Indian Journal of Gastroenterology (December 2020) 39 (Suppl 1):S1–S141
https://doi.org/10.1007/s12664-020-01133-9
ABSTRACTS
61st Annual Conference of Indian Society of Gastroenterology, Virtual
Diamond Jubilee ISGCON 2020, 19-20th December 2020
# Indian Society of Gastroenterology
Plenary Session
001
An open label trial to compare viral suppression with 0.5 and 1.0 mg
doses of entecavir in treatment naive hepatitis B related decompen-
sated cirrhosis
Amit Goel, Sumit Rungta, Prashant Verma, Abhai Verma, Ajay Verma,
Prveer Rai, Rakesh Aggarwal
Correspondence- Rakesh Aggarwal-aggarwal.ra@gmail.com
King George Medical University, Lucknow, India, Ram Manohar Lohia
Institute of Medical Sciences, Lucknow, India, and Department of
Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Lucknow 226 014, India
Objectives For patients with hepatitis B virus (HBV) infection who have
decompensated cirrhosis (DC), a higher dose (1.0 mg/day) of entecavir is
recommended than that used for those with compensated disease (0.5 mg/
day), though with very little supporting data. We therefore compared the
viral suppression achieved with 0.5 mg/day and 1.0 mg/day of entecavir
in patients with HBV-related DC (NCT03345498).
Methods Treatment-naïve patients with HBV-related DC and serum HBV
DNA titer exceeding 100,000 IU/mL received either dose of entecavir for 24
weeks. HBV DNA concentration was measured in blood specimens collect-
ed at baseline, and after 2, 4, 8, 12 and 24 weeks of entecavir treatment.
Results Participants in the 0.5 mg (n=13) and 1.0 mg (n=16) groups had
similar baseline HBeAg positivity rates (12/13 and 12/16; p=0.34) and
median (range) log10 serum HBV DNA levels (6.81 [5.01-8.12] and 7.45
[5.24-8.65]; p=0.17). The two doses led to similar reductions in serum
HBV DNA levels after 2, 4, 8, 12 and 24 weeks of entecavir administra-
tion. At 24 weeks, 3 of the 13 patients receiving 0.5 mg/day and one of the
16 patients receiving 1.0 mg/day of entecavir had undetectable serum
HBV DNA. Serum albumin level showed significant and similar im-
provement at the end of 24 weeks in both the groups.
Conclusion Treatment-naïve patients with HBV-related DC can be treat-
ed with entecavir in a 0.5 mg/day dose instead of the higher 1.0 mg/day
dose, without compromising the degree of virological suppression.
002
Bacterial spectrum and antibiotic sensitivity pattern in bile cultures
from endoscopic retrograde cholangiography patients
Mohammad Talha Noor, Praveen Vasepalli
Correspondence- Mohammad Talha Noor-noorpgi@gmail.com
Department of Gastroenterology and Hepatobiliary Sciences, Sri
Aurobindo Medical College, and PGI, SAIMS Campus, Indore-Ujjain
State Highway, Near MR-10 Crossing, Sanwer Road, Indore 453 555,
India
Introduction Temporal shifts have been known to occur in antibiotic sensi-
tivity patterns of organisms causing cholangitis. This study was conducted to
study the common microorganisms cultured from bile during endoscopic
retrograde cholangiography and their local sensitivity pattern.
Methods This was a prospective study conducted between January 2016 and
November 2017. Patients with extrahepatic biliary obstruction undergoing en-
doscopic retrograde cholangiography were included in the study. Bile was
aspirated aseptically during endoscopic retrograde cholangiography and aspirat-
ed bile was transported to microbiology laboratory under all aseptic precautions.
Bacteria were cultured, identified and antimicrobial susceptibility testing was
performed by broth micro dilution method.
Results Hundred patients (48% males, mean age 53.53±14.65 years) were
included. Sixty-six patients had growth in bile culture, out of which 9
patients had dual growth and thus a total of 75 microbial growths were
obtained. The maximum growths amongst all micro-organisms were of
Escherichia coli (40.9%) and pseudomonas aeruginosa (40.9%). With
regard to bacterobilia, there was no significant difference between pa-
tients with cholangitis and without cholangitis (61.36% vs. 69.64%, p =
0.288), patients who had underwent previous endoscopic retrograde chol-
angiography with stenting and those who had not undergone the same
previously (60% vs. 67%, p=0.301), patients who were empirically ad-
ministered antibiotics before intervention and not administered (67.92%
vs. 63.83%, p = 0.599). Growth rates were significantly higher in patients
with non-malignant causes of biliary obstruction vs. those with malignant
causes (70.76% vs. 57.14%, p=0.03). Polymixins had the highest sensi-
tivity to cultured bacteria followed by aminoglycosides and Imipenem.
Conclusion Gram negative bacteria like Escherichia coli and
Pseudomonas aeruginosa were the most common isolates from bile.
Empirical antibiotic therapy in patients with cholangitis should be based
on local sensitivity patterns.
003
Outcome of conservative therapy in COVID-19 patients presenting
with gastrointestinal bleeding
Manas Vaishnav, Anshuman Elhence, Piyush Pathak, Soumya
Mahapatra, Saurabh Kedia, Govind Makharia, Pramod Garg, Anoop
Saraya, Shalimar
Correspondence- Shalimar-drshalimar@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction There is a paucity of data on the management of gastroin-
testinal (GI) bleeding in patients with COVID-19 amid concerns about
the risk of transmission during endoscopic procedures. We aimed to study
the outcomes of conservative treatment for GI bleeding in patients with
COVID-19.
S2
Methods In this retrospective analysis, 24 of 1342 (1.8%) patients with
COVID-19, presenting with GI bleeding from 22nd April to 22nd
July 2020, were included.
Results The mean age of patients was 45.8±12.7 years; 17 (70.8%) were
males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two
(91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleed-
ing while one had bleeding from hemorrhoids. Two patients without
cirrhosis were presumed to have non-variceal bleeding. The medical ther-
apy for UGI bleeding included vasoconstrictors-somatostatin in 17
(73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI
bleeding received proton pump inhibitors and antibiotics. Packed red
blood cells (PRBCs), fresh frozen plasma and platelets were transfused
in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median
PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding
was achieved in all 23 patients and none required an emergency endos-
copy. At 5- day follow-up, none rebled or died. Two patients later rebled,
one had intermittent bleed due to gastric antral vascular ectasia, while
another had rebleed 19 days after discharge. Three (12.5%) cirrhosis
patients succumbed to acute hypoxemic respiratory failure during hospi-
tal stay.
Conclusion Conservative management strategies including pharmaco-
therapy, restrictive transfusion strategy, and close hemodynamic moni-
toring can successfully manage GI bleeding in COVID-19 patients and
reduce need for urgent endoscopy.
004
Exclusive enteral nutrition enhances the efficacy of intravenous ste-
roids in acute severe ulcerative colitis: A randomized controlled trial
Pabitra Sahu, Sudheer Kumar, Aditya Bajaj, Manasvini Markandey,
Namrata Singh, Mukesh Singh, Bhaskar Kante, Peeyush Kumar,
Mukesh Ranjan, Peush Sahni, Raju Sharma, Prasenjit Das, Govind
Makharia, Simon Travis, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Objective Intravenous (IV) steroids are main stay of therapy in acute
severe ulcerative colitis (ASUC), but 30% to 40% patients fail to respond.
This study investigates the effectiveness of exclusive enteral nutrition
(EEN) as an adjunctive therapy to IV steroid in patients with ASUC.
Design This is an open label randomized controlled trial, in which pa-
tients with ASUC admitted between August 2018 to May 2020 were
randomized in 1:1 ratio to EEN and standard of care (SOC) group.
Patients in EEN arm received semi elemental EEN for 7 days along with
standard medical therapy including IV steroid. Primary outcome was rate
of steroid failure defined by the need for rescue medical therapy or
colectomy. In a subgroup of patients, day 1 and day 7 fecal microbial
analysis was done by 16s ribosomal RNA sequencing.
Results The study was stopped because of COVID pandemic and signif-
icant results in interim analysis. Out of 62 patients (mean age:35.3±12.1
years and 59.7%: male), 32 were randomized to EEN arm and 30 in SOC
arm. Steroid failure rate was significantly less in EEN arm compared to
SOC arm (per protocol analysis; 18.5% vs. 43.3%; p=0.04), but no dif-
ference seen in colectomy rate (9.4% vs. 13.3%; p=0.4). Patients in EEN
group had shorter hospital stay (10 [8-17] vs.13 [8-24] days; p=0.04),
higher day7 albumin level (p<0.01), and greater reduction in serum CRP
and fecal calprotectin (FCP) levels than SOC group (p=0.03). Although
there was no significant difference in fecal microbial diversity between
two groups on day 7 but patients in EEN group showed increased abun-
dance of Erysipelotrichaceae with reduced Bifidobacterium and
Veillonellaceae compared to SOC group.
Conclusion Short course of EEN is an effective and safe adjunctive ther-
apy that augment steroid responsiveness in patients with ASUC.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
005
Universal prophylactic per-rectal nonsteroidal anti-inflammatory
drug with a discretionary policy of selective pancreatic duct stenting
significantly reduces post-ERCP pancreatitis in unselected consecu-
tive patients: A real world comparative study
Ashish Agarwal, Rahul Sethia, Soumya Jagannath Mahapatra, Deepak
Gunjan, Pramod Garg
Correspondence- Pramod Garg-pgarg10@gmail.com
Department of Gastroenterology and Human Nutrition Unit, All India
Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction and Aims Rectal NSAIDs have been shown to be effective for
the prevention of post-endoscopic retrograde cholangiopancreatography
(ERCP) pancreatitis in high-risk patients. However, it is not clear if a strategy
of routine rectal NSAID administration prior to ERCP is beneficial in non-high-
risk patients. Our aim was to assess the benefit of prophylactic rectal NSAID in
unselected consecutive patients to prevent post-ERCP pancreatitis (PEP).
Methods All patients undergoing index ERCP procedures from January
2018 till March 2020 in a tertiary care centre were included. All patients
were given prophylactic rectal diclofenac. A prophylactic pancreatic duct
(PD) stent was placed if there was repeated wire cannulation of or contrast
injection into the PD, at the discretion of the endoscopist. Trainee fellows
were involved in performing ERCP. The outcome measure was frequen-
cy of PEP which was compared with that in historical controls from a
previous randomized trial at our centre. Multivariable analysis was done
to find out the predictors of PEP.
Results Of a total of 769 patients who underwent index ERCP, 34 (4.4%)
developed PEP. PEP was mild in 29 (85.3%) patients, moderately severe
in four and severe in one patient. Female gender, pre-cut sphincterotomy,
inadvertent PD cannulation and procedural time (>30 minutes) were pre-
dictors of PEP in univariate analysis; and inadvertent PD cannulation (OR
4.6, 95% CI 1.8-11.7; p<0.001) and procedural time >30 minutes (OR
8.5, 95% CI 3.7-10.1; p<0.001) on multivariate analysis. When compared
with historical controls, the odds of developing PEP with prophylactic use
of rectal NSAIDs and selective PD stenting was 0.54 (CI 0.31-0.93,
p=0.027). The number needed to treat was 22 to prevent one PEP with
prophylactic rectal NSAID.
Keywords Rectal NSAIDs, Post ERCP pancreatitis, PD stenting
006
Development of a machine learning model to predict bleed in esoph-
ageal varices in compensated advanced chronic liver disease
Samagra Agarwal, Sanchit Sharma, Manoj Kumar * , Shanatan
Venishetty * , Ankit Bhardwaj * , Kanav Kaushal, Abhinav Anand,
Srikanth Gopi, Srikant Mohta, Deepak Gunjan, Anoop Saraya, Shiv
Kumar Sarin*
Correspondence- Deepak Gunjan-drdg_01@rediffmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and
*
Department of Hepatology and Liver Transplantation, Institute of
Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background and Aims Current endoscopic classification of esophageal
varices does not stratify and predicts bleeding in all patients with com-
pensated advanced chronic liver disease with varices. We aimed to sup-
plement it with a novel machine learning (ML) model for prediction of
hemorrhagic events in these patients.
Methods In a retrospective analysis from two centres, data from patients of
cACLD who underwent esophagogastroduodenoscopy, laboratory investiga-
tions and transient elastography within 3 months were included. Extreme-
gradient boosting (XGBoost) algorithm was used to generate a predictive
model including these parameters to predict the risk of future bleed. Its
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
performance characteristics were compared with the endoscopic classifica-
tion alone and was validated in internal and external validation cohorts.
Results Eight hundred and twenty-eight patients of cACLD with esoph-
ageal varices, predominantly related to non-alcoholic fatty liver disease
(28.6%), alcohol (23.7%) and hepatitis B (23.1%) were included, with
455 (55%) having the high-risk varices. Over a median follow-up of 24
months (interquartile range: 12-43 months), 163 patients suffered varice-
al-bleed, 139 (85.3%) in endoscopic high-risk group. Machine learning
(ML) model had good performance characteristics with 85% to 99%
accuracy in derivation (n=497), internal validation (n=149) and external
validation cohorts (n=182), and was able to identify “true high-risk”
group with 1-year and 3-year bleed rates of 31% to 43% and 64% to
85%, respectively. “True low-risk” varices identified by the model had
significantly lower 1-year (0-1.6%) and 3-year (0-3.4%) bleed-rates.
SHapley Additive exPlanations (SHAP) analysis showed endoscopic
classification to be the most important determinant of the model predic-
tion, followed by the liver stiffness measurement.
Conclusions Machine learning model allows a better risk stratifica-
tion for the prediction of the incident variceal bleed in patients
with cACLD with esophageal varices compared with endoscopic
classification alone.
Young Investigator Award Session
007
Isolation and genome analysis of gluten-degrading bacteria from
small intestinal of celiac disease patients
Sahabram Dewala, Yogesh Shouche
Correspondence- Yogesh Shouche-yogesh@nccs.res.in
Department of ICMR, National Centre for Cell Science, NCCS Complex,
University of Pune Campus, Pune University Road, Ganeshkhind, Pune
411 007, India
Introduction Gluten intolerance or celiac disease is the most com-
mon genetically related food intolerance, worldwide. Celiac dis-
ease (CeD) is T-cell mediated small intestinal inflammation trig-
ger by wheat gluten protein in genetically susceptible individual
who carry HLA-DQ2/8 risk alleles. Lifelong elimination of gluten
from diet is very challenging due to many reasons including
availability of good quality gluten-free food items, cost, palatabil-
ity. Thus, gluten and its’s immunogenic peptides degradation ap-
proach is considered to be a novel therapy for CeD. Researchers
have made adequate efforts for isolation of gluten-degrading bac-
teria (GDB) from human body and other environment. Oral sup-
plementation of GDB and gluten digesting enzyme is emerging
therapeutic approach for the CeD.
Method Gluten agar plates assay for screening of gluten-degrading bac-
teria. Illumina Miseq was applied for whole genome sequencing of
bacteria.
Results Aerobic and facultative anerobic bacteria were isolated from human
small intestine with gluten-degrading activity. Indeed, 70 bacterial strains
belonging to 35 bacterial species were isolated; 12 strains were able to show
gluten-degrading activity on gluten plates. Moreover, proline-glutamine
specific endopeptidase genes were confirmed in gluten-degrading bacteria
by whole genome sequencing approach. Additionally, a docking model
was proposed of representative gliadin substrate in active side of endopep-
tidase enzyme. We cultivated and sequenced new gluten-degrading micro-
organisms from the human small intestine.
Conclusion Study suggests that these bacteria or their gluten-degrading
enzymes can be explored further for their application in treatment of
celiac disease.
Keywords Celiac disease, Gluten-degrading bacteria, Endopeptidase,
HLA-DQ 2/8
S3
008
HSP70 modulates immune response in pancreatic cancer through
dendritic cells
Bharti Garg, Bhuwan Giri, Prateek Sharma, Ashok Saluja, Vikas
Dudeja, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, All India
Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India,
Jackson Memorial Hospital, University of Miami, USA, and Miller
School of Medicine, University of Miami, USA
The role of heat shock protein 70 (HSP70), a protein chaperone, is largely
unknown in the tumor micro-environment (TME). We evaluated if
HSP70 in the TME modulated tumor growth.
Cancer cells were derived from various genetic models (KPC, MC-38,
PKT) and were implanted in HSP70-/- or WT controls, thus simulating a
TME with or without HSP70. Tumor size, metastases pattern, histology
and immune infiltration were evaluated at endpoint. Splenocytes, CD8+
ve T cells and dendritic cells (DCs) were isolated from HSP70-/- or WT
mice to evaluate for specific absence of HSP70 in the immune cells.
Splenocytes, CD8 cells and DCs were co-incubated with cancer cells to
immune activation.
Tumors from HSP70-/- mice were smaller compared to tumors in WT
mice. There was no difference in stromal markers and no effect on tumor
growth when HSP70 was specifically depleted in the stromal compart-
ment. HSP70-/- immune cells exhibited greater anti-tumor activity and
HSP70/- dendritic cells showed greater expression of anti-tumor effectors
against KPC cells both in vitro and in vivo. Thus, we show that absence of
HSP70 in the TME results in inhibition of tumor through dendritic cells.
HSP70 inhibition in DCs may emerge as novel therapeutic strategy
against pancreatic cancer.
Keywords Pancreatic cancer, HSP70, Immunotherapy, Stroma, Dendritic
cells
009
Platelet deactivation ameliorates hepatic fibrosis by modulating in-
flammation, intrahepatic microbiome and reduces hepatic stellate
cell activation via ryanodine-receptor-2
Adil Bhat, Sudrishti Chaudhary, Gaurav Yadav, Anupama Kumari,
Chhagan Bihari, Jaswinder Singh Maras, Shiv Kumar Sarin
Correspondence- Shiv Kumar Sarin-shivsarin@gmail.com
Department Molecular and Cellular Medicine, Institute of Liver and
Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India
Introduction Platelet deactivation possibly help in the regression of liver
fibrosis. However, the mechanism linked to the regression of fibrosis post
antiplatelet treatment (APT) is elusive.
Methods To explore, aspirin (APT) was administered in the murine model
of liver fibrosis and molecular signatures/signalling associated with fibro-
sis regression were validated in vivo (murine model and patients with
liver fibrosis) and in vitro studies.
Results Increase in intrahepatic platelet number (CD42b) and acti-
vation (PDGFR-β) directly correlated with an increase in liver fi-
brosis (p<0.05, r2>0.3). APT reduced intrahepatic platelet number,
platelet, and immune cell activation thereby reducing inflammation
and fibrosis (p<0.05). APT in mice model increases autophagy,
glutathione, energy metabolism, and decrease arachidonic acid and
butanoate metabolism (p<0.05). APT modulated the liver microen-
vironment and showed a decrease in intrahepatic immune cell acti-
vation (blood transcription module) which correlated with histidine
and tryptophan metabolism (r2>0.5, p<0.05). APT also modulate
the liver microbiome by increasing the abundance of Firmicutes
S4
(Ruminococcaceae, Lachnospiraceae, and Clostridiaceae) and their
functionality (p<0.05). Multi-omics of APT identified decreases in
expression of Ryanodine-receptor-2 (RyR2), Arginase-1 and
Kynurenine-3-monooxygenase correlate with the reduction in α-
SMA and degree of hepatic fibrosis (r2>0.75; p<0.05). Expression
of RyR2 was high in activated hepatic stellate cells (HSCs) and pan-
specific blocking of RyR2 by carvedilol/flecainide markedly inhibits
HSCs activation and proliferation (in vitro) via reducing Ca2+ over-
load, ER, and mitochondrial oxidative stress (p<0.05). Interestingly
RyR2 blockade in HSCs reduced its activation by activated platelet
secretome or TGFβ1 (p<0.05). This suggests that RyR2 induction is
critical for fibrosis development and pharmacological inhibition of
RyR2 could ameliorate liver fibrosis.
Conclusion Antiplatelet treatment modulates hepatic fibrosis by decreas-
ing platelet activation, inflammation, and intrahepatic microbiome. Our
findings demonstrate RyR2 suppression as a therapeutic approach for
liver fibrosis regression.
Keywords Liver fibrosis, Hepatic proteome, Hepatic metabolome,
Integrome, RyR2, ALOX5, ARG-1
010
Fluconazole reduces disease activity in active ulcerative colitis: A
double-blind randomized placebo-controlled trial
Anuraag Jena, Usha Dutta, Jimil Shah, Vishal Sharma, Kaushal Kishor
Prasad, M R Shivaprakash, Harshal S Mandavdhare, Jayanta Samanta,
Pankaj Sharma, Priyanka Popli, A K Sharma, Saroj Kant Sinha,
Arunaloke Chakrabarti, Rakesh Kochhar
Correspondence- Usha Dutta-ushadutta@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Introduction There is an emerging role of fungal dysbiosis in the patho-
genesis of inflammatory bowel disease (IBD). In such scenario, what is
the prevalence of Candida in patients with active ulcerative colitis (UC)
and can fluconazole therapy reduce disease activity?
Methods All patients with active UC defined as Mayo score ≥ 3 were
evaluated for presence of Candida by stool culture. Patients with Candida
positive in stool were randomized to receive oral fluconazole 200 mg
daily or placebo for 3 weeks. Patients were assessed by clinical, sigmoid-
oscopy and laboratory parameters at baseline and at 4 weeks. The primary
outcome variables were clinical and endoscopic response at 4 weeks.
Secondary outcomes were reduction in fecal calprotectin, histological
response and adverse events.
Results Of 242 patients with active UC, 68 (28%) patients had
Candida in stool culture. Sixty-one patients were randomized to
receive fluconazole (n=31) or placebo (n=30). Post intervention
median Mayo score was lower in fluconazole than placebo group
(4 [3, 5] vs. 5 [4, 6]; p=0.034). Patients in fluconazole group
showed significant improvement in stool frequency (17 [54.8%]
vs. 9 [30%]; p=0.07), lower median bleeding score (0 [0, 1] vs. 1
[0, 1]; p=0.018) and decrease in severity (21 [67.7%] vs. 10
[33.3%]; p=0.01) compared to placebo. Patients in fluconazole
group had reduction in Mayo score (19 [61.2%] vs. 12 [40%];
p=0.12), three-point Mayo score (5 [16.1%] vs. 1 [3.33%];
p=0.19), fecal calprotectin (26 [83.9%] vs. 11 [36.7%]; p=0.001)
and histological scores (23 [74.1%] vs. 10 [33.3%]; p=0.001)
compared to placebo. All patients were compliant and did not
report any serious adverse event. Independent predictors for pres-
ence of Candida were partial Mayo score ≥3 and steroid exposure.
Conclusion Oral fluconazole therapy in patients with active UC was
associated with reduction in disease activity and severity. Candida
colonization was found in 28% of patients with UC. Steroid expo-
sure and active disease were independent predictors for presence of
Candida.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Keywords Ulcerative colitis, Candida, Fluconazole
011
Conventional versus oblique fibers sparing endoscopic myotomy for
achalasia cardia: A randomized controlled trial
Vincy Chandran, Zaheer Nabi, Mohan Ramchandani, Rajesh Goud,
Santosh Darisetty, Arun Karyampudi, Rama Kotla, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-
3-661, Somajiguda, Hyderabad 500 082, India
Background and Aim Gastroesophageal reflux disease (GERD) is com-
mon after per-oral endoscopic myotomy (POEM). Selective sparing of
oblique fibers during POEM may reduce the incidence of reflux esopha-
gitis after POEM. In this study, we aim to compare the incidence of
GERD between conventional (CM) vs. oblique fiber sparing (OFS) tech-
niques of endoscopic myotomy in cases with type I and II idiopathic
achalasia.
Methods Eligible patients with type I and II achalasia who
underwent POEM from January 2020 to April 2020 were random-
ized into two groups (CM and OFS). Exclusion criteria were: type
III achalasia, sigmoid esophagus and history of Heller’s myotomy
with fundoplication. The primary outcome of the study was com-
parison of reflux esophagitis at two months in the two groups.
The secondary aims included reflux symptoms, esophageal acid
exposure, and clinical success.
Results Sixty patients were randomized in CM (30) and OFS (30) groups.
Both the groups were similar with regards to the symptom scores, sub-
types of achalasia and history of previous treatment. The mean operation
time was similar in both the groups (CM 42.21±13.17 mins vs. OFS 48
±29.12 mins). Mean length of total myotomies were comparable in the
two groups (9.57±3.25 cm vs. 9.43 ±3.15 cm). Clinical success (Eckardt
≤3) was recorded in all the patients. Overall, reflux esophagitis was found
in 30 (51.7%) patients. Grade B or higher esophagitis was similar in the
two groups (34.6% vs. 41.4%, p=0.782). Symptoms of GERD were more
frequent in the conventional group (35.7% vs. 16.7%, p=0.570). The
mean number of reflux episodes (57.42±39.94 vs. 56.41±43.70), propor-
tion of patients with increased esophageal acid exposure >6% (41.6% vs.
33.2%, p=0.574) and DeMeester scores (>14.7) (41.6% vs. 33.2%,
p=0.574) were similar in both the groups.
Conclusion Sparing of sling fibers has no significant impact on the inci-
dence of GERD after POEM. (NCT04229342).
012
Combination of intravenous antibiotics in acute severe ulcerative
colitis: A placebo controlled randomized trial
Shubhra Mishra, Harshal Mandavdhare, Harjeet Singh, Arup
Choudhury, Jimil Shah, Sant Ram*, Dimple Kalsi, Jayanta Smanta,
Kaushal Prasad, Arun Sharma, Usha Dutta, Vishal Sharma
Correspondence- Vishal Sharma-docvishalsharma@gmail.com
Departments of *Biochemistry, and Gastroenterology, Postgraduate
Institute of Medical Education and Research, Chandigarh 160 012, India
Background Recent evidence suggest that targeted antibiotic combination
could improve response in active ulcerative colitis (UC) but similar data is
not available in acute severe UC (ASUC).
Methods Patients ASUC diagnosed as per modified Truelove and
Witt’s classification were randomized to placebo infusions or combi-
nation antibiotics (intravenous ceftriaxone and metronidazole)
groups. Primary outcome was response on day three (Oxford’s
criteria). Also, we assessed the need for second line drug therapy,
colectomy, length of hospital stays, mortality by day 28 and the
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
changes in partial Mayo score, CRP levels and reduction in fecal
calprotectin by day three.
Results Fifty patients were randomised: 25 in each arm (Median age: 33,
IQR 25-45, 23 (46%) males). Twenty-two patients had extensive disease
while the median disease duration was 24 months. Sixteen patients (64%)
in antibiotic arm responded (complete and partial response) at day three
while 18 (72%) in the placebo arm responded. Three patients from the
antibiotic group underwent colectomy. Three patients in the antibiotic
arm received intravenous cyclosporine whereas four patients in the pla-
cebo group received cyclosporine (p=0.725). There was no significant
difference in change in CRP, Partial Mayo and fecal calprotectin between
the two groups on day three.
Conclusion Combination of intravenous ceftriaxone and metronidazole in
patients with ASUC neither improved the day 3 response nor reduced the
need for second line therapy.
Presidential Posters
013
Feasibility of de-prescription of proton pump inhibitors in patients
with typical reflux symptoms- A clinical experience
Mayank Jain
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre,
283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India
Background Proton pump inhibitors (PPI) are commonly used drugs in
management of reflux symptoms. These drugs are frequently abused and
have side effects on long-term use.
Aim To determine the feasibility of de prescription of PPI in patients with
typical reflux symptoms in Indian setting. Moreover, symptom resolution
and PPI requirement were assessed in patients with erosive and
nonerosive reflux disease (NERD).
Methods This retrospective study recruited all patients, >18 years,
with heartburn and/or regurgitation. Severity of reflux was assessed
white light endoscopy and graded as per Los Angeles classification.
All patients were advised lifestyle changes, aerobic exercises for >
30 min/day and dietary interventions. Follow-up details, including
symptom resolution and drug requirement, were noted at 3 months
after initial visit.
Results A total of 106 patients formed the study cohort. Nearly three fifths
of the cases were males and median age was 43 years. Reflux esophagitis
was noted in 30% of cases. Of these patients, 25% had grade A esopha-
gitis and the remaining had grade B or beyond. Three fourths of the
patients were prescribed once a day dose of PPI. On follow-up at 3
months, PPI therapy could be stopped completely in 58 (54.7%) cases.
Thirty-two (30.2%) and 16 (15.1%) patients were on on-demand PPI and
continuous low dose therapy, respectively. Significantly higher propor-
tion of patients with reflux esophagitis could stop PPI at the end of three
months. The need for on demand PPI and continuous low dose therapy
was higher in patients with NERD.
Conclusion De prescription of PPI is attained in nearly 85% of patients at
3 months. PPI are effective in symptom resolution, more so in patients
with erosive esophagitis.
014
Nutritional assessment and factors affecting dietary intake in pa-
tients with cirrhosis: A single center observational study
Praveen Sharma, Charu Gupta, Ashish Kumar, Anil Arora, Naresh
Bansal, Vikas Singla, Shivam Khare, Sakshi Jasrotia
Correspondence- Praveen Sharma-drpraveen_sharma@yahoo.com
S5
Department of Gastroenterology, Institute of Liver, Gastroenterology and
Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar,
New Delhi 110 060, India
Objectives Malnutrition is predictor of morbidity and mortality in
patients with cirrhosis. We investigated prevalence of malnutrition
and factors affecting dietary intake in patient with cirrhosis.
Methods Two hundred and fifty-one patients with cirrhosis
underwent dietary and nutritional assessment by subjective global
assessment (SGA) and anthropometric measurement (dry body mass
index [BMI], mid am circumference [MAC], mid arm muscle cir-
cumference [MAMC], tricep skin fold thickness [TSF] and handgrip
strength [HGS]). Dietary intake assessed in terms of total calories
and protein intake, percentage of recommended intake along with
per kilogram body weight per day. Factors influencing dietary in-
take were also assessed.
Results Of 251 patients 199 (79%) were males and 52 (21%) were
female (mean age 51±14 yrs, Child’s A: B: C:: 83:116:52). SGA
analysis 87 (35%) were well nourished (SGA-A), 106 (42%) moder-
ately nourished (SGA-B) and 58 (23%) severely malnourished (SGA-
C). Child’s C patients were severely malnourished compared to
Child’s B and A. MAC, MAMC, TSF and HGS was significantly
higher in SGA-A compared to SGA-B and SGA-C. Patients in
SGA-A (1939±479 kcal/d) consumed significantly higher calories
than SGA-B (1494±216kcal/d) and SGA-C (1321±213kcal/d).
Percentage of recommended calories intake (SGA-A [76%], SGA-B
[61%] and SGA-C [59%], p=0.001) and calories/kg/d is also higher
in SGA-A compared to SGA-B and C. Similar were the results with
protein intake (SGA-A [61±14 gm/d], SGA-B [56±7 gm/d] and SGA-
C [51±9 gm/d], p=0.001). Sixty-one percent patients were vegetarian
and 84% did not take evening snacks. Poor appetite (n=68, 27%),
early satiety (n=75, 30%), abdominal fullness (n=62, 25%), low salt
diet (n=52, 21%) and social myth about diet 43 (17%) were the
common reason of poor intake. Distension of abdomen, social myth
about diet and low sodium in diet were key factors affecting dietary
intake in patients with cirrhosis and malnutrition.
Conclusion Malnutrition seen in 65% of patients. Distension of abdomen,
social myth about diet and low sodium in diet were key factors affecting
dietary intake in patients with cirrhosis.
015
Clinical, endoscopic and management profile of cytomegalovirus co-
litis in inflammatory bowel disease patients at tertiary centre in
North India: A retrospective observational study
Sharad Dev, Dawesh Prakash Yadav, Vinod Kumar Dixit, Sunit Kumar
Shukla
Correspondence- Dawesh Prakash Yadav-devesh.thedoc@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Aurobindo Colony, Banaras Hindu University
Campus, Varanasi 221 005, India
Background Cytomegalovirus (CMV) colitis in immunocompetent
patients generally manifests as benign, self-limiting disease where-
as gastrointestinal tissue-invasive disease is frequently seen in
immunocompromised and inflammatory bowel disease (IBD)
patients.
Methods A retrospective study was conducted of all patients diagnosed as
CMV colitis with IBD during a three-year period. From electronic data-
base, patients’ clinical information, treatment regimens, endoscopic and
pathologic findings and outcome were analyzed. CMV colitis was diag-
nosed by positive inclusion bodies on H&E staining or by immunohisto-
chemistry (IHC) in colonic tissue biopsy.
Results Twenty-seven patients with CMV colitis were studied with me-
dian age of 32 (15-62) years and median IBD duration of 22 (2-36)
S6
months. There were 23 (85%) patients of UC and 4 (15%) patients of CD.
Ten patients were on immunomodulators (steroid dependent or steroid
refractory status). Predominant symptoms included bloody diarrhea
(93%), abdominal pain (55%), low grade fever (20%) and anemia
(70%). Endoscopic evaluation mainly noted deep punched out ulcerations
(48%), longitudinal and geographic ulcerations (33%) and diffuse muco-
sal hemorrhage with superficial erosions (14%). Histopathology demon-
strated inclusion bodies in 55% of patients and remaining were diagnosed
by IHC. CMV DNA PCR was detected in 16/18 patients. Seven (25%)
patients responded to intravenous steroids whereas intravenous ganciclo-
vir followed by oral valganciclovir was required in 20/27 (75%) patients.
Clinical response was noted in 14/20 (70%) patients whereas colectomy
was required in 3/27 (11%) and 3/27 (11%) died due to complications.
Conclusion CMV colitis complicating IBD is independently associated
with refractory disease, immunomodulator use and age over 30.
Conventional H&E “owl eye” inclusions are specific but less sensitive
(55% in this study) whereas IHC remain the gold standard for diagnosis.
Deep punched out ulcerations (observed in 48% patients) may hint to-
wards the diagnosis. Antiviral therapy significantly improves outcome.
Few patients may develop life threatening complications carry high risk
of mortality and necessitates surgical intervention.
016
FAT score: A novel predictive score to differentiate non-alcoholic
steatohepatitis (NASH) from simple steatosis
Jijo Varghese, Krishnadas Devadas
Correspondence- Jijo Varghese-jairusjijo@gmail.com
Department of Medical Gastroenterology, Medical College, Ulloor -
Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Background Advanced fibrosis in NAFLD has got clinical and biochemical
scoring like NAS score, APRI, FIB-4 score, ELF, Hepa score etc. as well as
imaging system for diagnosis. The main problem is to distinguish NASH
from simple steatosis. Liver biopsy is the Gold standard investigation to
distinguish simple steatosis from NASH. Though there is a handful of
scoring system to distinguish simple steatosis from NASH the deficits are.
& Most of the scoring system were done in patient with morbid obesity.
& The rest contains laboratory variables like cytokeratin 18, collagen
etc. which are costly and not easily available.
Aims and Objectives Aim of the study is to propose a simple predictive
score to differentiate NASH from simple steatosis. NASH is defined as
NAS score >5.
Methods Cross-sectional study. All patient’s who with liver biopsy prov-
en NAFLD.
Results Sixty-four patients were taken up for the study. Among the var-
iable's platelet count, ferritin and transaminase (ALT and AST) were
independent predictors of NASH by logistic regression and cut off were
found out. This lead to proposal of a new score, FAT score (Table 1) to
differentiate NASH from simple steatosis (F stands for Ferritn, A for AST
and ALT, T for t in Platelet) with AUROC of 0.95 (Fig. 1). Each com-
ponent carry a score of 0 or 1 and a score of more than or equal to three
can predict NASH from non-NASH NAFLD with sensitivity of 76.5%,
specificity of 100%.
Conclusion FAT score is a simple predictive model to differentiate
NASH from non-NASH NAFLD or simple steatosis (cut off of more than
or equal to 3) without liver biopsy with high sensitivity, specificity and
accuracy. FAT score less than 3 rules out the need for biopsy. It can be
used as a screening tool instead of biopsy.
017
A comparative study on EUS-FNA and ERCP based brush cytology
for tissue diagnosis in malignant biliary obstruction
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Praveen Mathew, Jaseem Ansari, Prashant Kanni, Chandra Babu,
Manoj Gowda, Achal Garg, Nithin Kumar, Raghuveer Balabhadra
Correspondence- Praveen Mathew-drpraveenmathew@yahoo.com
Department of Medical Gastroenterology, Vydehi Institute of Medical
Sciences and Research Centre, 82, Near BMTC 18th Depot,
Vijayanagar, Nallurhalli, Whitefield, Bengaluru 560 066, India
Introduction Patients with suspected malignant biliary strictures frequent-
ly undergo endoscopic retrograde cholangiopancreatography (ERCP)
based brush cytology and endoscopic ultrasound (EUS) guided fine nee-
dle aspiration (FNA) for establishing the diagnosis. The outcomes of
these tests aid in further management of the patient. A comparison of
these two modalities in establishing the diagnosis is seldom reported.
Aims To compare the diagnostic efficacy of ERCP based brush cytology
and EUS FNA for tissue diagnosis in malignant biliary obstruction. It was
obtained by performing a retrospective audit of all patients admitted in
Vydehi Institute of Medical Sciences and Research Centre for EUS and
ERCP from 2015–2019.
Method Data were collected from 1 January 2015 to 31 December 2019.
Majority of the patients were in the 5th decade with a slight female
predominance. Most common CT finding was periampullary mass with
59.7% of the having common bile duct stricture. EUS-FNA was more
sensitive than ERCP based tissue sampling. The overall sensitivity was
90.63% for EUS-FNA and 65.63% for ERCP sampling. EUS-FNA was
found to have diagnostic accuracy of 92.63% in comparison to 71.43%
for brush cytology.
Conclusions EUS –FNA is found to be superior to ERCP based tissue
sampling with excellent sensitivity and diagnostic accuracy. Performing
EUS before ERCP in all the patients with suspected malignant biliary
obstruction would definitely improve the diagnostic accuracy and thereby
help in the management of such cases.
018
The prevalence and clinico-demographic profile of the histopatholog-
ically confirmed esophageal cancer patients at tertiary care center in
South India: A retrospective study
Achal Garg, Praveen Mathew, Prashant Kanni
Correspondence- Praveen Mathew-drpraveenmathew@yahoo.com
Department of Medical Gastroenterology and Hepatology, Vydehi
Institute of Medical Sciences, 82, Near BMTC 18th Depot,
Vijayanagar, Nallurhalli, Whitefield, Bengaluru 560 066, India
Background and Aim Esophageal cancer is a disease of advanced age,
peaking in the seventh and eighth decades of life. Most of the tumors of the
esophagus are malignant and the pinpointing side effect, dysphagia, happens
late. To assess the prevalence and clinico-demographic profile of the histo-
pathologically confirmed esophageal cancer patients at a tertiary care center.
Methods The present retrospective observational study was carried out in
the Department of Gastroenterology, among 210 patients, 196 patients
were diagnosed with esophageal cancer (histologically proven) from
January 2017 to December 2019. The demographic factors incorporate
age; sex and the dependence normal for the patients were considered. The
site of the ailment and the histopathology were likewise assessed.
Results The overall mean age of the study population diagnosed
with esophageal cancer was 58.37±11.54. Of the 196 patients, 142
(72.4%) of them exhibited squamous cell carcinoma followed by
adenocarcinoma 44 (22.4%) and dysplasia in 10 (5.2%) patients.
Dysphagia was the most common presenting clinical symptom
followed by vomiting and weight loss.
Conclusion Squamous cell carcinoma (SCC) is still the most common
histological subtype and is way ahead of adenocarcinoma (AC). The mid
esophagus is still the most common site.
Keywords Adenocarcinoma, Esophageal cancer, Squamous cell carcino-
ma, Dysphagia
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
019
Does inflammatory bowel disease behave differently at extremes of
age?
Nikhil Bhangale, Devendra Desai, Philip Abraham, Tarun Gupta,
Anand Joshi, Adesh Andhale
Correspondence- Devendra Desai-devendracdesai@gmail.com
Division of Gastroenterology, P D Hinduja Hospital, Mumbai 400016,
India
Introduction Studies on characteristics of inflammatory bowel disease
(IBD) with onset at extreme ages, which forms 10% to 25% of patients
with IBD, have focused on either pediatric or elderly population, but not
all age groups together.
Methods To compare the characteristics of IBD with onset in the pediatric
(≤16 years) and elderly (≥60 years) age group with those with onset at age
17-59 years.
Results Of 266 patients (137 men), 47 had pediatric onset, 175 middle age
and 44 elderly onset (ulcerative colitis [UC], median age 38 years [inter-
quartile range 27], Crohn’s disease [CD], median age 35 years, interquartile
range 30]). Among UC patients, pancolitis was more common in the pedi-
atric group (p=0.018) and indolent behavior more common in the elderly
group (p=0.005). Among CD patients, the pediatric group more often had
colonic (p=0.02) and the elderly more often had ileal (p=0.04) involvement;
perianal disease was least common in the elderly group (p=0.03). There was
no treatment difference between the three groups in UC, while pediatric CD
patients needed biologics more frequently (p=0.005) and elderly CD pa-
tients less frequently required steroids, biologics, immunosuppressants and
surgery (p<0.05) than the middle age group.
Conclusion This study highlights the spectrum of IBD according to age at
onset. Pediatric patients with UC more often had pancolitis while the
elderly had milder disease, similar to earlier studies. Pediatric CD patients
more often had colonic disease with more requirement for biologics as
compared to western studies which showed ileo-colonic involvement and
more of complicated disease behavior. Elderly CD patients more often
had ileal disease, least common perianal disease, and less requirement for
immune-suppressant drugs and surgery as compared to the middle age
group in contrast to colonic involvement with commoner uncomplicated
disease behavior (B1) in western studies.
020
Study of the role of non-invasive surrogate as predictor of esophageal
varices in cirrhosis of liver
Jigar Patel, Ankur Jain, Kaushal Vyas, Sushil Narang
Correspondence- Jigar Patel-jskap1992@gmail.com
Department of Medical Gastroenterology, Sardar Vallabhbhai Patel
Institute of Medical Sciences and Research (SVPIMSR), Riverfront
Road, Ellis Bridge, Ahmedabad 380 006, India
Introduction Screening endoscopy for all, becomes difficult approach in
developing countries where the burden of liver cirrhosis is high and use of
endoscopy is limited by its cost. Moreover, it increases the burden that
endoscopy units have to bear. Moreover, only about 30% of patients with
cirrhosis are found to have varices on initial screening endoscopy and
there is low prevalence of varices that require primary prophylaxis.
Methods The present study was a prospective analysis of 75 patients admit-
ted at a tertiary care hospital in Gujarat. Our study included all consecutive
patients with newly diagnosed liver cirrhosis. Platelet count (PC), bipolar
splenic diameter (BSD), platelet count to spleen diameter (PC/SD), aspartate
aminotransferase (AST) to platelet ratio index (APRI), fibrosis-4-index
(FIB-4), model for end-stage liver disease (MELD), AST to alanine amino-
transferase (ALT) ratio (AAR) were measured for all participants. All pa-
tients underwent endoscopic assessment for screening and grading of EV if
S7
present. The diagnostic performance of “predictors” for the presence of EV
were assessed based on receiver operating characteristics curve.
Results On endoscopy, 25 patients (33.33%) had no EV and 75 (66.67%) had
EV, of which 37 (74%) were medium-large varices and the rest (26%) small
varices. On univariate analysis, the overall mean for presence of EV of
MELD (17.88 vs. 20.34, p=0.17) and AAR (2.48 vs. 2.47, p=0.978) were
not significant. However, the overall mean of PC (2.06 lakh vs. 1.1 lakh,
p<0.0001), BSD (129.76 mm vs. 153.1 mm, p<0.0001), PC/SD (1604.41 vs.
759.28, p<0.0001), APRI (0.9737 vs. 2.2964, p<0.0001), FIB-4 (3.1621 vs.
6.9334, p=0.0001) significantly predicted the presence of EV. On multiple
regression analysis only, PC (p<0.0001), APRI (p=0.0405), FIB-4
(p=0.0001) significantly predicted presence of EV. The optimal cut-off of
these parameters for prediction of EV were, PC<1.57 lacs (sensitivity: 80%,
specificity:80%, AUC:0.896), BSD >135 mm (sensitivity: 72%, specificity:
76%, AUC=0.775), PC/SD<1086.67 (sensitivity: 84%, specificity: 92%,
AUC=0.924), APRI>0.87 (sensitivity: 82%, specificity:68%, AUC=0.788),
FIB-4>3.0766 (sensitivity:80%, specificity:64%, AUC=0.766).
Conclusion PC, BSD, PC/SD, APRI, FIB-4 are reliable non-invasive
surrogate for predicting EV.
021
Changes in liver and spleen stiffness following endoscopic variceal
ligation predicts variceal eradication
Atul Hareendran, Krishnadas Devadas, Swetha Sattanathan
Correspondence- Atul Hareendran-atul354@gmail.com
Department of Medical Gastroenterology, Government Medical College,
Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011,
India
Introduction Endoscopic variceal ligation (EVL) for high-grade varices
(HGV) has reduced the morbidity and mortality of variceal bleed. Relook
endoscopy is recommended after 2 weeks to confirm the eradication of
varices. We tried to look at the changes in shear wave elastography
(SWE) of spleen and liver following EVL and to identify the predictors
for the eradication of varices at relook endoscopy.
Methods Prospective observational study conducted in a university hos-
pital in south India over one year. Cirrhotic patients undergoing EVL for
primary prophylaxis (PP) and secondary prophylaxis (SP) with multiband
ligator were included. Spleen stiffness (SS) and liver stiffness (LS) were
measured by 2dSWE using Supersonic Aixplorer, before and 1-hour post
banding. Endoscopy was repeated along with SWE of spleen and liver at
2 weeks.
Results One hundred and fifty patients, 75 undergoing PP and 75 SP,
were included. The Child status distribution was A: B: C = 40%: 44%:
16%. Splenic volume increased following variceal ligation in patients
with CHILD C disease but difference was not significant. Mean increase
in splenic volume in CHILD C was 177 cm3. Relook endoscopy showed
HGV in 75 patients (42 - SP, 33 – PP). In the PP group, predictors of
HGV were high baseline SS, increased serum creatinine and serial in-
crease in LS at 2 weeks post EVL. ROC curve plotted for the new score
(SLC score) devised using the above 3 parameters had an accuracy of
87% (p-value 0.001). In the SP subgroup, only ascites proved significant
on regression analysis.
Conclusion Variceal banding causes an increase in splenic volume and
liver stiffness in patients with severe liver disease. Relook endoscopy
after EVL may be avoided in patients undergoing EVL for primary pro-
phylaxis using SWE of liver and spleen, and serum creatinine before
banding. Using this score, we would be able to avoid 53% of unwanted
endoscopies.
022
Real-world re-treatment outcomes of direct-acting antiviral therapy
failure in patients with chronic hepatitis C
S8
Anshuman Elhence, Achintya Singh**, Ramesh Kumar*, Anzar Ashraf,
Sonu Kumar, Dibyabhaba Pradhan***, Piyush Pathak, Manas Vaishnav,
Mahendra Rajput, Vikas Banyal, Baibaswata Nayak, Shalimar
Correspondence- Shalimar-drshalimar@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, *All India
Institute of Medical Sciences, Patna - Aurangabad Road, Phulwari Sharif,
Patna 801 507, India, * * Cleveland Clinic, Ohio, US, and
***
Computational Genomics Centre, ICMR, New Delhi, India
Introduction Direct-acting antiviral (DAA) drugs are associated with high
(>95%) sustained virological response at 12 weeks (SVR12) in chronic
hepatitis C (CHC) patients. There is a paucity of data regarding the char-
acteristics and re-treatment outcomes of DAA treatment failure patients.
Methods In a retrospective analysis of prospectively collected da-
tabase, we assessed the outcomes of re-treatment among patients
with previous DAA failure. Patients’ characteristics, viral charac-
teristics including resistance associated substitutions (RAS) in a
subgroup of patients, SVR12, and clinical outcomes were studied.
Results Of 40 patients with DAA failure, among whom 36 were
retreated, mean age was 45.7 years, 63.9% (n=23) were male,
63.9% (n=23) had genotype-3 infection and 63.9% (n=23) were
cirrhotic. The re-treatment regimens included combination of pan-
genotypic DAA, mainly sofosbuvir and velpatasvir with or with-
out ribavirin. Three patients who declined retreatment and one
who was still on treatment was excluded. Patients who completed
re-treatment, SVR12 was 100% irrespective of genotypes. SVR12
among genotype 3 was 75% (15/20) when lost to follow-up was
considered treatment failure. Six patients died due to liver-related
causes, including five (83.3%) with hepatocellular carcinoma.
RAS analysis in 17 randomly selected patients did not reveal
any dominant substitutions in NS5A or NS5B region affecting
SVR12, though several novel mutations were observed.
Conclusion Re-treatment of CHC patients with prior DAA failure
using pangenotypic DAA is associated with high SVR12 rates
irrespective of genotype or presence of RAS.
023
Clinical and endoscopic picture of periampullary tumor at an Indian
tertiary centre
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Rithesh Gundam, Vijay Kumar T R, Nandeesh H P, Deepak Suvarna,
Aradya H V
Correspondence- Vijay Kumar T R-drvijaytr@gmail.com
Department of Gastroenterology and Hepatology, J S S Medical College
and Hospital, Bangalore - Mysore Road, Bannimantap A Layout,
Bannimantap, Mysuru 570 015, India
Introduction Periampullary tumor is a clinical condition often en-
countered by gastroenterologist. There is limited data regarding
clinical profile and endoscopic management of patients with
periampullary tumor.
Methods We retrospectively analyzed the ERCP (endoscopic retrograde
cholangiopancreatography) records of periampullary tumor patients who
were referred to Department of Gastroenterology for ERCP over a period
of three years from January 2015 to January 2018. Demographic profile,
clinical findings and ERCP management were taken into consideration.
Statistics used were mean and standard deviation for continuous vari-
ables, frequencies and percentages were calculated for categorical vari-
ables were determined.
Results We retrospectively analyzed 86 patients who had under-
gone ERCP for periampullary tumors from January 2015 to
January 2018. Data interpretation revealed that majority of the
cases were between 41 to 50 years (23.6%). There was a male
preponderance (66.3%). Maximum number of cases were of am-
pullary growth (46.5%), followed by lower CBD stricture
(32.6%). The predominant presenting symptom was jaundice
(77.9%), followed by abdominal pain (54.6%). Twelve patients
(14%) had cholangitis at presentation. Mean bilirubin in the cur-
rent study ranged from 11.76 to 23.72. CBD cannulation was
achieved in 98.8% cases (selective cannulation 65.1%, pre-cut
sphincterotomy 33.7%). Biliary drainage was done using plastic
biliary stent (PC) in 84.7% and SEMS (self-expandable metallic
stent) in 15.2% cases. Ampullary growth biopsy and biliary brush
cytology revealed malignancy in 55% and 35.7% cases respective-
ly. At 3 months, 4 patients with PC stent developed block.
Conclusion In our study, ampullary growth was the most common
type of periampullary tumor. Cholangitis was present in 14%
cases at presentation. ERCP had good success for biliary drain-
age. Ampullary growth biopsy and biliary brush cytology has
sensitivity rate of 50% and 35.7% respectively. Rate of PC stent
block was low (< 5%).
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
024
Optimal utilization and efficacy of endoscopic therapy for acute gas-
trointestinal bleeding with low risk of cross-infection of SARS-CoV2:
A multi-centre study of 638 patients during COVID-19 pandemic
Ashish Agarwal, Soumya Jagannath Mahapatra, Deepak Gunjan, Samir
Mohindra, Vishal Sharma, Rajeeb Jaleel, Sudipta Dhar Chowdhury,
Sanjeev Sachdeva, Rakesh Kochhar, Vivek Saraswat, Pramod Garg
Correspondence- Pramod Garg-pgarg10@gmail.com
Department of Gastroenterology and Human Nutrition Unit, All India
Institute of Medical Sciences, New Delhi 110 029, India, Department of
Gastroenterology, Christian Medical College, Vellore 634 004, India,
Department of Gastroenterology, G B Pant Institute of Postgraduate
Medical Education and Research, 1, J L N Marg, New Delhi 110 002,
India, Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India, and Department of
Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Raebareli Road, Lucknow 226 014, India
Background and Study Aims Data on endoscopic management for
gastrointestinal (GI) bleeding during the COVID-19 pandemic
are limited. Our objective was to study the utilization and efficacy
of endoscopic services for acute GI bleeding despite ergonomic
challenges after wearing personal protective equipment (PPE) and
limited resources.
Methods In an observational retrospective multicentre study across
5 academic tertiary-care centres in India, the utilization of endo-
scopic therapy, its efficacy and risk of cross-infection of SARS-
CoV2 were assessed during April 1 to May 31, 2020, for an
emergency endoscopic procedure such as GI bleeding. Outcome
measures were primary hemostasis, rebleeding, mortality and risk
of cross-infection.
Results Of a total of 1294 endoscopic procedures in an unselected
patient population with no strict policy of pre-procedure testing
for SARS COV-2, 638 were performed for GI bleeding: 500 for
upper GI bleeding and 138 for lower GI bleeding. The primary
hemostasis was achieved in 98% with 3.1% in-hospital rebleeding
rate and 5.3% 28-day mortality which was similar to historical
controls. The risk of a health care worker getting a COVID-19
infection with the use of adequate PPE was 0.49% per 100 endo-
scopic procedures performed with the use of adequate PPE.
Median difficulty level faced by an endoscopist using level-2
PPE was 2 (2-3) on a Likert scale.
Conclusion Emergency endoscopic procedure for GI bleeding is
safe during COVID-19 pandemic with adequate infection control
measures and can be performed with outcomes similar to the
usual setting despite ergonomic challenges.
Keywords COVID-19; Endoscopy; Gastrointestinal bleeding; SARS-
CoV-2
025
Endoscopic submucosal dissection in duodenal neuroendocrine tu-
mors using a novel traction technique
Zaheer Nabi, Mahiboob Sayyed, Mohan Ramchandani, Radhika
Chavan, Shujaath Asif, Santhosh Darisetty, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-
3-661, Somajiguda, Hyderabad 500 082, India
Background and Aim The incidence of duodenal neuroendocrine
tumors (DNETs) is increasing. Endoscopic resection has been rec-
ommended for small DNETs. However, there is limited data on
the outcomes of endoscopic submucosal dissection (ESD) in
S9
DNETs. In this study, we aimed to evaluate the outcomes of
ESD in DNETs.
Methods Data of consecutive patients who underwent ESD for
DNETs from January 2018 to October 2019 were analyzed, ret-
rospectively. All the cases of ESD were performed with or with-
out traction using rubber band and two endoclips. En-bloc resec-
tion, complete endoscopic resection (C-ER), complete pathological
resection (C-PR), adverse events and recurrence were evaluated.
Results Eighteen patients (17 males, 57.39 ± 9.72 years) underwent
ESD for DNETs. The median size (IQR) of the DNETs was 1 (0.9-
1.5) cm. ESD was performed with and without traction in 8 and 10
cases, respectively. Mean operating time was significantly lower in
cases where traction was utilized (50.25 ± 14.98 vs. 69.6 ± 14.53
minutes; p=0.014). En-bloc resection, C-ER, C-PR were recorded in
88.9%, 100%, and 72.2% respectively. The histopathology revealed
grade I DNET in 16 and grade II DNET in two patients. Vertical
margins were positive in five patients. Adverse events (27.8%) in-
cluded full thickness (3) and partial thickness (2) muscle injuries
which could be closed endoscopically. Muscle injuries were less
frequent in the traction group (12.5% vs. 40%). There was no recur-
rence at a 11.39±5.77 months (range 6-26).
Conclusion ESD is feasible and effective for the management of
DNETs. The use of rubber band traction improves the visualiza-
tion of submucosa, reduces operating duration and risk of muscle
injuries in ESD for DNETs.
026
Management of walled-off necrosis: Comparison between nasocystic
irrigation with hydrogen peroxide and biflanged metal stent - A ran-
domized controlled trial
Sandeep Ratra, Sudhir Maharshi, Shyam Sunder Sharma, Bharat Sapra,
Sandeep Nijhawan
Correspondence- Shyam Sunder Sharma-shyamsharma4@rediffmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L
N Marg, Jaipur 302 004, India
Background and Aims Walled-off necrosis (WON) is a known com-
plication of acute necrotizing pancreatitis (ANP). There is no
study on comparison of nasocystic irrigation with hydrogen per-
oxide (H2O2) vs. biflanged metal stent (BMS) in the management
of WON. The aim of the study was to compare the clinical effi-
cacy of both the treatment strategies.
Methods This study conducted on patients with symptomatic WON
who were randomized to nasocystic irrigation with H2O2 (group
A) and BMS placement (group B). Primary outcomes were clin-
ical and technical success while secondary outcomes were proce-
dure time, adverse events, need for additional procedures, duration
of hospitalization and mortality.
Results Fifty patients were randomized into two groups. Group A
(n=25, age 37.8 and plusmn;17.6 years, 16 men) and group B
(n=25, age 41.8 and plusmn;15.2 years, 17 men). There was no
significant difference in baseline characteristics between the two
groups. The most common etiology of pancreatitis was alcohol,
observed in 27 (54%) patients. Technical success (100% vs. 96%,
p=0.98) and clinical success (84% vs. 76%, p =0.76), requirement
of additional procedures (16% vs. 24%, p=0.70) and adverse
events (4 vs. 7, p=0.06) were comparable in both the groups.
The duration to get clinical success (34.4 and plusmn;12 vs.
14.8 and plusmn;10.8 days, p=0.001) and procedure time (36
and plusmn; 15 vs. 18 and plusmn; 12 minutes, p=0.01) was
longer in group A compared to group B.
Conclusions Biflanged metal stent and nasocystic irrigation with H2O2
are equally effective in the management of WON but duration to get
clinical success and procedure time is longer with nasocystic irrigation.
S10
027
Prospective validation of AIIMS' index as a predictor of steroid fail-
ure in patients with acute severe ulcerative colitis
Pabitra Sahu, Saransh Jain, Saurabh Kedia, Sudheer Vuyyuru, Peush
Sahni, Raju Sharma, Rajesh Panwar, Prasenjit Das, Vipin Gupta,
Govind Makharia, Simon Travis, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Optimal outcomes in acute severe ulcerative colitis
(ASUC) are related to time-bound management based upon early
prediction of response to intravenous (IV) steroids. In an earlier
study we described the AIIMS' (All India Institute of Medical
Sciences) index (baseline UCEIS >7 and day 3 fecal calprotectin
(FCP) >1000 μg/g) for predicting failure of IV steroids. The cur-
rent study designed to validate the index in a prospective cohort.
Methods Intravenous steroid naïve patients with ASUC, satisfying
Truelove and Witts’ criteria, hospitalized from August 2018-July
2019 were included. Patients’ assessment included baseline sig-
moidoscopy, day1 and 3 FCP, hemogram, biochemistry and
day3 C-reactive protein. All patients received IV steroids and
the primary outcome was steroid-failure, defined as need for
colectomy or rescue therapy with cyclosporine/infliximab during
admission.
Results Of 47 patients, 8 were excluded (4-received steroids out-
side, 2-directly taken for surgery/infliximab therapy, 1-toxic
megacolon and 1-infectious colitis), and 39 patients included
(mean age-36.1+/-12.6 years, male [31%]). Fifteen patients
(38%) failed IV steroid and required rescue therapy (10-
infliximab, 2-cyclosporine, 4-surgery). On univariate analysis,
UCEIS >7 at baseline (p=0.006), Day 1 FCP (p=0.03), Day 3
FCP >1000 μg/g (p=0.001), Oxford criteria (p=0.04) and
AIIMS' index (p<0.001) were significantly different between
steroid-responders and -failures. On multivariate analysis, day 3
FCP >1000 μg/g (Odds ratio [OR]-10.1[95% CI:2.1-80.2]) and
baseline UCEIS >7 (OR-6.4 [95% CI:2.2-196.1]) were indepen-
dent predictors. AIIMS' index predicted steroid-failure with a bet-
ter specificity (100% vs. 83%, p=0.04) and positive predictive
value (100% vs. 64%, p=0.03) than Oxford criteria.
Conclusion AIIMS' index has been validated as an effective early predic-
tor of steroid failure in patients with ASUC.
028
Clinical course of chronic pancreatitis during pregnancy and its ef-
fect on maternal and fetal outcomes
Soumya Jagannath Mahapatra, Shallu Midha, Gadella Varun Teja,
Tanmay Vajpai, Nilanchali Singh, Sushree Monika Sahoo, Shivam
Pandey, Anshuman Elhence, Rahul Sethia, Pramod Kumar Garg
Correspondence- Pramod Kumar Garg-pkgarg@aiims.ac.in
Departments of Gastroenterology, Obstetrics and Gynecology,
Biostatistics, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India
Introduction and Aims There are limited data on the effect of chron-
ic pancreatitis (CP) on pregnancy outcomes and vice versa. Our
aim was to evaluate the clinical trajectory of CP during pregnancy
and its effect on pregnancy outcomes.
