Sarthak Malik

Visceral scalloping on abdominal computed tomography due to abdominal tuberculosis

Objective: Scalloping of visceral organs is described in pseudomyxoma peritonei, malignant ascites, among other conditions, but not tuberculosis. Methods: We report findings from a retrospective study of patients with abdominal tuberculosis who had visceral scalloping on abdominal computed tomography (CT). Diagnosis of abdominal tuberculosis was made on the basis of combination of clinical, biochemical, radiological and microbiological criteria. The clinical data, hematological and biochemical parameters, and findings of chest X-ray, CT, Mantoux test, and HIV serology were recorded. Results: Of 72 patients with abdominal tuberculosis whose CT scans were included, seven patients had visceral scalloping. The mean age of these patients was 32.14u2009±u20098.43u2009years and four were men. While six patients had scalloping of liver, one had splenic scalloping. The patients presented with abdominal pain (all), abdominal distension (five patients), loss of weight or appetite (all), and fever (four patients). Mantoux test was positive in five, while none had HIV infection. The diagnosis was based on fluid (ascitic or collections) evaluation in four patients, ileo-cecal biopsy in one patient, fine needle aspiration from omental thickening in one patient, and sputum positivity for acid fast bacilli (AFB) in one patient. On CT examination, four patients had ascites, five had collections, one had lymphadenopathy, four had peritoneal involvement, three had pleural effusion, and two had ileo-cecal thickening. All except one patient received standard ATT for 6u2009months or 9u2009months (one patient). Pigtail drainage for collections was needed for two patients. Discussion: This report is the first description of visceral scalloping of liver and spleen in patients with abdominal tuberculosis. Previously, this finding has been reported primarily with pseudomyxoma peritonei and peritoneal carcinomatosis. Conclusion: Visceral scalloping may not conclusively distinguish peritoneal tuberculosis from peritoneal carcinomatosis or pseudomyxoma peritonei.

Hepatic visceral larva migrans: a diagnostic enigma

A 75-year-old woman presented with suspected disseminated malignancy. She had had a history of epigastric pain for two months. She was known to have type II diabetes mellitus diagnosed 43 years previously. She had undergone an abdominal hysterectomy with bilateral salpingo-oopherectomy 25 years previously for dysfunctional uterine bleeding. She denied any alcohol intake and had never smoked. On examination, there was mild pallor. She was afebrile and normotensive. There was mild non-tender hepatomegaly present. A blood count revealed mild anaemia (Hb 115 g/L) and mild leukocytosis (total count 115,000/L). Biochemical evaluation, including liver and renal function tests and electrolytes, was within normal limits. Tumour markers (including carcinoembronic antigen, CA 19-9 and CA-125) were within normal limits. The chest radiograph was unremarkable and abdominal ultrasonography performed elsewhere had been reported as left nephrolithiasis with mild hydronephrosis. Abdominal computed tomography (CT), performed before presentation to our hospital, had demonstrated multiple well defined hypodense lesions of variable sizes in both liver lobes (Figure 1a), suspicious of metastases, as well as calculi in the left kidney. Our patient later underwent a 5-flouro-deoxy glucose (FDG) positron emission tomography (PETCT) scan. The liver lesions were subsequently described as metabolically inactive (Figure 1b). There were no metabolically active lesions found elsewhere. Consequently, all imaging studies were thoroughly reexamined. An absolute eosinophil count (AEC) revealed a marked eosinophilia (4928; normal range1⁄4 40–400/ mm), the differential count being 44% (normal range1⁄4 2–6%). Ultrasound-guided fine needle aspiration and cytology (FNAC) revealed sheets of eosinophils on a background of reactive hepatocytes (Figure 1c). No parasites or Charcot-Leyden crystals were seen. IgG TES-ELISA was positive. A diagnosis of hepatic visceral larva migrans was proposed and treatment with albendazole 400mg twice daily commenced. A follow-up at four weeks, after two weeks of treatment, showed resolution of her abdominal pain, but the advent of generalised pruritis. AEC had reduced to 1100/mm. CT examination was repeated and revealed resolution of most of the liver lesions (Figure 2). Symptomatic relief with oral antihistamines (Cetrizine 10mg o.d.) was achieved and no recurrence of abdominal pain presented over the next three months of follow-up.

