Lactated Ringers Use in the First 24 Hours of Hospitalization Is Associated With Improved Outcomes in 999 Patients With Acute Pancreatitis

INTRODUCTION

Recent pilot trials in acute pancreatitis (AP) found that lactated ringers (LR) usage may result in decreased risk of moderately severe/severe AP compared with normal saline, but their small sample sizes limit statistical power. We investigated whether LR usage is associated with improved outcomes in AP in an international multicenter prospective study.

METHODS

Patients directly admitted with the diagnosis of AP were prospectively enrolled at 22 international sites between 2015 and 2018. Demographics, fluid administration, and AP severity data were collected in a standardized prospective manner to examine the association between LR and AP severity outcomes. Mixed-effects logistic regression analysis was performed to determine the direction and magnitude of the relationship between the type of fluid administered during the first 24 hours and the development of moderately severe/severe AP.

RESULTS

Data from 999 patients were analyzed (mean age 51 years, female 52%, moderately severe/severe AP 24%). Usage of LR during the first 24 hours was associated with reduced odds of moderately severe/severe AP (adjusted odds ratio 0.52; P = 0.014) compared with normal saline after adjusting for region of enrollment, etiology, body mass index, and fluid volume and accounting for the variation across centers. Similar results were observed in sensitivity analyses eliminating the effects of admission organ failure, etiology, and excessive total fluid volume.

DISCUSSION

LR administration in the first 24 hours of hospitalization was associated with improved AP severity. A large-scale randomized clinical trial is needed to confirm these findings.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Kinetics of Covid-19 antibodies in terms of titre and duration among healthcare workers: A longitudinal study

Background Most individuals with Covid-19 infection develop antibodies specific to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the dynamics of these antibodies is variable and not well-studied. We aimed to determine the titres of naturally acquired antibodies over a 12-week follow-up. Methods We recruited healthcare workers who had tested positive on a specific quantitative reverse transcription-polymerase chain reaction (qRT-PCR) for SARS-CoV-2, and then tested for the presence of immunoglobulin G (IgG) antibody against the same virus at baseline and again at 6 and 12 weeks. The antibody titre was determined by a semi-quantitative assay based on signal/cut-off ratio. Healthcare workers with antibody positivity were divided into those with high titre (ratio ≥12) and low titre (<12). Their demographic details and risk factors were surveyed through a Google form and analysed in relation to the antibody titres at three time-points. Results Of the 286 healthcare workers, 10.48% had high antibody titres. Healthcare workers who had tested positive by qRT-PCR and those who had received the Bacille Calmette-Guérin (BCG) vaccination or other immune-boosters had a higher frequency of high antibody titres. While there was a significant decline in antibody titres at 6 and 12 weeks, 87.46% of individuals positive for IgG antibody persisted to have the antibody even at 12 weeks. Conclusion Healthcare workers who tested positive for SARS-CoV-2 on qRT-PCR had a high positivity for the specific antibody, which continued to express in them even at 12 weeks. Further follow-up is likely to enhance our understanding of antibody kinetics following SARS-CoV-2 infection.

Role of artificial intelligence-guided esophagogastroduodenoscopy in assessing the procedural completeness and quality

BACKGROUND AND AIMS

The quality of esophagogastroduodenoscopy (EGD) can have great impact on the detection of esophageal and gastric lesions, including malignancies. The aim of the study is to investigate the use of artificial intelligence (AI) during EGD by the  endoscopists-in-training so that a real-time feedback can be provided, ensuring compliance to a pre-decided protocol for examination.

METHODS

This is an observational pilot study. The videos of the EGD procedure performed between August 1, 2021, and September 30, 2021, were prospectively analyzed using AI system. The assessment of completeness of the procedure was done based on the visualizsation of pre-defined 29 locations. Endoscopists were divided into two categories - whether they are in the training period (category A) or have competed their endoscopy training (category B).

