this condition is challenging with limited current evidence to date. Case Report We are reporting a 45 yrs male patient presenting with complaints of cough with green coloured sputum and shortness of breath since 2 months. He is a K/C/O portal cavernoma. He had a past history of right liver lobe abscess with rupture into pleural cavity 4 years back.

Investigations TSB -1.61 mg/dL, ALP -628 IU/L, sputum is positive for bile pigments. Ultrasound abdomenportal cavernoma with mild central IHBrD. Chest X-rayright lower lobe patchy consolidation. MRCPstricture at CHD and CBD level secondary to portal biliopathy with mild upstream IHBrD. ERCP was done confirming the stricture and on dye injection leakage of dye into right lower lobe of lung noted.8Fr DPT CBD stent deployed with free flow of bile noted. Bilioptysis and dyspnea decreased after stenting and CXR was cleared of patchy consolidation. Symptoms again recurred after 2 months and patient underwent stent exchange. Despite improvement for short-time symptoms recurred again. So patient was referred for surgery. He underwent shunt procedure in view of portal cavernoma and fistula was identified and closed. Conclusion Bronchobiliary fistula is a serious complication associated with high morbidity and mortality and requires high index of suspicion for diagnosis and requires well planned management strategy. A 16-year-old female child with no significant past illness presented to the outpatient department with 10-day history of abdominal pain and high colored urine. The pain was localized to the right upper quadrant, associated with nausea and vomiting and was intermittent, each episode lasting for 3-4 hours. The patient reported normal colored stools. Patient did not report fever, pale stools or pruritus during the course of illness. Examination was remarkable for scleral icterus and mild tenderness over the right hypochondrium. Blood investigations were done, showed cholestatic jaundice (total bilirubin: 2.99 mg/dL, direct bilirubin: 1.63 mg/dL, alkaline phosphatase: 319 IU/L, alanine transaminase: 204 IU/L, aspartate transaminase: 125 IU/L, serum albumin: 4.3 g/dL). Abdominal ultrasonography showed a normal liver size and echo texture, dilated common bile duct (1.8 cm) along with dilated intrahepatic biliary radicles. Multiple calculi were noted in the gallbladder, with wall thickening suggestive of calculous cholecystitis. An MRCP (magnetic resonance cholangiopancreatography) was done. The findings were suggestive of a choledochal cyst (type IV a) along with a complex type of anomalous pancreatobiliary ductal union and a variant of pancreas divisum with choledocholithiasis. Patient was taken up for ERCP (endoscopic retrograde cholangiopancreatography) under general anesthesia. Ampulla was noted deep in 2nd part of duodenum. Selective bile duct cannulation was done and guidewire was placed into the right intrahepatic duct. Cholangiogram confirmed the findings of MRCP. Endoscopic biliary sphincterotomy was done. Balloon trawling was done to extract CBD stones. Multiple tiny calculi and sludge was extracted. Biliary stenting was done using a double pigtail stent of size 7Fr. Patient improved symptomatically, and liver functions normalized over a week. Patient was referred to a specialized center for surgery.

Introduction Laparoscopic cholecystectomy is the most commonly done procedure for gallstone disease. Preoperative prediction factors are helpful to categorize patients and take timely measures. The CLOC score compromises of preoperative variable such as patient demographics, indications for surgery, ASA grade, admission type and ultrasound findings. The key aspects of operative grading system (OGS) include: 1) gallbladder appearance and amount of adhesions, 2) degree of distension/contracture of gallbladder, 3) ease of access, 4) local/septic complications, and 5) time taken to identify the cystic artery and duct. OGS grades the difficulty into mild, moderate, severe and extreme. This study is a prospective observational study with the aim to predict intraoperative grading score for conversion from laparoscopic to open cholecystectomy. Methods This study was done at L N Medical College, Bhopal of 100 patients who underwent laparoscopic cholecystectomy from June 2018 to June 2020. Inclusion criteria are patient >18 years, giving informed consent, with acute or chronic cholecystitis with cholelithiasis. A comparison was made between the preoperative risk factors and intraoperative findings based on OGS. The outcome measures are prediction of conversion from laparoscopic to open cholecystectomy, bile duct injury, intraoperative and postoperative complication and duration of hospital stay.

Result Out of 100 cases, 14 cases were converted into open procedure. The cases with intraoperative complications like bile leak, bile duct injury etc were found to be 19. In converted cases, 1 case fell into moderate grade, 3 into severe grade and 10 into extreme grade. Also, 4 cases underwent bile duct exploration and repair in the same sitting while 2 cases underwent delayed bile duct exploration. Out of 100 cases, 3 cases were associated with postoperative complications. Conclusion Operative grading system provides a better scoring system and aids the surgeon in making decision in case of difficult cholecystectomy. Traumatic bile leaks often result in high morbidity and prolonged hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Our study objective was to evaluate the efficacy of the endoscopic management of a traumatic bile leak. We performed a retrospective case review of patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP) after traumatic bile duct injury secondary to blunt trauma (motor vehicle accident or fall from height) for management of bile leaks at our tertiary hospital. Three patients underwent ERCP for the management of a traumatic bile leak over a 1-year period. The etiology included blunt trauma from motor vehicle accident in 2 patients or fall from height accident in 1 patients. Liver injuries were grade III in 1 patient, grade IV in 2 patients. All patients were treated by biliary stent placement, and the outcome was successful in 3 of 3 cases (100%). The mean duration of follow-up was 90 days. There were no ERCP-related complications. In our case review, endoscopic management with endobiliary stent placement was found to be successful and resulted in resolution of the bile leak in all 3 patients. Based on our study results, ERCP should be considered as first-line therapy in the management of traumatic bile leaks.

Prevalence of gallbladder stasis in patients with asymptomatic and symptomatic gallstones

Introduction Patients with gallstone disease (GSD) are at increased risk for gallbladder cancer (GBC). H pylori (Hp) has been identified as a cofactor in the pathogenesis of GBC. Prevalence of Hp in patients with GSD and its relationship with GB function is not known. This study was planned to study prevalence of Hp and its relationship to symptom profile and GBEF in patients with GSD.

Methods Consecutive patients of GSD in a prospective cross-sectional study between March 2019 to November 2019 were enrolled. All patients underwent clinical, demographic and ultrasound abdomen assessment for GS and gallbladder ejection fraction (GBEF). GBEF was calculated after 30 and 60 min of standard fatty meal. Gallbladder stasis was defined as GBEF<40%. Sera was analyzed for anti H. pylori IgG antibody. Upper gastrointestinal endoscopy (UGIE) was done to assess for Hp related changes and biopsies were taken for histopathology and rapid urease test (RUT). Chi-square and Mann-Whitney U tests were used for comparison and p value < 0.05 was taken as significant.

Results Patients with GS (n=87) with a mean age of 48.5±14.9 yrs (F:73.6%) were evaluated. Multiple stones were present in 61%. Mean GBEF at 30 min was 35±21% and at 60 min was 48±26%. GB stasis was present in 55.8% (48/87) patients of GS. UGIE showed antral hyperaemia in 95.4% and duodenitis in 35.3% of the patients. Hp+vity by RUT or serology, was seen in 40% patients; of which RUT was positive in 75%. Active Hp infection (RUT +ve) was more often associated with gallbladder stasis (45.7% vs. 15.6%, p=0.1); however, it was not significant. Aim and Objectives Patients try to correlate varieties of symptoms with abdominal gas. So, this study was designed to see the patients' view regarding abdominal gas and its relation with medically explained symptoms.

Method Consecutive patients with complain of abdominal gas were included in this study. Their demographical information and explanation of symptoms resulting from abdominal gas, they believed were recorded on a predesigned data sheet. Statistical analysis was done using SPSS 20 version. the entire patient cohort (n=300) in 2022 will provide a robust estimate of the prevalence of MSI and LS in CRC patients in India. These estimates would help in formulation of national guidelines for MSI testing, LS diagnosis and aspirin based chemoprevention strategies of CRC in India. Gender distribution and Site of foreign body females presented slightly more commonly following a foreign body ingestion. Of the children s admitted with symptoms of foreign body ingestion, the most common site of FB lodgement were in post cricoid and lower esophagus (9.375%).

Others side of impaction were base of tongue, pyriform area, upper esophagus, stomach and duodenum. No foreign body were seen in OGD in 13 % of males and 16 % of female children with suspected foreign body ingestion. Presentation of foreign body ingestion. The most common presentation was a foreign body sensation or something struck in the throat after an accidental ingestion which occurred in 43.75 % of children's followed by odynophagia and dysphasia occurring in 25% and 21.82% children´s. 15.6% had no complaints on presentation expect history of foreign body ingestion. Type of foreign body and site of presentation 18.75% presented were impacted coins. other foreign body found were fish bone, metal pins, batteries, and food impactions.

Conclusions Expert hands and clinical skills are necessary for early and safe removal. It is necessary to educate the parents about keeping away the article from reach of children and to observe the activity of child will prevent the higher incidence of a foreign body in children.

In today's era of high resolution-anorectal manometry and magnetic resonance defecography -Would you still use the finger? Background Magnetic resonance defecography (MRD) and highresolution anorectal manometry (HR-ARM) are advanced tools for defining pelvic floor anatomy and thus help in detection of dyssynergia.

Digital rectal examination (DRE) is a simple bedside test done on outpatient basis which has also shown to detect dyssynergia in patients with constipation with high sensitivity. The objective of the study was to evaluate usefulness of DRE as compared with HR-ARM and MRD as a marker for detection of dyssynergic defecation (DD).

Methods Thirty patients of chronic constipation (CC) defined by ROME IV criteria were enrolled. After ruling out structural causes of constipation using colonoscopy, all patients were subjected to undergo DRE and subsequently HR-ARM, blinded to DRE findings. MRD was reported by radiologist who was also blinded to the findings of DRE and ARM. Background Fever with jaundice is a common entity seen in routine practice. This manifestation is seen in many individuals infected with viral hepatitis A to E. Excluding these hepatotropic viruses, many other pathogens can clinically manifest as fever with jaundice which include bacteria, protozoa, fungi, and non-hepatotropic viruses. Aim and Objectives India, being a tropical country, the study aims to evaluate the tropical and other infectious causes barring viral hepatitis A to E, which manifest as fever associated with jaundice. Methods This study includes 60 patients admitted in Kalinga Institute of Medical Sciences from 2019 who were found to have febrile jaundice after initial evaluation by liver function tests and hepatotropic viral markers (HBsAg, anti-HCV IgM, anti HAV IgM, anti HEV IgM). Routine laboratory parameters, chest Xray, ECG was performed in all cases. Appropriate investigations like specific serological, radiological investigations and cultures were performed to identify the causal pathogen. Patients infected with hepatotropic viruses, if associated with any other confounding organisms responsible for their clinical picture were included in this study.

Results Out of 60 patients, 23 (38.3%) patients were found to have scrub typhus (4 had associated encephalopathy). Dengue was found in 8 (13.3%) patients (3 had dengue associated with scrub typhus). Malaria was identified in 5 (8.3%) patients (2 had associated scrub typhus). Four (6.6%) patients had tuberculosis (2 are on ATT) and 3 (5%) patients had varicella-zoster clinically. S. typhi was found in 2 (3.3%) patients. K. pneumonia, E. coli, A. baumannii, B. cepacia, E. feacalis were isolated in other individuals. Among these 21 patients had associated transaminitis (elevated AST/ALT >3 times of ULN). Eleven cases had hepatomegaly and 5 were found to have splenomegaly. Ten cases had septic shock of which 4 could not be revived. No definitive etiology was found in 10 patients.

Eosinophilic ascites as rare unusual initial presentation of eosinophilic gastroenteritis Thirty-three-year-old male presented with progressive abdominal distension and discomfort associated with nonspecific abdominal pain of 1 week duration. Physical examination was unremarkable except for ascites. Routine labs showed high eosinophilic count with leukocytosis in hemogram and peripheral smear, AEC-7890 cells/cumm. Stool exam was nil contributory. Abdominal sonogram showed moderate to gross ascites, no features of CLD/portal hypertension. Ascitic fluid cytology and cell block were suggestive of low SAAG high protein ascites, ascitic fluid TC-15,600 cells/ cumm, AEC-13,950 cells/cumm. Prior to current admission there was also a history of consuming seafood containing prawns followed by loose stools and pain abdomen for 2 days which was self-limiting. EGD showed mild duodenitis. Biopsy from D2, Antrum, esophagus showed histopathologic evidence of eosinophilic gastroenteritis. CT thorax and abdomen showing diffuse esophagial wall thickening and edematous and thickened small bowel loops. He was treated albendazole, ivermectin and PPI. Within a week there was significant improvement in symptoms. He was not put on steroids as there was clinical improvement on PPI and antielminthics. There was no ascites on repeat ultrasound scan of abdomen done two weeks later. He remained asymptomatic even at one-year follow-up. Conclusion Eosinophilic ascitis is a rare unusual presentation of eosinophilic gastroenteritis, usually occurs in serosal involvement. Mostly ascites is mild and not clinically significant and usually associated with abdominal pain. Rarely, isolated ascites can be the initial presentation.

