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Singh AK, Vaithiyam V, Sonika U, Goyal S. Severe Acute Liver Injury: First Manifestation of Systemic Lupus Erythematosus. J Clin Exp Hepatol 2024; 14:101339. [PMID: 38264573 PMCID: PMC10801300 DOI: 10.1016/j.jceh.2023.101339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a common multisystem disease characterised by a wide variety of presentation patterns and complex manifestations. As a lymphoid organ, the liver plays an important role in the immune response and is a target of autoimmune responses.1 SLE can affect the liver in approximately 25-60 % of patients during their disease course.2,3 Liver dysfunction and SLE can present with complicated differential diagnoses. Liver dysfunction in SLE is usually mild and rarely leads to advanced liver diseases such as cirrhosis and liver failure.4,5 Liver dysfunction in SLE is usually caused by non-SLE-related causes such as drug toxicity, fatty liver, alcoholism, and associated autoimmune hepatitis. However, primary liver involvement in SLE is also well-recognised. Patients with SLE who present with acute liver failure are rare. We report a rare case of SLE-associated acute severe liver injury along with a literature review.
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Affiliation(s)
- Alok K. Singh
- Department of Gastroenterology, GB Pant Hospital (GIPMER), New Delhi, India
| | | | - Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital (GIPMER), New Delhi, India
| | - Surbhi Goyal
- Department of Pathology, GB Pant Hospital (GIPMER), New Delhi, India
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2
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Affiliation(s)
- Shrey Bhatt
- Department of Gastroenterology, G B Pant Hospital, J L N Marg, New Delhi, 110 001, India
| | - Ajay Kumar
- Department of Gastroenterology, G B Pant Hospital, J L N Marg, New Delhi, 110 001, India
| | - Ashok Dalal
- Department of Gastroenterology, G B Pant Hospital, J L N Marg, New Delhi, 110 001, India
| | - Ujjwal Sonika
- Department of Gastroenterology, G B Pant Hospital, J L N Marg, New Delhi, 110 001, India.
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Chauhan D, Goyal S, Sakhuja P, Sonika U. Russell body typhilitis: An unusual mimicker of malignancy! J Clin Pathol 2024:jcp-2023-209308. [PMID: 38286611 DOI: 10.1136/jcp-2023-209308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Affiliation(s)
- Devika Chauhan
- Department of Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Surbhi Goyal
- Department of Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Puja Sakhuja
- Department of Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
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Singh AK, Srivastava S, Sonika U, Sachdeva S, Aneesh P, Kumar A, Sharma BC, Dalal A. Motorized Power Spiral Enteroscopy (MSE): Is Routine Bougienage of the Upper Esophageal Sphincter (UES) Necessary? Cureus 2024; 16:e52342. [PMID: 38361713 PMCID: PMC10867537 DOI: 10.7759/cureus.52342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Wire-guided bougienage of the upper esophageal sphincter (UES) was performed routinely before per-oral motorized power spiral enteroscopy (MSE). In the present study, we aimed to answer the clinical question of whether routine bougienage of UES is required. Methods This was a retrospective study that included 20 patients who underwent antegrade spiral enteroscopy for various indications. The feasibility and safety of anterograde MSE without prior bougie dilatation of the upper esophageal sphincter were assessed. The technical success rate (TSR), diagnostic yield, and adverse events (AEs) were also assessed. Results In 16 out of the 20 patients, a spiral enteroscope was taken directly across UES into the esophagus without a prior bougie dilatation. The spiral enteroscope could not be negotiated across UES only in one patient, and bougie dilatation was done. The technical success rate was 100%. The diagnostic yield was 80%. Four patients reported AEs. Conclusions MSE had a good technical success rate and diagnostic yield. Routine dilatation of the UES before the procedure may be unnecessary.
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Affiliation(s)
- Alok Kumar Singh
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
| | | | - Ujjwal Sonika
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
| | - Sanjeev Sachdeva
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
| | - Payila Aneesh
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
| | - Ajay Kumar
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
| | - Barjesh C Sharma
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
| | - Ashok Dalal
- Gastroenterology and Hepatology, G.B. Pant Hospital, New Delhi, IND
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Pandey T, Sonika U, Dalal A, Kumar A, Palle SH, Gera R, Choudhary H, Sachdeva S, Srivastava S, Sharma BC. Quality of life and nutritional status of patients with refractory or recurrent corrosive-induced esophageal strictures on long-term endoscopic dilation. Indian J Gastroenterol 2023:10.1007/s12664-023-01484-z. [PMID: 38044358 DOI: 10.1007/s12664-023-01484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Affiliation(s)
- Toshali Pandey
- Department of Gastroenterology, Maulana Azad Medical College, New Delhi, 110 002, India
| | - Ujjwal Sonika
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India.
| | - Ashok Dalal
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India
| | - Ajay Kumar
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India
| | - Sri Harsha Palle
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India
| | - Raghav Gera
- Department of Gastroenterology, Maulana Azad Medical College, New Delhi, 110 002, India
| | - Harshita Choudhary
- Department of Gastroenterology, Maulana Azad Medical College, New Delhi, 110 002, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India
| | - Siddharth Srivastava
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, Room No. 209 Academic Block, Jawahar Lal Nehru Marg, New Delhi, 110 002, India
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Singh AK, Sachdeva S, Srivastava S, Sonika U, Kumar A, Sharma BC, Puri AS, Dalal A. Comparing Myelosuppression Frequency in Indian Inflammatory Bowel Disease Patients: A Randomized Trial of Full Dose Versus Gradual Escalation of Thiopurines. Cureus 2023; 15:e50969. [PMID: 38259414 PMCID: PMC10801346 DOI: 10.7759/cureus.50969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION We aimed to compare the frequency of myelosuppression in patients initiating azathioprine (AZA) at full dose versus those undergoing gradual dose escalation. METHODS Forty patients with inflammatory bowel disease were recruited over one year and randomized into two groups of 20. Group A initiated AZA at a full dose of 2 mg/kg, while group B started at 1 mg/kg with subsequent dose increases at regular intervals. RESULTS Seventeen patients from each group were included in the final analysis. During follow-up, two patients (11.8%) from group A and four patients (23.5%) from group B experienced relapses (p=0.65). Myelosuppression occurred in two patients (11.8%) from each group. Absolute neutrophil counts in group A tended to have lower median values than those in group B, particularly four weeks after AZA initiation. Univariate analysis identified serum proteins, albumin, and bilirubin as significantly associated with leukopenia, but these factors were not significant according to multivariate analysis. CONCLUSIONS The incidence of myelosuppression was similar between the groups. Patients with full-dose initiation of AZA had numerically fewer relapses during the follow-up period.
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Affiliation(s)
- Alok Kumar Singh
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | | | - Ujjwal Sonika
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Ajay Kumar
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Barjesh C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
| | - Amarender S Puri
- Department of Gastroenterology, Medanta - The Medicity Hospital, Gurugram, IND
| | - Ashok Dalal
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, IND
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Sharma BC, Maharshi S, Sachdeva S, Mahajan B, Sharma A, Bara S, Srivastava S, Kumar A, Dalal A, Sonika U. Nutritional therapy for persistent cognitive impairment after resolution of overt hepatic encephalopathy in patients with cirrhosis: A double-blind randomized controlled trial. J Gastroenterol Hepatol 2023; 38:1917-1925. [PMID: 37354045 DOI: 10.1111/jgh.16266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/27/2023] [Accepted: 06/06/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND AND AIM Minimal hepatic encephalopathy (MHE) reflects cognitive impairment in patients with liver cirrhosis and is associated with poor prognosis. We assessed the effects of nutritional therapy on cognitive functions, health-related quality of life (HRQOL), anthropometry, endotoxins, and inflammatory markers in cirrhotic patients with MHE. METHODS In a double-blind randomized controlled trial, cirrhotic patients with MHE were randomized to nutritional therapy (group I: 30-35 kcal/kg/day and 1.0-1.5 g of protein/kg/day) and no nutritional therapy (group II: diet as patients were taking before) for 6 months. MHE was diagnosed based on psychometric hepatic encephalopathy score (PHES). Anthropometry, ammonia, endotoxins, inflammatory markers, myostatin, and HRQOL were assessed at baseline and after 6 months. Primary endpoints were improvement or worsening in MHE and HRQOL. RESULTS A total of 150 patients were randomized to group I (n = 75, age 46.3 ± 12.5 years, 58 men) and group II (n = 75, age 45.2 ± 9.3 years, 56 men). Baseline PHES (-8.16 ± 1.42 vs -8.24 ± 1.43; P = 0.54) was comparable in both groups. Reversal of MHE was higher in group I (73.2% vs 21.4%; P = 0.001) than group II. Improvement in PHES (Δ PHES 4.0 ± 0.60 vs -4.18 ± 0.40; P = 0.001), HRQOL (Δ Sickness Impact Profile 3.24 ± 3.63 vs 0.54 ± 3.58; P = 0.001), anthropometry, ammonia, endotoxins, cytokines, and myostatin levels was also significantly higher in group I than group II. Overt hepatic encephalopathy developed in 6 patients in group I and 13 in group II (P = 0.04). CONCLUSIONS Nutritional therapy is effective in treatment of MHE and associated with improvement in nutritional status, HRQOL, ammonia, endotoxins, inflammatory markers, and myostatin levels.
