Ragesh Babu Thandassery

Prospective validation of 4-category classification of acute pancreatitis severity.

Objective Atlanta classification divides patients with acute pancreatitis (AP) into mild and severe disease. A 4-category severity classification has been proposed based on the presence or absence of local and systemic determinants, giving rise to mild, moderate, severe, or critical AP. The aim of this study was to validate this new 4-category system of severity classification by examining markers of severity and outcome. Methods Data from 151 consecutive patients with AP from January 2009 to December 2010 [mean age (SD), 41.1 (3.5) years; 101 men] were collected. Management was standardized. Patients were classified as mild [no necrosis or organ failure (OF)], moderate (sterile necrosis or transient OF), severe [infected necrosis (IN) or persistent OF], or critical (IN and persistent OF) AP. Data were compared between groups for severity and outcome. Results There were 21 (13.9%) patients with mild, 63 (41.7%) moderate, 59 (39.1%) severe, and 8 (5.3%) critical AP. There was a significant difference between these categories for length of hospital stay, computed tomographic severity index scores, occurrence of bloodstream infections, incidence of IN, requirements for percutaneous catheter drain, numbers of operations, and mortality. Conclusions This prospective case series clinically validated the 4-category classification of AP severity.

Dynamic nature of organ failure in severe acute pancreatitis: the impact of persistent and deteriorating organ failure

BACKGROUND AND AIMS In acute pancreatitis (AP), patients with persistent organ failure [POF, duration of organ failure (OF) ≥48 h] and transient organ failure (TOF, duration of OF <48 h) have different outcomes. We have compared the clinical course and outcome of patients with severe AP (SAP) with TOF and POF in the first week of hospitalization as well as the impact of change in the OF score in the first week on patient outcome. METHODS Consecutive patients with SAP were evaluated for OF and its dynamics during the first week of hospitalization. The modified multiple organ failure score (MOFS) was used to identify OF, grade its severity and monitor its progression. The clinical course and outcome of patients were studied. RESULTS Of 114 patients, mean age 39.2 ± 13.7 years, 37 (32.5%) patients had no OF, 34 (29.8%) had TOF and 43(37.7%) had POF. Patients with POF had the higher infected necrosis, increased requirement for percutaneous drain placement, surgery and higher mortality as compared with those with TOF. The odds ratio for mortality with persistent and deteriorating OF was 26.2 [confidence interval (CI) 5.1-134.9] compared with only persistent OF. CONCLUSION The dynamics of OF in the first week of SAP predicts the clinical course and outcome. Persistent and deteriorating OF indicates a poor outcome.

Diagnostic yield of EUS-guided FNA and cytology in suspected tubercular intra-abdominal lymphadenopathy.

BACKGROUND Intra-abdominal lymphadenopathy is a common diagnostic challenge faced by clinicians. In the absence of palpable peripheral nodes, tissue is usually obtained from the abdominal nodes by image-guided biopsy or surgery. We speculate that EUS-guided FNA (EUS-FNA) avoids the morbidity of a laparotomy and might be equally effective. OBJECTIVE To evaluate the role of EUS-FNA in abdominal lymphadenopathy. DESIGN Prospective study conducted over 42 months. SETTING Tertiary care center in New Delhi, India. PATIENTS Patients with abdominal lymphadenopathy in whom image-guided node biopsy failed were considered for EUS-FNA. INTERVENTION A total of 3 passes were performed at each site. Slides were prepared per protocol and sent for cytopathologic evaluation. RESULTS A total of 142 patients were enrolled, but only 130 (91.5%) underwent FNA. The mean lymph node size was 22 ± 3.2 mm; 71.8% of the nodes were hypoechoic (n = 102), and 28.1% were heterogeneous with an anechoic center (n = 40). In 120 patients (84.5%), the lymph nodes were intra-abdominal only, and in 22 patients (15.5%), they were both intra-abdominal and mediastinal in location. MAIN OUTCOME MEASUREMENT EUS-FNA was successful in establishing a diagnosis in 90.8% of these patients; 76.1% were found to have tuberculosis, 7.04% sarcoidosis, 6.33% Hodgkins lymphoma, and 0.74% non-Hodgkins lymphoma. LIMITATIONS In 8.4% patients, nodes were inaccessible because of their retropancreatic location. CONCLUSIONS EUS-FNA is a safe, accurate, and minimally invasive modality for diagnosing the cause of abdominal lymphadenopathy. In highly endemic areas, tuberculosis is the most common cause.