A rare case of concurrent primary gastric and bone diffuse large B cell lymphoma Chunduri Vikranth, Chunduri Venkata Viswa Vikranth, Ganesh Panchapakesan, Shanmugnathan Subramanyam Correspondence-Chunduri Vikranth-chvv.vikranth@gmail.com Department of Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai 600 116, India

Primary bone lymphoma (PBL) is an uncommon clinical entity and a rare non-Hodgkin's lymphoma presentation. PBL accounts for less than 5% of malignant bone tumors, 4% to 5% of extranodal lymphoma, and less than 1% of all non-Hodgkin's lymphoma. Primary gastric lymphoma (PGL) is rare cancer, but it is the most common site for extranodal non-Hodgkin lymphoma. We report a rare case of concurrent presentation of a bone lymphoma and gastric lymphoma. The patient presented with a slow-growing swelling around the knee joint for two years. Positron emission tomography incidentally picked up an FDG avid lesion in the fundus of the stomach. Tissue specimens of both the lesions were obtained and conformed to have diffuse large B cell lymphoma on histology and immunochemistry. He was followed up with the oncology department and treated with R-CHOP regimen (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin [vincristine], and prednisone).

Preoperative successful thrombectomy and thrombolysis of acute extensive splanchnic venous system and TIPSS thrombosis in a child with Budd-Chiari syndrome-Creating a window to enable living donor liver transplantation Background Preoperative extensive portal vein (PV) thrombosis can pose a technical challenge during liver transplantation. Extensive and diffuse thrombosis of the splanchnic venous system may even necessitate multivisceral transplantation. We describe the case of a pediatric patient with Budd-Chiari syndrome (BCS) and decompensated cirrhosis, who developed extensive acute thrombosis of the portospleno-mesenteric venous system prior to living donor liver transplantation (LDLT). We used a combination technique of thrombus aspiration using a novel trans-TIPPS approach followed by thrombolysis to achieve complete pre-operative resolution of the thrombus. Case Report A 10-year-old child with BCS who had underwent a prior TIPPS, presented with TIPPS thrombosis, ascites, hepatic encephalopathy and hepatopulmonary syndrome (HPS). Two days prior to a planned LDLT, he developed an acute extensive thrombosis of the portospleno-mesenteric venous system. As the window for a prompt LDLT was fast fading due to multiple and recurrent episodes of decompensation and severe HPS, a decision to perform interventional radiology guided mechanical thrombectomy and thrombolysis was taken. Using a retrograde right transjugular trans-TIPSS approach, mechanical thrombus aspiration using a 6F shuttle sheath was performed. This was followed by thrombolysis using tissue plasminogen activator (tPA). Post procedure, there was near-total recanalization of all the veins (Fig. 1) . He was then started on intravenous tPA and continuous heparin infusion. This allowed the creation of a brief window to enable LDLT. Intraoperatively, PV showed complete recanalization with a good flow. A triangulated reconstruction of left hepatic vein to IVC/right hepatic vein and donor left PV to right main PV was performed. Post LDLT, anticoagulation was continued with intravenous heparin followed by subcutaneous enoxaparin and oral warfarin. He was discharged uneventfully. Conclusion In prudently selected patients, performing an early mechanical and chemical thrombolysis of an extensive acute splanchnic venous thrombosis can help expedite a planned LDLT.

Retrospective study of inflammatory bowel disease unclassified at tertiary care hospital Biomedical Sciences, Shri Dharmasthala Manjunatheshwara University, 5th Floor, Specialty Block, SDMCMS&H, Campus, Manjushree Nagar, Sattur-Dharwad 580 009, India

Background Inflammatory bowel disease unclassified is allocated to cases of colitis where endoscopic and histological findings are not adequate to differentiate between ulcerative colitis and Crohn's disease. Altered bowel, functional bowel, irritable bowel, esoinophilic colitis and microscopic colitis in its histological distinct patterns, lymphocytic colitis, infective colitis, and bacterial colitis are increasing common causes of non-bloody diarrhea. There appears to be an association with other autoimmune conditions, and also there is be variability in patient journey from referral to treatment. Aim To know the frequencies of unclassified inflammatory bowel diseases/to evaluate various causes of unclassified inflammatory bowel diseases.

Methodology It is an observational study. All the cases diagnosed as IBDU in the department of gastroenterology from the year 2015 to 2019 were included in the study. Cases with incomplete evaluation of suspected IBDU cases were excluded from the study. Diagnosis of IBDU was made based on clinical, radiological, endoscopy and histopathologic findings.

Results Total cases included from study period were 226.These patients were diagnosed with altered bowel, irritable bowel, functional bowel, lymphocytic colitis, infective colitis, bacterial colitis and eosinophilic colitis with 115 (66.86%), 09 (5.23%), 10 (5.81%), 9 (5.23%), 19 (11.04%), 07 (4.06%) and 03 (1.74%) respectively. The average age of the patients ranged from 17-40 years and many cases were >40 years.

Conclusion Unclassified inflammatory bowel disease is not infrequent problem for the gastroenterologist and should be considered in the evaluation of IBD with clinical features. Extra awareness and extensive biopsy sampling are required in order to avoid an erroneous diagnosis purely based on histological mimicry of changes seen in bacterial colitis and infective colitis.

Autoimmune ascites -A diagnostic dilemma Investigations Hemoglobin 8.4 g%, platelet 7.4 lakhs, LFT A/G reversal with normal enzymes, viral markers negative, ascitic fluid shows low SAAG, high protein ascites with normal ADA, and amylase; ascetic fluid geneXpert and cytology for malignant cells was negative. Normal urine routine. Thyroid profile-normal, 2D echo-normal. USG abdomen moderate ascites, liver normal echotexture. Portal vein doppler was normal. CECT abdomen liver normal, moderate ascites, no evidence of malignancy, CA 19.9, CEA, CA125 was normal. Fibroscan normal, UGI scopy and colonoscopy was normal, HRCT chest-interstitial lung disease (ILD) NSIP pattern. ANA was strongly positive1:1000, anti scl70, anti Ro-52, anti SS-A positive. Diagnostic laparoscopy no evidence of malignancy or tuberculosis. Since patient was not fulfilling any diagnostic criteria of autoimmune disease, a diagnosis of undifferentiated CTD with CTD associated ILD, CTD associated ascites was made. Patient was started on hydroxychloroquine and steroids. Patient became symptomatically better and in follow-up.

Conclusion To the best of our knowledge and review of literature autoimmune ascites in a patient with undifferentiated CTD with normal liver and normal cardiac status is unreported. Though rare, yet treatable autoimmune cause should be kept as a differential diagnosis. Background Median arcuate ligament syndrome is a rare condition caused by compression of celiac artery with or without celiac ganglia by median arcuate ligament (MAL). Most of the patients asymptomatic due to celiac compression but may present with complaints like bloating, nausea, vomiting, postprandial epigastric pain, and other non-specific symptoms.

Case A 37-year-old male with sober personal history, hospitalized with multiple episodes of severe epigastric postprandial pain and bilious vomiting over last 2 months. Weight loss of about 10 kg also present. No other significant past medical history. On clinical examination hemodynamically stable but mild dehydration present, rest was normal. His BMI was 21kg/mt2.On per abdomen examination everything is unremarkable. His laboratory report of hemogram, renal function tests, liver function tests, lactate, LDH, iron, C-reactive protein, amylase and lipase within normal limits. Ultrasound abdomen also normal. CT angiography revealed moderate external compression and luminal narrowing of aorta by the MAL at the diaphragmatic hiatus. Rest of the aorta and its branches shows normal contrast opacification. Visualized abdominal organs and bowel normal. Endoscopy was unremarkable. Doppler showed reduced flow distal to compression. After informed consent underwent laparoscopic division MAL causing compression. Normal flow pattern conformed intraoperatively and postoperatively by doppler. He is asymptomatic and gain 6 kg weight, with 2 months follow-up period.

Conclusion Diaphragmatic aortic hiatus syndrome is a rare cause and should be considered in the checklist for evaluation of postprandial pain and weight loss. Computed tomography angiography is diagnostic. Laparoscopic resection is curative.

Do the patients of COVID-19 with predominant gastrointestinal presentations behave differently from those with classical presentations?

Introduction Graft versus host disease (GVHD) is a common cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Skin, gastrointestinal tract and liver are commonly affected in GVHD. The outcome of gastrointestinal acute GVHD is poor and depends on clinical, endoscopic, or histological severity. We retrospectively studied the frequency, clinical profile, and outcome of acute gastrointestinal GVHD following allogenic HSCT. Methods Patients who underwent allogenic HSCT between December 2018 and May 2020 were included. The clinical symptoms, gastroscopy or colonoscopy findings, histopathology, details of treatment and outcome of acute gastrointestinal GVHD were analyzed. Results Eighteen patients underwent allogenic HSCT. A total of 8 (44.4%) recipients developed acute gastrointestinal GVHD. Their median age was 29.5 years (12-36) with a male preponderance (n=5). The median duration of onset of GVHD was 41 (17-92) days after HSCT. All patients received fludarabine and busulfan followed by GVHD prophylaxis. Six recipients had matched sibling donor, one had matched unrelated donor and another had mismatched sibling donor. All except one had 10/10 HLA matching. The symptoms of nausea, vomiting and anorexia were seen in five; abdominal pain in thyroid profile was suggestive of hypothyroid state so we started supplementation for the same and discharged patient on levothyroxine 25 microgram OD. On subsequent follow up 1 month after discharge trial to remove tracheostomy tube was given with success and dose of levothyroxine was titrated to levothyroxine 50 microgram OD. Patient is on regular follow-up and euthyroid on levothyroxine supplementation without any complications. Conclusion High degree of suspicion for postoperative tracheomalacia in case of thyroidectomy for large mass and timely diagnosis and management can avert rare but catastrophic event with necessary precaution.

Keywords Tracheomalacia, Thyroidectomy, Tracheostomy Background Renal angiomyolipoma (AML), also referred to as renal hamartoma, is a rare solid tumor without malignant characteristics. The inheritance pattern of renal AML is autosomal dominant. Renal angiomyolipoma (R-AML) is a benign mesenchymal neoplasm that includes smooth muscle cells, adipose tissue and thick-walled blood vessels in different compositions. It is usually asymptomatic and found incidentally by routine imaging techniques and rarely becomes symptomatic. The prevalence of R-AML in the general population is between 0.3% to 3% and females are 4 times at risk than males . It develops 80% sporadically and might be a clinical sign of tuberous sclerosis. Case presentation A 32-year-old, male patient presented to OPD with abdominal distension and abdominal pain with no history of trauma. On clinical examination abdominal distension was present and ballotable mass palpable in right hypochondrium and lumber region. On ultrasonographic examination approx. 20

x 11 cm sized large well-defined heterogeneous echo texture lesion with evidence of multiple hypoechoic areas within. p/o myolipoma. On CECT abdomen approx. 12.8*13.6*17.9 cm (AP*ML*SI) sized well defined soft tissue density lesion with hyperdense component (HU +56) (s/o hemorrhage) and fat density component noted in right suprarenal region with ill defined posterior wall noted. Superiorly lesion abuts inferior surface of the right lobe of liver with preserved fat plane. Right adrenal gland not seen separately from lesion. Exploratory laparotomy with right side nephrectomy with en mass removal with large hematoma was done. On histopathological examination all finding suggestive of angiomyolipoma of right kidney, immunoreactive for SMA (smooth muscle actin), vimentin and focally immunoreactive for HMB45. Background Non traumatic spontaneous epidural hematoma is a rare and often unmentioned complication of sickle cell F. It is often associated with skull bone infarction. An 18 yrs old boy with sickle cell anemia who developed persistence headache during a vaso-occlusive crisis. Brain CT revealed a right frontal extradural hematoma (EDH) compressing on the brain. No other etiologic factor was identified. A right frontal craniotomy and evacuation of the hematoma was performed.

Case report An 18-year-old male with sickle cell disease was admitted to another hospital to receive treatment for headache and vomiting with no improvement after one day of hospitalization. CT brain revealed a right frontal extradural hematoma with midline shift. An emergency craniotomy with evacuation of extradural hematoma was performed. The patient was discharged with normal neurological examinations on the fifth postoperative day.

Results Non traumatic spontaneous EDH is a rare occurrence; in SCD patients is rarer still. A high index of suspicion is required in the diagnosis and treatment of EDH in patient with sickle cell anemia. Operative management is associated with excellent outcomes as demonstrated in our index patient. It is often associated with skull bone infarction. An eighteen-year old boy with sickle cell anemia who developed persistence headache during a vaso-occlusive crisis. Brain CT revealed a right frontal EDH compressing on the brain. No other etiologic factor was identified. A right frontal craniotomy and evacuation of the Haematoma was performed and he made good recovery.

Conclusion Spontaneous EDH is a rare occurrence; its occurrence in SCD patients is rarer still. A high index of suspicion is required in the diagnosis and treatment of EDH in patient with sickle cell anemia. Operative management is associated with excellent outcomes as demonstrated in our index patient. Background Lumbar hernias are rare among all other hernias in which abdominal contents protrude through a defect in the posterolateral abdominal wall. Hafner et al. stated that general surgeons will get only one opportunity to repair a lumbar hernia during their lifetime. Lumbar hernia was first suggested by P. Barbette in 1672 and R.J.C. Garangeot published a case for the first time in 1731. Since then, only about 300 cases have been reported. We here describe a successful case of laparoscopic primary acquired lumbar hernia Repair with IPOM approach in a 65-year-old female patient who had a complain of reducible abdominal swelling with no other com plains.