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Affiliation(s)
| | | | - Sanjeev Sachdeva
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - Bhawna Mahajan
- Department of Biochemistry, G.B. Pant Hospital, New Delhi, India
| | - Ashok Sharma
- Department of Radiology, G.B. Pant Hospital, New Delhi, India
| | - Sushma Bara
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | | | - Ajay Kumar
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - Ashok Dalal
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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George R, Sonika U, Mahajan B, Sharma A, Dalal A, Sachdeva S, Kumar A. Diagnostic utility of urine neutrophil gelatinase-associated lipocalin and renal resistive index in patients of decompensated cirrhosis with acute kidney injury. Dig Liver Dis 2023; 55:1230-1235. [PMID: 37244788 DOI: 10.1016/j.dld.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/18/2023] [Accepted: 03/10/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND The differentiation between types of acute kidney injury(AKI) in decompensated cirrhosis(DC) patients in clinical practice is done by clinical adjudication. Biomarkers have good diagnostic accuracy for predicting acute tubular necrosis(ATN), however they are not available routinely. AIMS We compared the diagnostic accuracy of urine neutrophil gelatinase-associated lipocalin(UNGAL) and renal resistive index(RRI) in predicting type of AKI among DC patients. METHODS Consecutive DC patients with AKI stage≥1B seen between June/2020 to May/2021 were evaluated. UNGAL levels and RRI were measured at diagnosis of AKI(Day 0) and 48hrs(Day 3) after volume expansion. Diagnostic accuracy of UGNAL and RRI was compared for differentiating ATN and non-ATN AKI by area under receiver operating characteristic curve(AUROC), using clinical adjudication as gold standard. RESULTS 388 DC patients were screened, 86 patients(Pre-renal AKI[PRA] n=47,55%; Hepatorenal syndrome[HRS] n=25,29%;ATN n= 14,16%) were included. The AUROC of UNGAL for differentiating ATN-AKI and non-ATN AKI at day 0 was 0.97(95%CI, 0.95-1.0) and on day 3 was 0.97(95%CI, 0.94-1.0). The AUROC of RRI for differentiating ATN and non-ATN AKI at day 0 was 0.68(95%CI, 0.55-0.80) and on day 3 was 0.74(95%CI, 0.63-0.84). CONCLUSION UNGAL has an excellent diagnostic accuracy in predicting ATN-AKI in DC patients both at day 0 and 3.
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Affiliation(s)
- Roshan George
- Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India
| | - Bhawna Mahajan
- Department of Biochemistry, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India
| | - Ashok Sharma
- Department of Radiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India
| | - Ashok Dalal
- Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India
| | - Ajay Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, 110002 New Delhi, India.
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Pandey T, Sonika U, Dalal A, Kumar A, Gera R, Choudhary H, Sachdeva S, Srivastava S, Sharma BC. Validity and Reliability of the European Organization Research and Treatment of Cancer Quality of Life Questionnaire-Oesophagogastric 25 in Indian Patients With Corrosive-Induced Benign Refractory Esophageal Strictures. Cureus 2023; 15:e37190. [PMID: 37159769 PMCID: PMC10163362 DOI: 10.7759/cureus.37190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 04/09/2023] Open
Abstract
Background The European organization Research and Treatment of Cancer Quality of Life Questionnaire-Oesophagogastric 25 (EORTC QLQ-OG 25) is designed for patients with esophagogastric cancer. Its performance has never been tested with benign disorders. A health-related quality-of-life questionnaire does not exist for patients with benign corrosive-induced esophageal strictures. Hence, we evaluated the EORTC QLQ-OG 25 in Indian patients with corrosive strictures. Methods The English or Hindi version of QLQ-OG 25 was administered to 31 adult patients undergoing outpatient esophageal dilation at GB Pant hospital, New Delhi. These patients had refractory or recurrent esophageal strictures due to corrosive ingestion and had not undergone reconstructive surgery. Score distribution was analyzed, and item performance was determined based on floor and ceiling effects. Convergent validity, discriminant validity, and internal consistency were checked. Results The average time to finish the questionnaire was 6.70 minutes. Most scales fulfilled convergent validity (corrected item-total correlation >0.4), barring the Odynophagia scale and one item of the Dysphagia scale. Most scales exhibited divergent validity except for odynophagia and one item of dysphagia. Cronbach's alpha was >0.70 for all scales except odynophagia. Responses to questions evaluating taste, cough, swallowing saliva, and talking were highly skewed and had prominent floor effects. Overall, the questionnaire demonstrated good internal consistency, convergent validity, and divergent validity in benign corrosive-induced refractory esophageal strictures patients. Conclusion The EORTC QLQ-OG 25 can be satisfactorily used in patients with benign esophageal strictures to assess health-related quality of life.
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Ahuja H, Sharma BC, Sachdeva S, Mahajan B, Sharma A, Bara S, Srivastava S, Kumar A, Dalal A, Sonika U. A double blind randomized controlled trial to assess efficacy of nutritional therapy for prevention of recurrence of hepatic encephalopathy in patients with cirrhosis. J Gastroenterol Hepatol 2023; 38:433-440. [PMID: 36574769 DOI: 10.1111/jgh.16096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/05/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Overt hepatic encephalopathy (OHE) has high risk of recurrence and is associated with poor survival. The role of nutrition therapy is well documented in cirrhosis, but its efficacy in preventing the recurrence of OHE has not been studied. METHODS In double blind RCT, we randomly assigned 150 patients with liver cirrhosis, with history of OHE in recent past to receive nutrition therapy (group I) or no nutrition therapy (group II) and followed up for 6 months. The primary efficacy end points were occurrence of breakthrough episodes and time to breakthrough episode of OHE. Secondary end points were OHE related hospitalizations and time to hospitalization involving OHE. Other parameters included anthropometry, changes in serum cytokines (IL-1, IL-6, IL-10, and TNF-α), endotoxin and myostatin. RESULTS There was significant reduction in occurrence of breakthrough episodes of OHE in group I [10 vs 36, hazard ratio 0.20; P < 0.001], OHE-related hospitalization [8 vs 24, hazard ratio 0.27; P < 0.001)]. Times to breakthrough episode of OHE and OHE-related hospitalization were longer in group I. At the end of 6 months, inflammatory and anthropometry parameters showed significant improvement in group I compared with worsening of serum albumin, anthropometric parameters, IL-6, IL-10 and TNF-α in group II. At the end of 6 months, ascites (50 vs 66, P = 0.01), gastrointestinal bleed (2 vs 11, P = 0.007), and jaundice (16 vs 41, P < 0.001) were lower in group I. CONCLUSIONS Treatment with nutrition therapy prevented recurrence of OHE and decreased OHE-related hospitalizations as compared with no nutrition therapy.