RESULTS

A total of 277 procedures, which included 114 category-A and 163 category-B endoscopists, respectively, were included. Most commonly covered areas by the endoscopists were greater curvature of antrum (97.47%), second part of duodenum (96.75%), other parts of antrum such as the anterior, lesser curvature and the posterior aspect (96.75%, 94.95%, and 94.22%, respectively). Commonly missed or inadequately seen areas were vocal cords (99.28%), epiglottis (93.14%) and posterior, anterior, and lateral aspect of incisura (78.70%, 73.65%, and 73.53%, respectively). The good quality procedures were done predominantly by categoryB endoscopists (88.68% vs. 11.32%, p < 0.00001).

CONCLUSION

AI can play an important role in assessing the quality and completeness of EGD and can be a part of training of endoscopy in future.

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures

BACKGROUND/AIMS

Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group.

METHODS

This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events.

RESULTS

Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events.

CONCLUSION

FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.

COVID ‐19 vaccine‐associated myositis – a case report

Myositis is one of the uncommon adverse events following COVID‐19 vaccination, and its mechanism is still unclear. A strong clinical suspicion and further evaluation are important not only for early diagnosis and management but also for better understanding of the unprecedented effects of this novel vaccine. We present a case of myositis following the first dose of the ChAdOx1 nCoV‐19 Corona Virus Vaccine, evidenced by serology and MRI.

Endovascular management of massive hemoptysis due to covid-19 related pulmonary artery pseudoaneurysm: A rare entity

Pulmonary artery pseudoaneurysms are rare causes of massive hemoptysis, even less common in setting of COVID-19 pneumonia. We describe and discuss an index case of cavitating COVID-19 pneumonia complicated by a pulmonary artery pseudoaneurysm without concomitant pulmonary thromboembolism. The patient presented with severe hemoptysis and was managed by endovascular coil embolization. Good technical and clinical success was achieved with complete resolution of hemoptysis.

Difficult Biliary Cannulation for Intradiverticular Papilla: Forceps Technique Revisited

Periampullary diverticula (PAD) have been encountered in 5.9 to 18.5% of patients during all the endoscopic retrograde cholangiopancreatography (ERCP). Cannulation in the presence of PAD can sometimes be difficult, time consuming, and often requires a higher level of endoscopic skills. Several techniques have been reported to facilitate and increase the chances of successful bile duct cannulation in the presence of PAD. The two-devices in one-channel method has been sparingly used. It involves the simultaneous use of a biopsy forceps and another instrument, either a cannula or sphincterotome through the same working channel. We successfully performed ERCP in three cases, where bile duct cannulation was performed in the setting of intradiverticular papilla using two-devices in one-channel method. We feel that the two-devices in one-channel method can be very useful and positioned higher up in the algorithm for successful cannulation in patients with PAD.

Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study

Background

Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied.

Objective

We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis.

Methods

Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance.

Results

Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83–5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01–2.69) were independent risk factors for oral feeding intolerance.

Conclusion

Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.

Current knowledge on this subject

Oral feeding intolerance is a relatively common complication of acute pancreatitis.

Oral feeding intolerance results in longer hospitalization and frequent readmissions.

What is new in this study

The incidence of oral feeding intolerance is similar irrespective of the timing of the initial feeding attempt.

Oral feeding intolerance is independently associated with systemic inflammatory response syndrome at 48 h and nonbiliary etiology.

COVID-19 prevalence among health-care workers of Gastroenterology department: An audit from a tertiary-care hospital in India

BACKGROUND AND AIM

In the present coronavirus disease-19 (COVID-19) era, health-care workers (HCWs) warrant special attention because of their higher risk and potential to transmit the disease. Gastroenterology services include emergency and critical care along with the endoscopy procedures, which have aerosol-generating potential. This study was aimed at auditing the COVID-19 impact on HCWs working in the Gastroenterology department of our hospital.

METHODS

The COVID-19 status of 117 HCWs was collected using either polymerase chain reaction (PCR) or Immunoglobulin G (IgG) seroassay. COVID-19 positivity was correlated with demographic characteristics, job profile, area of work, and medical history.