Case presentation A 65-year-old female patient presented to OPD with right sided reducible, gradually progressive abdominal swelling for 2 years, with impulse on coughing, diagnosed as a primary acquired lumbar hernia. Laparoscopic right lumbar hernia repair with IPOM approach was done; intraoperatively, all the contents including terminal part of ileum, ileocecal junction, cecum, appendix , proximal part of ascending colon with its mesentry were reduced. 6 × 5 cm 2 sized defect seen.15 cm 2 sized circular parietex composite pre-placed sutures mesh kept and fixed. There were no postoperative immediate complications. Patient was discharged on 4th postoperative day. Conclusion Laparoscopic lumbar hernia repair is effective as there is minimal tissue handling with very little dissection of surrounding tissues with minimal to no postoperative morbidity. 

Introduction There is paucity of data on acute lower gastrointestinal bleed

Results Fifty-three patients were included in study (male-67%, Mean age=12 years, range:-1-18 years)

Anal canal length (1.86±0.68 cm vs. 2.5±0.68 cm), anal push residual pressure without inflation (59±21 mmHg vs. 81±22 mmHg) and first sensation (34±17 ml vs. 47±28 mL) were significantly lower (p<0.05) in females compared to males. No statistical difference was found in resting anal pressure, maximum squeeze pressure, push residual pressure with inflation, urgency to defecate and MTV in males and females. Mean anal resting (91±29 mmHg) and mean squeeze max pressure (155±38 mmHg) were lower in >50-year age group compared to <50-year age group (100±28 mmHg) and (169±45 mmHg) respectively. Balloon expulsion was failed in 30 (32%) study participants. Conclusion HRAM parameters anal canal length, anorectal pressure and volume are influenced by age and gender (significantly low in females). Results must be interpreted concerning gender and age-adapted normal values

Mary George Correspondence-Sajith Sebastian-drsaseneeruvelil@gmail.com Department of Medical Gastroenterology

Mallikarjun Patil Correspondence-Syed Shafiq-syed.dr.s@gmail.com Fortis Hospital, Bannerghatta Road, Bengaluru, India, and Department of Gastroenterology

Results A total of 56 patients were enrolled in our study

Keywords Button battery, Impaction, Endoscopic retrieval, Laparotomy

Hardoi Road, Sarfarazganj, Lucknow 226 003, India Background Impacted button battery (BB) in the esophagus can be fatal unless managed urgently. Case characteristics A 2-year-old male child presented with respiratory distress from three weeks. Chest X-ray suggested a radiopaque foreign body, which was confirmed to be esophageal BB during esophagoscopy and subsequently removed. Corrosive nature of BB had perforated the lower esophagus leading to pyopericardium and pyothorax. Outcome Inspite of appropriate antibiotics and surgical drainage, child died of sepsis. Message Impacted esophageal BB should be removed as an emergency procedure. Any delay might lead to poor outcome. Keywords Button Battery, Esophagus, Perforation 337 Safety and efficacy of endoscopic retrograde cholangio

Vineet Ahuja Correspondence-Vineet Ahuja-vineet.aiims@gmail.com Departments of Gastroenterology, Gastrointestinal Surgery, and Radiodiagnosis

Sarcopenia was defined as SMI <36.5 cm2/m2 and 30.2 cm2/m2 for males and females respectively. Disease severity, behavior, and long-term outcomes (surgery and disease course) were compared with respect to sarcopenia and VF/SC ratio. Results Forty-four patients (age at onset:34.4±14.1 years, median disease duration:48 [24-95] months, follow-up duration:32 [12-53.5] months, males:63.6%) were included. Prevalence of sarcopenia was 43%, more in females, but independent of age, disease severity, behavior and location. More patients with sarcopenia underwent surgery (31.6% vs. 4%, p=0.01). VF/SC ratio was also significantly higher in patients who underwent surgery (1.76+1.31 vs. 0.9+0.41, p=0.002), and a cut-off of 0.88 could predict surgery with sensitivity and specificity of 71% and 65% respectively. On survival analysis, probability of remaining free of surgery was lower in patients with sarcopenia

Refeeding syndrome in a child with celiac disease: A rare entity

Lucknow 226 003, India Background Refeeding syndrome is a rare and life-threatening pathology ascribed in those celiac patients who deteriorated clinically after initiation of a gluten-free diet (GFD) and had biochemical parameters such as hypophosphatemia, hypokalemia, hypocalcemia, and hypoalbuminemia. Case characteristics Four-year-old girl presented with complaint of constipation, abdominal distension, vomiting, failure to thrive and anorexia. The child was emaciated and weighed 10.3 kg. Had pallor, distended abdomen but no organomegaly. Upper GI endoscopy was done showing D2 bald mucosa with scalloping. Duodenal biopsy had Marsh Gr 3c features. She was diagnosed as celaic disease and was discharged on GFD with weight gain of 500 g. However, she was readmitted after 12 days with complaint of poor oral intake, diarrhea and pain abdomen. She had severe dehydration with severe anemia and CHF. On investigation hypophosphatemia, hypokalemia, hypocalcemiaemia and hypoalbuminemia was present suggestive of refeeding syndrome. Patient was managed in the PICU with IV antibiotics, albumin and PRBC transfusion along with correction of all metabolic abnormalities as per protocol. Gradually, her enteral feeding was resumed and was discharged on 12 days

Message Refeeding syndrome in children with celaic disease is a rare but known entity. It can result in prolonged hospital stay and even death if not recognized and treated promptly. Prevention is the key to avoid metabolic

Celiac disease

Results Of the 344 patients studied 263 (76.5%) were males and 81 (23.5%) were females. 82% of patients who underwent nasogastric tube (NGT) insertion and 62.9% of dilatation were males. Feeding procedures done were (NGT) insertion (66.3%), esophageal dilatation (25.9%), esophageal self-expanding metal stent (SEMS) (0.6%) and percutaneous endoscopic gastrostomy (PEG) (0.3%). 7% of patients underwent both dilatation and NGT insertion. Most of the patients had grade 3 dysphagia (61.9%). The median age of feeding procedures was 55 years (NGT-58 years; dilatation-52 years). The most common indications for NGT insertion were carcinoma of oropharynx (46.9%), hypopharynx (29.4%) and esophagus (10.1%). The most common indications for esophageal dilatation were carcinoma of esophagus (34.8%) and hypopharynx (21.3%). Two patients with carcinoma esophagus underwent SEMS. PEG was done for a case of neurogenic dysphagia. Carcinoma esophagus affected upper third in 49.6% and middle third in 37.4% cases. Squamous cell carcinoma (96.9%) was the most common histological variant among malignancies. Corrosive injuries requiring feeding procedures were mainly of Grade 2B (60%) severity. Conclusion In this study the most common feeding procedure was NGT insertion. Oropharyngeal cancer and esophageal cancer were the most common indications for NGT insertion and dilatation respectively. Squamous cell carcinoma was the most common histological variant in malignancies. Among corrosive injuries, acid poisoning and grade 2B injuries were more common

Barjesh Chander Sharma Correspondence-Arpan Jain-drjain.arpan@gmail.com Department of Gastroenterology, Gobind Ballabh Pant Institute of

751 019, India Laboratory investigations showed pancytopenia, hyperbilirubinemia, mild transaminitis and elevated alkaline phosphatase. CECT abdomen revealed bulky pancreas and CBD dilatation

Clinical profile of patients included jaundice (100%), abdominal pain (68%), loss of appetite (50%) and weight (40%), fever (27%), abdominal mass (29%), pruritus (20%), vomiting (14%). 64% of patients of gallbladder cancer had a history of cholelithiasis. Cholangitis was present in 32% gallbladder cancer, 25% in cholangiocarcinoma, 30% in ampullary carcinoma, 7.7% in carcinoma head of the pancreas. Imaging was suggestive of type 1 block in 100% patients with ampullary carcinoma and carcinoma head of the pancreas

Endoscopic ultrasound for characterization of distal common bile duct block-Is it better than MRCP?

India Background Endoscopic ultrasound (EUS) is a novel technology which is being increasingly utilised to visualize the gastrointestinal tract as well as nearby structures mainly liver, gallbladder, pancreas, biliary tract and lymph nodes. EUS guided FNAC or biopsy helps to obtain tissue diagnosis. Role of EUS has now increased from diagnostic tool to therapeutic tool

Both EUS and MRCP were done in these patients. In case of mass lesions, EUS guided FNAC was done either from mass lesion or from metastatic lymph nodes, whichever feasible. Results The most common pathology was choledocholithiasis (n=110), followed by pancreatic malignancy (n=57), gallbladder (GB) malignancy with common bile duct (CBD) involvement (n=45), distal CBD cholangiocarcinoma (n=17), ampullary malignancy (n=16), hilar cholangiocarcinoma (n=5) and choledochol cyst (n=5)

Conclusions EUS has very high sensitivity and specificity for the characterization of distal CBD lesions in patients presented with SOJ as compare to MRCP. It also has an additional advantage of obtaining tissue for diagnosis as compare to other diagnostic modalities

Laparoscopic single-stage management of cholecystogastric fistula-A rare case report and review of literature

After thorough investigation, patient was taken up for laparoscopic cholecystectomy for chronic calculous chlecystitis. Intraoperatively, incidentally along with lot of adhesions to the gallbladder there was a cholecystogastric fistula which was managed by laparoscopic singlestage approach entirely. We here by present this case, highlighting the rarity of its incidence, the clinical findings and complications associated, diagnostic imaging and, the surgical approaches and its technical challenges in managing

Chezhian Annasamy Correspondence-Shubha Immaneni-gastroshubha@gmail.com Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, India Introduction Among patients with gallbladder cancer (GBC), 80% have gallstones (GS), most of whom are asymptomatic. Gallbladder (GB) stasis in patients with GS promotes development of preneoplastic lesions. The prevalence of GB stasis in patients with asymptomatic gallstones (AGS) is not known

Gallbladder stasis (GBS) was defined as GBEF <40%. Chi-square and Mann-Whitney U tests were used for comparison and p< 0.05 was taken as significant. Results The mean age and gender profile were similar in the SGS (n=50) and AGS (n=37) groups. Dyspepsia symptom score and biliary symptom scores were significantly higher

001) respectively. GBEF at 30 minutes showed a significant negative correlation with dyspepsia score (-0.230, p=0.03) and biliary symptom score (-0.216, p=0.04). All the patients with SGS had history of definite biliary colic with median biliary symptom score of

Median GBEF at 30 minutes and 60 minutes were significantly higher in patients with AGS

S1-S127 Result Total 346 patients, male 239 (69.1%), female 107 (30.9%), age varying from 17 to 83 years (mean 38.27) were enrolled. Common symptoms were bloating (fullness) of abdomen (194, 56.1%), abdominal pain (164, 47.41%), belching or eructation (149, 43.1%), heart burn (137, 39.6%), anorexia (124, 35.8%), nausea (120, 34.7%), noisy bowel (88, 25.4%), chest pain (79, 22.8%), headache (56, 16.2%), whole body pain (58, 16.8%), incomplete bowel evacuation (185, 53.5%), excess flatus (76, 22.4%), movement of gas to different part of body including head 87 (25.1%) and expulsion of hot air from ear, nose and head in 69 (19.9%) patients. Among them 107 (30.9%) patients believed abdominal gas to be a curable disease with treatment and 222 (64.2%) believed it to be a relapsing disease even after treatment. And 307 (88.7%) patients were taking proton pump inhibitor (PPI) as its remedy regularly. Conclusion Most of the symptoms of patients can be explained by abdominal gas. Again, some patients have a misperception regarding some symptoms like heart burn, noisy bowel and sense of incomplete bowel evacuations are also related with abdominal gas

Assessing prevalence of microsatellite instability and Lynch syndrome amongst colorectal cancer patients in

India, 3 FRIGE's Institute of Human Genetics

Of these, 17 patients (85%) were negative for BRAF V600E mutation. Germline testing in these patients have shown known and novel mutations in the MLH1 and PMS2 genes. More than 90% of LS patients had a mutation in MLH1 gene with highest occurrence of c.156delA mutation. Ad hoc analysis of the prospective study cohort suggests higher prevalence of MSI and LS in CRC patient population in India. Analysis of Introduction Gastrointestinal stromal tumors (GIST) comprise 1% to 3% of all malignant gastrointestinal (GI) tumors. GIST is the most common mesenchymal tumor of the GI tract. GISTs are extremely heterogeneous from a clinical perspective. We aim to explore the clinical and pathological profile of all newly diagnosed GIST including clinical presentation, morphology (gross and microscopic), location of tumors, risk stratification and management among patients

The median age was 56.2 years with a malefemale ratio of 2:1 (14 males and 6 females). The mean age for men was 58.3 and for women 51.2. Four (20%) patients had metastatic disease and unresectable or incompletely resected disease. The most common primary site was small intestine in 10 (50%) patients which were followed by the stomach in 5 (20%) patients. The most common site of metastases was liver in 2 (50%) patients. Median tumor size was 6.2cm (range 5cm -20 cm). Nine (45%) patients had mitotic counts of >5/50 HPF. Spindle cell type was the predominant histological type 80% and CD117 was found to be positive in 14 patients (70%)