Methods All female patients of child-bearing age (≥15 years) di-
agnosed with CP were studied from January 2004 to July 2019.
The change in frequency of painful episodes was assessed before,
during and after pregnancy. Maternal and fetal outcomes were
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
compared between pregnant women (early onset) and women pre-
senting with CP after completion of all pregnancies (late onset).
Results Of 187 women with CP, pregnancy outcomes and clinical
course were assessed in 99 patients. The frequency of painful
exacerbations was significantly lower during pregnancy compared
to pre-pregnancy and post-pregnancy period (p<0.001). The medi-
an pain score decreased significantly to 0 (0-2) during pregnancy
from 3 (0-6) prior to conception and increased to 4 (0-8) after
pregnancy (p=0.002). Women with early onset CP (n=57) had
their first child later and had fewer pregnancies compared to those
with late onset CP (n=42). There was no difference in maternal
outcomes such as gestational diabetes, hypertension, preterm de-
livery and fetal outcomes such as abortion and still birth between
the groups. There was no reported congenital anomaly.
Conclusion Younger patients with CP had later and fewer pregnancies
but there was no increased risk of adverse maternal and fetal outcomes.
The clinical course of CP was usually benign during pregnancy with
decreased frequency and severity of pain.
029
Efficacy and tolerability of hyperbaric oxygen therapy in small bowel
stricturing and fistulising Crohn’s disease
Kante Bhaskar, Pabitra Sahu, Sudheer Kumar Vuyyuru, Peeyush
Kumar, Mukesh Ranjan, Kapil Soni, Saurabh Kedia, Raju Sharma,
Govind Makharia, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110 029, India
Introduction Majority of patients with complicated CD including B2 and
B3 require surgery and biologicals which have considerable morbidity
and side effects. Hyperbaric oxygen therapy (HBOT) can alleviate the
hypoxia driving chronic inflammation in CD. It has shown a beneficial
effect in ASUC and perianal fistulising CD.
Aim To assess the efficacy and tolerability of HBOT in small bowel B2
and B3 CD.
Methods Selected patients of small bowel B2 and B3 active CD who were
refractory to medical treatment were subjected to HBOT. Clinical disease
activity was assessed using CDAI, patient-reported outcomes by SIBD
questionnaire, baseline Hb, Alb and imaging findings (CTE or MRE) were
noted. Patients were subjected to sessions of HBOT. Follow-up done at 2
months and 6 months by CDAI, SIBD questionnaire, MRE at 6 months.
Results Fourteen patients (mean age 42.9 ± 15.67 years, 7 [50% males])
were subjected to HBOT. Thirteen (92.7%) patients had B2 and 1 had B3
phenotype. Mean CDAI at baseline 252 (165-396). Median sessions of
HBOT were 11(3-20), extended over an average of 4 weeks with duration
of each session lasted for 60 mins with a pressure of 1.5-2.5 atm. One
patient had hemotympanum. At 2 months of follow-up, 9 (64.2%) pa-
tients had a clinical response (reduction in CDAI >100), 7 (50%) had
clinical remission, 8 (57.1%) had a steroid-free response. At 6 months
of follow-up, 9 (64.2%) patients had clinical remission, 8 (57.1%) main-
tained steroid-free response. On MRE pre and post HBOT of patients
having clinical response, 4 (50%) had no worsening, 2 (25%) had subtle
improvement in enhancement scores and 2 (25%) had worsened.
Significant improvement in SIBD scores at 2 months (p=0.03) and 6
months (p=0.07).
Conclusion HBOT is effective and well-tolerated therapy in patients of
B2 CD. Long-term follow-up needed in these patients whether HBOT
can maintain this response.
030
Efficacy of antioxidants in relieving pain in chronic pancreatitis in
children: A prospective observational study
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Amrit Gopan, Anshu Srivastava, Amrita Mathias, Surender Kumar
Yachha, Sunil Jain, Prabhakar Mishra, Moinak Sen Sarma, Ujjal Poddar
Correspondence- Anshu Srivastava-avanianshu@yahoo.com
Departments of Biostatistics, Pediatric Gastroenterology, and
Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Lucknow 226 014, India
Introduction Pain is the major problem in 90% of patients with CP.
Although antioxidants are often used in children with CP but no study
has objectively assessed its role in children. Adult data should not be
directly extrapolated to children due to variation in etiology, severity
and nutritional status.
Aims To study the efficacy of antioxidant supplementation in improving
pain, markers of oxidative stress (OS) and antioxidant (AO) levels in
children with chronic pancreatitis (CP).
Methods Children with CP were given antioxidants for 6 months. Pain
assessment and measurement of OS (serum thiobarbituric acid reactive
substances [TBARS], superoxide dismutase [S-SOD]), and AO levels
(vitamin C, selenium, total antioxidant capacity-ferric reducing ability
of plasma [FRAP]) were done at baseline and after 6 months. Good
response was defined as ≥ 50% reduction in number of painful days per
month.
Results Forty-eight CP children (25 males, median age 13 y, pain duration
24 months) and 14 healthy controls were enrolled. 38/48 cases completed
6 month follow-up on antioxidant supplements. Baseline OS marker
(TBARS [7.8 vs. 5.20 nmol/mL; p<0.001]) was higher and AO markers
(FRAP [231 vs. 381.3 μmol/L]; p= 0.003), vitamin C (0.646 vs. 0.780
mg/dL; p<0.001]) were lower in CP as compared to controls. Significant
reduction in TBARS, S-SOD and increase in FRAP, vitamin C and
Selenium occurred after 6 months of antioxidant therapy. Good response
in pain was seen in 26 (68%) cases, with 9 (24%) becoming pain-free.
Responders also had significant reduction in the requirement of analge-
sics and hospitalization. Baseline hemoglobin and selenium were signif-
icantly lower in non-responders than responders. Patients with
Cambridge grade III responded in 100% as compared to 58% in grade
IV-V (p=0.03). No predictor of response was identified on multivariate
analysis.
Conclusion CP children have higher oxidative stress than controls. Nearly
2/3rd show response in pain after antioxidant therapy with improvement
in markers of OS.
Keywords Children, Pancreatitis, Pain, Antioxidants, Oxidative stress
031
Post locoregional therapy changes in oncomiR for tumor response
and targeting of microRNA modulating mTOR pathways in hepato-
cellular carcinoma
Neeti Nadda, Baibaswata Nayak
Correspondence- Baibaswata Nayak-baibaswat@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Hepatocellular carcinoma (HCC) is the fourth leading cause
of cancer mortality and mainly managed by locoregional therapy (LRT).
Aberrantly expressed oncomiRs have diagnostic, prognostic and thera-
peutic implications which need to be evaluated in cancer. Post-LRT
changes in OncomiR expression may predict tumor responses. In HCC,
mTOR pathway activation leads malignant transition of hepatocytes and
miRNAs modulating pathway can be targeted.
Aims Evaluation of oncomiRs as tumor response marker and therapeutics
by targeting oncomiR modulating mTOR pathway.
Methods OncomiRs (miR-21, 221 and 16) change in circulation and AFP
ratio at one-month post-LRT to baseline was estimated in viral HCC
patients to differentiate tumor response as per mRECIST criteria.
Activation of mTOR pathway was studied by real time PCR and western
S11
blot in miR-21, -221 overexpressing Huh7 stable cell lines. Target vali-
dation of these miRs were carried out by UTR assay and targeting by
LNA anti-miR.
Result Significant increase of miRNA -21 and-221 expression was ob-
served in PD (p=0.040, 0.047) and PR patients (miR-21, p=0.045). The
AUROC of miR -21 fold change 0.718 (95% CI 0.54 -0.81) can differ-
entiate in group 1 (CR+PR from PD) and the AUROC of 0.703 (95% CI,
0.572- 0.799) can differentiate in group 2 (CR from PR+PD). Luciferase
reporter-3'UTR assay confirmed PTEN as miR target. Over expression of
miR-21 and miR-221 had shown down-regulation of PTEN and upregu-
lation of p70S6K in Huh-7 cell lines. This indicates mTOR pathway
activation which confirmed by MTT assay for increase in cell prolifera-
tion. LNA anti-miR-21 reduced mTOR activation by reducing expression
of AKT, mTOR and RPS6KB1.
Conclusion The miR-21-fold change correlates well with imaging in
predicting tumor response and are also comparable to AFP ratio in AFP se-
creting HCC patients. LNA anti-miR-21 can prevent mTOR pathway activa-
tion in HCC and may have potential for miRNA based anti-cancer therapeutics.
Keywords OncomiR, HCC, Tumor response, Locoregional therapy
032
Efficacy of amitriptyline in pediatric functional abdominal pain dis-
orders: A randomized placebo-controlled trial
Jayendra Seetharaman, Ujjal Poddar, Surender Kumar Yachha, Anshu
Srivastava, Moinak Sen Sarma
Correspondence- Ujjal Poddar-ujjalpoddar@hotmail.com
Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow 226 014, India
Introduction Amitriptyline is useful in improving symptoms in functional
abdominal pain disorders (FAPD) in adults with variable results in pedi-
atric studies. The aim of this study was to evaluate the efficacy of ami-
triptyline in pediatric FAPD.
Methods In this randomized placebo-controlled trial children (≤18 years)
diagnosed as FAPD based on ROME IV criteria were randomized to
amitriptyline (10 mg for <35 kg and 25 mg for > 35 kg for 12 weeks)
or placebo for 12 weeks. Post-treatment improvement of pain scores
(intensity, duration, and frequency) and quality of life (QOL) from the
baseline were compared between the two groups.
Results The mean age of 149 children (amitriptyline 75, placebo 74) was
11.3± 3.5 years (79 boys). There was significant difference in pain im-
provement in terms of percentage reduction of intensity (64.0% vs.
11.0%), frequency (61.5% vs. 5.3%), duration (64.3% vs. 7.7%) and
percentage improvement in QOL (79.1% vs. 28.4%) between amitripty-
line and placebo group (p<0.001 in all). Good improvement (>50% re-
duction) in pain was seen in 76% in amitriptyline compared to 14.9% in
placebo group (p<0.001). On multivariate analysis, use of amitriptyline
was the only factor predictive of response (OR 24.1, 95% CI: 9.1- 42.6,
p<0.001). Minor adverse events were comparable between the groups
(25.3% vs. 13.5% respectively, p=0.07).
Conclusions A three-month trial of amitriptyline is significantly more
effective in reducing the pain in children with FAPD. The safety profile
of the drug and its efficacy necessitate for more frequent use in clinical
setting.
Keywords Functional abdominal pain, Amitriptyline, Children
033
Effects of enteral nutrition on intestinal permeability and expression
of tight junction proteins in patients with acute pancreatitis
Shekhar Poudel, Deepak Gunjan, Pooja Goswami, Samagra Agarwal,
Namrata Singh, Rajni Yadav, Prasenjit Das, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
S12
Department of Gastroenterology and Human Nutrition Unit, All India
Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background Tight junction proteins (TJP) maintain integrity of gut-
barrier function and are disrupted in the early phase of acute pancreatitis
(AP) leading to increased infectious complications, organ failure and
mortality. We studied the effect of enteral nutrition (EN) on intestinal
permeability (IP), endotoxinemia and duodenal TJP expression in pa-
tients with AP.
Methods Consecutive patients of AP (n=47) and patients with functional
dyspepsia (n=21) as controls were prospectively included. Intestinal perme-
ability was measured with lactulose/mannitol ratio (L/M) and serum anti-
endotoxin was measured by ELISA. Expression of claudin-3 and zonula
occludens-1(ZO-1) TJP was studied in duodenal biopsy by immunohisto-
chemistry in all patients at baseline and in 22 patients with AP after two weeks
of EN. Intensity and distribution of TJP were graded in scale of 0-3 and total
score (0-6) was calculated by adding up the intensity and distribution grades.
Results In comparison to controls, patients with acute pancreatitis had
significantly higher gut permeability (median L/M:16.76 [inter-quartile
range: 6.48-34.87] vs. 2.039 [1.041-4.216]; p<0.001), significantly low
serum IgM anti-endotoxin (72.0 [41.1-95.2] vs. 151.4 [62.3-245.8];
p=0.005), lower claudin-3 expression at both crypts (0 [0–1] vs. 6 [4-
6]; p<0.001) and villi (0 [0-1] vs. 6 [5-6]; p<0.001) and lower ZO-1
expression at both crypts (2.5 [2-6] vs. 6 [6-6]; p=0.005) and villi (4 [2-
6] vs. 6 [6-6]; p=0.017). There was a trend towards improvement in IP
with EN (L/M:16.76 [6.48–34.87] at baseline vs. 6.76 [4.38–23.443] at 2
weeks; p=0.0646). Claudin-3 expression at villi also improved signifi-
cantly after EN (0 [0-1] vs. 3 [1-4]; p=0.002). There was also improving
trend in expression of both claudin-3 and ZO-1 at crypts.
Conclusions Acute pancreatitis is associated with significant derange-
ment in IP possibly due to diminished TJP expression and enteral nutri-
tion may have an important role in restoring it.
Keywords Intestinal permeability, Acute pancreattis, Enteral nutrition,
Claudin, Zonulin
034
Early experience with endobiliary radiofrequency ablation (Endo-
RFA) in patients with unresectable malignant hilar biliary obstruc-
tion
Arun Singh Bhadauria, Samir Mohindra, Gaurav Pandey, Vivek
Saraswat
Correspondence- Vivek Saraswat-profviveksaraswat@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of
Medical Sciences, Raebareli Road, Lucknow 226 014, India
Background Biliary obstruction is the most important determinant of
survival and quality of life in patients with hilar malignancy.
Radiofrequency ablation (RFA) induces coagulative necrosis within stric-
tures, controls tumor growth and may prolong stent patency and patient
survival.
Methods A pilot single-center, comparative prospective study to assess
whether endobiliary-RFA (Endo-RFA) improves survival in patients with
unresectable hilar obstruction. Patients with unresectable malignant hilar
EHBO were included, and alternatively assigned into the study and con-
trol group. Patients with short expected survival, GOO, KPS<50 and
severe comorbidities were excluded. After assessing the stricture by chol-
angiography, RF energy (8-10 watts x 120 seconds) was delivered using
the HabibTM-Endo-RFA 8F probe (delivers RF-energy over a 2.5 cm
length). The stricture was treated at one or two levels, followed by the
placement of plastic stent(s). The stent exchange was done when stent
blocked, with repeat endo-RFA, if stricture persisted.
Results Seventeen patients (GB carcinoma [GBC]) (7), cholangiocarci-
noma [CCA] (10)] in RFA-group, while 15 patients [GBC] (8), CCA (7))
in control-group were included. Median RFA-sessions were 1 and 1.5
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
(range 1-5) in RFA-GBC and RFA-CCA respectively. In patients with
GBC, median survival was similar in RFA and control-group (6.7 mo [CI
95% 4.8-8.6] vs; 4 mo [CI 95% 1.4-6.6], p=0.378), while in patients with
CCA survival was better in the RFA-group (15.8 mo [CI 95% 8.5-23.1]
vs; 7.1 mo [CI 95% 2.5-11.7]; p=0.040, Breslow [Generalized-Wilcoxon]
test). The most common adverse event was abdominal pain in both
groups (more common in RFA group). Other adverse events-cholangitis
(2) and minor hemobilia (1) in RFA-group, while cholangitis (4) in
control-group were managed conservatively. The most common cause
of death was metastasis (RFA-group), and cholangitis (control-group).
Conclusion Endo-RFA is safe, and may improve survival in patients with
hilar malignant EHBO, particularly in those with cholangiocarcinoma.
Keywords: Radiofrequency ablation, Hilar block, Endobiliary stenting
035
Panel of serum miRNAs as potential non-invasive biomarkers for
pancreatic ductal adenocarcinoma
Anoop Saraya, Imteyaz Khan, Safoora Rashid, Nidhi Singh, Sumaira
Rashid, Vishwajeet Singh, Deepak Gunjan, Prasenjit Das, Nihar Dash,
Ravindra Pandey, Shyam Chauhan, Surabhi Gupta
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Biochemistry, Biostatistics, Gastroenterology and
Human Nutrition Unit, Gastrointestinal Surgery, Pathology, and
Reproductive Biology, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India
Introduction Early-stage diagnosis of pancreatic ductal adenocarcinoma
(PDAC) is difficult due to non-specific symptoms. Circulating miRNAs
in body fluids have been emerging as potential non-invasive biomarkers
for diagnosis of many cancers. Thus, this study aimed to assess a panel of
miRNAs for their ability to differentiate PDAC from chronic pancreatitis
(CP), a benign inflammatory condition of the pancreas.
Methods Next-generation sequencing was performed to identify miRNAs
present in 60 FFPE tissue samples (27 PDAC, 23 CP and 10 normal pan-
creatic tissues). Four up-regulated miRNAs (miR-215-5p, miR-122-5p, miR-
192-5p, and miR-181a-2-3p) and four down-regulated miRNAs (miR-30b-
5p, miR-216b-5p, miR-320b, and miR-214-5p) in PDAC compared to CP
were selected based on next-generation sequencing results. The levels of
these 8 differentially expressed miRNAs were measured by qRT-PCR in
125 serum samples (50 PDAC, 50 CP, and 25 healthy controls [HC]).
Results and Conclusion The results showed significant upregulation of
miR-215-5p, miR-122-5p, and miR-192-5p in PDAC serum samples. In
contrast, levels of miR-30b-5p and miR-320b were significantly lower in
PDAC as compared to CP and HC. ROC analysis showed that these 5
miRNAs can distinguish PDAC from both CP and HC. Hence, this panel
can serve as a non-invasive biomarker for the early detection of PDAC.
Keywords Pancreatic ductal adenocarcinoma, Chronic pancreatitis,
Formalin-fixed paraffin-embedded tissue, Serum
036
Pediococcus pentosaceus I44, a novel beneficial bacteria from human
gut
Lavanya Vasudevan, Jayanthi V, Srinivas M, T S Chandra
Correspondence- T S Chandra-lavanyavasudevan08@gmail.com
Department of Biotechnology, Gleneagles Global Health City, Chennai,
India, Indian Institute of Technology, Madras, India, and Sri
Ramachandra Institute of Higher Education and Research, Chennai, India
Background Gut bacteria are now known to influence metabolic process-
es, immunity, and mental health. Hence the study of gut microbiota is an
emerging topic of research.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Aim Most research on human microbiota are done with molecular
tools. Very few studies attempt to physically isolate gut bacteria
due to various difficulties involved. Many studies use stool sam-
ples which provide only the transient passengers of the gut.
Tissue samples (over stool samples) provide better expression of
autochthonous gut bacterial population. This research focuses on
challenges involved in isolation of "autochthonous" gut bacteria
and how dietary constituents may influence their properties.
Methods and Results Biopsy samples were collected from ileum and
cecum of healthy volunteers who underwent routine colonoscopy.
Pediococcus pentosaceus I44, isolated from ileum, was studied for
acid and bile tolerance and surface properties. It was unable to
survive in acidic conditions (pH 2 and pH 3) but could grow well
in pH 6.5-8.0. It could withstand high bile stress of 0.5% w/v and
1% w/v for 24h. The cell surface was hydrophilic and showed
good aggregation of 87%. The effect of tween-80, oleic acid,
olive oil and sesame oil on properties of P. pentosaceus I44
was analyzed. These factors did not improve the acid tolerance.
Tween-80 and oleic acid facilitated the growth of organism under
bile stress.
Conclusion P. pentosaceus I44 is a permanent inhabitant of gut and
is deposited at National Centre for Microbial Resource, Pune. To
our knowledge this is the first study on laboratory culturing of
gut bacteria in Indian population. It is increasingly evident that
dietary habits govern the gut microbiota, and hence what may
benefit one ethnic human population may not be of use to anoth-
er. Hence this study strives to provide the groundwork for the
emerging concept of “personalized probiotics”.
Keywords Autochthonous, Biopsy, Pediococcus pentosaceus, Gut micro-
biota
Esophagus
037
A rare cause of dysphagia post living donor liver transplantation in a
child
Shankar Bhanushali, Aabha Nagral, Deepakkumar Gupta, Amey
Sonavane, Rahul Deotale, Abhijit Bagade, Puneet Jain, Darius Mirza,
Pravin Mahajan1
Correspondence- Shankar Bhanushali-shankru07@gmail.com
Department of Gastroenterology and Hepatology, Apollo Hospitals, Plot
13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai 400 614,
India, and 1S L Raheja Hospital, Raheja Rugnalaya Marg, Mahim West,
Mahim, Mumbai 400 016, India
Introduction Post-transplant lymphoproliferative disorders (PTLD) is a life
threatening disorder of the immunosuppressed state in transplanted patients.
Common sites include lymph nodes, gastrointestinal tract and airways.
Case A 12-year-old boy underwent a living donor liver transplantation for
Budd-Chiari syndrome. Eighteen months later, he presented with pro-
gressive dysphagia. He was on Tacrolimus and Azathioprine with normal
counts and liver function and a trough tacrolimus level of 10 ng/mL. His
EGD scopy revealed two deep ulcers with overhanging edges in mid
esophagus. Histopathology showed atypical small to medium sized lym-
phoid infiltrate in the esophageal mucosa, expressing CD79a, CD138 and
MUM-1, EBERsBY ISH. He was immunonegative for CD20, CD3 CD5,
Pax-5, CD2, CD7, CD4, CD8, CD30 and ALK-1. No light chain restric-
tion was seen. Mib-1 proliferation index was 60% suggestive of polymor-
phic PTLD. PET-CT was unremarkable. EBV viral load was 12,50,00
copies/mL. Azathioprine was omitted and tacrolimus was reduced to
maintain a trough level of 2-3 ng/mL. There was complete resolution of
dysphagia and an endoscopy after 3 months showed complete healing of
ulcers with mild hypertrophied mucosa with no evidence of any residual
PTLD on histology. Currently he is well with normal liver function and
S13
an undetectable EBV infection. EBV-infected B cells cannot be con-
trolled by EBV-specific cytotoxic T cells. Restoring recipient immunity
helps control of EBV driven lymphoproliferation. Ours being the only
one in a post liver transplant setting. Ours is the first esophageal PTLD
reported in a post liver transplant setting; other being a renal transplant
recipient treated with rituximab.
Conclusion Esophageal PTLD should be considered in the DD of dys-
phagia in the post-transplant setting.
038
Esophageal stricture dilatation with Savary-Gilliard dilators-
Etiological spectrum and response to treatment, a single centre expe-
rience from Central India
Mohd. Talha Noor, Praveen Vasepalli
Correspondence- Mohd. Talha Noor-noorpgi@gmail.com
Department of Gastroenterology, Sri Aurobindo Medical College, and
PGI, SAIMS Campus, Indore-Ujjain State Highway, Near MR-10
Crossing, Sanwer Road, Indore 453 555, India
Introduction Esophageal stricture dilatation is a therapeutic procedure for
the management of dysphagia secondary to structural or neuromuscular
disorders of the esophagus that offers the benefits of temporary or per-
manent relief of dysphagia, with an improved quality of life and some-
times avoidance of surgery. Benign causes include peptic stricture,
Schatzki’s ring, esophageal web, corrosive ingestion, post-radiotherapy
or post-surgical strictures. Malignant causes include adenocarcinoma,
squamous cell carcinoma, pseudo-achalasia and metastases. In this study,
we aimed to investigate the effectiveness of dilatation with Savary-
Gilliard dilators (SGD) with respect to etiology.
Methods We retrospectively analyzed the cases treated with esoph-
ageal dilatation with SGD in the Department of Gastroenterology at
Sri Aurobindo Institute of Medical Sciences from January 2014 to
August 2020. All the demographic and clinical data was recorded as
well as endoscopic dilatation count and complications.
Results A total of 108 patients (52 [48.14%] males and 56 [51.85%]
females) were included in the study with mean age of 52.4±14.7
(17-80) years. A total of 1025 dilatations of 108 patients were done
in 225 sessions. The most commonly seen etiologies were post-
radiotherapy strictures (n=46, 42.59%), peptic strictures (n=23,
21.29%), corrosive strictures (n=21, 19.44%) and esophageal web
(n=11, 10.18%). Mean dilatation session count was 4.5 (1-10) in
patients with post-radiotherapy strictures, 3.2 (1-8) in corrosive
strictures, 2.1 (1-8) in peptic strictures, 1.3 (1-3) in esophageal
web No major complications such as perforation, major bleeding
were observed.
Conclusion SGD for the treatment of esophageal strictures is a relatively
safe, cheap, easily performed method. While esophageal web is usually
treated in a single session, repeated endoscopic dilation sessions are re-
quired for the strictures caused by radiotherapy and corrosive ingestion as
majority of them are long and complex strictures.
039
Quality of life changes in patients of achalasia cardia undergoing
pneumatic dilatation vs. laparoscopic Heller’s cardiomyotomy
Pratik Jha, Mumtaz Ansari, Vivek Srivastava
Correspondence- Mumtaz Ansari-mumtazbhu@gmail.com
Department of General Surgery, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221 005, India
Introduction There are various treatment options available for achalasia
cardia like botulinum toxin injection into the distal esophagus, balloon
dilatation, calcium channel blockers or nitroglycerine, and open/
S14
laparoscopic Heller’s cardiomyotomy. However, the optimal approach is
still a matter of debate.
Objectives To compare the clinical outcomes and overall quality of life in
achalasia cardia patients undergoing pneumatic dilatation (PD) and lapa-
roscopic Heller’s cardiomyotomy (LH).
Methods A total of 30 patients with achalasia cardia were divided into two
groups using computer-generated randomization in this prospective study
conducted from July 2017 to July 2019 at Institute of Medical Sciences,
Banaras Hindu University. The diagnosis was confirmed by timed barium
swallow study/esophagoscopy and high-resolution manometry. Pre-
procedure data regarding demography, symptom duration and severity,
and manometric pressure was collected. Group 1 and 2 underwent PD and
LH respectively. The post-procedure evaluation was done on the basis of
Eckardt score, manometric data and quality of life based on SF-36 ques-
tionnaire at 1 week and 3 months. Statistical analysis was done using
SPSS 16.0 software.
Results Both the study groups were similar. The mean age was 40.70 ±
13.42 in the PD group and 39.70 ± 9.71 in the LH group. The symptom
severity as evaluated by Eckardt score was less in the PD group initially
but at 3 months LH group had fewer scores (p<0.01). The decrease in
lower esophageal sphincter pressure (PD: 9.20 ± 3.75, LH: 1.79 ± 8.98),
integrated relaxation pressure and distal contractile integral was more in
the LH group (p<0.01). Role limitation due to physical functioning and
emotional problems were comparable in both groups. However, physical
function, energy, general health, mental health, emotional well-being and
social functioning were better in the LH group at 3 months (p<0.01).
Conclusion Laparoscopic Heller’s cardiomyotomy is a better treatment
option with comparable safety as pneumatic dilatation.
040
Efficacy of POEM for achalasia cardia in a tertiary care center of
Odisha
Manas Kumar Behera, Manoj Kumar Sahu, Jimmy Narayan,
Debakanta Mishra, Shobhit Agarwal
Correspondence- Manoj Kumar Sahu-manojsahu427@gmail.com
Department of Gastroenterology, Institute of Medical Sciences and SUM
Hospital, (SOA deemed to be University), K8 Kalinga Nagar, Shampur,
Bhubaneswar, Odisha 751 003, India
Introduction Per oral endoscopic myotomy (POEM) is a highly effective
and safe technique for treatment of achalasia cardia and has received
worldwide acceptance for its promising results. The aim of this study is
to evaluate the efficacy of POEM technique in patients with achalasia
cardia.
Methods Patients of achalasia cardia treated by POEM between January
2018 to March 2019 were retrospectively analyzed. These patients were
followed up for a period of 1 year. All the patients had undergone timed
barium swallow and high-resolution esophageal manometry before and
after procedure. The outcomes of POEM procedures including Eckardt
score, and occurrence of gastroesophageal reflux disease (GERD) and
periprocedural complications were compared.
Results A total 42 patients were performed POEM for achalasia cardia
(Type I-9%, Type II-91%). POEM was successfully completed in all
patients. Mean age was 37.12 ± 12.34 years, with males constitute 68%
of all cases. Median duration of disease was 3 years. Dysphagia (81%),
chest pain (62%), regurgitation (50%) were presenting symptoms, and
mean pre-POEM Eckardt score was 8.51 ± 1.68 and mean post POEM
Eckardt score was 1.63 ± 0.55 (p<0.001). The mean lower esophageal
pressure before and after POEM procedure were 39.58 ± 7.82 and 15.86 ±
6.98 respectively (p<0.001). Technical success was 100 % and clinical
success, defined as Eckardt score ≤?3 after POEM procedure, was
achieved in 40 (95.2%) patients. Nine (21.4%) patients developed
GERD, as documented by 24-hour pH-impedance study.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusion POEM is a very effective, safe technique, and should be
undertaken as a first treatment option in patients with achalasia cardia.
041
Esophageal stricture dilatation with Savary-Gilliard dilators-
Etiological spectrum and response to treatment, a single centre expe-
rience from Central India
Mohd. Talha Noor, Praveen Vasepalli
Correspondence- Mohd. Talha Noor-noorpgi@gmail.com
Department of Gastroenterology, Sri Aurobindo Medical College, and
PGI, SAIMS Campus, Indore-Ujjain State Highway, Near MR-10
Crossing, Sanwer Road, Indore 453 555, India
Introduction Esophageal stricture dilatation is a therapeutic procedure for
the management of dysphagia secondary to structural or neuromuscular
disorders of the esophagus that offers the benefits of temporary or per-
manent relief of dysphagia, with an improved quality of life and some-
times avoidance of surgery. Benign causes include peptic stricture,
Schatzki’s ring, esophageal web, corrosive ingestion, post-radiotherapy
or post-surgical strictures. Malignant causes include adenocarcinoma,
squamous cell carcinoma, pseudoachalasia and metastases. In this study,
we aimed to investigate the effectiveness of dilatation with Savary-
Gilliard dilators (SGD) with respect to etiology.
Methods We retrospectively analyzed the cases treated with esophageal
dilatation with SGD in the Department of Gastroenterology at Sri
Aurobindo Institute of Medical Sciences from January 2014 to August
2020. All the demographic and clinical data was recorded as well as
endoscopic dilatation count and complications.
Results A total of 108 patients (52 [48.14%] males and 56 [51.85%]
females) were included in the study with mean age of 52.4±14.7 (17-
80) years. A total of 1025 dilatations of 108 patients were done in 225
sessions. The most commonly seen etiologies were postradiotherapy
strictures (n=46, 42.59%), peptic strictures (n=23, 21.29%), corrosive
strictures (n=21, 19.44%) and esophageal web (n=11, 10.18%). Mean
dilatation session count was 4.5 (1-10) in patients with postradiotherapy
strictures, 3.2 (1-8) in corrosive strictures, 2.1 (1-8) in peptic strictures,
1.3 (1-3) in esophageal web No major complications such as perforation,
major bleeding were observed.
Conclusion SGD for the treatment of esophageal strictures is a relatively
safe, cheap, easily performed method. While esophageal web is usually
treated in a single session, repeated endoscopic dilation sessions are re-
quired for the strictures caused by radiotherapy and corrosive ingestion as
majority of them are long and complex strictures.
042
Fully covered stent in a case of endoleak for post aortic stenting in a
case of primary aortoesphageal fistula
Deepakkumar Gupta, Amey Sonawane, Aabha Nagral, Rahul Deotale,
Shanker Bhanushali
Correspondence- Deepakkumar Gupta-dkgt@rediffmail.com
Department of Gastroenterology, Apollo Hospital, Plot # 13, Parsik Hill
Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Introduction Endoleak post aortic stenting for primary aortoesophageal
fistula is a rare complication requiring reintervention, however with high
risk of mortality. We hereby used a fully covered self-expanding covered
esophageal metal stent (SEMS) in one such case to control the rebleeding.
Case Seventy-eight-year-old gentleman with hypertension came with 2
episodes of hematemesis with hypotension, after resuscitation he
underwent gastroscopy which showed a large non-occluding mass pro-
truding from the posterior wall and occupying the esophageal lumen,
biopsy taken which turned out to be inconclusive. CT scan thorax done
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
showed a large aneurysm extending uptil the diaphragmatic opening and
a large thrombus protruding into esophageal wall causing a large defect of
3.5 cm on the posteromedial wall in mid esophagus. Patient was imme-
diately taken for aortic stenting which was successfully placed across the
entire length of the aneurysm, patient was continued on ventilatory sup-
port overnight, however within 9 hours post-surgery patient had melena
and a significant drop in hemoglobin. Patient underwent an urgent endos-
copy which showed the clot at 20 cm insitu with active oozing of blood
from the site, post-flushing the bleeding worsened and visibility reduced,
hence initially a foleys balloon passed orally was inflated at 20 cm and a
guidewire passed across into the gastric lumen and temporarily a rigiflex
balloon placed along it, the bleeding was controlled for 24 hours, and
patient underwent a CT scan which showed a type 2 endoleak. In view of
high risk of surgery and no radiological intervention feasible we decided
to use a covered esophageal stent for maintain hemostasis. Patient im-
proved and was kept on RT feeds and was discharged after 7 days. Patient
however readmitted and succumbed after 40 days due to persistent leak
causing mediastinitis.
Conclusion Fully covered SEMS can be used in endoleak management to
control hemostasis.
043
Esophageal tuberculosis in health care workers: A report of 2 cases
Swapnika Gadde, P Shravan Kumar, M Umadevi, K Saikrishna, Sriram
S, Murali NSVM, Anirudh K, Abhinay P, Samad P
Correspondence- Swapnika Gadde-swapnikagadde@gmail.com
Department of Gastroenterology, Gandhi Medical College,
Musheerabad, Secunderabad 500 003, India
Introduction Esophageal tuberculosis (ET) is rare in both immunocom-
petent and immunocompromised hosts with pulmonary tuberculosis,
even in countries with high prevalence rates like India. Most reports of
esophageal tuberculosis are secondary to direct extension from adjacent
structures, such as mediastinal lymph nodes or pulmonary sites.
Case Presentation We present two cases of esophageal tuberculosis in
patients with initial complaints of dysphagia and epigastric pain, empha-
sizing the diversity of endoscopic presentation of TB. Upper gastrointes-
tinal endoscopy was used in the diagnosis of esophageal tuberculosis
following the biopsy of lesions of ulcerated mucosa in one case; other
was based on confirming tuberculosis in adjacent strucrues. Pulmonary
tuberculosis was detected in one patient. Anti-tuberculosis treatment
(ATT) was curative in both patients.
Conclusion Although rare ET has to be considered in the differential
diagnosis of patients with dysphagia, especially in TB endemic areas,
even in young immunocompetant patients. Detection of these cases by
careful examination, biopsies and treatment with standard ATT appear
effective.
Keywords Esophageal tuberculosis, Dysphagia, Endoscopy, Pulmonary
tuberculosis
044
Cerebellar metastasis as first presentation from undiagnosed esoph-
ageal carcinoma: A case report
Dhaval Choksi1, Sanjay Vekhande2, Ketaki Choksi3, Vidya Kale3
Correspondence- Dhaval Choksi-dhavalrchoksi@gmail.com
1
Departments Medical Gastroenterology, 2 Neurosurgery, and
3
Pathology, Apollo Hospitals, Plot No. 1, Swaminarayan Nagar, New
Adgaon Naka, Panchavati, Nashik 422 003, India
Introduction Brain metastasis from esophageal carcinoma is an uncom-
mon event. Amongst these, cerebellar metastasis without cerebral metas-
tasis is extremely rare.
S15
Methods We report a case of a 74-years male presenting with headache
and ataxia. Brain imaging was suggestive a cerebellar lesion which was
operated upon. Biopsy was suggestive of metastatic squamous cell carci-
noma. Patient had upper gastrointestinal bleeding on postoperative day 3
which was investigated with upper gastrointestinal endoscopy, biopsy
and computed tomography scan of the chest. A diagnosis of metastatic
esophageal carcinoma with cerebellar metastasis was made.
Result Patient succumbed to his illness after 2 months.
Conclusion Our case is an addition to this rare entity of cerebellar metas-
tasis from esophageal carcinoma presenting with neurological features.
Keywords Esophageal carcinoma, brain metastasis, cerebellar metastasis
045
Clinical profile, etiology and outcome of esophageal strictures in a
tertiary care centre in Kerala
Gouri S, Sunilkumar Kandiyil, T M Ramachandran
Correspondence- Gouri S-mailme2gouri@gmail.com
Department of Gastroenterology, Government Medical College, Calicut
673 008, India
Introduction Esophageal strictures are a commonly encountered problem
in daily practice and can occur from a variety of benign and malignant
etiologies, which varies in developed and developing countries. This
study was intended to describe the clinical profile of esophageal strictures
and assess the outcome and complications associated with endoscopic
dilatation.
Methods A prospective study was conducted among 96 patients with
esophageal stricture, attending Department of Gastroenterology in a ter-
tiary care centre in Kerala from July 2019 to June 2020. The outcomes
were to assess clinical and technical response to dilatation, procedure
related complications and the factors predicting refractoriness to
dilatation.
Results Among the 96 patients studied, (M:F–1.46:1), mean age–54 years),
corrosive and radiation induced strictures were the commonest contributing
20.8% each. Malignant, post-anastomotic, peptic, web and inflammatory
strictures were 16.7%, 12.5%, 9.4%, 9.4% and 4.2% respectively.
Esophageal dilatations were performed with bougie (91.5%), balloon or both
with a clinical and technical success rates of 73% and 65%, and 22.9%
remained refractory. Severe grades of dysphagia on presentation, poor nutri-
tional status and long segment strictures involving multiple sites in corrosive
induced and malignant strictures were found to predict refractoriness. A com-
plication rate of 4.16% was noted during the periprocedural period.
Conclusion Ingestion of corrosives and radiation therapy appear to be the
most common causes of esophageal strictures. Endoscopic dilatation is
usually successful and safe in achieving luminal patency, but corrosive
and malignant strictures are mostly refractory, and the former tend to
recur even after successful dilatation.
Keywords Esophageal stricture, Etiology, Dilatation success,
Complications
046
Role of high-resolution manometry and 24 hours ambulatory pH
impedance study in patients with PPI refractory non erosive gastro-
esophageal reflux disease
Charu Gupta, Piyush Ranjan, Shrihari Anikhindi, Munish Sachdeva,
Mandhir Kumar
Correspondence- Piyush Ranjan-piyushranjan70@gmail.com
Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder
Nagar, New Delhi 110 060, India
Introduction Refractory gastroesophageal reflux disease (GERD) is a
common problem faced by a gastroenterologist. Understanding the cause
S16
of treatment refractory GERD helps in guiding the further course of
treatment. We aim to study the physiological basis of patients with
nonerosive refractory gastroesophageal reflux disease and classify these
patients based on findings of high-resolution manometry (HRM) and 24-
hour ambulatory pH impedance monitoring.
Methods This is a single centre prospective study from March 2019 to
August 2020 in which clinical profile and data of HRM and pH imped-
ance studies was analyzed in patients on PPI with refractory non erosive
GERD. Refractory GERD was defined as persistence of heartburn or
regurgitation at least once a week after receiving standard dose of PPI
for at least 8 weeks. Patients on NSAIDs, pregnant females, patients with
organic disease of the upper digestive tract or previous upper digestive
tract surgery, significant comorbidities like decompensated chronic liver
disease, chronic kidney disease, poorly controlled diabetes mellitus or
any malignancy were excluded.
Results One hundred and fifty-one patients with refractory GERD were
analyzed of which, 48 had abnormal esophagogastroduodenoscopy and
103 were nonerosive GERD. Amongst, nonerosive disease, acid reflux
disease was found in 29.1%, non-acidic reflux disease in 21.4%, 30.1%
patients had reflux hypersensitivity whereas, 19.4% patients had func-
tional heartburn. On HRM, 8.74% had esophageal motility disorders,
most commonly being IEM in 5.82% patients followed by
esophagogastric junction (EGJ) obstruction in 1.94% and absent contrac-
tility in 0.97%. 25.2% had hiatus hernia; 20.4% patients had type II EGJ
morphology, 2.9% had type IIIa and 1.9% had type IIIb EGJ morphology.
Conclusion True acid reflux disease was found in less than 1/3rd refrac-
tory non erosive GERD patients only and around 50% patients had func-
tional esophageal disorder as found on pH impedance studies. Majority
patients have normal esophageal motility but 1/4th have abnormal EGJ
morphology.
Keywords Refractory NERD, pH impedance studies, High resolution
047
An unusual cause of hematemesis: Managed by endoscopic and ra-
diological interventions
Mahesh Kumar Gupta1, Rinkesh Kumar Bansal2, Rajesh Puri3
Correspondence- Mahesh Kumar Gupta-guptamahesh1982@gmail.com
1,2
Department of Gastroenterology and Hepatobiliary Science, Fortis
Memorial Research Institute, 44, Opp. HUDA City Centre, Gurugram
122 002 India, Department of Gastroenterology, Medanta -The
Medicity, CH Baktawar Singh Road, Sector 38, Gurugram 122 001, India
Background Perforation of esophagus secondary to bursting of tubercular
mediastinal lymph nodes, presenting with hematemesis rare. Commonest
site is mid-esophagus, due to proximity to mediastinal lymph nodes.
Case A 50-year-old male, diagnosed case of sputum positive pulmonary
tuberculosis, on first line ATT x 2 months, presented with multiple episode
of massive hematemesis X 2 days. Clinical examination revealed mild-
grade fever, tachycardia and tachypnoea. His hemoglobin was 5 gm%,
managed by multiple units of blood transfusion. Patient shifted to ICU for
close monitoring and intensive care. After stabilization endoscopy done
which showed lymph node eroding in the esophagus at 30 cm from incisors
with suspected bronchoesophageal fistula without active bleeding at eroded
site. CECT chest showed enlarged subcarinal nodes with
bronchoesophageal fistula. Bronchoscopy conformed bronchoesophageal
fistula. He had another episode of hematemesis on next day so repeat
endoscopy was done which showed there was active oozing through eroded
site on which OTSC applied. He responded well to endotherapy and was
discharged in stable condition on ATT. After one month, he again had
hematemesis, endoscopy showed a small bleeding vessel at previously
clipped site, another clip tried but not succussed. His CT angiography chest
showed right bronchial artery pseudoaneurysm measuring 1.1 cm x 0.7 cm.
Urgent interventional radiology team called and he underwent angiographic
embolization of pseudoaneurysm. He responded well to the given
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
treatment. Follow-up endoscopy showed no bleeding and clip in position.
He was discharged in stable condition on ATT. He is doing well on 4
months follow-up without any further bleed.
Conclusion It is important to consider esophageal perforation due to
mediastinal lymph nodes in endemic areas of tuberculosis; the patient
can be managed by simple clipping with anti-tubercular drug therapy
and without removing the esophagus.
Keywords Hematemesis, Tubercular lymphadenopathy, Perforation,
OTSC clipping, Embolization
048
Ten-year study on management of corrosive esophageal stricture
Neeraj Nagaich1, Radha Sharma2
Correspondence- Neeraj Nagaich-drneerajn@gmail.com
1
Department of Gastroenterology, Fortis Hospital, Jawahar Lal Nehru
Marg, Malviya Nagar, Jaipur 302 017, India, and 2RUHS College of
Medical Sciences, Kumbha Marg, Sector 11 Road, Pratap Nagar, Jaipur
302 033, India
Objective Analysis of outcome and safety of esophageal dilatation in
caustic esophageal strictures.
Methods This prospective and retrospective study was conducted to eval-
uate the safety and efficacy of endoscopic dilatation in corrosive esoph-
ageal stricture. All eligible patients with caustic esophageal strictures
presenting between 2010 to 2020 and above 03 years of age were includ-
ed. Patient with caustic stricture and fistulae or diverticulae, peptic stric-
ture and malignant stricture were excluded. Barium swallow and meal
was done if required Savary-Gilliard plastic dilators of increasing sizing
were employed. Repeated sessions were performed fortnightly till a
15 mm (45 Fr) lumen size was achieved. Follow-up session were ar-
ranged whenever dysphagia developed after completing initial session
of adequate dilatation. In patients with refractory stricture injection triam-
cinolone or topical mitomycin C application was done during dilatation
session.
Results Out of 320 patients, 192 patients (60%) were more than 12 years
of age. Mean age is 20.25 ranging from 5 years to 64 years. There were
185 males (58%) and 135 females (42%). Total dilatations were 4822.
Successful dilatation up to a lumen size of 15 mm could be achieved in
211 patients (66%). In 48 patients (15%) with refractory stricture appli-
cation of triamcinolone or mitomycin C lead to success. In 108 patients
(34%) satisfactory dilatation could not be achieved and were referred for
surgery. Nine patients (2.8%) had perforation with an incidence rate of
0.30%.
Conclusion Caustic stricture is more common in adolescent and adults in
our population. Endoscopic dilatation of esophageal strictures is a rela-
tively safe procedure with good results and low rate of complications.
Resection with esophagogastric anastomosis or colonic interposition is
required in severe cases. Injection Triamcinolone and topical Mitomycin
are safe and effective adjuvants in refractory stricture.
Keywords Corrosive, Stricture
Stomach
049
Incidence, prevalence of H. pylori and eradication following treat-
ment in general population
Syed Ibrahim Hassan
Correspondence- Syed Hassan-doctorhassanibrahim@yahoo.co.in
Department of Medical Gastroenterology, Deccan College of Medical
Sciences, Princess Esra Hospital, Kanchanbagh, Hyderabad 500 058,
India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction H. pylori is world’s most common bacterial infection
affecting majority of population. Its incidence ranges between
7% to 97% in developed vs. less developed areas. Since incidence
in our country is high eradication of the bacteria is necessary to
prevent health disability due to its complications. The present
study was undertaken to know the incidence and response to
treatment.
Methods Patients of different age groups and of either sexes pre-
senting with symptoms of epigastric pain related to food of var-
iable duration, from 2 weeks and above with no comorbidity were
included in the study. All patients underwent UGIE, RUT, US
abdomen and CBP, stool for occult blood. Those patients positive
for H. pylori were given triple drug regimen of amoxycillin
(750 mg BD), clarithromycin (500 mg BD) with esomeprazole
40 mg BD for 10 days with food precautions. After 10 days of
treatment UGIE was repeated with RUT to know the clearance of
H. pylori. Patients still positive were given tinidazole (500 mg 2
tablets OD), azithromycin (1 tablet OD) and rabeprazole 40 mg
BD for a period of 10 days and subsequently underwent UGIE
with RUT to know the response.
Results Fifty patients of age groups 11-70 years were included in
the study. Seventy-six percent of patients responded to the first
line of treatment. Non responders were given second line of treat-
ment who responded completely (100%). After treatment all were
asymptomatic.
Discussion H. pylori infection which is a worldwide problem can be
corrected by good food habits, good sanitation, avoiding specific un-
cooked, unhygienic preserved food and water.
Conclusion Screening of patients of APD is the first step followed by
eradication with specific drug regimen to clear the infection and bringing
good health in the community.
050
Is use of proton pump inhibitors associated with renal dysfunction?
A prospective cohort study
Adeshkumar Andhale, Philip Abraham, Devendra Desai, Anand Joshi,
Tarun Gupta, Jatin Kothari, Pavan Dhoble, Nikhil Bhangale
Correspondence- Philip Abraham-dr_pabraham@hindujahospital.com
Department of Gastroenterology, P D Hinduja Hospital and MRC,
Mahim, Mumbai 400 016, India
Introduction Long-term use of proton pump inhibitors (PPI) has been
linked with infrequent but serious adverse events, including acute kidney
injury (AKI), chronic kidney disease (CKD), and progression of CKD.
Objective To determine whether use of PPI is associated with any short-
or long-term renal dysfunction.
Methods Patients taking PPI for 6 weeks had serum creatinine tested pre
and post treatment; those with baseline eGFR <90 mL/min/1.73m2 were
excluded. Patients taking PPI for at least 90 days in the next 6 months, and
at least another 90 days in further 6 months, had serum creatinine tested at
such follow-up. Renal dysfunction was classified as per the KDIGO
criteria for AKI.
Results At baseline, a majority of patients were aged 21-40 y (median 39;
IQR 31-47); 98 (49%) had history of previous PPI use (median 6 mo; IQR
3–24). Serum creatinine was tested at baseline, 6 weeks, 6 mo and 1 y in
200, 180, 77 and 50 patients, respectively. Corresponding creatinine
mean (SD) values were: 0.76 (0.14), 0.69 (0.16), 0.71 (0.15) and 0.76
(0.16) mg/dL. Although there was statistically significant difference
(p<0.05) in creatinine at 6 weeks and 6 mo as compared to baseline, the
difference was not clinically significant. Increase in creatinine was noted
in 20 (11.1%), 11 (14.3%) and 6 (12%) patients at 6 weeks, 6 mo and 1 y,
respectively; 14, 8 and 4 of these had less than Stage 1 dysfunction (i.e.
less than 0.3 mg/dL increase), and 10, 5 and 5 had other risk factors for
renal dysfunction. No patient developed CKD during the study period.
S17
Conclusion Increase in serum creatinine occurred in 10% to 15% of patients
on PPI but was mild (KDIGO Stage 1 or less) in a majority and not
progressive. A majority of them had other risk factors for renal dysfunction.
051
Gastric cancer in young patients with no alarm symptoms: Focus on
delay in diagnosis
Rathod Vivek, A Anand
Correspondence- Rathod Vivek-rathodrockzz@gmail.com
Department of Medical Gastroenterology, Government Kilpauk Medical
College, Chennai 600 010, India
Introduction There has been a tendency in recent years to delay endos-
copy in dyspeptic patients younger than 45 years with no so-called "alarm
symptoms." This study was conducted to test whether this policy might
lead to an increased rate of delayed diagnosis of gastric cancer.
Method A prospective study was carried out on dyspeptic patients < or =
45 years of age in our hospital from October 2019 to July 2020.
Characteristics analyzed included duration and features of dyspeptic
symptoms, presence of alarm symptoms, time interval from the onset of
symptoms to diagnosis and pathological characteristics.
Results In the study group we found 30 patients had gastric cancer (17
females, 13 males). Six patients (20%) presented with uncomplicated
dyspepsia and 24 patients with (80%) alarm symptoms (persistent
vomiting, anemia, weight loss, dysphagia). None had positive family
history. In those with uncomplicated dyspepsia epigastric pain was the
most common complaint (64.1%) followed by vomiting (30.4%). Weight
loss was the most common alarm symptom (53.3%), followed by anemia
(46.6%). Of the 6 patients without alarm features 3 were having adeno-
carcinoma, 2 lymphoma, 1 signetring cell carcinoma.
Conclusion Significant proportion of young (<=45 yrs) gastric cancer
patients present without alarm symptoms. We need to review the existing
standard age criteria (>45 yrs) for endoscopy in dyspepsia without alarm
features particularly in high gastric cancer prevalence areas.
052
High prevalence of APD in general population and its approach
Syed Ibrahim Hassan, Syed Hassan
Correspondence- Syed Hassan-doctorhassanibrahim@yahoo.co.in
Department of Medical Gastroenterology, Deccan College of Medical
Sciences, Princess Esra hospital, Kanchanbagh, Hyderabad 500 058,
India
Introduction H. pylori is the world’s most common bacterial infection in
humans effecting more than half population of the world and seems to be
increasing in less developed countries vs. developed countries. The fac-
tors responsible for infection and increasing transmission include low
socioeconomic status, poor sanitation, overcrowding, contaminated water
ingestion, and consumption of raw and uncooked vegetables, person to
person transmission. Hence it is imperative to clear the infection in indi-
vidual patient and explain risk factors to them.
Aim To study the incidence of gastritis, reflux esophagitis, peptic ulcer
disease in patients presenting with epigastric discomfort, related to food
intake and lasting for few hours more than 1 week and work up with
UGIE, RUT to know the changes and presence of H. pylori.
Methods We are presenting the one year data from April, 2019 to March,
2020 in which patients have presented with dyspepsia of more than 10
days and underwent the UGIE with RUT, US abdomen, CBP and stool
for occult blood comorbiditis were also recorded. Pediatric, pregnant
female were excluded from the study.
Results Total number of UGIE for year was 2274. 1996 patients
underwent procedures for dyspepsia (88%) 5.1% had prepyloric and
S18
duodenal ulcers and 94.9% had evidence of gastritis and 10% also had
reflux esophagitis. The 90.1% of patients were H. pylori positive and
advice anti H. pylori treatment.
Discussion The present study shows high incidence of H. pylori dyspep-
sia which needs specific treatment and correction of risk factors which
have to be taken up by the family sanitary agencies.
Conclusion H. pylori infection is a major problem for all developing
countries which requires good sanitation and good eating habits to pre-
vent its further spread which is 2% in advance countries and 12% in
developing countries.
053
NK cell enteropathy with extraintestinal involvement: Presenting as
symptomatic anemia
Chandan Kumar, Manas Panigrahi, Hemanta Kumar Nayak, Subash
Chandra Samal
Correspondence- Manas Panigrahi-medgast_manas@aiimsbhubaneswar
.edu.in
Department of Gastroenterology, All India Institute of Medical Sciences,
Bhubaneswar 751 003, India
Introduction NK cell enteropathy is a newly described disease of un-
known etiology withh indolent clinical course characterized by atypical
proliferation of NK cells throughout gastrointestinal tract while term lym-
phomatous gastropathy defines disease localized too stomach only.
Case history A 26-year-old male presented with recurrent oro-genital ul-
ceration for 8-yearr with significant weight loss, postprandial fullness and
intermittent vomiting. He required blood transfusion for low hemoglobin.
No history of NSAID intake. He has BMI=17.5 kg/m2. Unlike in Behcet’s
disease (being closest differential) ulcers were painless, non-scarring and
located on glans penis. Laboratory values: Hb: 7g/dL (microcytic hypo-
chromic), low B12 level, low normal serum ferritin and normal serum folate
level and negative IgA negative IgA tTG. Stool for occult blood was pos-
itive. Esophagogastroduodenoscopy revealed pangastricc nodular mucosa
with multiple superficial ulcers and occasional discrete ulcers in first and
second part of duodenum. Ileocolonoscopy showed multiple small aphthae
throughout colonn and ileum.
Gastric biopsy was mimicking MALT lymphoma with mixed infil-
trates of lymphocytes, histiocytes, eosinophils, and neutrophils
expanding the glands. Overlying epithelium were ulcerated.
Atypical cells were strongly positive for CD3, CD7, CD56 and
granzyme with low proliferative index. CD30 and CD20 (Pan-B)
markers and immune stain for EBV weree negative. CD4 and
CD8 were variably positive in different sites. Similar findings noted
inn colonic and penile ulcer biopsy. Bone marrow examination re-
vealed megaloblastic maturation without any NK cell infiltration.
He already received 2 courses for H. pylori.
Management He is started with budesonide (9 mg OD) followed by
azathioprine (50 mg) therapy. Response included dramatic weight gain
with improvement of hemoglobin level till 6 months of therapy with no
effect on gastric lesions.
Conclusion Over-investigation and aggressive therapy described in
the literature (chemotherapy/gastrectomy). Symptomatic response
to budesonide therapy points towards low-grade autoimmune pro-
cess.
054
Metastatic involvement of stomach- A rare complication of Ca breast
Hozefa Runderawala, Nutan Desai, Hardik Shah, Boman Dhabhar
Correspondence- Hozefa Runderawala-hozaaee@gmail.com
Department of Gastroenterology, Fortis Hospital Mumbai, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction Breast cancer accounts for 29% of newly diagnosed cancer
in women and frequently, it metastasizes to liver, lungs, bones or brain
and rarely is reported to metastasize to stomach. We report a rare case of
Ca breast metastasizing to the stomach 12 years after the first diagnosis.
Case Report Seventy-six-year-old female presented with pain in left hy-
pochondriac region and backache which was continuous and dull aching
without any radiation or aggravating or relieving factor and with no his-
tory of fever, vomiting or cough. Twelve years back, she was diagnosed
with right side breast invasive ductal carcinoma grade 3, underwent sur-
gery and subsequently chemo and hormonal therapy. For her persistent
abdominal pain, upper gastrointestinal endoscopy was done which was s/
o diffuse thickening of gastric folds with poor distensibility with multiple
ulcers extending beyond pylorus, biopsies s/o poorly differentiated tumor
and IHC was consistent with metastasis from primary breast invasive
ductal carcinoma.
Discussion A high index of suspicion is required for metastatic
breast cancer when patient develops gastric symptoms with prior
history of breast cancer. Due to non-specific symptoms of anorex-
ia, dyspepsia, dysphagia, nausea, vomiting, early satiety, abdomi-
nal pain and bleeding, it is difficult to distinguish between prima-
ry gastric cancer and gastric metastases from breast cancer.
Moreover, gastric metastases may develop after many years fol-
lowing the first diagnosis of breast cancer as seen in our patient.
Combinations of endoscopic, radiological, histological and IHC
examination is the only reliable method to distinguish between
metastatic and primary gastric cancer and the optimal treatment
is chemotherapy or hormonal therapy.
Conclusion Gastric metastasis from breast cancer is rare and it requires
complete diagnosis by endoscopic, radiological and histological exami-
nation with IHC to differentiate from primary gastric cancer and hormon-
al or chemotherapy is the mainstay treatment modality.
055
Spectrum of gastric outlet obstruction in north west India
Rishabh Gupta, Deepak Sharma, Sudhir Maharshi, Bharat Sapra,
Sandeep Nijhawan, S S Sharma, Rupesh Pokharna
Correspondence- Rishabh Gupta-rishabh1313@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College And
Attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Gastric outlet obstruction (GOO) is a partial or complete
mechanical obstruction at antrum-pyloric region or first and second seg-
ment of duodenum. Earlier benign causes of GOO were more common
than malignant causes. Now, recent studies suggests that 50% to 80% of
cases are attributable to an underlying malignancy, in developed and
developing countries.
Methods This prospective study was conducted at Gastroenterology
Department of SMS Hospital, Jaipur, India between June 2017 to
June 2020. Consecutive patients having symptoms, and endoscopic or
radiological evidence of gastric outlet obstruction were included in this
study.
Results A total of 451(288 male/163 female) patients with GOO were
included. 248/451 (54.9 %) patients had malignant etiology and 203/451
(45.1 %) had benign etiology. In females, malignant etiology was present
in 74.8 % and benign etiology in 25.2 % patients. In males, malignant
etiology was present in 43.7 % and benign etiology in 56.3% patients. In
malignant GOO, common causes were gallbladder carcinoma in 95
(37.5%); gastric carcinoma in 48 (31.8%) and carcinoma head of pancre-
as (HOP) in 49 (19.6%). Other causes were periampullary carcinoma in 9
(3.5%); cholangiocarcinoma in 10 (4%); Duodenal carcinoma in 4(1.6%);
gastrointestinal lymphoma in 3 (1.2%) and neuroendocrine tumor and
retroperitoneal sarcoma in 1 patient each. In benign GOO, common
causes were opioid abuse in 59 (29%); peptic ulcer disease in 44
(21.6%) corrosive ingestion in 41 (20.2%) and chronic pancreatitis in
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
25 (12.3%). Other causes were acute pancreatitis in 15 (7.3%); NSAID
abuse in 9 (4.4%); tuberculosis in 6 (2.9%); celiac disease in 3(1.5%) and
Crohn’s disease in one patient.
Conclusion Overall, malignant causes are responsible for more than half
of the cases of GOO in North West India. In males and females, most
common causes are benign and malignant respectively.
056
To study the performance of prognostic scores in acute non variceal
upper gastrointestinal bleeding
A Balakrishna, T M Ramachandran, K Srijith
Correspondence- A Balakrishna-dr.balu.bk@gmail.com
Department of Gastroenterology, Government Medical College, Medical
College Road, Kozhikode 673 008, India
Background Acute upper gastrointestinal bleeding is a common medical
emergency that has a 10% hospital mortality rate. Different scoring sys-
tems and risk factors have been used and implemented to assess the risk of
rebleeding and mortality in patients with uppegastrointestinal bleeding.
The primary objective of this study is to assess the performance of these
prognostic scores (clinical Rockall score, complete Rockall score and
Glasgow-Blatchford score) in patients with acute non variceal UGI bleed-
ing. Secondary objective is to assess the risk factors of re-bleeding and
mortality rates.
Methods Sixty patients were assessed with respect to their clinical param-
eters, organ dysfunction, laboratory parameters and three risk assessment
scores i.e. clinical Rockall score (cRS), Complete Rockall score (CRS)
and Glasgow-Blatchford score (GBS) were calculated. The scores were
correlated with outcome. The sensitivity and specificity of scores in
predicting the outcomes were calculated using AUROC.
