Vinita Chaudhary

Naso-jejunal fluid resuscitation in predicted severe acute pancreatitis: Randomised comparative study with intravenous Ringer's Lactate.

Early management of severe acute pancreatitis (SAP) includes intravenous fluid resuscitation.

Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of 10 cases

Background: Duodenal varices (DV) although an uncommon cause, are an important cause due to the severe nature of the bleed and associated adverse outcome. Materials and Methods: We retrospectively evaluated patients with DV seen at our institution over past 4 years. Results: A total of 10 patients (nine males; mean age was 35.8 ± 7.68 years) with DV were studied. Five patients had underlying cirrhosis and five had DV because of non-cirrhotic portal hypertension (four patients had extra-hepatic portal venous obstruction and one patient had non-cirrhotic portal fibrosis). Five patients presented with upper gastrointestinal (GI) bleed, whereas in the remaining five patients DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient an initial endoscopic diagnosis of Dieulafoys lesion was made. However endoscopic ultrasound (EUS) could clearly identify DV in all patients. Of five patients presenting with upper GI bleed, three had the esophageal varices eradicated and two presented 1st time with bleed form DV and did not have esophagogastric varices. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients and there has been no recurrence of bleed in these four patients over a follow-up period of 4-46 months. The five non-bleeding DV were already on beta- blockers and the same were continued. Two of these five patients succumbed to progressive liver failure with none of these five patients having GI bleed on follow-up. Conclusion: EUS is a useful investigational modality for evaluating patients with DV and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.

Comparison of abdominal ultrasound, endoscopic ultrasound and magnetic resonance imaging in detection of necrotic debris in walled-off pancreatic necrosis

Background: Walled-off pancreatic necrosis (WOPN) is an important complication of acute pancreatitis that is diagnosed by imaging modalities such as endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI), which can clearly visualize necrotic debris. The effectiveness of abdominal ultrasound (USG) in detecting solid debris in WOPN is not clear. Methods: A total of 52 patients (37 males, mean age 38.9 ± 12.6 years) with symptomatic WOPN were prospectively studied using EUS, MRI and USG. These investigations were done at a mean of 11.7 ± 5.5 weeks of onset of acute pancreatitis and within two days. Results: WOPN was detected by EUS & MRI in all patients, whereas USG could not detect it in 4 (7.6%) patients (3 had predominantly solid WOPN, whereas one had air foci in WOPN). USG, MRI and EUS could detect solid debris in all patients with detectable WOPN. EUS and USG detected <10% debris in 10 (20%) patients, whereas MRI detected <10% debris in 14 (27%) patients. EUS and USG detected 10–40% debris in 33 patients whereas MRI detected 10–40% debris in 30 (58%) patients. More than 40% debris was better characterized on EUS and MRI with both detecting >40% debris in 8 patients (15%) compared to 5 (11%) patients having >40% debris on USG. EUS detected collaterals around WOPN that were not detected on USG or MRI. Conclusion: USG can characterize the majority of WOPN, with accuracy comparable to that of EUS/MRI. However its limitations are the inability to detect collaterals around WOPN and characterize collections with high solid content or air.

Infected pancreatic pseudocyst of spleen successfully treated by combined endoscopic transpapillary stent placement and transmural aspiration

A 32-year-old man with a known case of idiopathic chronic pancreatitis for the previous 2 years presented with abdominal pain and a high-grade fever of 2 weeks’ duration. The clinical examination revealed splenomegaly, and hematologic investigations revealed neutrophilia. Contrast-enhanced CT of the abdomen showed a pseudocyst in the subcapsular region of the spleen measuring 9 5 cm (Fig. 1). The patient was given intravenous antibiotics, and endoscopic retrograde pancreatography was performed. Because of the patient’s ongoing fever, a minimal amount of contrast medium was injected, and the pancreatogram revealed disruption at the tail end of the pancreas. A 5F 12-cm stent was placed into the disruption (Figs. 2, 3). However, even after 48 hours of stenting there was no improvement in the patient’s condition, and the fever persisted. Thereafter, EUS-guided single-time aspiration of the splenic cyst was done (Fig. 4). The collection was punctured under EUS guidance with a 19-gauge needle (Echotip; Cook Endoscopy, Winston-Salem, NC) through the stomach. The cyst was completely emptied, and 200 mL of purulent material was aspirated. After this, the patient had marked improvement in his symptoms and became afebrile within 24 hours of drainage. The amylase and lipase in the aspirated fluid were very high, and the culture grew Escherichia coli. The antibiotics were continued for 2 weeks. He was thereafter discharged, and MRCP performed 6 weeks later revealed a small residual collapsed cyst in the spleen along with

Esophageal duplication cyst in an adult masquerading as submucosal tumor.

Gastrointestinal duplications usually manifest in children and may involve the esophagus in 20% cases. Esophageal duplication cysts are a rare cause of dysphagia in adults. We report the case of a 35-year-old male who presented to us with progressive dysphagia of 6 months duration. Contrast enhanced computed tomography showed a soft-tissue lesion in right lateral wall of distal thoracic esophagus. On endoscopic ultrasound, a heterogeneously echotextured lesion with anechoic component present at intramural location in the lower esophagus was noted. The patient underwent surgical excision of the lesion and histopathology confirmed the diagnosis of esophageal duplication cyst.

Opium-related sphincter of Oddi dysfunction causing double duct sign

Double duct sign where there is a simultaneous dilatation of both the common bile duct (CBD) and pancreatic duct is usually associated with sinister causes like malignancies of pancreatic head or ampulla. Occasionally, benign causes like chronic pancreatitis or sphincter of Oddi dysfunction (SOD) may cause double duct sign. Chronic opium abuse is a rare cause of the double duct sign, and endoscopic ultrasound (EUS) findings of this rare entity have been occasionally reported. We report about a 54-year-old male with a history of chronic alcohol and opioid abuse evaluated for episodes of abdominal pain and found to have opioid-related SOD and improved with biliary sphincterotomy. EUS was done to rule out malignancy and revealed hypoechoic prominence around terminal CBD suggestive of hypertrophied muscle.