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Affiliation(s)
- Hardik Ahuja
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Bhawna Mahajan
- Department of Biochemistry, GB Pant Hospital, New Delhi, India
| | - Ashok Sharma
- Department of Radiology, GB Pant Hospital, New Delhi, India
| | - Sushma Bara
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Ajay Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ashok Dalal
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
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Kumar M, Sonika U, Sachdeva S, Dalal A, Narang P, Mahajan B, Singhal A, Srivastava S. Natural History of Asymptomatic Walled-off Necrosis in Patients With Acute Pancreatitis. Cureus 2023; 15:e34646. [PMID: 36895535 PMCID: PMC9990741 DOI: 10.7759/cureus.34646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/07/2023] Open
Abstract
Background and objectives Studies on the natural history of asymptomatic walled-off necrosis (WON) in acute pancreatitis (AP) are scarce. We conducted a prospective observational study to look for the incidence of infection in WON. Material and methods In this study, we included 30 consecutive AP patients with asymptomatic WON. Their baseline clinical, laboratory, and radiological parameters were recorded and followed up for three months. Mann Whitney U test and unpaired t-tests were used for quantitative data and chi-square and Fisher's exact tests were used for qualitative data analysis. A p-value <0.05 was considered significant. Receiver operating characteristic curve (ROC) analysis was done to identify the appropriate cutoffs for the significant variables. Results Of the 30 patients enrolled, 25 (83.3%) were males. Alcohol was the most common etiology. Eight patients (26.6%) developed an infection on follow-up. All were managed by drainage either percutaneously (n=4, 50%) or endoscopically (n=3, 37.5%). One patient required both. No patient required surgery and there was no mortality. Median baseline C-reactive protein (CRP) was higher in infection group 76 (IQR=34.8) mg/L vs asymptomatic group, 9.5 mg/dl (IQR=13.6), p<0.001. IL-6 and tumor necrosis factor (TNF)-alpha was also higher in the infection group. The size of the largest collection (157.50±33.59 mm vs 81.95±26.22 mm, P<0.001) and CT severity index (CTSI) (9.50±0.93 vs 7.82±1.37, p<0.01) were also higher in infection group as compared to the asymptomatic group. ROC curve analysis of baseline CRP (cutoff 49.5mg/dl), size of WON (cutoff 127mm) and CTSI (cutoff of 9) showed AUROC (area under ROC) of 1, 0.97, and 0.81 respectively for the future development of infection in WON. Conclusion Around one-fourth of asymptomatic WON patients developed an infection during three-months follow-up. Most patients with infected WON can be managed conservatively.
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Affiliation(s)
- Manish Kumar
- Gastroenterology, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Ujjwal Sonika
- Gastroenterology, Govind Ballabh Pant Hospital, New Delhi, IND
| | | | - Ashok Dalal
- Gastroenterology, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Poonam Narang
- Radiology, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Bhawna Mahajan
- Biochemistry, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Ankush Singhal
- Biochemistry, Govind Ballabh Pant Hospital, New Delhi, IND
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Affiliation(s)
- Sanjeev Sachdeva
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002, India
| | - Ujjwal Sonika
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002, India.
| | - Ashok Dalal
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002, India
| | - Sukrit Singh Sethi
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002, India
| | - Manish Kumar
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002, India
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Sonika U, Sachdeva S, Kumar A, Srivastava S, Dahale A, Sharma BC, Kumar M, Pandey T, Yadav DP, Maharshi S, Nair SV, Dalal A. Impact of the COVID-19 Pandemic on Gastroenterology Training in India. Journal of Digestive Endoscopy 2022. [DOI: 10.1055/s-0042-1748636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic has affected the healthcare system. The residents who are at the frontline of this pandemic have suffered the most. The extent of the training loss due to the COVID-19 pandemic on gastroenterology (GE) training is not studied in India.
Methods We designed a 36-question based google survey and distributed it to the GE residents all across India, via email. All the responses collected were analyzed using appropriate statistical methods.
Results A total of 140 responses were received. No significant decrease in teaching sessions/ classes was reported. Most of the residents (83.5%) reported inability to complete the target thesis enrolment. The number of patients seen by the residents in outpatient department, patients managed in wards and endoscopic procedures done by residents have decreased significantly (p-valve <0.001 for all). An overwhelming 89.9% (n = 125) of the GE residents were posted for COVID-19 duties. Almost half (50.4%) of them were COVID-19 positive.
Conclusion The COVID-19 pandemic has affected the training of GE residents in India immensely and an extension period of 3 months may be offered to them.
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Affiliation(s)
- Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ajay Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Amol Dahale
- Department of Gastroenterology, DY Patil Medical College, Pune, Maharashtra, India
| | | | - Manish Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Devesh Prakash Yadav
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College, Jaipur, Rajasthan, India
| | - Sandeep V. Nair
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Ashok Dalal
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
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Jain A, Sharma BC, Mahajan B, Srivastava S, Kumar A, Sachdeva S, Sonika U, Dalal A. L-ornithine L-aspartate in acute treatment of severe hepatic encephalopathy: A double-blind randomized controlled trial. Hepatology 2022; 75:1194-1203. [PMID: 34822189 DOI: 10.1002/hep.32255] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/13/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Data on the use of intravenous L-ornithine L-aspartate (LOLA) in the treatment of overt HE (OHE) is limited. We evaluated the role of intravenous LOLA in patients of cirrhosis with OHE grade III-IV. APPROACH AND RESULTS In a double-blind randomized placebo-controlled trial, 140 patients were randomized to a combination of LOLA, lactulose, and rifaximin (n = 70) or placebo, lactulose, and rifaximin (n = 70). LOLA was given as continuous intravenous infusion at a dose of 30 g over 24 h for 5 days. Ammonia levels, TNF-α, ILs, and endotoxins were measured on days 0 and 5. The primary outcome was the improvement in the grade of HE at day 5. Higher rates of improvement in grade of HE (92.5% vs. 66%, p < 0.001), lower time to recovery (2.70 ± 0.46 vs. 3.00 ± 0.87 days, p = 0.03), and lower 28-day mortality (16.4% vs. 41.8%, p = 0.001) were seen in the LOLA group as compared with placebo. Levels of inflammatory markers were reduced in both groups. Significantly higher reductions in levels of blood ammonia, IL-6, and TNF-α were seen in the LOLA group. CONCLUSIONS Combination of LOLA with lactulose and rifaximin was more effective than only lactulose and rifaximin in improving grades of HE, recovery time from encephalopathy, with lower 28-day mortality.
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Affiliation(s)
- Arpan Jain
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
| | | | - Bhawna Mahajan
- Department of BiochemistryGB Pant HospitalNew DelhiIndia
| | | | - Ajay Kumar
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
| | | | - Ujjwal Sonika
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
| | - Ashok Dalal
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
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Sachdeva S, Dalal A, Sonika U, Srivastava S. Mediastinal dumbbell pancreatic pseudocyst: An amazing cause of dysphagia. Dig Liver Dis 2022; 54:413-414. [PMID: 33139194 DOI: 10.1016/j.dld.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India.
| | - Ashok Dalal
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
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Kumar M, George R, Vaithiyam V, Sakhuja P, Dahale AS, Dayal A, Dalal A, Sonika U, Sachdeva S, Kumar A. Enhanced Liver Fibrosis Score: Is It Useful for Evaluation of Fibrosis Severity in Chronic Hepatitis C Infection? Cureus 2022; 14:e21168. [PMID: 35165618 PMCID: PMC8831389 DOI: 10.7759/cureus.21168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: The assessment of liver fibrosis is important in patients with chronic hepatitis C (CHC). In recent years, non-invasive tests like enhanced liver fibrosis (ELF) have been developed as an alternative to liver biopsy for estimating the severity of liver fibrosis. Therefore, we aimed to assess whether the ELF score can be used for fibrosis severity estimation using liver biopsy as the gold standard. Materials and methods: Forty-nine patients with CHC were enrolled in this study. Liver biopsy, ELF assessment, and transient elastography (TE) were performed in all patients, and severity of fibrosis on histopathology was assessed by meta-analysis of histological data in viral hepatitis (METAVIR) score. In addition, the diagnostic performance of ELF was evaluated by receiver operator characteristic curve (ROC) analyses, and liver biopsy histopathology was taken as the gold standard for the severity of liver fibrosis. Results: The area under receiver operator characteristic curve (AUROC) for significant fibrosis of ELF score was 0.64 (95% confidence interval {CI}, 0.48-0.79) and of TE was 0.85 (95% CI, 0.73-0.96). The AUROC for advance fibrosis of ELF was 0.77 (95% CI, 0.57-0.97) and TE was 0.98 (95% CI, 0.94-1.0). The calculated cut-offs of ELF overestimated fibrosis in 53.06% (26/49) of patients and underestimated fibrosis in 6.12% (3/49) patients. AUROC of TE was significantly better than ELF for diagnosis of significant fibrosis (p=0.004) and advanced fibrosis (p=0.034). Conclusion: The ELF score can be used for estimating the severity of fibrosis but it is inferior to TE in estimating liver fibrosis severity.