Results The mean age of the group was 44.14years (±14.9). The average
duration of hospital stay in the study population was 5.72 days. The
incidence of re-bleed in this study was found to increase with increasing
age. The incidence of rebleeding highest for the patients with GI malig-
nancy and those patients with Mallory-Weiss tear. For prediction of out-
comes, GBS was superior to the others (AUROC of 0.839) followed by
the complete Rockall score (AUROC of 0.819), followed by clinical
Rockall score (AUROC 0.80) all values being statistically significant.
Conclusions The CRS score is best in predicting the mortality in patients with
upper GI bleed. The optimum cut off being >3. Though GBS may be better in
predicting the need for intervention, it is inferior in predicting the mortality.
Keywords CRS-Complete Rockall Score, cRS-Clinical Rockall Score,
GBS-Glasgow Blatchford Score
057
Spectrum of primary gastric lymphoma in northern India: A series
of thirty patients
Akash Mathur, Uday C Ghoshal, Sushil Kumar, Neeraj Kumari
Correspondence- Uday C Ghoshal-udayghoshal@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of
Medical Sciences, Lucknow 226 014, India
Background Primary gastric lymphoma (PGL) is less commonly reported
in India. Since gastric cancer is a relatively less common malignancy in
northern India, the possibility of PGL being less common in this region
can’t be excluded. However, another possibility could be under-reporting
due to lack of adequate diagnostic workup and awareness.
Methods During a 12-y period (2000-2012), data of gastric neoplasm in a
teaching institute were retrospectively analyzed with the aim to know (i) the
frequency of PGL among patients with gastric neoplasm, (ii) their demographic
and clinical profile, and (iii) the diagnostic procedures needed for the diagnosis.
S19
Results 30/324 (9.2%) patients (median age 56, range 25-72, 73.3% male) with
gastric neoplasm had PGL. 40% of them had H. pylori infection (2/3 tests
positive). Most presented with dyspepsia with or without weight loss (9,
30%); others presented with gastric outlet obstruction (n=7, 23.3%), upper
gastrointestinal bleeding (n=5, 16.7%), dysphagia (n=4, 13.3%), malignant as-
cites (n=3, 10%) and other (n=2, 6.7%). In most (60%) diagnosis could be
established on endoscopic biopsy while in 40%, surgical resection was required.
The endoscopic and surgical diagnosis groups were comparable in age (53.4 vs.
52.7 years), sex (male 77.8% vs. 66.7%), H. pylori (38.9 vs. 16.7%), presenta-
tion with dyspepsia with or without weight loss (38.9 vs. 16.7%), presentation
with organic symptoms (61.1 vs. 83.3%) and need for repeated endoscopic
biopsies before conclusive diagnosis was established (12.5 vs. 33.3%).
Conclusion The study demonstrates the comparatively high frequency of
PGL in this population (9.2%) and confirms the intimate association of
H. pylori infection (40%). PGL should always be considered in the dif-
ferential diagnosis of gastric malignancy.
Keywords Lymphoma, Gastric, Primary Gastric Lymphoma
Small Intestine
058
Seroprevalence of celiac disease in high altitude area in India
Brij Sharma, Alka Singh, Neetu Sharma, Rajesh Sharma, Vishal Bodh,
Anmol Gupta, Anam Ahmed, Ashish Chauhan, Vikas Jinda2, Govind K
Makharia
Correspondence- Govind K Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and
Departments of Gastroenterology, Community Medicine, and
Physiology, Indira Gandhi Medical College, Ridge Sanjauli Road,
Lakkar Bazar, Shimla 171 001, India
Introduction While celiac disease (CeD) is known to occur in many
regions on the plane, there is a lack of data on its prevalence in high
altitude area of India.
Methods We screened serum samples of 332 participants of another
population-based study in Lahaul and Spiti districts of (mean altitude
>4000 meter) Himachal Pradesh, for estimation of prevalence of CeD
in high altitude area. The screening of CeD was done using commercially
available IgA human anti-tissue transglutaminase antibody (anti-tTG
Ab).
Results Of 332 samples (mean age 31.5±15.9) screened, two were found
to have a positive anti-tTG Ab at low titre, suggesting a seroprevalence of
0.6%.
Conclusions The seroprevalence of CeD in high altitude area is 0.6%,
almost equal to the rest of the country. The physicians working in high
altitude areas to be aware about CeD in their communities.
Keywords Celiac disease, High altitude, Prevalence, Anti-tissue
transglutaminase
059
Single balloon enteroscopy for small bowel evaluation in pediatric
patients- A tertiary care experience
Sachin Kasle, Manohar Reddy, Sujay Kulkarni, Zaheer Nabi, Radhika
Chavan, Mahiboob Sayyed, Partha Pal, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-
3-661, Somajiguda, Hyderabad 500 082, India
Background and Aim Balloon enteroscopy is the cornerstone for small
bowel evaluation in adult patients. However, the data are limited in pedi-
atric patients. In this study, we aim to evaluate the safety and diagnostic
S20
utility of single balloon enteroscopy (SBE) in children with suspected
small bowel diseases.
Methods The data of all the children (≤ 18-years) who underwent SBE
from November 2010 to July 2020, was analyzed retrospectively. The
safety and diagnostic yield of SBE were assessed.
Results One hundred and eighty-nine SBE procedures (males 117, mean
age 15.1±2.76, range 3-18 years) were performed in 174 children. The
most common indication for SBE was abdominal pain with or without
additional symptoms in 119 (68.4%), followed by gastrointestinal bleed
17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%).
Antegrade and retrograde enteroscopy procedures were performed in 98
(51.8%) and 77 (40.7%), respectively. Both (antegrade and retrograde)
were performed in 7 (3.7%) cases. The mean length of small bowel
intubation in antegrade and retrograde SBE groups were 168.9±58.6 cm
and 120.7±52.1 cm, respectively. Overall, a positive finding was seen in
117 (67.2%) cases. The most common findings were ileal and jejunal
ulcers with or without strictures found in 76 (64.9%). A final diagnosis
could be established in 63.8% children. The diagnostic yield was higher
in cases with additional symptoms besides pain abdomen as compared to
pain abdomen alone (85.1% vs. 50%, p=0.001). A total of 17 therapeutic
enteroscopic procedures were performed in 11 children including
polypectomy in 7 children with Peutz-Jeghers syndrome and argon plas-
ma coagulation therapy in 4 cases with vascular lesions. There were no
major adverse events. Self-limiting bleeding not requiring blood transfu-
sion was noticed in one patient after polypectomy.
Conclusion SBE is a safe procedure for the evaluation of small bowel
diseases in children and adolescents. SBE establishes a diagnosis in near-
ly two-thirds of the children.
060
Retrospective study of tissue transglutaminase antibody (ttgA) levels
in celiac disease suspected patients at tertiary care hospital in
Uttarakhand
Swati Rajput, Rohit Gupta, Itish Patnaik, Yogesh Arvind Bahurupi,
Prashant Kumar, Kiran Meena, Nowneet Kumar Bhat, Satyavati Rana
Correspondence- Satyavati Rana-svrana25@hotmail.com
Department of Biochemistry, All India Institute of Medical Science,
Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Background and Objective Celiac disease (CeD) is a chronic gastrointes-
tinal disorder arising due to gluten sensitivity in susceptible individuals.
In India, one person per 100 is suffering from this disease. CeD has been
reported more in high wheat consuming areas like northern India. But the
incidence of CeD in patients attending tertiary care hospital of
Uttarakhand has not yet been reported. Therefore, this study was planned.
Methods A retrospective study with 603 patients was done at AIIMS,
Rishikesh in Biochemistry Department. These patients were screened
for CeD by tissue transglutaminase antibodies (ttgA) levels using
ELISA method. Percentage of levels of ttgA <4 U/mL (normal value)
and >4 U/mL in male, female adults and children was calculated. Chi-
square test was applied to compare results.
Results Out of 603 patients, 23 (3.81%) had abnormally raised ttgA
levels (>4 U/mL). Percentage (15.18%) of ttgA levels in male chil-
dren was significantly (p=0.01) higher than 2.56 % in female chil-
dren. Mean + SD of normal and abnormal ttgA levels in patients was
1.17 + 0.45 vs. 66.81+34.80 U/mL respectively. Mean+SD of abnor-
mal ttgA levels in children and adults was 72.84+41.91 vs. 32.38+
24.75 U/mL respectively. There was significant difference in abnor-
mal ttgA levels among children and adults with children predomi-
nantly being higher (p value= 0.0235).
Conclusion This study shows that the levels of ttgA suggestive of
CeD in children is higher as compared to adults and more in males
than females attending the tertiary care hospital of Uttarakhand.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
061
Seronegative celiac disease - Frequently encountered yet undiag-
nosed clinical entity
Kapil Dhingra, Sudhir Maharshi, Bharat Sapra, Sandeep Ratra, Shyam
Sunder Sharma, Sandeep Nijhawan
Correspondence- Kapil Dhingra-kapil7029@yahoo.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L
N Marg, Jaipur 302 004, India
Background There are limited studies on seronegative celiac disease from
Indian subcontinent. The aim of the study is to assess the prevalence,
pathological, genetic and clinical profile of patients with seronegative
celiac disease.
Methods This prospective observational study was conducted in the
Department of Gastroenterology, SMS Hospital, Jaipur between
October 2017 to March 2019. Consecutive patients of seronega-
tive celiac disease with age ≥3 years were enrolled for the assess-
ment of demography, clinical features, histological findings, celiac
serology, genetic analysis, and response to gluten-free diet.
Results Out of total 312 celiac disease patients, 13 (4.16 %) pa-
tients (median age 25 years [range 5-46 years], 10 female) were
diagnosed as seronegative celiac disease. Presenting symptoms
were chronic diarrhea in 9 (69.23%), pain abdomen in 6 (46.15
%), weight loss in 5 (38.46%) and short stature in 2 (15.38 %)
patients. On histological analysis, Marsh stage 2 seen in 5
(38.46%), Marsh 3c in 2 (15.38%), Marsh 3a in 3 (23.07%),
and Marsh 3b in 3 (23.07%) patients. On HLA analysis, HLA-
DQ2.5 seen in 6 (46.15%) patients, HLA-DQ2.2 in 5 (38.46%)
and HLA-DQ8 in 2 (15.38%) patients.
Conclusions The prevalence of SNCD in our study is 4.16%. Most com-
mon symptoms were chronic diarrhea and pain abdomen and histological
grade was Marsh stage 2.
062
Castleman disease variant of POEMS syndrome: A case report of a
patient with diarrhea
Manas Kumar Panigrahi, Mohd Imran Chouhan, Hemanta Kumar
Nayak, Subash Chandra Samal, Shivam Sethi
Correspondence- Manas Kumar Panigrahi-medgast_manas@
aiimsbhubaneswar.edu.in
Department of Gastroenterology, All India Institute of Medical Sciences,
Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Castleman disease, a variant of POEMS syndrome is a mul-
tisystem disorder of monoclonal plasma cell disorder. To reduce mortality
and morbidity associated with POEMS syndrome proper diagnose and
early treatment should be started. We report a case of POEMS syndrome
who presented with diarrhea, skin hyperpigmentation, and edema and
weight loss.
Clinical presentation A 40-year-old male presented with chronic small
bowel diarrhea, weight loss, swelling of feet, hyperpigmentation, and
tingling sensation of both lower limbs. Examination revealed BMI of
15 kg/m2, pallor, papilledema, generalized lymphadenopathy, hyperpig-
mentation clubbing, hepatosplenomegaly, edema, decreased pain and
temperature. Investigation showed anemia (Hb 10 gm%), thrombocytosis
(6.5 lakh), raised ESR (42 mm in 1st hour), raised TSH (14 ng/mL).
CECT revealed multiple sclerotic lesions, hepatosplenomegaly, and mul-
tiple subcentimetric lymphnodes. Lymph node biopsy showed reactive
lymphadenitis with plasmacytosis and vascular proliferation. Gastric
biopsy- pangastrtis with activity and lymphoid follicle formation and
increased IEL. Bone marrow aspirate showed 7% plasma cells. NCV-
asymmetrical sensory motor demyelating polyneuropathy. Serum
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
immunoelectrophoresis did not reveal monoclonal gammopathy. Patient
met the diagnostic criteria for Castleman disease variant of POEMS syn-
drome. He had polyneuropathy, sclerotic bone lesions, Castleman’s dis-
ease, organomegaly (splenomegaly, hepatomegaly, and lymphadenopa-
thy), endocrinopathy (hypothyroidism), skin changes (hyperpigmenta-
tion, white nails), papilledema, thrombocytosis, extravascular volume
overload (edema), clubbing, weight loss and diarrhea. Polyneuropathy
is one of the most common presentation; however in our case diarrhea
was the predominant symptom which may mislead in reaching the diag-
nosis. Though gastrointestinal (GI) involvement is not a predominant part
of the syndrome but GI symptoms may be an accompanying clinical
feature and may occasionally be the predominant symptom like this case.
Conclusion In this rare disorder diagnosis can be challenging but a high
level of suspicion, good history and general physical examination followed
by appropriate investigation can help to diagnose and start early treatment.
063
Clinical profile of patients with acute mesenteric ischemia in
Northern India
Jatin Agrawal, Ashish Kumar, Anil Arora, Shrihari Anikhindi, Vikas
Singla, Praveen Sharma, Naresh Bansal
Correspondence- Jatin Agrawal-jatinagrawal1989@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and
Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar,
New Delhi 110 060, India
Introduction and Aims Acute mesentric ischemia (AMI) is a rare medical
emergency and constitutes around 0.09% to 0.2% of all cases of acute
abdomen. According to Western literature, AMI most commonly occurs
in 7th-8th decade, with 50% mortality, and arterial occlusion being the
most common cause. The clinical profile of patients of AMI in India may
be different from Western patients, however, the data is lacking. We
aimed to study clinical profile of patients of AMI at a tertiary care centre
in northern India.
Methods We retrospectively collected data of consecutive patients of
AMI admitted our department from March 2015 to January 2019. Data
regarding epidemiology, clinical presentation, etiology, imaging, treat-
ment and outcome were studied.
Results Our study included 59 patients (78% males, median age 47 years).
The most common presentation was pain abdomen in 88%, obstipation
43%, gastrointestinal bleeding 17%, and peritonitis 0.5%. Mesenteric
venous thrombosis was seen in 68% and mesenteric artery thrombosis
in 32%. On imaging wall necrosis seen in 45 (65.2%) while additional 3
(4.34%) found during laparotomy. Most (68%) patients required surgical
resection. The overall in-hospital mortality was 14%.
Conclusions Unlike the Western literature, the AMI in North India
is most commonly due to venous thrombosis, presenting in fifth
decade, and has a lower mortality rate than West. Large prospective
studies will be required to elucidate the cause of these differences
from Western data.
064
Clinical outcomes in Crohn’s patients newly initiated on azathioprine
– A large single center cohort
Alok Bansal, A J Joseph, Ebby George Simon, Amit Kumar Dutta,
Sudipta Dhar Chowdhury, Reuben Thomas Kurien, Ratnaprabha Gupta
Correspondence- A J Joseph-ajjoseph@cmcvellore.ac.in
Department of Gastroenterology and Hepatology, Christian Medical
College Hospital, Vellore 632 004, India
Background Azathioprine remain the first choice for maintenance therapy
in Crohn’s disease (CD) as biologicals are expensive. Response to
S21
treatment is commonly assessed by clinical and laboratory parameters
rather than by endoscopy. The recent literature is limited regarding clin-
ical outcomes and variables predicting response to thiopurines.
Methods Crohn's disease patients started on azathioprine in the IBD clin-
ic, Christian Medical College (CMC), Vellore between January 2016 to
December 2019 were retrospectively reviewed. Outcomes were assessed
using the Harvey-Bradshaw score (HBS). Patients were grouped as (i)
remission = HBS < 5, (ii) response = reduction of 3 points and (iii) non-
response.
Results Among 318 patients who received azathioprine (AZA) for CD,
155 (48.7%) received higher doses (>1.5 mg/kg) and 163 (51.7%) re-
ceived lower doses (<1.5 mg/kg). Among those who followed up at least
once, 3 months from drug initiation, 188 (76%) patients had remission/
response on AZA, while 60 (24%) did not. A greater proportion of pa-
tients who had remission/response (116 [61.7%]) received higher doses
(>1.5 mg/kg) of AZA compared to non-responders 26 (43.3%)
(p<0.001). Among patients who initially achieved remission or response,
26 relapsed on follow-up. Nineteen (73%) of these patients were on a
higher dose (>1.5 mg/kg) of AZA. The mean weight gain was signifi-
cantly higher in the remission (5.3 kg) and response (6.8 kg) groups as
compared to non-responders (1.3 kg) with p<0.001. Mean CRP improve-
ment was significantly higher in remission (11 mg/L) and response (27.7
mg/L) groups as compared to non-responders (-1.3 mg/L). The drug was
discontinued in 52 (16%) patients because of cytopenia, anemia, hepatitis,
pancreatitis, tuberculosis and perianal abscess.
Conclusion Patients on higher doses (>1.5 mg/kg/day) of AZA were
more likely to achieve remission or response as compared to those on
lower doses (<1.5 mg/kg/day). However, patients who required higher
doses for disease control were more likely to relapse. Weight improve-
ment was a useful parameter reflecting the response to AZA in CD
patients.
Keywords AZA azathioprine, HBS Harvey Bradshaw Score, CRP C-
reactive protein
065
Timely management of a case of obscure upper gastrointestinal
bleed: A team approach saves the
Nikhil Thomas, L Venkatakrishnan, Mukundan S, Prudhvi Krishna
Chandolu, R K Karthikeyan, Ravindra Kantamneni, Elango S, Balu K
Correspondence- Nikhil Thomas-nikhilkennythomas@gmail.com
Department of Medical Gastroenterology, PSG Institute of Medical
Sciences and Research, Peelamedu, Coimbatore 641 004, India
Background Gastrointestinal stromal tumor (GIST) comprises 1% to 3 %
of all malignant GI tumors with up to 40% with acute hemorrhage fol-
lowing tumor rupture. Our patient presented with acute upper GI bleed
with severe hypotension. A prompt and early diagnosis and multidisci-
plinary teamwork saved the patient.
Case Presentation A 57-year-old male, engineer with no prior comorbid-
ities presented to the ER at 5 pm with h/o 3 - 4 episodes of hematemesis
and melena since 1 day. Cinical examination revealed alert patient with
pallor and severe hypotension (60 systolic) digital rectal examination
revealed melena. He was admitted to the MICU and resuscitation done.
He has severe anemia with relative neutrophilia and hypoalbuminemia.
Urgent UGI scopy was done which showed only grade A GERD with
erosive gastritis. However, there was altered blood in D2 with no active
bleeding point. A possibility of small bowel bleed was considered.
Emergency CT angiography revealed lobulated exophytic heteroge-
neously enhancing soft tissue lesion with coarse calcifications and small
non enhancing areas in the proximal jejunum supplied by jejunal
branches of superior mesenteric artery. We considered the possibility of
jejunal GIST and angioembolization was done the same night by the
interventional radiologist. With supportive care patient made a remark-
able recovery.
S22
Once stabilised he underwent laparoscopic excision of proximal jejunum
with GIST and side to side duodenojejunostomy.
Discussion Most of GIST arise in the stomach (60% to 70%), 20% to 30%
originate in the small intestine and less than 10% in the esophagus, colon,
and rectum. The most important element in diagnostic evaluation is a high
index of suspicion for any mass lesion noted throughout the length of the
GI tract. Our case highlights the need for a team approach in successful
management of GI bleed in these cases.
066
Celiac disease - Atypical is the new typical !
Shraddha Sharma, Rahul Kakkar, Naveen Kumar, Sabir Hussain,
Sewaram Chaudhary, Sunil Dadhich, Narendra Bhargava
Correspondence- Shraddha Sharma-shraddhasharma.udr@gmail.com
Dr S N Medical College, India
Introduction Classically recognized for its gastrointestinal manifestations,
celiac disease (CD) is now increasingly identified in patients with non-
specific manifestations like iron deficiency anemia (IDA), short stature,
infertility, osteoporosis, asymptomatic transaminitis and cryptogenic cir-
rhosis. The aim of this study was to explore the spectrum of atypical
presentation in CD patients and to highlight the differences in modes of
presentation in adult and pediatric population.
Methods Case records of 42 diagnosed CD patients presenting to
Gastroenterology OPD between January to June 2020 were retrospective-
ly reviewed for their chief manifestation. The diagnosis of CD was made
on the basis of serology and/or histology.
Results The median age of the study group was 12 years (range 1-52
years). Majority of them (55%) belonged to pediatric population. Out of
42 patients, 38% were male and 62% were female. Our study showed
typical gastrointestinal symptoms in 29% patients while 71% patients had
atypical presentation. In adult group, chronic diarrhea (31.5%), IDA
(31.5%) and cryptogenic cirrhosis (36.8%) were common modes of pre-
sentation. Pediatric group had short stature (43.5%), IDA (34.7%) and
chronic diarrhea (17%) as dominant presentations. Transaminitis was
present in 23.8% patients. The typical symptoms of diarrhea and vomiting
were more frequent in adult as compared to paediatric patients.
Conclusion Atypical Presentation is becoming dominant and typical for
CD. More than half of the CD patients present with atypical manifesta-
tions and create a diagnostic dilemma. Paediatric patients tend to have a
wider spectrum of presentation than adult patients. More awareness and a
high index of suspicion is required for timely management.
067
Glasgow-Blatchford score and risk stratifications in acute upper gas-
trointestinal bleed: Our experience in tertiary care centre for extend-
ing this to 3 for urgent outpatient management
Vinod Kumar Dixit, Indresh Dixit, Sunit Kumar Shukla, Dawesh Yadav
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Banaras Hindu University Campus, Varanasi 221 005,
India
Background Upper gastrointestinal bleeds are a common presentation to
emergency departments. The Glasgow-Blatchford score (GBS) predicts
the outcome of patients at presentation. NICE and ESGE recommend
outpatient management for a GBS of 0.
Aim Our aim was to assess whether extending the GBS allows for early
discharge while maintaining patient safety. We also analyzed whether
pathologies could be missed by discharging patients too early.
Methods Data were prospectively collected and analyzed on patients ad-
mitted with upper GI bleed between 1 October 2019 and 31 December
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
2019. GBS calculated and gastroscopy reports were obtained for each
patient. Patients were assessed for need for blood transfusion, endoscopic
intervention during admission and for rebleeding, repeated endoscopic
intervention, surgery or radiological intervention and mortality in 1-
month follow-up.
Results Eighty patients were included in study between 16 and 85 years of
age, 72.5% were male and 27.5% female. Most common endoscopic find-
ings were duodenal ulcer in 27.5% patients followed by gastric ulcer in
22.5%. GBS score was between 1 to 3 in 58 patients, none of them needed
blood transfusion or endoscopic intervention during admission, none had
upper GI bleeding related events or mortality during 1 month. Six patients
having GBS between 4 to 6, 2 out of 6 (33%) needed endoscopic interven-
tion and blood transfusion, None reported any upper GI bleed related
adverse event or mortality during 1 month. Sixteen had GBS more than
6. Twelve (75%) required blood transfusion, endoscopic intervention done
in 10 (62.5%), during 1 month period, 8 patients (50%) had rebleeding, 4
managed by endoscopic management successfully, 2 required surgical in-
tervention and 2 out of these 16 (12.5%) expired due to rebleed.
Conclusion Study concluded, GBS may be extended to 3 for safe outpa-
tient management, reducing the number of bed days in centres with high
volume patient load with limited health care resources for better patient
management.
068
A rare case of isolated jejunal tuberculosis
Nithin K R, Umashankar U S, Akhilandeshwari, Anand A, Arun N,
Vaishnavi Priya, Kani Sheikh, Aravind
Correspondence- Nithin K R-Nith.kr@gmail.com
Department of Medical Gastroenterology, Government Kilpauk Medical
College, Chennai 600 010, India
Introduction Abdominal TB accounts for 11% of extrapulmonary tubercu-
losis. Intestinal TB accounts for 1% to 3% of TB worldwide. Any part of
bowel may be involved and usually presents as multiple lesions. Most com-
monly distal ileum/ileocecal region is involved. Jejunal involvement is seen in
terminal stages of extensive tuberculosis of bowel. It's rare, however, to find
isolated tuberculosis of jejunum without tuberculosis elsewhere in bowel.
Here, we present a rare case of isolated Jejunal tuberculosis.
Case Sixty-year-old lady presented with complaints of upper abdominal
pain, intermittent, colicky pain since 2 months, increasing with food
intake and partly relieved by non-induced vomiting, associated with ball
rolling movements with history of significant weight loss and loss of
appetite. No history of loose stools, obstipation, constitutional symptoms,
fever and cough.
On examination Pallor present, no lymphadenopathy/edema. Per abdom-
inal examination and per rectum examination- normal.
Investigations Anemia+. Total count, platelets, RBS, RFT, LFT,
amylase- normal. Viral markers-negative. Chest X-ray, erect abdomen
X-ray-normal. USG abdomen- normal. UGI endoscopy- normal.
Colonoscopy-normal.
CT abdomen and CT enterography showed proximal jejunal thickening of 6 cm
with sub-centimetric para aortic lymph nodes. Tumor marker CEA-normal.
On day 4 of admission patient developed severe abdominal pain, abdom-
inal distension with sluggish bowel sounds. X-ray erect abdomen showed
features suggestive of small bowel obstruction. Surgical gastroenterology
opinion was taken. Diagnostic laparoscopy was done, showed an obstruc-
tive jejunal mass and resection anastomosis was done. Surgical biopsy-
suggestive of tuberculosis, no evidence of malignancy or inflammatory
bowel disease. Postoperative period was uneventful. Patient was started
on ATT and is on follow-up.
Conclusion Involvement of jejunum as part of abdominal tuberculosis is
not uncommon. Isolated tuberculosis of jejunum can occur, though very
rare. Hence abdominal TB should be considered in patients presenting
with isolated jejunal mass lesions.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
069
Prevalence of SIBO in IBS-D patients and role of rifaximin in the
management
Nirdesh Chauhan, B Shankar Sharma
Correspondence- Nirdesh Chauhan-drnirdesh@live.com
Department of Gastroenterology, Kurnool Medical College, Bharath
Petroleum, Near, Bhudawarapet, Kisan Ghat Road, Kurnool 518 002,
India
Irritable bowel syndrome (IBS) is characterized by the presence of ab-
dominal pain associated with disturbed defecation. Because of non-
uniformity in the definition, the prevalence of IBS is varied from 1% to
45% worldwide and in India; prevalence is about 11% to14%.
The pathogenesis of IBS is multifactorial. There is a paradigm shift from
brain-gut axis disorder, as previously thought, to gut-brain axis disorder,
which has shown increased importance to gut dysbiosis, including small
intestinal bacterial overgrowth (SIBO).
The gold standard to diagnose SIBO is the quantitative culture of a jejunal
aspirate, but being invasive and costly as it generally requires endoscopy
for sample collection, glucose hydrogen breath test (GHBT) is a reliable
test to diagnose SIBO with about 80% to 100% specificity and sensitivity
of about 40%.
This study was done in the tertiary hospital to find the prevalence of SIBO
in IBS-D patients by using the GHBT (LactoFAN2*) and response of
rifaximin (400 mg TID for 14 days) in treating these patients. Eighty
diagnosed cases of IBS-D (using ROME IV criteria) were subjected to
GHBT using 100 g of glucose in 250 mL water and breath samples were
taken at baseline and 20 min interval for 2 hours. An increase >12 ppm
from baseline was considered to be positive for SIBO. Out of 80, only 18
patients came out positive and were treated with rifaximin. After 14 days,
out 18, only 15 patients showed improvement in symptoms clinically, and
there repeat GHBT was also negative.
According to this study, we conclude that the prevalence of SIBO in IBS-
D patients is 22.5% using GHBT and the use of broad-spectrum non-
absorbable antibiotics, rifaximin 400 mg TID dose for14 days is associ-
ated with good clinical response in treating SIBO in IBS-D patients.
Keywords IBS-D, SIBO, GHBT.
070
Celiac disease – Atypical is the new typical!
Shraddha Sharma, Rahul Kakkar, Naveen Kumar, Sabir Hussain,
Sewaram Chaudhary, Sunil Dadhich, Narendra Bhargava
Correspondence- Shraddha Sharma-shraddhasharma.udr@gail.com
Department of Gastroenterology, Dr. S N Medical College, Residency
Road, Sector-D, Shastri Nagar, Jodhpur 342 003, India
Introduction Classically recognized for its gastrointestinal manifestations,
celiac disease (CeD) is now increasingly identified in patients with non-
specific manifestations like iron deficiency anemia (IDA), short stature,
infertility, osteoporosis, asymptomatic transaminitis and cryptogenic cir-
rhosis. The aim of this study was to explore the spectrum of atypical
presentation in CeD patients and to highlight the differences in modes
of presentation in adult and pediatric population.
Methods Case records of 42 diagnosed CeD patients presenting to
Gastroenterology OPD were retrospectively reviewed for their chief manifesta-
tion. The diagnosis of CeD was made on the basis of serology and/or histology.
Results The median age of the study group was 12 years (range 1-52
years). Majority of them (55%) belonged to pediatric population. Out of
42 patients, 38% were male and 62% were female. Our study showed
typical gastrointestinal symptoms in 29% patients while 71% patients had
atypical presentation. In adult group, chronic diarrhea (31.5%), IDA
(31.5%) and cryptogenic cirrhosis (36.8%) were common modes of
S23
presentation. Pediatric group had short stature (43.5%), IDA (34.7%)
and chronic diarrhea (17%) as dominant presentations. Transaminitis
was present in 23.8% patients. The typical symptoms of diarrhea and
vomiting were more frequent in adult as compared to paediatric patients.
Conclusion Atypical presentation is becoming dominant and typical for
CeD. More than half of the CeD patients present with atypical manifes-
tations and create a diagnostic dilemma. Pediatric patients tend to have a
wider spectrum of presentation than adult patients. More awareness and a
high index of suspicion is required for timely management.
071
HLA haplotypes in patients with celiac disease in India: High fre-
quency of non-DQ2/8 haplotypes
Balakrishnan Ramakrishna5, Giriprasad Venugopal1, Alka Singh2,
Srinivasan Pugazhendhi4, Sangitanjan Dutta3, Vineet Ahuja2, Govind
Makharia2
Correspondence- Balakrishnan Ramakrishna-wurama@hotmail.com
1
All India Institute of Medical Sciences, AIIMS Road, Sijua, Patrapada,
Bhubaneswar 751 019, India, 2Department of Gastroenterology and
Human Nutrition, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India, 3Guwahati Medical College, India,
4
Kansas University Medical Center, US, and 5 Department of
Gastroenterology, SRM Institutes for Medical Science, India
Objectives HLA-DQ2 and/or DQ8 are believed to be essential for devel-
opment of celiac disease (CeD). We conducted a case control study to
determine HLA DQ haplotypes in patients with CeD and healthy adults
using next generation sequencing.
Methods HLA-DQA1 and DQB1 loci were amplified using long range
PCR, from DNA of 400 patients with CeD (259 symptomatic, 45 asymp-
tomatic, 96 potential) and 300 healthy adults. Amplicons were Illumina
sequenced and HLA-DQ genotypes and haplotypes were assigned by
matching against the HLA-IMGT database, while DQ serotypes were
assigned on the basis of DQB1 genotype.
Results Of 300 healthy controls, 80 expressed DQ2, and 33 expressed DQ8.
DQ6 (170) and DQ7 (120) were the most common serotypes. Haplotypes
DQ2.2, DQ2.5 and DQ8.1 were noted in 61, 32 and 33, respectively. Among
400 CeD patients, 221 had DQ2 serotype, 37 had DQ8 while 24 could
express both. DQ6 and DQ7 serotypes were found in 53 and 29, respectively.
DQ2.2, DQ2.5, and DQ8 haplotypes were found in 52, 147, and 36, respec-
tively, while double heterozygote haplotypes were noted in 47. DQ2.5 hap-
lotype was strongly associated with CeD (odds ratio 10.31, 95%CI 6.80-
15.30), with a gradient in the strength of association between symptomatic,
asymptomatic, and potential CeD phenotypes. In an overall analysis, DQ5.1
and 5.3 haplotypes showed protective associations with CeD.
Conclusion Thirty three percent of healthy individuals expressed HLA
DQ2 and/or DQ8, while thirty percent of CeD patients expressed neither.
072
Duodenoduodenal intussusception with invagination of the pancre-
atic head into the duodenum secondary to tubulovillous adenoma in
the setting of duodenal malrotation: A case report
Sara Jessica Pizarras, Maria Raisa Katrina Fontanilla, Maria Joanne
Paula Rubio, Roehl Salvador, Nelson Cabaluna
Correspondence- Sara Jessica Pizarras-sarajessicapizarras@gmail.com
Department of Internal Medicine - Section of Gastroenterology and
Digestive Endoscopy, Manila Doctors Hospital, Philippines
Introduction Duodenoduodenal intussusception (DDI) is a rare entity due
to the fixed position of the duodenum in the retroperitoneum. We report a
rare case of documented DDI with invagination of the pancreatic head
into the duodenum in a patient with a lead point (a tubulovillous
S24
adenoma) and duodenal malrotation with spontaneous resolution of the
pancreatic invagination as noted intraoperatively.
Methods/Presentation Our patient is a 31-year-old male presenting with a 2-
month history of vague epigastric pain, melena, anemia and weight loss.
Results Esophagogastroduodenoscopy revealed a duodenal mass with
adenomatous features. A triple contrast abdominal CT scan initially
showed a duodenojejunal intussusception with invagination of the pan-
creatic head into the duodenum, causing dilatation of the pancreatic duct
and the biliary tree. A follow-up MRI was then done which showed a
duodenoduodenal intussusception, still with invagination of the pancre-
atic head. Patient underwent exploratory laparotomy where duodenal
malrotation and intussusception at the second segment of the duodenum
where the mass was also located with resolution of the pancreatic invag-
ination were noted. Reduction of the intussusception and wedge resection
of the mass was done. Patient was discharged with no complications.
Conclusion Adult DDI is a rare entity that is challenging to diagnose due
to its nonspecific symptoms and is possible in cases of malrotation and
duodenal lesion which can act as lead point, such as in our patient. Hence,
DDI should be considered in patients presenting with abdominal pain,
bowel obstruction or bleeding.
Keywords Case report, Duodenoduodenal intussusception, Intussusception
073
Abdominal cocoon – An enigmatic entity
Gongati Venu, Ramesh Kumar B, Ramanna M
Correspondence- Gongati Venu-venu.gongati@gmail.com
Department of Medical Gastroenterology, Osmania General Hospital,
Afzalgunj Road, Afzal Gunj, Hyderabad 500 001, India
Introduction Encapsulating peritoneal sclerosis (EPS) is a rare benign cause
of acute or subacute small bowel obstruction. It is also called as "abdominal
cocoon" to describe total or partial encasement of the small bowel within a
thick fibrocollagenous membrane. It is called as "icing gut" due to the
intestinal surface appearing white from the membrane covering. EPS is
classified as primary (idiopathic) or secondary based on the etiological
factors. We report a case of EPS secondary to tuberculosis.
Case report A 40-year-old male patient presented with abdominal pain,
distension, altered bowel habits and significant weight loss since 3
months. No prior history of tuberculosis, dialysis, and abdominal surgery.
On examination per abdomen is firm, tender, a fixed mass was felt ex-
tending from 2-3 cms above the umbilicus to the suprapubic area. CT
abdomen showed clustering of small bowel loops encased in a sac like
structure, diffuse omental thickening, mesenteric lymphadenopathy.
Colonoscopy was normal up to the terminal ileum. USG guided FNAC
from omentum revealed fibroblasts with epitheloid histiocytes suggestive
of tuberculosis. Patient denied laparoscopy. He was started on ATT. On
follow-up he improved symptomatically and clinically with decreased
abdominal pain, distension and weight gain.
Conclusion EPS is a rare clinical entity causing intestinal obstruc-
tion. The primary form is of unknown origin and has been clas-
sically described in young adolescent females. Secondary EPS has
been reported in association with abdominal tuberculosis, perito-
neal dialysis, sarcoidosis, systemic lupus erythematosus and prior
abdominal surgeries. Peritoneal tuberculosis in the form of scle-
rosing variant is an unusual entity. Early recognition and initiation
of ATT may prevent the need for operative intervention or bowel
resection in these patients.
Keywords Encapsulating Peritoneal Sclerosis,Tuberculosis, Intestinal
obstruction
074
Enteroscopic management of life threatening obscure gastrointesti-
nal bleeding due to jejunal leiomyoma
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Dhaval Choksi, Ketaki Choksi, Vidya Kale*, Milind Shah**
Correspondence- Dhaval Choksi-dhavalrchoksi@gmail.com
Department of Medical Gastroenterology, *Pathology, and **Surgery,
Plot No. 1, Swaminarayan Nagar, New Adgaon Naka, Panchavati,
Nashik 422 003, India
Introduction Obscure gastrointestinal bleeding is a difficult medical
emergency to manage. Benign small bowel tumors are rare cause of
obscure gastrointestinal bleeding.
Methods A 64-year-old male presented with massive gastrointestinal bleed-
ing with hemorrhagic shock. The patient had severe comorbid conditions like
diabetes mellitus, hypertension, ischemic heart disease with cardiomyopathy
(Ejection Fraction-30%) and chronic kidney disease. After a non-conclusive
upper GI scopy, colonoscopy and a plain CT scan, capsule endoscopy was
done which showed proximal jejunal bleeding. Push enteroscopy was the
done which showed a jejunal polyp measuring 3 x 2 cms.
Result The polyp was successfully removed en-bloc by endoscopic mu-
cosal resection (EMR) technique without any complications like bleeding
or perforation. Histopathology examination and immunohistochemistry
confirmed the polyp to be a leiomyoma. Patient was asymptomatic on
follow-up at 6 months.
Conclusion With adequate surgical back up, endoscopic resection of benign
small bowel tumors can be done in selected high risk group of patients in
whom surgery may be associated with increased morbidity and mortality.
Keywords Gastrointestinal bleeding, Jejunal leiomyoma, Endoscopic mu-
cosal resection, Capsule endoscopy, Push
075
Dental enamel defects and oral cavity manifestations in Asian pa-
tients with celiac disease
Anam Ahmed, Alka Singh, Smile Kajal, Ashish Chauhan, Vikas Jindal,
Mahendra Singh Rajput, Vikas Banyal, Vineet Ahuja, Govind K
Makharia
Correspondence- Govind K Makharia-govindmakharia@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110 029, India
Introduction Small intestine is the main site of celiac disease (CeD),
affecting other organs also. Dental enamel defects are common indicators
of CeD, in absence of other classical symptoms. Aims was to study dental
and oral manifestations in Asian patients with CeD.
Methods We recruited 118 patients with biopsy-confirmed CeD (36 treat-
ment naïve and 82 follow-ups on at least one year of gluten-free diet) and
40 controls. Diagnosis was made as per standard criteria. Oral and dental
manifestations were evaluated by a dental surgeon. The dental enamel
defects (DED) were evaluated according to Aine’s criteria.
Results Overall higher number of patients with CeD (66.9%); both treat-
ment naïve (69.4%) and those on GFD (65.8%) had DED in comparison
to controls (20%) (Odds ratio, 8.1, 95% CI 3.4-19.2; p<0.001). Specific/
bilaterally symmetrical DED were present in significantly higher number
of patients with CeD than controls. Recurrent aphthous ulcers were sig-
nificantly higher in patients with CeD. Approximately 80.6% and 63.4%
treatment naïve patients and those on GFD, respectively reported dry
mouth sensation which was significantly higher than that in controls.
Conclusions Almost two third of patients with CeD have DED.
Physicians and dietitians caring for patients with CeD should train in
identification of DED and other oral manifestations of CeD.
Keywords Gluten; Teeth; Recurrent aphthous ulcers; Dry mouth
076
The proteome of the human small intestinal mucosa by SWATH-MS
analysis
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Govind K Makharia, Atreyi Pramanik*, Praveen Singh**, Alka Singh,
Prasenjit Das6, Vineet Ahuja5, Pragyan Acharya*, Shantanu Sengupta**
Correspondence- Govind K Makharia-govindmakharia@gmail.com
Department of Gastroenterology, *Biochemistry,***Pathology, and
****
Pathology, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India, ** CSIR-Institute of Genomics and
Integrative Biology, New Delhi, India; Academy of Scientific and
Innovative Research (AcSIR), Ghaziabad 201 002, India
Introduction Small intestinal mucosa, maintain and control a number of
structural, functional, and regenerative activities in the human body.
Understanding of diseases that damage small intestinal mucosae such as
celiac disease or Crohn’s disease necessitates understanding the normal
human small intestinal mucosa proteome. However, an in-depth charac-
terization of the normal small intestinal mucosal proteome is lacking.
Therefore, we have carried out proteomics analysis of the small intestinal
mucosa by obtaining small intestinal biopsies from twelve subjects with
gastrointestinal reflux disease undergoing the routine endoscopic exami-
nation and having normal small intestinal morphology.
Methods A spectral ion library representing the total proteome of small
intestinal mucosa from 45 biopsies was generated in data-dependent ac-
quisition mode. Small mucosal biopsies from 12 participants having
GERD were included as representatives of normal human small intestinal
tissue. Proteins extracted from the biopsies were subjected to tryptic di-
gestion and SWATH-MS analysis.
Results A total of 3369 proteins were identified with high confidence.
Amino acid metabolism, endoplasmic reticulum-secretory pathway,
spliceosome complex, and glycolysis were among the most prominent
pathways as represented by the proteome. Proteins from various parts of
the small intestinal mucosal structure mapping to enterocytes, goblet
cells, Paneth cells, intestinal crypts were found in the dataset.
Conclusions Cataloging the proteome in a healthy intestinal mucosa pro-
vides baseline characterization data that will help to better understand the
alteration in the small intestinal proteome during various stress conditions
and diseases associated with the small intestinal mucosa.
Keywords Proteome, Small intestine, Gene ontology, Enteropathy, Celiac
disease
077
Acute mesentric ischemia- A series of 8 cases
Raghuveer Balabhadra, Praveen Mathew
Correspondence- Praveen Mathew-drpraveenmathew@yahoo.com
Department of Gastroenterology, Vydehi Institute of Medical Sciences,
82, Near BMTC 18th Depot, Vijayanagar, Nallurhalli, Whitefield,
Bengaluru 560 066, India
Introduction Acute mesenteric ischemia (AMI) refers to sudden onset of
intestinal hypoperfusion. Incidence of acute mesenteric ischemia appears
to be rising- partly due to increased awareness among clinicians, ageing
population with cardiovascular disease. Intestinal ischemia can be classi-
fied as acute or chronic and of venous or arterial origin. In young patients
without cardiovascular disease, mesenteric venous thrombosis is the com-
mon cause of intestinal ischemia.
Aims To evaluate and study the clinical profile of cases of AMI in our
tertiary care centre. It was obtained by performing a audit of all patients
presenting with Acute abdomen in Vydehi Institute of Medical Sciences
and Research Centre from 2019-2020.
Method Data were collected from 1 September 2019 to 31 August 2020.
All relevant investigations including CECT abdomen- Mesenteric ische-
mia protocol, Procoagulant work up was done where indicated.
Observations A total of 8 cases were enrolled in the study. Mean age of
patients was 43.2 years (Range: 21-60 years). Majority of the patients
were in the 4th and 5th decade. Male preponderance was noted. All
patients presented with abdominal pain. Four patients (50%) had arterial
S25
thrombosis. Four patients (50%) had venous thrombosis. Seven cases
were involving superior mesenteric territory. One case was involving
inferior mesenteric artery territory. CECT abdomen was diagnostic in
all cases. One patient had arterial thrombosis secondary to atrial fibrilla-
tion. Venous thrombosis was secondary to APLA in 2 cases, Protein S
deficiency in 1 case. Evaluation for thrombosis could not be done in 4
cases.
Keywords Mesenteric ischemia. Superior mesenteric vein thrombosis,
Superior mesenteric artery thrombosis
078
Celiac disease: Western Indian perspective
Khwaja Aminodddin Siddiqui, Vaibhav Somani
Correspondence- Vaibhav Somani-drvaibhavsomani@gmail.com
Department of Gastroenterology, Bombay Hospital and Medical
Research Centre, Mumbi 400 020, India
Introduction Celiac disease (CeD) is an autoimmune disorder diagnosed
predominantly in pediatric population in western countries. With the ad-
vent of better awareness, CeD is being increasingly diagnosed in India
across all regions. The aim of this study was to evaluate the clinical profile
of CeD in western Indian population.
Methods We retrospectively analyzed prospectively maintained data.
Total 111 consecutive patients who were diagnosed with CeD as per
the European Society for Paediatric Gastroenterology Hepatology and
Nutrition (ESPGHAN) criteria in a tertiary care center in Western India.
Their clinical profile was studied.
Result Of total 111 patients, 71 (63.96%) cases were females and 40
(36.03%) cases were males. Median age of presentation was 37
years. Diarrhea was the commonest symptom. Many patients pre-
sented with atypical symptoms like nausea, vomiting and bloating
of abdomen. Extraintestinal symptoms are common in CeD and
include weight loss, anemia, osteopenia, neurological abnormality
and gynecological abnormality. CeD can present in adult as well as
elderly age groups.
Conclusion CeD is not an uncommon disease is Western India. High
index of suspicion is required in patients with atypical presentation.
Keywords Diarrhea, extraintestinal manifestations, hypertransaminasemia
079
Gluten content in labeled and unlabeled gluten-free food products
used by patients with celiac disease
Wajiha Mehtab, Vikas Sachdev, Alka Singh, Samagra Agarwal,
Namrata Singh, Rohan Malik*, Anita Malhotra**, Vineet Ahuja, Govind
K Makharia
Correspondence- Govind K. Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition Unit, and
*
Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi 110 029, India, **Department of Home Science, University of
Delhi, New Delhi, India, *** Department of Food Technology,
Lakshmibai College, University of Delhi, New Delhi, India,
Objective Gluten-free (GF) diet is the only reliable treatment for patients
with celiac disease (CeD), but data on the extent of gluten contamination
in GF-food available in India is scanty. We evaluated gluten content in
labeled, imported and non-labeled GF-food products currently available
in the Indian market.
Methods Seven hundred and ninety-four processed and commercially
available packaged GF products (labelled GF [n=360], imported GF
[n=80] and non-labelled/naturally GF [n=354]) were collected from su-
permarkets of National Capital Region of India. Those unavailable in
stores, were purchased from e-commerce sites or directly from the
S26
manufacturers. Gluten level in them was determined by Ridascreen
Gliadin sandwich R5-enzyme-linked immunosorbent assay (R-
Biopharm AG, Germany). As per Codex Alimentarius and Food Safety
and Standard Authority of India, “gluten-free” labelled products must not
contain >20 mg/kg of gluten.
Results Overall, 10.1% of 794 GF products including 38 (10.8%)
of 360 labelled and 42 (11.8%) of 354 non-labelled/naturally GF-
food products had gluten content >20 mg/kg (range: 24.43–355
and 23.2–463.8 mg/kg, respectively). None of the imported GF
products had gluten more than the recommended limits. The level
of contamination was more in the labelled GF-food products
manufactured using oats, amaranth, buckwheat and pearl millet
than others which used Bengal gram dal, rice, maize, sorghum
and multi-grains as ingredients. Contaminated products most com-
monly belonged to cereal and their products (flours, coarse grains,
pasta/macaroni, snack foods) pulse flours, spices and bakery
items.
Conclusions A substantial proportion (10.1%) of GF-food products
(both labelled and non-labelled) available in India have gluten
content greater than the prescribed limits of <20 mg/kg.
Physicians, dietitians, support group and patients with CeD should
be made aware of this fact and regulatory bodies should ensure
quality assurance.
Keywords Labelled gluten-free, Naturally gluten-free, Contamination,
Quality assurance, India
080
Falsely elevated anti-tissue transglutaminase antibodies in patients
with immunoproliferative small intestinal diseases: A case series
Srikant Mohta, Ashish Chauhan, Mahendra Rajput, Alka Singh,
Prasenjit Das*, Soumita Bagchi**, Vineet Ahuja, Govind Makharia
Correspondence- Govind Makharia-govindmakharia@gmail.com
Departments of Gastroenterology and Human Nutrition, *Pathology and
**
Nephrology, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India
Introduction There is an overlap between clinical symptoms of celiac dis-
ease many other diseases including tropical sprue, parasitosis and
immunoproliferative small intestine disease (IPSID). They are distin-
guished by presence of celiac specific antibodies and certain histological
characteristics. We present a case series of 11 patients with IPSID, 8 of
which were found to have falsely elevated anti-anti-tissue transglutaminase
(anti-tTG Ab) in them.
Methods We reviewed all patients who were diagnosed to have IPSID
between 2016 and 2019. As part of evaluation, all patients had undergone
complete work up including anti-tTG Ab, intestinal mucosal biopsies.
Wherever feasible, anti-endomysial Ab, HLA haplotype, and serum
IgA levels were estimated. A trial of gluten-free diet was also done in 4
patients before committing a diagnosis of IPSID.
Results While diagnosis of IPSID was confirmed in all 11 patients, eight
of them had persistent rise in IgA anti-tTG Ab; 6 of them had anti-tTG Ab
more than 2 times upper limit of normal (ULN), 4 had values >5 times
ULN and only one patient had a value 10 times ULN. EMA could be
done in seven patients and it was negative in all of them. Haplotyping of
HLA-DQ2 and -DQ8 could be done in five of them and only one of them
had HLA-DQ2 haplotype. A gluten-free trial was given to 4 patients with
a significantly raised anti-tTG Ab (>5x ULN), none demonstrated signif-
icant reduction symptoms and IgA-tTG Ab titre.
Conclusion Patients with IPSID can have a false positive anti-tTG Ab. By
making a diagnosis of celiac disease based only on anti-tTG Ab may lead
to a false diagnosis of celiac disease.
Keywords Anti tTG, IPSID, celiac disease
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
081
Spectrum of height in patients with celiac disease
Nishant Aggarwal, Vignesh Dwarakanathan, Alka Singh, Ashish
Agarwal, Akhilesh Khuttan, Anam Ahmad, Mahendra Singh Rajput,
Ashish Chouhan, Vikas Banyal, Anil Verma, Vipin Gupta, Rakesh
Lodha, Vineet Ahuja, Govind Makharia
Correspondence- Govind Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Growth retardation and growth failure are important
features of celiac disease (CeD) that lead to failure of attainment
of full potential of adult height. Although there is data on the
proportion of patients having short stature in CeD, there is a lack
of data on the spectrum of height, with normal expected height at
one end and short stature being the other end.
Methods We performed a retrospective analysis of a prospectively
maintained database at our center, including a total of 419 adults
(183 [43.7%] males) and 164 adolescents (12-18 years) (72
[43.9%] males). The data from the National Family Health
Survey 2015-16 (NFHS-4) from India was used as control group.
Height and BMI Z-scores were defined according to the Indian
Academy of Pediatrics (IAP) growth charts and compared with
the control group.
Results Overall, 19.6% of adult and 57.9% of adolescent patients with
CeD had short stature. Mean height of male patients with CeD was similar
whereas women were taller than the population controls. Higher propor-
tion of men with CeD had short stature, as compared to population con-
trols (32.2% vs. 20%, p<0.0001). In contrast, a lower proportion of wom-
en with CeD had short stature as compared to the controls (9.7% vs.
18.9%, p=0.0003). Higher proportion of adolescents with CeD had short
stature compared to adults (57.9% vs. 19.6%, p<0.001). On multivariate
analysis, adulthood was found to be independently associated with a
lower prevalence of short stature.
Conclusions The mean height of men with CeD was not significantly
different from that of population controls, whereas females were taller
than the population controls. Adolescent boys and girls with CeD are
significantly shorter than their peers from the general population.
Keywords Short stature, Enteropathy, Small intestine, Growth failure
082
Neuroendocrine tumor in ulcerative colitis- ? Coincidence OR asso-
ciation
Binila Jose, George Thomas, Ramesh M, Satheesh A V
Correspondence- Binila Jose-binilajose@gmail.com
Department of Gastroenterology, Pushpagiri Institute of Medical
Sciences, Near Pvt Bus Stand, Thiruvalla 689 101, India
Introduction Association between inflammatory bowel disease (IBD) and
neuroendocrine tumor (NET) is not well established till now. NETs are
seen rarely in IBD patients but some new reports shows increased prev-
alence of NET in IBD patients compared to general population. Increased
number of neuroendocrine cells along with other cells present in colonic
mucosa which inflamed for long period in setting of IBD may be the
triggering factor for NET along with IBD. NET is rare among colonic
or small bowel neoplasms and its infrequently described along with IBD.
Here we report a case of distal ileal carcinoid arising in a UC patient.
Case report A 47-year-old man with 9 years history of ulcerative colitis
and diabetes mellitus was admitted due to intermittent bleeding per rec-
tum and constipation. He was well maintained with mesalamine 1.2g/day
and symptomatic treatment. Previous colonoscopy showed features of
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
remission. Colonoscopy showed thickening in rectosigmoid region and
exophytic intraluminal polypoidal lesion (12.7 x 10.5 mm) in distal ileum.
Biopsy from rectal and sigmoid region showed features suggestive of
mild colitis. Biopsy specimen from distal ileal polyp showed features
suggestive of carcinoid. Laparoscopic resection was done, biopsy showed
features consistent with carcinoid.
Discussion Previous literature showed NET predominantly carci-
noid tumors associated with IBD, most of them were clinically
indolent and incidentally reported in surgical specimens of IBD
patients. Siegel et al. suggested multipotential cells in dysplastic
epithelium in IBD might be the prerunner for neuroendocrine
differentiation leads to NET. Concept of cellular dysplasia involv-
ing neuroendocrine cells in inflamed mucosa of IBD patient lead-
ing to NET including carcinoids needs further validation.
Keywords Carcinoid, Ulcerative colitis
083
Genetic polymorphisms in prediction of thiopurine related cytopenia
in inflammatory bowel disease: A prospective study
Narinder Grover, Prateek Bhatia, Antriksh Kumar, Minu Singh**,
Deepesh Lad*, Harshal Mandavdhare, Kaushal Prasad, J Samanta,
Usha Dutta, Vishal Sharma
Correspondence- Vishal Sharma-docvishalsharma@gmail.com
Departments of Gastroenterology, *Internal Medicine, and **Pediatrics,
Postgraduate Institute of Medical Education and Research, Chandigarh
160 012, India
Background Genetic polymorphisms in TPMT and NUDT enzymes are
implicated in thiopurine related cytopenia. The contribution of these polymor-
phisms in Indian population with inflammatory bowel disease (IBD) is
uncertain.
Methods Consecutive patients with the diagnosis of ulcerative co-
litis or Crohn disease initiated on thiopurines (azathioprine or 6-
mercaptopurine) were included in the study. Only those patients
who developed an adverse event resulting in discontinuation or
had at least three months of follow-up were included.
Polymorphisms for TPMT and NUDT were detected. The patients
with the genetic polymorphisms were compared to those without
any detectable polymorphisms for frequency of cytopenia, maxi-
mal tolerated thiopurine dosage and occurrence of idiosyncratic
reactions.
Results Of the 119 patients (mean age was 36.8 ± 13.5 years)
included, 61 (51.3%) were males. One hundred and five had ul-
cerative colitis while 14 had Crohn’s disease. Of these 119, cy-
topenia were noted amongst 33 (27.7%), gastrointestinal tolerance
in 5 (4.2%) and pancreatitis in 2 (1.6%). TPMT polymorphisms
were noted amongst five patients while NUDT polymorphism was
noted in 13 patients. One of these had both TPMT and NUDT
polymorphism. The occurrence of cytopenia was more frequent in
those with NUDT polymorphism than those with wild phenotype
(53.8% vs. 24.5%) but was similar in those with TPMT polymor-
phism as compared to wild type (20% vs. 24.5%).
Conclusion In Indian population with IBD, NUDT polymorphisms are
more frequent than TPMT and are predictive of development of cytopenia.
Keywords Ulcerative colitis, Crohn's disease, Azathioprine
084
A rare case of multiple jejunal diverticulosis with perforation
T Ashokkumar, A Amudhan, R Kamalakannan, J Saravanan, M
Thiruvarul, Satish Devakumar, S Jeswanth, T Selvaraj
Correspondence- Ashok Kumar-asasupernova@gmail.com
S27
Institute of Surgical Gastroenterology and Liver Transplantation, Stanley
Medical College, Chennai 600 003, India
Background Small bowel diverticular disease occurs in in 0.3 % to 20%
of the population less common than large bowel diverticular disease .of
these only 4% will develop symptoms. Three types of small bowel diver-
ticula the duodenal, jejunoileal and Meckel diverticula, of these most
frequently encountered diverticula are the duodenal 45%, jejunoileal
25% and Meckel diverticula 25%.
Case report An 80-year-old women admitted in medical ward with
complaints of abdominal pain vomiting and diarrhea patient
underwent imaging after atypical presentations found to have
small bowel thickening with mesenteric haziness patient
underwent laparotomy for peritonitis and was discovered to have
multiple jejunal diverticula with perforation and enterolith patient
underwent resection anastomosis and her postoperative period was
uneventful.
Conclusions Jejunal diverticula are the least common 60% to 70%
patients are symptomatic peaks around 6th for 7th decade, these
diverticula usually in the mesentric side of the bowel acquired
diverticula result of smooth muscle dysfunction or defect in the
myentric plexus resulting in irregular bowel contraction and in-
creased intraluminal pressure these diverticula can present with or
without perforation hemorrhage and after auction obstruction.
Asymptomatic cases are left alone if there are signs of hemody-
namic instability sepsis or peritonitis surgical resection is
recommended.
Keywords Small bowel diverticula, jejunal diverticula, perforation, enterolith
085
Hemangio-lymphangioma of small bowel - A rare cause of recurrent
gastrointestinal bleed and chronic anemia
Govind Purushothaman, Jeswanth S
Correspondence- Govind Purushothaman-govindmmc@gmail.com
Institute of Surgical Gastroenterology and Liver Transplantation, Stanley
Medical College, 1, Old Jail Road, Chennai, 600 001, India
Introduction Benign vascular lesions occur rarely in the gastrointestinal
(GI) tract and are diagnosed by endoscopy or angiography. Rarely, these
present with refractory bleed and a surgical resection is required to arrest
the hemorrhage.
Case Capsule Forty-eight-year-old female, presented with melaena
and anemia for 2 years. She had undergone hemorrhoidectomy
elsewhere 1 year back. Colonoscopy and upper GI scopy were
normal. Abdominal CECT scan showed mesenteric lymph node
enlargement. She had undergone diagnostic laparoscopy elsewhere
and intraoperative enteroscopy was done. Intraoperatively she had
mesenteric lymph node enlargement, nodular mucosa of the small
bowel and Meckel’s diverticulum. Meckel’s diverticulum along
with a segment of adjoining bowel was resected. Postoperatively
she had recurrent melaena. CECT scan abdomen showed
hemoperitoneum. She underwent exploratory laparotomy.
Intraoperative enteroscopy showed highly vascular nodular lesion
of the jejunum. Resection of 80 cm of small bowel was done.
Histopathology report was suggestive of Hemangiolymphangioma.
At follow-up, patient was symptom free.
Discussion Hemangiolymphangioma is a benign disease, mainly
found on the skin. Rarely, it is found in small bowel, spleen,
colon, rectum and thorax. The incidence of hemangio-
lymphangiomas varies between 1.2 and 2.8 per 1000 live births.
Most are asymptomatic, or show painless GI hemorrhage. Eighty
percent of patients show intraluminal GI bleeding symptoms, and
50 % have chronic anemia. Most effective treatment is surgical
resection, but other treatment modalities include sclerotherapy and
angioembolization.
S28
Keywords Small bowel hemangiolymphangioma, Upper gastrointestinal
bleed
086
An interesting case of intestinal obstruction
Pavan Kumar, A Aravind, Caroline Selvi, Kani Shaikh Mohamed,
Jayakumar Jayakrishnan, A R Akilandeshwari, Vaishnavi Priyaa, S
Kavitha, A Anand, N Arun
Correspondence- Pavan Kumar-drpavankumar19@gmail.com
Department of Medical Gastroenterology, Kilpauk Medical College,
Chennai 600 010, India
Introduction Gallstone ileus is a rare complication of cholelithiasis and is
one of the rarest forms of all mechanical bowel obstructions.
• It is caused by impaction of a gallstone in the gastrointestinal
(GI) tract after passing through a biliary-enteric fistula.