Conclusion In our study of GISTs, the commonest site of the tumor was detected to be small intestine followed by stomach, the majority were of the high-risk malignant category and of pure spindle cell morphology

Objective To study the quantitative analysis of various sarcopenic parameters in Indian population. Methodology This cross-sectional study was conducted at a super speciality hospital in New Delhi among 2002 normal Indian individuals over a period of one year. Normative values for all abdominal muscles and individually for psoas and erector spinae muscles were measured using the latest software, Tomovision Slice0matic version5.0 with Alberta protocol. Standardized psoas muscle thickness (PMTH), psoas muscle index (PMI), erector spinae muscle index (ESMI), total skeletal muscle index (SMI) and skeletal muscle radiation attenuation (SMRA) were computed. Their mutual relationships and correlations between either sex were determined statistically by applying Pearson's and student's t test. Results A total of 2002 individuals, including 1308 males and 694 females, underwent CT evaluation

PMI (cm2/m2) was 6

±1.40 in males vs 5.57±1.18 in females

SMI (cm2/m2) was estimated to be 51.00±5.70 in males vs. 43.93±6.05 in females (p=0.0001) and SMRA was 55.80±3.91 HU in males vs 52.36±3.67 HU in females (p=0.0001). Cut off values for PMTH, PMI, ESMI, SMI and SMRA for sarcopenia at L3 vertebral level were observed to be 10.53 mm/m, 3.89 cm2/m2, 11.40 cm2/m2, 39.59 cm2/m2 and 47.98 HU among males and 7.69, 3.20, 9.42, 31.83 and 45.01 among females. Conclusion Normative values of sarcopenic parameters for either sex among

Incidental retroperitoneal ancient neurilemmoma-A rare variety of neurilemmoma Mukesh Pancholi, Devendra Chaudhri, Divya Sinhar Correspondence-Mukesh Pancholi-dr_mpancholi@yahoo.co

Gastrointestinal and hepatic involvement in patients with COVID-19 infection at a tertiary care centre in Northern India: An observational prospective study

Rohit Gupta Correspondence-Rohit Gupta-docgupta1976@gmail.com Department of Gastroenterology, All India Institute of Medical Science, Virbhadra Road, Shivaji Nagar, Sturida Colony

All patients were confirmed by real-time PCR and were analyzed for clinical characteristics, laboratory data, and treatment. The patients were followed throughout their hospital stay and their outcomes noted. Results In the present study, 180 patients including 117 patients with COVID-19 and full clinical and laboratory data were analyzed. The average age was 43.4 years (SD±14.9), including 121 men and 59 women

Hepatic 393 A study on pain and palliative management in advanced gastrointestinal tract malignancy endoscopy suite, there is high risk of infection during endoscopic procedures. Adequate protection of HCP is utmost important. Methods Retrospective study who underwent endoscopic procedures during COVID-19 pandemic. Patients were pre-screened and risk was categorized into urgent (GI bleed, urgent feeds, biliary sepsis) and semiurgent (GI cancers, ERCP for hepatobiliary pancreatic cancers, EUS for diagnosis of malignant conditions) for endoscopic procedures according to APSDE guidelines. Prior to procedure hemogram, chest X-ray, CRP done to all patients. HCW's used modified PPE (cap, mask, shield, gown, gloves). Anesthesia preference-TIVA (midaz, fentanyl, propofol), GA with intubation. Gap between each procedure 20-30 mins. Divided our clinical force into two teams and followed the rotation policy on weekly basis

4%), EVL-35 (15%) 6 (1.2%) died during hospitalization following terminal illness. Follow-up of patients according to different procedures 2 weeks -1 month did not develop Covid-19 symptoms and were not detected positive. Conclusions Proper precautions there was no event of cross COVID-19 viral transmission between healthcare workers and patients. Judicious use of basic tests we followed will help in resource constraints settings like peripheral hospitals and nursing homes

Introduction and Aim Endoscopic retrograde cholangiopancreatography (ERCP) is universally established modality in evaluation and treatment of suspected biliary and pancreatic diseases. The aim of this study is to evaluate our experience in ERCP and to study the etiology, indications and findings of ERCP and complications of the procedure. Methods This is a retrospective study carried out in the Department of Medical Gastroenterology at Govt. Stanely Medical College, Chennai. All the patients who underwent ERCP from January 2020 till August 2020 were included in the study. Etiology, indications, findings of ERCP and procedure related complications were assessed in these patients. Result Records of 73 consecutive patients who underwent ERCP were analyzed, out of which 46 (63%) were males and 27 (37%) were females. Most common indications were choledocholithiasis (61.6%), biliary stricture (13.6%) and periampullary growth (9.5%). Other less common etiologies were portal biliopathy (4.1%), head of pancreas mass (2.7%), cholangiocarcinoma (2.7%), pancreatic duct stricture (1.3%), duodenal growth (1.3%) and traumatic bile duct injury (1.3%). In choledocholithiasis, single stone was found in 22 (48.8%), multiple stones were found in 10 (22.2%) and sludge was seen in 13 (28.8%) patients. Black pigment stones were seen in 78% and yellow cholesterol stones seen in 22%. Periampullary diverticulum was noted in 6 (8.2%). Sphincterotomy was performed in 44 (60.2%) patients. Biliary cannulation failed in

Introduction The two commonly used risk scoring systems to categorize patients with upper gastrointestinal bleed (UGIB) into high-risk and lowrisk subgroups include the Complete Rockall scoring (CRS) system and the Glasgow-Blatchford scoring (GBS) system. The present study aimed to compare CRS and GBS systems for predicting clinical outcomes of patients of UGIB. Methods Two hundred patients with the age >18 years who presented with UGIB in the emergency department of SVPIMSR, were enrolled in the study. Patients with past history of variceal bleeding and those who received any treatment before admission were excluded. Diagnostic endoscopy was performed for all assigned patients. Relevant clinical and laboratory parameters were also recorded. In addition, the cases were followed for any episode of rebleeding and 1-month mortality. The outcomes of UGIB were categorized as need for endoscopic intervention and ICU admission, 1-month mortality, rebleeding episode. CRS and GBS systems were calculated for each patient. A receiver operating characteristic (ROC) curve by using areas under the curve (AUC) was used for statistical comparison. P-value less than 0.05 was considered statistically significant. Results GBS was better than CRS system to predict need of endoscopic intervention (AUC: 0.927 v/s 0.822; p value <0.0001). However CRS system was better than GBS to predict outcome (treated or death) (AUC: 0.997 vs. 0.768; p value <0.0001. There was no statistically significant difference between GBS and CRS systems to predict need of ICU admission (AUC: 0.845 vs. 0.851; p value= 0.8354) and rebleeding at 1 month (AUC: 0.749 vs. 0.728; p value= 0.6063). Conclusion We found that Glasgow-Blatchford Score is better to predict need of endoscopic intervention, while the Complete Rockall Score is better for 1-month mortality prediction. There was no statistically significant difference between both scoring systems to predict need of ICU admission and rebleeding at 1 month.Conclusions Pediatric gastrointestinal endoscopy is a high-end, informative, diagnostic and therapeutic procedure in infants done in very few centre across India. Endoscopy helped in comprehensive evaluation and in depth management of various GI disorders in infants.

Endoscopic removal of giant rectal polyp in a child-A case report Gunjan Makkar, Shrish Bhatnagar, Geetika Srivastava Correspondence-Shrish Bhatnagar-drshrishbhatnagar@gmail.com Department of Pediatrics, Era Lucknow Medical College and Hospital (ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India Solitary pedunculated Juvenile rectal polyps (JP) are a recognized cause of painless rectal bleeding in preschool age children however Giant juvenile polyps (greater than 30 mm) are exceedingly rare in children.A 10-year-old boy with prior history of something coming out of rectum for one year presented with sudden onset of massive painless hematochezia. On evaluation a giant rectal polyp measuring 3 x 3 x 2 cm was found and removed endoscopically. Histological evaluation revealed juvenile adenomatous polyp. To best of our knowledge only few case reports are available where a giant rectal polyp has been removed endoscopically in pediatric age group. Keywords Polyp, Giant, Endoscopy

Endoscopic radial incisional stricturotomy using flushknife followed by balloon dilatation of a benign esophageal anastomotic stricture: A case report John Christopher Onilla, James Crisfil Fructuoso Montesa Correspondence-John Christopher Onilla-onillajc@gmail.com Department of Internal Medicine -Section of Gastroenterology and Digestive Endoscopy, Manila Doctors Hospital, PhilippinesIntroduction Esophageal strictures develop from various etiologies; peptic strictures from gastroesophageal reflux disease (GERD), caustic ingestion, anastomotic stricture from previous surgery. Benign esophageal strictures are usually managed with dilation using Savary-Gilliard or balloon dilatation. There are a small group of patients with refractory or recurrent stenosis for which alternative treatment modalities may be required. There are only a few reports of the use of needle knife for incisional therapy to manage esophageal anastomotic stricture. Methods Presentation: This is a case report of a 45-year-old male, known to have recurrent esophageal anastomotic stricture after colon interposition, managed with repeated mechanical dilation who had progressive dysphagia 4 weeks from the previous dilatation. Results The patient underwent radial incision stricturotomy using Flushknife (Fujifilm) followed by CRE balloon dilatation with no complications. He was discharged stable with no recurrence of symptoms on follow-up after 2 months. Conclusion Endoscopic incisional stricturotomy using Flushknife followed by CRE balloon dilatation is a safe and effective modality for the treatment of anastomotic stricture provided it is done in a tertiary hospital by an experienced therapeutic endoscopist. Keywords Case report, Incisional stricturotomy, Esophageal anastomotic stricture 305 Study of gastric mucosal changes and Helicobacter pylori prevalence in patients with metabolic syndrome Introduction Helicobacter pylori (HP) has been implicated as a causative agent in many non-gastrointestinal diseases like insulin resistance, cardiovascular disorders and diabetes mellitus. Metabolic syndrome (MetS) refers to cluster of diabetes and cardiovascular factors including raised blood pressure, low HDL levels, elevated serum triglycerides (TG) levels, obesity and hyperglycemia. Lifestyle and dietary changes have been attributed to high prevalence of MetS. However, they don't justify all the MetS cases and hence study of alternative emerging risk factors is necessary. The current study was undertaken to ascertain if any relationship exists between the GI mucosal changes, HP infection and various components of metabolic syndrome. Methodology Cross-sectional, prospective study done between June 2018 to January 2020 in Maharashtra, India. Total 100 patients who came for UGIE were studied out of which 58 patients had MetS. Gross mucosal changes in the stomach were noted and biopsies were taken from the body and the antrum of the stomach and sent for histopathlogy examination for detection of HP. P value of <0.05 was taken as statistically significant. Results Out of total 58 patients with MetS 18 were males (31.03%) and 40 were females (68.97%). Average age was 49.81 ± 11.10 years. HP infection was found in 31 out of 58 patients with MetS which was statistically significant. Chronic superficial antral gastritis was the common finding in 39 patients (67.25%). Presence of HP infection positively correlated with higher abdominal obesity (WC), fasting blood glucose levels and Serum TG levels (p<0.05). Conclusion HP colonization of gastric mucosa may predispose patients to develop MetS. High blood sugar levels, abdominal obesity and high triglyceride levels in MetS were associated with HP infection. Thus, eradication of HP infection may reduce prevalence of metabolic syndrome and in turn the prevalence of cardiovascular disorders in the patients. Keywords Helicobacter pylori, Metabolic syndrome, Upper gastrointestinal endoscopy