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Kaushal K, Gupta V, Goswami P, Agarwal S, Sharma S, Das P, Yadav R, Anand A, Sonika U, Gunjan D, Saraya A. Acute Variceal Bleed in Cirrhosis is Associated With Reversible Changes in Tight Junction Protein Expression in the Intestine: A Proof-of-Concept Study. J Clin Exp Hepatol 2022; 12:89-100. [PMID: 35068789 PMCID: PMC8766542 DOI: 10.1016/j.jceh.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/23/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Tight junction proteins (TJPs) play an important role in gut-barrier dysfunction in cirrhosis and its complications such as acute variceal bleed (AVB). However, the dynamics of TJPs expression after AVB, its relation to bacterial translocation, and impact on clinical outcome is largely unknown. AIMS The aim of this study was to study the expression of TJPs in cirrhosis and assess its dynamic changes in AVB. In addition, the relation of TJP expression to endotoxemia and clinical outcomes was assessed. METHODS In this prospective pilot study, 17 patients of cirrhosis with AVB, 59 patients of cirrhosis without AVB (non-AVB cirrhosis), and 20 controls were assessed for claudin-2 and claudin-4 expression in the duodenal biopsy. In the AVB-cirrhosis group, additional biopsies were obtained after 3 weeks. Endotoxemia was assessed by measuring IgG anti-endotoxin antibody levels. Claudin expression was correlated with a 6-month survival. RESULTS Claudin-2 expression was downregulated in patients with AVB and non-AVB cirrhosis in villi (P < 0.001 and 0.013) and crypts (P < 0.001 and 0.012), respectively, compared with the controls. Claudin-4 expression was similar in villi (P = 0.079), but lower in crypts (P = 0.007) in patients with cirrhosis. Claudin-2 expression was upregulated on serial biopsies in both villi and crypts (P = 0.003 and 0.001, respectively) in AVB-cirrhosis with postbleed expression comparable with those with non-AVB cirrhosis. IgG anti-endotoxin antibody levels were elevated in cirrhosis with no correlation with claudin-2/4 expression. Claudin-2 expression independently predicted survival at 6 months. CONCLUSION Both claudin-2 and claudin-4 expression are downregulated in cirrhosis. AVB is associated with dynamic changes in TJPs expression. Gut-barrier dysfunction might predict outcomes independent of bacterial endotoxemia in cirrhosis.
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Key Words
- AVB, Acute Variceal Bleed
- DAB, 3,3′-Diaminobenzidine
- EBL, Endoscopic Band Ligation
- EGD, Esophagogastroduodenoscopy
- HRV, high-risk varices
- IHC, Immunohistochemistry
- NSBB, Non-selective Beta Blockers
- PAMP, Pathogen associated molecular patterns
- TJP, Tight Junction Protein
- TMB, 3, 3′, 5, 5′-tetramethylbenzidine
- acute variceal bleed
- claudin-2
- endotoxemia
- tight junction proteins
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Affiliation(s)
- Kanav Kaushal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vipin Gupta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pooja Goswami
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Rajni Yadav
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ujjwal Sonika
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India,Address for correspondence: Anoop Saraya, Professor and Head, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India. Tel.: +91 9868397203.
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Dalal A, Dahale A, Gupta M, Saxena P, Kumar A, Sonika U, Kumar M, Srivastava S, Sachdeva S, Sharma B, Puri A. Endoscopic retrograde cholangiopancreaticography-related complications – Experience from tertiary care teaching centre over half a decade. J Minim Access Surg 2022; 18:526-532. [PMID: 35046182 PMCID: PMC9632712 DOI: 10.4103/jmas.jmas_272_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: Endoscopic retrograde cholangiopancreaticography (ERCP) is an essential therapeutic procedure with a significant risk of complications. Data regarding the complications and predictors of adverse outcomes such as mortality are scarce, especially from India and Asia. We aimed to look at the incidence and outcome of complications in ERCP patients. Materials and Methods: This study is a retrospective analysis of prospectively collected data of all the patients who underwent ERCP and had a complication from January 2012 to December 2018. Data were recorded in predesigned pro forma. The data analysis was done by appropriate statistical tests. RESULTS: A total of 17,163 ERCP were done. A total of 570 patients (3.3%) had complications; perforation (n = 275, 1.6%) was most common followed by pancreatitis (n = 177, 1.03%) and bleeding (n = 60, 0.35%). The majorities of perforations were managed conservatively (n = 205, 74.5%), and 53 (19%) required surgery. Overall, 69 (0.4%) patients died. Of these, 30 (10.9%) patients died with perforation. Age (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.005–1.07) and need of surgery (OR: 5.11, 95% CI: 1.66–15.77) were the predictors of mortality in patients with perforation. The majority pancreatitis were mild (n = 125, 70.6%) and overall mortality was 5.6% (n = 10). Conclusion: ERCP complications have been remained static over the years, with perforation and pancreatitis contributing the most. Most perforations can be managed conservatively with good clinical outcomes.
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Chawla G, Keena M, Sonika U, Abrol N, Hiremath S, Meena V. Indian tubercular belly: A prospective study of 140 patients of abdominal tuberculosis and their outcomes. J Family Med Prim Care 2022; 11:2423-2430. [PMID: 36119178 PMCID: PMC9480814 DOI: 10.4103/jfmpc.jfmpc_1198_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Abdominal tuberculosis is an important yet ignored entity in the spectrum of tuberculosis which has been dominated by pulmonary tuberculosis. Diagnosis and treatment are often delayed due to nonspecific symptoms. In this study, we aimed to highlight the clinical features, diagnostic methods and outcomes of abdominal tuberculosis. Methods: A prospective study was conducted in tertiary referral centre where all patients referred to drug distribution centres (DOTS centre) for abdominal tuberculosis were identified. Their demographic clinical and radiological profile was evaluated. These patients were followed-up for their treatment course for complications and outcomes. Results: A total of 140 patients who were labelled abdominal tuberculosis over a period of 2 years were reviewed at tuberculosis drug distribution centre (DOTS). Mean age of study population was 35.42 ± 12.53 years and majority of the population were males, 58.6% (82). The most common presenting symptom was abdominal pain which was seen in 82.8% (n = 116) of the patients, followed by feverin 65.6% (n = 92); 22.8% (n = 32) were seropositive for HIV and 44.2% (n = 62) had luminal tuberculosis of which ileocecal was the most common site. Peritoneum was second most common site which was involved in 26.4% (n = 37) of the patients followed by mixed tuberculosis involving more than one type. Confirmed diagnosis was achieved in 74 patients (52.8%), while the remaining 66 patients (47.14%) were diagnosed clinically. During follow-up, 12 patients were lost to follow-up; 113 (80.7%) had complete response, while 3 (2.14%) patients died during treatment. Conclusion: Abdominal tuberculosis usually presents with nonspecific complaints which require high index of suspicion. Most patients require only medical therapy which has good results.
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Sachdeva S, Dalal A, Dahale AS, Sonika U. Triple-A Syndrome: A rare cause of pediatric achalasia. Dig Liver Dis 2021; 53:1352-1353. [PMID: 32900647 DOI: 10.1016/j.dld.2020.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/15/2020] [Accepted: 08/20/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, New Delhi 110002, India.
| | - Ashok Dalal
- Department of Gastroenterology, GB Pant Hospital, New Delhi 110002, India
| | - Amol S Dahale
- Department of Gastroenterology, GB Pant Hospital, New Delhi 110002, India
| | - Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital, New Delhi 110002, India
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21
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Dalal A, Kumar A, Arivarasan K, Dahale A, Sachdeva S, Sonika U, Pawar A. Colonic Stenting Using Side-Viewing Endoscope: A Case Report. Journal of Digestive Endoscopy 2021. [DOI: 10.1055/s-0040-1713833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractColonic self-expandable metal stents (SEMS) are widely used as palliation for malignant obstruction. The conventional method involves using a forward-viewing endoscope as part of the procedure. Sometimes, however, the sharp angle of the stricture poses difficulty in evaluating the stricture, so a guidewire is placed across the stricture. Here, we present a case where a side-viewing endoscope was employed for colonic stent placement and propose its use in patients with sharp bends to increase success.