RESULTS

Thirty-eight HCWs (32.48%) showed evidence of COVID-19 using PCR (23.93%) or only IgG assay (8.55%). Endoscopy technicians (68.75%) exhibited significantly higher (P = 0.003) COVID-19 incidence compared to doctors (20.69%). Those working in the critical care units exhibited a trend toward higher COVID-19 incidence (42.86%). None of the six HCWs who received adequate hydroxychloroquine prophylaxis developed evidence of COVID-19. All the HCWs with COVID-19 disease recovered. However, there was a considerable loss of "man-days."

CONCLUSIONS

In our setting, we observed a high COVID-19 risk for HCWs working in the Gastroenterology department, with the highest risk among the endoscopy technicians. A more stringent triaging and pretesting of patients, as well as HCWs, might decrease the risk of COVID-19. Further multicenter studies are needed to evaluate the risk and related parameters.

A comprehensive review of vaccination in patients with inflammatory bowel diseases: An Indian perspective

The disease burden of inflammatory bowel diseases (IBD) in India is estimated to be one of the highest in the world in the near future. Patients with IBD, particularly those on immunosuppressive therapy, are at increased risk for developing vaccine-preventable illnesses. Adult vaccination policy and vaccination in patients with IBD are presently being at a very low level in India. This review discusses in detail the need for vaccination, levels of immunosuppression, a brief account of live and inactivated vaccines, available vaccines, and their utility in patients with IBD, with a special focus on recent recommendations.

Clinical features of hypertriglyceridemia-induced acute pancreatitis in an international, multicenter, prospective cohort (APPRENTICE consortium)

BACKGROUND

The clinical features and outcomes of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) are not well-established.

OBJECTIVE

To evaluate the clinical characteristics of HTG-AP in an international, multicenter prospective cohort.

METHODS

Data collection was conducted prospectively through APPRENTICE between 2015 and 2018. HTG-AP was defined as serum TG levels >500 mg/dl in the absence of other common etiologies of AP. Three multivariate logistic regression models were performed to assess whether HTG-AP is associated with SIRS positive status, ICU admission and/or moderately-severe/severe AP.

RESULTS

1,478 patients were included in the study; 69 subjects (4.7%) were diagnosed with HTG-AP. HTG-AP patients were more likely to be younger (mean 40 vs 50 years; p < 0.001), male (67% vs 52%; p = 0.018), and with a higher BMI (mean 30.4 vs 27.5 kg/m²; p = 0.0002). HTG-AP subjects reported more frequent active alcohol use (71% vs 49%; p < 0.001), and diabetes mellitus (59% vs 15%; p < 0.001). None of the above risk factors/variables was found to be independently associated with SIRS positive status, ICU admission, or severity in the multivariate logistic regression models. These results were similar when including only the 785 subjects with TG levels measured within 48 h from admission.

CONCLUSION

HTG-AP was found to be the 4th most common etiology of AP. HTG-AP patients had distinct baseline characteristics, but their clinical outcomes were similar compared to other etiologies of AP.

Oral Sulfate Solution versus Polyethylene Glycol as a Single-Day Preparation for Colonoscopy: A Randomized Control Trial

Background Colonoscopy is a principal diagnostic tool for most colonic disorders. Adequate bowel preparation is essential for proper visualization of the mucosa. The aim of this study was to compare the tolerability, efficacy, and safety profile of 1 L of oral sulfate solution (OSS) in comparison to 2 L of polyethylene glycol (PEG) solution.

Methods In this single-center prospective study conducted at our institute, patients were randomly assigned to receive either OSS or PEG solutions for colonoscopy preparation. Patients enrolled in either group completed a questionnaire assessing the taste of the solution used, adverse effects, and number of stools passed. Grading of the bowel cleansing quality was done as per Boston Bowel Preparation (BBP) score.

Results Total of 400 patients, with 222 patients in the PEG group and 178 patients in the OSS group, were assessed. In the PEG group, 148 (66.75%) patients were males and in the OSS group 112 (62.9%) patients were males. There was no statistical significance on comparison of the taste as “good” or “bad” in both groups. All the adverse events were mild to moderate in intensity and their frequencies were comparable for both the groups. The OSS group had better bowel preparation as per the BBP score (p = 0.021) and lesser cecal intubation time (p = 0.028).