Comparison of risk scores for predicting mortality in patients presenting with acute upper gastrointestinal bleed Aim Endoscopic glue injection is recommended as first-line treatment for bleeding gastric varices (GV). However, there is limited data with this method in eastern India. Our aim was to analyze efficacy and safety of endoscopic glue injection for treatment of gastric variceal bleeding. Methods We prospectively studied 463 portal hypertension patients from December 2017 to December 2019 at Gastroenterology Department, SCB Medical College, Cuttack. Bleeding GV underwent injection of one to three mL of glue in one sitting and repeat injections were administered after two to three weeks whenever required. Patients were evaluated in terms of primary hemostasis, recurrent bleeding, complications and in-hospital mortality. Results Thirty-five bleeding GV patients underwent glue injection. Male: female, 19:16 (54%:46%). Causes of varices-cirrhosis 18 (51%), EHPVO 15 (43%), noncirrhotic portal hypertension 1 (3%), Budd-Chiari syndrome 1 (3%). Out of 35 patients, 22 had GOV2, 12 had IGV1 and one had IGV2. Twenty-three patients had large varices and 12 had medium sized varices. Initial hemostasis was achieved in 33 (94%) patients. During follow-up, bleeding recurred in 6 (17%) patients. Median time to rebleed was 60 days (15-180 days). Five patients underwent repeat glue therapy for rebleeding and all five patients had achieved homeostasis after injection glue. One patient was referred for shunt surgery. The average volume of glue injected per session was 2 (0.2) mL per patient. The average amount of glue needed per patient was 2.5±1 mL. For 10 patients, repeated sessions of glue injections were given to achieve gastric variceal obliteration. Three patients had mild abdominal pain and one patient had mild fever. There was no distant embolization and channel block or damage to lens of the endoscopes noted during these procedures. Introduction There is sparse data from India about indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population. Methods Retrospective analysis of the prospectively maintained endoscopic database was performed to identify paediatric patients (age </=18 years) from January 2017 to September 2020 who underwent ERCP at Gastroenterology Department of Seth GSMC and KEM hospital. Demographics and details about the procedure including indication, type of sedation, cholangiopancreatogram findings, type of endotherapy done, technical and functional success as well as complications were noted. All procedures were done using standard duodenoscopy (Olympus TJF-Q180V) by experienced operators (experience of more than 300 ERCP procedures with selective cannulation rate of more than 95%). Results Seventy-two procedures were done in 56 patients during the study period (Mean age 13 years; range:3-17 years; 60% male). ERCP for biliary and pancreatic diseases was performed in 20 (35.7%) and 36 (64.2%) cases respectively. ERCPs were done for choledocholithiasis 11 (55%), bile duct injuries/leaks 4 (20%), biliary strictures 3 (15%), choledochal cyst 2 (10%), and chronic pancreatitis 22 (61.1%), pancreatic duct injuries/leaks 6(16.6%), pancreas divisum 4 (11.1%), recurrent acute pancreatitis 3 (8.3%), anomalous pancreatobiliary union 1 (2.7%) amongst biliary and pancreatic indications respectively. General anesthesia, total intravenous anesthesia and endoscopist directed sedation was given in 26 (36.2%), 41 (56.9%) and 5 (6.9%) procedures respectively. No sedation related adverse events were noted. Cannulation was successful in 35 (83.3%) pancreatic and 25 (86.2%) biliary procedures respectively. In 10 (13.8%) procedures, pre-cut sphincterotomy was done for cannulation. Technical success in 63 (87.5%) and functional success in 62 (86.1%) procedures. Reasons for failure include failed cannulation 6 (8.3%) and failed guidewire passage across stricture 4 (5.5%). There was no correlation between technical failure and age, sex or type of ERCP. Complications include mild post ERCP pancreatitis and bleeding in 3 (4.1%) and 1 (1.3)% cases respectively. Conclusion ERCP is safe and effective for evaluation and management of various biliary and pancreatic diseases in children.Keywords ERCP, Pediatric patients Background SARS-CoV-2, global pandemic, causes aerosol borne viral illness . GI endoscopy, an aerosol generating procedure, carries high-risk for transmission. Despite several guidelines, protecting healthcare workers (HCW) and patients from cross transmission remains a challenge. This study elaborates measures implemented at a highvolume tertiary center to reduce transmission risk and also discusses outcomes. Methods Since pandemic began, department functioning was as per modified APSDE guidelines. Elective endoscopy procedures stopped, only emergency and semi-emergent procedures scheduled. Important differences from guidelines-routine COVID testing not employed, triage protocol-history of symptoms/exposure, blood count including differential count, CRP, chest X-ray within 48 hours of scheduled procedure. All HCWs used modified-PPE (cap, mask, face shield, surgical gown, gloves). All procedures performed under propofol/GA with endotracheal intubation. Departmental staff divided into two working groups by weekly rotation to avoid simultaneous exposure of all. Air-conditioning settings modified to reduce positive pressure and improve ventilation. Minimum 30-min-interval between procedures. Social distancing norms enforced in patient waiting/recovery areas. Results During 3-month period , 467 patients (70.9% male, mean age 57 years) underwent 507 endoscopic procedures vs. 2110 procedures in preceding 3-months (22.9% of regular workload). One hundred and ninety (40.7%) patients had associated comorbidities. Indications for endoscopy-GI bleed-121 (25.9%), severe abdominal pain-89 (19%), suspected cancer-128 (27.4%), obstructive jaundice and cholangitis-67 (14.3%), others-253 (54.1%). Two hundred and seventy-four (54%) diagnostic, 233 (46%) therapeutic procedures. Therapeutic-ERCP-85 (36.5%), EUS-7 (3%), feeding access including esophageal/enteral stent-9 (3.8%), treatment for GI bleed-35 (15%). Six (1.2%) patients died during hospitalization due to non-COVID causes. Follow-up as per protocol-no occurrence of COVID symptoms in any patients at 2 weeks post procedure, none detected positive. No HCWs developed COVID symptoms or tested positive during 3-month period. Conclusions This audit demonstrates low incidence of cross transmission of SARS-COV-2 between patients and HCWs by using measures listed above. At reduced workload of 25% of normal, department could serve patients in need of emergency/semi-emergency endoscopic intervention.

Motility Disorders 320 Evaluation of esophageal motor function in patients with gastroesophageal reflux using multiple rapid swallows Mayank Jain, Vinodini Agrawal Correspondence-Mayank Jain-mayank4670@rediffmail.com Department of Gastroenterology, Arihant Hospital and Research Centre, 283-a, Gumasta Nagar, Scheme 71, Indore 452 009, IndiaBackground Multiple rapid swallow (MRS) is a complementary test performed during high resolution esophageal manometry. Aims To assess the MRS findings in patients with gastroesophageal reflux disease (GERD) who have normal peristalsis and minor motility disorders.Methods This is a retrospective analysis from a prospectively maintained database of patients referred for HREM study to our centre. The details recorded included age, sex, symptoms with duration and upper gastrointestinal endoscopy reports. HREM data included basal inspiratory and expiratory pressures, median integrated relaxation pressure and peristaltic pattern. Three MRS sequences were recorded per patient. The inhibition and contraction phases were interpreted for each MRS sequence. Results A total of 68 patients (38-normal motility, 30 minor motility disorders) formed the study cohort. Hiatus hernia was commoner in GERD patients with minor motility disorders (p 0.02). Patients with minor motility disorders were more likely to have poor peristaltic reserve than patients with normal peristalsis (p<0.05). MRS patterns in inhibition and contraction phases are similar in three MRS sequences for patients with normal peristalsis, while in patients with minor peristaltic disorders, the inhibition phase is significantly discordant on repetitive MRS swallows. (p 0.049). Conclusion In GERD patients, those with normal peristalsis are more likely to have normal MRS pattern. On the contrary, those with minor peristaltic disorders have a higher incidence of poor peristaltic reserve and show significant discordance in the inhibition phase of MRS.

Bowel habit pattern of patients with self-reported constipation at out patient department in north east part of Bangladesh Aim This study was designed to see the symptoms and bowel habit pattern of patients presenting with self reporting constipation at Out Patient Department in a tertiary care hospital. Method This study was conducted in out patient Department of gastroenterology department in North East Medical College Hospital during January 2017 to December 2018. Total 228 consecutive patients with self reported constipation were enrolled in this study. Patients with history of abdominal surgery, known chronic disease, age below 18 years, pregnant women, patients using drugs like anti-depressant, anti-psychotic and patients unwilling to take part in the study were excluded. Demographic data, symptoms, bowel habit pattern and character of stool were recorded at in a pre-designed data sheet. Result Total 228 patients, male 130 (57%), female 98 (43%), age varying from 18 to 81 years (mean 38.7±15.10) were included. Among them 127 patients (55.7%) had daily bowel motion with frequency one to seven and 101 patients (44.3%) had infrequent stools. Sixteen patients (7.0%), 182 patients (79.8%) and 30 patients (13.2%) had feeling of complete bowel evacuation all time, days a week and almost never respectively. Among the patients 127 (55.7%), 29 (12.7%), 06 (2.6%), 02 (0.9%) and 64 (28.1%) complained of hard, soft, semi liquid, liquid and stool of variable consistency respectively. In this study 159 (63.73%), 21 (9.21%) and 43 (18.85%) patients were regularly taking proton pump inhibitor (PPI), antidiabetic drugs and anti-hypertensive drugs respectively. Conclusion Patient's perception regarding constipation does not always match the traditional medical definition. Symptoms like stool consistency, volume, and feeling of incomplete evacuation are more important to patients' perception regarding constipation.

Quality of life, prevalence of psychiatric comorbidities and extraintestinal functional disorder in patients with functional gastrointestinal diseasesThe aim of this study was to find out whether the causes of pediatric upper GI bleeding to our center and outline their presentations and treatments. Children presenting to Endoscopy unit of Medical Trust Hospital, Kochi with upper GI bleeding for a year and half from December 2018 to June 2019 were evaluated and included in the study after obtaining a informed consent from the parents. Information retrieved from patient's records and results of upper GI endoscopy regarding etiology of bleeding, managements, and the mortality rate were also analyzed. Results Age distributions of paediatric patients presented with UGI bleeding shows most common age of presentations were between 2-5 years of age, followed with 8-12 years both of which occurred in 33.34%. Males presented slightly more with UGIB. Children's presented with UGIB presented with Melena in 33.4%, hematemesis in 22.22%. Children's with accidental foreign body ingestions also present with UGI Bleeding in 11.13%. But none of them presented with major bleeding with hypotension or required blood transfusion. Most common cause of UGIB was gastric and duodenal erosion´s as par with other studies. No source was identified in 1/3rd of patients during the initial endoscopy. While one patient had a Dieulafoy's lesion picked up and managed in subsequent endoscopy. Conclusion Our findings showed that most common sources of upper GI bleeding in pediatric patients from our center was due to gastric and duodenal erosions. We conclude that the causes of upper GI bleeding in children in our center, a developing country, are not different from those in developed ones. Various regions of the world have reports indicating variation in the source, etiology, cause and approaches for pediatrics GI bleeding. Furthermore, multicenter studies considering various countries or review articles investigating the mentioned issues in GI bleeding of children is essential. Background and Study Aims Rome 4 criteria has classified pediatric functional abdominal pain (FAP) into 4 variants i.e. functional dyspepsia (FD), functional abdominal pain not otherwise specified (FAP-NOS), irritable bowel syndrome (IBS), abdominal migraine (AM). However, there is lack of information on endoscopy and histopathological findings in this subset of children. Hence our study was to evaluate the endoscopic and histopathological findings in children with FAP. Methods It was prospective observational study. 110 children (aged 4 to 17 years) with diagnosis of FAP according to Rome 4 criteria were enrolled from paediatric OPD. All children underwent gastrointestinal endoscopy and biopsy. Results Most of the children belonged to age group 6-12 yrs (52.7%). Majority of children were girls (n=62, 56.4%). Fiftyeight (52.7%) children were suffering from FD, 42 (38.2%) children suffering from FAP NOS, 9 (8.2%) had IBS and 1 child had AM. In view of small sample size the IBS and AM patient were removed from statistical analysis. Endoscopic assessment showed 28 (42.3%) children with FD had significant lesions while it was seen only in 2 (4.8%) children with FAP NOS (p<0.001. Rapid urease test for H pylori was positive in 30 (51.7%) of children with FD, while only 1 in FAP NOS (p<0.001). Histopathological assessment collaborated with endoscopic assessment in both the categories. Thirty-five children of FD had evidence of mucosal inflammation against only 4 children of FAP NOS group (p<0.001). On follow-up 96.6% children with FD improved when given treatment with PPI and H. pylori (in positive cases). Conclusion Indian children with functional dyspepsia have evidence of significant endoscopic and histopathological abnormalities including H pylori infection. Hence, we recommend that children with functional dyspepsia should be subjected to both upper GI endoscopy and H pylori evaluation while FAP-NOS usually do not require the same.

A challenging case of unusual liver mass in a teenage girl Viswanathan M S, Anand Khakkar, Satheesh Ramamurthy Correspondence-Viswanathan M S-vichums@rediffmail.com Department of Pediatric Gastroenterology, Children's Hospital, India, Apollo Hospital, Chennai, India History and Examination A 14-year-old girl presented with intermittent epigastric pain, vomiting and amenorrhea for 3 months. On examination: Growth was appropriate, anicteric, tenderness over epigastrium, and significant hepatomegaly. Otherwise normal. Evaluation Hb 11, other CBC normal. LFT -AST-52 u/L, ALT-54 u/L, GGT-95 u/L, Normal bilirubin and synthetic function. Ultrasound abdomen revealed diffuse right liver lobe mass, otherwise unremarkable. Alfa-fetoprotein: normal. MRI abdomen: diffuse right lobe hepatic mass (17.8 cm x 13.3 cm) with compression of intrahepatic IVC, suggestive of hepatic adenoma. Liver biopsy confirmed hepatic adenoma. Management In the multidisciplinary (MDT) meet options were discussed. In view of the risk of postoperative acute liver failure following a complete mass resection and technical surgical challenges it was Department of Pediatric Gastroenterology and Hepatology, Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel, Mumbai 400 012, India COVID-19 has rapidly spread all over the world. Little is known about hepatic infections associated or aggravated in pediatric age groups. Objectives To study the incidence of liver abscess in pediatric patients between January 2019 to August 2020 and the impact of COVID-19 pandemic on demographics of the same. Design A retrospective cohort study of 29 patients diagnosed as liver abscess at a tertiary care Pediatric Centre in India. The patients presented between January 2019 August 2020. The cases reported from January 2019 to February 2020 were classified as "Pre-Covid cases" and the ones there after as "Intra-Covid cases". Factors associated with liver abscesses were analyzed by Fischer's exact test and Student t test. P value <0.05 was considered significant. Results Twelve (40%) patients presented in the Intra-covid months whereas 17 (60%) in the pre-Covid period of which 2 were COVID-19 positive. Boys predominated in the pre-Covid era (59%, n=10) whereas a female preponderance was seen in the intra-Covid period (68%, n=7) (p=0.462). Table 1a and 1b depicts the factors associated with liver abscess in the pre-and intra-Covid period. Salmonella typhi was isolated in the pus culture in one patient while no other aerobic organisms could be isolated other cases. There was no mortality in our study. Conclusions Prevalence of liver abscesses was higher in the COVID-19 era. During the Covid period, the lesions were multiple and had higher volume of pus requiring pigtail insertion, as well as longer hospital stay with prolonged duration of intravenous antibiotics. Further studies are needed to determine if there is a difference in the causative organisms during the COVID period, and whether COVID-19 causes a change in the epidemiological prevalence of bacterial infections in the community. Introduction Severe spasm and pain in acute fissure-in-ano is primarily aggravated by defecation. Fissure are usually constipated and the shearing force of the hard stools aggravates the spasm. Moreover, the 'narrowed' anal outlet due to spasm further increases the impact of this shearing force.Methods Acute fissure-in-ano patients with refractory spasm were managed by DePOT (defecation is put on-hold temporarily) regimen. This not only provided immediate pain relief but would also led to earlier resolution of fissure-in-ano by removing the aggravating factor (defecation process). While implementing DePOT, the daily requirements of protein, minerals, vitamins, water, and fats were taken care of. This was done by liquid diet having zero fiber plus full nutrition (oral rehydration solution [ORS] , vitamin supplementation and protein [whey] supplementation [50-60 grams/day]). Once these nutritional needs of the patient are taken care of, then it is not difficult for the patient to sustain on the liquid diet for a week. An enema is given on the first day of the DePOT regimen to evacuate the rectum so as to avoid hardening of residual stools already present in the rectum.