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Affiliation(s)
- Ashok Dalal
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ajay Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - K Arivarasan
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Amol Dahale
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ankush Pawar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
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22
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Kumar M, Sachdeva S, Kumar A, Sonika U, Gupta M, Srivastava S, Dahale A, Dalal A. Gastric Foreign Bodies in Prison Inmates. Journal of Digestive Endoscopy 2021. [DOI: 10.1055/s-0041-1731963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective Gastric foreign bodies are a common problem brought to an endoscopist. Prisoners are more prone to ingesting unusual foreign bodies for a secondary gain. The objective of this study was to study the profile of foreign body ingestion among the prisoners brought to a tertiary care center.
Methods This is a retrospective case series. All the prisoners brought for endoscopic removal of foreign bodies between January 2018 to December 2019 were included in the analysis. Patients’ baseline characteristics, type of foreign body, management, and outcome were noted
Results A total of eight inmates presented with ingestion of foreign body to our department. Most common foreign bodies ingested were drug packets and mobile phones. All ingestions were for secondary gain. Endoscopic removal was successful in all cases.
Conclusion Endoscopic removal can be tried with all necessary precautions by an expert endoscopist.
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Affiliation(s)
- Manish Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ajay Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Manish Gupta
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Amol Dahale
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ashok Dalal
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
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Padia G, Mahajan B, Kumar A, Sonika U, Dahale AS, Sachdeva S, Dalal A, George R. Cystatin C and interleukin-6 for prognosticating patients with acute decompensation of cirrhosis. JGH Open 2021; 5:459-464. [PMID: 33860096 PMCID: PMC8035439 DOI: 10.1002/jgh3.12516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/10/2022]
Abstract
Background and Aim Systemic inflammation and organ dysfunction/failure can complicate acute decompensation (AD) of cirrhosis with progression to acute‐on‐chronic liver failure (ACLF), leading to increased mortality. There are few studies on serum biomarkers predicting renal dysfunction (RD) or ACLF in AD. Serum cystatin C (CysC) and interleukin‐6 (IL‐6) were evaluated for predicting RD, ACLF, and mortality in AD patients. Methods Consecutive AD patients seen from January 2018 to June 2019 were included. IL‐6 and CysC were measured in serum at the time of index presentation. Patients were followed for 90 days or until primary (development of RD) or secondary outcomes (development of ACLF or mortality). Multivariate analysis was performed to find whether CysC and IL‐6 can independently predict primary and secondary outcomes. Results A total of 124 patients were screened; 88 patients were included. On follow up, 22 (27.3%) developed RD, 11 (11/57, 19.3%) developed ACLF, and 21 (24%) died. The CysC predicted RD (odds ratio [OR] 7.97, 95% confidence interval [CI] 2.70–23.53, P = 0.001) and ACLF (OR 5.486, 95% CI 1.456–20.6, P = 0.012) development. IL‐6 was not an independent predictor of RD (P = 0.315), ACLF (P = 0.168), and mortality (P = 0.225). Conclusion Serum CysC can predict the development of RD and ACLF in patients of cirrhosis with AD.
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Affiliation(s)
- Gaurav Padia
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Bhawana Mahajan
- Department of Biochemistry G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Ajay Kumar
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Ujjwal Sonika
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Amol S Dahale
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Sanjeev Sachdeva
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Ashok Dalal
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
| | - Roshan George
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research (GIPMER) New Delhi India
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Dalal A, Sonika U, Kumar M, George R, Kumar A, Srivastava S, Sachdeva S, Sharma BC. COVID-19 Rapid Antigen Test: Role in Screening Prior to Gastrointestinal Endoscopy. Clin Endosc 2021; 54:522-525. [PMID: 33657784 PMCID: PMC8357579 DOI: 10.5946/ce.2020.295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/23/2020] [Indexed: 01/27/2023] Open
Abstract
Background/Aims The severe acute respiratory syndrome coronavirus 2 pandemic has affected the gastrointestinal (GI) endoscopy units globally owing to the risk of transmission. We present our data on the use of rapid antigen test (RAT) as a screening tool prior to endoscopy to prevent the transmission of coronavirus disease (COVID-19).
Methods This study was a retrospective analysis of patients who underwent any GI endoscopic procedure from July 2020 to October 2020 at a tertiary referral center in New Delhi, India. All patients underwent screening for COVID-19 using RAT, and endoscopy was performed only when the RAT was negative. The data are presented as numbers and percentages.
Results A total of 3,002 endoscopic procedures were performed during the study period. Only one endoscopic procedure was performed in a COVID-19 positive patient. A total of 53 healthcare workers were involved in conducting these procedures. Only 2 healthcare workers (3.8%) were diagnosed COVID-19 positive, presumably due to community-acquired infection, during this period.
Conclusions The COVID-19 RAT is easily usable as a simple screening tool prior to GI endoscopy during the COVID-19 pandemic.
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Affiliation(s)
- Ashok Dalal
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Manish Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Roshan George
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Ajay Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Siddharth Srivastava
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
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Abstract
Background/Aims The management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce.
Methods Prospectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities.
Results A total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group.
Conclusions ED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.
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Affiliation(s)
- Ankush Pawar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Manish Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sundeep Saluja
- Department of Gastrosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Siddharth Srivastava
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are mucin-secreting cystic neoplasm of pancreas. They have a malignant potential. They are usually localised to the pancreas but occasionally can involve surrounding structures (1.9%-6.6%), like bile duct and duodenum, and are labelled as IPMN with invasion. Jaundice as a manifestation of IPMN is not common (4.5%). It can present as jaundice as a result of invasion of common bile duct (CBD) resulting in stricture formation or uncommonly as a result of fistulising to CBD with resultant obstruction of CBD by thick mucin secreted by this tumour. As only few cases (around 23) of mucin-filled CBD are reported in the literature. We are presenting our experience in dealing a rare case of obstructive jaundice caused by IPMN fistulising into CBD, highlighting the difficulties faced in managing such case, especially with regards to biliary drainage and what can be the optimum management in such cases.
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Affiliation(s)
- Manish Kumar
- Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Ashok Dalal
- Gastroenterology, GB Pant Hospital, New Delhi, India
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Sachdeva S, Sahu BK, Sonyabapu AD, Dalal A, Sonika U. Abdominal
CT
in a pregnant woman: Bane or boon? JGH Open 2021; 5:155-156. [PMID: 33490628 PMCID: PMC7812491 DOI: 10.1002/jgh3.12471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/25/2020] [Indexed: 11/07/2022]
Affiliation(s)
| | - Bimal K Sahu
- Department of Gastroenterology GB Pant Hospital New Delhi India
| | | | - Ashok Dalal
- Department of Gastroenterology GB Pant Hospital New Delhi India
| | - Ujjwal Sonika
- Department of Gastroenterology GB Pant Hospital New Delhi India
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Affiliation(s)
- Ujjwal Sonika
- Department of Gastroenterology, Academic Block GB Pant Hospital New Delhi India
| | - Ashok Dalal
- Department of Gastroenterology, Academic Block GB Pant Hospital New Delhi India
| | - Ajay Kumar
- Department of Gastroenterology, Academic Block GB Pant Hospital New Delhi India
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Agarwal S, Sharma S, Gunjan D, Singh N, Kaushal K, Poudel S, Anand A, Gopi S, Mohta S, Sonika U, Saraya A. Natural course of chronic pancreatitis and predictors of its progression. Pancreatology 2020; 20:347-355. [PMID: 32107194 DOI: 10.1016/j.pan.2020.02.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/26/2020] [Accepted: 02/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The natural course of chronic pancreatitis(CP) and its complications has been inadequately explored. We aimed to describe the natural history and factors affecting the progression of alcoholic(ACP), idiopathic juvenile(IJCP) and idiopathic senile(ISCP) variants of CP. METHODS This study was a retrospective analysis from a prospectively maintained database of patients with CP following up at a tertiary care centre from 1998 to 2019. Cumulative rates of pain resolution, diabetes, steatorrhea, pseudocysts and pancreatic cancer were computed using Kaplan-Meier analysis, and the factors affecting their incidence were identified on multivariable-adjusted Cox-proportional-hazards model. RESULTS A total of 1415 patients were included, with 540(38.1%) ACP, 668(47.2%) IJCP and 207(14.6%) ISCP with a median follow-up of 3.5 years(Inter-quartile range: 1.5-7.5 years). Diabetes occurred at 11.5, 28 and 5.8 years(p < 0.001) while steatorrhea occurred at 16, 24 and 18 years(p = 0.004) after onset for ACP, IJCP and ISCP respectively. Local complications including pseudocysts occurred predominantly in ACP(p < 0.001). Ten-year risk of pancreatic cancer was 0.9%, 0.2% and 5.2% in ACP, IJCP and ISCP, respectively(p < 0.001). Pain resolution occurred more frequently in patients with older age of onset[Multivariate Hazard Ratio(HR):1.7(95%CI:1.4-2.0; p < 0.001)], non-smokers[HR:0.51(95%CI:0.34-0.78); p = 0.002] and in non-calcific CP[HR:0.81(0.66-1.0); p = 0.047]. Occurrence of steatorrhea[HR:1.3(1.03-1.7); p = 0.028] and diabetes[HR:2.7(2.2-3.4); p < 0.001] depended primarily on age at onset. Occurrence of pancreatic cancer depended on age at onset[HR:12.1(4.7-31.2); p < 0.001], smoking-history[HR:6.5(2.2-19.0); p < 0.001] and non-alcoholic etiology[HR:0.14(0.05-0.4); p < 0.001]. CONCLUSION ACP, IJCP and ISCP represent distinct entities with different natural course. Age at onset of CP plays a major prognostic role in all manifestations, with alcohol predominantly causing local inflammatory complications.