Case 57-year-old female presented with days h/o abdominal pain,
vomiting, constipation. No h/o jaundice, fever, distension of ab-
domen. h/o caesarean section 35 years back h/o incisional hernia
repair 10 years back k/c/o DM. O/E: Patient conscious, oriented
pulse:92/min BP:110/80 mm of hg.
•P/A: soft tenderness present in the epigastric and right hypochondrium
no VIP/VGP ,BS+
•Other systems: normal
•P/R : fecal matter+
Investigations: HB 13.7, TLC 12900, PLT 5 lakhs, blood urea 53, S
creatinine 1.1, amylase 31, LFT normal, CXR - normal,
Erect Abdomen X-ray - normal, CT abdomen F/S/O chronic cholecystitis
with cholecysto duodenal fistula subacute small bowel obstruction? gall-
stone ileus.
•Emergency laparotomy was done, impacted stone in jejunum
measuring 4*4 cm seen with ?sealed perforation, removel of stone
and resection anastamosis of bowel small bowel done post op
period was uneventful.
Conclusion Gallstone ileus occurs in 0.3% to 0.5% of all patients
with gallstones. It is one of the rarest causes of gallstone ileus,
occurring in about less than 0.1% of all mechanical obstruction
cases and 1% to 4% of non-strangulating mechanical small bowel
obstructions. Mortality remains high, ranging from 12% to 27%,
because of non-specific symptoms, unremarkable biochemical in-
vestigations, high misdiagnosis rate, and delayed discovery. So
gallstone ileus should be kept as differential diagnosis in evaluat-
ing a patient with subacute intestinal obstruction.
Keywords Gallstones, Ileus
087
Jejunal gastrointestinal stromal tumor in a case of duodenal perfo-
ration in a COVID-19 positive patient
Venkatesh G, Arun Babu C, Sofia J
Correspondence- Arun Babu C-arun_dr@yahoo.com
Department of General Surgery, Government Stanley Medical College
and Hospital, Chennai 600 001, India
Introduction Gastrointestinal stromal tumors are rare. GISTs com-
prise 0.2% of gastrointestinal tumors and only 0.04% of small
intestinal tumors. Jejunal GISTs are the rarest subtype. Only
10% to 30% progress to malignancy.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Case capsule A 65-year-old male was admitted with abdominal
pain for 6 hours. He was diagnosed to have hollow viscous per-
foration and on further evaluation found to be COVID-19 posi-
tive. Intra-operatively, he was found to have D1 perforation which
was repaired by using Graham’s patch repair. During exploratory
laparotomy, the patient was found to have well circumscribed
growth of size 3X3X2 cm which was 10 cm distal to
duodenojejunal flexure. No mesenteric lymph nodes were found,
no ascites was present, and liver was normal. Resection and anas-
tomosis of the bowel was done with 2 cm margins on both ends.
Histopathological examination revealed gastrointestinal stromal tu-
mor which is of spindle cell type. Immunohistochemical analysis
showed that the tumor is CD117 positive and S100 negative.
During follow-up, patient was asymptomatic.
Discussion GISTs are uncommon mesenchymal neoplasms of the
alimentary tract. The incidence of GIST is very low (i.e. 2 in
1,00,000). Most common site of presentation is stomach, but it
can crop up anywhere in the digestive tract. Two-thirds of GISTs
occur in the stomach while about one-fourth develop in the small
intestine, usually in the duodenum. while jejunal GIST is ex-
tremely rare accounting for 0.1% to 3% of all gastrointestinal
(GI) tumors. Usually they are asymptomatic but can present as
abdominal pain, bleeding, or mechanical obstruction. Surgery is
the primary treatment of choice and imatinib mesylate is the first
and only effective drug for the treatment of gastrointestinal stro-
mal tumor at present.
Keywords GIST, Jejunal, CD117, Imatinib, Perforation
088
Extraintestinal gastrointestinal tract involvement in patients with
celiac disease: An early proof
Ashish Chauhan, Mahender Singh Rajpoot, Alka Singh, Vikas Sachdev,
Vikas Banyal, Ashish Upadhyay, Wajiha Mehtab, Asif Iqbal, Anam
Ahmed, Ashish Aggarwal, Rimlee Dutta, Madhu Rajeshwari, Prasenjit
Das, Vineet Ahuja, Govind Makharia
Correspondence- Govind Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction While celiac disease (CeD) is considered to affect
mainly small intestine, a few of them also have lymphocytic in-
filtration of other parts of gastrointestinal tract. Whether these
changes are due to CeD is not well-established. Deposits of IgA
anti-tissue transglutaminase antibody (anti-tTG Ab) in the small
intestinal mucosa has been used as an evidence of CeD.
Methods Forty-two treatment naive patients with CeD (as cases)
and 45 patients with irritable bowel syndrome (as controls) were
recruited. They underwent esophagogastroduodenoscopy and sig-
moidoscopy and multiple mucosal biopsies were collected from
the esophagus (lower, mid and upper), stomach (multiple sites
as per Sydney protocol), duodenum (bulb and post ampullary)
and rectosigmoid, both at baseline and at 6-month post gluten-
free diet (GFD). All biopsies were evaluated for histological char-
acteristics and immunostaining, for co-localization of IgA anti-
tTG deposits, using dual-colour immunohistochemistry, as an ev-
idence of CeD at these sites.
Results Significantly higher number of patients with CeD had ev-
idence of lymphocytic esophagitis (9.7% vs. 0%, p<0.05), lym-
phocytic gastritis (35% vs. 8.8%, p<0.01), duodenal intraepithelial
lymphocytosis (100% vs. 0%, p <0.001) and lymphocytic colitis
(17.4% vs. 0%, p<0.05) than that in controls. Significantly higher
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
number in patients with CeD had anti-tTG Ab deposits in esoph-
agus (30.9% vs. 6%, p<0.001), stomach (62.2% vs. 9.3%,
p<0.01), duodenum (88.5% vs. 0%, p<0.001) and rectum (17.4%
vs. 0%, p<0.05) in comparison of controls. On follow-up on
GFD, there was a decline not only in severity of intra-epithelial
lymphocytosis but also in the intensity of anti-tTG deposits at all
sites.
Conclusion A significantly higher number of patients with CeD having
intraepithelial lymphocytosis and anti-tTG Ab deposits in the esophagus,
stomach and rectum in addition to small intestine suggests that other
organs are also affected in CeD.
Keywords Celiac disease, Immunohistochemistry, IgA tTG mucosal de-
posits
089
Colonic mucormycosis in fistulizing Crohn’s disease: A case report
Akash Mathur, Piyush Mishra, Neha Nigam, Uday C Ghoshal
Correspondence- Uday C Ghoshal-udayghoshal@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of
Medical Sciences, Lucknow 226 014, India
Background Gastrointestinal mucormycosis, a rare fatal fungal infection
in an immunocompromised host, commonly affects the stomach.
Case Report A 46-year-old female with long-standing diabetes
mellitus, hypothyroidism, and hypertension, presented with a 3-
month history of fecal discharge per vagina. She reported having
intermittent loose stools, mixed with blood and mucus for 1.5 years.
Based on the evaluation and unsuccessful treatment with anti-
tubercular drugs elsewhere, Crohn’s disease was diagnosed, and
adalimumab biosimilar started; however, the response was partial.
Examination revealed: pallor and large perianal tags. Investigations:
Hb 9.4 g/dL, total serum protein, and albumin 5.5 and 2.8 g/dL,
respectively. A computerized tomography (CT) scan with rectal
contrast showed inflammatory involvement of the rectum and sig-
moid along with a rectovaginal fistula. A magnetic resonance (MR)
enterography showed a loss of haustrations in the transverse colon
with a prominent vasa recta in the sigmoid colon. Colonoscopy
showed loss of vascular pattern with pseudopolyps in the terminal
ileum, IC valve, cecum, ascending, transverse, descending, sigmoid
colon, and rectum; a fistulous opening was seen in the rectum (Fig.
2A, B and C). Descending and sigmoid colon biopsies revealed
crypt distortion, mononuclear cell infiltrates in lamina propria, exu-
date with broad aseptate fungal hyphae suggesting mucormycosis
(Fig. 1A, B and C). The serology for the human immunodeficiency
virus was negative. With a diagnosis of colonic mucormycosis with
fistulising Crohn’s disease, liposomal amphotericin B was started,
but the patient succumbed.
Conclusion This rare patient highlights the need for increasing awareness
about fungal infestations as a cause of disease flare in patients with in-
flammatory bowel disease.
Keywords IBD, Crohn's disease, Fistulizing Crohn's disease,
Mucormycosis
Large Intestine
090
Mimics of inflammatory bowel disease in clinical practice
Mayank Jain
Correspondence- Mayank Jain-mayank4670@rediffmail.com
S29
Department of Gastroenterology, Arihant Hospital and Research Centre,
283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India
Introduction There are several conditions that mimic inflammatory
bowel disease (IBD) because of location, symptoms, or appear-
ance on endoscopy, imaging and histology. Consideration of al-
ternative diagnosis is important when conventional therapy does
not work or worsens the symptoms. The present study is a retro-
spective analysis of cases where IBD mimics were diagnosed.
Methods Over a nine-year period, 104 cases with suspected IBD
were seen by the author. Of these, 88 were suspected as ulcera-
tive colitis (UC) and the remaining as Crohn’s disease (CD).
Diagnosis of IBD was suspected if 2 or more of the following
symptoms were present- fever, weight loss, abdominal pain,
chronic mucoid or bloody diarrhea, subacute intestinal obstruction
with or without right iliac fossa mass. The diagnosis was con-
firmed using radiological investigations (ultrasound, computed to-
mography), colonoscopy evaluation and histopathology. Based on
histology, and re–evaluation in cases with non-response, the even-
tual diagnosis was changed in 11 cases.
Results Infections were commonest mimics and were noted in 6
cases (54.5%). Tuberculosis and amebic colitis were detected in 3
and 2 cases respectively. Five other cases (45.5%) were diagnosed
with rarer diseases based on the clinical profile, histology and
response to treatment. These included segmental colitis with di-
verticulosis (SCAD), solitary rectal ulcer syndrome, eosinophilic
enteritis, Behcet’s disease and NSAID enteropathy are rarer IBD
mimics seen in India and reported mainly as case series.
Conclusion IBD mimics are detected in nearly 10% of cases of suspected
IBD. They are commoner in CD than UC. Infections are the commonest
IBD mimics in Indian scenario.
091
Clinical and endoscopic profile of inflammatory bowel disease in a
tertiary care hospital in South India
Rithesh Gundam, Deepak Suvarna, Aradya H V, Nandeesh H P, Vijay
Kumar T R
Correspondence- Deepak Suvarna-drdeepaksuvarna@gmail.com
Department of Gastroenterology and Hepatology, JSS Medical College
and Hospital, Mysore Road, Bannimantap A Layout, Bannimantap,
Mysuru 570 015, India
Introduction We aim to study the clinical profile of inflammatory
bowel disease (IBD) patients in a tertiary care hospital of
Karnataka.
Methods We retrospectively analyzed the clinical profiles of IBD
patients who had presented to Department of Gastroenterology
over a period of four years from January 2015 to January 2019.
Demographic profile, clinical and endoscopic findings along with
management and complications were taken into consideration.
Results Of the 143 patients, there were 126 (88.1%) patients with ulcer-
ative colitis (UC), 6 (4.2%) with Crohn’s disease (CD) and 11 (7.7%)
with inflammatory bowel disease unclassified (IBDU). Chronic diarrhea
(77.8%) and blood in stools (75.4%) were common in UC, whereas
abdominal pain (50%) was common in CD. E2 (57.1%) was more com-
mon in UC, there were equal number of L2 (50%) and L3 (50%) in CD.
Left sided colon involvement (81.8%) was common in IBDU.
Extraintestinal manifestations were noted in CD (66.6%), IBDU
(54.5%) and UC (53.3%). Most of the patients had moderate disease
activity and responded well to pharmacotherapy.
Conclusion In our study, we found that IBD was common in rural
population of India and UC was more common than CD.
S30
092
Profile of colonic polyps in north Indian population
Anurag Mishra, Arpan Jain, Manish Tomar
Correspondence- Anurag Mishra-dr.anuragmishrakgmc@gmail.com
Department of Gastroenterology, Govind Ballabh Pant Institute of
Postgraduate Medical Education and Research (GIPMER),1, Jawaharlal
Nehru Marg, 64 Khamba, Raj Ghat, New Delhi, Delhi 110002
Introduction Data on the prevalence and distribution of colonic
polyps in Indian/Asians is limited. To study this we conducted
a retrospective study on 202 polyps out of 7936 colonoscopies.
Method The objective was to analyse demographic, clinical, endo-
scopic and histopathological characteristics of polyps in patients
undergoing colonoscopy from 2016 to 2019 at GIPMER, New
Delhi. All polyps were removed colonoscopically by polypectomy
and specimen were sent for histopathological examination.
Parameters like age, gender, symptoms, site, gross morphology
and histological subtypes of polyps were assessed.
Result Total 7936 colonoscopies were performed in this period.
Polyps were seen in 202 patients. Mean age was 23 years.
Seventy-two percent were males. Eighty-two percent were below
40 years and 18% were above 40 years of age. 69% polyps were
found in rectum. Sixty-three percent polyps were juvenile, 10%
Peutz-Jegher, 17% adenomatous, 3% inflammatory and 7% others.
Mean age of adenomatous polyp was 48 year. Sixty-six percent
polyps were pedunculated. Fifty-one percent polyps were less than
1 cm. Eighty-one percent patients presented with bleeding P/R.
Seventy-eight percent of adenomatous polyps were dysplastic.
Out of adenomatous polyp 44% were tubular, 34% tubulo-
villous and 22% villous.
Conclusion Frequency of polyps on colonoscopy at our centre was
2.5%. Most common type was juvenile polyp. Polyps were more
common in younger age group. Adenomatous polyps were com-
mon in middle to old age group. Most polyps were small, pedun-
culated and located in rectum. Tubular was most common type of
adenomatous polyp. Dysplasia was more common in villous type.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
093
Solitary rectal ulcer syndrome and its relation to specific food
Padmanabhan Purushottam, Mohammed Syed, Syed Mohd Akbar
Hassan
Correspondence- Mohammed Syed-drakhassan@gmail.com
Department of Gastroenterology, Meenakshi Medical College, Enathur,
Karrapettai Post, Kanchipuram 631 552, India
Introduction Solitary rectal ulcer syndrome (SRUS) was first identified as
clinical identity in 1969. But the etiology is not known. Anal fissure,
inflammatory bowel disease (IBD), proctagia fugax and malignancy, rec-
tal polyps, hemorrhoids, and infections. Rarely ischemia, trauma and
cystic profunda colitis and stercoral ulcers have to be excluded. Hence
a careful history is important.
Methods Patients presenting with C/O constipation or straining at stools
with difficulty in passing motion with associated minimal bleeding per
rectum on and off period less than a month were included in the study. All
patients were investigated for stool for occult blood, US abdomen,
BMFT, CBP and flexible sigmoidoscopy
Results 1. Patients presenting with constipation and bleeding PR were
investigated. Flexible sigmoidoscopy showed multiple pinpoint superfi-
cial ulcers on the anterior rectal wall without involvement of sigmoid
colon. The incidence age group wise was seen very high between 20 to
60 years. M: F ratio 47:53. All were positive for stool for occult blood,
negative for IBD and malignancy by biopsy. They responded to dietary
changes i. e. veg, non-spicy, non-fried diet with antibiotic, mesalamine
(400 mg BD) and lactulose 15 mL at bed time. Ten days after the test
follow-up sigmoidoscopy was found normal and patient asymptomatic
even after 3 months.
Discussion The incidence of SRUS has become common irrespective of
age and sex. The type of food used by all these patients was found to be
more or less similar with majority of them using fast food, fried food, and
spicy food. Stoppage of the above-mentioned food with specific treat-
ment for 10 days resulted in recovery with normal sigmoidoscopy.
Conclusion SRUS incidence is high in general population due to specific
food type and evacuation behavior.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
094
Management of inflammatory bowel disease in active phase for in-
duction of remission - Steroid vs. tacrolimus
Padmanabhan Purushottam, Mohammed Syed, Syed Mohd Akbar
Hassan
Correspondence- Mohammed Syed-drakhassan@gmail.com
Department of Gastroenterology, Meenakshi Medical College, Enathur,
Karrapettai Post, Kanchipuram 631 552, India
Introduction Steroids along with amino salicylates are classically used for
induction of remission but the side effects of steroids are many and cause
multiple problems to patients receiving it. A result many non-inflammatory
bowel disease (IBD) immune suppressants are being tried for induction of
remission and include methotrexate, cyclosporine, infliximab, azathioprine,
6-mercaptopurine, adalimumab, vadalizumab, tafacitimabb, golimumab,
and tacrolimus. The major problem in its use is development of adverse
side effects, increase hospital stay and high cost.
Aim To compare and evaluate the efficacy and safely of tacrolimus
with aminosalicylates vs. use of aminosalicylates with corticosteroid
therapy in active phase of inflammatory bowel disease (IBD).
Methods Fifty patients of acute IBD were evolved in this study based on
inclusion and exclusion criteria. Group –I:(25 patients) received cortico-
steroid (prednisolone 10 mg BD) along with aminosalicylates 1.3 gms/
day Group –II: (25 patients) received tacrolimus in a dose of 0.1 mg/kg
body weight per day (2 tablets of 1 mg twice daily) along with
aminosalicylates 1.3 gms/day along with maintenance drugs required
for patients for a period of 10 days. Colonoscopic evaluation was done
before starting the drugs and after 10 days of completion of treatment and
the efficacy assessed using Mao endoscopic scoring system. Follow-up of
these patients was done at the end of 2 months with repeat colonoscopy to
assess the effectiveness of the treatment.
Results After initial therapy of 10 days clinical remission was ob-
served in both groups of patients. Follow-up at 2 months no patient
of group –II was admitted for exacerbation whereas in group –I 5/25
patients were re hospitalized following exacerbation (20%).
Conclusion Tacrolimus has prolonged period of remission compared to
corticosteroid with better efficacy, safety profile and cost effective which
was well tolerated by patients.
095
Microbiological spectrum, endoscopic and histological characteris-
tics and outcomes of enteric infection associated flare of ulcerative
colitis - A retrospective analysis
Senthamizhselvan Kuppusamy, Pazhanivel Mohan, Abdoul Hamide
Correspondence- Senthamizhselvan Kuppusamy-senthamizh
2909@gmail.com
Department of Medical Gastroenterology, Jawaharlal Institute of
Postgraduate Medical Education and Research, Dhanvantri Nagar,
Gorimedu, Puducherry 605 006, India
Introduction Enteric infections in ulcerative colitis (UC) can cause ad-
verse outcomes in terms of increased severity, failure to attain remission,
refractoriness to medical treatment and increased colectomy rates. Hence,
this study was conducted to find the frequency, microbiological spectrum,
endoscopic and histological characteristics, and outcomes of enteric in-
fection associated flare of UC.
Methods This retrospective study included patients hospitalized for
moderate or severe UC between January 2019 and June 2020.
The baseline characteristics, laboratory values, clinical severity,
endoscopic and histological grading of disease severity, stool cul-
ture and sensitivity, stool microscopy, Cytomegalovirus (CMV)
cytopathic changes in colonic biopsy, were collected.
S31
Results A total of 17 (n=75, cases 22.7%) enteric infection associated
moderate or severe flare of UC was seen during the study period.
Their median age was 36 years (22-48 years), with a male prepon-
derance (M:F=12:5). Stool culture was positive in 12 patients
(70.6%), Salmonella species was the commonest organism isolated
in 5 patients (41.7%), followed by Aeromonas punctate, Aeromonas
caviae, Vibrio cholera, Vibrio vulnificus, Edwardsiella tarda,
Pleisomonas shigelloides, and Shigella dysenteriae, in each of the
remaining 7 patients (each 5.9%). Stool microscopy for parasites
was positive in 3 patients (17.6%). The parasites include
Ankylostoma duodenale, Blastocystis hominis, and Entameba
histolytica. Cytopathic changes of CMV were seen in histology in 2
patients (11.8%). Mayo Endoscopic score was 1, in 4 patients
(23.5%) and Geboes histological activity score was less than 3, in
10 patients (58.8%). All patients showed significant clinical improve-
ment with appropriate dose and duration of antimicrobial treatment.
None of them required colectomy or change in their maintenance
therapy during this period.
Conclusions In conclusion, clinically severe enteric infection associated
flare of UC may have milder histological disease activity. Their symp-
toms and endoscopic findings improve with antimicrobial treatment and
rarely warrant newer or change in immunosuppression or
immunomodulation.
096
Thrombotic thrombocytopenic purpura as extraintestinal manifesta-
tion of ulcerative colitis
Ronak Ajmera, Ashish Garg, Anant Kumar Chauhan, Sushil Kumar
Sharma, Subhasish Mazumder
Correspondence- Subhasish Mazumder-subhasish.dr@gmail.com
Department of Gastroenterology, Max Super Speciality Hospital, W-3,
near Radisson Blu Hotel, Sector-1, Vaishali, Ghaziabad 201 012, India
Ulcerative colitis (UC) is autoimmune disease with varied extra-
intestinal manifestation. Acquired TTP is associated with autoim-
mune diseases but very rare with ulcerative colitis (only 4 cases
reported in literature). We had a case of 31-year-old male who
was a known case of UC since 5 years but not on regular treat-
ment. Patient presented with history of index episode of focal
seizures with secondary generalization with altered sensorium.
Patient was having persistent seizures and altered sensorium after
admission in spite adding of multiple antiepileptics and supportive
care. No cause was found after blood investigations and brain
imaging for seizures. His bowel habits were normal and there
were no features of sepsis. His investigations revealed high serum
creatinine, falling hemoglobin (8.3 gm%) and thrombocytopenia.
Peripheral smear showed evidence of Schistocytes, high serum
LDH, low serum haptoglobulin and negative coombs test sugges-
tive of micorangiopathic hemolytic anemia (MAHA). In view of
MAHA, thrombocytopenia, seizures and renal dysfunction diagno-
sis of acquired TTP was made and he was initiated immediately
to plasmapheresis. After multiple sessions of plasmapheresis, pa-
tient improved clinically, his sensorium improved and also there
was normalization of serum creatinine, steady Hb and platelet
count. Hence, we concluded that acquired TTP can be an extra
intestinal manifestation of UC which clinicians should keep in
mind and initiate prompt management in the form of plasma ex-
change.
097
Incidence and anatomical distribution of colorectal cancer - A single
centre retrospective study
S32
Aswin Jacob, A Aravind, J Jayakumar, C Vaishnavi Priya, S Kavitha, A
Anand, Kani Shaikh Mohamed, Caroline Selvi
Correspondence- A Aravind-aswingeorgejacob@gmail.com
Department of Medical Gastroenterology, Government Kilpauk Medical
College, Chennai 600 010, India
Background Colorectal cancer (CRC) is one of the major cancers in the
developed world causing significant morbidity and mortality. Most colo-
rectal cancers are due to old age and lifestyle factors, with only a small
number of cases due to underlying genetic disorders. A recent study had
shown a rising incidence of CRC in patients younger than 50 years of age.
The incidence of CRC is low in India due to high dietary fiber intake.
Aim of the study To determine the incidence and anatomical distribution
of colorectal colorectal cancer at a tertiary care centre in south India.
Methods Retrospective descriptive analysis of anatomical distribution,
age at diagnosis and demography of 238 cases (149 [57.1%] men) of
adenocarcinoma of the colon or rectum diagnosed by colonoscopy and
biopsy over a period of five years (June 2014- May 2019) at Government
Kilpauk Medical College, Chennai.
Results Total numbers of patients presented with colorectal cancer were
238, with M: F 1.3:1. The mean age at diagnosis was 54.55 years (SD
14.12; range 19–89 years). Thirty-five (14.7%) cases were below the age
of 40 years. The majority (45.3%) cases were aged between 41–60 years.
Most of the tumors (n=178, 78.5%) were located distal to the splenic
flexure.
Conclusion Almost half of the colorectal cancers in this series occurred in
the fifth and sixth decades of life and most of them were located distal to
the splenic flexure.
098
Frequency and characteristics of colonic polyps in Indian patients
Ajith C Kuriakose, Rajeeb Jaleel2, Anoop John, Rajesh S, Ajith Thomas,
Lalji Patel, Sudipta Dhar Chowdhury, Ebby G Simon, A J Joseph, Amit
Kumar Dutta
Correspondence- Amit Kumar Dutta-akdutta1995@gmail.com
Department of Gastroenterology, Christian Medical College, Vellore 632
004, India
Introduction Data on the frequency and characteristics of colonic polyps
from our country are limited. We aimed to study the frequency and profile
of colonic polyps among our patients.
Methods We conducted a retrospective study of patients who underwent
colonoscopy from November 2019-June 2020. Clinical records including
colonoscopic findings were evaluated. Patients with polyposis syndrome
or incomplete colonoscopy were excluded. The demographic profile and
indications for colonoscopy were assessed. The morphological and his-
tological characteristics of polyps were recorded. In addition, the risk
factors of adenomatous polyps were assessed.
Results Among the consecutive 2000 patients who underwent colonos-
copy during the study period, 135 (6.75%) had sporadic colonic polyps.
These 135 patients had a total of 251 colonic polyps and histology report
was available for 222 of them. Mean age of patients was 52+18.1 years
and 71.1% were males. Majority (88,62.8%) of the patients had single
polyp. Common indications for colonoscopy were altered bowel habits
(25.2%), lower GI bleeding (21.5%) and surveillance in patients with
prior polyps (20%). Most of the polyps were sessile (60.2%) and located
in the left colon (60.2%). Majority were <1cm in size 189 (75.3%) and
were adenomatous (56.3%) or inflammatory (25.7%). Other types includ-
ed hyperplastic (9.9%), juvenile (4.1%), Peutz-Jeghers (0.9%), serrated
(0.9%) and lipomatous polyps (0.9%). In adenomatous, tubular variety
was more common (80.8%) and 12% showed features of high-grade
dysplasia. Synchronous cancer was found in 8 patients. Risk factors for
adenomatous polyps are shown in Table1.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Table 1
Features Adenomatous Non adenomatous P
(n=69) (n=54) val-
ue*
Age (mean+SD) years 57.3+14.4 43+20.1 0.013
Sex (male) 74% 64.8% 0.28
Size (>1cm) 30.3% 33.3% 0.61
Location (left colon) 65.2% 79.6% 0.08
Hemoglobin (mean+ 11.9+2.3 11.8+2.3 0.77
SD) gm/dL
*Categorical variables by Chi Square Test and continuous variables by
Student-t test
Conclusion Among our patients, adenomatous and inflammatory polyps
are the commonest histological subtype and most polyps are located in
the left colon. Patients with older age have higher risk of having adeno-
matous polyps.
099
Clinicopathological profile of colorectal polyps : A retrospective
study at a tertiary care center in South India
Hitesh Ramesh, Deepak Suvarna
Correspondence- Deepak Suvarna-drdeepaksuvarna@gmail.com
Department of Medical Gastroenterology, J S S Medical College, Mysore
Road, Bannimantap A Layout, Bannimantap, Mysuru 570 015, India
Introduction A gastrointestinal polyp is a discrete mass of tissue
that protrudes into the lumen of the bowel wall. It is postulated
that certain varieties of colonic polyps turn malignant over a
period of time. The most common precursor of colorectal cancer
is adenoma. The biggest concern is their ability to progress into
carcinoma, through the adenoma-carcinoma sequence. In this ret-
rospective study we analyzed clinical features, location, pattern of
distribution, histopathological types of polyps and its association
with severity of dysplasia.
Methods We retrospectively analyzed data of patients diagnosed to
have polyps who had undergone colonoscopy between January
2016 to December 2019 in our hospital. We analyzed the associ-
ation between age, sex, location of polyps, histopathological types
and correlated size of polyps with degree of dysplasia.
Results Among the 2595 complete colonoscopies 140 (5.39%) patients
were found to have colonic polyps. Mean age of the study population was
53.97 years and majority were men (69.2%). 48.69% polyps were located
in rectum and 34.78% were seen in sigmoid colon. Commonest histo-
pathological type was Adenomatous polyps in 64 (45.7%) followed by
inflammatory in 41 (29.2%), hyperplastic in 23 (16.4%), juvenile in 10
(7.14%), hamartomatous and Peutz-Jeghers polyp in 1 each (0.71./.). 83%
of polyps with size (>2 cms) and 57.1% of polyps with villous histology
were associated with severe dysplasia.
Conclusion Adenomatous polyps were the predominant histologic type
similar to the west. Among the adenomatous polyps larger polyps (>2
cm) were more commonly associated with severe dysplasia. Polyps with
villous histopathological variant were associated with severe dysplasia.
100
Demographic, etiological and histopathological profile of ileo-colonic
ulcers from a tertiary care centre in North India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Arpan Jain, Anurag Mishra, Manish Kumar, Ujjwal Sonika, Ajay
Kumar, Siddharth Shrivastava, Sanjeev Sachdeva, Barjesh Chander
Sharma, Puja Sakhuja*, Ashok Dalal
Correspondence- Arpan Jain-drjain.arpan@gmail.com
Departments of Gastroenterology, and *Pathology, Govind Ballabh Pant
Institute of Postgraduate Medical Education and Research (GIPMER),1,
Jawaharlal Nehru Marg, 64 Khamba, Raj Ghat, New Delhi 110 002, India
Background Data on ileocolonic ulcers due to inflammatory bowel dis-
eases (IBD) is extensive. We retrospectively studied demographic profile
and etiology of non IBD related ileocolonic ulcers over 6 months in
patients undergoing colonoscopy for various reasons.
Methods All patients undergoing colonoscopy from July 2019 to
December 2019 and diagnosed as non IBD ulcers were included. The
demographic, clinical, radiological data was extracted from patient case
files. The endoscopic location of ulcers and their histopathological diag-
nosis were assessed. The data entry and analysis was done using SPSS
version 23.
Results A total of 101 patients of ileocolonic ulcers were included with
median age of 38 (range 6-75) yrs. There were 61 males and 40 females.
Abdominal pain (n=73) was the most common symptom followed by
diarrhea (n=33), bleeding PR (n=28) and fever (n=17). Drug intake his-
tory was present in (n=22) patients. Ileocecal thickening with lymphade-
nopathy on computed tomography was the common radiological finding
requiring colonoscopy. Cecum (n=29) was the most common location of
ulcers followed by ileum and rectum (n=25) each. Ulcers were present at
more than one location (n=13), with most common being combined
ileocecal involvement (n=4).
Histopathological examination revealed non-specific colitis/ileitis (n=60,
59.4%) as the most common cause followed by amebic as well as solitary
rectal ulcer syndrome (SRUS) (n=12, 11.9%) each. Tubercular ulcers
were present in 9 patients (8.8%). Infectious colitis and drug induced
ulcers in 5 and 1 patient (NSAID related) respectively. Benign appearing
ulcers were reported as malignant in 2 patients.
Conclusion Abdominal pain, diarrhea and bleeding PR were the common
symptoms. Most common non IBD related ileocolonic ulcers were non-
specific/idiopathic. Amebic and SRUS were the next common cause
followed by tuberculosis. In 2 cases we had benign appearing ulcers
which were histopathologically malignant.
101
Efficacy of hepatitis B vaccination in patients with ulcerative colitis:
A prospective cohort study
Anurag Mishra, Arpan Jain, Manish Tomar
Correspondence- Anurag Mishra-dr.anuragmishrakgmc@gmail.com
Department of Gastroenterology, Govind Ballabh Pant Institute of
Postgraduate Medical Education and Research (GIPMER),1, Jawaharlal
Nehru Marg, 64 Khamba, Raj Ghat, New Delhi 110 002, India
Introduction Response to vaccine in Patients with inflammatory bowel dis-
ease (IBD) seems to be considerably lower than in general population, prob-
ably because of nature of disease and immunosuppressive regimens used.
Aim Aim of this study was to evaluate the efficacy of hepatitis B (HBV)
vaccination in patients with ulcerative colitis (UC) vs. controls.
Method This is a prospective cohort study. One hundred IBD-UC cases and
100 healthy controls were taken. UC patients with no prior history of HBV
vaccination between 18 to 60 years of age were included. HBV vaccination
was given to all the cases and controls at 0/1/6 months. Anti-HBs titres were
done 4 weeks after 1st and 3rd dose vaccination. Adequate immune response
(AIR) was considered if anti-HBs titre was >10 IU/mL and effective immune
response (EIR) if anti-HBs titre was >100 IU/mL.
Result Total of 100 (59 male, 41 female) patients with IBD-UC and 100
(54 male, 46 female) healthy controls were included (p=0.47). Mean age
for cases and controls was 33 ± 11 and 36 ± 10 respectively (p<0.05). AIR
S33
was significantly lower in cases than in controls (82% vs. 96%, p=0.003).
EIR was also significantly lower in cases than in controls (41% vs. 66%,
p=0.0007). Sixty-four percent IBD patients were on immunosuppressive
therapy before vaccination. Among the IBD patients who were taking
immunosuppressant AIR was 72% and EIR was 23%. Among the IBD
patients who were not taking immunosuppressant AIR was 100% and
EIR was 72%.
Conclusion Response rate of IBD patients receiving HBV vaccinations
were significantly lower compared to controls. Response rate of those
receiving immunosuppressive therapy was also low.
102
Etiological spectrum of intestinal obstruction In North India in gas-
troenterology practice
Dilip Singh Mudgal, Shyam Sunder Sharma, Sudhir Maharshi, Bharat
Sapra, Mayank Ameta
Correspondence- Shyam Sunder Sharma-shyamsharma4@rediff.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L
N Marg, Jaipur 302 004, India
Background and Aims Dynamic intestinal obstruction is a common and
potentially dangerous surgical emergency with high morbidity and mortal-
ity. Early diagnosis and timely treatment in order to improve the chance of
survival are of paramount importance. Regional as well as worldwide var-
iations in the pattern of intestinal obstruction from time to time are well
documented. Periodic studies are needed to evaluate the etiological factors
for prevention. In India regarding regional changes in etiological spectrum
of acute intestinal obstruction the literature are not much. The aim of this
study was to study the clinical profile and to find out the underlying cause
of acute intestinal obstruction in patients under study .
Methods This prospective descriptive study of 224 patients, presenting with
dynamic acute intestinal obstruction was conducted in Department of
Gastroenterology, SMS Medical College and Hospitals, a tertiary care cen-
ter at Jaipur from August 2017 to July 2019. All patients with clinical and
radiological evidence of acute intestinal obstruction were included. Details
of individual patients regarding age, sex distribution, presentation duration,
symptomatology and workup related to etiology was carried out according
to proforma sheet and data analyzed statistically on SPSS version-22.
Results A total of 224 patients with dynamic acute intestinal obstruction
were admitted and treated conservatively for 48 hours, if patient not im-
proved or sign and symptoms progressed patients were further managed in
surgery department. Mean age of study population was 43.74 years and
male were 57.14% and female were 42.86%. Neoplasia was most common
cause (33.92%) with large intestinal colorectal cancer causing 28.64% of
intestinal obstruction (mean age- 54.58 years) followed by intestinal tuber-
culosis and benign stricture with nonspecific histology each with 20.54%.
Conclusion Colorectal cancer, tuberculosis and benign strictures with
nonspecific histology were the common cause of dynamic intestinal ob-
struction.
103
A retrospective single blinded study comparing efficacy of six months
versus nine months antitubercular treatment in intestinal tuberculo-
sis
Saiprasad Lad, Gaurav Kumar Singh, Pratik Sethiya, Mayur Gattani,
Kailash Kolhe, Shamshersingh Chauhan, Deepti Vishwanathan, Akash
Shukla*, Meghraj Ingle, Vikas Pandey
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Department of Gastroenterology, Lokmanya Tilak Municipal Medical
College and General Hospital, Sion, Mumbai 400 022, India, and
*
Department of Gastroenterology, Seth G S Medical College and KEM
Hospital, Mumbai 400 012, India
S34
Introduction The duration of treatment in intestinal tuberculosis, whether
six months or more than six months, remains a dilemma. We conducted this
study to assess efficacy of six months vs. nine months antitubercular treat-
ment (ATT).
Methods Retrospective, single blinded, single center study was done in
out patient department to evaluate efficacy of 6 months vs. 9 months of
daily administered directly observed ATT. One hundred patients with
intestinal tuberculosis who received ATT either for 6 months (n=55;
55%) or 9 months (n=45; 45%) were included and both pre-treatment
as well as post-treatment details of clinical features, radiologic evaluation,
endoscopic examination, histopathologic findings and special investiga-
tions like Gene Xpert and MGIT were noted. Patients from both the
groups were observed for adverse drug events (nausea, vomiting, abdom-
inal pain, ATT hepatotoxicity).
Results One hundred patients were included in study (mean age - 32.2 years,
females- 44; 44%). There was statistically significant difference between pre-
treatment tenderness (higher in 9 months group 6 [13.3%] vs. 0 [0%]) when
compared to 6 month group. Rest all the symptoms, signs and pre-treatment
investigation findings were similar in both the groups. There was no statisti-
cally significant difference between clinical response (53 [96.4%] vs. 45
[100%]; p=0.196), radiologic resolution (52 [94.5%] vs. 43 [95.6%];
p=0.818) and endoscopic healing (49 [89.1%] vs. 43 [95.6%]; p= 0.236), also
in adverse drug events like vomiting (22 [40%] vs. 21 [46.7%]; p=0.503),
abdominal pain (12 [21.8%] vs. 6 [13.3%]; p=0.272), hepatotoxicity (2 [3.6%]
vs. 2 [4.4%]; p=0.837) in 6 months and 9 months group respectively.
Conclusions For intestinal tuberculosis 6 months therapy is equally effi-
cacious as that of 9 months.
104
An interesting case of bilateral lower limbs swelling in a patient of
chronic diarrhea: A case report
Amit Agarwal, Amit Soni,
Correspondence- Amit Agarwal-amitbijnor2010@gmail.com
Department of Gastroenterology, MMIMSR, MMU Campus, Mullana
University Road, MMIMSR, Mullana 133 207, India
Patients with inflammatory bowel disease (IBD) are at an increased risk
for venous thromboembolism (VTE). VTE is a serious complication of
IBD that carry significant cost, morbidity and mortality. Certain risk
factors such as active disease, immobilization and drugs increases the
risk. Thromboembolism in IBD is either overlooked or delayed as pa-
tients new symptoms are attributed to their disease severity or side effects
of drugs. We present a case of 22 years old male patient presented in OPD
with complains of chronic diarrhea and bilateral lower limbs swelling and
breathlessness. On workup patient was diagnosed as a case of active
Crohn’s disease. Bilateral lower limb swelling is common in IBD patients
due to malnutrition (anemia and hypoalbuminemia), in our case it was
found to be due to extensive bilateral lower limb deep vein thrombosis
also and breathlessness was due to pulmonary embolism. Bilateral deep
vein thrombosis extending up to inferior vena cava (IVC) with pulmonary
embolism is a rare finding which was seen in our patient. Balloon angio-
plasty of IVC was done with placement of a self expandable stent and
IVC filter. In conclusion VTE has substantial morbidity and mortality and
when IBD patients presents with a new symptom complex thromboem-
bolic phemonenon needs to be considered.
105
Are all colonic thickening on CT worrisome - A tertiary care experi-
ence
Sourav Kr Chhajer, Vinod Kumar Dixit, Sunit K Shukla, Dawesh Yadav,
Anurag Tiwari
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221 005, India
Background and Aim Increasing use of abdomino-pelvic CT for various
indications has greatly increased the diagnosis of bowel wall thickenings.
We aim to find out the correlation between bowel thickening with subse-
quent colonoscopic and histopathological findings.
Methods Data of patients referred for colonoscopy on basis of Colonic
thickening on CT were collected retrospectively between January 2019
and April 2020 and their histopathology reports were traced. Patients
undergoing CT for known GI disease or known malignancy were
excluded.
Results A total of 320 patients were identified. Mean age of pa-
tients was 37.8 years (15-80) with male to female ratio of 0.7:1.
The most common location of thickening was ileocecal (62.5%,
n=200), followed by ascending colon (13%, n=42) and
rectosigmoid (10.9%, n=35). Colonoscopy was normal in 29%
cases. More than 75% patients under age group <40 yrs had
ileocecal thickening and 42% of them had normal colonoscopy.
The most common colonoscopic abnormality found was presence
of ulcers and erosions (n=82, 25.6%), followed by stricture (n=67,
20.9%) and growth (n=52, 16.25%). Other less common findings
included diverticulosis, telangiectasia, pseudomelanosis coli. Non-
specific colitis was most commonly reported in patients with ul-
cers (57.8%). Tuberculosis was diagnosed in 17.5% (n=56) mostly
in pts with strictures (63%). The diagnosis of IBD was made in
23 patients (7.18%). Malignancy was found in 16.56% patients.
Adenocarcinoma was most common (> 95%) followed by lym-
phoma, metastatic and NET in remainder Two patients had eosin-
ophilic colitis. The diagnosis of malignancy was significantly
more present in age group >40 yrs with only 5.3% cases less
than 40 yrs had malignancy, most common site in them being
rectosigmoid.
Conclusion Ileocecal thickening remain the most common reported site of
thickening in CT. However, a significant proportion of patients may have
normal colonoscopy and many have non-specific colitis on histopathol-
ogy especially in younger age group patients.
106
Fecal calprotectin levels in patients with diarrhea at the tertiary care
hospital of Uttarakhand
Swati Rajput, Rohit Gupta, Itish Patnaik, Prashant Chauhan, Satyavati
Rana
Correspondence- Satyavati Rana-svrana25@hotmail.com
Department of Biochemistry, All India Institute of Medical Sciences,
Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Aim To find out the incidence of raised fecal calprotectin levels in patients
with diarrhea at tertiary care hospital of Uttarakhand.
Methods For this study, 193 adult patients with diarrhea attending
Gastroenterology OPD at tertiary care hospital of Uttarakhand were en-
rolled. The study period was from July 2019 to February 2020. Levels of
fecal calprotectin were measured using ELISA method. Patients with
fecal Calprotectin levels >43 μg/g was suggestive of IBD and <43 μg/g
of IBS. On the basis of fecal calprotectin levels, percentage of IBD and
IBS patients was calculated.
Results Out of 193 adult patients with age range 18 to 85 years, 138
(71.5%) were males and 55 (28.5%) females. Mean + SD of age of these
patients was 34.89 + 15.69 years while of males 34.08 + 14.45 years and
of females 36.9 + 18.44 years. 124 out of 193 (64.2%) patients had fecal
calprotectin levels <43 μg/g suggestive of IBS and 69 out of 193 (35.8%)
patients had fecal calprotectin levels >43 μg/g suggestive of IBD. Out of
69 patients, 53 had fecal calprotectin levels between 43-500 with Mean +
SD of 138.73 +105.48 μg/g, 8 between 500-1000 with Mean + SD of
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
769.38 + 187.36 μg/g and 8 between 1000- 2000 with Mean + SD of
1600.67 + 268.36 μg/g.
Conclusion 64.2% patients had fecal calprotectin levels <43 μg/g sugges-
tive of IBS and 35.8% patients had fecal calprotectin levels >43 μg/g
suggestive of IBD at tertiary care hospital of Uttarakhand during a period
of 8 months.
107
An unusual cause for sudden massive hematochezia in ICU-A case
report
Manmohan U S, Arun R S, Prashanth B Gandhi
Correspondence- Manmohan U S-manmohanus@gmail.com
Department of Medical Gastroenterology, Madras Medical Mission
Hospital, 4A, Dr, CLRI Staff Quarters, Mogappair, Chennai 600 037,
India
Introduction The incidence of gastrointestinal bleed varies from 15% to
50% in the first 24 hrs of ICU stay. Severe painless hematochezia results
from foregut source in 15% of non-cirrhotics. The common colonic
causes of severe hematochezia are diverticulosis, hemorrhoids, ischemic
colitis, colon cancers and rectal ulcers.
Case presentation We reported a 64-year-old female who is known case
of diabetes and hypertension, underwent emergency cardiac bypass sur-
gery for coronary artery disease with ventricular tachycardia (VT). She
had on table VT with cardiogenic shock and was revived. On 7th post OP
day, she developed fresh bleeding per rectum with significant drop in
hemoglobin. On examination she was anemic and mild left iliac region
tenderness. Initially upper GI scopy done which showed clean based
duodenal ulcer. But as she continued to bleed and was on inotropic sup-
port, bedside colonoscopy was done which revealed large irregular ulcer
~3 cm overlaid with exudates in rectum and multiple clean based ulcers in
cecum. The distribution was unlikely to be ischemic in origin.
Histopathological examination of colonic ulcers biopsies revealed inva-
sive intestinal mucormycosis. Patient showed full clinical resolution after
course of parenteral Amphotericin B followed by oral posaconazole. She
had an uneventful recovery and on follow-up after 2 months, she was in
good health. Mucormycosis is life threatening opportunistic invasive fun-
gal infection caused by mucorales of class Zygomycetes. It’s commonly
seen in immunosuppressed cases like diabetes, organ transplantation,
Human immunodeficiency virus infection and those on immunosuppres-
sive medications. Gastrointestinal mucormycosis has high mortality rate.
Conclusion Invasive Intestinal Mucormycosis is a rare cause of hematochezia
in immunocompromised individuals. Timely diagnosis and treatment with
antifungals plays a major role in reducing mortality. A good histopathological
examination including IHC markers (if needed) for all colonic ulcers and to
have high index of suspicion plays a crucial role for diagnosis
108
Clinical profile and outcome of patients presenting with acute flare of
ulcerative colitis: A tertiary care experience
Sourav Kr Chhajer, Vinod Kumar Dixit, Sunit K Shukla, Dawesh Yadav,
Anurag Tiwari, Piyush Thakur
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221 005, India
Introduction Acute flare of ulcerative colitis is a life-threatening condition
carrying high morbidity and mortality. We aim to find out the profile of
patients presenting with ASUC and assess response to treatment.
Methods A prospective study was conducted between January 2019 and
May 2020. All patients admitted with acute flare of ulcerative colitis as
defined by the truelove and Witts criteria were included in our study.
S35
Patients were investigated and treated according to standard guidelines
and were followed for 4 weeks.
Results A total of 66 patients were evaluated. Baseline characteristics are
listed in Table1. The average duration of disease was 4.6 years (2 months
-18 yrs). Fifteen patients (22.7%) had recent onset disease symptoms with
mean duration of 2.5±0.4 months. The most common cause of flare was
treatment default in 30.3% (n=20) followed by Cl. difficle infection
(15.15%, n=10) and CMV infection in 10.6% (n=7). Two patients had
recent h/o NSAID intake and one patient had amoebiasis. In remaining
cases no obvious cause was identified. About 50 patients (75.7%)
achieved clinical remission with IV steroids. In remaining 16 patients
rescue therapy was initiated of which 12 patients (75%) responded.
Three patients required surgery and there was one mortality. Rescue
therapy was needed more frequently in patients who had E3 disease,
became steroid dependant early in their disease course with no obvious
cause of flare (60%). Albumin < 2.4 g/dL and CRP level >77 mg/dL at
D3 of steroids had significant association with steroid non responsiveness
(p<0.05).
Conclusion The most common cause of flare in our cohort of patients was
treatment default followed by Clostridium difficle infection. Low albu-
min and high CRP at day 3 along with prior steroid dependence had
significant association with failure to steroid response.
Table 1
Age (yrs) 30.8 (15-54)
Male:Female 1.3:1
Hemoglobin (g/dL) 8.2±1.8
Albumin 2.8±0.8
CRP (mg/dL) 68±26
CMS 7 (5-9)
UCEIS 6 (5-8)
109
Clinical response to anti tubercular therapy given as a diagnostic
strategy does not affect long-term outcomes in patients with
Crohn’s disease
Srikant Mohta, V Pratap Mouli, Akshita Gupta, Kalaivani Mani*,
Saurabh Kedia, Govind Makharia, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Departments of Gastroenterology and Human Nutrition, and
*
Biostatistics, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India
Introduction Intestinal tuberculosis and Crohn’s disease (CD) are
often indistinguishable even with imaging and endoscopy. To
tackle the dilemma, a therapeutic trial of antitubercular therapy
(ATT) is often given to which patients show variable response.
ATT has been shown to modify the disease course in CD espe-
cially in the long-term.
Methods We conducted a retrospective study to compare long-term
course and outcomes among CD patients who received a trial with ATT
based on the symptomatic response to ATT.
Results 29.1% (n=221) of the 760 patients received ATT and clinical
response was seen in 42.8%. The baseline disease characters were similar
in both groups. The median duration of ATT trial (9 [IQR=6-12] vs. 6 [6-
9] months; p=<0.01) and median time to make a diagnosis of CD after
starting ATT (15 [9-30] months vs. 10 [6-14] months, p<0.01]) were
longer in the ATT responders group. More non responders were given
steroids (93.7% vs. 72.9%, p<0.01) but long-term outcomes including
disease behavior, extent, need for immunomodulators, biological or
S36
surgery did not differ among both groups. No baseline parameter could
predict response to ATT.
Conclusion Symptomatic response to a therapeutic ATT trial in CD
patients did not affect long-term clinical course and it should not
affect long-term treatment strategy. Reassessment by endoscopy
and/or imaging for mucosal response should be early in indeter-
minate cases.
110
Systematic review and network meta-analysis: Comparative efficacy
and safety of faecal microbial transplantation and targeted therapies
for induction in active ulcerative colitis
Sudheer K. Vuyyuru, Saurabh Kedia, Mani Kalaivani, Pabitra Sahu,
Bhaskar Kante, Peeyush Kumar, Mukesh Kumar Ranjan, Govind
Makharia, Ashwin Ananthakrishnan*, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and
*
Massachusetts General Hospital and Harvard Medical School, Boston,
Massachusetts, USA
Background/Aims To compare the efficacy and safety of FMT with
targeted therapies for induction of remission in active UC.
Methods We analyzed data from randomized controlled trials (RCTs)
evaluating induction of remission in adults with UC treated with anti-
TNF (infliximab and adalimumab), anti-integrin (vedolizumab), anti-
IL23 (ustekinumab), Janus kinase (JAK) inhibitors (tofacitinib), and
FMT, compared with placebo or another active agent.
Results Overall nineteen studies were included, among which there was
only one head to head RCT (adalimumab vs. vedolizumab). All interven-
tions including FMT were superior to placebo in inducing clinical remis-
sion (except adalimumab-OR 1.66; 95%CI, 0.97-2.85), clinical response
and endoscopic remission. FMT was comparable with other agents for all
efficacy outcomes including clinical remission and response, and endo-
scopic remission. Infliximab was ranked highest in inducing clinical re-
mission (SUCRA, 0.8), vedolizumab in clinical response (SUCRA, 0.9)
and tofacitinib in endoscopic remission (SUCRA, 0.9). There was no
difference in safety outcomes between FMT and other targeted therapies,
among which ustekinumab ranked the safest.
Conclusions FMT is effective than placebo in inducing remission and
appears to be as effective and safe as targeted therapies in inducing re-
mission in patients with active ulcerative colitis. Further studies needed
for definitive conclusion and the cost effectiveness of FMT with targeted
therapies needs to be analyzed.
111
Utility of noninvasive markers in predicting mucosal healing in ul-
cerative colitis - A longitudnal follow-up study
Deepak C, Senthamizh Selvan, Pazhanivel Mohan, Abdoul Hamide
Correspondence- Deepak C-drdeepakcjipmer@gmail.com
Department of Medical Gastroenterology, Jawaharlal Institute of
Postgraduate Medical Education and Research, Dhanvantri Nagar,
Gorimedu, JIPMER Campus, Puducherry 605 006, India
Introduction ‘Treat to target approach’ is the current approach to man-
agement of ulcerative colitis (UC). Mucosal healing and histological re-
mission are the targets associated with better long-term outcome but their
assessment requires invasive tests. Hence, this study was conducted to
determine the utility of noninvasive biomarkers in predicting mucosal
healing in UC.
Methods It was a longitudinal follow-up study conducted on newly diag-
nosed acute UC or a relapse of pre-existing UC between September 2018 and
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
February 2020. The disease activity was assessed using clinical, Mayo endo-
scopic sub-score (MES) and histological scores at baseline and at remission.
Biomarkers such as ESR, CRP, fecal calprotectin, serum NGAL and 24-hour
urinary potassium were estimated at baseline and at clinical remission. The
correlation of biomarkers with mucosal healing (MES of 0 or 1) was analyzed
using Chi-square or Fisher’s exact test.
Results During the study period, 40 patients were recruited with a total of
43 episodes of flare. The mean age (SD) of study population was 35 (10)
years. At baseline, majority had moderate or severe disease activity by
clinical score (88%) as well as by MES (93%). At clinical remission, there
was a significant reduction in fecal calprotectin (p=0.036), serum NGAL
(p=0.002), ESR (p= < 0.001), and CRP (p= 0.002) and a significant
increase in 24-hour urinary potassium (p=0.001) from baseline. The
change in levels of all the biomarkers were also significantly associated
with mucosal healing at clinical remission. Fecal calprotectin was the
only biomarker that significantly correlated with mucosal healing
(p=0.03). Delta calprotectin with cut off of 77μg/g had a significant
AUC (0.738) for predicting mucosal healing with a sensitivity of 0.77
and specificity of 0.72.
Conclusion Our study confirmed that changes in the level of biomarkers
after treatment could predict remission in UC. Fecal calprotectin correlat-
ed well with mucosal healing.
112
A rare case of gastrointestinal polyposis, where steroids work
Hemant Nayak, Sunil Jee Bhat, Manas Kumar Panigrahi, Subash
Chandra Samal
Correspondence- Hemant Nayak-drhemantnayak@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Cronkhite-Canada syndrome (CCS) is a rare cause of
gastrointestinal (GI) polyposis syndrome presenting with protein
losing enteropathy and diarrhea. Here we report one such case.
Case presentation A 42-year-old female presented with abdominal
pain, vomiting, frequent loose watery stools for the last six months
and generalized body swelling, excessive fatigue, and decreased
appetite for one month. She also noticed increasing hair fall, de-
creased taste sensation, nail changes and patchy skin darkening all
over the body. Physical examination revealed anasarca, frontal alo-
pecia, finger and toenails dystrophy, and diffuse hyperpigmentation
of the skin. Laboratory investigations showed anemia with hemo-
globin 9.5 g/dL (12-14 g/dL), hypoproteinemia with serum protein
3.4 g/dL (6–8 g/dL), hypoalbuminemia with serum albumin 1.2 g/
dL (3.5 - 4.5 g/dL) and hypokalemia with serum potassium 2.8 mg/
dL (3.5-4.5 mg/dL). Ultrasound revealed mild ascites and mild bi-
lateral pleural effusion. Esophagogastroduodenoscopy showed nu-
merous nodular and polypoid lesions in stomach, first and second
part of duodenum. Ileocolonoscopy also revealed numerous polyps
throughout the colon and terminal ileum. Segmental biopsies from
stomach, duodenum, ileum and colon were taken. Evaluating her for
protein losing enteropathy, the characteristic ectodermal and endo-
scopic findings made us to think of a rare GI polyposis syndrome
known as CCS. Our diagnosis was further confirmed on histopathol-
ogy of GI polyps which revealed hamartomatous polyps with inter-
vening mucosal biopsies remarkable for marked edema, mild
lymphoplasmacytic infiltrates, and cystically dilated glands with in-
spissated mucin. She showed dramatic response to steroids (predni-
sone 40 mg daily for 1 month) followed by tapering over 2 months
with overlap of azathioprine 50 mg. She is asymptomatic for last 18
months on azathioprine 50 mg.
Conclusions To the best of our knowledge, CCS is the only gastrointes-
tinal polyposis syndrome which responds to steroids.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
113
A case of noacardia empyema in Crohn’s disease on Adalimumab:
Suspect unexpected opportunistic infection on immunosuppression
Chandan Kumar5, Hemant Nayak2, Manas Kumar Panigrahi3, Subash
Chandra Samal4, Srujana Mohanty1
Correspondence- Hemant Nayak-drhemantnayak@gmail.com
Departments of Microbiology, and Gastroenterology, All India Institute
of Medical Sciences, AIIMS Road, Sijua, Patrapada, Bhubaneswar 751
019, India
Introduction Nocardia is an emerging infection in the era of bio-
logical therapy with a fatal outcome without treatment. Risk of
dissemination and multisystem involvement demands an early di-
agnosis from the treating physician. To the best of our knowl-
edge, nine cases have been described in immunosuppressed in-
flammatory bowel disease (IBD).
Case Description We are sharing our experience with such opportunistic
infection (pulmonary nocardiosis) in a 23-year-old male with Crohn’s
disease on Inj. Adalimumab. He received anti tubercular therapy for six
months without improvement before presenting to our center. For ileo-
colonic Crohn’s disease, he initially received prednisolone (60 mg/day)
and azathioprine (100 mg) for symptoms control. During tapering of
steroid, relapse of the disease occurred so injection Adalimumab was
initiated. There was overlapping period of two weeks when he was on
inj. Adalimumab, steroid and azathioprine. After receiving two doses of
inj. Adalimumab (160 mg, 80 mg), he again presented with fever for 2
days with dry cough. CECT revealed multiple loculated pleural space
collections with well-defined abscess formation along mediastinal pleura
in 9, 10 and 11th intercostal spaces invading muscles. Pleural fluid aspi-
ration was purulent in infra-axillary pocket. Gram staining suggested
bacilli with filamentous elements and on modified acid-fast staining
branching bacilli were seen. MRI brain was normal.
Management Patient was managed with Inj. Meropenem and Inj
Linezolid followed by Tab. Cotrimoxazole for 6 months. Inj.
Adalimumab was reinitiated as he developed perianal disease with con-
tinued Cotrimoxazole prophylaxis without recurrence.
Conclusion Human nocardiosis is a rare opportunistic bacterial infection.
The optimum duration of antibiotic therapy is uncertain but 1-year ther-
apy seems to be advisable. The safety and timing of re-initiation of bio-
logical therapy remains unsettled.
114
Study of profile of hepatic disorders in patients with inflammatory
bowel disease: Our experience in tertiary care hospital
Vinod Kumar Dixit, Indresh Dixit, Sunit Kumar Shukla, Dawesh Yadav
Correspondence- Vinod Kumar Dixit-drindreshdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Aurobindo Colony, Banaras Hindu University
Campus, Varanasi 221 005, India
Background Ulcerative colitis (UC) and Crohn’s disease (CD) are inflam-
matory bowel diseases (IBD) that have different clinical presentations and
are responsible for chronic idiopathic inflammation of the intestine.
Several extraintestinal manifestations may be associated with IBD, and
the disease may have a profound impact on patients’ quality of life.
Hepatobiliary extraintestinal manifestations are sometimes
underdiagnosed in IBD patients, and their presence may impair the pa-
tients’ prognosis.
Aim Our study is to evaluate the prevalence of hepatobiliary extraintesti-
nal manifestations of IBD and to compare frequency of different
hepatobiliary extraintestinal manifestations in ulcerative colitis and
Crohn disease.
S37
Methods It is a Cross-sectional study in our hospital, with interviews and
review of medical charts between 1 January 2019 and 31 December 2019.
Results We interviewed 198 patients, out of which 140 (70.7%) had UC
and 58 (29.3%) had Crohn's disease. Proportion of females is 64.6% and
males were 35.4%. Hepatobiliary manifestations were observed in 40
(20.2%) patients with IBD of which 27(19.3%) were UC patients.
Among 27 UC patients, the hepatobiliary disorders identified were 15
(10.7%) non-alcoholic fatty liver disease, 8 (5.7%) cholelithiasis, 1
(0.7%) primary sclerosing cholangitis (PSC), 1 (0.7%) hepatotoxicity
associated with azathioprine, 1 (0.7%) hepatitis B, and 1 (0.7%) hepatic
fibrosis. Thirteen (22.4%) out of 40 patients having hepatobiliary mani-
festations had Crohn's disease of which 4 (6.9%) had cholelithiasis, 4
(6.9%) non-alcoholic fatty liver disease,1 (1.7%) hepatotoxicity, 1
(1.7%) hepatitis B, (1.7%) hepatitis C, 1 (1.7%) alcoholic liver disease,
and 1 (1.7%) autoimmune hepatitis (AIH).
Conclusion Hepatobiliary disorders are frequent extraintestinal
manifestations of IBD and abnormal liver biochemical tests are
present in significantly high proportion of patients with IBD.
They are varied and range from limited mild diseases to serious
progressive life-threatening diseases. Therefore, patients with IBD
should be periodically monitored by liver function tests and a full
diagnostic workup is required when elevated liver enzymes are
found.
