Mandhir Kumar

Endoscopic ultrasound-guided drainage of pelvic abscess without fluoroscopy guidance

Background and Aims:  Few case series are reported on endoscopic ultrasound (EUS)‐guided drainage of pelvic abscesses under fluoroscopy guidance. We hypothesized that EUS‐guided drainage of pelvic abscesses without fluoroscopy is an effective alternative to surgery in patients whose abscesses are not amenable to percutaneous drainage techniques. The aim of this study is to evaluate the clinical efficacy of EUS‐guided trans‐rectal/transcolonic drainage of pelvic abscess without fluoroscopy.

Air cholangiogram: a new technique for biliary imaging during ERCP

BACKGROUND Palliation of patients with malignant hilar stenosis by stent insertion is fraught with risk of cholangitis because of contrast injection in the undrained segment. OBJECTIVE The purpose of this study was to evaluate the results of unilateral metal stenting in type II and III malignant hilar biliary obstruction by using air as a contrast medium. DESIGN Prospective, uncontrolled, single center pilot study. SETTING Tertiary care referral center. PATIENTS Cohort of 17 patients with malignant hilar obstruction. INTERVENTION A single metallic stent was inserted in type II and III malignant hilar obstruction by using air as a contrast medium. Patients were evaluated weekly up to 1 month after stent placement. MAIN OUTCOME MEASURES Successful implantation, successful drainage, early complications, procedure-related mortality, 30-day mortality. RESULT Successful stent placement and drainage was achieved in 100% of the patients (17 of 17). No patient developed cholangitis or died within 30 days of the procedure. LIMITATIONS Small cohort of patients. CONCLUSION Air cholangiography provides a safe and effective roadmap for unilateral metallic stenting in type II and III malignant hilar biliary obstruction.

SYNTHESIS OF 2,4-DIARYL-2,3-DIHYDRO-1, 5-BENZOTHIAZEPINES

A new series of functionalized 2,4-diaryl-2,3-dihydro-l,5benzothiazepines have been synthesized by a convenient single step synthesis involving heterocyclization reaction of 2-aminobenzenethiols with a, ß-unsaturated ketones in toluene in the presence of catalytic amount of glacial acetic acid. The synthesized compounds have been characterized by their elemental analyses and spectral characteristics.

Pseudoaneurysm of the inferior phrenic artery presenting as an upper gastrointestinal bleed by directly rupturing into the stomach in a patient with chronic pancreatitis.

Pseudoaneurysms occurring in patients with chronic pancreatitis are associated with significant morbidity and mortality. These pseudoaneurysms occur more commonly in the splenic, pancreaticoduodenal, and gastroduodenal arteries. Upper gastrointestinal bleeding (UGIB) due to pseudoaneurysms in patients with pancreatitis with pseudocyst usually presents as hemosuccus pancreaticus. However, pseudoaneurysm directly perforating the gastrointestinal tract and presenting as UGIB is a rare complication. We report here the first case of UGIB from the inferior left phrenic artery pseudoaneurysm rupturing directly into the stomach of a patient with chronic pancreatitis.

Prospective study of profile of hepatic osteodystrophy in patients with non-choleastatic liver cirrhosis and impact of bisphosphonate supplementation

Background and objectives Patients with liver cirrhosis are more prone to develop reduced bone mineral density (BMD), i.e. hepatic osteodystrophy (HOD). There are few data on the prevalence of HOD in the Indian population and its treatment. We aimed to determine the prevalence of HOD, factors associated with it and the impact of bisphosphonates on BMD in patients with liver cirrhosis. Patients and methods Consecutive patients with liver cirrhosis admitted at Sir Ganga Ram Hospital, New Delhi, between August 2012 and July 2013 were enrolled. Patients with chronic kidney disease, hyperparathyroidism and those on steroids were excluded. BMD was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar spine and femoral neck. Osteopenia and osteoporosis were defined according to WHO criteria. Ibandronic acid 150 mg per day orally for six months was given to patients with osteoporosis and DEXA scan repeated. Results A total of 215 patients (males 179, 83%) with a mean age of 50.9 ± 11 years were enrolled in this study. Prevalence of HOD was found to be 66% (142/215). On multivariate analysis BMI, TLC, total serum bilirubin and transient elastography values were found to be independently associated with HOD. All the patients with osteoporosis (n = 47) were treated with ibandronic acid as per protocol. Treated patients had significant improvement in DEXA scans after six months as compared to baseline. Conclusions HOD was seen in two-thirds of patients with liver cirrhosis. Higher liver stiffness as determined by transient elastography is significantly associated with HOD. Severity scores of liver disease (CTP and MELD) and etiology of liver cirrhosis did not determine HOD. Ibandronic acid is a safe drug that showed significant improvement in BMD in patients with liver disease along with osteoporosis.

Low eosinophil count predicts in-hospital mortality in cirrhosis with systemic inflammatory response syndrome.