Sarcoidosis presenting as acute pancreatitis

Hypercalcemic states may result in acute pancreatitis. Sarcoidosis has been rarely reported as a cause of acute pancreatitis. A 42-year-old female came with abdominal pain and was found to have acute pancreatitis. Evaluation revealed hypercalcemia and evidence of pulmonary infiltrates and mediastinal lymphadenopathy. Transbronchial lung biopsy revealed noncaseating granulomas consistent with sarcoidosis. In conclusion, sarcoidosis may result in acute pancreatitis by causing hypercalcemia.

Unusual cause of obstructive jaundice revealed by endoscopic ultrasound guided fine-needle aspiration of mediastinal lymph node.

A 65-year-old male presented to us with jaundice of 2-month duration. His liver function tests were suggestive of cholestatic jaundice with serum bilirubin of 28 mg/dL. Ultrasound of the abdomen revealed dilated intrahepatic biliary radicles with a suspicion of intra-ductal mass lesion at the hilum. Contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography of the abdomen showed a soft tissue lesion in the common bile duct (CBD) extending into the right ductal system as well as distal bile duct with bilobar biliary radical dilatation [Figures 1 and 2 respectively]. Positron emission tomography CT detected a non-fl ourodeoxyglucose (non-FDG) avid mass in the bile duct along with a moderately FDG avid (SUV

537 Impact of Vitamin D Supplementation on the Course, Severity, Complications and Outcome of Patients of Acute Pancreatitis With Vitamin D Deficiency

Background: Vitamin D (Vit D) is important hormone playing diverse role in calcium and bone metabolism. Recently its deficiency has been shown to be associated with poor outcome in critically ill patients as well as in patients with acute pancreatitis. Earlier, we had shown that Vit D deficiency is widely prevalent in patients with acute pancreatitis (AP) and its deficiency is more commonly associated with persistent organ failure. There is paucity of data on effect of Vit D supplementation on course of AP. Aim: Prospectively study effects of Vit D supplementation on course, severity, complications and outcome of patients of AP with Vit D deficiency. Methods: Eighty seven patients (58M; age 39.1±13.6 years) with AP andVitamin D deficiency admitted between January 2013 toOctober 2013were prospectively included (study group). The serum 25-hydroxy D3 levels were analysed at time of admission and all patients with Vitamin D levels of 0.05). Persistent organ failure developed in 62.1% patients in study group and this was significantly lower than control group (83.3%). The mortality rates were lower but not significantly different in study group as compared to control group (5.8% vs.16.6%; p>0.05). Development of acute fluid collections (p=0.29), need for radiological intervention (p= 0.24), or surgery (p=0.19) were similar in both the groups. Conclusions: Vit D replacement in patients of acute pancreatitis with Vitamin D deficiency seems to decrease the development of persistent organ failure. Further studies with larger sample size and randomization are needed to confirm these results.

Mo1338 Comparative Evaluation of Abdominal Ultrasound, Endoscopic Ultrasound and Magnetic Resonance Imaging in Detecting Solid Necrotic Debris in Walled off Pancreatic Necrosis

Background Two new classification systems for the severity of acute pancreatitis (AP) have been proposed recently, the determinant based classification (DBC) and revised Atlanta classification (RAC). We aimed to validate and compare these classification systems with original Atlanta classification (OAC). Aims To validate and compare the DBC and RAC with original Atlanta classification (OAC) Methods 469 adult patients with AP admitted to a tertiary care center from January 2009-June 2013 were included in the study. The new classification systems were validated and compared in terms of outcomes (need for interventions, total hospital and intensive care unit (ICU) stay and mortality). Results The mean age of patients was 39.9±13.4 years (331 males) with the commonest etiology being alcohol (161, 34.3%) followed by gall stones (125, 26.6%). There were 119 (25.4%) patients with mild and 250 (74.6%) patients with severe AP as per OAC. Pancreatic necrosis was present in 66.1% and infected pancreatic necrosis in 23.1% patients. 126 (26.9%) patients underwent interventions (endoscopic n= 49, 10.4%, radiological n=95, 20.2% and surgical n=47, 10%). 93 (19.8%) patients died. As per DBC, 97(20.7%), 172 (36.7%), 152 (32.4%), and 48(10.2%) patients were determined to have mild, moderate, severe, and critical AP, respectively. As per RAC, 119 (25.4%), 160 (34.1%), and 190 patients (40.3%) were determined to have mild, moderately severe, and severe AP, respectively. Higher grades of severity were associated with worse outcomes in DBC, RAC and OAC. Predictive accuracies were evaluated using area under the receiver operator characteristics curve (AUROC) and Somers D co-efficient. The DBC, RAC and OAC were comparable in predicting the need for interventions (AUROC 0.53, 0.55, 0.54, p=0.36) and length of hospital stay (Somers D, 0.27, 0.26, 0.23, p=0.41). However, both DBC and RAC had comparable but better accuracy than OAC in predicting need for ICU admission (AUROC 0.73 for both vs. 0.62 for OAC, P<0.001), length of ICU stay (Somers D, 0.35 for both vs. 0.24 for OAC, p<0.001) and mortality (AUROC 0.78 for both vs. 0.61 for OAC, p<0.001). Conclusion Determinant based classification and revised Atlanta classification categorize patients into subgroups that reflect clinical outcomes. Both have comparable and higher predictive accuracy than old Atlanta classification for need for ICU admission, length of ICU stay and mortality.