115
Identification of colorectal carcinoma in symptomatic young adult: A
preliminary study from tertiary care centre in south India
Sai Harish, Ganesh P, Shanmuganathan Subramanyam, Anand T K,
Kaushik A K
Correspondence- Sai Harish-harishreddy87@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Medical
College, Chennai 600 116, India
Introduction Sporadic colorectal cancer is traditionally diagnosed
after the sixth decade of life, and current recommendations for
surveillance include only patients older than 50 years. Increasing
incidence of colorectal cancer in young adults has been reported.
This study looks into the epidemiology of colorectal cancer in
population under screening age group.
Aims To study the age, gender, site of primary tumor, histopathological
type of colorectal cancer with special reference to adults 45 years or
younger.
Study design Retrospective observational Study conducted at
Department of MGE, Chennai between January 2017 and
February 2020.
Methods The study retrospectively analyzed the case records of all cases
of colorectal cancer diagnosed between January 2017 and February 2020.
The records were analyzed in detail for age, gender, site of primary tumor
and histopathological type and presence of metastasis.
Results A total of 241 cases were studied. 58.9% of the patients
were males and 41.1% were females. Significant 26.1% cases
were reported in young adults less than 45 yrs. 71.4% of patients
had bleeding PR as primary complaint in age group <45 yrs.,
85% patients had left sided lesion and rectum as the most com-
mon site of primary lesion in age group <45 yrs, adenocarcinoma
was most common accounting for 95.4%, 79% presented in ad-
vance stage in age group < 45 yrs.
Conclusions An increased incidence of colorectal carcinoma was
seen amongst younger individuals in our study group. It is possi-
ble that CRC in our study is of a different phenotype as com-
pared to the West. Moreover, in light of a significant number of
young patients presenting with advanced CRC in our study, it is
advisable to recommend for an early screening protocol for CRC
in our population.
S38
116
Objective assessment of the rectal effluent before colonoscopy gives
fairly good idea about the quality of bowel preparation
Ajay Patwa, Sandeep Verma*, Guddoo Kumar, Virendra Atam
Correspondence- Ajay Patwa-drajaymd12345@gmail.com
Departments of Medicine, and * Surgery, King George Medical
University, Shah Mina Road, Chowk, Lucknow 226 003, India
Multiple factors including color and consistency of the rectal effluent
determine the quality of bowel preparation during colonoscopy. Patients
verbal statement regarding color and consistency of the rectal effluent
always does not give the idea of real picture. Our aim was to correlate
the objective assessment of the color and consistency of rectal effluent
with the quality of bowel preparation along with other factors such as
preprocedural diagnosis, comorbid illnesses, amount of bowel preparato-
ry agent consumed and runway time. 10 mL of the last rectal effluent was
collected in plastic specican for visual inspection and grading for the color
and consistency. Ottawa bowel preparation scale was used to assess the
adequacy of bowel preparation. A pilot study involving 11 patients
showed that objective assessment of color and consistency of the rectal
effluent were good predictors of bowel preparation. This observation may
help in improving the quality of bowel preparation and avoid hustle in
colonoscopy room.
117
An unusual etiology of a left colon “tumor”
Rahul Deotale, Deepakkumar Gupta, Amey Sonavane, Aabha Nagral,
Shankar Bhanushali
Correspondence- Rahul Deotale-rahuldeotale23@gmail.com
Department of Gastroenterology, Apollo Hospitals, Plot # 13, Parsik Hill
Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Ameboma is a tumor-like mass involving whole thickness of the bowel
wall and a rare manifestation of intestinal amoebiasis. We report an
ameboma of left colon masquerading as an intra-abdominal mass.
A 72-year-old man presented with loose motions a month prior to presen-
tation: 2-3 episodes/day, not associated with blood per rectum and lasted for
7 days, followed by fever with chills, breathlessness and pain in epigastric
and left hypochondriac region. Physical examination of the abdomen re-
vealed a 10 x 6 cm firm, tender, immobile lump in the left upper quadrant.
Blood investigations showed Hb 9.4 g/dL, WBC of 29,450/μL, N 88%,
platelet count of 551 x 103/μL. CECT of the abdomen showed circumfer-
ential wall thickening causing moderate luminal narrowing of colon (12-
13 cm length) near splenic flexure with no leakage of contrast and no
evidence of proximal dilatation, few subcentimetric sized enhancing lymph
nodes in paracolic region. A possibility of neoplastic etiology was raised.
Colonoscopy showed ulceroproliferative lumen occluding lesion suspi-
cious of malignancy. Histopathology of the biopsy from the involved area
revealed necrotic mass, fibrinous and granulation tissue. The patient was
treated with left hemicolectomy with ileostomy and parenteral metronida-
zole. Colonic specimen showed necrotic mass, fibrinous and granulation
tissue with multiple trophozoites of Entamoeba histolytica with small ec-
centric nucleus and cytoplasmic vacuole containing red blood cells. Patient
is well on follow- up for 7 months.
Amebomas are most commonly found in cecum and ascending colon. They
are usually solitary with variable size and may measure up to 15 cm in
diameter. Men, between 20 and 60 years of age, are most commonly affected.
The exact incidence of ameboma is unknown with only isolated case reports.
Conclusion “Ameboma” should be considered in the differential diagno-
sis of colonic tumors presenting with fever and diarrhea, especially in
countries with high prevalence of amebiasis.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
118
Correlation of fecal calprotectin level with disease activity in active
idiopathic inflammatory bowel disease
Smitkumar Vaghasia, Sudeep Khanna, Milan Kumar Vaghasia*
Correspondence- Smitkumar Vaghasia-vaghasiasmit@gmail.com
Departments of Gastroenterology and *General Surgery, Indraprastha
Apollo Hospital, Mathura Road, New Delhi 110 076, India
Introduction Inflammatory bowel disease (IBD) is caused by immune
dysregulation of the digestive tract that results in chronic inflammation.
Ulcerative colitis and Crohn’s disease are the two major forms of idio-
pathic IBD. Endoscopy (and histology) remains the gold standard method
for detecting and assessing bowel inflammation. Nevertheless, it has the
disadvantage of being invasive, time consuming and not well tolerated by
patients. Within the last years various laboratory markers have been in-
vestigated in search to provide non-invasive, cheap and rapid methods
able to help in assessment of IBD activity. The most widely used labora-
tory parameters of inflammation, such as ESR and CRP resulted not
sufficiently specific or sensitive and poorly correlated with symptoms
and disease activity index. On the other hand, a series of studies indicate
fecal calprotectin as the most useful marker able to quantify bowel acute
inflammation. We propose to undertake a study to find out the correlation
of fecal calprotectin levels with clinical, endoscopic and histological in-
dices currently in use to classify the severity of IBD.
Methods Total number of 60 patients with IBD were studied to find out
correlation of fecal calprotectin levels with endoscopic index, clinical
index, histological index currently in use to classify the severity of IBD.
Results Among total number of 60 patients of IBD 40 patients were of UC
(57.5% patients were male) and 20 patients were of CD (65% patients
were male).
Conclusions Fecal calprotectin levels correlate well with disease activity
scores in ulcerative colitis and Crohn’s disease.
119
Misdiagnosed case of anal canal malignant melanoma: A case report
Nikhileswar Yandamuri, Ramesh Kumar B, Ramanna M
Correspondence- Nikhileswar Yandamuri-itsnikhil.rio@gmail.com
Department of Medical Gastroenterology, Osmania Medical College and
General Hospital, 5-1-876, Turrebaz Khan Road, Troop Bazaar, Koti,
Hyderabad 500 095, India
Introduction Anorectal malignant melanoma (ARMM) is an uncommon
and aggressive disease. It accounts for only 0.4% to 1.6% of all melano-
mas and less than 1% of anal canal tumors. They tend to occur more often
in women than men with peak incidence in the sixth and seventh decade.
We report a much rarer scenario of a young male presenting with bleeding
per rectum treated as hemorrhoids found to have anal melanoma on fur-
ther evaluation.
Case report A 32-year-old male patient presented with blood in stools
and anal mass of one month duration. DRE -mass protruding from anus.
Colonoscopy revealed polypoidal lesion in the anal canal just above the
dentate line suggestive of hemorrhoid for which he underwent
hemorrhoidectomy. The specimen sent for HPE revealed nests of
epitheloid and spindle like cells with brisk mitosis -10% of cells showing
melanin pigmentation. IHC with HMB45 and S100 found to be positive
diagnostic of ARMM. MRI revealed circumferential wall thickening in
anal canal with no evidence of nodal spread (AJCC stage 1). He further
underwent Wide local excision and under follow-up.
Discussion Anorectum is the third most common location of ma-
lignant melanoma after skin and retina. The common initial symp-
toms are bleeding PR, anal mass, tenesmus, change in the bowel
habits. ARMM most often misdiagnosed as hemorrhoids, polyp or
adenocarcinoma. Confirmed by IHC panels S-100, Melan A,
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
HMB-45. It is staged as stage I (local disease), stage II (local
disease with regional lymph nodes), stage III (with distant metas-
tasis) by CT, MRI, PET. Surgical approaches include Wide local
excision and abdomino perineal resection.
Conclusion Anorectal malignant melanoma though uncommon and de-
scribed in elderly females, this case report suggests it can present in young
males. Due to its polypoid appearance and lack of obvious pigmentation
in majority of cases misdiagnosed as hemorrhoids/polyps. High index of
suspicion is warranted in this innocuous looking lesion as it is an aggres-
sive neoplasm with local invasion and distant metastasis.
Keywords Anorectal malignant melanoma, Misdiagnosed hemorrhoids,
HMB45, S100.
120
Surgical technique to prevent redundancy after colon interposition
for corrosive stricture of the esophagus
Vasur Ladumor, Praveen Sharma, Mukesh Pancholi, Rajan Jagad*
Correspondence- Vasur Ladumor-vasurladumor@gmail.com
Department of General Surgery, Government Medical Collage and New
Civil Hospital, Opp. Income Tax Department Office, Majura Gate, Surat
395 001, India and * Synergy Hospital, Synergy Circle, Near
Gokulmathura Apartment, Ayodhya Chowk, BRTS Stand, 150 Feet
Ring Road, Rajkot 360 005, India
Background In 1911, Vuillet and Kelling independently described the
anatomical and surgical bases for the use of the colon for esophageal
replacement and currently retrosternal coloplasty is the gold standard
for post corrosive esophageal replacement. An important complication,
in particular in later follow-up, is redundancy of the interposed colon,
seen more after retrosternal interposition. The objective of this study is
to share our experience of colon interposition for corrosive stricture of the
esophagus in 150 patients within duration of 09 years and use of two-
point fixation technique in 25 patients to prevent redundancy of colon
conduit.
Methods This was a retrospective study of colon interposition for corro-
sive stricture of esophagus in 150 patients from March 2011 to
March 2020.
Results There were 112 female and 38 male (3:1) patients; the mean age
was 30.6 years (ranges from 21 to 47 years); 130 patients had suicidal and
20 patients had accidental ingestion; mean hospital stay was 14.5 days
(range 10 to 25 days) and mean operative duration was 4.5 hours (range
2.5 to 7 hours). In our study, out of 150 patients with 10 deaths and 01
patient lost in follow-up, more than 80% patients (n=114) had ‘good’
result, 09 patients had ‘fair’ and 01 patient had ‘poor’ result. After using
two-point fixation technique in 25 patients, we did not encounter any
subjective or objective (barium swallow) evidence of redundancy in
any patients during follow-up period of 2.5 years.
Conclusion Colon redundancy is the most common late morbidity and
second most common complication that required surgical correction with
inherent morbidity and mortality of revision surgeries. Our two-point
fixation technique is refinement of already performed and tried fixation
techniques to prevent redundancy of colon conduit considering kinetics,
anatomical alignment and pathology.
Keywords Redundancy, Colon interposition, Corrosive stricture, Two-
point fixation technique
121
Uncommon presentation of a common disease
Ramya Mamidipalli, Arun R S, Prashanth Gandhi
Correspondence- Ramya Mamidipalli-RAMYA.MAMIDIPALLI27
@GMAIL.COM
S39
Department of Gastroenterology and Liver Diseases, Madras medical
mission Hospital, 4A, Dr, CLRI Staff Quarters, Mogappair, Chennai
600 037, India
Introduction Enteric fever is a systemic infection caused by gram nega-
tive bacillus salmonella typhi or paratyphi. It’s a feco-orally transmissible
disease endemic in southeast Asia. The most serious complications are
intestinal ulceration, bleeding and perforation seen in 3rd week. We re-
port a rare case of typhoid fever with atypical distribution of ulcers on
colonoscopy.
Case report A 52-year-old man presented to us with high grade fever and
loose stools since 10 days. On admission he was febrile and had relative
bradycardia. Abdominal examination revealed mild periumbilical tender-
ness. Routine blood investigations showed a leukocytosis (11,900 cells/
cumm) with lymphopenia (12.5%), elevated alanine transaminase (79 IU/
L) and C-reactive protein (62.5 mg/L). Colonoscopy revealed variable
sized ulcers with punched out margins throughout the colon including
rectum and an ulcer with everted erythematous margins noted in terminal
ileum extending up to ileocecal valve raising the possibility of Crohn’s
disease or intestinal tuberculosis. TB PCR was negative. Histological
examination revealed features of active colitis with cryptitis and crypt
abscess suggestive of infective etiology. Blood and stool cultures re-
vealed growth of Salmonella typhi. He became asymptomatic after treat-
ment with IV ceftriaxone 2 grams for 10 days and Tab. azithromycin 1
gram for a week.
Discussion The classical colonoscopic findings in Typhoid are multiple
round and oval punched-out ulcers along the long axis of bowel with
elevated margins. The most common site for typhoid ulcers is the terminal
ileum (100%), followed by the ileocecal valve (57%), the ascending
colon (43%), and the transverse colon (29%) with sparing of left colon.
Our patient had involvement of left colon along with rectum.
Conclusion This case highlights the importance of considering Typhoid
fever as a differential for diffuse colonic ulcers.
Keywords Typhoid fever, Colonic ulcers, Rectum
122
Non-invasive assessment of cardiovascular risk using carotid intima-
media thickness in patients with inflammatory bowel disease: Does
non-alcoholic fatty liver disease add on to the risk?
Anju Krishna, Krishnadas Devadas, Nidhin R, Sandesh K
Correspondence- Nidhin R-nidhinraveendranputhoor@gmail.com
Department of Gastroenterology, Medical College, Ulloor - Akkulam
Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction We compared the carotid intima-media thickness test
(CIMT) of patients with IBD and controls without IBD to know the
association between subclinical atherosclerosis in IBD and the cardiovas-
cular risk. We also looked at whether NAFLD is an important factor
affecting CIMT in IBD.
Methods Descriptive study on 80 patients with IBD and 80 sub-
jects without IBD conducted in a tertiary care hospital. Subjects
aged more than 55-years, obese individuals, patients already diag-
nosed with cardio/cerebrovascular disease and those with other
chronic inflammatory conditions were excluded. CIMT was mea-
sured using B mode Doppler imaging. Presence of fatty liver and
shear wave elastography of the liver were assessed. The quantita-
tive data were compared using students t test and the qualitative
data by Chi-square test. Pearson and Spearman correlation was
done to find out the factors correlating with CIMT.
Results Age, sex distribution and traditional cardiovascular risks
(hypertension, diabetes and dyslipidemia) were comparable in
both groups. The CIMT was higher in patients with IBD as com-
pared to controls (0.532±0.091 vs. 0.476±0.038, p=000). On ana-
lyzing the factors affecting CIMT in patients with IBD, those
S40
with NAFLD as an extra intestinal manifestation had increased
CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP and
ultrasound grades of fatty liver had positive correlations with
CIMT. There was no change in CIMT with disease type (UC/
CD), extent of disease, disease activity or severity of disease.
Multivariate regression analysis showed that age and ultrasound
grading of fatty liver (R2=0.576, p=000) were independent pre-
dictors of CIMT.
Conclusion We found that CIMT was increased in patients with IBD as
compared to controls. Age and NAFLD were independently associated
with increased CIMT in IBD. Patients with IBD especially those with
NAFLD may require enhanced monitoring for cardiovascular events.
Keywords Inflammatory bowel disease; Ulcerative colitis; Crohn’s dis-
ease; Carotid intima media
123
Lower gastrointestinal bleed: Experience from a tertiary care hospi-
tal in coastal Odisha
Reshu Khandelwal, Haribhakti Seba Das, Chittaranjan Panda, Rakesh
Kumar Barik, Subhasis Pradhan, Saroj Kanta Sahu, Pankaj Bharali,
Mrinal Gogoi, Prajna Anirvan
Correspondence- Haribhakti Seba Das-reshu_rocks@yahoo.co.in
Department of Gastroenterology, Sriram Chandra Bhanj Medical College
and Hospital, Cuttack 753 007, India
Introduction Lower gastrointestinal bleeding (LGIB) is a frequently
encountered medical emergency with marked geographic variation
in the frequency of its different etiologies. Colonoscopy is con-
sidered as first-line diagnostic procedure for LGIB. We analyzed
the etiological spectrum of LGIB in coastal Odisha by
colonoscopic examination.
Methods Retrospective analysis of patients with overt LGIB pre-
senting to Gastroenterology Department of SCB Medical College,
Odisha from August 2017 to August 2020 and undergoing colo-
noscopy, was done. The data, including patient’s age, sex, etiol-
ogy of bleed and treatment given was recorded.
Results During the study period 1109 patients who had presented
with LGIB, underwent colonoscopy. Of these, colonic source of
bleed could be identified in 1040 (93.77%) patients. Patients were
sub-grouped according to their ages into paediatric (<18 yrs, n=79
[7.59%]), adult (18-60 yrs, n=767 [73.75%]) and elderly ([>60
yrs], n=194 [,18.65%]). Male preponderance was noted across
all age groups and overall M:F ratio was 1.4:1. The common
causes of LGIB in paediatric group were solitary pedunculated
polyps 38 (48.10%), inflammatory bowel disease 15 (18.98%)
and colonic TB 7 (8.86%). Other etiologies were hemorrhoids,
infective ulcers, sessile polyps, polyposis syndromes, SRUS and
colonic malignancy. However, in adults and elderly, colorectal
malignancy was the commonest etiology found in 224 (29.20%)
and 82 (42.2%) patients respectively. Other common etiologies in
the 2 groups were IBD seen in 154 (20.07%) and 23 (11.85%)
patients, hemorrhoids in 150 (19.55%) and 42 (21.64%) patients
and colonic TB in 32 (4.17%) and 5 (2.57%) patients respective-
ly. Etiologies like infective/non-specific ulcers, polyps and
polyposis syndromes, rectal varices, diverticulosis, rectal prolapse,
radiation proctitis, diversion colitis, SRUS, angioectasia and be-
nign strictures constituted less than 1/4th of the total cases.
Conclusion Although causes of LGIB in pediatric population in our study
match the data from the West, common causes seen in adults and elderly,
including colorectal malignancies, IBD and hemorrhoids, are in stark
contrast with causes, namely diverticulosis and angioectasia, that are
mentioned in Western literature.
Keywords Lower gastrointestinal bleeding
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
124
Efficacy of fecal microbiota transplantation for induction of remis-
sion in patients with active ulcerative colitis: Results from a series of
192 patients
Arshdeep Singh, Vandana Midha, Ramit Mahajan, Dharmatma Singh,
Kirandeep Kaur, Ajit Sood
Correspondence- Ajit Sood-ajitsood10@gmail.com
Departments of Gastroenterology,*Medicine, and **Pharmacology,
Dayanand Medical College and Hospital, Udham Singh Nagar, Civil
Lines, Ludhiana 141 001, India
Background Fecal microbiota transplantation (FMT) targeting gut
microbiome dysbiosis is an emerging therapy for ulcerative colitis
(UC). We report our experience with FMT used for induction of remis-
sion in 192 patients with active UC.
Methods This is a single-center retrospective analysis of patients with
active UC (total Mayo score≥3 and Mayo endoscopic sub-score of>1)
treated with FMT between September 2015 and December 2019 at
Dayanand Medical College and Hospital, India. Fecal samples from ran-
dom unrelated donors were administered through colonoscopy at weeks
0, 2, 6, 10, 14, 18, and 22. The primary outcome was achievement of
steroid-free clinical remission (Mayo score ≤2, with each sub-score ≤1) at
week 24. Secondary end points were clinical response (reduction of Mayo
score ≥30% and ≥3 points compared to baseline), and endoscopic remis-
sion (Mayo score 0 or 1).
Results During the study period, 192 adult patients (mean age 34.54
±11.68 years; 123 [64.06%] males) with active UC (mean mayo score
7.46±2.22) were treated with FMT. The main indications for FMT were
steroid dependent UC (n=121 [63.02%]) followed by chronic active and
acute severe UC (n=39 [20.31%] and 32 [16.66%] respectively). Majority
of the patients had moderately-severe disease. Ninety-six (50%) patients
completed 7 FMT sessions as per protocol. On intention to treat analysis,
steroid-free clinical remission was achieved in 94 (48.95%) patients
(mean FMT sessions needed to induce remission 4.08±1.69), whereas
clinical response and endoscopic remission were achieved in 135
(70.31%) and 95 (49.47%) patients, respectively (Table 1). The propor-
tion of patients in remission increased with number of FMT sessions (Fig.
1). Twenty-six (13.54%) patients dropped out (non-response, n=10; per-
sistent worsening of diarrhea, n=5; bleeding per rectum, n=4; perianal
pain, n=4 and fever, n=3). No serious adverse events were noted.
Conclusions Multisession FMT via colonoscopic route is a promising
therapeutic option for patients with active UC to induce clinical
remission.
Keywords: Ulcerative colitis, FMT, Fecal microbiota transplantation
125
Expression of NDRG4 in neurons of myenteric plexus of colonic
tissue of colorectal carcinoma patients
Esha Singh
Correspondence- Esha Singh-esha.singh.rmch@gmail.com
Department of Anatomy, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India
Introduction Colorectal cancer (CRC), the third major cause of mortality
among various cancer types in United States, has been increasing in
developing countries due to changing lifestyle and dietary habits.
Colorectal cancer is largely asymptomatic until alarming features develop
to advanced stages. The implementation of the screening program is very
much essential to reduce cancer incidence and mortality rates. N- Myc
downstream-regulated gene 4 (NDRG4) is a novel candidate tumor sup-
pressor and related to carcinogenesis.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Aim To study the NDRG4 protein expression in neurons of myenteric
plexus of colorectal tissues.
Methods Samples collected from 22 patients undergoing surgery for co-
lorectal adenocarcinoma in department of gastrointestinal surgery and 8
normal colon tissues from the department of forensic medicine, All India
Institute of Medical Sciences, New Delhi, after obtaining ethical clear-
ance. Tumor grading determined by pathologist and tissues were proc-
essed. Colonic tissues from the cancer site and normal specimens proc-
essed for paraffin blocks and 3μm thick sections used for H&E and
immunohistochemistry (antibody used anti-NDRG4 antibody).
Results H&E stained sections showed infiltration of tumor cells in sub-
mucosa, inner circular muscle and in vicinity of myenteric plexus.
Increase in the number of inflammatory cells in myenteric ganglia
appeared with increasing grades of colorectal adenocarcinoma.
Immunohistochemistry results showed the decreasing pattern of
expression of anti-NDRG4 antibody in neurons with increasing
grades of colorectal adenocarcinoma as compared to normal hu-
man colonic tissue.
Conclusion These results proved that NDRG4 could be a potential tumor
suppressor and prognostic marker for colorectal cancer.
Acknowledgement The work reported is part of postgraduate dissertation
in department of Anatomy, AIIMS, New Delhi
Conflict of interest No
Keywords Colorectal carcinoma, NDRG4, Neurons
126
Early fecal microbiota transplantation after donor stool defecation
predicts response for patients with active ulcerative colitis
Arshdeep Singh, Vandana Midha*, Ramit Mahajan, Dharmatma Singh,
Kirandeep Kaur**, Ajit Sood
Correspondence- Ajit Sood-ajitsood10@gmail.com
Departments of Gastroenterology,*Medicine, and **Pharmacology,
Dayanand Medical College and Hospital, Udham Singh Nagar, Civil
Lines, Ludhiana 141 001, India
Background Fecal microbiota transplantation (FMT) targeting gut
microbiome dysbiosis is an emerging therapy for ulcerative colitis
(UC). FMT infusions prepared from fresh or frozen (80 degree C) stool
have demonstrated comparable efficacy in recurrent Clostridium difficile
infection (rCDI). There is however no consensus on protocols for FMT in
UC.
Methods This is a single-center retrospective analysis of patients with
active UC (total Mayo score ≥3 and Mayo endoscopic sub-score of >1)
treated with FMT between January 2017 and December 2019 at
Dayanand Medical College and Hospital, India. Fresh fecal samples from
unrelated voluntary donors were administered through colonoscopy at
weeks 0, 2, 6, 10, 14, 18, and 22. Time interval between donor stool
defecation and FMT procedure (t) was recorded for each FMT session.
Impact of (t) on achievement of steroid-free clinical remission (Mayo
score ≤2, with each sub-score ≤1) and clinical response (Mayo score
declined by ≥3) was evaluated.
Results During the study period, 123 adult patients (mean age 33.74
±11.96 years; 77 [62.6%] males) with active UC (mean mayo score
7.17±2.03) were treated with FMT. Mean (t) was 2.29±0.75 hours (me-
dian 2.2 hours). With increase in (t), clinical remission and response rates
decreased (Fig.1). Sixty-five (52.84%) patients achieved clinical remis-
sion. Patients achieving clinical remission had shorter interval between
donor stool defecation and FMT procedure (2.18±0.76 hours) as com-
pared to patients not achieving clinical remission (2.50±0.74 hours;
p=0.02). On comparing patients who received FMT within 2 hours
(n=41) of donor stool defecation with those who received after an interval
of ≥2 hours (n=82), a greater proportion of patients were in clinical re-
mission in the former group (63.41% vs. 47.56%; p=0.09).
S41
Conclusions Early FMT after donor stool defecation favorably impacts
the clinical remission rates in patients with active UC. More data evalu-
ating the ‘ideal window period’ after donor stool defecation is needed.
Keywords Ulcerative colitis, Timing of FMT, Fecal microbiota transplan-
tation
127
Expression of nerve growth factor (NGF) in myenteric ganglia of
colorectal carcinoma tissues in human
Asha Gupta
Correspondence- Asha Gupta-gasha5207@gmail.com
Department of Anatomy, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India
Introduction Colorectal carcinoma (CRC) is one of the most com-
mon carcinoma of gastrointestinal tract in the. CRC develops
from the epithelium of the colon or rectum and are mainly ade-
nocarcinoma (≥ 90%). Nerve growth factor (NGF) is an essential
neurotropic factor for the survival and maintenance of neurons.
There is an important role for NGF in maintenance of gut integ-
rity. The role of NGF in cancer development and progression has
been reported in gastric mucosa and pancreatic cancers but in
colorectal cancer is unknown.
Aim To study expression of nerve growth factor (NGF) in myenteric
ganglia of the colorectal carcinoma in human.
Objectives To evaluate the expression of NGF in colorectal carcinoma
tissue by haematoxylin and Eosin (H & E) and immunohistochemistry by
anti-NGF antibody.
Methods Samples collected from 22 patients undergoing surgery
for colorectal adenocarcinoma in department of gastrointestinal
surgery, All India Institute of Medical Sciences, New Delhi.
Tumor grading determined by pathologist and tissues were proc-
essed. Sections processed for paraffin blocks and 3 μm thick
sections used for H&E and immunohistochemistry (antibody used
anti-NGF antibody: neuronal markar).
Results H&E stained sections showed myenteric plexus containing
myenteric ganglia (MG) located between the inner circular muscle
(CM) and outer longitudinal muscle (LM) layers of the muscularis
externa in all grades of adenocarcinoma tissue sections and invasion of
tumor cells and increase in the number of inflammatory cells in the
myenteric ganglion appeared to increase with different grades of colorec-
tal adenocarcinoma. Immunohistochemistry results showed the increase
expression of anti-NGF antibody with in poorly differentiated
adenocarcinoma.
Conclusion It is concluded that loss of neuron and neurodegeneration
takes place in colorectal adenocarcinoma which is of supreme importance
in understanding the problems of CRC patients who suffer from many GI
symptoms. Expression of NGF in myenteric ganglion in different grades
of adenocarcinoma.
Keywords NGF CRC
Liver
128
Hepatitis C treatment in the era of directly acting antivirals- An
encouraging scenario!
Mayank Jain
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre,
283-A, Gumasta Nagar, Scheme 71, Indore 452 009, India
S42
Introduction The availability of directly acting antivirals (DAA) has
revolutionised the management of hepatitis C in developing countries like
India.
Aim of the study To determine the spectrum of hepatitis C related liver
disease and response to treatment using generic DAAs.
Methods The study is a retrospective analysis of prospectively collected
data from a cohort of adult (>18 years) patients with hepatitis C infection.
Patients with hepatocellular carcinoma, co infections with hepatitis B,
HIV and those with incomplete data were excluded. The data analyzed
included the severity of liver disease, treatment offered and response
rates.
Results A total of 106 patients (84 males, median age 55 [22-80 years])
formed the study cohort. Eleven cases (10.4%) had received prior
treatment with interferon based regimens but did not attain SVR.
Twelve patients (11.3%) were on maintenance hemodialysis. Eight
cases (7.5%) were patients with thalassemia major on regular
blood transfusions. Genotype 3 (53.7%) and 1 (37.7%) were com-
monly noted. Sustained virological response was documented in
101 cases (95.3%)
Conclusion DAA drugs are highly effective in management of hepatitis C
infection across a wide spectrum of clinical presentations.
129
Acute HBV or chronic HBV with acute flare: Distinguishing clinical,
biochemical, immunonological and virological parameters
Ravi Kant Thakur, Sunit Kumar Shukla, Vinod Kumar Dixit, Dawesh
Prakash Yadav, Tuhin Mitra, Piyush Thakur
Correspondence- Sunit Kumar Shukla-sunitshuklabhu@gmail.com
Department of Medical Gastroenterology, Institute of Medical Sciences,
Banaras Hindu University, Varanasi 221 005, India
Introduction Acute HBV infection and chronic HBV infection pre-
senting as acute illness have differing prognosis. Differentiation
between acute viral hepatitis B (AVH-B) and chronic hepatitis B
with an acute exacerbation (CHB-AE) is difficult if prior HBsAg
status is unknown. This prospective study was undertaken to
screen various factors which could help with this differentiation.
Methods All consecutive patients presenting with AVH-B like ill-
ness were enrolled in this study and were evaluated as per
predefined study protocol. Patients were presumptively divided
into AVH-B and CHB-AE groups based on HBsAg status at the
end of 6 months.
Results Significant differences in clinical and laboratory parameters were
found between AVH-B and CHB-AE. No statistically significant differ-
ence in prodromal symptoms and jaundice was seen. Ascites (40%) and
hepatic encephalopathy (10%) were seen only in patients with CHB-AE
patients (p=0.002 and 0.244 respectively). IgM anti-HBc levels ≥10.15
(S/CO) had PPV and NPV of 90% for diagnosis of AVH-B. HBV DNA
levels ≥25032 IU/ML has 62.5% PPV and 69% NPV for diagnosis of
CHB-AE. Alpha-fetoprotein at > 22.5 ng/mL for diagnosing CHB-AE
has PPV and NPV of 83% and 62% respectively. All six mortality were
seen in CHB-AE group with median survival of two months.
Conclusions Differentiation of AVH-B and CHB-AE is important as
management and prognosis differs. Low IgM anti-HBc levels (22.5 ng/
mL) favors CHB-AE over AVH-B.
130
Evaluation of pro-inflammatory markers IL-6 and TNF-a and their
correlation with non-alcoholic fatty liver disease
Pratap Singh, Jayanti Khura
Correspondence- Pratap Singh-drpratapsingh@yahoo.co.in
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Department of Medicine and Gastroenterplogy, Ram Manohar Lohia
Hospital, Type III, President's Estate, New Delhi 110 001, India,
Background Non-alcoholic fatty liver disease (NAFLD) is a condition in
which excess fat accumulates in the liver of a patient with no history of
alcohol abuse or other causes for secondary hepatic steatosis. The patho-
genesis of NAFLD and non-alcoholic steatohepatitis (NASH) has not
been fully elucidated. NAFLD consists of a complex spectrum of dis-
eases, ranging from asymptomatic steatosis with possible aminotransfer-
ase alterations to NASH, cirrhosis, and also hepatocellular carcinoma. Pro
inflammatory cytokines like IL-1, IL-6 and TNF-α play a major role in
the pathogenesis of NAFLD. These cytokines also play a crucial role in
the development of insulin resistance, which is a key factor in the path-
ogenesis of NAFLD. There is limited data on the association of IL-6 and
TNF-α with NAFLD from India. Hence, we aim to assess the correlation
of IL-6 and TNF-α with NAFLD.
Methods It was a cross sectional observational study which was conduct-
ed on 40 cases of NAFLD and 40 healthy controls. All relevant investi-
gations and serum levels of IL-6 and TNF-α were measured. Statistical
analysis was done using Pearson Chi-square/fisher exact test, student t-
test (un-paired). Pearson correlation test was used to see the relationship
between the variables.
Result The serum levels of IL-6 and TNF-α correlated significantly with
NAFLD with a p-value of <0.001. The serum levels of IL-6 showed a
significant correlation with the severity of NAFLD (p<0.001), but the
same was not seen with TNF-α.
Conclusion Our study showed significant correlation of TNF-α and IL-6
with NAFLD, which suggested a proven role of these pro-inflammatory
markers in the pathogenesis of this disease as shown in past studies. In
future target-based therapy is new field of research.
131
Acute liver failure due to viral hepatitis E and thyroid storm: A case
report
Vivek Sharma, Amit Mathur, Kandarp Saxena, Arun Singh
Correspondence- Vivek Sharma-vivekmohansharma@gmail.com
Department of Gastroenterology, National Institute of Medical Science
and Research (NIMS), NH-11C, Delhi - Jaipur Expy, Shobha Nagar,
Jaipur 303 121, India
Introduction Thyroid storm and acute liver failure are both independently
associated with high mortality. Hepatic dysfunction in a patient with
thyroid storm presents a diagnostic and therapeutic challenge.
Case A young male presented with symptoms suggestive of acute liver
failure. Examination revealed bilaterally enlarged thyroid gland. Initial
laboratory investigations showed suppressed thyroid stimulating hor-
mone (0.0009 μIU/mL), high triiodothyronine (1.7 ng/mL),
tetraiodothyronine (24 μg/dL), and positive anti–thyroid peroxidase.
Liver function tests revealed total bilirubin (15.6 mg/dL), direct bilirubin
(14.24 mg/dL), AST 1327 U/L, ALT 1186 U/L, ALP 1023 U/L, and
serum ammonia (> 400 μmol/L). Furthermore, the patient was found to
be IgM anti-hepatitis E virus (HEV) positive. Other viral, metabolic and
autoimmune profile was negative. USG abdomen was normal. Working
diagnosis of acute liver failure due to HEV and thyroid storm was made.
In view of hepatic dysfunction methimazole and propylthiouracil were
avoided and the patient was stabilized with Lugol’s iodine and lithium,
after which the patient underwent total thyroidectomy. Post-surgery pa-
tient had significant clinical improvement and he was put on oral thyrox-
ine. Histopathology of the removed thyroid gland showed congested
blood vessels with colloid filled spaces suggestive of adenomatous goitre.
He achieved normal liver function on subsequent follow-ups.
Conclusion Though uncommon, uncontrolled thyrotoxicosis can result in
severe hepatic dysfunction. Patient’s remarkable recovery following total
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
thyroidectomy indicates that thyroid storm was the probable cause of acute
liver failure, although HEV leading to acute liver failure could not be
completely ruled out. Early recognition of thyroid storm and total thyroid-
ectomy may have played a major role in clinical recovery of liver failure.
132
Prevalence of bacterial infection at admission in patients with acute
on chronic liver failure: A single centre experience
Chitta Ranjan Khatua, Ansuman Mishra, Putul Bara, Kamalakhya
Samantaraya, Ajaya Kumar Biswal, Saroj Kanta Sahu, Rina Mohanty,
Shivaram Prasad Singh
Correspondence- Chitta Ranjan Khatua-chittamedicine@yahoo.co.in
Department of Medicine, MKCG Medical College and Hospital, Medical
College Campus, NH59, Brahmapur, Odisha 760 004, India, Department
of Gastroenterology, S C B Medical College, Cuttack 753 007, India
Introduction Acute on chronic liver failure (ACLF) is a life-threatening
condition in patients of chronic liver disease (CLD). However, the prev-
alence and impact of bacterial infection in ACLF patients has not been
assessed in this region of Asia. Hence, we performed a prospective study
to evaluate the spectrum of ACLF patients and the impact of bacterial
infection on outcome.
Method This study was conducted in consecutive ACLF patients (as per
EASL-CLIF consortium criteria), hospitalized in Gastroenterology
Department, SCB Medical College, India between October 2016 and
December 2018. Demographic, clinical, laboratory and microbiological pa-
rameters were recorded, and survival was compared between patients with
and without infection during hospitalization, and also at 28 days and 90 days.
Results Two hundred and thirty-two (40.3%) out of 576 CLD patients had
ACLF, of which 67.2% (n=126) had infection. 50.9% (n=118) had uri-
nary tract infection (UTI), 15.5% (n=36) had spontaneous bacterial peri-
tonitis (SBP), 13.8% (n=32) had respiratory infection, and 6% (n=4) had
infection of skin and soft tissue. 20.7% (n=48) patients had more than one
type of infection. 55.8% (n=67) of grade 1 ACLF patients, 77.6% (n=52)
of grade 2 ACLF patients, and 82.2% (n=37); (p=0.001) of grade 3 ACLF
patients had infection. Patients with infection had higher serum creati-
nine, serum urea, and higher MELD UNOS, MELD Na+, CTP score
(p<0.01), and decreased serum albumin level (p=0.024). Further, ACLF
patients with infection had a trend of prolonged hospitalization, increased
hospital death, and decreased 28 days and 90 days survival.
Conclusion In our institution, over two thirds of ACLF patients had
infection during hospitalization and higher grade ACLF patients were
increasingly associated with infection. UTI was the commonest infection
and about one fifth of patients had multiple infections. There was a trend
towards decreased survival of ACLF patients with bacterial infection.
133
A case report- A rare case of carbimazole induced liver injury
Nirdesh Chauhan
Correspondence- Nirdesh Chauhan-drnirdesh@live.com
Department of Gastroenterology, Kurnool Medical College and
Government General Hospital, Kurnool Medical College, Budhwarpet
Road, Budhawarapeta, Kurnool 518 002, India
The anti-thyroid drugs methimazole (MMZ) and its prodrug –
carbimazole (CBZ) and propylthiouracil (PTU) are often used as first-
line treatment for hyperthyroidism. Because of a higher risk of causing
severe liver injury by PTU, as highlighted in the U S Food and Drug
Administration's boxed warning, CBZ is more preferred except during the
first trimester of pregnancy (can cause birth defects) and in patients with
an adverse reaction to methimazole.
S43
The following case report of 60-year-old female, known case of hyper-
thyroidism, admitted for urgent evaluation of new-onset jaundice, pruri-
tus, nausea, fatigue, and clay-colored stool for 15 days. As per the patient
history and investigations, a probable diagnosis of a cholestatic pattern of
drug-induced liver injury was made. CBZ was stopped and with the
advice of the endocrinology department, lithium carbonate and propran-
olol were started.
Clinicians should be aware that hepatotoxicity though rare, can occur
with CBZ and should swiftly consider an alternative treatment strategy.
Patients who take anti-thyroid drugs should be informed about the risk of
liver injury and be advised to avoid other possible susceptibility factors
such as alcohol consumption, which might hasten liver damage induced
by their anti-thyroid medications.
134
Psoas muscle index: A simple and reliable method of sarcopenia
assessment on CT scan in chronic liver disease
Gajanan Rodge, Usha Goenka, Rachit Agarwal, Shivaraj Afzalpurkar,
Bhavik Shah, Surabhi Jajodia, Mahesh Goenka
Correspondence- Gajanan Rodge-grodge3@gmail.com
Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, 58,
Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata
700 054, India
Background L3-Skeletal Muscle Index (SMI) is a CT based conventional
method for sarcopenia assessment. However, recently psoas muscle pa-
rameters have been proposed as a simple and quick method without need
of a special software. The aim of this study was to assess sarcopenia in
cirrhotics by psoas muscle quantification on CT scan.
Methods One hundred and fifty patients were assessed for the psoas muscle
on CT scan and psoas muscle index (PMI) was calculated: PMI = total
psoas muscle area (mm)/(height) 2 (m). The cut off values for diagnosis of
sarcopenia were derived from the local control group (n=75) who did not
have CLD/other causes of sarcopenia. The case group included consecutive
CLD patients (n=75) who underwent CT scan of abdomen. Hand Grip
(HG) dynamometer was used to assess the HG strength.
Results Sarcopenia assessed by PMI was seen in 36% (n=27) of CLD
patients. Ascites, hepatic encephalopathy (HE) and gastrointestinal bleed
was seen in 48%, 18.7% and 24% respectively, among the cases. The
association of sarcopenia was statistically significant with ascites and HE
(p value < 0.05). Sarcopenia was significantly higher in patients with
CHILD C. HG weakness was seen in 41.3% (n=31) and mid-arm muscle
circumference was low in 25.3% (n=19) of CLD patients. Fifty-three out
of 75 patients completed the follow-up period of 1 year. Out of patients
with sarcopenia, 77.8% (n=7) succumbed to liver related illness, while
22.2% (n=2) without sarcopenia expired during follow-up. The associa-
tion of 1-year mortality and sarcopenia was statistically significant (p
value = 0.01). The Kappa measure of agreement between HG and
sarcopenia assessment was 0.608 (good strength of agreement).
Conclusions In conclusion, PMI sarcopenia proved to be a reliable pre-
dictor of mortality and HG dynamometer seems to be a good alternative
for sarcopenia assessment.
135
Comparison of efficacy of rifaximin and norfloxacin in prevention of
spontaneous bacterial peritonitis
Mukesh Kumar, Ankur Jain
Correspondence- Mukesh Kumar-mukesh98153@gmail.com
Department of Medical Gastroenterology, Sardar Vallabhbhai Patel
Institute of Medical Sciences and Research (SVPIMSR), Riverfront
Road, Ellisbridge, Ahmedabad 3800 061, India
S44
Background Norfloxacin is the most commonly used agent for the pro-
phylaxis against spontaneous bacterial peritonitis (SBP) in patients with
liver cirrhosis. Rifaximin, another broad-spectrum antibiotic, is used for
the treatment of traveller’s diarrhea and hepatic encephalopathy.
Objective We aimed to test the efficacy of rifaximin versus norfloxacin
for prevention of SBP in patients with hepatitis C virus (HCV)-related
liver cirrhosis.
Methods One hundred patients with HCV-related liver cirrhosis
and ascites were included in study and divided into two groups
of matching age, sex and Child–Pugh class. Group I patients were
given norfloxacin 400 mg/day and group II patients were given
total dose of rifaximin 1200 mg/day in three divided doses. The
follow-up time was one year.
Results Patients on rifaximin developed fewer episodes of SBP
than those on norfloxacin (8% vs. 16% respectively) although it
was statistically insignificant (p=0.265). Also, the duration before
developing a new attack of SBP was longer in patients treated
with rifaximin as compared to those taking norfloxacin (9.0 vs.
5.5 months, respectively). Additionally, rifaximin significantly re-
duced the rate of new compared to past episodes of SBP by 24%
(p while the rate reduction with norfloxacin was only by 18% and
not statistically significant (p= 0.45). Overall survival was equal
in both groups.
Conclusion Rifaximin is – at least – as good as norfloxacin. It seems to be
an appropriate alternative for long-term primary and secondary prophy-
laxis of SBP in cirrhotic patients with ascites.
136
Daclatasvir and half-dose sofosbuvir is an effective and pangenotypic
treatment for hepatitis C virus infection in patients with estimated
glomerular filtration rate
Harshita Katiyar, Amit Goel, Dharmendra Singh Bhadauria, Anupma
Kaul, Prachi Tiwari, Abhai Verma, Narayan Prasad, Amit Gupta,
Praveer Rai
Correspondence- Amit Goel-agoel.ag@gmail.com
Departments of Gastroenterology, and Nephrology, Sanjay Gandhi
Postgraduate Institute of Medical Sciences, Lucknow 226 014, India
Aim Sofosbuvir, the backbone of hepatitis C virus (HCV) treatment, use is
controversial in patients with estimated glomerular filtration rate (eGFR)
<30 mL/min. We report here off label treatment with daclatasvir and half
daily dose of sofosbuvir in patients with eGFR <30 mL/min on real life
experience with increase in sample size and data in continuation with
previous data reported.
Methods Adult patient with eGFR <30 mL/min and detectable HCV
RNA were screened. We included those who (i) started treatment
with direct acting antiviral drugs (DAAs) between July 2013 and
January 2020 (ii) had taken DAAs at least for four weeks and (iii)
had reached one of the end points either during HCV treatment or
up to 12 weeks after stopping the treatment (death; lost to follow-up;
quantitative HCV RNA assay at 12 weeks after stopping the treat-
ment, SVR12; relapse). All the patients, regardless of HCV geno-
types, were treated with daily doses of daclatasvir 60 mg and
sofosbuvir 200 mg. Patients with or without cirrhosis were treated
for 24 weeks or 12 weeks respectively.
Results Eighty-seven participants (age mean±SD 44 ± 12.9 years; male 63
[72%]) were included in final analysis. Two had compensated cirrhosis.
The genotypes were tested for 67 (77%) participants. The HCV genotype
1, 3, and 4 were identified in 31 (36%), 34 (39%), and 2 (2%) respective-
ly. Serum HCV RNA (log10) was 5.73±1.24 IU/mL. Seventy-seven
(89%) achieved SVR12, 6 (7%) lost to follow-up, 2 (2%) died during
treatment and 2 (2%) relapsed.
Conclusion Daclatasvir and half-dose of sofosbuvir is effective against all
the HCV genotypes in ESRD patients.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
137
A clinical study of spontaneous bacterial peritonitis in cirrhosis of
liver
Arnab Dey, Krishnasamy Narayanasamy
Correspondence- Arnab Dey-arnie303@gmail.com
Department of Hepatology, Institute of Hepatobiliary Sciences, Madras
Medical College, Chennai 600 003, India
Introduction Spontaneous bacterial peritonitis (SBP) is one of leading
cause of death in cirrhosis. The studies have shown that causative bacte-
riological agent and empirical therapy guidelines are different in different
parts of world and even different in same region on different time periods.
This study was undertaken with an idea to evaluate bacteriological profile
and preciseness of preformed guidelines for treatment, monitoring of
therapy and prognostic factors in SBP in patients catering to Madras
Medical College, Chennai.
Method A hospital based prospective observational study between
June 2019 to April 2020 conducted in the Department of Hepatology,
MMC Chennai, Tamil Nadu.
Result Total 50 patients of age group >12 years, diagnosed as SBP.
Cirrhosis and SBP was seen predominantly in older age group, 72% of
patients >40 yrs. Predominantly in male population i.e. 34 cases (68%)
and only 16 (32%) females. Majority (72%) alcoholics. Sixty-two percent
had fever and 58% had abdominal pain at the time of presentation, while
40% were brought with h/o altered sensorium. Mean ascitic fluid PMN
cell count at the time of diagnosis was 492 in patients who survived, while
it was 1721 in patients who died. An ascitic fluid PMN count of >450 at
48 hours predicted poor prognosis with sensitivity of 87.5% and 94.15%.
Achievement of ascitic fluid PMN cell count of < 450/or >28% reduction
at 48 hours of treatment was associated with good outcome. Ascitic fluid
culture did not show any growth in 56% of cases while 38% showed E.
coli. Mean serum creatinine levels was 1.5 in patients who expired.
Conclusions Increased TLC, low serum albumin, increased creatinine
levels and low ascitic fluid protein are associated with poor prognosis.
Once SBP is diagnosed, serial ascitic fluid cell count is helpful in
predicting prognosis and should be used to monitor treatment.
138
Study of cytopenias and neutrophil lymphocyte ratio in rodenticidal
hepatotoxicity patients
C E Eapen, Ajith C Kuriakose, B Vijayalekshmi, Lalji Patel, Uday
Zachariah, Sukesh Nair
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Department of Gastroenterology, Hepatology, Transfusion Medicine and
Immunohematology, and Wellcome Trust Laboratory, Christian Medical
College, Vellore 632 004, India
Introduction As clinical significance of cytopenias in rodenticidal hepa-
totoxicity patients is unclear, we aimed to analyse incidence of cytope-
nias, any complications due to cytopenias and prognostic role of cytope-
nias and neutrophil lymphocyte ratio (NLR) in these patients.
Methods We retrospectively analyzed prospectively collected data on
rodenticidal hepatotoxicity patients managed in our department from
December 2017 to June 2020. Adverse outcome of hospital stay was
defined as death/discharged against medical advice (DAMA). We looked
for complications due to cytopenias (bacteremia in leucopenic patients,
bleeding in thrombocytopenic patients).
Results Of 80 rodenticidal hepatotoxicity patients (age: 24 [7-45] years,
median [range], female: male – 1.2:1, MELD score: 31.5 14-49]) studied,
15 patients (19%) had adverse outcome (died:13, DAMA:2). 10 patients
had bacteremia. During hospital stay, 54 patients (67%) had leucopenia
(WBC count 4000-2000/mm3 in 32 patients, WBC count <2000/mm3 in
22 patients) and 56 patients (70%) had thrombocytopenia (platelet count
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
1,50,000-50,000/mm3 in 40 patients, platelet count <50,000/mm3 in 16
patients). Time from alleged ingestion of rodenticide to maximum cyto-
penia was 5 (1-9) days for leucopenia, 7 (2-16) days for thrombocytope-
nia and to onset of hepatotoxicity was 4.5 (2-8) days. Time to onset of
hepatotoxicity correlated with time to maximum leucopenia (correlation
coefficient =0.485, p<0.01). Leucopenia normalized by 7 (4-10) days and
thrombocytopenia by 10 (6-26) days. Presence of leucopenia did not
affect occurrence of bacteremia or outcome. However, 44% of patients
with severe thrombocytopenia had adverse outcome (p=0.02). One pa-
tient (platelet count-43,000) had minor bleed (from erosive gastritis).
NLR > 3 was seen in 40 (50%) patients, 27.5% of patients with NLR
>3 had adverse outcome (p =0.04).
Conclusion Cytopenias were common in rodenticidal hepatotoxicity pa-
tients and maximum leucopenia correlated with onset of hepatotoxicity.
Severe thrombocytopenia and NLR > 3 were associated with adverse
outcome, however, clinically significant bleeding was uncommon.
139
Low volume plasma exchange and low dose steroid to treat idiosyn-
cratic drug induced liver failure - Our experience in 34 patients
Kunwar Ashish Singh, Santosh Kumar, Uday Zachariah, Vinoi David,
Dolly Daniels, Subramani Kandasamy, Kishore Pichamuthu, Ashish
Goel, C E Eapen
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Department of Hepatology, Christian Medical College, Vellore 632 004,
India
Introduction Acute liver failure (ALF) and acute on chronic liver failure
(ACLF) due to idiosyncratic drug-induced liver injury (I-DILI) carry high
short-term mortality without liver transplantation. We present our expe-
rience of plasma exchange to treat I-DILI patients.
Methods We retrospectively analyzed prospectively collected data on I-
DILI patients treated with low volume plasma exchange (PLEX) and low
dose steroid in our department from October 2016 to May 2020. Patients
who met listing criteria were advised urgent liver transplantation, those
not opting for transplantation were treated with PLEX. The disease se-
verity parameters were measured at admission. Primary outcome was
survival at 30 days from the date of admission.
Results Thirty-four I-DILI patients (17 males, age 35.8 (15-36) years,
median (range) underwent plasma exchange for ALF (12 patients), sub-
acute liver failure SAHF (9) and ACLF (13). Causative agents are native
medication (44%), antimicrobial (21%), antiepileptics (11%), antituber-
cular drugs (9%), hormonal pills (5%) and others (10%). By RUCAM
score, 29 patients had probable DILI and 5 had possible DILI. Twenty-
two patients had hepatic encephalopathy. The 34 patients underwent 2 (1-
7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma were exchanged per
session. Twenty-one patients received prednisolone up to 20 mg per day
for a duration of 32 (4-160) days median (range). The survival at day 30
from date of admission was 64.2% in 34 patients, 42% in ALF pa-
tients,78% in SAHF patients and 76% in ACLF patients. Of 19 ALF/
SAHF patients who fulfilled Kings College Criteria for liver transplanta-
tion,11 patients (58%) survived with plasma exchange.
Conclusion Plasma exchange appears a promising treatment option in I-
DILI patients not opting for liver transplantation.
Changes in parameters before and after PLEX
Parameters Baseline values Post PLEX values p-value
Median, IQR (at admission) (at discharge)
Bilirubin (mg/dL) 21.6 (14.7-26.7) 15.7 (10.4-16.1) 0.033
INR 2.45 (1.73-3.9) 1.99 (1.2-2.45) 0.002
Creatinine (mg/dL) 0.8 (0.6-1.2) 0.7 (0.6-1.1) 0.5731
MELD 30 (27.2-34.7) 27 (19.5-29) <0.001
S45
VWF Antigen % 480.7 (348.5-709) 297.9 (229.8-501) 0.0001
SOFA 8 (7-9) 7 (6-8) 0.116
Ferritin (ng/mL) 727 (407.5-1427.9) 348.8 (218-788.9) 0.009
All parameters in 34 patients except Ferritin (23 patients)
140
Analysis of liver function tests in rodenticidal hepatotoxicity patients
Gadadhar Panda, B Vijayalekshmi, Uday Zachariah, Ashish Goel, C E
Eapen
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Department of Gastroenterology, Christian Medical College, Vellore 632
004, India
Introduction Hyperferritinemia is a macrophage activation marker. We
aimed to study the pattern of liver injury and of aspartate aminotransfer-
ase (AST) and alanine aminotransferase (ALT) and to correlate these with
hyperferritinemia and with the outcome.
Methods We retrospectively analyzed LFTs in rodenticidal hepatotoxicity
patients managed in our department from December 2017 to June 2020. R
values (i.e. [ALT/ALT upper normal limit (ULN)]/ [alkaline phosphatase
(ALP)/ALP ULN]) of ≥ 5, ≤ 2 and 2– 5 were taken to indicate hepato-
cellular, cholestatic and mixed hepatocellular-cholestatic liver injury
respectively.
Results Of 80 consecutive rodenticidal hepatotoxicity patients (age: 24 [7-
45] years, median [range], female : male: 1.2:1,MELD: 31.5 [14-49]), 64
patients were discharged alive, 14 died and 2 discharged against medical
advice. Time from rodenticidal ingestion to first abnormal LFT was 4 (1-
18) days. Initial liver injury was hepatocellular in 72 patients (90%),
cholestatic (2 patients) and mixed (6 patients); 62 patients (78%) had
AST 941 (25-4994) U/L > ALT 539 (16-2893) U/L and 18 patients had
ALT 463 (111-1361) U/L > AST 280 (95-1153) U/L. Concomitant fer-
ritin levels were 4447 (161-72001) ng/mL in 39 patients with AST>ALT
and 758 (59-3787) ng/mL in 13 patients with ALT>AST (p <0.001). Of
62 patients with initial AST>ALT, 51 patients (82%) had ALT>AST 2
(1-6) days later.14 /62 patients (22.5%) with AST>ALT had poor out-
come compared to 2/18 patients (11.1%) with ALT>AST (p=0.24). AST
levels were higher in patients with poor outcome (1022 [361-4134] U/L)
compared to those with good outcome (668 [25-4994] U/L) (p=0.02).
Ferritin levels were higher in those with poor outcome (4520 [562-
72001]) ng/mL compared to those with good outcome (2029 [59-
30344] ng/m) (p=0.07).
Conclusion Rodenticidal hepatotoxicity causes hepatocellular liver injury
with AST>ALT in most patients. AST>ALT was associated with higher
ferritin, this may indicate macrophage activation. Patients with poor out-
come had higher initial AST and ferritin levels.
141
Effect of dapaglifozine in Type 2 DM with non-alcoholic fatty liver
disease – ‘A single centre experience’
Navin Sudhakaran, Girish Kumar Pati, Chandan Das, Abhay Sahoo
Correspondence- Girish Kumar Pati-pati.drgirishkumar@gmail.com
Department of Gastroenterology, IMS and SUM Hospital, Bhubaneswar
751 003, India, and Sum Ultimate Medicare Hospital, K8 Kalinga Nagar,
Ghatikia, Bhubaneswar 751 003, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is the most com-
mon chronic liver disease, affecting around one third of global popula-
tion. As there is paucity of reports on effects of dapaglifozine (SGLT2
inhibitor) in NAFLD cases with diabetes mellitus (DM) from this part, we
aimed to evaluate the same.
S46
Method Consecutive cases with Type 2 DM and NAFLD were included
in the study and subjected to dapaglifozine 10 mg therapy for 3 months.
Biochemical parameters, ultrasonographic fatty liver grading, fibroscan
scoring, and non-invasive scoring for hepatic fibrosis (FIB4 and NAFLD
fibrosis scores) of all the cases were evaluated at baseline and again after 3
months of completion of therapy and compared with each other.
Result In our study, amongst total of 100 cases, males outnumbered females
(Male: Female – 4.27: 1). Mean age of presentation was 44.11±8.24 years.
Mean body mass index (BMI) of cases decreased from 27.31±1.87 to 26.21
±1.51 Kg/ m2 (p–0.0001) following therapy. Seventy percent cases presented
with dyspeptic symptoms, whereas 29% cases had no symptoms and only 1%
case had occasional upper abdominal pain. Significant decrease (p-0.0001) in
transaminitis (SGOT: 55.88±20.92 vs. 49.52±16.61 IU/L and SGPT: 64.69
±22.73 vs. 58.69±17.98 IU/L) and blood sugar level (FBS: 137±18.91 vs.
125.54±15.87 mg% and 2 hour PPBS: 188.38±34.49 vs. 169.13±29.49 mg
%) occurred following therapy. Significant decrease (p< 0.05) in hepatic
steatosis occurred following therapy. Although significant decrease (p -
0.001) in fibroscan value: 6.95±1.42 to 6±1.44 kPa occurred following ther-
apy but significant decrement in FIB4 score: 1.66±0.91 vs. 1.54±0.76 and
NAFLD Fibrosis score: - 0.58±0.92 vs. - 0.64±0.91 (p>0.05) did not occur.
Hepatic fibrosis did not decrease significantly following therapy (p>0.05).
Conclusion Although dapaglifozin improved transaminitis, glycaemic
status and hepatic steatosis but had minimal effect on hepatic fibrosis.
142
Clinical characteristics and management of liver abscess: A tertiary
care centre experience
Adarsh C K, Puneeth B S, Bhuvan Shetty, Jairaj V Bomman
Correspondence- Adarsh C K-adarshck@gmail.com
Department of Medical Gastroenterology, BGS Global Hospital,
Bangalore, India
Introduction Liver abscess is a space-occupying lesion in liver associated
with high morbidity and mortality. Our objective was to study the clinical
characteristics and management outcomes in patients with liver abscess.
Methods Prospective study was done from August 2019 to July 2020 on 52
patients with liver abscess at BGS Global Hospital, Bangalore. History,
examination, laboratory investigations, imaging findings were recorded.
Ultrasound guided aspiration was done and samples were investigated.
Results Out of 52 patients, 31 were male and 21 were female patients.
Twelve of them were diabetic and 16 were alcoholics. Pain abdomen
(96%) was predominant symptom. Hepatomegaly was found in 88%,
jaundice in 23%. Elevated ESR was found in 65%, TLC was elevated
in 88%, Total bilirubin was elevated in 28%, AST was elevated in 38%,
ALT was elevated in 27% and serum albumin was reduced in 76%. On
imaging liver abscess was found in right lobe in 65%, left lobe in 25%,
bilateral in 10%; solitary in 79% and multiple in 21%. Segment VIII
(46%) was predominantly involved. Pus culture was positive in 31%
out of which K. Pneumonia was seen in 50%, E. coli in 31% and pseu-
domonas in 19%. Amebic serology was seen in 27%, AFB was positive
in only 1 patient. Percutaneous abscess drainage was needed in 63% of
patients and rest 37% were managed medically. No mortality was seen.
Conclusion Early diagnosis and treatment is necessary in management of
liver abscess since the presentation may be subtle and nonspecific.
Combined antibiotic therapy and percutaneous drainage will improve
the patients prognosis.