DePOT was also prescribed for seven days to four patients of acute fissure-in-ano with refractory spasm in whom conservative management was not working (26-year/male, 23-year/female, 34-year/female, 29-year/male). All patients except the third patient, had immediate pain relief and the acute spasm improved progressively over next 7-10 days. The third patient had to stop DePOT after 3 days as she developed an intersphincteric abscess and was operated for the same. Conclusion The DePOT regimen puts defecation process on hold for a week by zero fiber, full nutrition, liquid diet. It is a simple, novel, economical, safe and easily reproducible concept to provide immediate relief and helps prevent surgery in acute thrombosed hemorrhoids and acute fissure with refractory spasm. Keywords Acute anal fissure, Fissure-in-ano, Defecation Introduction Bleeding hemorrhoids can be extremely troublesome in patients on anti-coagulants/anti-platelet drugs, especially in high-risk elderly patients, who are also unfit for surgery. There is no effective management available in such a scenario. Regular rectal enema as conservative treatment (REACT) is a new non-surgical life-saving concept which was tried in these patients. Methods The root causes bleeding (bursting of hemorrhoids) are increased straining, prolonged time spent during defecation and increased frequency of motions. If these root causes of hemorrhoidal rupture could be eliminated by converting the act of defecation from an active mechanism to a passive one, then it would be extremely effective in controlling the bleeding and relieving the symptoms. Regular daily enema does precisely this. It is like a rectal wash and almost completely removes the need to strain for defecation. It also decreases the time spent during defecation. It simply gives time to the torn hemorrhoids to repair themselves, thus stopping bleeding and diffusing the emergency situation. In the study, the enema was given once daily for ten days. REACT was repeated if bleeding happened again. Results REACT was tried in two patients (76 yrs/F, 82/M) who and presented with persistent bleeding for three weeks due to grade III hemorrhoids. Both were on anti-coagulants and had developed anemia (Hb-6.2, 7.3 gm/dL). Due to associated comorbid conditions (cardiac and cerebrovascular), the anti-coagulants couldn't be stopped and surgery was very high risk. Both the patients were advised REACT with sodium-phosphate rectal enema for 10 days The bleeding stopped in both patients within 3 days. Both the patients were doing well after 6 months of follow-up. Conclusions REACT is a new, simple, safe, economical, non-surgical, domiciliary and effective method to stop bleeding in hemorrhoids patients on anti-coagulants and having associated comorbidities (especially the patients whose anticoagulants cannot be stopped). Keywords Hemorrhoids, Bleedings, Anti-coagulants Introduction With the improvement and advancements in endoscopic imaging, the diagnosis of the synchronous multiple primary early cancers in esophagus and stomach is increasing, while the traditional surgery for these malignancies are radical and much more invasive leading to significant morbidity. With evolving experience, endoscopic submucosal dissection (ESD) has become the preferred treatment option of early cancer in the digestive tract. Case Summary Sixty-four-year old male, chronic smoker and alcoholic, presented with history of recurrent melena and severe anemia requiring blood transfusion. Upper gastrointestinal endoscopy revealed mid esophageal lesion (Paris 0-IIA) and gastric antral lesion (Paris 0-IIB). On endoscopic biopsy esophageal lesions was moderately differentiated squamous cell carcinoma and gastric lesion was intramucosal adenocarcinoma. On endoscopic ultrasound esophageal lesion was arising from mucosal layer with intact muscularis propria (T1a, N0) and gastric lesion was superficial without invasion of the submucosa (T1 N0). Patient underwent ESD of both lesions in single sitting with complete en-block excision of the lesion. On follow up check endoscopy at 3 months and 6 months, no evidence of recurrence lesion was observed. Introduction GISTs are rare mesenchymal tumors that can arise in any part of the GIT. Most of these tumors arise in the stomach and small intestine. It should be noted that, GISTs that originate from outside of the GIT, are defined as EGISTs and are usually arise from omentum, mesentery and retroperitoneum, adjacent, but separate from the stomach and the intestine. EGIST accounts for 10% of all GISTs. Case Study Sixty-year-old male presented with left hypochondrial pain for 1 week with fever and vomiting, no addictions. Examination showed non tender mass in left hypochondrium, not moving with respiration. Blood investigations were normal. USG abdomen showed 8*10 cm cystic lesion in epigastrium, abutting inferior margin of liver and distended gallbladder and cholelithiasis. MRI showed a 15*7.2*8 cm bilobed lobulated thick walled lesion, ? pancreatic pseudocyst in body and tail projecting anteriorly into lesser sac, wall thickness of 7 mm, with normal MPD in head and uncinate region, with cholelithiasis. With a preoperative diagnosis of pseudocyst pancreas, patient was planned for cystogastrostomy. However intraoperatively there was a large multilobulated cystic lesion, 15*15*20 cm ?arising from tail of pancreas with areas of hemorrhage inside the lesion along with solid components, extending from gastric pylorus to splenic hilum abutting stomach posterior wall to transverse mesocolon, suggestive of an extraluminal neoplasm. The patient thus underwent distal pancreatectomy along with splenectomy and cholecystectomy (in view of cholelithiasis). Histopathology report showed gastrointestinal stromal tumor, staining positive for CD 117.Conclusion We present a case of EGIST which masqueraded as pseudocyst pancreas on imaging. Other than individual case reports and small case series on EGIST, the number of cases has been limited. Further studies on the pathogenesis, behavior, and molecular biology of EGIST are needed before evidence-based diagnostic or prognostic recommendations can be made. Keywords Extra-gastrointestinal stromal tumor incidence Introduction Hospital malnutrition is malnutrition diagnosed at any time during hospital stay. Hospital malnutrition which depends on various factors is common in pediatric inpatients as their nutritional status often deteriorates during hospital stay. Acute viral hepatitis in children is a major public health problem in both developing and developed countries .Given the protein catabolism and higher energy requirement and dietary taboos associated with acute viral hepatitis, energy intake will probably be inadequate, increasing the risk of hospital malnutrition and its complications. Hence we planned this study to identify nutritional risk in hospitalized children with acute viral hepatitis and to evaluate its correlation with clinical outcome. Methods This cross-sectional study was conducted for a period of 18 months with a sample size of 70. All admitted children between 6-16 years who were clinically diagnosed as acute viral hepatitis were included. Nutritional assessment was done at admission, discharge, 2 weeks and 3 months post discharge. Nutritional assessment included W/A;H/A;W/H, and BMI. Nutritional risk screening was done by PYMS scoring system and on that basis the children were classified into high, medium and low risk patients. Outcomes were assessed in two aspects Nutrition and disease related. Results The mean age of the cases was 10.10±3.71 years with maximum age of the cases was 16 years and minimum was 5.5 years. At the time of admission and discharge, 37.1% cases were at high risk, 38.65 were at medium risk and only 24.3% at low risk. The mean length of hospital stay of high-risk cases was maximum 13.23±1.48 days and minimum 4.12±2.12 days in low risk cases (p<0.001). The mean hospital expenses of high-risk cases was maximum Rs 3589.62±395.98 (p<0.001).Conclusions Hospitalized children of acute viral hepatitis with high nutritional risk have significantly higher length of hospital stay and hospital expenses 344 Combination of sarcopenia and high visceral fat predict poor outcomes in patients with Crohn's disease Case Report A 27-year-old male patient presented as yellowish discolouration of urine for 5 days with history of clay colored stool. There was no history of fever, vomiting, weight loss, abdominal pain and distension. Patient had history of contact with tuberculosis patient. On physical examination, icterus was present but normal GI examination. In laboratory investigation, LFT showed the pattern of obstructive jaundice. USG showed CBD dilatation of 9 mm. MRCP showed cystic lesion at posterior aspect of head of pancreas with loss of fat plane appearing hyperintense on T2W and STIR images while hypointense on T1W images. Multiple small cysts seen in lesion. Size of lesion 29×24×38 mm. This lesion compressing CBD with diameter 11 mm. So patient kept for EUS which showed multiple, enlarged, discrete to ill defined, hypoechoic lymph nodes in per pancreatic and hilar region with few lymph nodes were matted and these lymph node were compressing the distal CBD causing proximal CBD dilatation of 8.7 mm with normal pancreatic duct. EUS guided biopsy was taken which showed granulomatous lymphadenitis with caseating necrosis indicated tubercular lymphadenopathy. Conclusion Isolated peripancreatic tuberculous lymphadenitis is extremely rare. It is a diagnostic challenge and for that a high index of suspicion is needed and should be considered in the context of the peripancreatic or pancreas head mass especially in a young adult.

Background Lack of clarity remains whether COVID-19 patients with predominant gastrointestinal complaints differ in basic descriptive parameters, natural course and outcome in comparison to those cases with classical presentations. So, our objective was to determine whether such difference exist between these two group of patients. Methods Consecutive patients admitted in Medical College, Kolkata inbetween May 2020 to July 2020 were enrolled. The classification into the subsets was based on predominant subjective complaints of the patients in the 1st 5 days of illness. The parameters assessed were age, gender, presence of comorbidity, symptomatology duration, need of ICU care and case fatality rate. Results Of the 678 patients enrolled, 23 (3.4%) subjects complained of predominant gastrointestinal symptomatology. The mean ± SD of age of presentation in years (46.9 ± 10.4 vs 53.7 ± 13, p=0.01) and duration of symptoms in days (7.9 ± 5.3 vs. 10.8±4.7, p=0.004) were significantly less in patients with gastrointestinal symptoms. The sex ratio and presence of comorbidity did not differ statistically (p 0.93 and 0.5 respectively). Though ICU care (5.9% vs. 1.3%) and death rate (2.4% vs. 0.4%) were proportionally higher in patients with classical symptoms, they were not found to be significant (p>0.05). Conclusion Our study failed to show any significant difference of outcome between COVID-19 patients with classical and gastrointestinal symptoms, though there was some dissimilarity in demographic and clinical parameters. Further studies in this regard with special emphasis on background viral genomic aspects need to be done to find out the basis of any difference, if any which in turn will assist to modify guidelines in clinical settings for such subset of cases. Introduction TB can involve any part of the gastrointestinal system. It is the sixth most common type of extrapulmonary tuberculosis. Our country has the highest burden in the whole world. We are reporting a case of a young male who had rare presentation of abdominal tuberculosis. Case report A 17-year-old male presented with pain in the right lower quadrant of abdomen, loss of appetite and weight loss since 2 months and dysuria since 2 weeks. He had no history of cough, fever, or bowel disturbance. He was averagely built and moderately nourished. On general physical examination, no abnormality was detected, and abdominal examination revealed mild tenderness in the right iliac fossa. His routine hematological parameters showed high CRP and ESR with normocytic normochromic anemia. CECT abdomen showed long segment circumferential thickening of the terminal and distal ileum with ill defined retroperitoneal mass in right pelvic wall in close proximity to the ileocecal mesentry, right psoas and terminal ilem. And this mass was involving right distal ureter resulting in moderate hydronephrosis. Colonoscopy showed multiple ulcers in the terminal ileum with surrounding edematous and friable mucosa with luminal narrowing. Biopsy was done from the terminal ileum. FNAC was done from mass adjacent to the thickened small bowel. Both biopsy and FNAC showed numerous epitheloid granulomas and multinucleated giant cells with histiocytes. Further, AKT was started and his symptoms improved. Review USG KUB was done after 1 month, it showed resolution of hyderonephrosis. The patient is now on ATT and doing well. Conclusion Tuberculosis can rarely present as retroperitoneal mass with hydronephrosis. Early suspicion and diagnosis can help in initiating the treatment early. Background Gastrointestinal is the commonest site for neuroendocrine tumors (NET). appendix, ileum, rectum are considered to be common sites. Majority of tumors have an indolent course. Some of them are diagnosed incidentally and few have disseminated disease and also present as metastatic disease. Methods We retrospectively analyzed the data in Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore over a period of 10 years from Jan 2010 to July 2020. Gastroenteropancreatic NETs were included in the study. Clinical details, site of tumor, metastasis at the time of diagnosis were reviewed. Results Our analysis showed a male predominance with ratio of 3:1 with a mean age of 51.6667±5.56 Of the 12 tumors, the commonest site was found to be duodenum 4 (33.3%), followed by pancreas 3 (25%) and stomach 2 (16.6%), appendix, sigmoid colon, ileum were 1 (8.33%) each. The disease was localized in 4 patients (33.3%) and with metastasis 8 (66.6%). Most of gastric and duodenal NETs were localized where as pancreatic NETs have metastasis at presentation. Conclusion This analysis showed gastrointestinal pancreatic NET are not rare and incidence of these tumors is increased over the past decade due to availability of higher imaging and increased rate of biopsy.