Conclusion The present study demonstrated that 1 L of OSS is better than the well-established 2 L PEG solution, in terms of bowel preparation and shorter time to cecal intubation.

Endoscopic Management with a Novel Over-The-Scope Padlock Clip System

Background/Aims:

The Padlock clip is a recently introduced over-the-scope clip (OTSC) that requires the use of an alternate technique and has a different design from previous OTSCs. However, data regarding its clinical use are limited. The aim of this study is to present our clinical experience using this novel Padlock clip system.

Methods:

Between September 2018 and June 2019, 7 consecutive patients underwent Padlock clip application at our center by an experienced endoscopist. A Padlock clip was used for achieving hemostasis in 4 patients presenting with gastrointestinal (GI) bleeding, as well as for endoscopic full-thickness resection in the remaining 3 patients.

Results:

All 7 patients achieved technical as well as clinical success, with absence of complications or rebleeding, during a follow-up of a minimum of 3 weeks. All patients were hospitalized post procedure for a minimum of 48 hours, and an absence of adverse events was noted in our patient population throughout the procedure and post-procedure period. Antiplatelet therapy was reinstated shortly after the application of the Padlock clip, with no GI bleeding observed.

Conclusions:

The Padlock clip is a novel OTSC, with benefits that include safe, simple, and rapid deployment. Antiplatelet therapy may be reinstated for patients, when necessary, shortly after applying the Padlock clip due to full-thickness closure of the tissue.

Transgastric migration of gossypiboma: A preventable complication

Gossypiboma is term given for retained piece of cotton/sponge during surgery. The incidence of gossypiboma has described as 1 in 1000-3000 surgeries. Incidence is underestimated because of underreporting due to fear of medico-legal litigation and extreme criticism by media. Intraluminal migration is a rare complication of gossypiboma. Small intestine is most common intraluminal site followed by duodenum. Here, we report sixth case of transgastric migration of gossypiboma.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H₂ receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Spectrum of upper gastrointestinal bleed: An experience from Eastern India

Background/Aims: The etiology of upper gastrointestinal bleed (UGIB) is variable in different geographical regions. Epidemiological data are helpful in knowing the burden of the problem. This study was conducted to know the etiological spectrum, mortality, morbidity, and predictors of outcome in patients with acute UGIB. Materials and Methods: We retrospectively analyzed the data of patients admitted to our hospital between January 2013 and May 2015, with UGIB and noted the clinical presentation, etiology of bleed, and outcome. Results: A total of 337 patients [272 (80.7%) male, 65 (19.3%) female (male:female ratio: 4:1)] of UGIB were included in the study. The mean age of the patients was 55.11 ± 14.8 years (Range - 14–85 years). The most common etiology of UGIB was peptic ulcer (40.05%) followed by varices (33%). Majority of patients were managed medically. Endotherapy was required only in 33% patients. The mean duration of hospital stay was 6.6 ± 5.79 days. Rebleed was seen in 11 (3.2) patients and surgery was required in 6 (1.7%). In hospital, mortality was 2.6%. Age ≥65 years (odds ratio [OR]: 9.5, 95% confidence interval [CI]: 3.108–29.266), serum albumin <3 g/dl (OR: 3.1, 95% CI: 1.049–9.682), and serum creatinine >2 mg/dl (OR: 4.1, 95% CI: 1.068–8.591) were associated with increased mortality. Conclusions: Peptic ulcer disease is still the most common cause of UGIB. Majority of patients can be managed medically. Rebleed rate, need for surgery, and mortality due to UGIB are declining. Elderly age (>65), hypoalbuminemia serum albumin<3g/dl (<3) and renal dysfunction (serum creatinine >2) are important factors associated with increased mortality.