143
A study on role of Lille’s score in predicting response to granulocyte
colony-stimulating factor therapy in patients with severe alcoholic
hepatitis
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Sagar Dembla, Harsha M, Srinivas M G
Correspondence- Srinivas MG-demblasagar@gmail.com
Department of Medical Gastroenterology, Narayana Medical College
Hospital, Chinthareddipalem, Nellore 524 002, India
Introduction Alcohol-related liver disease is a broad spectrum of disease.
Severe alcoholic hepatitis has high short-term mortality up to 50%. The
therapeutic options are limited. Glucocorticoids are recommended but
have various limitation. A liver transplant is limited therapeutic option.
G-CSF stimulates pluripotent stem cells which contribute to regeneration
and repair of hepatocyte. In few RCTs, G-CSF therapy has improved liver
function and survival. However, these studies lacked a prognostic guide
for G-CSF. Thus, we hypothesized that G-CSF has better outcomes and
Lille’s score may be used in predicting response to G-CSF.
Result We enrolled total 67 patients, all were male. 26 were excluded as
per exclusion criteria. Thus, 41 enrolled for therapy. Out of which 37
received first 5 doses and 25 patients completed 12doses. Overall mor-
tality at 90days was 31.7% (13/41). Lille’s score on day 6 had significant
correlation (p-value <0.005) with survival at 90 days. AUC was 0.925 (CI
95%, 0.838 to 1.000). The cut-off value of 0.195 (sensitivity-81.8% and
specificity-86.7%). Kaplan-Miere plot showed that the two groups as
≤0.195 and >0.195, showed at survival at 90days was 90% and 26.7%
respectively. Lille’s score also independently predicted mortality with
cut-off 0.195 (p-value 0.009) and Odds ratio is 16.3. In survival group
there was a significant improvement in CTPS, DF, bilirubin and transam-
inases on day 6 and day 30. MELD score improved on day6 and day 30,
but was significant on day 30. Creatinine and serum albumin showed no
significant change at day 6 and day 30. In non-survival group, no signif-
icant improvement in liver disease clinical score and biochemical param-
eters. G-CSF therapy was well tolerated in patients.
Conclusion G-CSF is appearing as a promising therapy in alcoholic hep-
atitis and Lille’s score may be used as prognostic marker for survival. But,
we need larger data and more similar studies to validate it as tool in G-
CSF therapy.
144
Study of association of serum homocysteine levels with non-alcoholic
fatty liver disease
Aditya Srivastava, B K Tripathi
Correspondence- Aditya Srivastava-adityasrivastava2301@gmail.com
Department of General Medicine, Vardhman Mahavir Medical College
and Safdarjung Hospital, Mahatma Gandhi Marg, Safdarjung Campus,
Ansari Nagar West, New Delhi 110 029, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is an emerging
public health problem ultimately progressing to fibrosis, cirrhosis and
hepatocellular carcinoma. The absence of specific symptom or sign war-
rants the need for identifying non-invasive tools for early identification of
the disease and it's progression. Homocysteine is a sulfhydryl containing
amino acid which can alter intracellular lipid metabolism thereby promot-
ing hepatic fat accumulation. Thus, it is plausible that high homocysteine
levels could be a marker for early identification, and an effective target for
preventing the progression to NAFLD and it's related complications.
Aim To determine if there is any association of serum homocysteine
levels with NAFLD.
Methods Forty NAFLD patients along with 40 healthy volunteers
underwent serum homocysteine level measurement along with a gamut
of baseline investigations from August 1, 2019 to January 31, 2020 in this
observational case control study conducted on an out-patient basis in the
Gastroenterology Unit, Department of General Medicine, Safdarjung
Hospital. USG and Fibroscan were done in 40 NAFLD patients.
Results 57.5% (23) of case cohort were males and rest were females.
Mean age of case cohort was 43.08 years. 40% of patients were diabetic.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Mean homocysteine levels were 44.87 micromoles/L in cases as com-
pared to 27.57 micromoles/L in controls. 47.50% of cases had Grade I
fatty liver. Mean liver stiffness was 6.44 kPa on fibroscan. All cases with
homocysteine levels in first quartile (<17.9) had Fibrosis score of F0-F1.
On the other hand, only 33.3% cases with Homocysteine levels in fourth
quartile (>51.5) had Fibrosis score of F0-F1.
Conclusion Higher serum homocysteine levels were significantly associ-
ated (p value<0.0001) with progressive grades of hepatic fibrosis, as
assessed by fibroscan, in NAFLD patients and holds the potential to be
used as a tool for early identification of hepatic fibrosis in NAFLD.
145
Melioidosis: A rare cause of liver abscess
Manas Panigrahi, Mohd Imran Chouhan, Hemanta Kumar Nayak,
Subash Chandra Samal, Srujana Mohanty*, Shivam Sethi
Correspondence- Manas Panigrahi-medgast_manas@aiimsb
hubaneswar.edu.in
Departments of *Microbiology, and Gastroenterology, All India Institute
of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Melioidosis, caused by the gram-negative bacillus,
Burkholderia pseudomallei is clinically indistinguishable to other causes
of pyogenic liver abscess. A high index of suspicion is needs to diagnose
early as it is poorly responsive to usual empiric antibiotics and is associated
with significant mortality. Isolated liver abscess however is extremely rare.
Here we report two cases of hepatic meliodiosis who were previouly treated
as liver abscess elsewhere and were not responsive to the treatment.
Clinical presentation Case 1: A 39-years-old female with no known co-
morbid illness presented with history of pain right upper quadrant and
fever of 3 months. On examination liver and spleen were enlarged. Patient
was diagnosed elsewhere as liver abscess and had received multiple an-
tibiotics (oral and intravenous) over last 2 to 3 months without any im-
provement in her symptoms. ultrasonography and CECT showed liver
and splenic abscesses. USG guided aspiration was done and on culture
Burkholderia pseudomallei was grown. She was started on IV
meropenam for 2 weeks followed by oral trimethoprim and sulfamethox-
azole for six months. She improved symptomatically after 48 hours of IV
Meropenam.
Case 2: A 42-years-male, diabetic with uncontrolled blood glucose pre-
sented with high grade fever and pain right upper quadrant. On examina-
tion there was rigidity and gaurding in the right hypochondrium. USG
and CT showed multiple liver abscess in both the lobes. USG guided
aspiration was done and on culture Burkholderia pseudomallei was
grown. He was started on I.V Meropenam (as per sensitivity) and
responded to the treatment.
Conclusion In clinical practice liver abscess is a commonly encountered
problem and majority of which responds to standard antibiotic therapy.
These reports highlights the specific problem of non-responsive to anti-
biotic therapy and stresses the need to be aware of Burkholderia
pseudomallei as a potential cause of liver abscess.
146
A prospective study on profile of hepatic Wilson disease at a tertiary
care centre
Sharad Dev, Vinod Kumar Dixit, Sunit Kumar Shukla, Dawesh Prakash
Yadav, Anurag Tiwari
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221 005, India
Introduction Wilson disease is a rare inherited disorder characterized by
excess deposition of copper in liver, brain and other tissues. In this study
S47
we assess the clinical profile of Wilson disease in patients with hepatic
involvement.
Methods A total of 45 patients (M:F-2.5:1) of Wilson disease; diagnosed
by low serum ceruloplasmin, high 24 hr urinary copper and D-
penicillamine challenge test were enrolled in the prospective study con-
ducted between August 2018 and July 2020.
Results Mean age of patients was 24.7±12.6 years. Twenty-eight (62%)
patients presented with decompensated CLD (ascites–82%, jaundice–
75%, hepatic encephalopathy–28%, variceal bleeding–18%) with mean
baseline CTP 8.9±2.4 and MELD 22.5±5.4 values. Clinical presentation
was acute hepatitis in 12/45 (27%) patients (2 mimicking autoimmune
hepatitis), asymptomatic transaminitis with hepatomegaly in 3/45 (7%)
patients and fulminant hepatic failure in 2/45 (4%) patients. KF ring on
slit lamp examination was present in 20/45 (44%) patients. Upon diag-
nostic evaluation, mean 24 hr urinary Cu was 392.62± 206.08 mg/day
and mean serum ceruloplasmin was 18.40±6.34 mg. On liver function
tests, mean value of total bilirubin was 19.64±11.84 mg/dL, AST was 227
±131 U/L, ALT was 161±125 U/L and ALP was 194±55 U/L whereas
other parameters were normal. On hemogram, anemia was found in 23/45
patients with mean of 9.85±3.15 g/dL and evidence of hemolysis in 4 of
them. Thirty-five patients (78%) responded to treatment with D-
penicillamine and/or zinc therapy, three underwent liver transplant, two
died of complications and five were lost to follow-up.
Conclusion In this study, most patients of Wilson disease presented
as decompensated CLD, followed by acute hepatitis like presen-
tation. Early institution of pharmacotherapy is usually very effec-
tive but meticulous follow-up to monitor clinical wellbeing, ad-
herence and long-term adverse effects is mandatory for better
outcome.
147
Outcome of wait-listed recipients without the option for living donor
liver transplantation at a newly established tertiary care liver trans-
plant centre in Western India
Amey Sonavane, Deepak Gupta, Aabha Nagral, Ameet Mandot, Vikram
Raut, Ketul Shah, Amruthraj C, Ashok Thorat, Ambreen Sawant, Harshit
Chaksota, Suresh Vasanth, Darius Mirza
Correspondence- Amey Sonavane-amey_max@yahoo.com
Department of Gastroenterology, Hepatology and Liver Transplantation,
Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur,
Navi Mumbai 400 614, India
Background The scenario of cadaveric organ donation is rapidly evolving
in Western India. However, living donor liver transplantation (LDLT)
still forms the backbone of most transplant programs in this region. The
aim of our study was to analyse the outcome of wait-listed recipients who
did not have the option for LDLT.
Methods All patients listed for the cadaveric transplant program since
inception at a newly established tertiary care liver transplant centre in
Western India were included. We studied the outcome of recipients
who did not have a living related liver donor; or whose donor(s) were
rejected during evaluation and thus were listed for cadaveric transplant.
Results We performed 102 liver transplants (75 LDLTs and 27 deceased
donor liver transplants [DDLT]) over 56 months since inception. All of
the 32 pediatric transplants performed were LDLT. Total 286 potential
recipients were listed for the cadaveric program. 220/286 (76.92%) did
not have a related living donor whereas 66/286 (23%) patients had living
related donor(s) who were rejected during donor evaluation. Non-
alcoholic steatohepatitis (64%), low graft-recipient weight ratio (13%),
alcoholic steatohepatitis (7%), unsuitable anatomy (7%) and withdrawal
of consent (5%) were common reasons for donor rejection. After a
waiting period of 15±8 months, the overall wait-list mortality was
13.63% (39/286). 57.69% of the recipients experienced at least one epi-
sode of decompensation post listing for DDLT. Amongst the cohort
S48
having an unsuitable donor, the wait-list mortality was 21.21% (14/66). 2/
66 patients with an unsuitable donor and 25/220 without a living liver
donor underwent DDLT.
Conclusion Wait-list mortality is high amongst patients listed for DDLT.
LDLT significantly contributes to the available organ pool and fulfils the
void of organ deficit. This assumes importance especially in countries
with an evolving cadaveric transplant program, thus reducing waitlist
morbidity and mortality.
148
Atypical presentation of hepatic tuberculosis: a case series
Manas Kumar Panigrahi, Madhav Sameer Makashir, Hemanta Kumar
Nayak, Subash Chandra Samal, Srujana Mohanty*
Correspondence- Manas Panigrahi-medgast_manas@aiims
bhubaneswar.edu.in
Departments of *Microbiology and Gastroenterology, All India Institute
of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction Since the description of tuberculosis in literature, it has been
always a challenge for the clinicians. Though endemic in developing nations,
its atypical presentation makes it an enigmatic entity. Tuberculosis can mimic
malignancy, exposing the patient to unnecessary investigations and some-
times even surgery. The hepatic involvement of tuberculosis is a rare entity
with paucity of literature on the presentation. We are reporting our experience
with four such cases seen over last 2 years.
Case presentation Case 1, a 38-year-old male, presented with pyrexia of
unknown origin (PUO) with jaundice which later turned to be granuloma-
tous liver disease of tubercular origin with mediastinal lymphadenopathy.
Case 2 is a 40 year old male, in whom portal vein thrombosis secondary to
hepatic tuberculosis was the etiology of portal hypertension causing
esophaegeal varices and long-term sequelae, including formation of por-
tal cavernoma leading to portal cholangiopathy, who also had tubercular
ascites and active pulmonary tuberculosis.
Case 3 is a case of 59-year-old male with tuberculoma of the liver mim-
icking malignancy (hepatocellular carcinoma) on imaging, who
responded to anti-tubercular therapy.
Case 4 is a 65-year-female, an interesting case of paradoxical response to
anti-tubercular therapy forming tubercular liver abscess which extended
to involve the gallbladder fossa, leading to spontaneous perforation of the
gallbladder.
Conclusion Even in modern era, tuberculosis still poses a great diagnostic
challenge for gastroenterologists. Deviation from normal clinical presen-
tation keeps the treating physician in diagnostic dilemma. Sometimes,
response to anti-tubercular therapy is the only option left in endemic
countries like India.
149
CHIBA score, A novel model for predicting 3 month mortality in
decompensated liver disease
Bony George, Krishnadas Devadas, Jijo Vargheese, Anoop Vaeghese
Correspondence- Bony George-bonygeorge88@gmail.com
Department of Medical Gastroenterology, Medical College, Ulloor -
Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Introduction Decompensated Liver Disease (DCLD) has got a high mor-
tality rate and prediction of mortality is important to prognosticate the
patient and to channel high risk patients for liver transplantation.
Objectives To propose a new prognostic model for DCLD which is better
than the existing scores.
Methods Retrospective study. Clinical and biochemical variables were
assessed on the date of admission from the medical records and patient/
patient relatives were telephonically contacted regarding the date of death
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
and mortality at 3 months from the date of admission. Logistic regression
was done, coefficient of beta of independent variables were found out and
a new score was proposed (New score/CHIBA score = Creatinine *0.6 +
HE*0.4+ INR *0.8 + bilirubin *0.125 + INR *0.8 + ascites* 1.2) C stands
for creatinine, H for hepatic encephalopathy, I for INR, B for bilirubin and
A for ascites. Ascites was further divided into absent or mild with score of
0, moderate -1 and tense 2. Hepatic encephalopathy absent with score of
0, Grade I west heaven score of 1, Grade II score of 2 and Grade III and IV
a score of 3.
Results CHIBA score has AUROC of 0.793 (at a cut off of >5.5 it has
sensitivity of 66% and specificity of 76%) compared to MELD-Na of
0.735 (0.735, cut off >25 sensitivity 65% and specificity 72%), MELD
of 0.727 (cut off >17 sensitivity of 80.37% and specificity of 55.14 %), i-
MELD of 0.7223, MESO index of 0.727 and UKELD of 0.686.
Conclusion CHIBA score is superior to MELD and MELD variants
in predicting 3 month mortality. In short CHIBA score is better
than all existing prognostic models for DCLD. CHIBA score
needs to be validated in a different cohort to find out it’s prog-
nostic performance.
150
Analysis of effect of blood group on plasma von Willebrand factor
levels, liver disease severity and survival in rodenticidal hepatotoxic-
ity patients
Rutwik Loya, B Vijayalekshmi, Uday Zachariah, Jess Rasalam, Joy
Mammen, Dolly Daniel, Sukesh Nair, Ashish Goel, C E Eapen
Correspondence- C E Eapen-eapen@cmcvellore.ac.in
Departments of Gastroenterology, Hepatology, Transfusion Medicine
and Immunohematology, and Wellcome Trust Research Laboratory,
Divison of GI Sciences, Christian Medical College, Vellore 632 004,
India
Introduction In health, plasma von Willebrand factor (VWF) levels are
significantly lower levels in group O compared to non – O group indi-
viduals. We have previously reported raised VWF levels correlate with
liver disease severity and predict in-hospital survival in rodenticidal hep-
atotoxicity patients. The aim of this study was to analyse VWF levels,
liver disease severity, and outcomes in rodenticidal hepatotoxicity pa-
tients as per their blood group.
Methods We retrospectively analyzed prospectively collected data on
rodenticidal hepatotoxicity patients managed in our department from
January 2016 to June 2020, in whom blood grouping data was available.
Normal plasma VWF antigen level is 50% to 150%.
Results Fifty rodenticidal hepatotoxicity patients 40% males, age 22 (7-
44) years, acute liver injury (78%), acute liver failure (22%) had blood
group O (21 patients), A (12 patients), B (13, patients), AB (4 patients).
28 patients underwent plasma exchange. Baseline parameters were serum
bilirubin 5.52 (1.7-19.5) mg/dL, INR 5 (1-10), creatinine 0.8 (0.48-2.8)
mg/dL, MELD 31.5 (14-49) and VWF 430.6 (121-1106.8)%. VWF
levels were 408 (121-1106.8)%, 415.5 (263.9-646)%, 506.3 (186.8-
890)%, and 588 (376.3-990)% in O, A, B and AB blood group patients
respectively (p value =0.10). MELD scores were 33 (14-49), 31.5 (18-
44), 30 (14-45) and 38 (28-40) in O, A, B and AB blood group patients
respectively (p value =0.61). At 30 days, 38 patients were alive and 12
died. Survival at day 30 in O group vs. non – O blood group patients was
76.2 % and 75.9 % respectively (p=0.97).
Conclusion VWF levels tended to be higher in non – O blood group
compared to O blood group in rat killer hepatotoxicity patients, however,
30 day survival was not different in these blood groups.
151
The triglyceride and glucose index (TyG) as screening biomarker to
identify non-alcoholic fatty liver disease
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Hozefa Runderawala, Nutan Desai
Correspondence - Hozefa Runderawala-hozaaee@gmail.com
Fortis Hospital, Mumbai, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is associated
with insulin resistance through an accumulation of fat in the liver. The
triglyceride and glucose index (TyG), which is defined as the product of
an individual’s serum levels of triglycerides (TG) and fasting plasma
glucose (FPG), has been recommended as a reliable and simple surrogate
index for insulin resistance. We compare the ability of triglyceride and
glucose index (TyG), as compared with the predictive value of alanine
aminotransferase (ALT), to identify individuals at risk for NAFLD.
Methods People attending our institution health check-up OPD as per
inclusion and exclusion criteria are selected between December 2019-
March 2020. People of age >18 years were included and those with
significant alcohol intake, known case of diabetes mellitus, hypertension,
dyslipidemia or any known liver disease were excluded. Routine blood
parameters were noted, and fatty liver assessed as the presence or absence
of hepatic steatosis by abdominal USG. The TyG is calculated with
established formula: TyG= Ln (Tg [mg/dL] X FBS [mg/dL]/2).
Results A total of 95 people were enrolled, among which 53 were (56%)
found to have fatty liver by abdominal USG. TyG index was calculated
by using above mentioned formula and taking cut off value of 8.6, and
that for ALT of 40 IU/L, Sensitivity of TyG index is 72% and for ALT is
27.08%, also negative predictive value (NPV) for TyG index is 82.35%
and for ALT is 54.5%. By using McNemar Chi-square test, p value is
found to be significant with p <0.01.
Conclusion TyG index is found to have higher sensitivity in comparison
with ALT for an effective screening biomarker to identify NAFLD.
152
Clinical profile and outcome of chronic hepatitis C patients in a ter-
tiary care centre in North India
Chandan Kumar, Itish Patnaik, Ashok Kumar, Anand Sharma, Rohit
Gupta
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Introduction Hepatitis C virus (HCV) infection is known to cause cirrhosis.
Advent of direct antiviral agents (DAA) have significantly altered the disease
course of these patients. We describe our experience with HCV patients.
Methods A prospective observational study was done over a one-year
period (1st February 2019 to 31st January 2020) in patients of our depart-
ment. Patients were evaluated and treated as per standard of care and
followed up for 12 weeks after completion of DAA for sustained viro-
logical response (SVR12).
Results During the study period 189 patients (Median [Range] Age 37.5
[17-69] years; 57% were males, family history of HCV in 7%; high risk
behavior in 39%) were diagnosed to have HCV infection. Cirrhosis was
present in 30 (15.8%) patients (MELD 10, [6- 18]), of which 18 patients
were decompensated (ascites in 12, jaundice in 8, hepatic encephalopathy
in 1, variceal bleed in 2). One patient presented with acute hepatitis. One
hundred and seventy-three patients were asymptomatic. None were co-
infected with hepatitis B or human immunodeficiency virus. Among ge-
notypes, 3a was the most common (65.75%). All patients were treated
with DAA (sofosbuvir/daclatasvir given to 146 cases for 12 weeks,
sofosbuvir/velpatasvir given to 24 cases for 12 weeks and 18 cases for
24 weeks and sofosbuvir/ledipasvir to 02 cases for 12 weeks). End of
treatment response (ETR) was achieved in 188/189 (99.5%) patients and
SVR12 was achieved in 188/189 (99.5%) patients.
Conclusion Most of the patients with chronic HCV in our centre were
asymptomatic. Genotype 3a was the most common. It responded well to
current DAA regimens with excellent rates of SVR12.
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153
Clinical profile of autoimmune liver disease in north India: Tertiary
care experience
Vishnu Agarwal, Rishabh Gupta, Anubhav Jain, Girish Dhakad,
Sandeep Nijhawan
Correspondence- Rishabh Gupta-rishabh1313@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College and
attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Autoimmune hepatitis (AIH) is a disease of unknown etiol-
ogy, characterized by chronic hepatocellular inflammation, serum auto-
antibodies, and hypergammaglobulinemia, which in most cases respond
to immunosuppression. AIH is considered to be rare in Asia-Pacific
region.
Aim of the study To determine the clinical, biochemical, serological and
histopathological profile of autoimmune hepatitis.
Method It was a prospective observational study conducted in the depart-
ment of gastroenterology, SMS Medical College, Jaipur. Study period
was from May 2018 to June 2020. Inclusion criteria were consecutive
patients of chronic or acute liver disease who were newly diagnosed as
AIH, PSC, PBC or Overlap syndrome.
Results Total 83 patients were included and 67 (80.7%) were females.
The mean age was 33 years. Seventy-nine had AIH, 3 had PBC with AIH
overlap and 1 had PSC with AIH overlap. Modes of presentation was
chronic hepatitis (n=24) and decompensated cirrhosis (n=40), 7 had
ACLF like presentation, while 8 were asymptomatic. Liver biopsy was
done in 34 patients. The presentations were jaundice in 45 (56.9%), ab-
dominal distention in 40 (50.6%), pruritis in 15 (18.9 %), amenorrhea in
10 (12.6%), abortion in 5 (6.3%). Hepatomegaly was present in 30
(37.9%), splenomegaly in 35 (44.3%), encephalopathy in 15 (18.9%),
and fever in 7 (8.8%) patients. Nineteen had esophageal varices (24%)
and 2 had variceal bleed. The autoimmune markers were ANA (n=58),
ASMA (n=30), both SMA and ANA (n=25), AMA (n=3), rheumatoid
factor (n=2), p-ANCA (n=1), and anti-LKM (n=6). 25 patients (31.6%)
had definite AIH. Associated diseases were seen in 20/79 (25.3%)
patients.
Conclusion Autoimmune liver disease is not an uncommon entity and high
index of suspicion may lead to a timely diagnosis and improved prognosis.
154
Hepatic angiosarcoma presenting as a hemorrhagic cyst
Sujit James, Benoy Sebastian, Sunil Mathai, Anil Jose, Mary George,
Santhosh R, Cyril Alex, Swaran Kumar, Sunil T**, Varun Rajan*
Correspondence- Sujit James-jamessujit@gmail.com
Department of Medical Gastroenterology, *Medical Oncology, and
**
Surgical Gastroenterology, Medical Trust Hospital, Ernakulam 682
016, India
We report a very rare presentation of angiosarcoma of liver as a simple
hemorrhagic cyst. The patient is a 68-year-old male, who came with non-
specific right hypochondriac pain since 3 months. Contrast CT done showed
a 10 X 10 cm cystic lesion in the right lobe of liver and MRI abdomen done
showed T1 hyperintensities giving us a differentials of a hemorrhagic/ hyda-
tid cyst. He then underwent laproscopic deroofing of the liver cyst and cyst
fluid which was hemorrhagic was sent for analysis and tissure for histopa-
thology. Cyst fluid analysis was negative for tumor markers and bilirubin
levels. Histopathology showed clusters of atypical cells and pleomorphic
nuclei and eosinophilic cytoplasm. However, IHC done was suggestive of
angiosarcoma. Hepatic angiosarcoma presenting as a simple hemorrhagic
cyst is a very rare presentation. The importance of keeping an open mind
to the differentials even in a simple cyst is the highlight of this case report.
S50
155
Profile of hepatocellular carcinoma in a tertiary care centre in South
India with etiologic association and treatment outcome
Mohamed Fawas, Krishnasamy Narayanasamy
Correspondence- Mohamed Fawas-ncfawaz@gmail.com
Department of Hepatology, Institute of Hepatobiliary Sciences, Madras
Medical College, Poonamallee High Road, Park Town, Chennai 600 003,
India
Introduction Hepatocellular carcinoma (HCC) is the most common pri-
mary liver malignancy. Risk factors involved in development of HCC
include underlying cirrhosis, hepatitis B, hepatitis C, non-alcoholic fatty
liver disease etc. This study aims to describe clinical profile, underlying
risk factors, tumor characteristics and outcomes of therapy.
Methods One year prospective study on patients coming to our OPD with
either imaging or biopsy proven HCC cases. Detailed history, examina-
tion and laboratory tests were performed. The statistical analysis of the
data was performed.
Results The mean age was 56.8 yrs. Presenting complaints included loss
of appetite in 83%, abdominal distension in 71%, weight loss in 61%,
abdominal pain in 60%, hemetemesis in 10%, jaundice in 18% and he-
patic encephalopathy in 6% cases. The risk factors were hepatitis B virus
(HBV) in 43.6%, hepatitis C virus (HCV) in 24.6%, non-alcoholic
steatohepatitis (NASH) in 20.4%, alcohol in 13.6%, hepatitis B and alco-
hol in 35.5%, hepatitis C and alcohol in 13%. 86% of patients had un-
derlying cirrhosis while 14% were non-cirrhotics. Most of the patients
were in advanced stage BCLC-C 43.3%, followed by BCLC-D 28.3%,
BCLC-B 26.6%, BCLC-A 28.3%. Most of the patients were CTP B
68.3%. Patients having ascites had significant greater mortality at 1 year
(p=0.025). Portal vein thrombosis (PVT) increased the mortality at 1
month (p=0.002) and 1 year (p=0.001) follow-up. Higher mortality was
found with higher BCLC class,1 month (0.05) and at 1 year (p=0.001).
Conclusion Most patients diagnosed HCC belonged to 6th decade.
Hepatitis B was the commonest etiology. Decreased appetite was the
commonest complaint. Most patients were diagnosed at an advanced stage
which narrows down the therapeutic options and this study further empha-
sizes the importance of periodic screening in patients with risk factors.
156
Hepatic hydrothorax: Clinical profile and initial management of
symptomatic patients not responding to medical therapy - Case series
from a tertiary care centre
Swaran Kumar S, Sunil K Mathai, Benoy Sebastian, Anil Jose Kokkat,
Mary George, George Mothi Justin, Vivian Wilson, Varghese Louis,
Cyril Alex, Santhosh R, Sujit Jacob James
Correspondence- Swaran Kumar S-swarankumar29@gmail.com
Department of Gastroenterology, Medical Trust Hospital, Mahatma
Gandhi Road, Pallimukku, Kochi 682 016, India
Background Hepatic hydrothorax is known to occur in 5% to 15% of
patients with cirrhosis and can lead to respiratory failure and also
aggravate the clinical course of cirrhosis. The development of spon-
taneous bacterial empyema is also associated with significant mor-
tality. We outline the clinical profile and initial management of 7
patients who were admitted to our centre over a duration of 14
months. (03/2019 – 07/2020).
Methods and Results Mean age was 60 yrs and 6 out of 7 patients were
male and one was female. Five of the 7 patients had CHILD C Cirrhosis
(CTP score > 10) and 2 patients belonged to CHILD Class B. All patients
had MELD Na score of 15 or more with 4 patients having a Score > 21.
All patients had ascites clinically. All patients had transudative effusion. 5
patients had right sided effusion, one had bilateral effusion and one had
left sided effusion. All patients were treated with dietary sodium
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
restriction, diuretics and albumin. All patients required thoracocentesis.
5/7 patients had recurrence of effusion during the initial follow-up within
2-4 weeks. All patients required a minimum of two pleural fluid aspira-
tions during the initial admission. Indwelling Pleural Catheter (IPC)/
Pigtail was inserted in 6/7 patients including the two patients who did
not have recurrence of Effusion on follow-up. One patient developed
Empyema and died.
Conclusion Hepatic hydrothorax is a relatively uncommon complica-
tion of cirrhosis. Temporary usage of an IPC/Pigtail for intermittent
pleural aspiration obviated the need for repeated thoracocentesis. In
our small case series, one patient developed empyema and
succumbed and others did not have any procedure related complica-
tions. IPC/Pigtail catheter may be a good option to optimise the
patient before transplant.
157
Transfusion associated lung injury is uncommon in liver failure pa-
tients treated with low volume plasma exchange and low dose steroid
Vijay Alexander, Jess Rasalam, Dolly Daniel, Joy Mammen, Lalji Patel,
Uday Zachariah, Ashish Goel, Chundamannil Eapen
Correspondence- Chundamannil Eapen-eapen@cmcvellore.ac.in
Department of Hepatology, Christian Medical College, Vellore 634 004,
India
Introduction Transfusion of plasma containing blood products is associ-
ated with a small risk of breathing difficulty that can be broadly classified
as TRALI and TACO. This study aimed to analyze the incidence of
TRALI and TACO in patients undergoing plasma exchange (PLEX) to
treat liver diseases.
Methods We retrospectively analyzed prospectively collected data
in consecutive patients undergoing PLEX to treat liver failure in
our department who did not require respiratory support prior to
initiation of PLEX. Cases who had onset of dyspnoea within 12
hours of a PLEX session were identified. TRALI and TACO were
diagnosed as per Consensus Panel recommendations. The cases
were categorized as TRALI, TACO, or any other cause using a
predefined algorithm. The patients were treated with low volume
PLEX (50% of plasma volume exchanged with equal volume of
fresh frozen plasma) and low dose steroid.
Results From October 2016 to April 2020, 180 liver disease pa-
tients underwent 563 PLEX sessions. Twenty-eight patients who
were intubated prior to initiation of PLEX were excluded. A total
of 152 patients (age – 35.42 +/- 15.15), (M – 100, 65.7% and F –
52, 34.2%) were identified who underwent 492 PLEX sessions
and were transfused 4598 units of different blood products. Five
patients who had new-onset dyspnoea within 12 hours of transfu-
sion were identified. Among the 5 patients, 2 had TACO, and 3
had pneumonia (2 of these were aspiration pneumonitis). No pa-
tient fulfilled the diagnostic criteria for TRALI. The incidence of
TRALI was 0%, and that of TACO was 1 in 2299 units of
product transfusion in these patients.
Conclusion We did not find TRALI in liver failure patients treated with
low volume PLEX and low dose steroids. However, TACO seems a
potential and life-threatening problem that needs careful monitoring, es-
pecially in those at risk of fluid overload.
158
Dengue fever in liver transplant recipients: report of 2 cases
Sachin Jain, Nihar Ranjan Dash
Correspondence- Nihar Ranjan Dash-nagranjan@gmail.com
Department of GI Surgery and Liver Transplant, All India Institute of
Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction Dengue fever is a common mosquito borne disease in India.
Dengue fever in liver transplant recipient has rarely been described. We
report here 2 cases of dengue fever in our liver transplant patients.
Case Presentation We report 2 cases of dengue fever in our liver trans-
plant patients.
Case 1- presented 3 months after transplantation with history of febrile
illness with myalgia, arthralgia, thrombocytopenia, leukopenia. His low
platelet and WBC counts were initially attributed to hypersplenism.
Dengue was diagnosed using NS1antigen test and he was managed con-
servatively as for dengue fever. He recovered well and his graft is func-
tioning well till last follow- up.
Case 2: Presented 2 years after transplantation with a history of fever,
thrombocytopenia, mildly elevated liver enzymes. He had history of bil-
iary stenting for post op anastomotic stricture. Initial diagnosis was
suspected to be stent block cholangitis. Dengue IgM antibody test was
negative but NS1 antigen test was positive. Final diagnosis of dengue
fever was made. He improved well with conservative management. He
is also doing well till last follow-up.
Conclusion Reports of dengue fever in liver transplant recipients
are limited. The presentation may be atypical. It should be
suspected when patient present with febrile illness with thrombo-
cytopenia, along with other possible causes. NS1 antigen has bet-
ter sensitivity than IgM Elisa. Both should be included in diag-
nostic work up. Dengue fever usually follows a mild course in
primary infection and most patients recover well. Dengue fever
does not affect graft function in long-term.
159
Assessment of visceral fat volume and its correlation with the severity
of hepatic fibrosis in patients with non-alcoholic fatty liver disease
David Thomas, Krishnadas Devadas, Jijo Varghese
Correspondence- David Thomas-davidmathew186@gmail.com
Department of Medical Gastroenterology, Government Medical College,
Thiruvananthapuram 695 005, India
Introduction Non-alcoholic fatty liver disease (NAFLD) has progressive-
ly surpassed other etiologies in leading to the development of chronic
liver disease. The clinical spectrum of NAFLD includes simple steatosis,
non-alcoholic steatohepatitis (NASH) and fibrosis. Knowledge of the
stage of NAFLD would greatly influence treatment and outcome.
Numerous studies have outlined the association between visceral fat
and fibrosis in NAFLD1. This study aimed at calculating visceral fat
volume at the L3-L4 vertebral level which was then correlated with he-
patic fibrosis as assessed by transient elastography.
Methods All patients above 18 years undergoing CT abdomen who were
incidentally detected to have NAFLD were included. Transient
elastography was performed to assess hepatic fibrosis. Patients were cat-
egorized into advanced fibrosis (>10 kpa) and those without (<10 kpa).
AUROC was plotted to determine the cut off for visceral fat volume in
predicting advanced fibrosis. Pearson correlation was used to calculate
the variables that correlated with visceral fat volume.
Results Sixty-four patients which comprised 36 males and 28 females.
Thirty-one (46%) were having advanced fibrosis (TE>10 kpA) and 34
(54%) patients without advanced fibrosis. Age, weight, BMI, visceral fat
volume, ALP, HbA1c, FBS and ferritin were all found to be statistically
significant between the 2 patient groups. AUROC curve for visceral fat in
predicting advanced fibrosis was 0.733 and at a cut off of 167. 5cm3.
Visceral fat had a sensitivity of 77.4% and a specificity of 51.5% in
predicting advanced fibrosis. Subgroup analysis revealed visceral fat to
be a predictor of advanced fibrosis in males with a BMI >25.
Conclusion Visceral fat measured at L3-L4 level with a cut off of 167.5
cm3 had a sensitivity of 77.4% and specificity of 51.5% in predicting
development of advanced fibrosis in NAFLD. In male patients with a
BMI >25 kg/m2 visceral fat was a predictor of advanced fibrosis.
S51
160
Efficacy and outcome of endoscopic cyanoacrylate injection for gas-
tric variceal bleed - A prospective observational study
Dharanesh Daneti, Senthamizh Selvan, Pazhanivel Mohan, Vikram
Kate*, Abdoul Hamide
Correspondence- Senthamizh Selvan-senthamizh2909@gmail.com
Departments of Medical Gastroenterology, and *Surgery, Jawaharlal
Institute of Postgraduate Medical Education and Research, Dhanvantri
Nagar, Gorimedu, JIPMER Campus, Puducherry 605 006, India
Introduction Gastric variceal bleeding (GVB) compared to esophageal
varices is rare but often massive and associated with a high mortality.
Endoscopic cyanoacrylate glue injection is the first line treatment for
GVB. Hence, we conducted this study to assess the efficacy and short-
term outcome of cyanoacrylate for gastric variceal bleed.
Methods This was a prospective observational study of patients with
endoscopic cyanoacrylate treatment for GVB between June 2019 to
July 2020. Demographic characteristics, details regarding etiology and
severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate
used, number of sessions required, technical success, rebleeding rate and
survival at three months were collected.
Results A total of 39 patients underwent endoscopic cyanoacrylate injec-
tion for GVB. Their mean age was 48.2+-13.8 years with a male prepon-
derance (n=23). 26 patients (66.7%) had cirrhosis, and half of them
(n=13) were due to alcoholic liver disease. Gastric varices were GOV2
in 29 (74.4%), IGV1 in six (15.4%) and GOV1 in four (10.6%) patients.
Varices were tortuous and medium sized in 21 (53.8%) and 16 (41%)
patients respectively. Successful obliteration of gastric varices was
achieved in 31 patients (79.5%). Median sessions required were 1 (1-4)
and median volume of cyanoacrylate per session was 2 (1-6) mL. The
procedure was associated with minor complications like transient abdom-
inal pain in three (7.7%) and fever in one patient (2.6%). Rebleeding was
observed in six (15.4%) patients, five of whom had a high MELD score.
Cyanoacrylate failed in one patient (2.6%) who under-went emergency
devascularization. Two patients (5.1%) died during follow-up due to
advanced cirrhosis.
Conclusion In conclusion, our study demonstrated endoscopic in-
jection of cyanoacrylate to be very effective and safe for gastric
variceal bleed. The technical success was high and can be
achieved in fewer sessions and smaller volume of cyanoacrylate
during each session.
161
Change in muscle mass with nutritional therapy in cirrhotic patient-
A randomized controlled trial
Gireesh Dhaked, Sudhir Maharshi, Sandeep Nijhawan
Correspondence- Gireesh Dhaked-dr.gireeshdhaked2210@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L
N Marg, Jaipur 302 004, India
Introduction Sarcopenia has been associated with poorer survival in pa-
tients with cirrhosis. Nutrition may very well have a direct influence on
sarcopenia and functional status. There is no study on the nutritional
management of patients with sarcopenia. We performed a randomized
controlled trial to assess the effects of nutritional therapy on sarcopenia
in patients of cirrhosis.
Methods In a tertiary care setting in Jaipur, India, patients with cirrhosis
with sarcopenia were randomly assigned to groups given nutritional ther-
apy (30–35 kcal/kg/day, 1.0–1.5 g vegetable protein/kg/day; (n=49) or no
nutritional therapy (patients continued on their same diet; (n=47) for 6
months. Sarcopenia was diagnosed based on computerized tomography
psoas muscle index (PMI), handgrip strength, gait velocity. Primary
S52
endpoints were an improvement or worsening in sarcopenia at a 6month
follow-up.
Result To date total 97 patients were enrolled. Thirty-eight patients were
analyzed in each group. Alcohol (65.8%) was the most common etiology.
Baseline characteristics like age, body mass index (BMI), hemoglobin,
MELD score, mid-arm circumference (MAC), handgrip, gait velocity, and
PMI were comparable in both groups. On 6 month follow-up, there was a
significant improvement in MAC (22.80±1.63 vs. 21.18± 2.41, p-value-
0.003), handgrip strength (31.57±5.4 vs. 22.61±7.96, p-value- 0.03), gait
velocity (0.96±0.20 vs. 0.73± 0.33, p-value < 0.05), PMI, (7.29±2.26 vs.
4.70 ±2.17, p-value- 0.001) in nutrition group compare to no nutrition group.
Conclusion Nutritional therapy is effective in the improvement of
sarcopenia in cirrhotic patients.
162
Hepatic sinusoidal obstruction syndrome by oxaliplatin based che-
motherapy in relapsed refractory case of diffuse large B cell lympho-
ma
Maitrey Patel, Apurva Shah, Shravan Bohra
Correspondence- Apurva Shah-apurvashah411@gmail.com
Department of Gastroenterology, Apollo Hospitals International Limited,
Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Bhat,
Ahmedabad, Gujarat 382428
Introduction Hepatic sinusoidal obstruction syndrome (SOS) is common-
ly recognized vascular pattern of drug-induced liver injury and has been
frequently associated with oxaliplatin-based chemotherapy.
Methods and Results In this case report, we describe a case of 70-
years-old male who was diagnosed case of relapsed refractory diffuse
large B cell lymphoma and received 3rd line chemotherapy R-GEMOX
(Rituximab, Gemcitabine, Oxaliplatin, Ifosfamide. After receiving seven
cycles of R-GEMOX, patient developed jaundice, abdominal distension,
vomiting and 5 kg weight gain in one week duration. On examination he
had tender right upper quadrant, icterus, pedal edema and gross ascites.
Investigations revealed raised total bilirubin (13.1 mg/dL), elevated liver
enzymes (SGOT 131U/L, SGPT 67U/L, ALP 114U/L, GGT 162U/L),
total protein 4.8 gm/dL, albumin 2.6 gm/dL albumin: globulin 1.1, INR
1.45. Viral markers showed HBsAg positive, HBeAg and anti-Hbc IgM
negative, HBV DNA viral load 69,56,53,574 IU/mL with HEV IgM
positive. Ascitic fluid analysis showed high SAAG and low protein with
fluid negative for malignant cells. CECT abdomen was showing multiple
cystic lesions in liver in segment III, IVa, VI with moderate ascites. No
splenomegaly, venous collaterals or changes of cirrhosis seen. Patient
refused for liver biopsy. Repeat investigations revealed rising bilirubin
(30.2 mg/dL) and SGPT-57 U/L so diagnosis of oxaliplatin induced
HSOS, reactivation of hepatitis B, acute viral hepatitis E was made and
treated with entecavir, therapeutic ascitic paracentesis, albumin and di-
uretics. He got better in initial two weeks but unfortunately after one-
month patient expired due to advanced lymphoma.
Conclusion The incidence of oxaliplatin induced HSOS was 77.4%.
Hepatic SOS should be included in the differential diagnosis of patients
with rapid onset ascites, weight gain and jaundice following the admin-
istration of oxaliplatin based chemotherapy regimens.
163
Hepatic sarcoidosis with acute hepatitis E presenting as cholestatic
jaundice in a young male
Apurva Shah, Shravan Bohra, Maitrey Patel
Correspondence- Apurva Shah-apurvashah411@gmail.com
Department of Gastroenterology, Apollo Hospitals International Limited,
Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Bhat,
Ahmedabad 382 428, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction Hepatic sarcoidosis covers a broad spectrum from asymp-
tomatic and slightly deranged liver function tests to clinically evident
cholestasis or, in advanced cases, cirrhosis, portal hypertension.
Methods and Result We report a case of 30-year-old male without comor-
bidity presented with painless progressive jaundice without itching
followed by abdominal distension, pedal edema and weight loss of 20
kilograms since three months. No history of hepatotoxic/alternative med-
icine present. On examination, pallor, icterus, pedal oedema, moderate
ascites and right axillary lymphadenopathy. Investigations showed pan-
cytopenia, cholestatic liver pattern with raised total bilirubin (13.5 mg/dL)
with direct 12 mg/dL, albumin: globulin ratio 0.9, PT-INR 1.3, raised
ACE level 97 U/L (Reference range 8-53U/L), IgM hepatitis E virus
(HEV) positive with negative HBsAg and HCV antibody. anti-
mitochondrial antibody was negative. Diagnostic ascitic fluid analysis
showed high SAAG, low protein, ADA 29 U/L and fluid negative for
malignant cell. Contrast enhanced CT abdomen showed mild
hepatosplenomegaly with poorly enhancing ill-defined hypodense lesions
in liver and spleen of granulomatous etiology with moderate ascites.
HRCT thorax showed mild bilateral pleural effusion with normal lungs,
axillary lymphadenopathy largest measuring 3.9*1.6 cm, no hilar lymph-
adenopathy. Axillary lymph node excision biopsy was inconclusive, so
USG guided percutaneous liver biopsy was done and it showed non
caseating epithelioid granulomatous disease likely sarcoidosis. Gene
Xpert for M. tuberculosis was negative on both liver, axillary lymph node
biopsy. Patient treated with oral steroid, got better symptomatically and
biochemically at one week but lost to follow-up. This patent had hepatic
sarcoidosis with cholestasis as a primary disease complicated by acute
viral hepatitis E. He responded to oral steroids.
Conclusion Sarcoidosis should be kept in differential diagnosis of patient
presenting with cholestatic liver pattern with lymphadenopathy and sig-
nificant weight loss.
164
Terlipressin induced hyponatremia in patients with hepatocellular
carcinoma presenting with acute variceal bleed in a cancer center
Utkarsh Chhanchure, Aditya Kale, Shaesta Mehta, Prachi Patil
Correspondence- Prachi Patil-prachipatil@gmail.com
Department of Digestive Diseases and Clinical Nutrition, Tata Memorial
Hospital, Homi Bhabha National Institute (HBNI), Parel, Mumbai 400
012, India
Introduction Terlipressin is used in treatment of acute variceal bleeding
due to its selective splanchnic and extrarenal vasoconstrictor effect by
stimulation of V1 receptors. Due to its partial agonist effect on V2 recep-
tors, it can also increase water reabsorption in the renal collecting ducts
and cause hyponatremia. We planned a retrospective study to evaluate
Terlipressin induced hyponatremia in patients with hepatocellular carci-
noma (HCC).
Methods From August 2017 till August 2020, 32 patients with HCC
presenting to our centre with variceal bleeding who were treated with
Terlipressin were analyzed.
Results Among 32 patients, there were 29 males. Mean age was 53 years
(range 27-75 years). Most patients had advanced BCLC stage (B-1, C-25 and
D-6). All patient underwent endoscopic variceal ligation (EVL) at admission
and were started on Terlipressin 1 mg 6 hourly for 3-5 days. Serum sodium
decreased from a mean of 132.8 ± 3.6 mEq/L (126-139 mEq/L) to 128.2 ±
6.0 mEq/L (113-138 mEq/L) (p< 0.001) in 29 patients over 3 days. It de-
creased by ≤ 5 mEq/L in 16 patients (50%), by 5-10 mEq/L in 8 patients
(25%) and >10 mEq/L in 5 patients (16%). In this latter group, serum sodium
decreased from mean of 130.2 ± 2.1 to 117.2 ± 2.7 mEq/L and 2/5 patients
developed neurological manifestations in the form of nausea, headache and
mental confusion. Risk of hyponatremia decreased with increasing MELD
score (p=0.037). Serum sodium returned to baseline values in most patients
after stopping therapy. Four patients (all BCLC D with poor performance
status) died during hospitalization due to other complications.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusion Terlipressin can cause an acute reduction in serum sodium
concentration in most patients with HCC during treatment for portal-
hypertensive bleeding. It develops rapidly after starting therapy, may be
severe in some patients where it can cause neurological manifestations,
but is usually reversible.
165
Comparison of visceral and subcutaneous adipose tissue in lean and
obese non-alcoholic fatty liver disease patients: An observational
study
Manoj Kolhe, Anil Arora, Ashish Kumar, Praveen Sharma
Correspondence- Manoj Kolhe-manojck008@gmail.com
Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder
Nagar, New Delhi 110 060, India
Non-alcoholic fatty liver disease (NAFLD) is major cause of cirrhosis in
India and around the world. Asians are more predisposed to NAFLD at
lower BMI rates as compared to west. Although lean NAFLD population
has been shown to share metabolic features and hepatic pathology as the
classical obese NAFLD, there is lack of linear correlation with adiposity.
As per Framingham heart study the distribution of adipose tissue in the
body has more relevance in the pathogenesis of lean NAFLD. Abdominal
fat is compartmentalized into two parts, visceral and subcutaneous adi-
posity. Lean NAFLD patients also have visceral adiposity as obese pop-
ulations. Visceral fat is a driving factor for insulin resistance, activation of
innate immunity, hepatic inflammation and finally fibrosis. So it is a
necessity of time to quantify subcutaneous and visceral adipose tissue
in patients. It will help to understand the pathogenesis of lean NAFLD.
We studied 52 patients, 25 were lean (BMI =< 23 kg/m2) and 27 were
obese (BMI >23 kg/m2). We evaluated biochemical and imaging profile
in both groups. We quantified the visceral and subcutaneous adipose
tissue at 5th lumbar vertebra by non-contrast computed tomography scan.
Thirty-six out of 52 patients had insulin resistance (HBA1c ≥5.7 gm%).
This study showed that obese NAFLD group has higher visceral fat,
subcutaneous fat and lower visceral to subcutaneous fat ratio (VSR).
On subgroup analysis, non-diabetic lean NAFLD group had lower sub-
cutaneous fat and VSR as compared to obese NAFLD group. In conclu-
sion, lean NAFLD group had lower visceral and subcutaneous fat and
higher VSR. Subcutaneous fat is more in obese NAFLD group. Visceral
fat may be more associated with NAFLD than subcutaneous fat.
166
Clinical profile and factors influencing mortality of patients diag-
nosed with acute hepatitis E in a tertiary center in South India
Damodar Krishnan, Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Gastroenterology, Sri Ramachandra Institute of Higher
Education and Research, No.1, Ramachandra Nagar, Porur, Chennai
600 116, India
Introduction In this study, we aimed to explore the clinical and epidemi-
ological profile of all patients with hepatitis E virus (HEV) who were
admitted to a tertiary care hospital in Chennai, India and to further assess
various factors that influence the prognosis of these patients.
Methods Hospital records of patients who presented with features of acute
hepatitis taking into consideration inclusion and exclusion criteria were
taken from medical records from 2018-2020. History and clinical exam-
ination including the presence of signs of organ failure were obtained.
Investigations collected included routine parameters with viral markers
for HBV, HAV, HCV, HEV. Outcomes are recorded in the form of
discharge or death.
S53
Results Based on the inclusion and exclusion criteria, 43 patients were
analyzed. Males had a higher (81.39% n=35) incidence of HEV infection.
Yellowish discoloration of urine was the most common symptom (n=19,
44.19%) followed by fever (n=16, 37.21%), and icterus was the most
common sign at presentation (n=28, 65.11%). Hepatomegaly was the
most common finding on abdominal examination (n=10, 22.72%).
Overall, mortality observed was 13.90% (n=6), including 2 patients pre-
sented as ACLF and 3 patients developed sepsis. Higher mean prothrom-
bin time-international normalised ratio (PT-INR) (2.08 vs 1.41), total
bilirubin (11.94 vs. 11.01 mg/dL), and direct bilirubin (7.35 vs.
6.43mg/dL) was associated with higher mortality, whereas lower mean se-
rum albumin (2.86 vs. 3.06 gm/dL) was associated with higher mortality.
Increase in renal parameters (i.e, BUN [44.17 vs. 14.46 mg/dL] and creatinine
(1.98 vs. [1.08 mg/dL]) and electrolyte imbalances (i.e. hyponatremia [128.5
vs. 132 mmol/L]) were associated with higher mortality.
Conclusions Higher mean age, duration of hospital stay, PT-INR, total
bilirubin, direct bilirubin, blood urea, serum creatinine, lower mean serum
albumin, and sodium values were associated with higher mortality along
with co-morbidities especially chronic liver disease which can result in
ACLF and cause higher mortality.
167
Circulating tumor cells assessment in patients with hepatocellular
carcinoma by imaging flowcytometry and it`s relationship with stag-
ing - An interim analysis
Partha Debnath, Kruti Dalal*, Shreyasi Athalye*, Bhavik Dalal*,
Saurabh Bansal, Prasanta Debnath, Sujit Nair, Siddhesh Rane,
Shubham Jain, Sanjay Chandnani, Aruna Shankarkumar*, Pravin Rathi
Correspondence- Partha Debnath-partha628@gmail.com
*
Department of Transfusion Transmitted Disease, National Institute of
Immunohaematology (ICMR), Mumbai, India, and Department of
Gastroenterology, Topiwala National Medical College, B Y L Nair
Hospital, Mumbai 400 008, India
Introduction Circulating tumor cells are considered as potential
biomarkers for the detection of hepatocellular carcinoma. It is
expected to play an important role in early diagnosis and dynamic
monitoring. This study aimed to evaluate the relationship of cir-
culating tumor cells with hepatocellular carcinoma Barcelona clin-
ic liver cancer (BCLC) staging.
Methods An imaging flow cytometry method, using immunofluorescence
of cytokeratin, EpCAM, AFP together with the analysis of size, morphol-
ogy and DNA content for detection of circulating tumor cells was devel-
oped and applied to 20 hepatocellular carcinoma patients and 10 patients
with cirrhosis of liver without any evidence of hepatic or extrahepatic
malignancy.
Results Among 20 hepatocellular carcinoma patients 17 (85%) were
male. Two patients were BCLC stage A, 5 were BCLC stage B and
13 were BCLC stage C. Out of 10 cirrhotic patients 7 were CTP B
and 3 were CTP C. Circulating tumor cells were detected in 20 of
20 patients of HCC and none among cirrhosis of liver patients. The
mean number of circulating tumor cells was 9.9 (range 1- 20).
Circulating tumor cells positive for EpCAM were detected in 18
patients with a mean value of 4.6. Circulating tumor cells positive
for cytokeratin were detected in 16 patients with a mean value of
1.8. Circulating tumor cells positive for AFP were detected in all
patients with a mean value of 3.5. The number of circulating tumor
cells was significantly associated with BCLC stage (p<0.0005) and
portal vein thrombosis (p=0.025).
Conclusion This study shows the potential role of circulating tumor cells
as a biomarker of hepatocellular carcinoma and also a significant associ-
ation between the number of circulating tumor cells with BCLC staging
and portal vein thrombosis.
S54
168
Predictors of response to therapy with terlipressin and albumin in
patients with cirrhosis and hepatorenal-acute kidney injury accord-
ing to new International club of ascites criteria
Jatin Agrawal, Ashish Kumar, Anil Arora, Praveen Sharma, Naresh
Bansal, Vikas Singla
Correspondence- Ashish Kumar-jatinagrawal1989@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and
Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar,
New Delhi 110 060, India
Introduction Hepatorenal syndrome-acute kidney injury (HRS-AKI)
or HRS -1 carries high short-term mortality in patients with ad-
vanced cirrhosis. Recently International club of ascites (ICA) has
proposed new definition criteria for HRS and at present we lack
literature on the predictors of response of terlipressin according to
this new definition. So, we aimed to evaluate the response rate of
terlipressin and factors affecting the response rate according to
this new HRS-AKI definition.
Methods We performed a prospective study on 114 cirrhotic patients with
HRS-AKI diagnosed according to ICA definition 2015 from August
2018 to April 2020 using terlipressin and albumin. Baseline clinical and
biochemical details were noted. Response was defined as improvement in
serum creatinine within 0.3 mg/dL of baseline (if baseline s. cr <1.5 mg/
dL) or < 1.5 mg/dL (if baseline s. cr >1.5 mg/dL). Further responder and
non-responder were followed up to 90 days or death.
Results Among 114 HRS-AKI patients the median age was 52.5
years and 83.3% were male. Response to terlipressin was seen in
70 (61.4%) patients. On subgroup analysis, response rate in acute
decompensation (AD) was seen in 37 (78.7%) patients and in acute
on chronic failure (ACLF) was seen in 32 (47.7%) patients.
Independent predictive factors of response to therapy were serum
creatinine before start of terlipressin and baseline Child-Pugh score
(CTP). Response to therapy was associated with improved 90 days
survival compare to patients with non-response (69.56 % vs. 10%,
p<0.00001). The best cut off for serum creatinine that best predicted
response to treatment was 2.3 mg/dL (AUROC, 0.79; p<0.0001;
sensitivity, 87%; specificity, 64%). and for CTP was 12 (AUROC,
0.72; p<0.0001; sensitivity, 84%; specificity, 58%).
Conclusions Serum creatinine before start of terlipressin and CTP
predicts response to terlipressin in HRS-AKI. Early transplantation
should be considered in patients of HRS low likelihood of re-
sponse.
169
HCC mimickers: Unusual presentation
Abhishek Mahajan, Shiran Shetty, Ganesh Bhat, Ananth Pai
Correspondence- Abhishek Mahajan-abhi141191@yahoo.co.in
Department of Gastroenterology, Kasturba Medical College, Manipal
576 104, India
Carcinoid tumors are neuroendocrine origin neoplasms producing sero-
tonin and other functional peptide hormones. 74% carcinoid tumors arise
from GI tract of which 75% metastasize to liver. We present 2 patients
with features of HCC on CT abdomen but were later diagnosed with NET
after histology analysis.
1st case: 43-year-old female presented with low grade fever and loss of appetite
since 1 month. Ultrasound abdomen showed multiple hyperechoic lesions in
liver. CECT abdomen suggested multifocal hepatocellular carcinoma involv-
ing both lobes, largest lesion measuring 10.8 x 9.2 x 14.2 cm. Biopsy revealed
neuroendocrine tumor grade-1, IHC positive for synaptophysin and Ki 67
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
index 2%. Ga-68 DOTANOC PET CT showed multiple somatostatin recep-
tors avid retroperitoneal lymph node and liver metastasis.
Arterial phase Portovenous phase Delayed phase
2nd case: 60-year-old female presented with loss of appetite and mild
right hypochondriac pain since 1 month. CECT abdomen showed few
lesions in liver suggesting multifocal HCC. Biopsy revealed NET – grade
1 with IHC positive for synaptophysin and chromogranin. Ga-68
DOTANOC PETCT showed multiple somatostatin receptor avid hepatic
nodules and para aortic lymphadenopathy.
Arterial phase Porto venous phase Delayed phase
Hence, it’s important to know conditions mimicking imaging appearance
of HCC to avoid false-positive diagnosis of HCC and subsequent man-
agement. A multimodality imaging approach along with a careful review
of clinical and laboratory findings can be helpful when in doubt for these
potential tumor mimicking lesions.
170
Atherosclerotic cardiovascular disease (ASCVD) risk assessment in
non-alcoholic steatohepatitis (NASH), alcoholic steatohepatitis
(ASH), and both alcoholic and non-alcoholic steatohepatitis (BASH)
Dinesh Meher, Debakanta Mishra, Chitta Ranjan Khatua, Subhendu
Panigrahi, Rakesh Barik, Saroj Kanta Sahu, Subhasish Pradhan,
Gautam Nath, Reshu Khandelwal, Prajna Anirvan, Mrinal Gogoi,
Pankaj Bharali, Shivaram Prasad Singh
Correspondence- Shivaram Prasad Singh-scb_gastro_dept@hotmail.com
Department of Gastroenterology, S C B Medical College and Hospital,
Cuttack 753 007, India
Introduction Alcoholic steatohepatitis (ASH) and non-alcoholic
steatohepatitis (NASH) are known to possess increased atherosclerotic car-
diovascular disease (ASCVD) risk. Although, there are studies correlating
severity of liver injury with future cardiovascular risks in ASH and NASH,
in cases of BASH there is very little data on future ASCVD risks.
Aim To assess and compare future ASCVD risks for ASH, BASH, and
NASH patients.
Methods We studied 934 patients with fatty liver during 2010-2019. They
were classified into 3 groups: ASH, BASH, and NASH on the basis of
obesity (BMI ≥25) and alcohol intake. After appropriate matching, 551
included for statistical analysis. Future cardiovascular risk was assessed
using American College of Cardiology (ACC)/American Heart
Association (AHA) guideline of 2013.
Results Of 551 patients, 73 had ASH, 185 had BASH and 253 had
NASH. Using calculator provided by ACC/AHA, median 10-years
ASCVD risk for ASH, BASH and NASH was 4.2%, 2.5% and 1.8%
whereas for control groups (similar characteristics and optimal risk
factors), the median values were 1.7%, 1.3% and 1.2% respectively
with significant differences among them (p<0.0001, 0.0001 and
0.004 respectively). Similarly, the median lifetime ASCVD risk
for each groups was 36%, whereas for control groups (50 year-old
persons with optimal risk factors), it was 5% (p<0.0001) in each.
When inter group comparison was made among the three groups,
median 10 years ASCVD risk was higher in ASH group while me-
dian lifetime risk was same across all 3 groups.
Conclusion Our study shows that in ASH, BASH and NASH, the 10-year
and lifetime ASCVD risk are higher compared to normal healthy individ-
uals of same age and optimal risk factors. Among the three groups, 10-
year median ASCVD risk was highest in ASH although the median
lifetime risk was same across all three groups.
171
Transjugular intrahepatic portosystemic shunt for refractory ascites
in Gaucher’s disease: First case report in literature
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Kunal Adhyaru, Pratik Jaydeokar, Aabha Nagral, Shaji Marar*
Correspondence- Kunal Adhyaru-getkunal12@yahoo.com
Departments of Gastroenterology and Hepatology, and *Interventional
Radiology, Jaslok Hospital and Research Centre, 15, Pedder Road,
Mumbai 400 026, India
Gaucher’s disease is a rare disease, but the most common amongst the
lysosomal storage disorders in India. Patients present with cytopenias and
massive splenohepatomegaly arising from deficiency of beta glucosidase
enzyme. Splenectomised patients may develop portal hypertension and
its complications. The main stay of treatment is enzyme replacement
therapy (ERT).