Background Absolute eosinophil count (AEC) and procalcitonin (PCT) level may have a prognostic value in critically ill patients. However, their role in cirrhotic patients has never been studied. We evaluated the role of AEC and PCT, obtained at admission, in predicting in-hospital mortality in cirrhotic patients with systemic inflammatory response syndrome (SIRS). Patients and methods In consecutive cirrhotic patients with SIRS (with or without sepsis), the levels of AEC and PCT were estimated at admission. Their outcome was correlated with these baseline parameters. Results One hundred patients were enrolled [median age 52 (range 17–78) years, 84% men]. The etiology of cirrhosis was alcohol (47%), cryptogenic (35%), viral (13%), and others (5%). Their median model for end-stage liver disease (MELD) and Child–Turcotte–Pugh scores were 24 (range 6–40) and 11 (range 5–15), respectively. Infection was present in 59 patients and the rest of the 41 patients had SIRS without infection. There was a significant difference between the median levels of AEC and PCT between patients who had infection and those who did not have infection (P<0.01). Sixty-three patients recovered from SIRS and were discharged, 33 patients died, and four patients received orthotopic liver transplantation during the same admission. Baseline AEC and PCT levels were significantly different between patients who recovered and died. On multivariate analysis, baseline AEC values could independently predict in-hospital mortality, in addition to MELD and serum sodium. The area under receiver operating characteristic curve of AEC for predicting mortality was 0.785, and the best cutoff of AEC, obtained by Youden’s index, was 104 cells/cumm, indicating that patients with baseline AEC values less than 104 cells/cumm had higher in-hospital mortality (sensitivity 78%, specificity 70%, positive predictive value 60%, negative predictive value 85%, and accuracy 73%). Conclusion In critically ill cirrhotic patients with SIRS, a baseline AEC value of less than 104 cells/cumm accurately predicts in-hospital mortality. The prediction of mortality by AEC is independent of the MELD score and serum sodium.

Hepatogastric fistula: A rare complication of liver abscess

Rupture of amebic liver abscess into stomach is a rare complication. We report a case of a young male presenting with haematemesis due to a rupture of left lobe amebic liver abscess into stomach. We discuss the diagnosis and management of this rare clinical entity.

Dysphagia as initial presentation of primary amyloidosis

Amyloidosis involves all parts of the gastrointestinal tract including the esophagus. The esophageal involvement in amyloidosis has been reported to vary from 13% in a radiology study to 22% in an autopsy series; however, such patients have symptoms of gastroesophageal reflux. Dysphagia is an uncommon presentation of amyloidosis. We report a 64-year-old patient who presented with progressive dysphagia of 4 months duration which was confirmed to be due to primary amyloidosis with multiple myeloma. The esophageal involvement by amyloidosis was confirmed by esophageal mucosal biopsies, and 22-channel high-resolution manometry.

All ileo-cecal ulcers are not Crohn’s: Changing perspectives of symptomatic ileocecal ulcers

AIM To investigated clinical, endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy. METHODS Consecutive symptomatic patients undergoing colonoscopy, and diagnosed to have ulcerations in the ileocecal (I/C) region, were enrolled. Biopsy was obtained and their clinical presentation and outcome were recorded. RESULTS Out of 1632 colonoscopies, 104 patients had ulcerations in the I/C region and were included in the study. Their median age was 44.5 years and 59% were males. The predominant presentation was lower GI bleed (55, 53%), pain abdomen ± diarrhea (36, 35%), fever (32, 31%), and diarrhea alone (9, 9%). On colonoscopy, terminal ileum was entered in 96 (92%) cases. The distribution of ulcers was as follows: Ileum alone 40% (38/96), cecum alone 33% (32/96), and both ileum plus cecum 27% (26/96). The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon. Based on clinical presentation and investigations, the etiology of ulcers was classified into infective causes (43%) and non-infective causes (57%). Fourteen patients (13%) were diagnosed to have Crohn’s disease (CD). CONCLUSION Non-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region. And if all infections are clubbed together then infection is the most common (> 40%) cause of ulcerations of the I/C region. Cecal involvement and fever are important clues to infective cause. On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers. So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn’s.

Predictors of Response and Outcome to Terlipressin in Patients With Hepatorenal Syndrome

P0213 DIABETES IS A MAJOR DETERMINANT FOR REFRACTORY ASCITES IN PATIENTS WITH CIRHOSIS AND IS ASSOCIATED WITH HEPATIC MICROCIRCULATORY CHANGES L. Elkrief, S. Buyse, X. Panhard, C. Baudry, R. Moreau, P.-E. Rautou, J. Belghiti, F. Durand, P. Bedossa, D. Valla, V. Paradis. Service d’Hepatologie, Hopital Beaujon – AP-HP, Universite Paris Diderot, and INSERM U1149, Centre de Recherche sur l’Inflammation, Service d’Anatomie et cytologie pathologiques, Hopital Beaujon – AP-HP, Universite Paris Diderot, and INSERM U1149, Centre de Recherche sur l’Inflammation, Service de Chirurgie digestive Hopital Beaujon – AP-HP, Universite Paris Diderot, and INSERM U1149, Centre de Recherche sur l’Inflammation, Clichy, France E-mail: laure_elkrief@yahoo.fr