Nanotechnology in gastrointestinal endoscopy: A primer

Nanotechnology is the understanding, control of matter and development of engineered devices in nanometer range (1-100 nm). Nanoparticles have different physicochemical properties (small size, large surface area to volume ratio, and high reactivity) in comparison to bulk materials of the same composition. The nanotechnology has proved its usefulness in early diagnosis, proteonomics, imaging diagnostics and multifunctional therapeutics. Recent studies have shown its role in early diagnosis and targeted therapy of various gastrointestinal disorders such as hepatitis B virus and hepatitis C virus related liver disease, inflammatory bowel disease, gastric ulcer, and malignancy. Application of this technology appears promising in diagnostic and therapeutic endoscopy such as the endoscopic hemostasis of peptic ulcer bleeding, prevention of clogging of plastic stent and advance capsule endoscopy. This article will highlight the basic concepts of nanotechnology and its potential application in gastrointestinal endoscopy.

Endoscopic ultrasound coil placement of gastric varices: Emerging modality for recurrent bleeding gastric varices

Gastric varices are the probable source of bleeding in 10-36% of patients, with acute variceal bleeding and carry high mortality and rebleeding rates. Till date, cyanoacrylate glue injection is considered as the standard of care but has high complication rate. Endoscopic ultrasound (EUS) guided coil placement is a new emerging technique of management of gastric varices. In this case report, we detail the EUS guided coil placement for management of gastric varices after failed glue injections.

A study on confocal endomicroscopy in comparison with histopathology for polypoidal lesions of the gastrointestinal tract: A prospective single-centre experience

BACKGROUND

Confocal laser endomicroscopy (CLE) has a potential to make optical diagnosis of neoplastic polypoidal lesions and may replace traditional histology in the proposed "diagnose and discard approach". The present study was planned to assess the accuracy of probe-based CLE in predicting histology of polypoidal lesions of gastrointestinal (GI) tract in vivo before their removal.

METHODS

In this prospective single-centre study, patients with upper and/or lower GI polypoidal lesions were enrolled. After detection of polypoidal lesions with white light endoscopy, probe-based CLE examination was performed. Real-time and offline presumptive CLE diagnosis of polypoidal lesions was made as per Miami classification and was compared with histopathology as the gold standard.

RESULTS

A total of 50 GI polyps from 50 patients (28 males) were assessed. The mean (±SD) size of polyps was 13.7 (± 8.5) mm. Most polyps were located at the cecum (24.0%) or stomach (24.0%). On histological examination, hyperplastic and adenomatous polyps, adenocarcinoma, and lipoma were seen in 54%, 26%, 18% and 2% patients, respectively. On comparison of real-time CLE examination with histopathology, 40 (83.3%) and 8 patients (16.7%) had concordant and discordant results, respectively. Two polyps were inconclusively diagnosed on CLE. On offline examination, concordance with histopathology was observed in 85.4% (n = 41) of polyps, which was marginally better than online examination, though the difference was not statistically significant (p = 0.45). On comparing the real-time and offline findings of CLE, concordance was found in 91.7% of the cases. Accuracy, sensitivity, specificity, positive and negative predictive values on real-time evaluation were 83.3%, 87.5%, 79.1%, 80.7%, and 86.3%, respectively.

CONCLUSION

CLE is a useful tool for prediction of histology to assess the polypoidal lesions of the GI tract, and it may avoid polypectomy at least in some patients.

Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System

BACKGROUND/AIMS

To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system.

METHODS

Consecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined.

RESULTS

Of the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement.

CONCLUSION

The PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.

Routine Screening before Endoscopic Procedures: A Systematic Review

Routine screening prior to endoscopic procedures includes ordering a panel of tests on all patients undergoing endoscopic procedures without seeking any history and physical examination of the patients. These laboratory testing increases the cost burden on the patient but can have a strong impact on complications after endoscopic procedures. Selective preoperative tests (i.e., tests ordered after consideration of careful history taking and physical examination) may assist in making decisions about the process of perioperative assessment and management. We believe that the Society of Gastrointestinal Endoscopy of India should take initiative to draw its own position paper / guideline in view of the strong impact on cost and medico-legal issue in an Indian setting.