We report a case of 30-year-old man diagnosed at the age of 8
years with Gaucher’s disease (L444P variation) when he was
splenectomised for a massive splenomegaly. He also had recurrent
bone crisis and underwent bilateral hip joint replacement for avas-
cular necrosis of the femoral head. He had variceal bleeding two
years back followed by development of ascites which had become
refractory in the past 6 months. He was referred to us for liver
transplantation. On examination, he was sarcopenic, had tense
ascites, with hugely dilated veins on the abdominal wall.
Investigations revealed pancytopenia and liver function tests re-
vealed mildly elevated transaminases and an albumin of 1.5g/dL.
He had a high SAAG ascites. He underwent a transjugular study
and was found to have an HVPG of 22 mm Hg. Transjugular
intrahepatic portosystemic shunt (TIPS) was performed with post
TIPS pressures fell to 2 mmHg. The ascites and the dilated ab-
dominal veins resolved significantly after the TIPS procedure over
a period of 2months. He also been started on ERT (imiglucerase).
Few cases of Gaucher disease needing liver transplantation for end-stage
liver disease have been reported in literature with one of these patients
needing TIPS for variceal bleeding. However, ours is the first Gaucher
disease patient in literature to have received a TIPS for management for
refractory ascites
Conclusion TIPS can be used to successfully treat refractory ascites sec-
ondary to severe Gaucher related liver disease.
172
Profile of liver abscess patients in a tertiary care hospital
Ashutosh Gupta, Vinod Kumar Dixit, S K Shukla, D P Yadav, Anurag
Tiwary
Correspondence- Vinod Kumar Dixit-drvkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221 005, India
Introduction Liver abscess is a common disease entity and early diagnosis
and prompt intervention improve the survival and outcome of the disease.
The objective of the study is to assess the clinical profile and management
of liver abscess in the patients attending tertiary care hospital.
Methods This is a retrospective cross-sectional study carried out from
January 2019 to February 2020. A total of 138 patients presenting with
signs and symptoms of liver abscess were accessed. Confirmation of
diagnosis was made by abdominal ultrasound and examination of
aspirates.
Results The mean age of patients was 43.54 years and majority of them
(86.7 %) were males. There was a strong correlation of the occurrence of
liver abscess with addiction to alcohol and history of diabetes mellitus.
Most common presenting complaint was pain abdomen (91.3%) followed
by fever (85.5%), vomiting (27.5%) and abdominal distension (10.1%).
Clinical examination revealed tender hepatomegaly in (70.5%) of cases
while ascites, pleural effusion and icterus were present in (23.6%),
(26.8%) and (13.04%) cases respectively. On evaluation, mean TLC
was 15860/cumm, serum albumin was (2.78 gm/dL) while serum creat-
inine was raised in (8.69%) of patients. The abscess were predominantly
in right lobe (73.9%) and solitary (53.62%) with mean volume of 363.8
S55
mL. Left lobe abscess were present in (10.1%) while both lobes were
involved in (17.39%) of patients. Etiological analysis revealed that 79%
were amebic, 18% pyogenic and 1.4% were tubercular in origin.
Percutaneous needle aspiration was done in 73.9%, pigtail drainage in
23.1% and surgical intervention for rupture in 2.8% patients. Mortality
rate was 1.4%.
Conclusion The commonest presentation was in the middle aged males
with history of alcohol intake having right lobe solitary amebic liver
abscess. Minimally invasive drainage techniques reduced mortality.
173
Neutrophil lymphocyte ratio and platelet lymphocyte ratio are excel-
lent markers for predicting survival and severity of hepatocellular
carcinoma
Sagar Walinjkar, Ashish Kumar, Praveen Sharma, Naresh Bansal, Vikas
Singla
Correspondence- Anil Arora-dranilarora50@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and
Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar,
New Delhi 110 060, India
Background and Aims Hepatocellular carcinoma (HCC) is the 5th
most common malignancy worldwide. Neutrophil lymphocyte ra-
tio (NLR) and platelet lymphocyte ratio (PLR) are the markers
which have been proven useful in prognostication of many ma-
lignancies. We aimed to evaluate the predictive value of NLR and
PLR in prognosticating patients with HCC and to study its asso-
ciation with severity of HCC.
Methods Patients with newly diagnosed HCC getting admitted at our
centre were included in the study. The imaging features, ECOG status
and liver functional status were analyzed and BCLC staging was done.
Patients were given treatment according to the BCLC stage. Pre-treatment
NLR and PLR were calculated from differential leukocyte count. Repeat
imaging was done at 1- and 3-months post treatment. Patients were
followed up for 6 months for survival. Optimum cut off values of NLR
and PLR were calculated by ROC curve analysis. The OS at 6 months
was compared on Kaplan-Meier curve using high and low NLR, PLR
values. Association between NLR and PLR was also tested with BCLC
stages.
Results The optimum cut off for high NLR and PLR were >= 3 and >=
102 respectively. OS rates at 6 months in patients with NLR >= 3 and < 3
were 41% and 93.5% (p< 0.01) and with PLR >= 102 and < 102 were
34% and 88% respectively (p< 0.00). 90.47 % and 96% of BCLC stage C
and D had NLR >= 3 (p 0.000) whereas 71.42% and 84% of BCLC Stage
C and D had PLR >= 102 (p 0.000).
Conclusion NLR and PLR are strong markers for predicting survival and
severity in patients with HCC.
174
Evaluation of fibrosis by transient elastography (Fibroscan) and
acoustic radiation force impuse elastography in Type II DM individ-
uals without overt liver disease
Manjit Kanungo, A Satya Sahi, L R S Girinath
Correspondence- Manjit Kanungo-drmanjitkanungo@gmail.com
Department of Gatroenterology, Andhra Medical College, Jagadamba
Junction, Visakhapatnam 530 002, India
Introduction Patients with non-alcoholic fatty liver disease (NAFLD) and
T2DM have up to 20% advanced fibrosis. Clinicians treating the diabetic
population are underestimating the covert hepatic injury which account
for future complications. This study was conceived to assess the fibrosis
in Type 2 DM without overt liver disease by comparison of various non-
S56
invasive fibrosis scores with Fibroscan and acoustic radiation force
impuse (ARFI) and risk factor determination for advanced fibrosis.
Methods This was a cross-sectional study including Type 2 DM patients
attending Endocrinology OPD of AMC between March 2019 to April
2020 with steatosis on ultrasound. BMI >35 kg/m2, alcohol intake (men
>20 g/d and women >10 g/d), drugs causing steatosis, hepatitis viral
markers were excluded.
Results Among total 100 patients, mean age was 57.80 years. Mean BMI
was 28±2.09 kg/m2. No subject had ALT or AST ≥ 2 x ULN. The mean
value of APRI, NFS, FIB4, ARFI and LSM were 0.41±0.24, -0.58±1.37,
1.56±0.91, 1.44±0.39 and 8.94±2.71 respectively. 0%, 17%, 15%, 47% and
47% were categorized advanced fibrosis (F3/F4) by APRI, NFS, FIB 4,
ARFI and LSM respectively. There was an increasing trend of HbA1c with
fibrosis stage (mean HbA1c=10.54 in F4 group). 28%, 3% and 12% subjects
having advanced fibrosis by LSM values were categorised under low group
of APRI, NFS and FIB 4 respectively. Majority of advanced fibrosis subjects
who were missed by the non-invasive scores had values in the intermediate
groups. APRI, NFS, FIB 4 and ARFI correlated significantly with Fibroscan
(r=0.374, r=0.594, r=0.411, r=0.963, p< 0.001). The AUROC of APRI,
NFS, FIB 4 and ARFI for advanced fibrosis were 0.683, 0.676,0.703 and
0.886 respectively. On multivariate analysis, duration of T2DM, platelet
count and albumin levels were significantly associated with LSM.
Conclusions ARFI had significant correlation with Fibroscan for
predicting advanced fibrosis. Fibroscan and ARFI are useful in assessing
the subjects in the intermédiate zones of the various non-invasie scores.
175
Sarcoidosis presenting as acute liver failure-the first case report
Smitkumar Vaghasia, Yogesh Batra, Milan Kumar Vaghasia
Correspondence- Smitkumar Vaghasia-vaghasiasmit@gmail.com
Department of Gastroenterology, Indraprastha Apollo Hospital, Mathura
Road, New Delhi 110 076, India
Introduction Sarcoidosis is a chronic multisystem disease with different
clinical presentations. Asymptomatic presentation (75%) is the commonest,
but others include jaundice with chronic cholestasis, cirrhosis, portal hyper-
tension, hepatic venous outflow tract obstruction and extrahepatic biliary
obstruction. Cirrhosis and portal hypertension are the rarest manifestation
of hepatic sarcoid and represent less than 1% of all cases. Acute liver failure
as a presentation of sarcoidosis has never been reported before. Here we
present a patient of sarcoidosis presenting with acute liver failure.
Case A 60-year-old man was admitted to the Indraprastha Apollo
Hospital, New Delhi with complaints of fever, jaundice, altered
mental status for 2 days. He had history of pulmonary sarcoidosis
20 years back for which he took medication for around 10 years
after that he stopped medication. Based on history, clinical and
investigational analysis, the patient was diagnosed as a case of
acute liver failure (ALF) with acute insult being probable sarcoid
flare secondary to pulmonary sarcoidosis.
Management He was started on weight based corticosteroid therapy, with
other anti-hepatic coma measures. The patient did not recover clinically
and manifestations of hepatic encephalopathy, worsened substantially.
He was kept on ventilatory, inotropic, CRRT and other supportive treat-
ment. Patient’s relatives were explained for liver biopsy (transjugular
approach) and liver transplant repeatedly but they refused for the same
due to some financial constraints and we lost the patient.
Conclusion The patient of sarcoidosis may present as acute liver failure.
Conservative management of acute liver failure in sarcoidosis associated
with an increased risk of mortality.
176
Association of lifestyle and metabolic risk factors with grades of fatty
liver
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Swapna Chaturvedi*, Neena Bhatia*, Naval K Vikram, Kumble S
Madhusudan, Ravindra Mohan
Correspondence- Swapna Chaturvedi-swapnaaiims@gmail.com
Department of Dietetics, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India, and *Department of Dietetics, Lady
Irwin College, University of Delhi, India
Background and Aim Non-alcoholic fatty liver (NAFL) is a public
health problem in India. We aimed to study association of life-
style and metabolic risk factors with grades of fatty liver (FL).
Methodology NAFL (n=160) cases constituted the study group, FL
was diagnosed by ultrasound of abdomen. Anthropometric and
biochemical parameters were recorded. Lifestyle risk factors
(physical activity, diet, nutrient, snacks and alcohol intake) and
metabolic risk factors as per standard cut-offs were compared in
different grades of FL.
Results Grade 1 FL was present in 69% and grade 2 in 31% of subjects.
The prevalence of lifestyle risk factors were higher in grade 2 FL vs.
grade 1 FL but were non-significant: Low physical activity (57.1% vs.
55.8%), snack intake (87.7% vs. 81.0%), saturated fatty acid >8% of total
calories (18.3% vs. 16.2%), edible oil >25 g for males and >20 g for
females (93.8% vs. 90.9%) alcohol intake (81.6% vs. 78.3%). The prev-
alence of metabolic risk factors were significantly higher in grade 2 FL
versus grade 1 FL: BMI > 25 (87.7% vs. 61.2%), waist circumference
(75.5% vs. 45.0%), WHR (91.8% vs. 76.5%), IGT (24.4% vs. 6.3%),
triglycerides (53.0% vs. 28.8%), metabolic syndrome (MetS) (46.9/%
vs. 22.5%). On univariate regression analysis, grade 2 FL showed posi-
tive association with metabolic factors (OR [95% CI]) for BMI > 25
(11.38 [1.46- 18.37]), waist circumference (3.7 [1.77-7.97]), WHR (3.4
[1.13-4.47]), IGT (4.8 [1.76-13.16]), triglycerides (2.7 [1.39-5.59]), MetS
(3.0 [1.48-6.22]).
Conclusions The worsening grades of fatty liver are associated with met-
abolic risk factors and should initiate workup of patients to avoid progres-
sion of NAFL to severe forms.
177
The triglyceride and glucose index (TyG) as screening biomarker to
identify non-alcoholic fatty liver disease
Hozefa Runderawala, Nutan Desai
Correspondence- Hozefa Runderawala-hozaaee@gmail.com
Department of Gastroenterology, Fortis Hospital Mumbai, India
Introduction Non-alcoholic fatty liver disease (NAFLD) is associated
with insulin resistance. The triglyceride and glucose index (TyG), which
is defined as the product of an individual’s serum levels of triglycerides
(TG) and fasting plasma glucose (FPG), has been recommended as a
reliable and simple surrogate index for insulin resistance. NASH is diag-
nosed on basis of ultrasound and biochemical tests and exclusion of other
etiologies for liver disease. We compare the ability of triglyceride and
glucose index (TyG), compared with alanine aminotransferase (ALT), to
identify individuals at risk for NAFLD.
Methods Patients more than 18 yrs of age attending our institution health
check-up OPD were screened as per inclusion and exclusion criteria
between December 2019- March 2020. Pregnant women and those with
significant alcohol intake, history of diabetes mellitus, hypertension, dys-
lipidemia, viral hepatitis or any known liver disease were excluded.
Routine blood parameters were noted and fatty liver assessed as the pres-
ence or absence of hepatic steatosis by abdominal USG. The TyG is
calculated with established formula: TyG= Ln (Tg [mg/dL] X FBS
[mg/dL]/2).
Results A total of 95 people were enrolled, among which 53 were
(56%) found to have fatty liver by abdominal USG. TyG index
was calculated by using above mentioned formula and taking cut
off value of 8.6, and that for ALT of 40 IU/L, Sensitivity of TyG
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
index is 72% and for ALT is 27.08%, also negative predictive
value (NPV) for TyG index is 82.35% and for ALT is 54.5%. By
using McNemar Chi-square Test, p value is found to be signifi-
cant with p <0.01.
Conclusion TyG index is found to have higher sensitivity in comparison
with ALT for an effective screening biomarker to identify NAFLD.
178
Non-alcoholic fatty liver disease as independent risk factor for coro-
nary artery disease
Simna L, Krishnadas Devadas, Anjukrishna K, Nibin Nahaz, Jijo
Varghese, Tharun Tom Oommen, Athul Hareendran
Correspondence- Simna L-shyamsasi04@gmail.com
Department of Medical Gastroenterology, Government Medical College,
Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011,
India
Background Non-alcoholic fatty liver disease (NAFLD) is currently
the most common cause of chronic liver disease. The leading cause
of mortality in NAFLD patients is coronary artery disease (CAD).
Our study attempts to evaluate whether NAFLD is an independent
risk factor for CAD and to study the correlation between hepatic
steatosis and fibrosis with subclinical atherosclerosis.
Methods Case control study.125 cases with angiographic proven
CAD and 125 controls with normal angiogram were enrolled after
informed consent and subjected to sonography and blood investi-
gations. Carotid intima media thickness (CIMT) measurement was
also done to assess subclinical atherosclerosis. Hepatic steatosis
was measured by sonographic grading of fatty liver. Liver stiff-
ness measurement was done to assess fibrosis.
Results 65.6% (82/125) of cases were found to have NAFLD and it was
found to be an independent risk factor for CAD (adjusted OR= 2.6955,
p=0.0079). On multivariate analysis, the other independent risk factors
for CAD were male gender (adjusted OR=52.8314 (17.6521 - 158.1206),
p=0.001), waist to hip ratio (adjusted OR=59.7407 (1.6755 - 2130.0431),
p=0.0249), Type 2 diabetes mellitus (adjusted OR=2.3453 (1.1574-
4.7526), p=0.018), systemic hypertension (adjusted OR=2.9748
(1.4559-6.0785, p=0.0028) and smoking (adjusted OR=2.087 [1.2333 -
3.5316], p=0.0079). Mean CIMT did not differ between the two groups.
Subgroup analysis of NAFLD patients showed that mean CIMT differ
significantly between NAFLD with and without CAD patients. A mean
CIMT value of 0.55 mm had a sensitivity of 81% and specificity of 68%
(AUROC=0.696, p=0.0001) in predicting CAD in NAFLD patients.
Hepatic steatosis measured by sonographic grading of fatty liver correlat-
ed with CIMT (r=0.423, p<0.001). Liver fibrosis measured by liver stiff-
ness measurement did not correlate with CIMT (r=0.09, p=0.117).
Conclusions NAFLD is a risk factor for CAD independent of other tra-
ditional risk factors. In NAFLD patients hepatic steatosis not fibrosis
correlated with subclinical atherosclerosis.
179
Clinico-biochemical risk factors for non-alcoholic steatohepatitis and
significant fibrosis in patients with non-alcoholic fatty liver disease
Saroj Kanta Sahu, Rakesh Kumar Barik, Subhasis Pradhan, Dinesh
Meher, Reshu Khandelwal, Gautam Nath, Prajna Anirvan, Pankaj
Bharali, Mrinal Gogoi, Prasant Kumar Parida, Sambit Kumar Behera,
Kaibalya Ranjan Dash, Shivaram Prasad Singh, Kaumudi Pattnaik,
Pallavi Bhuyan
Correspondence- Shivaram Prasad Singh-scb_gastro_dept@hotmail.com
Department of Gastroenterology, S C B Medical College, Cuttack 753
007, India
S57
Introduction and Aim In patients with non-alcoholic fatty liver disease
(NAFLD) presence of non-alcoholic steatohepatitis (NASH) and/or sig-
nificant fibrosis (stage 2 to 4) is a key driver of liver disease-related
morbidity and mortality. Our aim is to identify the clinical and biochem-
ical risk factors associated with the presence of NASH and significant
fibrosis.
Methods Two hundred and forty-three consecutive biopsy-proven
NAFLD patients with clinical, anthropometric, biochemical, and liver
biopsy data (from 2013 to 2020) were included in the study.
Appropriate statistical analysis was done. P-value <0.05 was considered
significant.
Results The mean age of patients was 40.14 ± 9.36 years (range: 17 to 64
years) with a male to female ratio of 5.5:1. On liver biopsy 75 (37.28%)
patients had definite NASH and among them, 11 (15.1%) had significant
liver fibrosis (stage 2 or 3). Patients with concomitant NASH and signif-
icant fibrosis had significantly higher BMI, waist circumference, fasting
blood sugar, and serum aspartate aminotransferase levels. On uni-
variate analysis high AST/ALT ratio, TC/HDL ratio >3.5, insulin
resistance (IR) (HOMA IR >2) were the risk factors for concom-
itant NASH and significant fibrosis. On multivariate logistic re-
gression analysis, the only risk factors significantly associated
with concomitant NASH and significant fibrosis were high TC/
HDL ratio (OR= 1.524, 95% CI= 0.591-2.821, p=0.001) and IR
(OR=1.224, 95% CI= 0.360-2.684, p=0.047).
Conclusion Insulin resistance and TC/HDL ratio >3.5 were the
independent risk factors for the presence of concomitant NASH
and significant fibrosis. Patients with fibrotic NASH are at higher
risk of disease progression. So a high TC/HDL ratio >3.5 and
insulin resistance could identify the cohort of patients who are
at risk of progression of NAFLD and need timely intervention
with lifestyle modification and drugs.
180
A comparative study of non-A-E hepatitis with acute viral hepatitis
and autoimmune hepatitis - An interim analysis
Siddhesh Rane, Rahul Deshmukh, Shubham Jain, Sujit Nair, Saurabh
Bansal, Sameet Patel, Qais Contractor, Pravin Rathi
Correspondence- Siddhesh Rane-sid.6173@gmail.com
Department of Gastroenterology, Topiwala National Medical College, B
Y L Nair Charitable Hospital, Mumbai 400 008, India
Introduction The objective was to compare clinical/laboratory features
(and histopathology as needed) of non-A-E hepatitis with acute viral
and autoimmune hepatitis (AIH) and determine whether etiology is likely
to be viral or autoimmune.
Methods Cases of acute hepatitis were evaluated to segregate acute viral,
autoimmune and non-A-E hepatitis. Viral hepatitis was diagnosed by
viral serology. All the patients with negative viral serology and revised
AIH score between 10-14 (probable AIH) underwent liver biopsy.
Patients with negative conventional serology for AIH were tested for
other liver-defined autoantibodies. Those with post-biopsy revised AIH
score > 15 were diagnosed as AIH and rest were considered as non-A-E
hepatitis. Patients were followed up for 3 months.
Results Of 107 patients presenting with acute hepatitis, 8 (7%) had
non-A-E hepatitis, 10 (10%) AIH (acute presentations), 13 (12%)
acute viral hepatitis (hepatitis A, B, E). Jaundice, anorexia and
nausea were the most common presentations (100%) of non-A-E
hepatitis followed by fatigue (87.5%). Three out of 8 (37.5%)
patients with non-A-E hepatitis were males. Median age was 44
years (range 15-55). Total bilirubin was 11 mg/dL (range 4.5-
16.1), aspartate and alanine aminotransferases were 575 and 717
U/L (range 273-1665 and 445-2245 U/L, respectively). Two
(25%) patients had anti-nuclear antibody and 1 (12.5%) had
S58
anti-smooth muscle antibody positive. Three (37.5%) had raised
immunoglobulin G (median 14.6 gm/L, range 11.1-28.2 gm/L).
No patient developed liver failure or recurrent hepatitis.
Bilirubin, aspartate and alanine aminotransferases were not signif-
icantly different between all the groups. Non-A-E hepatitis is
more likely to have albumin >3.5 gm/dL compared to AIH
(p=0.006) but no difference in INR seen. Patients with AIH are
more likely to have anti-nuclear and anti-smooth muscle antibod-
ies (p=0.01), raised immunoglobulin G (p=0.006), interface
hepatitis/lymphoplasmacytic infiltration/rosette formation on histo-
pathology (p=0.0001) as compared to non-A-E hepatitis.
Conclusion Non-A-E hepatitis can present as a self-limiting illness.
Etiology is less likely to be autoimmune.
181
Change in frailty status with nutritional therapy in cirrhotic patient:
A randomized controlled trial
Surendra Khunte, Sudhir Maharshi
Correspondence- Sudhir Maharshi-sudhir.maharshi@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College and
attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Frailty is characterized by low physiologic reserve and de-
creased functional status. Whether frailty status in patient with cirrhosis
reduces with nutritional intervention is not well studied. Aim was to
assess the effects of nutritional therapy on change in frailty status in
cirrhotic patients.
Methods In a tertiary care centre in Jaipur, India, patients with cirrhosis
were randomly assigned to groups received nutritional therapy (30–35
kcal/kg/day, 1.0–1.5 g vegetable protein/kg/day; (n= 47) or no nutritional
therapy (patients continued on their same diet (n = 47) for 6 months.
Frailty status was assessed by liver frailty index (LFI) and gait velocity.
Primary endpoints were improvement or worsening in frailty status at the
end of 6 months.
Results Till date total 104 patients were enrolled. Forty patients were
analyzed in each group. Alcohol (70%) was most common etiology.
Baseline characteristics like age, body mass index (BMI), hemoglobin,
MELD score, mid arm circumference (MAC), hand grip, gait velocity
and LFI were comparable in both the groups. At the end of 6 months there
were significant improvement in hand grip strength (30.02 ± 3.01 vs.
26.17 ± 3.14, p= <0.001), MAC (24.59 ± 2.5 vs. 21.16 ± 2.27, p= <
0.001), gait velocity (0.91 ± 0.25 vs. 0.69 ± 0.32, p= <0.002) and LFI
(3.84± 0.34 vs, 4.14 ± 0.32, p= <0.001) in nutritional therapy group
compare to no nutritional therapy group.
Conclusion Based on a randomized controlled trial performed, nutritional
therapy is effective in the improving the frailty status.
182
Small intestinal bacterial overgrowth in patients with non-alcoholic
fatty liver disease- A tertiary care centre experience
Gursimran Kaur, Rinkesh Kumar Bansal, Avnish K Seth, Varun Gupta,
Gourdas Choudhuri
Correspondence- Gourdas Choudhuri-choudhuri.gour@gmail.com
Department of Gastroenterology and Hepatobiliary Sciences. Fortis
Memorial Research Institute, Sector - 44, Opposite HUDA City Centre,
Gurugram 122 002, India
Background The pathogenesis of non-alcoholic fatty liver disease
(NAFLD) is multifactorial. The gut microbiota has been suspected to
contribute to the pathogenesis of NAFLD through several mechanisms.
We evaluated the prevalence of small intestinal bacterial overgrowth
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
(SIBO) in NAFLD and its association with various lab parameters and
anthropometric measurements.
Methods One hundred patients with NAFLD (63 males)- diagnosed by
imaging, were enrolled. They were subjected to glucose hydrogen breath
test (GHBT). Anthropometric parameters and lab parameters (liver func-
tion tests, lipid profile, platelet count) were noted.
Results Of 100 NAFLD patients, 43/100 (43%) had SIBO. A significantly
higher number of patients with SIBO had elevations in transaminases:
AST (55.56% vs. 44.44%, p=0.029), ALT (60.61% vs. 39.39%,
p<0.006). There was also a significant relative risk of increase in trans-
aminases with SIBO –positive status: AST - 1.657 (95% CI, IQ range
0.985-2.788), and ALT- 2.039 (95% CI, IQ range 1.165-3.568). Both
these findings were more pronounced in females. The mean AST
(38.58 ± 16.66 IU/L vs. 32.28 ± 15 IU/L, p = 0.025) and mean ALT
(41.12 ± 21.28 IU/L vs. 33.96 ± 19.65, p= 0.043) values were also higher
in patients with SIBO. Majority of patients enrolled in our study had high
BMI (32.05 + 3.07 kg/m2), increased waist circumference (36.29 + 4.88
inches) and high mean cholesterol (167.4 ±30.22 mg/dL). There was no
significant relation of SIBO with grade of obesity, increased waist cir-
cumference, lipid profile (including serum triglyceride levels) or aspartate
aminotransferase to platelet ratio index (APRI) score in our patients.
Conclusion SIBO is prevalent in NAFLD patients and is associated with
significant derangement in aminotransferases. Patients with SIBO may
benefit from aggressive control of risk factors for NAFLD.
Keywords SIBO, NAFLD, Dysbiosis, Hydrogen breath test
183
Small intestinal bacterial overgrowth is more prevalent in non-
alcoholic fatty liver disease
Gursimran Kaur, Rinkesh Kumar Bansal, Avnish K Seth, Mahesh Kumar
Gupta, Gourdas Choudhuri
Correspondence- Gourdas Choudhuri-choudhuri.gour@gmail.com
Department of Gastroenterology and Hepatobiliary Sciences. Fortis
Memorial Research Institute, Sector - 44, Opposite HUDA City Centre,
Gurugram 122 002, India
Background The underlying mechanism for the development and pro-
gression of non- alcoholic fatty liver disease (NAFLD) is complex and
multifactorial. Studies have suggested the role of gut microbiota and,
association of small intestinal bacterial overgrowth (SIBO) with
NAFLD. We investigated the frequency of a SIBO in NAFLD.
Methods One hundred patients with NAFLD-diagnosed by imaging, and
20 healthy volunteers were enrolled. They were subjected to glucose
hydrogen breath test (GHBT) for detection of SIBO. Anthropometric
parameters were noted and compared in both groups. Lab parameters
were noted in NAFLD patients.
Results Of 100 patients of NAFLD 43/100 (43%) tested positive for SIBO,
and 6/20 (30%) tested positive in control group. This was not a statistically
significant difference (p=0.140). Obesity parameter remained associated
with NAFLD-healthy volunteers had a significantly lower BMI (27.09 +
4.03 kg/m2 vs. 32.05 + 3.07 kg/m2, p=<0.001), waist circumference (32.05
+ 3.07 inches vs 36.29 + 4.88 inches , p=<0.001) than NAFLD patients. In
NAFLD patients-elevation in transaminases was significantly more preva-
lent in patients with SIBO: AST (increased in 55.56% vs. 44.44%,
p=0.029), ALT (increased in 60.61% vs. 39.39%, p< 0.006). Also, among
those testing positive for SIBO in NAFLD- the relative risk of increase in
transaminases was significant: AST - 1.657 (95% CI, IQ range 0.985-
2.788), and ALT- 2.039 (95% CI, IQ range 1.165-3.568).
Conclusion SIBO is more prevalent in NAFLD, than healthy population.
Obesity parameters remain associated with NAFLD. SIBO may contrib-
ute to progression of liver disease.
Keywords SIBO, Hydrogen Breath Test, Gut microbiota, NAFLD
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
184
Langerhans cell histiocytosis - a rare and unusual case of obstructive
jaundice in a child
Harsha Vardhan Ganta, Ramesh Kumar B, Ramanna M
Correspondence- Harsha Vardhan Ganta-drharsha.rocks@gmail.com
Department of Medical Gastroenterology, Osmania General Hospital,
Afzalgunj Road, Afzal Gunj, Hyderabad 500 001, India
Background Langerhans cell histiocytosis (LCH) is an abnormal accu-
mulation of Langerhans cells in various organs that sometimes induces
organ dysfunction. LCH can affect the liver, resulting in sclerosing
cholangitis and biliary cirrhosis. However, liver and bile duct involve-
ment is usually observed in the disseminated form of LCH. We here in
report a rare case of LCH presented to us with cholestatic jaundice with
skin manifestations.
Case Presentation A 1-year-old girl with elevated liver enzymes, ob-
structive jaundice with crusted lesions on scalp and pruritic skin
lesions on hands and feet presented to our OPD TORCH panel
was negative. CECT abdomen and MRCP where normal except for
borderline hepatomegaly. Sections of liver biopsy showed histiocytic
cell proliferation with sclerosing fibrosis of portal tracts and IHC
revealed histiocytoses that were positive for Langerin, S-100 protein,
and CD1a. histiocytic cell proliferation was noted in the liver tissue
and correlated with skin biopsy findings. The definitive diagnosis
was LCH with skin and hepatic involvement. The patient was initi-
ated on prednisolone and vinblastine as bridge therapy prior to liver
transplantation with good response under follow-up.
Conclusions LCH can affect the liver rarely. LCH should be considered as a
differential diagnosis if pediatric patients show the presence of cholestatic
jaundice with skin lesions. sclerosing cholangitis is unusual complication and
eventually progress to cause cirrhosis and may require liver transplantation.
Keywords Langerhans cell histiocytosis, Sclerosing cholangitis, Biliary
cirrhosis, Liver transplantation
185
A study of acute kidney injury in cirrhosis of liver with special ref-
erence to precipitating factors and outcome
Saket Agrawal, Asokananda Konar, Bhaskar Bikash Pal
Correspondence- Asokananda Konar-asoke.konar@gmail.com
Department of Medical Gastroenterology, Peerless Hospital and B K Roy
Research Institute, 360, Pancha Sayar Road, Sahid Smirity Colony,
Pancha Sayar, Kolkata 700 094, India
Introduction Cirrhosis is frequent cause of death mostly as a result of
complication predominantly including sepsis and/or renal failure. Acute
kidney injury (AKI) is a common complication in cirrhotic estimated as
19% of hospitalization and mortality of 55% to 91%.
Methods A total 94 patient (74 (M) and 23 (F)) with either newly diag-
nosed or known case of cirrhosis of liver, admitted with AKI or developed
AKI during hospital stay with no documented renal parenchymal disease
were studied with AKI diagnosed by International club of ascites criteria
followed by history, medical evacuation and testing including creatinine,
LFT, lactate, uNGAL and then classified into types, stages of AKI and
followed till either death or discharge from hospital.
Results Mean age (56.79 +11.74 yrs) CTP score (10.41 + 1.75) and
MELD score of (24.84 + 7.97). NASH (41.5%) and alcoholism
(28.7%) were cause of cirrhosis. Cause and stage of AKI were prerenal
AKI (52.1%), HRS (28.7%) and ATN (19.1%) with Stage 1 (38.3%),
Stage 3 (31.9%) and Stage 2 (29.8%) AKI respectively. Majority of
prerenal AKI shows complete response with minority of ATN shows
response. 25.53% expired (predominantly male) with death classified
seen in ATN (37.5%), HRS (33.33%) and prerenal (29.1%), 41.66%
S59
(Stage3) 37.5% (stage 2) and 21% (Stage1). Hemodialysis is required
in 27.7% as modality of treatment majority in ATN and Stage3 AKI with
38.5 % of these patients didn’t recovered from HD. Urinary NGAL was
tested in 43 patients with 60.5% patients having level > 121 ng/mL with
level 1340.91 (ATN) and 727.49 (death). uNGAL is 84.2% sensitive and
54.2% specific for predicting mortality (cut-off 111.7ng/mL) and 100%
sensitive and specific for detecting ATN (cut-off value 771.9 ng/mL).
Conclusion Prerenal AKI is most common cause of AKI but hav-
ing better prognosis with ATN having highest mortality and most-
ly requiring HD. uNGAL is sensitive method to detect ATN lead-
ing to early diagnosis, improve prognosis and henceforth
predicting mortality.
Keywords uNGAL -neutrophil gelatinase associated lipocalin, AKI,
ATN, HRS
186
Normal reference range of liver stiffness measurement (LSM) by
transient elastography (TE) in healthy Indian children
Krishnadas Devadas, Nibin Nahaz, Avisek Chakravorty
Correspondence- Avisek Chakravorty-avisek.doc@gmail.com
Department of Medical Gastroenterology, Government Medical College,
Thiruvananthapuram 695 011, India
Introduction The use of liver transient elastography (TE) to assess liver
fibrosis is attractive for its non-invasiveness, but reference values in
Indian paediatric population has not been established.
Objectives We aimed to determine the liver stiffness (LS) and controlled
attenuation parameter (CAP) for healthy children in the age group 5-12
years, and to determine whether liver fibrosis is age dependent in
children.
Methodology We conducted a school based cross-sectional study in
Kerala, India for healthy children of age 5-12 years. Fatty liver
screening was done with ultrasound. TE and CAP were measured
using Fibroscan 502 Touch using M probe. Children were
grouped in to 2 groups, 5-8 years and 9-12 years. Student t test
was used to compare the mean for TE and CAP.
Results Total 110 children were screened. 60.9% (67) were male and
39.1% (43) female. 47.2% (52) belonged to 5-8 years age group and
52.8% (58) in 9-12 years group. 3.6% (4) children had fatty liver by
ultrasound. Pooled mean TE was 4.496±0.29 KPa (95%CI). For 5-8 years
group mean was 4.19±0.43 and for 9-12 years group 4.77±0.38 KPa.
Mean difference of TE was statistically significant (p value=0.027).
Mean difference was significant (4.19 vs. 4.73 KPa, p=0.036) even after
excluding children with fatty liver. Pooled mean for CAP was 180.01
±2.99dB. Mean difference between the 2 groups (5-8 years 178.1
±3.8dB vs. 9-12 years 181.7±4.4dB) was not statistically significant. In
the 4 children with fatty liver, the mean CAP was 198.5dB. None of the
children with fatty liver had steatosis according to CAP adult standards of
241dB.
Conclusion TE values in children increases with age. However, values in
children may be much less than in adults. CAP is age independent.
However, CAP value standards of 24dB to diagnose fatty liver may not
be applicable to Indian children.
Keywords Pediatric NAFLD, Transient elastography, Liver stiffness mea-
surement, Controlled attenuation parameter
187
Hepatitis B and C viral infections in chronic liver disease: Experience
from a resource constrained region of Asia
Chitta Ranjan Khatua, Saroj Kanta Sahu, Shivaram Prasad Singh
Correspondence- Chitta Ranjan Khatua-chittamedicine@yahoo.co.in
S60
Department of Medicine, MKCG Medical College and Hospital, Medical
College Campus, NH59, Brahmapur 760 004, India and Department of
Gastroenterology, S C B Medical College, Cuttack 753 007, India
Introduction Chronic liver disease (CLD) is associated with serious com-
plications and increased mortality, and is caused by different etiologies
like alcohol use, chronic viral hepatitis B (CHB), chronic viral hepatitis C,
and other etiologies. However, the prevalence of chronic hepatitis B,
hepatitis C infection in CLD patients has not been assessed in this region
of Asia. Hence, we performed this prospective study to evaluate the
prevalence and spectrum of hepatitis B, and hepatitis C related CLD
and its outcome.
Method A prospective study was carried out in consecutive CLD patients
hospitalized in the Gastroenterology Department, SCB Medical College
between December 2016 and October 2018. On admission all CLD pa-
tients were screened to identify the underlying etiologies. Further the
demographic, clinical, and laboratory parameters were recorded and sur-
vival during hospitalization was recorded.
Results Out of 708 CLD patients, alcohol was the underlying etiology in
59.7% (n=423) patients, CHB in 16.4% (n=116) patients, both alcohol and
CHB in 2.4% (n=17) patients, chronic viral hepatitis C in 0.8% (n=6) patients
and other etiologies in in 20.6% (n=164) patients. Among the patients with
chronic viral hepatitis B and C, 78.4% (n=109) were male, mean age was
53.39±12.42, BMI was 20.85±3.09, MELD UNOS score was 18.39±10.84,
MELD Na+ score was 20.09±2.50, and CTP score was 10.01±3.33. More no
of patients were admitted with severe liver disease (5% [n=7]) had Child A,
37.4% (n=52) had Child B, and 57.6% (n=80) had Child cirrhosis], and more
importantly 5% of patients died during hospitalization.
Conclusion In our institution chronic viral hepatitis B or C were found to
be the underlying etiologies of CLD in one fifth of patients. 95% of the
patients were hospitalized with either Child B or Child C cirrhosis and
were associated with mortality during hospitalization.
Keywords Chronic liver disease, Hepatitis B, Hepatitis C
188
Skin and soft tissue infections (SSTI) in cirrhotics: Bacteriology, clin-
ical profile and outcome
Gautam Vinay Kumar Budumuri, Itish Patnaik, Anand Sharma, Rohit
Gupta
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Background Skin and soft tissue infections (SSTI) are among the com-
mon bacterial infections noted in patients with cirrhosis and are related to
hypoalbuminemia and edema.
Aims This study aimed to determine the clinical profile, bacteriology and
in-hospital mortality in patients with cirrhosis with SSTI.
Methods In this retrospective study, we analyzed patients with cirrhosis
presenting to our department with soft tissue infections (SSTI) between
March 2019 and June 2020. Clinical and laboratory data were retrieved
from hospital records. Data retrieved included demographics, etiology,
comorbidity, cirrhosis related complications, site of Cellulitis, baseline
investigations, wound culture, blood, urine, and ascitic fluid culture and
clinical outcome.
Results During the study period, 387 patients with cirrhosis were admit-
ted, of whom 29 (7.5%) had skin and soft tissue infections (median
[IQR]) age 44.5 [16) years; 75.9% w]ere males, model for end-stage liver
disease score (MELD) score 27 (14), Child-Pugh (CTP) score 12 (3).
Etiology of cirrhosis was alcohol in 45%, hepatitis C virus in 27.6 %.
20.7% (6/29) had diabetes mellitus. Lower limbs were most commonly
involved. Of the 29 patients, cellulitis was noted in 15 (52%), ulcers in 10
(34.5%). Cultures were positive in 58.6% (17/29) patients. The majority
of cultures showed monomicrobial growth with predominant gram-
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
negative bacteria 64.7% (11/17). E coli 35.2% (6/17) was the commonest
isolate, followed by Klebsiella 10.3% (3/17). 11 (34.4%) patients died
during the hospital stay. Compared to non-survivors, survivors had higher
CTP score (13 [2] vs. 12 [4], p < 0.05).
Conclusion SSTI was noted in 7.5% of patients with cirrhosis. Alcohol
was the most common etiology of cirrhosis in these patients. Gram-
negative bacteria (E. coli and Klebsiella) were the most common bacterial
isolates. In-hospital mortality was noted in 34.3% of patients and was
higher in patients with higher CTP and MELD score.
Keywords Liver cirrhosis, Soft tissue infections, Bacteriology
189
Diffusion MRI in focal liver lesions and role of apparent diffusion
coefficient (ADC) in Barcelona clinic liver cancer (BCLC) staging of
hepatocellular carcinoma
Sujit Nair, Prasanta Debnath, Parmeshwar Junare, Siddhesh Rane,
Partha Debnath, Sanjay Chandnani, Ravi Thanage, Shubham Jain,
Pravin Rathi
Correspondence- Sujit Nair-sujitnair12345@gmail.com
Department of Gastroenterology, Topiwala National Medical College
and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai
Central, Mumbai 400 008, India
Introduction Diffusion weighted imaging has resulted in enhanced disease
detection and characterization with easy implementation techniques. The
quantitative apparent diffusion coefficient derived shows good measurement
reproducibility, which can be applied for tissue characterization, assessment of
tumor response and disease prognostication. We compared the diagnostic
utility of diffusion weighted imaging with conventional MRI in benign and
malignant focal liver lesions and compared the apparent diffusion coefficients
with Barcelona clinic liver cancer (BCLC) stage of hepatocellular carcinomas.
Methods Fifty patients of focal liver lesions were prospectively evaluated
by Diffusion Weighted-MRI and conventional MRI after approval of
Ethics Committee. ADC values of each benign and malignant lesion were
calculated. Ten patients of HCC were staged as per the BCLC staging.
The liver imaging in HCC patients was standardized with LI-RADS
(Liver imaging Reporting and Data system).
Results Of 210 focal liver lesions in 50 patients, 84 were benign lesions
and 126 were malignant lesions. Most common lesion was metastasis
(52.8%). There is significant difference between T2WI and DWI for
detection of malignant lesions. There was no difference between the use
of T2 weighted imaging and DWI for the detection of benign hepatic
lesions in our study. The mean ADC values of malignant lesions were
significantly lower than those of benign lesions (0.90 x 10-3 mm2/s vs.
2.52 x 10-3 mm2/s) (p<0.001). There was significant difference between
the mean ADC values of HCC and metastasis (p-value<0.001). Lower the
ADC values of the lesions, patients had a poorer outcome as per the
BCLC staging.
Conclusion DWI can be used as the imaging modality to differentiate
malignant from benign liver lesions, thus avoiding unnecessary biopsies.
Its utility in the assessment of diffuse hepatic parenchymal diseases is still
at a research level. Further investigations are needed to increase the reli-
ability of the technique for these indications.
Keywords Diffusion MRI, Apparent diffusion coefficient (ADC),
Hepatocellular carcinoma
190
Age and gender variations of FIB 4 score in fatty liver
Bhargav V Y, Mayank Jain, Alen Tom, Preetam Arthur, Shweta D,
Karthikeyan M U, Chandan Kumar Kedarisetty, Thamarai Selvan S,
Jayanthi Venkataraman
Correspondence- Bhargav V Y-varanasi.b4@gmail.com
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Arihant Hospital and Research Centre, 283-A, Gumasta Nagar, Scheme
71, Indore 452 009, India, and Department of Hepatology, Sri
Ramachandra Medical College and Research Institute, Chennai 600
116, India
Background FIB 4 score is known to have a significant negative and
positive predictive value in predicting lower and higher grades of liver
fibrosis.
Aim Correlate FIB-4 score with grades of fatty liver (FL) amongst men
and women greater and less than 45 years.
Methods Prospective data on hemogram, liver biochemistry, and ultra-
sound (USG) was collected in master health check. USG findings were
classified as normal, Gr 1, 2, and 3 FL, FIB-4 was calculated. Patients
with known liver disease were excluded. Cut-off of 45 years was taken for
comparison between men and women.
Statistical Analysis Appropriate non-parametric tests were used. AUROC
was obtained for the FIB-4 cut-off. SPSS version 23.0 version was used.
Results There were 741 subjects (474 men; 64%). 418 (56.4%) were > 45
years. Liver was normal in 297 (40.1%); grade 1, 2 and 3 FL in 293
(39.5%), 114 (15.4%) and 37 (5%) subjects respectively. The overall
mean FIB-4 score was high in males (1.37 ± 1.06 vs 1.15±0.83, p value
0.009) and remained so, for > 45 years (1.69+ 1.09 vs. 1.33+ 0.88, p value
0.000) and < 45 years (1.01±0.90 vs. 0.87±0.66; p NS). Mean FIB-4
scores increased with grades of FL (p 0.126). AUROC was 0.538,
0.516 and 0.602 respectively for Gr 1, 2 and 3 respectively.
Conclusion FIB-4 score in our study is lower than that reported in the
west with a poor prediction for any grade of FL.
Keywords FIB 4, Fatty liver
191
Perspectives in hepatocellular carcinoma management in a tertiary
care centre in South India
Nithin Kumar, Praveen Mathew, Prashant Kanni, Chandra Babu,
Manoj Gowda, Achal Garg, Jaseem Ansari, Raghuveer Balabadra
Correspondence- Nithin Kumar-nithinnagraj08@gmail.com
Department of Gastroenterology, Vydehi Institute of Medical Science
and Research Centre, 82, Near BMTC 18th Depot, Vijayanagar,
Nallurhalli, Whitefield, Bengaluru 560 066, India
Background and Aims Hepatocellular carcinoma (HCC) is a primary
cause of liver cancer leading to death worldwide. Meanwhile, in a country
like India where because of financial constraints for patients, liver trans-
plantation is not popular in spite of being offered to patients. Thus, HCC
is managed with the best available treatment options.
Methods Prospective study was conducted in which a total of 21 diag-
nosed cases of HCC patients were managed and treatment strategy was
planned according to Barcelona Clinic Liver Cancer staging over a period
of 3 years.
Results Study showed male predominance (85%). Mean age was 65+/- 5
years. The etiology was mainly hepatitis B (70%), followed by hepatitis C
(25%). 60 % patients were asymptomatic. Serum alpha fetoprotein was
raised in 45% of patients. Unresectable cases underwent loco regional
therapy. Trans arterial chemoembolization (TACE) was done in 9 pa-
tients, radiofrequency ablation (RFA) in 3 patients, TACE+RFA in 6
patients, TACE + ethanol ablation in 1 patient , TACE followed by
curative partial hepatectomy in 1 patient and only sorafenib in 1 patient.
Median survival of patients is 2 years after TACE + RFA with no recur-
rence; TACE patients had a median survival of 6-8 months in which 44%
had recurrence. RFA patient’s survival is around 1 year, after which the
patient developed recurrence. TACE + ethanol and TACE + surgery
patients are on follow-up with no recurrence.
Conclusion HCC is potentially curable if discovered in its initial stages.
Strategies for early diagnosis and treatment of HCC is a way to decrease
mortality.
S61
Keywords Hepatocellular carcinoma, Radiofrequency ablation, Trans ar-
terial chemoembolization
192
Giant cavernous hemangioma of left lobe of liver with epigastric
herniation: A rare presentation in postmenopausal woman
Nikhileswar Yandamuri, Ramesh Kumar B, Ramanna M
Correspondence- Nikhileswar Yandamuri-itsnikhil.rio@gmail.com
Department of Medical Gastroenterology, Osmania Medical College And
General Hospital, 5-1-876, Turrebz Khan Road, Troop Bazaar, Koti,
Hyderabad 500 095, India
Introduction Cavernous hemangioma is the most common benign tumor
of the liver and is found in as many as 7% of autopsies. Women are
predominantly affected (6:1) and often present at a younger age.
Majority are small (<2cm), predominantly in right lobe of liver and are
discovered incidentally during imaging of the liver for another reason.
Those larger than 5 cm are called giant cavernous hemangiomas. Upper
abdominal pain is the most common complaint. We report a case of
elderly female with giant hemangioma occupying entire left lobe present-
ing as epigastric hernia.
Case Report Sixty-two year-old female patient presented with pain
abdomen and distension since 3 months. She had prior history of
abdominal surgery 10 yrs back (no records). On examination she
had swelling in midline in epigastric region becoming prominent
while coughing. USG abdomen-midline defect noted at epigastric
region with herniation of abdominal fat. To our surprise large heter-
ogenous lesion noted in left lobe of liver. AFP-normal, viral markers-
negative, LFT and CBP within normal range. CECT triphasic done
revealed 15*12*17 cm hypodense lesion occupying entire left lobe
showing intense enhancement in arterial phase with progressive cen-
tripetal enhancement in delayed phase suggestive of giant hemangi-
oma. She is referred for surgical resection and hernia repair.
Discussion Giant hemangiomas are more likely to cause abdominal
discomfort or pain, vomiting. Infarction, bleeding or necrosis
may occur. Rare complications include compression of bile ducts,
portal vein, gastric outlet obstruction. Management include
surgical resection, arterial ligation, embolization or systemic
glucocorticoids.
Conclusion Though small hemangiomas are frequent finding, Giant hem-
angioma of 17 cm in left lobe of liver with epigastric herniation in a 62-
year-old post-menopausal woman not on estrogen supplements is an un-
usual presentation. Early diagnosis and prompt resection are indicated to
avoid rupture which is a catastrophic complication of giant hemangioma.
Keywords Giant cavernous hemangioma, Left lobe of liver,
Postmenopausal woman, Epigastric hernia
193
Neutrophil to lymphocyte ratio as a prognostic marker in patients
with alcoholic hepatitis
Bharat Sapra, Jagatjot Gill
Correspondence- Bharat Sapra-sudhir.maharshi@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L
N Marg, Jaipur 302 004, India
Background Alcoholic liver disease is one of the commonest causes of
advanced liver diseases. The prognosis of patients with alcoholic hepatitis
(AH) can be established by different scoring systems. The prognostic role
of neutrophil to lymphocyte ratio (NLR) has been documented in multiple
diseases but the overall evidence of prognostic role of NLR in AH is
relatively scarce. The aim of the study was to assess NLR as a prognostic
marker in patients with AH and compare it with other prognostic scores.
S62
Methods Patients of AH both admitted and from OPD were included.
Along with baseline investigations, various scores like MELD (model
for end-stage liver disease), DF (discriminant function), GAHS
(Glasgow alcoholic hepatitis score), CTP (Child Turcot-Pugh score)
and NLR were calculated. Patients were followed up at 1 and 3 months.
Correlation of NLR with other scores was done by appropriate statistical
analysis.
Results Till date 58 patients have been included in the study. Mean age
was 36.8±8.7 years. All patients were males. The lab parameters were
hemoglobin 8.9±1.4 gm%, bilirubin 7.6±3.8 mg/dL, serum creatinine 1.1
±0.5 mg/dL, serum albumin 2.9±0.4 g/dL. Various prognostic scores
were NLR 4.8±1.7, CTP 9.4±1.3, MELD 24.1±4.8, GAHS 8.1±1.3, DF
42.2±19.8. Correlation coefficient (r value) of NLR with CTP was 0.5,
with MELD-0.6, with GAHS-0.6 and with DF-0.7.
Conclusion NLR correlates positively with CTP score, MELD score, DF
and GAHS and can be used as a prognostic marker in patients of alcoholic
hepatitis.
Keywords Alcoholic hepatitis, scoring
194
A rare cause of portal hypertension in a 7-year-old child
Viswanath Kamisetty, Ramesh Kumar B, Ramanna M, Sindhu K*,
Sahitya L
Correspondence- Viswanath Kamisetty-vissu.ksp@gmail.com
Department of Medical Gastroenterology, Osmania Medical College and
General Hospital, Hyderabad 500 012 India, and *Department of
Pathology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji
Nagar, Secunderabad 500 003, India
Introduction Extrahepatic portal venous obstruction or cirrhosis is the
cause of portal hypertension (PHT) in majority of Indian children
(92%). Nodular regenerative hyperplasia (NRH) is a rare entity especially
in children which is clinically dominated by PHT with splenomegaly.
This condition is often associated with systemic diseases or drugs and is
characterized by a widespread benign transformation of liver parenchyma
into small regenerative nodules. We report a rare case of NRH with portal
hypertension with a normal spleen in a girl child, as an isolated
occurrence.
Case Report A 7-year-old girl, pre-morbidly well, presented with multiple
episodes of hematemesis. Clinically she had severe pallor without icterus
and hepatosplenomegaly. Labs showed severe anemia (Hb-6.8 g/dL) and
normal platelet count. Liver function tests were normal apart from mild
transaminitis. Ultrasonography abdomen revealed heterogeneous liver
echotexture without nodularity, portal vein measuring 4.2 mm at porta,
with normal spleen and minimal ascites. Grade III esophageal varices
were detected on gastroduodenoscopy. Liver biopsy showed early nodu-
lar regenerative hyperplasia with few porta showing obliterated portal
vein. Endoscopic variceal banding was done as a secondary prophylaxis.
Our patient had no drug exposure and further investigations did not reveal
any autoimmune, metabolic, myeloproliferative or neoplastic disorders.
Discussion NRH has rarely been described in children. It is important to
consider NRH in the differential diagnosis of unexplained PHT owing to
its relatively favorable prognosis. Though the largest pediatric series (16
cases) by Moran et al. emphasized the association of NRH with other
diseases, we did not find any association, suggesting the possibility as an
isolated occurrence. To the best of our knowledge this is the first case
report of NRH with clinically significant portal hypertension with a nor-
mal spleen which is inconsistent with the previous case reports.
Keywords Nodular regenerative hyperplasia, Portal hypertension, Spleen
195
Clinico-epidemiological profile of hepatic hydatid cyst patients pre-
senting to a tertiary care hospital
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Mayank Bhushan Pateriya, V K Dixit, S K Shukla, D P Yadav, Anurag
Tiwari
Correspondence- V K Dixit-vkdixit@gmail.com
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221005, India
Introduction Hydatid cyst is endemic zoonotic diseases in India. Due to
its different morphological presentation it has multiple treatment options
like PAIR, surgical enucleation and antihelmintics.
Methods This is retrospective cross-sectional observational study carried
out in consecutive 48 patients of hepatic hydatid cyst presented to
Department of Gastroenterology, SSH/BHU between January 2016 to
December 2019.
Observation Mean age of our patient group was 37.6 years (7 to 68 years).
Most of the patients were female (70.8%). Most common presenting
symptom was right hypochondrium pain (62.5%) followed by abdominal
lump (25%). Fifty-two percent of hydatid cysts were of Gharbi I , 31% of
Gharbi III. Mean cyst volume was 7.5*6.2*8.1cm. Hydatid serology was
positive in 47% cases and protoscolex of echinococcus granulosus in
aspirated fluid was present in 72% of the cases. Successful PAIR was
done in 66% 0f cases (out of which in 20% cases repeated PAIR was
required). PAIR was failed in 22% cases for which surgical referral was
taken and in remaining 12% of cases only albendazole was sufficient.
Conclusion For management of hepatic hydatid cysts of favo-rable mor-
phology PAIR is still a conservative treatment option.
196
Ischemic hepatitis: Easily identifiable but frequently overlooked
Anant Gupta, Jayant Sharma, Khushbu Jain***, Alok Gupta*, Sandeep
Nijhawan**
Correspondence- Jayant Sharma-dranantg@gmail.com
Department of Medical Gastroenterology, Fortis Escorts Hospital,
Jawahar Lal Nehru Marg, Sector 5, Malviya Nagar, Jaipur 302 017,
India, *PSC, Jaipur, India, **Sawai Man Singh Medical College, J L N
Marg, Jaipur 302 004, India, and ***Suryam Diagnostics,
Introduction Ischemic hepatitis (IH) presents as significantly raised liver
enzymes in ICU patients, who are more prone in view of co-existing
illness. This study aimed to evaluate the profile of IH.
Methods Patients admitted to ICU with cardiac/respiratory failure, hypo-
tension, sepsis, or those resuscitated after cardiac-arrest were screened.
LFT, INR, creatinine were measured on day 1. ALT, bilirubin (T), LDH
were measured on day 3, 7 and 14. ABG (in hypoxia) and cultures (in
sepsis) were done. Echocardiography and USG abdomen were done for
all. Patients with ALT >800 IU/L, negative IgM antibodies (HAV and
HEV) and with no history of drug-induced toxicity were followed.
Results Of 3794 patients screened over a year, 75 had IH. Mean age was
67 years and 46 were male. 60% had ≥2 predisposing causes.
Predisposing causes were bi-ventricular dysfunction (56%), left-
ventricular dysfunction (43%), hypotension (40%), sepsis (25%),
cardiac-arrest and resuscitated (20%), respiratory failure (17%). 3 (6%)
were cirrhotic, but none developed ACLF. Mortality was 46% but none
were primary liver related. Mean ALT (IU/L) level on day 1 (54 IU/L),
day 3 (4305 IU/L), day 7 (1915 IU/L), day 14 (523) and the ALT levels
reduced by >50% (day 7) and >80% (day 14). Mean T. bilirubin (mg/dL)
was 1.49 (day1), 3.2 (day7) and 2.6 (day 14). Mean AST (3711 IU/L) was
higher than ALT (3683 IU/L), ALT/LDH ratio was 1.15 and ALT were
higher in those who died (4305.17 ± 2465.0 and 3683.74 ± 2618.43
respectively). Peak ALT were on day 3 (non-cirrhotics) and on day 7
(in cirrhotics). Cirrhotics had higher mean bilirubin on day 7 and day 14.
Conclusions Incidence of IH was 1.98% of ICU admissions. Their pre-
sentation closely mimics acute viral/toxin-induced hepatitis. It has no
specific symptoms, is easily missed, unless looked for. Careful monitor-
ing of LFTs in critical-care patients would identify IH. Early aggressive
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
management of precipitating cause, avoiding the use of hepatotoxic drugs
may help in preventing ALF.
Keywords Ischemic Hepatitis, Hypoxic Hepatitis, ICU
197
Prospective observational study comparing sepsis-1, qSOFA and
sepsis-3 in predicting 90-days mortality in patients of cirrhosis with
infection
Ajay Kumar Jain, Abhilash Surela, Shohini Sircar, Amit Joshi, Arun
Singh, Sumit Singh, Vikas Raikwar
Correspondence- Abhilash Surela-surelaabhilash@gmail.com
Department of Gastroenterology, Choithram Hospital and Reasearch
Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction Patients with cirrhosis of liver are more prone to sepsis and
sepsis related complication with poor prognosis. Recently the internation-
al task force proposed new criteria to define sepsis and septic shock which
has been named as sepsis -3 criteria. The group also proposed qSOFA
criteria for screening of sepsis. It is believed that based on these new
criteria prognostication of patients of cirrhosis with sepsis will be more
accurate, therefore we aimed this study “to compare sepsis -3 with sepsis -
1 (old criteria for screening of sepsis) and qSOFA to predict 90-days
mortality in patients with cirrhosis of liver and infection”.
Method All patients with cirrhosis and proven infection were prospective-
ly included in our study. Demographic, clinical, laboratory and microbi-
ological data were collected at time of admission. Base line qSOFA score
was obtained from previous record. Sepsis 1, sepsis 3 and q SOFA were
calculated at the time of admission. The primary outcome was 90-days
survival.
Result A total of 108 patients of cirrhosis with proven infection were
recruited. Out of 108 patients, 60 patients (55.6%) fulfilled sepsis-1
criteria, 63 patients (58.3%) fulfilled sepsis -3 criteria and only 32
(29.6%) fulfilled positive qSOFA criteria. Overall 90-days mortality
was observed in 21 (19.4%) patients, out of these 21 patients who
died within 90 days, 13 patients (61.9%) fulfilled sepsis-1 criteria, 11
patients (52.4%) fulfilled q-SOFA criteria and all 21 patients (100%)
fulfilled sepsis-3 criteria. Sepsis-3 showed good accuracy for 90-days
mortality area under the receiver operating characteristic
(AUROC)=0.838, 95% CI, 0.755-0.902 than qSOFA
(AUROC=0.760, 95% CI, 0.669-0.837) and sepsis-1
(AUROC=0.658, 95% CI, 0.560-0.7) (Fig.1).
Conclusion Present study shows that sepsis-3 criteria are more accurate
than qSOFA and sepsis-1 in predicting 90-days mortality in patients of
cirrhosis with infection.
Keywords: Liver, Cirrhosis, Sepsis-3, qSOFA, Sepsis
198
Systemic amyloidosis - Hepatic presentation
Rushil Solanki, Krishnadas Devadas
Correspondence- Krishnadas Devadas-kdas40@gmail.com
Department of Gastroenterology, Medical College, Ulloor - Akkulam
Road, Chalakkuzhi, Thiruvananthapuram 695 011, India
Fifty-six-year old lady, Asha worker was referred to MGE, OPD with
complaints of bloating, belching and nausea with findings of hepatomeg-
aly on USG abdomen done outside. She gave additional h/o DM and
suspected CAD, on antiplatelets. LFTs done revealed an cholestatic pat-
tern with elevated ALP, GGT and borderline raised OT/PT and hepato-
megaly was confirmed with repeat USG abdomen. Subsequent serolog-
ical and imaging investigation (CT scan abdomen), done to determine the
etiology yielded no definitive results. A liver biopsy was planned to give a
definitive diagnosis. A liver biopsy was planned to give a definitive
S63
diagnosis. Liver biopsy showed congophilic material with apple green
birefringence which s/o hepatic amyloidosis. Once confirmed, SPE was
performed as part of determining the type of amyloid. SPE showed band
in gammaglobulin region and subsequent bone marrow showed biopsy
confirmed multiple myeloma. Screening for other organ involvement
showed involvement of heart (2Decho with bulls eye appearance on strain
imaging and cardiac MRI confirming cardiac amyloidosis) and peripher-
al; nerves showing length dependent axonal polyneuropathy. MRI spine
also showed multiple levels of degenerative vertebral bodies.