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Affiliation(s)
- Samagra Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kanav Kaushal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shekhar Poudel
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Srikant Gopi
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Srikant Mohta
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ujjwal Sonika
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Singh N, Sonika U, Moka P, Sharma B, Sachdev V, Mishra SK, Upadhyay AD, Saraya A. Association of endotoxaemia & gut permeability with complications of acute pancreatitis: Secondary analysis of data. Indian J Med Res 2019; 149:763-770. [PMID: 31496529 PMCID: PMC6755773 DOI: 10.4103/ijmr.ijmr_763_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives: In acute pancreatitis (AP) gut barrier dysfunction is considered as an important predisposing factor leading to increased intestinal permeability (IP). In this study a pooled analysis of data published in our previous four studies on various aspects of gut permeability and endotoxaemia in patients with AP was attempted to find an association between increased IP and severity of disease and associated complications. Methods: This study was a pooled analysis of data of four previously published prospective studies on AP. Gut permeability, assessed by lactulose/mannitol excretion in urine and endotoxin core antibodies type IgG and IgM (EndoCab IgG and IgM) were measured on days zero and seven (D0 and D7) of admission. All patients received standard treatment of AP. We studied whether IgG and IgM anti-endotoxin titres and lactulose-mannitol ratio (LMR) at admission and D7 were associated with organ failure, infection and mortality. Results: The titres of anti-endotoxin IgG and IgM were lower in all patients of AP (n=204), both in mild AP (n=24) and severe AP (n=180) in the first week, compared to controls (n=15). There was no significant difference in serum IgG and IgM anti-endotoxin levels and LMR at baseline and at D7 among patients with organ failure, infection and mortality. Interpretation & conclusions: Our findings showed that serum IgG and IgM anti-endotoxin titres and LMR at admission and at day 7 were not associated with organ failure, infection, and death of patients with AP.
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Affiliation(s)
- Namrata Singh
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Praneeth Moka
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Brij Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Sachdev
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil Kumar Mishra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Datt Upadhyay
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Dahale AS, Srivastava S, Sonika U, Dalal A, Goyal A, Sakhuja P, Sachdeva S, Puri AS. Role of linear endosonography in the diagnosis of biopsy-negative malignant esophageal strictures: Exploring the unexplored. JGH Open 2019; 4:113-116. [PMID: 32280752 PMCID: PMC7144779 DOI: 10.1002/jgh3.12225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/13/2019] [Indexed: 11/09/2022]
Abstract
Background and Aim Endoscopic biopsy is standard for the diagnosis of esophageal malignancy. However, few cases present with smooth stricture with repetitive negative biopsy results. We aimed to use linear endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) in the diagnosis of biopsy-negative suspected malignant esophageal strictures. Methods We retrospectively analyzed the data from August 2017 to December 2018 of biopsy-negative esophageal strictures. All adult patients with twice-negative biopsies and with smooth overlying esophageal mucosa on endoscopy were included. Clinical, epidemiological, endoscopic, imaging, and EUS findings were noted and analyzed. Results Eighteen patients underwent EUS for suspicion of malignant esophageal stricture. Seven were excluded as they were submucosal tumors. Eleven patients showed the presence of malignancy on EUS FNA samples. Nine were males. Computed tomography showed esophageal wall thickening in eight (16-38 mm) and esophageal mass in three patients. EUS showed loss of a normal five-layered wall structure of the esophagus in all patients. Fine-needle aspiration cytology demonstrated squamous cell carcinoma (n = 4), adenocarcinoma (n = 4), poorly differentiated carcinoma (n = 2), and neuroendocrine carcinoma (n = 1). There were no complications. Conclusion EUS with FNA is effective and safe for the diagnosis of biopsy-negative malignant esophageal strictures.
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Affiliation(s)
- Amol S Dahale
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Siddharth Srivastava
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Ujjwal Sonika
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Ashok Dalal
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Aditi Goyal
- Department of Pathology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Puja Sakhuja
- Department of Pathology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Sanjeev Sachdeva
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
| | - Amarender S Puri
- Department of Gastroenterology G B Pant Institute of Postgraduate Medical Education and Research New Delhi India
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Sonika U, Sahu B, Dahale AS, Srivastava R, Saran RK, Sachdeva S. Gastrointestinal: Radiation proctitis: Or is it something else? J Gastroenterol Hepatol 2019; 34:1131. [PMID: 30693563 DOI: 10.1111/jgh.14592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/16/2018] [Accepted: 12/28/2018] [Indexed: 12/09/2022]
Affiliation(s)
- U Sonika
- Department of Gastroenterology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - B Sahu
- Department of Gastroenterology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - A S Dahale
- Department of Gastroenterology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - R Srivastava
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - R K Saran
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - S Sachdeva
- Department of Gastroenterology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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Shalimar, Sonika U, Kedia S, Mahapatra SJ, Nayak B, Yadav DP, Gunjan D, Thakur B, Kaur H, Acharya SK. Comparison of Dynamic Changes Among Various Prognostic Scores in Viral Hepatitis-Related Acute Liver Failure. Ann Hepatol 2019; 17:403-412. [PMID: 29735790 DOI: 10.5604/01.3001.0011.7384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Multiple prognostic scores are available for acute liver failure (ALF). Our objective was to compare the dynamicity of model for end stage liver disease (MELD), MELD-sodium, acute liver failure early dynamic model (ALFED), chronic liver failure (CLIF)-consortium ACLF score and King's College Hospital Criteria (KCH) for predicting outcome in ALF. MATERIALS AND METHODS All consecutive patients with ALF at a tertiary care centre in India were included. MELD, MELD-Na, ALFED, CLIF-C ACLF scores and KCH criteria were calculated at admission and day 3 of admission. Area under receiver operator characteristic curves (AUROC) were compared with DeLong method. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) and diagnostic accuracy (DA) were reported. RESULTS Of the 115 patients included in the study, 73 (63.5%) died. The discrimination of mortality with baseline values of prognostic scores (MELD, MELD-Na, ALFED, CLIF-C ACLF and KCH) was modest (AUROC: 0.65-0.77). The AUROC increased on day 3 for all scores, except KCH criteria. On day 3 of admission, ALFED score had the highest AUROC 0.95, followed by CLIF-C ACLF 0.88, MELD 0.81, MELD-Na 0.77 and KCH 0.52. The AUROC for ALFED was significantly higher than MELD, MELD-Na and KCH (P < 0.001 for all) and CLIF-C ACLF (P = 0.05). ALFED score ≥ 4 on day 3 had the best sensitivity (87.1%), specificity (89.5%), PPV (93.8%), NPV (79.1%), LR positive (8.3) and DA (87.9%) for predicting mortality. CONCLUSIONS Dynamic assessment of prognostic scores better predicts outcome. ALFED model performs better than MELD, MELD, MELD-Na, CLIF-C ACLF scores and KCH criteria for predicting outcome in viral hepatitis- related ALF.