Clinical, endoscopic and histological characteristics of gastrointestinal graft versus host disease and its outcome after allogenic hematopoietic stem cell transplantation two and diarrhea in five recipients. A total of 11 endoscopic procedures were performed: gastroscopy in two, sigmoidoscopy in three and both upper and lower gastrointestinal endoscopy in three patients. The endoscopic findings included mucosal edema, erythema, erosions, ulcerations, and bleeding. The Freiburg endoscopic severity was grade 4 in two, grade 3 in one, grade 2 in two and grade 1 in six. Histopathology showed apoptosis of crypt epithelial cells and dropout of crypts in four patients. All patients received step-up treatment using steroids, cyclosporine-A, mycophenolate-mofetil, ruxolitinib and etanercept. Mortality was observed in four recipients (50%). Conclusion Gastrointestinal GVHD was observed in about half of our allogenic HSCT recipients and had a dismal prognosis.

To study clinicopathological profile of gastrointestinal tuberculosis and assess treatment response and outcome Abdominal TB is one of the most common forms of Extrapulmonary TB. Early diagnosis and initiation of antituberculous therapy is essential to prevent morbidity and mortality. Aims To study clinicopathological profile of gastrointestinal tuberculosis and assess treatment response and outcome. Methods This was a hospital based prospective study in Department of Gastroenterology in a tertiary care referral center from January 2019 to June 2020. The study variables included socio-demographic characteristics (i.e. age and sex), clinical presentation, HIV coinfection, radiological findings, endoscopic findings, Mantoux, ESR, GeneXpert and response rate to antitubercular drugs. Patients were followed at monthly interval in the intensive phase and then two monthly till the completion of treatment.Results Out of total 96 cases, 44 (45.83%) were males and 52 (55.17%). Maximum incidence of GITB was seen in 21-30 years age group. Abdominal pain (96.72%) was the most common presenting symptom. Luminal involvement was seen in 43.05% of patients out of which ileocecal junction (82.5%) was the most common site involved. Ascites was seen in 41.66% patients. A positive gene xpert was reported in 7.5% cases out of total 96 GITB cases. 4.1% patients develop complications in form of decompensation of cirrhosis and 6.2% in form of hepatitis. Conclusion Nonspecific features of the abdominal tuberculosis result in difficulty in establishing diagnosis. A high index of suspicion is therefore necessary for early diagnosis of abdominal. Neither clinical features nor laboratory findings are conclusive of GITB, histopathological findings by themselves provide a gold standard in the diagnosis.

Reduction in incidence of corrosive poisoning during this COVID-19 pandemic Viswanath Donapati, Ravi Shankar Bagepally, Guduru R Srinivas Rao, Rami Reddy Y, Bharani Correspondence-Viswanath Donapati-viswanathdr@yahoo.com Department of Gastroenterology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, IndiaIntroduction COVID-19 pandemic is troubling the entire world in most aspects. One good aspect which we noted was an overall reduction in poisoning cases particularly corrosive ingestion. Methods We did a retrospective analysis of the number of poisoning cases hospitalized at our tertiary care centre from March 2019 till August 2020 with particular reference to corrosive ingestion who underwent endoscopy. The age group of patients included was above 12 years. We looked at differences in the incidence of corrosive ingestion before the lockdown (March 2019-February 2020) and after the lockdown (March 2020-August 2020). Results We had 160 cases of poisoning admitted during March 2019 till February 2020 and of them 35 were corrosive ingestion cases (21.8%). Fifteen of the 35 were males (42.8%). Five patients of the 35 cases died (14.3%) due to complications related to corrosive ingestion like renal failure, sepsis and multiorgan failure. Seven of them (20%) required feeding jejunostomy. There were 68 cases of poisoning of which 11 were corrosive cases (16%) from March till August 31. 8 of the 11 cases were females (72.7%). Two of the 11 patients died (18.1%) due to complications. Three of them (27.2%) required feeding jejunostomy. There was considerable reduction of the overall incidence of poisoning and particularly corrosive ingestion. Our hypothesis was that during lockdown period, there was more family bonding and more emotional stability. Conclusion There was an overall reduction in number of poisoning cases particularly corrosive ingestion during this COVID-19 pandemic. Introduction Falciform ligament, is a broad and thin fold of peritoneum that divides the liver into left medial and right lateral lobe. It attaches liver to diaphragm and anterior abdominal wall. Primary or isolated falciform ligament necrosis is rare entity and often confused with gall bladder diseases due to its presenting symptoms. Case A 46-year-old male presented to our hospital with symptoms of pain upper abdomen which was continuous and dull aching type since 2 months. No history of nausea, vomiting, fever, obstipation or loose motion. Per abdomen-mild epigastric tenderness. Per rectal examinationnormal.Investigations CBC, RFT, LFT, S. amylase, viral markers, Erect AXR, CXR were normal USG abdomen suggestive of acalculous cholecystitis. UGI endoscopy-normal. CECT abdomen Non-enhancing heterodense lesion with air pockets noted extending along the falciform ligament to anterior abdominal wall till umbilical region with surrounding inflammatory changes and minimal fluid collection. Left branch of portal vein (PV) not visualized-features suggestive of falciform ligament necrosis and inflammation. PV Doppler normal. Surgical gastroenterology opinion taken. Surgical excision of ligament was done. Postoperative period uneventful. Patient symptoms relieved and patient is on follow-up. Conclusion Primary Falciform ligament inflammation and necrosis is a rare condition. It is difficult to diagnose as it is often confused with other intra-abdominal pathologies especially gallbladder diseases. CECT abdomen should be preferred over USG abdomen for its diagnosis. Surgery is the treatment of choice. It should be considered as one of the possibilities in cases presenting with pain abdomen with other common causes ruled out.

GIT and hepatic manifestations of Covid-19 in a tertiary care centre Pavankumar Evuri, Chezhian Annasamy Correspondence-Chezhian Annasamy-chezhianannasamy@gmail.com Department of Medical Gastroenterology, Madras Medical College, Poonamallee High Road, Park Town, Chennai 600 003, IndiaBackground The clinical syndrome caused by SARS-CoV-2 was called COVID-19 and became a pandemic from March 2020. Predominant clinical manifestations are fever, dry cough, and dyspnea. Multiple gastrointestinal (GI) symptoms, including diarrhea, nausea/vomiting, and abdominal pain, as well as liver enzyme abnormalities have been variably reported. This study aims to comprehensively outline the various GIT and hepatic manifestations of this virus. Methods A cross sectional observational study carried out from July 1st to July 30th at Madras Medical College Hospital, Chennaia tertiary care COVID hospital. Data obtained from the RT PCR positive COVID in patients by selected questionnaire and lab reports, analyzed with regards to GIT and hepatic manifestations.Results Out of 118 patients diagnosed to have COVID by RT PCR, 69 were male and 49 female. Mean age 55.6 years. Eighteen (15.2%) have GIT manifestations. Nine (7.6%) have diarrhea as a most common GI symptom, 6 (5%) nausea or vomiting, 3 (2.5 %) abdominal pain. Isolated GI symptoms were reported in 2 patients. Diarrhea presented earlier to respiratory symptoms in one patient. Fifteen (12.7%) patients have liver function test abnormalities. SGOT and SGPT both elevated but SGOT levels more than SGPT in 13 out of 15 patients. Conclusion Digestive symptoms are not uncommon in patients with COVID-19 and in some cases digestive symptoms may occur isolated or earlier to onset of respiratory symptoms. Hence GIT symptoms should be addressed promptly for early diagnosis and proper management. Attention should also be paid to monitor regularly liver function during the course of COVID-19.

Normative values of various parameters defining sarcopenia among Indian adult population Department of General Surgery, Government Medical College, Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India Ancient neurilemmoma are rare variants of tumors which arise from the peri-neural Schwann cells. These tumors are termed "ancient" because of the degenerative features such as cyst formation, hemorrhage, calcification, and hyalinization are acquired with increasing age in these tumors. They are benign, slow growing and usually detected only incidentally or due to local symptoms. Although most schwannomas are benign tumors, those that are associated with von Recklinghausen disease are malignant in 5% to 18% of cases. Retroperitoneal schwannomas account for only 0.5% to 5% of all cases and are extremely uncommon. They are well encapsulated and recurrences following complete surgical excision are uncommon. Case Study A 70-year-old Hindu male patient presented with bilateral lower limb pain, fever and headache. On blood investigations patients was found to be positive for Falciparum. With normal abdominal examination, radiological examination was suggestive of an incidental welldefined heterogeneous mass lesion measuring 4.8 x 4.8 cm is seen along left anterior surface of left psoas muscle in the left retroperitoneal space. Preoperative biopsy report was suggestive of predominantly fibro collagenous tissue and few benign spindle cells. Exploratory laparotomy and excision of the retroperitoneal mass was done. Overall histological features were suggestive of atypical neurilemmoma (ancient neurilemmoma). Conclusion Retroperitoneal ancient schwannoma is rare variety of schwannoma with least chance of malignant transformation. Keywords Ancient, Retroperitoneal schwannoma, Neurilemmoma, Benign, Excision Background Adult onset diaphragmatic hernia is rare condition with variable manifestation. Majority of adult onset diaphragmatic hernia is associated with trauma. Traumatic diaphragmatic injury is known to present with the wide range of symptoms, and most patients would have some symptoms due to abdominal organ herniation. These injuries may be left unrecognized when they occur but often uncovered in days during work related symptoms. Diaphragmatic hernia is repaired by laparotomy or thoracotomy or both. Here we present a diaphragmatic hernia in blunt abdominal trauma presented with chest pain, breathlessness that was repaired via laparotomy. Operative approach of diaphragmatic defect closure is given below. Case presentation A 50-year-male patient came to casualty with 7 day history of chest pain and breathlessness. It is due to fall down in well 7 days ago while walking on road. Chest X-ray suggestive of left pleural effusion along with collapsed left lung. Patient is further evaluated in the form of CT abdomen which confirmed herniation of stomach and large bowel in left hemithorax. Consolidation of right lower lobe also present. Conclusion Traumatic injury of diaphragm is rare and for diagnosis required heigh index of suspicion for diagnosis and late diagnosis result in wide range of symptom. Keyword Diaphragmatic, Hernia, Laparotomy