An audit of percutaneous drainage for acute necrotic collections and walled off necrosis in patients with acute pancreatitis

BACKGROUND AND OBJECTIVESnPercutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP.nnnMETHODSnConsecutive patients of AP with symptomatic ANC or WON undergoing PCD were evaluated. Primary outcome measures were need for additional surgical necrosectomy and mortality. Secondary outcome measures were need for up-gradation of first PCD, need for additional drain, in-hospital as well as total duration of PCD and length of hospital stay.nnnRESULTSnIndications of PCD in 375 patients (258 with ANC and 117 with WON) were suspected infected pancreatic necrosis (nu202f=u202f214), persistent organ failure (nu202f=u202f117) and pressure symptoms (nu202f=u202f44). Need for additional surgical necrosectomy was seen in 14% patients with ANC and in 12% of patients with WON (pu202f=u202f0.364) and mortality was 19% in patients with ANC as compared to 13.7% in those with WON (pu202f=u202f0.132). There was no significant difference in the secondary outcome parameters between patients who underwent PCD for ANC or WON. Complications of PCD were comparable between patients with ANC and WON except development of external pancreatic fistula which occurred more often in patients with WON than in those with ANC (24.4% versus 34.2% respectively, pu202f=u202f0.034).nnnCONCLUSIONnPersistent organ failure in more often an indication of PCD in patients with ANC than in WON and suspected infection is more commonly an indication in WON than in ANC. Early PCD is as efficacious and safe as delayed PCD.

Impact of timing of presentation of acute pancreatitis to a tertiary care centre on the outcome

BACKGROUND AND OBJECTIVESnDespite improvement in outcomes of acute pancreatitis (AP), some subgroups remain at increased risk. We studied the impact of onset-to-admission interval to a tertiary care centre on outcomes in AP.nnnMETHODSnRetrospective analysis of consecutive patients with first episode of AP admitted between 2009 and 2017 on the basis of onset-to-admission interval: ≤7 days, 8-21 days and >21 days was done. Patients were assessed for severity and managed using a step-up approach. Primary outcome measures were surgical necrosectomy and mortality.nnnRESULTSnOf 745 patients (age 39.26u202f±u202f13.18u202fyrs, 69% male), 380 (51%) had presented ≤7 days, 229 (30.7%) between 8 and 21 days and 136 (18.3%) >21 days after pain onset. Severe pancreatitis was highest in 8-21 days group (129; 56.3%) followed byu202f≤u202f7 days (166; 43.7%) and >21 days of illness (52; 38.2%).Surgical intervention rates were highest in the 8-21 days group(14%) followed byu202f>u202f21 days (12.5%) and ≤7 days (6.6%) respectively (pu202f=u202f0.007). Also, mortality was highest in patients with onset to admission interval of 8-21 days (24%) followed byu202f>u202f21 days (15.4%) and ≤7 days (14.2%) (Pu202f=u202f0.007). On the multivariate analysis, age, late presentation, and the presence of organ failure were found to predict the mortality.nnnCONCLUSIONnPatients presenting between 8 and 21 days after onset perform poorly than those presenting earlier or later than them in terms of severity, organ failure, need for surgery and mortality although organ failure remains the most important determinant of outcome. This data can help in devising guidelines for referral of such patients.

Multiplex Polymerase Chain Reaction for diagnosis of gastrointestinal tuberculosis: Multiplex Polymerase chain reaction

To evaluate the role of multiplex polymerase chain reaction (PCR) for diagnosis of gastrointestinal tuberculosis (GITB).

Differences between the outcome of recurrent acute pancreatitis and acute pancreatitis: Recurrent acute pancreatitis

Overall, a handful of studies are available on the outcomes of recurrent acute pancreatitis (RAP), in comparison to the first episode of acute pancreatitis (AP). We aimed to provide a more complete and updated picture of RAP and how it is different from the initial episode of AP.

Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction

BACKGROUND AND AIMSnPeptic ulcer disease (PUD)-related gastric outlet obstruction (GOO) is known to respond favorably to endoscopic balloon dilation (EBD). However, data on efficacy of EBD for other etiologies of benign GOO are sparse. We aimed to compare the response of EBD among different etiologies of GOO.nnnMETHODSnRecords of all patients with benign GOO who underwent EBD at our tertiary-care center between January 1998 and December 2017 were analyzed. Dilation was done by using through-the-scope balloons. Procedural and clinical success of EBD was compared among different etiologies.nnnRESULTSnA total of 306 patients were evaluated, of whom 264 (mean [± standard deviation] [SD] age 37.89 ± 17.49 years; men 183, women 81) underwent dilation. Etiologically, caustic ingestion was the commonest cause of GOO (53.8%) followed by PUD (26.1%) and medication-induced (8.3%). Overall procedural and clinical success was achieved in 200 (75.7%) and 243 (92.04%) patients, respectively, requiring a mean (± SD) of 2.55 (2.8) and 5.37 (3.9) sessions, respectively. Caustic-induced GOO responded less favorably, requiring a higher number of dilation sessions and having more refractory strictures than other etiologies. Medication-induced GOO performed worse than PUD-related GOO. Of the 264 patients, 9 (3.4%) had perforations during EBD, 3 had contained leaks and were managed conservatively, and 6 underwent successful surgery.nnnCONCLUSIONnEBD is successful in a majority of patients with benign GOO, with caustic-induced GOO and medication-induced GOO being more difficult than PUD-related GOO.

Endoscopic esophageal perforation extending upwards along the carotid arteries.

A 21-year-old man presented to gastroenterology services with progressive dysphagia, 6 weeks after ingestion of dichlorvos (2,2-dichlorovinyl dimethyl phosphate), an organophosphate insecticide used to control household pests. Barium swallow revealed a long stricture involving the middle and lower thirds of the esophagus. The difficulties, complications, and failure rates of endoscopic dilation for long strictures were explained to the patient, and surgery was advised. However, the patient wanted a trial of endoscopic management prior to surgery. Esophagogastroduodenoscopy revealed a stricture starting at 20cm from the incisors. It was dilated up to 10mm with a controlled radial expansion (CRE) balloon (CRE single-use wireguided balloon dilator; Boston Scientific, Natick, Massachusetts, USA). However, the endoscope could not be negotiated beyond the stricture. A week later, a second session of endoscopic dilationwasperformedwith an 8–10-mm balloon (Boston Scientific), during which the first stricture at 20cm was dilated up to 10mm, and the scope could be negotiated past the stricture. A second stricture starting at 24cm was noted, and this was dilated up to 10mm. After dilation, the scope could be passed as far as 27 cm; but further advancement was abandoned because of a circumferential ulceration seen at 27cm. In the immediate post-procedure period, the patient complained of right-sided neck pain. On examination, mild crepitus was felt, raising suspicion of an iatrogenic esophageal perforation. Water-soluble contrast study revealed a leak in the mid esophagus. The contrast was seen to track into the neck along the right carotid sheath as far as the skull base. Later the contrast outlined the left pericardial surface (● Fig.1,● Video1). Our patient was immediately taken for surgery. Intraoperatively, a 3×1-cm perforation was seen, 10cm below the cricopharynx. Transhiatal esophagectomy with cervical esophagostomy was done. A feeding jejunostomy was also created. The patient was discharged after an uneventful 1-week postoperative period. The patient’s condition is being improved for definitive surgery. The carotid sheath is a condensation of cervical fascia around the common and Fig.1 A 21-year-old man complained of neck pain following second dilation procedure for an esophageal stricture caused by ingestion of a corrosive agent. Fluoroscopic images following oral contrast administration showing: a contrast leak (arrow and circle) from the mid esophagus; b the contrast tracking along the carotid sheath on the right side (arrows); c the contrast then spreading along the surface of the pericardium (arrows).

Degree of Approximation of a Function Belongingto W (Lr, ξ (t)) (r > 1)-Class by (E, 1)(C, 2) Product Summabilty Transform

The field of approximation theory is so vast that it plays an increasingly important role in applications in pure and applied mathematics. The present study deals with a theorem concerning the degree of approximation of a function f belonging to W (Lr, ξ (t)) (r > 1)-class by using (E, 1) (C, 2) of its Fourier series.