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Affiliation(s)
- Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya J Mahapatra
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Harpreet Kaur
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K Acharya
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
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Sonika U, Jadaun S, Ranjan G, Rout G, Gunjan D, Kedia S, Nayak B, Shalimar. Alcohol-related acute-on-chronic liver failure-Comparison of various prognostic scores in predicting outcome. Indian J Gastroenterol 2018; 37:50-57. [PMID: 29476404 DOI: 10.1007/s12664-018-0827-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 01/10/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Various prognostic scores are available for predicting outcome in acute-on-chronic liver failure (ACLF). We compared the available prognostic models as predictors of outcome in alcohol-related ACLF patients. METHODS All consecutive patients with alcohol-related ACLF were included. At admission, prognostic indices-acute physiology and chronic health evaluation score (APACHE II), model for end-stage liver disease (MELD), MELD-Na, Maddrey's discriminant function (DF), age-bilirubin-INR-creatinine (ABIC), and Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C ACLF) score were calculated. Receiver operator characteristic (ROC) curves were plotted for all prognostic scores with in-hospital, 90-day, and 1-year mortality as outcome. RESULTS Of the 171 patients, 170 were males, and grade 1 ACLF in 20 (11.7%), grade 2 in 52 (30.4%), and grade 3 in 99 (57.9%) patients. One hundred and nineteen (69.6%) died in-hospital. The median (IQR) Maddrey's score, MELD, MELD-Na, ABIC, APACHE II, and CLIF-C ACLF were 87.8 (66.5-123.0), 33.1 (27.6-40.0), 34.4 (29.5-40.0), 8.5 (7.3-9.6), 15 (12-21), and 51.1 (44.1-56.4), respectively. On multivariate Cox regression analysis, independent predictors of in-hospital outcome were presence of hepatic encephalopathy (early HR, 2.078; 95%CI, 1.173-3.682, p = 0.012 and advanced, HR, 2.330; 95% CI, 1.270-4.276, p = 0.006), elevated serum creatinine (HR, 1.140; 95% CI, 1.023-1.270, p = 0.018), and infection at admission (HR, 1.874; 95% CI, 1.160-23.029, p = 0.010). On comparison of ROC curves, APACHE II and CLIF-C ACLF AUROC were significantly higher than MELD, MELD-Na, DF, and ABIC (p < 0.05) for predicting in-hospital, 90-day, and 1-year mortality. The AUROC was highest for APACHE II followed by CLIF-C ACLF (Hanley and McNeil, p = 0.660). CONCLUSIONS Alcohol-related ACLF has high in-hospital mortality. Among the available prognostic scores, CLIF-C ACLF and APACHE II perform best.
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Affiliation(s)
- Ujjwal Sonika
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shekhar Jadaun
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Gyan Ranjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Gyanranjan Rout
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
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Abstract
OBJECTIVE Infections are common and associated with complications and mortality in acute liver failure (ALF). The temporal relationship between ammonia and infection in ALF patients is unclear. We aimed to evaluate the predictors of infection and its relationship with arterial ammonia levels. MATERIALS AND METHODS Consecutive ALF patients hospitalized between January 2004 and December 2015, without signs of infection at/within 48 h of admission, were included. Occurrence of infection after 48 h was documented and ammonia levels were estimated for five consecutive days. Multivariate logistic regression analysis was used to assess factors associated with development of infection. Generalized estimating equations (GEE) were used to evaluate five-day time trend of ammonia in patients with and without infection. RESULTS Of 540 consecutive patients, 120 were infected at admission/within 48 h and were excluded. Of the rest 420 patients, 144 (34.3%) developed infection after 48 h and 276 (65.7%) remained non-infected. Infected patients had higher mortality than non-infected patients (61.8% vs 40.0%, p < .001). On multivariate analysis, presence of cerebral edema(HR 2.049; 95%CI, 1.30-3.23), ammonia level on day 3 of admission (HR 1.006; 95%CI, 1.003-1.008), and model for end stage liver disease (MELD) score (HR 1.051; 95%CI, 1.026-1.078) were associated with development of infection. GEE showed group difference in serial ammonia values between infected and non-infected patients indicating lack of ammonia decline in infected patients. CONCLUSIONS Cerebral edema, elevated ammonia on day 3, and higher MELD score predict the development of infection in ALF. Ammonia persists at high levels in infected patients, and elevated ammonia on day 3 is associated with complications and death.
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Affiliation(s)
- Shalimar
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Saurabh Kedia
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Hanish Sharma
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Sreejith Vasudevan
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Ujjwal Sonika
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Ashish Dutt Upadhyaya
- b Department of Biostatistics , All India Institute of Medical Sciences , New Delhi , India
| | - Subrat K Acharya
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
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Sonika U, Saha S, Kedia S, Dash NR, Pal S, Das P, Ahuja V, Sahni P. Predictive factors for malignancy in undiagnosed isolated small bowel strictures. Intest Res 2017; 15:518-523. [PMID: 29142520 PMCID: PMC5683983 DOI: 10.5217/ir.2017.15.4.518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/28/2017] [Accepted: 06/26/2017] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Patients with small bowel strictures have varied etiologies, including malignancy. Little data are available on the demographic profiles and etiologies of small bowel strictures in patients who undergo surgery because of intestinal obstruction but do not have a definitive pre-operative diagnosis. Methods Retrospective data were analyzed for all patients operated between January 2000 and October 2014 for small bowel strictures without mass lesions and a definite diagnosis after imaging and endoscopic examinations. Demographic parameters, imaging, endoscopic, and histological data were extracted from the medical records. Univariate and multivariate analyses were conducted to identify factors that could differentiate between intestinal tuberculosis (ITB) and Crohn's disease (CD) and between malignant and benign strictures. Results Of the 7,425 reviewed medical records, 89 met the inclusion criteria. The most common site of strictures was the proximal small intestine (41.5%). The most common histological diagnoses in patients with small bowel strictures were ITB (26.9%), CD (23.5%), non-specific strictures (20.2%), malignancy (15.5%), ischemia (10.1%), and other complications (3.4%). Patients with malignant strictures were older than patients with benign etiologies (47.6±15.9 years vs. 37.4±16.4 years, P=0.03) and age >50 years had a specificity for malignant etiology of 80%. Only 7.1% of the patients with malignant strictures had more than 1 stricture and 64% had proximally located strictures. Diarrhea was the only factor that predicted the diagnosis of CD 6.5 (95% confidence interval, 1.10–38.25; P=0.038) compared with the diagnosis of ITB. Conclusions Malignancy was the cause of small bowel strictures in approximately 16% patients, especially among older patients with a single stricture in the proximal location. Empirical therapy should be avoided and the threshold for surgical resection is low in these patients.