Primary mesorectal hydatid cyst in presacral area of pelvis: An unusual case of echinococcosis Background Hydatid disease is a parasitic infectious disease caused by Echinococcus granulosus. The parasite can form cysts in any part of the body with the liver and lung being the most common organs. It can rarely occur in other organs like the muscle, bone and pelvis. Mesorectal fossa hydatid cyst is rare. Surgical excision is treatment modality of choice and accepted to be curative with a very low recurrence. Case presentation A 48-year-old male presented with complaints of pain while defecating since 4 months. During clinical examination, abdomen was soft and nontender, proctoscopic examination was found to be normal. USG was suggestive of anechoic lesions with multiple septations in pelvic region. CT scan was suggestive of discrete cystic density lesion with septations and dependent debris. MRI scan was suggestive of multiloculated cystic lesion in mesorectal fossa. There were no such cysts found in any other organ. Patient received antihelminthic medications for 1 month before surgery. During surgery the cyst was excised from mesorectal fossa and was apparent to be hydatid cyst as it contained small daughter cysts. The cavity of the cyst was irrigated with 3% NaCl as a scolicidal agent. Preventing spillage of the contents of the cyst and use of scolicidal agents are mandatory to decrease the rate of recurrence. Histopathological examination confirmed the hydatid disease. Postoperatively, the patient was put on albendazole and patient's symptoms disappeared after surgery. Conclusion We conclude that Echinococcus granulosus can affect any organ in the body from head to toe, and a high suspicion of this disease is justified in endemic regions. Moreover, medical treatment should be given in the preoperative period as well as in the postoperative period for 4-6 weeks but surgical intervention is inevitable. Keywords Hydatid cyst, Mesorectal fossa, Scolicidal agent Background Post-thyroidectomy tracheomalacia has been a rare complication of thyroid surgery. High degree of suspicion is required to diagnose such grave complication in order to give timely management. Acquired tracheomalacia in patient with thyroid mass results from degeneration of myoelastic component due to continuous compression/ infiltration by thyroid mass. We here present a case of postthyroidectomy tracheomalacia and its successful conservative management. Case presentation A 31-year-old female an operated case of right hemithyroidectomy came with recurrent neck swelling. We suspected toxic multinodular goitre of residual left lobe. Patient was kept on maximum dose of oral anti-thyroid agent yet patient was hyperthyroid. After 10 days of medical management and titration of doses patient was made near euthyroid and operated for left sided hemithyroidectomy for left lobe multinodular colloid goitre with intrathoracic extension. Intraoperatively, thyroid mass found to be grossly displacing trachea and esophagus towards left side, raising concern of possibility of postoperative tracheomalacia. On completion of surgery patient was given extubation trial, but due to breathing difficulty and stridor, patient was re-intubated and kept on T-piece ventilation with oxygen support so we suspected tracheomalacia and tracheostomy was done. Attempts were made to remove tracheostomy tube without success. On 15th postoperative day Introduction Lumbar hernia is an uncommon abdominal wall hernia. It develop through weakening of posterolateral abdominal wall associated with Petit's triangle or Grynfeltt-Lesshaft triangle. In lumbar hernia bowel, omentum, or pre-peritoneal fat herniates through the lumbar triangles. Lumbar hernias have been misdiagnosed as lipomas, muscle strains, fibromas, abscesses, and kidney tumor. It is more common in males between 50-70 years old and are more frequent on the left side. We here report a case of such lumbar hernia in which we have done successful repair through sutureless tensionfree meshplasty. Methods A 40-year-old male patient with presented with right sided lumbar region swelling since 2 years. On USG evaluation there was 3 cm defect noted in anterior abdominal wall in right lumbar region. An open approach through a posterolateral lumbar incision, content dissected up to the neck of the sac, extraperitoneal fat excised, herniation was through the superior lumbar triangle, loose lumbar fascia adjacent to the defect was dissected enough to create flaps for approximation, fascia was approximated with interrupted prolene stitches, attenuated muscle layers were dissected by undermining thereby creating good muscle flap, prolene mesh was placed over this fascial layer. The muscle flaps were approximated over the mesh. Results The postoperative recovery was uneventful. The patient has followed up for six months with no recurrence. Conclusion Awareness of the anatomy of the lumbar triangles is essential for prompt diagnosis of lumbar hernias. Repair can be done by both laparoscopic and open approach. Open sutureless tensionfree meshplasty is an easy, safe, and effective means of curing this rare surgical condition. Keywords Lumbar hernia, Sutureless tensionfree meshplasty, Petit's triangle, Grvnfeltt-lesshaft hernia Introduction Neuroendocrine tumor (NET) is a rare type of tumor that arises from neuroendocrine cells. These cells have traits of both nerve cells and hormone-producing cells and release hormones into the blood in response to signals from the nervous system. Neuroendocrine tumors can develop anywhere in the body, but most occur in the digestive tract, pancreas, rectum, lungs, or appendix. We report a case of excision of neuroendocrine tumor of celiac axis. The patient's postoperative course was unremarkable. Excision of the celiac axis tumor may be safely performed in selected patient. Method A 49 yr/F patient presented with abdominal pain and vomiting since 3 weeks. On USG evaluation there was 82 x 61 mm2 sized heterogenous echo texture lesion with evidence of minimal vascularity and foci of calcification noted involving left lobe of liver (p/o neoplastic etiology). CECT abdomen and pelvis was done afterwards which suggested presence of neuroendocrine tumor of celiac axis. An open approach through Chevron incision taken, mass of about 7 x 7 cm2 found behind the left lobe of liver, arising from celiac axis. Mass separated from surrounding structure, excised and sent for histopathological examination.Result The postoperative recovery was uneventful. The patient has followed up for 1 year with no complications. Conclusion This was the first case operated at our centre for excision of neuroendocrine tumor involving celiac axis. Open as well as laproscopic approach can be done, but open approach provides better safety, visualization with less complications. Keywords Celiac axis tumor, Neuroendocrine tumor, Abdominal mass Introduction Pain is highly prevalent in cancer population. One third of patients with cancer related pain receive inadequate pain management. Methods The study was done on patients with advanced and inoperable gastrointestinal (GI) malignancies at institute of Gastrointestinal and Hepatobiliary Sciences, Gleneagles Global Health City, Chennai, between 1st August 2018 to 31st December 2019. Demographic data, laboratory parameters and radiological investigations, baseline visual analogue scale (VAS) score and subjective global assessment (SGA) were recorded on first contact along with details of medical, endoscopic, and palliative interventions as performed. Analgesic pain ladder approach was followed for pain management. Follow-up to assess response was done using VAS score and SGA at the end of 3 months or death within this period.Results Seventy-one patients were included in the study. Most of them were old aged males. Out of 7 malignancies, hepatocellular carcinoma (HCC) was the most common tumor (57.8%) in study group. 40.8% patients had metastatic cancer. Baseline mean VAS score of study population was 5.13 ± 2.38 and highest was in carcinoma gallbladder patients (8.0 ± 2.0). Most patients were having baseline SGA rating B (69%). Tramadol was the most commonly used analgesic (35.22%) followed by combination of tramadol and fentanyl (26.76%). the most common palliation was transarterial chemoembolization (TACE) in HCC (80.5%) and biliary self-expanding metal stent (SEMS) in carcinoma pancreas (77.8%). There was statistically significant reduction in VAS score in HCC (p<0.001), carcinoma pancreas (p=0.009) and colorectal cancer (CRC) (p=0.022). 15.5% patients moved from SGA rating B to rating A, 9.9% moved from SGA rating B to rating C, and 9.9% moved from SGA rating C to rating B. Conclusion Analgesic pain ladder approach is effective in cancer pain management. But there is need for patient-tailored treatment for better outcomes. Keywords Advanced gastrointestinal malignancy, Pain and palliative management, Visual Analogue Scale Introduction Systemic manifestation of adverse drug reaction have been studied extensively. Anti-epileptic drugs (AED) associated DRESS (drug reaction with eosinophilia and systemic symptoms) is a known entity. They are usually idiosyncratic in nature and patients commonly present to dermatologist due to skin manifestations with associated mortality of 10%. Our study aims to know the pattern of hepatic manifestation and correlation with drug dosage and duration in DRESS along with associated morbidity. Methods Clinical and laboratory parameters of four proven cases of DRESS syndrome according to RegiSCAR criteria were studied, who presented to internal medicine and medical gastroenterology department in a tertiary care hospital. Results Manifestations were seen across different age groups (2nd, 3rd, 4th and 7th decade) with female preponderance (3 out of 4). Phenytoin was the common AED with mean dose of 300 mg/day. Duration of AED usage till clinical manifestation varied from 4 weeks to 2 years. Absolute eosinophil count was elevated (mean AEC-2144). Hepatic involvement in the form of cholestatic hepatitis (3 of 4) and skin rash (2 of 4) were seen. Two patients had prolonged hospitalization for >1 week and both had hepatic manifestation necessitating additional workup.Conclusion Skin rash need not be the presentation in all patients with DRESS syndrome. It is of idiosyncratic in nature. Patient can present with fever of unknown origin to internal medicine mimicking infective causes and masquerading as extrahepatic biliary obstruction (EHBO) to gastroenterology, necessitating further workup for the same. Hepatic involvement in DRESS syndrome is associated with prolonged hospitalization and increased morbidity. Background Gastrointestinal malignancies account for significant number of cases managed in tertiary care centres. Although they are managed by medical or surgical oncology department, most patients are diagnosed or seek initial medical attention in gastroenterology department. Aim This study was done to analyze clinical profile of patients diagnosed with gastrointestinal malignancies. Method Detailed clinical information, investigation reports were collected from all patients admitted and diagnosed with gastrointestinal malignancies between January 2019 to January 2020 were included in the study. Results Total 650 patients with various gastrointestinal malignancies were hospitalized in the gastroenterology department. Mean age of presentation was 48±6 and among them 380 (58.4%) were male. Among various gastrointestinal malignancies 26% were diagnosed as carcinoma gallbladder, which represent the maximum number of cases. Other malignancies include carcinoma esophagus (5%), carcinoma stomach (14%), carcinoma duodenum (0.5%), periampullary cancer (5%), carcinoma head of pancreas (11.5%), cholangiocarcinoma (20%), hepatocellular cancer (5%), carcinoma colon (8%), carcinoma rectum and rectosigmoid (5%). Most cases of carcinoma gallbladder presented at late stage with jaundice. In periampullary and cholangiocarcionoma common presentation was jaundice (78%) and in 20 % cases initial presentation was cholangitis. Hepatocellular cancer patients commonly presented with jaundice and ascites. Most cases of carcinoma rectum presented with bleeding per rectum. Among carcinoma stomach patients 60% cases presented with gastric outlets obstruction. Conclusion Carcinoma gallbladder is the most common gastrointestinal malignancy in Odisha with female predominance and usually presented at advanced stage. Among other malignancies few cases like carcinoma colon and stomach were detected on screening gastrointestinal endoscopy for nonspecific gastrointestinal symptoms like loss of appetite, early satiety and anemia due to chronic blood loss. Keywords Gastrointestinal malignancies, Carcinoma gallbladder 396 Non-invasive assessment of cardiovascular risk using carotid intima media thickness in patients with inflammatory bowel disease-Does non-alcoholic fatty liver disease add on to the risk?Anju Krishna K, Krishnadas Devadas, Sandesh K, Nidhin R, Ravindra Pal Correspondence-Ravindra Pal-docravindrapal@yahoo.com Department of Medical Gastroenterology, Government Medical College, Ulloor -Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, IndiaIntroduction We compared the carotid intima-media thickness test (CIMT) of patients with IBD and subjects without IBD to know the association between subclinical atherosclerosis in IBD and the cardiovascular risk. We also looked at whether NAFLD is an important factor affecting CIMT in IBD. Methods Descriptive study on 80 patients with IBD and 80 subjects without IBD conducted in a tertiary care hospital. Subjects aged more than 55 years, obese individuals, patients already diagnosed with cardio/cerebrovascular disease and those with other chronic inflammatory conditions were excluded. The demographic, anthropometric and disease related data were recorded. Baseline blood investigations including CRP and ESR were done. CIMT was measured using B mode Doppler imaging. Presence of fatty liver and Shear wave elastography of the liver were assessed. The quantitative data were compared using students t test and the qualitative data by Chi square test. Pearson and Spearman correlation was done to find out the factors correlating with CIMT. Results Age, sex distribution and traditional cardiovascular risks (hypertension, diabetes and dyslipidemia) were comparable in both groups. The CIMT was higher in patients with IBD as compared to controls (0.532±0.091 vs. 0.476±0.038, p=.000). On analysing the factors affecting CIMT in patients with IBD, those with NAFLD as an extraintestinal manifestation had increased CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP and ultrasound grades of fatty liver had positive correlations with CIMT. There was no change in CIMT with disease type (UC/CD), extent of disease, disease activity or severity of disease. Multivariate regression analysis showed that age and ultrasound grading of fatty liver (R2=0.576, p=.000) were independent predictors of CIMT. Conclusion We found that CIMT, was increased in patients with IBD as compared to controls. Age and NAFLD were independently associated with increased CIMT in IBD. Patients with IBD especially those with NAFLD may require enhanced monitoring for cardiovascular events. Keywords Inflammatory bowel disease. Ulcerative colitis. Crohn's disease; Carotid intima media 397 Unexplained pain abdomen due to alternative medicines Ajay Jain, Arun Singh, Sohini Sirkar, Amit Joshi, Sumit Kumar Singh, Abhilash Surela, Sudhansu Yadav Correspondence-Arun Singh-arunptsv@gmail.com Department of Gastroenterology, Choithram Hospital and Research Center, 14, Manik Bagh Road, Indore 452 014, India Introduction In last three decades there is increasing use of various alternative medicines for the treatment of various chronic disorders. These drugs are claimed as wonder drugs for chronic illness. How-ever many of these drugs contain very high level of heavy metals including lead and its accumulation leads to abdominal pain of variable severity. Therefore we planned this study "to analyze those patients who were consuming these unnamed indigenous drugs and presented with severe abdominal pain". Methods This is an observational case series of prospectively maintained data of all patients having unexplained abdominal pain and found to have an elevated blood lead level from 2011 to 2019. Lead toxicity was diagnosed when the blood lead level was more than >25 ug/dL as per the recommendation of the Centers for Disease Control and Prevention (CDC). All these patients were further interrogated for chronic diseases for which they were consuming these alternative medicines. Result Total sixty-six patients of unexplained abdominal pain from 2011 to 2019 were recruited, out of sixty-six patients, seventeen had elevated blood lead levels. All seventeen patients had a history of ingestion of herbal medicines for more than six months. Among these seventeen patients, six were taking for D.M., one for hypertension, two for arthritis and remaining eight for infertility, and sexual dysfunction. Basophilic stippling was seen in one patient. Fourteen patients had low hemoglobin with median value 9.7g/dL. Mean serum blood lead level were 87.1 ug/ dL (range from 26.3-428 ug/dL). None of them required anti-chelating agent. Conclusion 1. Lead toxicity because of alternative medicine is not uncommon cause of otherwise unexplained abdominal pain with anemia. 2. Most of these patients do not require a chelating agent for the treatment. 3. There is an urgent need to bring these alternative medicines under strict regulations for displaying its constituents and their concentration.