Reexamination of the relationship between the prevalence of hepatitis C virus and parenteral antischistosomal therapy among Egyptians resident in Qatar

Egypt has the highest prevalence of recorded hepatitis C virus (HCV) worldwide, estimated nationally at 14.7%, which is attributed to extensive iatrogenic transmission during the era of parenteral antischistosomal therapy (PAT) mass-treatment campaigns. The objective of our study was to attempt to highlight to what extent HCV transmission is ongoing and discuss the possible risk factors. We studied the prevalence of HCV among 7.8% of Egyptians resident in Qatar in relation to age, socioeconomic status, and PAT and discuss the possible risk factors. HCV testing was conducted in 2,335 participants, and results were positive for 13.5%, and 8.5% for those aged below 35 years. The prevalence of HCV in the PAT-positive population was 23.7% (123 of 518, 95% confidence interval [CI] 20.2%–27.6%) compared with 11.2% in the PAT-negative group. Significantly higher HCV prevalence occurred in participants who were older than 50 years (23%, 95% CI 19.3%–27.1%) compared to those aged 45–50 years (19.3%, 95% CI 15.2%–23.8%), 35–45 years (11.1%, 95% CI 8.9%–13.7%), and less than 35 years (8.5%, 95% CI 6.8%–10.4%) (P<0.0001). Insignificant higher prevalence occurred in the low socioeconomic group (14.2%, 95% CI 11.3%–17.4%). Logistic regression analysis revealed that increasing age, history of PAT, bilharziasis, and praziquantel were common risk factors, but there was no relation with dental care. Host genetic predisposition seems to be a plausible underlying factor for susceptibility among Egyptians and intense ongoing infection.

Melanoma of Stomach

IntroductionMelanoma of gastrointestinal tract can be either primary or secondary to metastases from other sites like skin, mucous membranes, and uvea. Primary gastrointestinal melanoma is rare and still rarer is stomach involvement.Case ReportWe report a case of primary malignant melanoma of stomach in a 50-year-old female who presented with an axillary lymphadenopathy.ConclusionMelanoma of stomach is rare. It has characteristic endoscopic appearance. Differentiation of primary from secondary melanoma is possible on clinical behavior and histological characteristics.

Chronic Calcific Pancreatitis Presenting as an Isolated Left Perinephric Abscess: A Case Report and Review of the Literature

CONTEXT Acute and chronic pancreatitis may present with pseudocysts in atypical locations. Activated pancreatic enzymes track along anatomic fascial planes causing digestion of the surrounding tissues and resulting in distant pseudocysts. Pseudocysts at atypical locations pose significant diagnostic as well as therapeutic challenges. CASE REPORT We report an unusual presentation of a pancreatic pseudocyst in a young male who presented with a left perinephric abscess. Percutaneous drainage was not successful in resolving the abscess and he was subsequently diagnosed as having chronic pancreatitis together with a left perinephric abscess. Needle knife sphincterotomy of the ampulla of Vater resulted in the gradual resolution of the abscess. CONCLUSION We report a rare presentation of chronic pancreatitis with a perinephric abscess and its non-surgical management. This case report indicates that any patient presenting with a perinephric abscess of unknown etiology not responding to conventional treatment modalities should be investigated for underlying pancreatitis.