Migration of Pigtail Biliary Stent through Surface of the Left Lobe of Liver

We report a rare case of a patient of choledocholithiasis who underwent CBD stone removal with pigtail biliary stenting four year back, presenting with proximal migration of stent piercing the left lobe of liver. The stent was removed at laparotomy, by doing hepatotomy. We discuss this unreported case of proximal migration of pigtail biliary stent through surface of left lobe of liver.

Pancreatic Necrosectomy through Sinus Tract Endoscopy

Background/Aims

Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.

Methods

Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.

Results

Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1–4), with mean time of 70 minutes for each session (range, 15–70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.

Conclusions

Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.

Use of self-expanding metal stents for difficult variceal bleed

BACKGROUND/AIM

Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding.

METHODS

Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding.

RESULTS

Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30 days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6 h after stent placement. One patient had bleeding 10 days after stent removal and was re-stented but expired 7 days later. Stents were removed in eight patients at a mean duration of 17.5 days. (range 7 to 30 days).

CONCLUSIONS

Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.

Clinical correlates of trichuriasis diagnosed at colonoscopy

Diagnosis of Trichuris trichiura infestations is usually based on identification of barrel-shaped ova in stool, but is frequently missed on stool microscopy. We describe the clinical profile of patients in whom Trichuris infection was incidentally diagnosed at colonoscopy. In a cross-sectional study, patients with colonoscopic diagnosis of trichuriasis were enrolled from the endoscopy unit in a tertiary care center. Blood and stool samples were collected from all those who were willing to participate and provide samples. Sixty-two patients participated, with mean (SD) age of 50.5 (13.6) years and male to female ratio of 40:22. Abdominal pain (61.2%) and/or altered bowel habits (32.2%) were the most common indication for colonoscopy. Most (66.6%) of the Trichuris were located in the cecum and ascending colon. Majority of the patients had live worms, either motile or adhering to the colonic mucosa. The number of worms was single or a few (<15) in 74.2% of patients. Out of 62 patients, 16 (25.8%) had relatively heavy load of parasites. Most patients had normal colonoscopic findings (80.6%). Periappendicular and/or cecal ulcerations/erosions were the most common (16.1%) abnormalities noted. Stool examination showed parasite ova only in four (6.4%) patients. In conclusion, colonoscopy was better than stool microscopy for the diagnosis of trichuriasis in our study.

Acute pancreatitis patient registry to examine novel therapies in clinical experience (APPRENTICE): an international, multicenter consortium for the study of acute pancreatitis

Background

We have established a multicenter international consortium to better understand the natural history of acute pancreatitis (AP) worldwide and to develop a platform for future randomized clinical trials.

Methods

The AP patient registry to examine novel therapies in clinical experience (APPRENTICE) was formed in July 2014. Detailed web-based questionnaires were then developed to prospectively capture information on demographics, etiology, pancreatitis history, comorbidities, risk factors, severity biomarkers, severity indices, health-care utilization, management strategies, and outcomes of AP patients.

Results

Between November 2015 and September 2016, a total of 20 sites (8 in the United States, 5 in Europe, 3 in South America, 2 in Mexico and 2 in India) prospectively enrolled 509 AP patients. All data were entered into the REDCap (Research Electronic Data Capture) database by participating centers and systematically reviewed by the coordinating site (University of Pittsburgh). The approaches and methodology are described in detail, along with an interim report on the demographic results.

Conclusion

APPRENTICE, an international collaboration of tertiary AP centers throughout the world, has demonstrated the feasibility of building a large, prospective, multicenter patient registry to study AP. Analysis of the collected data may provide a greater understanding of AP and APPRENTICE will serve as a future platform for randomized clinical trials.

Endoscopic Management of Gastrointestinal Leaks and Bleeding with the Over-the-Scope Clip: A Prospective Study

Background/Aims

The over-the-scope clip (OTSC) is a device used for endoscopic closure of perforations, leaks and fistulas, and for endoscopic hemostasis. To evaluate the clinical effectiveness and safety of OTSC.