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Affiliation(s)
- Ujjwal Sonika
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sujeet Saha
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
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Saraswat V, Singh SP, Duseja A, Shukla A, Eapen CE, Kumar D, Pandey G, Venkataraman J, Puri P, Narayanswami K, Dhiman RK, Thareja S, Nijhawan S, Bhatia S, Zachariah U, Sonika U, Varghese T, Acharya SK. Acute-on-chronic liver failure in India: The Indian National Association for Study of the Liver consortium experience. J Gastroenterol Hepatol 2016; 31:1742-1749. [PMID: 26989861 DOI: 10.1111/jgh.13340] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/19/2016] [Accepted: 03/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to analyze etiologies and frequency of hepatic and extrahepatic organ failures (OFs) and outcome of acute-on-chronic liver failure (ACLF) at 10 tertiary centers in India. METHODS In this retrospective study (2011-2014), patients satisfying Asian Pacific Association for the Study of the Liver definition of ACLF were included. Etiology of acute precipitating insult and chronic liver disease and outcomes were assessed. Occurrence and severity of OF were assessed by chronic liver failure-sequential organ failure assessment score. RESULTS The mean (±SD) age of 1049 consecutive ACLF patients was 44.7 ± 12.2 years; Eighty-two percent were men. Etiology of acute precipitants included alcohol 35.7%, hepatitis viruses (hepatitis A, hepatitis B, and hepatitis E) 21.4%, sepsis 16.6%, variceal bleeding 8.4%, drugs 5.7%, and cryptogenic 9.9%. Among causes of chronic liver disease, alcohol was commonest 56.7%, followed by cryptogenic and hepatitis viruses. Predictors of survival were analyzed for a subset of 381 ACLF patients; OF's liver, renal, coagulation, cerebral, respiratory, and failure were seen in 68%, 32%, 31.5%, 22.6%, 14.5%, and 15%, respectively. Fifty-seven patients had no OF, whereas 1, 2, 3, 4, and 5 OFs were recorded in 126, 86, 72, 28, and 12 patients, respectively. The mortality increased progressively with increasing number of OFs (12.3% with no OF, 83.3% with five OFs). During a median hospital stay of 8 days, 42.6% (447/1049) of patients died. On multivariate analysis by Cox proportional hazard model, elevated serum creatinine (hazard ratio [HR] 1.176), advanced hepatic encephalopathy (HR 2.698), and requirement of ventilator support (HR 2.484) were independent predictors of mortality. CONCLUSIONS Alcohol was the commonest etiology of ACLF. Within a mean hospital stay of 8 days, 42% patients died. OFs independently predicted survival.
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Affiliation(s)
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- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Saraswat
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | - Ajay Duseja
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Shukla
- Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | | | - Gaurav Pandey
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | | - Radha K Dhiman
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Shobna Bhatia
- Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | - Ujjwal Sonika
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Nayak HK, Sonika U, Rajkumar VD, Premashiskar, Saran RK, Sureshkumar, Kumar N. An unusual presentation of Castleman's disease. ACTA ACUST UNITED AC 2014; 34:113-5. [PMID: 24377164 DOI: 10.7869/tg.2012.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hemanta Kumar Nayak
- Department of Medicine, LN Hospital, Maulana Azad Medical College, New Delhi, India.
| | - Ujjwal Sonika
- Department of Medicine, LN Hospital, Maulana Azad Medical College, New Delhi, India
| | | | - Premashiskar
- Department of Medicine, LN Hospital, Maulana Azad Medical College, New Delhi, India
| | - R K Saran
- Department of Medicine, LN Hospital, Maulana Azad Medical College, New Delhi, India
| | - Sureshkumar
- Department of Medicine, LN Hospital, Maulana Azad Medical College, New Delhi, India
| | - Naresh Kumar
- Department of Medicine, LN Hospital, Maulana Azad Medical College, New Delhi, India
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Nayak HK, Kar P, Bagchi A, Kapoor N, Kapahtia S, Sonika U, Kumar N, Kumar S. Waldenstrom macroglobulinemia presenting with pancreatic mass: a case report and review of literature. JOP 2013; 14:92-5. [PMID: 23306344 DOI: 10.6092/1590-8577/1271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 11/30/2012] [Accepted: 12/01/2012] [Indexed: 11/10/2022]
Abstract
CONTEXT Waldenstrom macroglobulinemia is a rare lymphoplasmacytic lymphoma characterized by a wide range of clinical presentations related to direct tumor infiltration and the production of IgM. Most commonly it presents with cytopenia, hepatosplenomegaly, lymphadenopathy, constitutional symptoms, and hyperviscosity syndrome. CASE REPORT We report a case of Waldenstrom macroglobulinemia in an 60-year-old female who initially presented with intermittent abdominal pain. The patient had no peripheral lymphadenopathy. On extensive investigation she was found to have pancreatic mass. The diagnosis of Waldenstrom macroglobulinemia was established after cytomorphology and immunohistochemical analysis of the patient's bone marrow revealed the presence of a lymphoid/lymphoplasmacytoid-like bone marrow infiltrate along with an elevated serum IgM level. The patient responded both clinically and serologically to chemotherapy. This case is unusual because the patient lacked all common clinical features of Waldenstrom macroglobulinemia with exception of anemia. CONCLUSION To our knowledge this is the first report of a patient with Waldenstrom macroglobulinemia presenting with a pancreatic mass adding to the spectrum of clinical presentations seen in this disease. This adds to the wide variety of gastrointestinal related clinical presentations of Waldenstrom macroglobulinemia and points to the need for considering Waldenstrom macroglobulinemia along with other lymphoid neoplasms in the differential diagnosis of pancreatic lesions.
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Affiliation(s)
- Hemanta Kumar Nayak
- Department of Medicine, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India.
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Abstract
Tuberculosis is one of the most common diseases in India and has attained epidemic proportions. Tuberculosis and liver are related in many ways. Liver disease can occur due to hepatic tuberculosis or the treatment with various anti-tubercular drugs may precipitate hepatic injury or patients with chronic liver disease may develop tuberculosis and pose special management problems. Tuberculosis per se can affect liver in three forms. The most common form is the diffuse hepatic involvement, seen along with pulmonary or miliary tuberculosis. The second is granulomatous hepatitis and the third, much rarer form presents as focal/local tuberculoma or abscess. Tubercular disease of liver occurring along with pulmonary involvement as in disseminated tuberculosis is treated with standard regimen for pulmonary tuberculosis. Granulomatous hepatitis and tubercular liver abscess are treated like any other extra-pulmonary tubercular lesions without any extra risk of hepatotoxicity by anti-tubercular drugs. Treatment of tuberculosis in patients who already have a chronic liver disease poses various clinical challenges. There is an increased risk of drug induced hepatitis in these patients and its implications are potentially more serious in these patients as their hepatic reserve is already depleted. However, hepatotoxic anti-tubercular drugs can be safely used in these patients if the number of drugs used is adjusted appropriately. Thus, the main principle is to closely monitor the patient for signs of worsening liver disease and to reduce the number of hepatotoxic drugs in the anti-tubercular regimen according to the severity of underlying liver disease.
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Affiliation(s)
- Ujjwal Sonika
- Department of Medicine, Maulana Azad Medical College, New Dehi, India
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Nayak HK, Vangipuram DR, Kumar S, Kar P, Gupta A, Kapoor N, Sonika U. Sweet's syndrome in a patient with infective endocarditis: a rare clinical entity. BMJ Case Rep 2012; 2012:bcr.12.2011.5398. [PMID: 22605716 DOI: 10.1136/bcr.12.2011.5398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Sweet's syndrome, also known as acute febrile neutrophilic dermatosis, has been associated with malignancy, autoimmune disease and collagen vascular disease. The association of infective endocarditis and Sweet's syndrome is rare. The authors report a case of Sweet's syndrome in a patient with infective endocarditis. Infective endocarditis should be excluded in patients of rheumatic heart disease presenting with Sweet's syndrome. Alternatively, Sweet's syndrome should be considered as a differential diagnosis when a patient with infective endocarditis develops skin lesions.
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Affiliation(s)
- Hemanta K Nayak
- Department of Medicine, Maulana Azad Medical College, Newdelhi, India.
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Nayak HK, Vangipuram DR, Sonika U, Kar P, Kumar N, Kapoor N. Mediastinal mass-a rare presentation of desmoplastic small round cell tumour. BMJ Case Rep 2011; 2011:bcr.10.2011.5042. [PMID: 22670008 DOI: 10.1136/bcr.10.2011.5042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Primary mediastinal desmoplastic small round cell cancer is an uncommon tumour usually located in the abdomen and pelvis. Here the authors report an extremely rare case of a young male with a primary desmoplastic small round cell tumour in the anterior and middle mediastinum. The patient had non-specific complaints but an abnormal shadow was seen in a routine chest x-ray. He was diagnosed as having mediastinal mass with few lung parenchymal deposits on CT. Mediastinoscopy and guided biopsy revealed desmoplastic small round cell tumour. Desmoplastic small round cell tumour is a rare and aggressive tumour which rarely involves the mediastinum as a primary site. The nature of the lesion and its prognosis were explained to the patient. He was offered chemotherapy and radiotherapy for the tumour management. He refused treatment and left against medical advice.
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Affiliation(s)
- Hemanta K Nayak
- Department of Medicine, Maulana Azad Medical College, Newdelhi, India.
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