Characterization of Cardiac Dysfunction by Echocardiography in Early Severe Acute Pancreatitis

Objective Persistent organ failure is a feature of severe acute pancreatitis (SAP) and the leading cause of death. Although usually defined by hypotension, cardiovascular dysfunction (CD) in early SAP has not been well characterized. We aim to characterize CD in patients with SAP and hypotension and determine its impact on clinical outcome. Methods Patients with SAP and hypotension were studied to define the frequency, nature, and prognostic significance of CD characterized by echocardiography and classified as systolic, diastolic, or combined dysfunction. Results Of the 72 patients (median age, 41 years, 44 men), 10 (14%) had percutaneous drain placement, 12 (17%) underwent surgery, and 14 (19%) died. Persistent hypotension was present in 58 (81%) and transient hypotension in 14 (19%) patients. Cardiovascular dysfunction was present in 47 (65%) patients: 28 (60%) with diastolic dysfunction, 8 (17%) with systolic dysfunction, and 11 (23%) with combined dysfunction. Left ventricular end diastolic volume, stroke volume index, cardiac index, and diastolic dysfunction correlated with mortality on univariate analysis. Conclusions Two thirds of patients with early SAP and hypotension had cardiac dysfunction, which was most commonly diastolic dysfunction. A better understanding of the nature of cardiac dysfunction in this setting may allow more accurate diagnosis, prognostication, and management.

Sa1351 Neutrophil Gelatinase-Associated Lipocalin: An Early Biomarker for Predicting Acute Kidney Injury in Patients With Acute Pancreatitis

GTL alone. CONCLUSIONS: High concentrations of UFA, IL-1beta and IL-8 in necrosis fluid relative to NIC fluids supports these to be the potential culprits in necrotic cell death as evidenced by high DNA content in the post-necrotic fluid. The ability of orlistat to reduce serum lipase, NEFA, UFA, LA concentrations in rat serum demonstrates its efficacy as a lipase inhibitor in this model. The high mortality, necrosis, IL-1beta and IL-8 concentrations, distant organ injury in GTL infused rats, and reduction of these with orlistat supports lipolytic generation of UFAs to be the driver of inflammation and necrosis. Therefore, the combined data suggests that lipotoxicity may drive inflammation and necrosis in human acute pancreatitis. Table 1: Human Data

Double Pylorus: An Optical Illusion or Reality?

Question: A 30-year-old woman underwent an upper gastrointestinal endoscopy for dyspepsia for 2 months not responding to proton pump inhibitors. The esophagus and stomach was normal except for the appearance of 2 pyloric openings (Figure A). She had no history of surgery. Further examination showed normal duodenum. Patient underwent an endoscopic ultrasound to confirm the diagnosis (Figure B, C; Video Clip 1). What is the diagnosis? If the second opening is virtual, which one is that and what does it correspond with? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Large "pedunculated" colonic lipoma: a word of caution while cutting into fat!

Sir, A 75-year-old female who had undergone low anterior resection 1 year back for synchronous anal canal and rectosigmoid adenocarcinoma was referred for surveillance colonoscopy. She was asymptomatic after surgery with normal carcinoembryonic antigen levels. Colonoscopy from the colostomy site revealed a large pedunculated polypoidal lesion measuring about 3 cm in the transverse colon (Fig. 1a). It did not show any dimpling on palpation with biopsy forceps. The “mucosal polyp” was removed with snare cautery (Fig. 1b). There were no immediate post-procedure complications. Twenty-four hours later, she developed mild fresh bleeding per rectum. She had no drop in hemoglobin and vitals were stable. Repeat colonoscopy revealed a clean-based ulcer on the polypectomy stump (Fig. 1c). Biopsy of the polypoidal structure revealed it to be a large submucosal lipoma with thick stalk (Fig. 1d). She is asymptomatic thereafter and is under follow up. Colonic lipomas are not uncommon and are generally asymptomatic, but can present with abdominal pain, bleeding, or intussusception [1]. Only symptomatic lesions require intervention, small lipomas (<2 cm) can be resected endoscopically with a snare. However, larger wide-based lesions require surgical resection. With this report, we also wish to emphasize that lipomas due to high fat content may require higher current during snare polypectomy. This can lead to inadvertent application of prolonged cautery, occasionally resulting in delayed perforation or bleeding [2]. In large or thick stalked lipomas, application of endoloop or hemostatic clips can reduce the risk of bleeding and perforation [3].