Methods

Between October 2013 and November 2015, 12 patients underwent OTSC placement by an experienced endoscopist. OTSC was used for the closure of gastrointestinal (GI) leaks and fistula in six patients, three of which were iatrogenic (esophageal, gastric, and duodenal) and three of which were inflammatory. In six patients, OTSC was used for hemostasis of non-variceal upper GI bleeding. Endoscopic tattooing using India ink was used to assist the accurate placement of the clip.

Results

All subjects except one with a colonic defect experienced immediate technical success as well as long-term clinical success, during a mean follow-up of 6 weeks. Only one clip was required to close each of the GI defects and to achieve hemostasis in all patients. There were no misfirings or complications of clips. The procedure was well tolerated, and patients were hospitalized for an average of 8 days (range, 3 to 10). Antiplatelet therapy was continued in patients with GI bleeding.

Conclusions

In our experience, OTSC was safe and effective for the closure of GI defect and to achieve hemostasis of non-variceal GI bleeding.

Esophageal lichen planus: A rare and under-recognized disorder

Lichen planus (LP) is a chronic idiopathic disorder involving the skin and mucosal surfaces. Although oral mucosal involvement is common, esophageal LP (ELP) is uncommon and also under-reported. Here, we present a case of ELP who was symptomatic with dysphagia for a year, but was untreated. Increasing awareness of this condition can help identify more cases and increase our understanding of this uncommon but interesting condition.

Endotherapy of leaks and fistula

Perforations, leaks and fistula involving gastrointestinal (GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips (through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula. Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.

Burdick's Technique for Biliary Access Revisited

The precut sphincterotomy is used to facilitate selective biliary access in cases of difficult biliary cannulation. Needle-knife precut papillotomy is the standard of care but is associated with a high rate of complications such as pancreatitis, duodenal perforation, bleeding, etc. Sometimes during bowing of the sphincterotome/cannula and the use of guide wire to facilitate biliary cannulation, inadvertent formation of a false passage occurs in the 10 to 11 o'clock direction. Use of this step to access the bile duct by the intramucosal incision technique was first described by Burdick et al., and since then two more studies have also substantiated the safety and efficacy of this non-needle type of precut sphincterotomy. In this review, we discuss this non-needle technique of precut sphincterotomy and also share our experience using this "Burdick's technique."

Focal intestinal lymphangiectasia: An unusual cause of acute overt obscure gastrointestinal bleeding

Detection of bleeding lesion in a patient of acute overt obscure gastrointestinal bleeding is a real challenge. Recently, authors have showed superiority of urgent capsule endoscopy (CE) over angiography in patients with acute overt obscure gastrointestinal bleeding. Focal type of intestinal lymphangiectasia is a rare cause of acute gastrointestinal bleeding. Here, we describe a case of focal lymphangiectasia who presented to us with acute overt obscure gastrointestinal bleeding and diagnosed by urgent CE.

Biliary ascariasis: an uncommon cause for recurrent biliary colic after biliary sphincterotomy and common bile duct stone removal

Endoscopic retrograde cholangiography is the most commonly used technique for removal of common bile duct stones. Biliary sphincterotomy during the procedure facilitates stone retrieval from the common bile duct. However, sphincterotomy ablates the normal biliary sphincter mechanism. This facilitates duodeno-biliary reflex and can result in inward migration of luminal parasite into the biliary system. In areas where ascariasis is endemic there is an increased risk of biliary ascariasis in postbiliary sphincterotomy patients. We report an unusual case where a patient presented with recurrent biliary colic after cholecystectomy and common bile duct stone extraction and was diagnosed to have biliary ascariasis with the help of endoscopic ultrasound examination of the biliary system.

Glue for sealing internal pancreatic fistula in a patient with liver cirrhosis: a useful technique

CONTEXT

Pancreatic fistulae are uncommon and usually follow acute or chronic pancreatitis. While most of these are treated conservatively, some require surgery. Recently endoscopic therapy has emerged as an effective alternative treatment modality.

CASE REPORT

We present a patient with internal pancreatic fistula due to alcohol related chronic pancreatitis. Endotherapy using glue resulted in resolution of the fistula.

CONCLUSION

The use of endoscopic glue injection may be a safe and effective method for the successful therapy of internal pancreatic fistula.