199
Clinicoepidemiological profile of liver abscess patients admitted in a
tertiary center in south India
Bontha Vineesha, Ganesh Panchapakesan, Shanmuganathan
Subramanyam
Correspondence- Bontha Vineesha-bontha.vineesha@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Institute of
Higher Education and Research, No: 1, Sri Ramachandra Nagar, Porur,
Chennai 600 116. India
Background India has the 2nd highest incidence of liver abscess in the
world due to overcrowding, poor sanitation and inadequate nutrition and
continue to be an important cause of morbidity and mortality. So identi-
fication of risk factors and early diagnosis are key issues for effective
interventions. Most of the Indian data are from north and north east with
sparse data from the south. The aim of this study is to evaluate the chang-
ing trends in clinical profile, microbiological etiology of patients diag-
nosed with liver abscess.
Methods A retrospective data of the 108 patients who admitted with a
liver abscess in a tertiary care center in south India from January 2018 to
January 2020 was collected including presenting complaints, lab param-
eters including cultures and serology along with necessary imaging.
Results Pyogenic liver abscess PLA (86.1%) is predominant over amebic
liver abscess ALA (13.8%). The mean age of the patients with PLA is
52.5 vs. 44.8 years for amebic with male preponderance (94.4%). There
was no significant difference in lab values between pyogenic and amebic
liver abscess. Alcoholism (23.1%) and diabetes (43.5%) are main predis-
posing factors. Pain abdomen and fever was present in 91.7% and jaun-
dice in 19.4% patients. The ALA were predominantly solitary and in right
lobe. The most common pathogen in pyogenic was klebsiella pneumonia
(36.8%) followed by E. coli (21%). More than 5 cm abscess required a
pigtail insertion. Forty-nine patients (45.3%) underwent pigtail insertion.
Mortality was 1.8% and was due to sepsis and multi organ dysfunction.
Conclusion The commonest type of liver abscess was pyogenic in con-
trast to studies from north India. Liver abscess was predominant in males.
Obstructive type of jaundice was more common in pyogenic abscess
compared to amoebic. Most of the patients can be effectively managed
with antibiotics covering gram negative spectrum and with proper selec-
tion of patients for drainage.
Keywords Liver abscess, Pyogenic liver abscess, Amebic liver abscess
200
Clinical profile and outcome of acute liver failure in north west India:
A tertiary care centre experience
Rishabh Gupta, Gaurav Gupta, Sandeep Nijhawan
Correspondence- Rishabh Gupta-rishabh1313@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College and
Attached Hospitals, J L N Marg, Jaipur 302 004, India
Introduction Acute liver failure (ALF) is a rapidly progressive syndrome
having high mortality rate with varied etiology. It is characterized by
development of coagulopathy (INR >1.5), and encephalopathy within 4
S64
weeks of the onset of symptoms in a patient without pre-existing cirrho-
sis. Geographical differences are seen in terms of etiology and outcome.
Viral hepatitis is the commonest cause in India unlike drugs and toxins in
the West. Thus, careful evaluation for the cause of ALF is important for
the management and prognosis of the patient.
Aim of the study To evaluate the etiology, clinical profile and outcome in
patients with acute liver failure.
Method It was a prospective observational study conducted in the
Department of Gastroenterology, SMS medical college, Jaipur, India.
All patients with the diagnosis of ALF as per IASL criteria were included
between September 2018 to July 2020.
Results Total 124 patients were included out of which 66 were
males and 58 females. Mean age was 36.68+/-18.44 years. Overall
mortality in our study was 65/124 (52.4%), with highest being viral
hepatitis 26/124 (20.96%), followed by indeterminate group 18/124
(14.5%). Viral hepatitis 63/124 (50.8%) was the most common
cause of ALF, of which HEV being the commonest with 35 patients,
followed by drug or toxin induced 30 (20.2%) and indeterminate
group 18 (14.5%). Among drug induced acute liver failure, 25 had
ATT induced ALF. Out of 58 females, 6 were pregnant. Predictors
of outcome were age, etiology, hepatic encephalopathy grade, coag-
ulopathy, deranged renal function, bilirubin, intracranial pressure
and other complications.
Conclusion ALF is a disease having mortality of 52.4%. Viral hepatitis is
the commonest cause in north west India, like the rest of India. ATT is
also an important cause of ALF. Prompt diagnosis and timely manage-
ment of complications is required.
Keywords Acute liver failure, Cirrhosis, Viral hepatitis
201
Cell free DNA integrity index differentiating hepatocellular carcino-
ma from chronic liver disease patients
Sonu Kumar, Neeti Nadda, Shashi Paul, Anoop Saraya, Shivanand
Gammanagatti, Shalimar, Baibaswata Nayak
Correspondence- Baibaswata Nayak-baibaswat@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110 029, India
Introduction Hepatocellular carcinoma (HCC) is fourth most deadly
cancer. Majority of HCC patients have underlying chronic liver
disease (CLD) that leads delayed HCC diagnosis. Surveillance of
high risk CLD patients can led to early HCC diagnosis. Delay in
diagnosis results in progression of HCC and metastasis. Routine
screening for HCC is not cost effective. Liquid biopsy holds great
promise for early detection, prognosis, and response to cancer
treatment. The cell free DNA (cfDNA) concentration and its in-
tegrity index changes early during carcinogenesis. The DNA in-
tegrity index by real time PCR of repetitive genomic sequences
(Alu, LINE1) and beta actin and GAPDH may predict early
hepatocarcinogenesis for which propose study was undertaken.
Objectives Cell free DII determination by real time PCR for the early
prediction of hepatocarcinogenesis in CLD patients.
Methods Consecutive HCC (n=100), CLD (n=55) and healthy (n=10)
controls were included. CfDNA was isolated from serum using Qiagen
kit. Genomic DNA from Huh7 cell line was used as control. Cf DNA
concentration and purity was checked by scan-iT software. The primer
pairs for large (>200 bp) and small (<200 bp) amplicon against Alu,
LINE1, beta- Actin and GAPDH gene were designed. Real time PCR
using SYBR was carried for both fragment. The DII by comparative Ct
method was used for differential ability CLD vs HCC.
Results More fragmentation was observed in DNA in cancer.
Normalization was done with genomic DNA. Increased DII indicates
lower integrity in HCC vs. CLD vs. healthy. ROC curve in CLD vs.
HCC subjects are significant for ALU and GAPDH gene having AUC
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
value 0.67 and 0.69 respectively. LINE1 elements and b-actin genes more
fragmented in but ROC curve is not significant for them.
Conclusions Both Alu and GAPDH holds great promise for prediction of
early hepatocarcinogenesis.
Keywords HCC, CLD, Cf DNA, RT PCR, DII,LB
202
Non-alcoholic steatohepatitis as an emerging cause of hepatocellular
carcinoma in India
Apurva Shah, Shravan Bohra, Maitrey Patel
Correspondence- Apurva Shah-apurvashah411@gmail.com
Department of Gastroenterology, Apollo Hospitals International Limited,
Plot No, 1A, Gandhinagar - Ahmedabad Road, GIDC Bhat, Ahmedabad
382 428, India
Introduction Hepatocellular carcinoma (HCC) is the third leading cause
of cancer related death worldwide. Although hepatitis B (HBV) and hep-
atitis C (HCV) have been the main drivers of HCC, non-alcoholic
steatohepatitis (NASH) is emerging as a leading cause of HCC. The
aim of this study was to assess NASH as cause of HCC.
Methods This retrospective observational study was carried out on
diagnosed patients of HCC during last one year at tertiary care
center in western India. Data included were clinical presentation,
comorbid conditions, biochemical parameters with alfa fetoprotein
levels, imaging (ultrasound/ computed tomography of abdomen).
Data regarding etiology of cirrhosis and HCC were collected.
Barcelona clinic liver cancer (BCLC) staging was used to stage
and guide HCC therapy.
Results Total 13 patients of HCC were included in analysis. Mean
age of patients was 64.53 ± 8.43 years with male predilection
(93.30%). Most common presentation was abdominal pain
(61.53%) followed by ascites (46.15%) and constitutional symp-
toms like anorexia and weight loss (46.15%). Eleven patients had
underlying cirrhosis and two patients were noncirrhotic. 69.23%
patients of HCC had diabetes mellitus as co morbidity. NASH
was the commonest etiology in cirrhotics with HCC (72.72%)
followed by HBV (18.18%) and alcohol (9.1%). HBV and
NASH was the etiology respectively in two noncirrhotics. Alfa
fetoprotein was normal, between 40-400 ng/mL and >400 ng/mL
in 54%, 23% and 23% respectively. Majority of patients had
higher stages of HCC (BCLC- C and D) at diagnosis even on
surveillance (62%) and received targeted therapy of sorafenib.
Conclusion NASH is the most rapidly emerging cause of HCC paralleled
with epidemic of metabolic syndrome components in India. Screening of
HCC should be considered in all patients of NASH cirrhosis and ad-
vanced fibrosis.
Keywords Non-alcoholic steatohepatitis, Hepatocellular carcinoma,
Diabetes mellitus, Alfa fetoprotein
203
A rare cause of sepsis in chronic liver disease
Binila Jose, George Thomas, Ramesh M, Satheesh A V
Correspondence- Binila Jose-binilajose@gmail.com
Department of Gastroenterology, Pushpagiri Institute of Medical
Sciences, Municipal Stadium Road, Pushpagiri Medical College
Campus, Thiruvalla 689 101, India
Introduction Pasteurella multocida is pleiomorphic, facultatively anaero-
bic, a Gram-negative coccobacillus commonly isolated as commensals in
the oral flora of a variety of animals. In dog and cat bite wounds,
Pasteurella multocida, are isolated in 50% to 70% of the cases.
Although direct inoculation of the skin through animal bite or scratch is
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141 S65

the most common route of human disease, infection has been documented
even in the absence of direct animal contact. Pasteurella multocida serves
as an opportunistic pathogen in humans, especially in patients with de-
pressed immune system. Few cases in the literature identify Pasteurella
multocida as the causative agent of septic shock, especially in cirrhotic
patients. Here, we present a rare case of Pasteurella multocida septic
shock in an elderly woman with chronic liver disease.
Case Report A 74-year-old female was admitted with abdominal disten-
sion, breathlessness and edema without any fever or gastrointestinal
bleed. She also gives history of close contact with pet dog, but no history
of any dog bite. She had past history of chronic obstructive pulmonary
disease, hypertension and recently detected chronic liver disease. Physical
examination showed drowsy, pallor, icterus, edema, cellulitis both legs,
hypotension, tachycardia and ascites. Evaluation showed features of sep-
sis with probable source as cellulitis and blood cultures grew P. multocida
which was managed with piperacillin/tazobactam with clinical
improvement.
Discussion Although cases of bacteremic P. multocida infections has
been infrequently reported in the literature, clinicians should consider this
organism as an important and potentially lethal pathogen in humans,
where it can cause life-threatening infections. It should be included in
the microbiologic differential diagnosis in patients with underlying chron-
ic liver diseases who presents with possible infection, with history of
exposure to domestic animals. Septic shock is an uncommon complica-
tion of P. multocida infection with a mortality rate of 15% to 30%.
Keywords Pasteurella, Septicshock, CLD
204
205
Prevalence of sarcopenia in patients with cirrhosis: A large observa-
tional study
Indu Grover, Namrata Singh, Deepak Gunjan, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Sarcopenia is common and camouflaged complication
which adversely affects quality of life and outcomes in the patients with
cirrhosis. The aim of this study is to describe the prevalence of sarcopenia
and its relationship with nutritional status, disease severity and disease
duration in patients with cirrhosis.
Methods The appendicular skeletal muscle mass index (ASMI) was
assessed by dual energy X-absorptiometry (DEXA). Cut off given by
Asian working group for sarcopenia (AWGS) was used to define
sarcopenia; for male (<7 kg/m2) and female (<5.4 kg/m2). Subjective
global assessment (SGA) modified for liver disease was used to assess
nutritional status. Patients were categorized in compensated and decom-
pensated group and MELD score was calculated.
Results A total 341 patients with cirrhosis (271 male, mean age 44.0±12.0
years) were included in this study. The prevalence of sarcopenia was
36.7% (male: 36.9% vs. female: 35.7%). The value of ASMI (kg/m2)
was for male (7.36±1.16), female (5.86±0.99), compensated (7.01
±1.25) and decompensated cirrhosis (7.01±1.32), respectively. More re-
sults are shown below:
Table: Comparison of patients with cirrhosis (n=341)

Elevated serum ferritin and CRP levels as prognostic markers in

decompensated cirrhosis: A prospective cohort study Variables No sarcopenia Sarcopenia P value
(n=216) (n=125)
Mithun Harold Thomas, Sunilkumar Kandiyil, T M Ramachandran ASMI (kg/m2) 7.71 ±1.03 5.91 ± 0.76 <0.001
Correspondence- Mithun Thomas-drmithunharold@gmail.com
Weight (kg) 66.4 ± 11.8 51.6 ± 8.6 <0.001
Department of Gastroenterology, Government Medical College, Medical
College Road, Kozhikode 673 008, India BMI (kg/m2) 24.6 ±3.5 19.3 ± 2.5 <0.001
Duration of 25 (0-312) 38 (1-219) <0.001
Introduction Serum ferritin, a marker of hepatic necroinflammation has disease (months)
been studied to predict early mortality in patients with decompensated MELD score 10.89 ± 4.5 10.5 ± 4.13 0.484
cirrhosis. But its significance when compared with serum CRP levels has Disease severity, n (%)
not been studied. The aim of the study was to analyze serum ferritin and
CRP levels as prognostic markers in patients with decompensated cirrho- Compensated 134 (62.1) 69 (55.2) 0.215
sis and compare it with MELD and CTP scores. Decompensated 82 (37.9) 56 (44.8)
Methods Two hundred and twenty consecutive patients with decompen- SGA, n (%)
sated cirrhosis were included. Serum ferrtin and CRP levels at presenta- Well nourished 100 (46.3) 39 (31.2) <0.001
tion and factors predicting mortality at 3 months were assessed. Moderately 106 (49.1) 64 (51.2)
Results Patients with decompensated cirrhosis (n=220) (M:F 168:52, malnourished
mean age 55.7 yrs +/- 11 ) were followed up for a period of 3 months. Severely malnourished 10 (4.6) 22 (17.6)
At presentation, median serum ferritin level was 321.45 (7.4-750) ng/mL
in survivors and 725 (275-3000) ng/mL in non-survivors, and median
serum CRP level was 9 (2-60) mg/L in survivors and 18.5 (6-64) mg/L *Expressed in Mean±SD and Median (min-max)
in non-survivors. Serum ferritin levels were significantly different between Conclusion Around one third patients with cirrhosis had sarcopenia, and
survivors and non-survivors (p<0.05) and showed significant correlation with they had longer duration of disease and lower BMI. As nutritional status
CRP levels (p<0.01). Serum ferritin, CRP, total leukocyte count, MELD worsens frequency of sarcopenia increases in patients with cirrhosis.
score, CTP score, presence of hepatorenal syndrome, spontaneous bacterial Keywords Cirrhosis, Sarcopenia, Dual energy X-ray absorptiometry,
peritonitis, hepatic encephalopathy and ACLF were significant predictors of Nutritional status
mortality on univariate analysis. Ferritin, MELD and presence of hepatorenal
syndrome were significant predictors of mortality on multivariate analysis. 206
Serum ferritin (AUROC 0.91, 95% CI 0.87-0.95) was comparable to MELD
score (AUROC 0.92, 95% CI 0.891-0.961) and better than CRP (AUROC LFT profile in intensive care unit patients: A prospective observa-
0.74, 95% CI 0.67-0.80) and CTP score (AUROC 0.847, 95% CI 0.79-0.89), tional study
in predicting death at 3 months.
Conclusion Elevated serum ferritin level is as an independent prognostic mark- Krishna Kartik Reddy B, Anand A, Aravind A, Kani Sheik Mohammed,
er in decompensated cirrhosis. Elevated serum CRP levels did not show asso- Akhilandeswari A R, Vaishnavi Priya, Arun N, Krishna Reddy B
ciation with mortality at three months in decompensated cirrhosis. Correspondence- Krishna Reddy B-bhumanakkr@gmail.com
S66
Department of Digestive Health and Diseases, Government Kilpauk
Medical College, Chennai 600 010, India
Background and study aim Deranged LFT, commonly noted along with
other abnormal blood parameters in ICU patients is both a consequence as
well as a significant cause of patient’s morbidity. In this observational
study we aim to analyse the pattern of liver injury noted in patients being
treated in ICU and suggest various precocious therapeutic measures for
better clinical outcomes.
Method We conducted a prospective observational study in ICU patients
irrespective of age and gender from October 2019 to July 2020. We
analyzed the pattern of liver injury (hepatocellular/cholestatic) and also
noted the derangement observed in specific liver parameters secondary to
hepatic dysfunction.
Results Of the 184 patients in study group, 132 (72%) found to have
abnormal LFT. Among them majority are found to have hepatocellular
pattern, 103 of 132 (78%). Cholestatic pattern is noted in 12 patients (9%)
and mixed pattern in 17 (13%) patients. The major causes for hepatocel-
lular injury are hypoxic hepatitis (shock/congestion/respiratory failure)
noted in 69 patients (77%) and ethanol related liver injury noted in 34
patients (33%). The major cause for cholestatic pattern and mixed pattern
noted is sepsis related.
Conclusion Liver dysfunction is a major contributor for significant morbidity
and mortality in ICU patients. Deranged LFT is seen in almost 2/3rd patients
of our study group. Precocious therapeutic measures like early and aggressive
treatment of sepsis, hemodynamic abnormalities and metabolic derange-
ments can prevent or reduce the severity of liver dysfunction there by leading
to improved clinical outcomes in measures of morbidity and mortality.
Keywords LFT profile in intensive care unit patients: Prospective obser-
vational study
207
Study of clinico-radiological profile of hepatocellular carcinoma:
Comparing viral with non-viral etiology
Manne Gowtam, Ganesh P
Correspondence- Manne Gowtam-gowtam.manne@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Medical
College and Research Institute, Chennai 600 116, India
Introduction Hepatocellular carcinoma (HCC) is the 5th common cause of
cancers affecting humans. In recent times non-viral causes of HCC have been
rising at an alarming rate. There are few studies comparing HCC patients with
non-viral liver diseases with HCC patients due to viral diseases.
Aim To study the clinical radiological profile of HCC patients and to
highlight the differences between viral HCC and non-viral HCC patients.
Methods In this retrospective study total of 61 case records of patients
diagnosed with HCC of all causes in our hospital from 2018 to 2020 were
studied. Clinical and radiological profile of HCC patients with viral eti-
ologies were compared with non-viral etiologies.
Results Of the 61 patients of HCC, 39 patients had non-viral etiologies
and 22 had viral etiologies. Non-alcoholic fatty liver disease (48.7%) is
the leading cause of non-viral etiology and hepatitis B virus (77.27%) in
viral etiology. Similar proportions of both groups were male (92.3% and
95.5%). A similar percentage of patients were cirrhotic at the time of
diagnosis of HCC (non-viral 71.8% and viral 77.3%). The most common
clinical presentation in both groups was abdominal pain. Viral HCC
patients were younger (52.59% vs. 65.23%) with tumor characteristics
on imaging similar to non-viral patients (arterial enhancement with de-
layed washout). The mean tumor size is 6.44 cm in the non-viral group
comparable to 6.76 cm in the viral group. Barcelona clinic liver cancer
(BCLC) stage C disease was more common at presentation among the
viral HCC group compared with the non-viral HCC group (50% vs.
35.89). BCLC stage D is seen in 33.33% in non-viral and 36.4% in the
viral group.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusion Patients with viral etiology of HCC are younger and present
with an advanced stage of HCC compared with non-viral causes of HCC.
Keywords Hepatocellular carcinoma
208
A novel predictor for fibrosis in pediatric non-alcoholic fatty liver
disease
Nibin Nahaz, Krishnadas Devadas, Arun P, Sandesh Kolassery
Correspondence- Arun P-arunarathy88@gmail.com
Department of Medical Gastroenterology, Government Medical College,
Thiruvananthapuram 695 005, India
Introduction Pediatric non-alcoholic fatty liver disease (NAFLD) poses a
risk for significant fibrosis and eventual cirrhosis. Vibration controlled
transient elastography (TE) noninvasively assesses the level of fibrosis.
We tried to predict the risk factors for fibrosis in pediatric NAFLD.
Methods Liver stiffness was assessed using TE and shear wave
elastography (SWE) in children with ultrasonologically diagnosed fatty
liver. Hepatic steatosis was quantified with hepatorenal index (HRI)/B
mode ratio and continuous attenuation parameter (CAP).
Results One hundred and fifty children were enrolled. Mean age was
11.5+3.7 years. 28% had normal weight, 22.7% were overweight and
47.3% obese. Any fibrosis (>F1) was present in 56.7%, significant fibro-
sis in 17.3% and advanced fibrosis in 5.3%. Waist circumference (WC)
(r=0.45), mid arm circumference (MAC) (r=0.437) and hip circumference
(HC) (r=0.391) correlated well with fibrosis. Controlled attenuation pa-
rameter (CAP) (r=0.559), screen-time (r=0.331), HOMA-IR (r=0.345)
and triglycerides (TG) (r=0.307) had moderate correlation. Age, WC,
aspartate aminotransferase (AST), alanine aminotransferase (ALT),
triglycerides (TG), gamma-glutamyl transferase (GGT), albumin
(Alb) and HOMA-IR were significantly different between no fi-
brosis (F0), any fibrosis (F1-F4) and significant fibrosis (>F2-F4).
A Pediatric NAFLD fibrosis predictor (PNFP) score was devel-
oped. PNFP = 2.564+ (0.049*WC) + (0.005*TG)+
(0.016*AST)-(0.578*ALB). PNFP score had an AUROC for any
fibrosis, significant fibrosis and advanced fibrosis of 0.747, 0.864
and 0.909 respectively when compared to pediatric NAFLD index
(PNFI) (0.604, 0.778 and 0.925). A PNFP score of 5.05 had a
sensitivity of 71% and specificity of 53% for any fibrosis. A
score of 5.94 had a sensitivity of 80% and specificity of 88.7%
for significant fibrosis.
Conclusion Significant fibrosis occurs in 15% to 20% of pediatric
NAFLD. Age, obesity, insulin resistance, and dyslipidemia increase fi-
brosis. Inactivity in the form of increased screen time accelerates fibrosis.
PNFP score, a simple score incorporating AST, Alb, WC, and TG can
predict significant fibrosis with better accuracy than existing models in
children.
Keywords Transient elastography, Fibrosis, Pediatric non-alcoholic fatty
liver disease fibrosis predictor (PNFP)
209
Does undetected non-alcoholic fatty liver disease lead to poorer treat-
ment outcomes in patients undergoing surgery for gastrointestinal
malignancy?
Sagar Narayan, C Kapil Tejaswy, Jacob Mathew, V P Gangadharan, H
Ramesh
Correspondence- Sagar Narayan-nsagar2591@gmail.com
Department of Gastrointestinal Surgery, VPS Lakeshore Hospital and
Research Centre, NH 47 Byepass, Nettoor, Maradu, Ernakulam 682
040, India
Introduction Patients with undetected liver disease seem to have poorer
outcomes after treatment for gastrointestinal malignancies. Liver disease
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
may not be picked up on routine preoperative screening and may be
incidentally detected intraoperatively. Suitable modifications in the treat-
ment plan could be made if liver disease is detected preoperatively. The
aim was to determine the prevalence of undetected non-alcoholic fatty
liver disease (NAFLD) in patients undergoing surgery for gastrointestinal
malignancy; to assess correlation between MRI, MR elastography and
liver biopsy and determine if morbidity is increased in patients with
undetected pre-existing liver disease.
Methods Patients undergoing surgery for primary gastrointestinal malig-
nancy without known liver disease between July 2018 and December
2019 were included. All patients underwent baseline LFT, MRI and
MR elastography in the preoperative period. Intraoperative liver biopsy
was done. Change in surgical or chemotherapeutic plan was noted. Any
morbidity in the postoperative period was noted and patients were follow-
ed up during chemotherapy period to look for worsening in the liver
function.
Results Sixty-two patients were included in our study. NAFLD was more
common in elderly males (n-46). Twenty-four of 62 patients (38.7%) had
NAFLD. Seven of 15 (44.6%) patients who were overweight and obese
had NAFLD. The sensitivity and specificity of MRI in detecting steatosis
was 62.5%, 94.7% respectively. The sensitivity and specificity of MR
elastography in detecting fibrosis was 29.2%, 100% respectively.
Treatment plan was modified in 7 patients due to pre-existing liver dis-
ease. On multivariate analysis presence of sinusoidal dilatation was asso-
ciated with statistically increased morbidity. There was an increased trend
of complications in patients with NAFLD, but the increase did not reach
statistical significance (p-0.070).
Conclusion The prevalence of NAFLD in our population was less than
Delhi and more than Eastern India. There was an increased incidence of
complications among patients with NAFLD though it did not reach sta-
tistical significance.
Keywords Non-alcoholic fatty liver disease (NAFLD), Magnetic reso-
nance imaging (MRI), Magnetic resonance elastography (MR
elastography)
210
Variations in CD14 gene and severity of alcoholic liver disease
Neelanjana Roy, Hem Kumar * , Hem Pandey, Yatan Pal Singh
Balhara**, Anoop Saraya*, Shalimar*, Baibaswata Nayak*
Correspondence- Neelanjana Roy-neelanjanam@gmail.com
Departments of Blood Transfusion Medicine, *Gastroenterology and
Human Nutrition, and ** Psychiatry, National Drug Dependence
Treatment Centre (NDDTC), All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110 029, India
Introduction Alcohol accounts for 60% of all injuries registered in emer-
gency rooms in India. Alcohol consumption in excess resulting in leaky
gut is attributed to liver injury due to portal translocation of bacterial
endotoxin ultimately leading to alcoholic liver disease (ALD).
Variations in genes for alcohol metabolism and inflammation also con-
tribute to development of ALD. The gene CD14 is a key player of
endotoxin-mediated inflammation and vulnerability to ALD.
Association of CD14 polymorphisms and the mechanisms relevant to
alter inflammatory responses leading to ALD was assessed in this study.
Aims Associations of CD14 gene polymorphisms and mechanisms rele-
vant to alcoholic liver disease.
Methods Alcoholics with (ALD, n=128) and without (ALCon, n=184)
liver disease and controls without alcohol habit (HLC, n=152) from North
India were enrolled. The CD14 SNP rs2569190 of all individuals (n=464)
were genotyping by RFLP and confirmed bysequencing. Secretory CD14
(sCD14), LBP, TLR4, MD2, TNFa, IL1b, IFNg, IL6, IL10 and IL4 levels
in serum were measured by ELISA. And circulatory bacterial DNA level
was estimated by realtime PCR.
S67
Results Sequencing of promoter and exonic regions for reported SNPs of
CD14 gene was done and majority found to be monomorphic except
rs2569190 in Indian population. The SNP rs2569190 (C/T) was geno-
typed and TT genotype showed significant association with risk of ALD
(ALD vs. ALCon [p=0.014] or vs. HLC [p=0.043]). Significant increased
sCD14 level was detected in ALD and ALCon as compared to HLC
(p=0.010, 0.013). Enhanced levels pro-inflammatory cytokines, like
LBP, TLR4, TNFa, IL1b, IFNg and IL6 and reduced levels of anti-
inflammatory cytokines, as MD2, IL10 and IL4 was observed among
the ALD patients (especially, in TT genotype) than the other two groups.
Conclusion Enhanced CD14 expression associated with inflammatory
responses increases susceptibility of ALD in risk TT genotype individual.
Keywords Alcoholic liver disease, CD14 gene, Polymorphism
211
Alterations in autophagy and mTOR pathways mediate sarcopenia
in patients with cirrhosis
Abhinav Anand**, Aruna Nambirajan, Vikas Kumar, Samagra Agarwal,
Sanchit Sharma, Srikant Mohta, Srikanth Gopi, Deepak Gunjan,
Namrata Singh*, Kumble Madhusudhan, Shyam Chauhan, Mehar
Chand Sharma, Virinder Kumar Bansal, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Gastroenterology and Human Nutrition, *Dietetics, and
**
Hepatology, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi 110 029, India
Introduction The pathophysiology of sarcopenia in cirrhosis is poorly
understood. We aimed to evaluate the histological alterations in the mus-
cle tissue of cirrhotic patients with sarcopenia and identify the regulators
of muscle homeostasis.
Methods Computed tomography images at the third lumbar vertebral
level were used to assess the skeletal muscle index (SMI) in 180 patients.
Sarcopenia was diagnosed based on the SMI cut-offs from a population of
similar ethnicity. Muscle biopsy was obtained from the vastus lateralis in
10 sarcopenic cirrhotics, and the external oblique in 5 controls (voluntary
kidney donors during nephrectomy). The histological changes were
assessed by hematoxylin and eosin staining and immunohistochemistry
for phospho-FOXO3, phospho-AKT, phospho-mTOR, annexin V, and
caspase 3. The mRNA expressions for MSTN, FoxO3, markers of
ubiquitin-proteasome pathway (FBXO32, TRIM63), markers of autoph-
agy (Beclin-1 and LC3-II) were also quantified.
Results The prevalence of sarcopenia was 14.4%. Muscle histology in
sarcopenics showed abundant atrophic angulated fibers (p=0.002).
Immunohistochemistry showed a significant loss of expression of
phospho-mTOR (p=0.026) and a trend towards loss of phospho-AKT
(p=0.089) in sarcopenic patients. There were no differences in the immu-
nostaining for annexin-V, caspase-3, and phospho-FoxO3 between the
two groups. The mRNA expressions of MSTN and Beclin-1 were higher
in sarcopenics (p=0.04 and p=0.04, respectively). The two groups did not
differ in the mRNA levels for TRIM63, FBXO32, and LC3-II.
Conclusions Significant muscle atrophy, an increase in autophagy
markers, MSTN gene expression and an impaired mTOR signalling were
seen in cirrhotic patients with sarcopenia.
Keywords Sarcopenia, AKT-mTOR, Beclin-1
212
Bacteriological profile and outcome of chronic liver disease patients
admitted with sepsis in a teritary care center in southern India
Ravindra Kantamaneni, Rathi Bhaskaran, Venkatakrishnan L,
Mukundan S, Joseph Jhon B, Thirumal Perumal, Prudhvi Chandolu,
Kartikayan K, Nikhil Kenny Thomas
Correspondence- Ravindra Kantamaneni-navyateja2803@gmail.com
S68
Department of Medical Gastroenterology, PSG Institute of Medical
Sciences and Research Center, Off Avanashi Road, Peelamedu,
Coimbatore 641 004, India
Background and Aims Bacterial infections are one of the most important
clinical problems commonly encountered in cirrhotic patients due to un-
derlying immunocompromised status. The most common infection in
cirrhotic patients are spontaneous bacterial peritonitis (SBP), urinary tract
infection (UTI), pneumonia and soft tissue infections.
Aim Aim of this study was to evaluate the most frequent infections in
patients with cirrhosis and bacteriological profile, complications and
prognosis.
Method This is retrospective analysis of two years from March 2017 to
March 2019 which included 316 patients. Demographic characteristics
were evaluated, including age, gender, sex, site of infection, CHILD,
bacterial resistance profile, antibiotic use and mortality rate.
Results Ethanol is the major (58.4%) cause of the liver disease, followed
by NAFLD (14.6%). Community acquired infections (78%) were more
common than the hospital acquired infections. Seventy-two percent of the
patients in this study was CHILD C. 27% of the patients had hepatic
encephalopathy. 32% patients had acute kidney injury. 17% of the pa-
tients had acute on chronic liver cell failure. Most common site of infec-
tion is ascitic fluid followed by urinary tract infections. Most common
organism isolated was E. coli ESBL (gram negative organism) and most
common gram positive organism isolated was Enterococcuss Faecalis.
Most common antibiotic used was third generation cephalosporins.
Mortality in this study was less than 1%.
Conclusion Our study showed high prevalence of gram negative bacterial
infections in patients with cirrhosis. Early identification and appropriate
antibiotic therapy will decrease the mortality.
Keywords Bacteriological profile, Cirrhosis, Gram positive, Gram
Negative
213
The masquerader: An interesesting tale of cystic SOL liver
Ashok Kumar, Kamalakannan R, Jeswanth Sathyanesan
Correspondence- Ashok Kumar-asasupernova@gmail.com
Department of Surgical Gastroenterology, Institute of Surgical
Gastroenterology and Liver Transplantation, Stanley Medical College,
Chennai 600 003, India
Background Etiology and clinical presentation of space occupying lesion
SOL of liver are varied it can be solid cystic for heterogeneous and it can
be very difficult for hepato-biliary-pancreatic surgeons to diagnose
preoperatively.
Case report An 27-year-old lady came with complaints of abdominal
pain for one month and fever of 1 episode. she was investigated outside,
her vitals was stable and abdominal findings was insignificant. Sonogram
showed a well-defined lesion in the left lobe of liver with no internal
vascularity possibly abscess, tumor markers where within normal limits,
CE CT suggested recurrent pyogenic cholangitis with abscess while MRI
suggested intrahepatic duplication of gallbladder. initial diagnosis of SOL
segment 4b of liver. patient underwent laparoscopic cholecystectomy
with enucleation of the lesion postoperative period was uneventful and
final histopathology came back as Caroli disease.
Conclusions Caroli disease has been broadly applied to describe any
patient with intrahepatic bile duct cyst regardless of the presence of ex-
trahepatic bile duct cyst or the shape of the intrahepatic cyst. This disease
occur in less than 1% of all the patients with biliary cystic disease and
isolated version is even more rare in medical literature. Routine diagnostic
armamentarium can not always achieve an accurate preoperative diagno-
sis. Caroli disease in adults main present in a localized form limited to 1
hepatic lobe or segment or a diffuse form most often the left side.
Keywords liver SOL, Cystic, Caroli disease
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
214
FibroScan-aspartate aminotransferase score in an Asian cohort of
non-alcoholic fatty liver disease and its utility in predicting histolog-
ical resolution with bariatric surgery
Abhinav Anand*, Anshuman Elhence, Manas Vaishnav, Amit Anurag
Singh, Mahendra Singh Rajput, Vikas Banyal, Vikas Jindal, Piyush
Pathak, Peeyush Kumar, Baibaswata Nayak, Rajni Yadav, Prasenjit
Das, Harshit Garg, Lokesh Agarwal, Sandeep Aggarwal, Ramesh
Kumar, Shalimar
Correspondence- Shalimar-drshalimar@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, and
*
Hepatology, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India
Background and Aim The FibroScan-aspartate aminotransferase (FAST)
score was developed for identifying patients with non-alcoholic
steatohepatitis (NASH), who also have an elevated non-alcoholic fatty
liver disease (NAFLD) activity score (NAS) ≥4 and significant fibrosis
(F≥2). We aimed to validate it in our NAFLD cohort and assess if it
correlates with the histological changes post-bariatric surgery.
Methods Patients with NAFLD, including those undergoing bariatric sur-
gery, were included. The FAST score was calculated using liver stiffness
measure, controlled attenuation parameter, and AST. Calibration and discrim-
ination of the model were assessed by calibration plots and area under the
receiver operating curve (AUROC), respectively. Sensitivity and specificity
were assessed at the rule-out and rule-in cut-offs (≤0.35 and ≥0.67), respec-
tively. Changes in the NAS and FAST scores were compared in the bariatric
cohort one-year after surgery.
Results The cohort comprised of 309 patients, of which 48 patients underwent
repeat liver biopsy at 1-year. The model showed good discrimination with
AUROC of 0.79 (0.74-0.84); however, it wasn’t satisfactorily calibrated
(Hosmer Lemeshow test p=0.008). The sensitivity and specificity at the rule-
out and rule-in cut-offs were 0.90 and 0.84, respectively. A significant corre-
lation was seen between the 1-year reduction in the NAS and FAST scores
(r=0.38, p=0.009). A significant reduction in the median FAST score was seen
in patients who had ≥2-point reduction in NAS post-bariatric surgery.
Conclusion FAST score demonstrated good discrimination for fibrotic
NASH in our cohort. However, a miscalibration resulted in over predic-
tion. The score correlated well with the histological response to interven-
tions for NAFLD.
Keywords NASH, NAFLD, AST
215
HAM score-A MELD-sodium variant for predicting 3 month mor-
tality in decompensated liver disease
Jijo Varghese, Krishnadas Devadas, Asif N Iqbal, Srijaya Sreesh
Correspondence- Asif Iqbal-asif.nn.iqbal@gmail.com
Department of Medical Gastroenterology, Trivandrum Medical College,
Ulloor-Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011,
India
Introduction Decompensated liver disease (DCLD) has got a high mor-
tality rate. Prediction of mortality is important to prognosticate the patient
and to channel high risk patients for liver transplantation. Objective of the
study was to propose a new prognostic model for DCLD which is better
than the existing scores.
Methods It was a retrospective and prospective observational study.
Clinical and biochemical variables were assessed on the date of admission
from the medical records and patient relatives were telephonically
contacted regarding the date of death and mortality at 3 months from
the date of admission. Logistic regression was done, coefficient of beta
of independent variables were found out and a new score (HAM score)
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
was proposed. HAM score=MELD-Na x 0.1 + (2 if moderate/severe
ascites present; 0 if absent) + (1 if overt hepatic encephalopathy present;
0 if absent). H-hepatic encephalopathy, A-ascites, M-MELD-Na (HAM
score).
Results In predicting 3 month mortality in DCLD, the New score (HAM
score) has an AUROC of 0.772 (cut off >=5; sensitivity of 71%, speci-
ficity of 72.9%, positive predictive value 56.7%, negative predictive val-
ue 83.4% and accuracy 72.3%) (Fig. 1) compared to CTP score of 0.769
(cut off >11; sensitivity 71% and specificity 73.8%) (Fig. 2), MELD-Na
of 0.735 (cut off >25; sensitivity 65% and specificity 72%) (Fig. 3),
MELD of 0.727 (cut off >17; sensitivity of 80.37% and specificity of
55.14 %),i-MELD of 0.7223, MESO index of 0.727 and UKELD of
0.686.
Conclusion HAM Score (New score) is superior to MELD and MELD
variants in predicting 3-month mortality. HAM Score is better than most
of the existing prognostic models for DCLD. HAM Score needs to be
validated in a different cohort to find out its prognostic performance.
Keywords New MELD-sodium variant, HAM Score, 3 month mortality
216
Patients with coronary disease have high prevalence but mild non-
alcoholic fatty liver disease
Kannan Murugesan**, Ajay Duseja*, Ajay Bah, Ankur Gupta, Prashant
Panda, Sunil Taneja*, Radha Krishan Dhiman*
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
Departments of Cardiology, *Hepatology, and **Internal Medicine,
Postgraduate Institute of Medical Education and Research, Chandigarh
160 012, India
Introduction Even though enough literature exists regarding the preva-
lence of CAD in patients with NAFLD, the literature on the prevalence
and severity of NAFLD in patients with CAD is sparse. Objective of the
present study was to assess the prevalence of NAFLD and its severity in
patients with CAD.
Methods In a prospective study, consecutive adult patients with CAD
were screened for the presence and severity of NAFLD after an informed
consent. The study had the approval of Institute’s Ethics Committee.
CAD was diagnosed on coronary angiography and severity assessed by
number of vessels involved and SYNTAX score. Prevalence and severity
of NAFLD was assessed on ultrasound (abdomen), transient elastography
[measuring liver stiffness measurement (LSM) and controlled attenuation
parameter (CAP)] and other non-invasive assessment.
Results Of 256 patients screened over one and half years, 100 patients
(males 71, mean age 56.7 ± 9.6 yrs) meeting the criteria were included.
Prevalence of NAFLD on USG and CAP was 48% and 42% respectively
and 38 patients (38%) had evidence of steatosis on both modalities.
Severity of hepatic steatosis as assessed on CAP (n=42) was S1 (248 to
≤ 268 dB/m) in 26%, S2 (268 to 288 dB/m) in 31% and S3 (>288 dB/m)
in 43% patients respectively. Seven (18.4%) patients had abnormal ALT
(>40 IU/L); significant hepatic fibrosis (LSM≥8 kPa) was observed in 6
(15.8%) among 38 patients with hepatic steatosis on both USG and CAP
with none of the patients having evidence of cirrhosis (LSM ≥12.5 kPa).
Severity of CAD did not affect the prevalence or severity of NAFLD;
severity of NAFLD did not affect the severity of CAD.
Conclusion NAFLD is common in patients with CAD; majority of them
have mild disease without significant necro-inflammation and hepatic
fibrosis.
Keywords Fatty liver, Steatosis, NAFLD, NASH, Cardiovascular disease,
Metabolic syndrome
217
Therapeutic plasma exchange is safe and effective in the treatment of
acute-on-chronic liver failure- A case-control, pilot study
S69
Sharanya Ramakrishnan, Rekha Hans, Ajay Duseja*, Rati Ram Sharma
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
Departments of Transfusion Medicine, and *Hepatology, Postgraduate
Institute of Medical Education and Research, Chandigarh 160 012, India
Background Acute-on-chronic liver failure (ACLF) is associated with
high in-hospital mortality. Efficacy of therapeutic plasma exchange
(TPE) in treating patients with ACLF is not yet established. The aim of
the present study was to assess the efficacy and tolerability of TPE in
patients with alcohol related ACLF.
Methods Twenty-eight patients (27 males [96.4%], mean age 39.8 ± 7.9
years) with alcohol related Asian Pacific Association for the Study of the
Liver (APASL)-ACLF with grade II AARC score without liver transplant
prospects were enrolled in this prospective, case-control, pilot study. Fourteen
cases received standard volume TPE in addition to standard medical treatment
(SMT) while 14 matched controls were managed with SMT alone. In addition
to tolerability and safety of TPE, biochemical parameters, cytokines, clinical
scores (AARC, MDF, MELD, CTP, SOFC at day 10) and 30-day and 90-day
mortality rates were compared between cases and controls.
Results Total of 51 TPE procedures were performed in 14 cases (average-
3.62 procedures/patient). In comparison to controls, cases had higher
reduction in mean serum bilirubin (-10.4 [14.75] vs. 1.55 [2.9],
p=0.000), ammonia (-32 [36] vs. 8.5 [24], p=0.0001), prothrombin time
(-7 [11.6] vs. 4 [5.3], p=0.0002) and INR (-0.45 [0.88] vs. 0.26 [0.1],
p=0.0022]. The difference in reduction of serum IL-6, IL-10 and TNF-a
concentrations among cases and controls was not significant. However, in
comparison to controls, cases had higher reduction in AARC score (-2
±1.10 vs. 0.36 ±0.84, p=0.000), MDF (-39.7 [34.2] vs. 4.7 [21.4],
p=0.0001) and MELD (-6 [7] vs. 2 [2], p=0.0005) at day 10. There was
no difference in 30-day (21.43% vs. 21.43%, p= 1.000) and 90-day mor-
tality (35.7% vs. 50, p=0.4450) rates and no difference in total and serious
adverse events (p= 0.663) among cases and controls.
Conclusion TPE is safe and effective in the treatment of alcohol related
patients with APASL ACLF.
Keywords Cirrhosis, Alcohol, AARC, MELD, Liver transplantation
218
Point shear wave elastography is helpful in prognosticating patients
with alcohol related patients with acute-on-chronic liver failure de-
fined by APASL definition
Vamsidhar Reddy, Ajay Duseja, Prajina Pradhan*, Radha Krishan
Dhiman, Sunil Taneja, Naveen Kalra*
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
Departments of Hepatology, and *Radiodiagnosis, Postgraduate Institute
of Medical Education and Research, Chandigarh 160 012, India
Background and Aim Various prognostic scores are available for acute-
on-chronic liver failure (ACLF). The aim of the present study was to
evaluate the utility of point shear-wave elastography (pSWE) in
predicting severity, organ failure andday-28 and day-90 mortality in pa-
tients with alcohol related ACLF.
Methods In a prospective study (January 2019 to February 2020), pSWE
was done at presentation in 102 patients with alcohol related ACLF de-
fined as per APASL, CANONIC and combined (APASL+CANONIC)
definitions to predict the baseline severity, organ failure and 28-day and
90-day mortality.
Results In the APASL ACLF group (n=46, males=45, mean age= 42.65
±8.92), baseline pSWE correlated with AARC score (r=0.371, p=0.01)
but not with the presence and number of organ failures. pSWE at the
baseline in the APASL ACLF group also predicted the 28-day (cut off
of 31.35 kPa, AUROC-0.983, p<0.001, diagnostic accuracy of 95.65%)
and 90-day mortality (cut off 26.5 kPa, AUROC-0.983, p<0.001, diag-
nostic accuracy 82.61%). In the CANONIC group (n=26, males=26,
mean age=44.27±10.09), baseline pSWE neither correlated with baseline
S70
severity nor with organ failures. Also, baseline pSWE in the CANONIC
group did not predict the 28 day (AUROC-0.670, p=0.179) and 90-day
mortality (AUROC-0.705, p=0.101). Similar to CANONIC group, in the
combined ACLF group as well (n=30, males=30, mean age=40.57±9.5),
baseline pSWE neither correlated with baseline severity nor with organ
failures and did not predict the 28-day (AUROC-0.531, p=0.179) and 90-
day mortality (AUROC-0.562, p=0.101).
Conclusion Baseline pSWE is helpful in predicting the severity, 28-day
and 90-day mortality in patients with alcohol related ACLF as defined by
the APASL definition but not in those having ACLF as per CANONIC
and combined (APASL+CANONIC) definitions.
Keywords Cirrhosis, Liver failure, ACLF, APASL, Elastography
219
A comparison study of steroid and pentoxifylline in alcoholic hepa-
titis
Dharmendra Tyagi, B Shankar Sharma
Correspondence- Dharmendra Tyagi-drdtyagi89@gmail.com
Department of Gastroenterology, Kurnool Medical College, Bharath
Petroleum, Near, Bhudawarapet, Kisan Ghat Road, Kurnool 518 002,
India
Introduction Alcoholic hepatitis is the most florid presentation of alcohol-
related liver disease. In its severe form, defined by a Maddrey’s discrim-
inant function (DF) ≥32, the 28-day mortality rate is approximately 35%.
Several potential treatments have been subjected to clinical trials, of
which two, corticosteroids and pentoxifylline, may have therapeutic
benefits.
Method This study was conducted in the dept of Medical
Gastroenterology in Govt. General Hospital, Kurnool in which 60 pa-
tients were taken. Patients were randomized in 2 groups:
Group A: 30 patients on steroid
Group B: 30 patients on pentoxifylline
The primary endpoint of mortality was 28 days
Result Treatment with steroid reduced the 28 days mortality to 13.3% (4
patient died out of 30) and treatment with pentoxifylline associated with
33.3% mortality (10 patient died out of 30 patient).
Conclusion Pentoxifylline did not improve survival in patients with alco-
holic hepatitis as compared to steroids. Prednisolone was associated with
a reduction in 28-day mortality.
Keywords Alcoholic hepatitis, Steroids, Pentoxifylline
220
Analysis of correlation of clinicopathological profile, prognostic indi-
cators, and survival outcomes in patients of hepatocellular carcinoma
with baseline alfa-fetoprotein levels: Bruised but not broken
biomarker
Vaneet Jearth2, Prachi Patil3, Vishal Seth3, Sridhar Sundaram1, Vidya
Rao2, Shaesta Mehta3
Correspondence- Vaneet Jearth-vaneet.jearth@gmail.com
1
Department of Gastroenterology, Seth G S Medical College and KEM
Hospital, Mumbai 400 012, India, and 2Departments of Surgical
Pathology, and 3 Digestive Diseases and Clinical Nutrition, Tata
Memorial Center, Dr. E Borges Road, Parel, Mumbai 400 012, India
Introduction Almost 60 years after its discovery, role of alfa fetoprotein
(AFP) in management of HCC is still matter of debate with disagreements
between different international guidelines. The purpose of this study was
to analyze relationship between clinicopathological profile, prognostic
indicators, and survival outcomes with respect to serum AFP levels.
Methods Retrospective analysis of a prospectively accrued dataset of
consecutive HCC patients registered in the hepatology clinic at the Tata
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Memorial Hospital, Mumbai between June 2017 and September 2019
was done.
Results Five hundred and eight treatment naïve HCC patients were in-
cluded in analysis, of whom 92 (18.1%) had normal AFP levels (<10 ng/
mL). One hundred and forty-six patients (28.7%) had AFP levels of 10-
400 ng/ml and 270 (53.2 %) patients had AFP greater than 400 ng/mL.
Patients with AFP > 400 ng/mL had poor hepatic reserves (higher mean
serum bilirubin, AST, ALT, INR, and lower mean albumin) and ad-
vanced disease at presentation (higher incidence of portal vein tumor
thrombosis [PVTT], extrahepatic metastasis, advanced Barcelona clinic
liver cancer [BCLC] stage and significantly less proportion of patients
with well differentiated tumors). On multivariate logistic regression, AFP
>400 ng/mL was independent predictor for presence of PVTT (OR, 4.08;
95% CI, 2.34–7.12; p< 0.001), higher tumor size (OR, 2.19; 95% CI,
1.36-3.54, p=0.001) and more advanced BCLC stage (OR, 4.19; 95% CI,
2.51–7.03; p < 0.001) at presentation. No statistically significant relation-
ship was seen between survival and baseline AFP levels in patients who
underwent surgery (p=0.113) but survival was significantly different in
patients who underwent non-surgical therapies (p=0.003) (Fig. 1). AFP
levels >400 ng/mL was independent predictor of survival in patients
receiving any form of therapy (HR=2.23; 95% CI=1.19-4.18, p=0.012).
Conclusion AFP as a biomarker have significant influence on manage-
ment in HCC patients and is here to stay till the search for ideal biomarker
in HCC is over.
Keywords Alfa fetoprotein, Portal vein tumor thrombosis, Barcelona clin-
ic liver cancer staging
221
DAA therapy is associated with improvement in state of MELD pur-
gatory in decompensated hepatitis C virus cirrhosis
Prasanta Debnath, Parmeshwar Junare, Sujit Nair, Pravin Rathi
Correspondence- Prasanta Debnath-prasantad89@gmail.com
Department of Gastroenterology, Topiwala National Medical College
and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai
Central, Mumbai 400 008, India
Introduction Decompensated HCV cirrhosis is a difficult-to-treat co-
hort, with an SVR rate of over 80%. DAAs are also associated
with an improvement in overall liver function. MELD purgatory
is used to describe patients, who experience viral eradication,
have an improvement in the biochemical parameters-MELD score,
yet remain decompensated, post-treatment. We conducted this
study to look for improvement in MELD purgatory state post-
treatment in decompensated HCV cirrhosis.
Methods A prospective analysis of data from decompensated HCV cir-
rhotics was done. MELD score was calculated for each patient and pa-
tients were stratified into Child-Pugh class B and C. clinical and biochem-
ical parameters were noted at baseline and factors predicting persistent
MELD purgatory state post-treatment were evaluated.
Results A total of 62 patients were recruited. Median age 52 (42-80)
years; male 36 (58.1%). Patients with Child class B 55 (88.7%%) and
Child class C 7 (11.3%). Median HCV RNA 2,24,000 with HCV geno-
type 3 in 80.7%. The number of patients with MELD purgatory state pre-
treatment was 48 (77.4%). Post-treatment follow-up period (36 weeks),
only 12 (19.3%) remained in the state. On multivariate analysis CTP
score (OR 0.34) and serum bilirubin (OR 0.28) and on univariate analysis
serum bilirubin (OR 0.41), albumin (OR 3.64), and eGFR (OR 1.03) were
significantly associated with MELD purgatory state post-treatment.
Conclusion DAA therapy is associated with improvement in MELD pur-
gatory status. The natural history of such patients is lacking in the long
run. A long-term follow-up study in a large population is advisable.
Keywords Hepatitis C, MELD purgatory, Decompensated cirrhosis
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
222
Prevalence of bacterial infections in acute-on-chronic liver failure:
Bacteriology, patient profile and clinical outcome
Beeram K Prasanna Kumar, Rohit Gupta, Anand Sharma, Itish Patnaik,
Ashok Kumar, Sahaj Rathi
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Biochemistry, All India Institute of Medical Sciences,
Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Background Bacterial infections are common triggers for acute-on-
chronic liver failure (ACLF). We aimed to study the prevalence of bac-
terial infections in ACLF patients.
Methods In an ongoing prospective study, consecutive hospitalized pa-
tients diagnosed with ACLF according to EASL criteria between January
2019 and July 2020 were recruited and followed up for one-month post
discharge.
Results During the study period, 100 consecutive patients with ACLF
(age 44.67±11.5 years; 90% were male; baseline CTP 13.72±1.06,
MELD-Na 34.4±5.87, CLIF SOFA 11.4±1.73, CLIF C ACLF 52.07
±9.18) were included in the study. Alcohol was the most common etiology
of acute insult (alcoholic hepatitis 49%; hepatitis B reactivation 17%; sepsis
16%; acute hepatitis A 2%; acute hepatitis E 4%;) as well as cirrhosis (alcohol
59%; hepatitis B 18%; hepatitis C 5%). Previous decompensation was present
in 20%. 64 % of patients had evidence of bacterial infections (blood 8%; ascitic
fluid 36 %; urine 13 %; cellulitis 6%) at admission. Gram negative bacteria
were the most common isolates (Escherichia coli 44%, Klebsiella sp 23%.
Acinetobacter 11%). Compared to patients without bacterial infection, those
with evidence of infection had higher CLIF C ACLF score (48.63±7.79 vs. 54
±9.39; p=0.004) Procalcitonin (2.13±2.64 ng/mL vs. 4.81±4.85 ng/mL;
p=0.002); blood leukocyte count (14.02 ±7.49 x 109 cells/L vs. 18.13±9.81
x 109 cells/L; p= 0.03) and mortality (41 vs. 15; p= 0.03). Forty-two of 100
(42%) patients died during hospital stay (duration of hospitalization 12 ±8
days). Fourteen of remaining 58 (24%) patients died within one month of
discharge.
Conclusion Bacterial infections were noted in 64% patients with ACLF
and was associated with significantly higher mortality.
Keywords ACLF, Bacterial infections, Mortality
223
“Bilioenteric anastomosis: Use the normal route”: A retrospective
analysis of hepaticoduodenostomy versus hepaticojejunostomy in liv-
ing donor liver transplantation
Jaya Agarwal, Binoj S T, Shweta Malick, Krishnanunni Nair, Johns
Shaji Mathew, Christi Varghese, Biju Chandran, Ramachandran
Menon, Dinesh B, Unnikrishnan G, Sudhindaran S
Correspondence- Sudhindaran S-sudhi@aims.amrita.edu
Department of GI Surgery and Liver transplantation, Amrita Institute of
Medical Sciences, Kochi 682 041, India
Introduction In living donor liver transplantation (LDLT) when donor
bile duct to recipient bile duct anastomosis is not feasible, usually in the
case of multiple ducts, hepaticojejunostomy (HJ) is often performed.
Recently in non-transplant biliary surgery hepaticoduodenostomy (HD)
has shown equivalent results to HJ. This study is our experience of out-
comes of HD in adult LDLT.
Method A retrospective case control study of 58 adult patients undergoing
right lobe LDLT with bilioenteric anastomosis was conducted at our
centre. Bilioenteric anastomosis was performed for patients who had ≥
2 donor bile ducts with > 3 mm separation (n=54) or unsuitable recipient
bile ducts (n=4). Though HJ was our initial practice of choice (n=23), for
the last 8 years HD has been our preference (n=35). We compared inci-
dence of biliary complications between HJ and HD.
S71
Results Baseline demographic parameters, MELD score as well as biliru-
bin and liver enzymes in the immediate postoperative period and at 3 and
6 months were similar in both groups. Between HD and HJ the occur-
rence of leak rates (23% vs. 22%), cholangitis (11.4% vs. 17%) and
strictures (11.42% vs. 17%) were similar. Need for radiological interven-
tions or re-exploration (11.4% vs. 4.34%) for biliary complications were
likewise similar. However 17% of HJ required percutaneous transhepatic
biliary drainage (PTBD) vs. 2% of HD (p- value=0.05). Mortality was
comparable between HD (20%) and HJ (17%).
Conclusion HD is an alternative to HJ when bilioenteric anastomosis is
required following LDLT. As duodenum could be easily accessed using
endoscope, the requirement of transhepatic approach for biliary interven-
tion is significantly less in HD as compared to HJ.
Keywords Liver transplantation, biliary anastomosis,
hepaticoduodenostomy, hepaticojejunostomy.
224
Budd-Chiari syndrome management : A single institution experience
Govind Purushothaman, Rohit Mudadla, Amudhan A, Kamala Kannan
R, Saravanan J, Thiruvarul M, Selvaraj T, Jeswanth S
Correspondence- Govind Purushothaman-govindmmc@gmail.com
Department of Surgical Gastroenterology and Liver Transplant, Institute
of Surgical Gastroenterology and Liver Transplantation, Stanley Medical
College, 1, Old Jail Road, Chennai, 600 001, India
Aim To investigate challenges, risk factors, prognostic indicators and
treatment outcomes of various methods associated with Budd-Chiari syn-
drome (BCS) at a tertiary care center.
Methods A retrospective analysis of 100 patients with BCS who
underwent radiological intervention (HV/IVC angioplasty, TIPSS), sur-
gical portal decompression shunt procedure (SSPCS, PSRS) and liver
transplant.
Results Among 100 patients, 40 patients were excluded from analysis due
to death and missed follow–up. In 60 patients with BCS 30 patients
underwent various hepatic vein/IVC angioplasty and TIPSS, 11 patients
underwent SSPCS and PSRS shunts and remaining 18 patients underwent
liver transplant work-up and 1 patient underwent LTX. Radiological in-
tervention was done in 30 patients. Twenty-four patients are doing well
and have well preserved liver function with intervention procedure alone.
In surgical portal decompression group 9 out of 11 survivors remain
symptoms free and with normal liver function. In liver transplant group,
1 patient underwent DDLT. Three years follow-up is good, maintaining
liver function and good quality of life. Remaining patients have under-
gone liver transplant work up. In radiological intervention group 5 pa-
tients died of liver failure and one patient lost follow-up. In Surgical shunt
one patient died of postoperative liver failure, one due to pulmonary
complication and 6 patients died of liver failure while awaiting liver
transplant.
Conclusion Effective treatment of BCS requires multidisciplinary ap-
proach. Early diagnosis and decompression of porto-mesenteric venous
system can provide excellent survival. Accurate assessments of duration
of symptoms, extent of thrombosis and liver function are critical in deter-
mining the course of treatment.
Keywords Budd-Chiari syndrome management, Portocaval shunt
225
Auxillary partial orthotopic liver transplantation (APOLT) in treat-
ment of acute liver failure: The Amrita experience
Jaya Agarwal, Shweta Malick, Krishnanunni Nair, Johns Shaji Mathew,
Christi Varghese, Biju Chandran, Binoj S T, Ramachandran Menon,
Dinesh B, Unnikrishnan G, Sudhindaran S
Correspondence- Sudhindaran S-sudhi@aims.amrita.edu
S72
Department of GI Surgery and Liver Transplantation, Amrita Institute of
Medical Sciences, Ponekkara, AIMS PO, Kochi 682 041, India
Introduction Acute liver failure (ALF) often affects the young in the
prime of life. Over 70% survivors are on medical management and have
complete morphological and functional recovery. In the subset of patients
who need liver transplantation (LT), if APOLT can be offered, life-long
immunosuppression may be avoided. We report a case series of 6 patients
who had undergone APOLT for ALF.
Method Out of 810 LT performed at our institute between 2006 and 2019,
68 were for ALF. Out of these 6 were APOLT, the first one being per-
formed in 2011 December. Decision to perform APOLT was made by
assessing the hemodynamic stability of the patient and the appearance of
the native liver. Post operatively LFT, INR, 6 monthly and 1-year HIDA
scan and CT abdomen was done. When the native liver regeneration
(NLR) was > 50 % decision to discontinue the immunosuppression grad-
ually was made.
Results Out of 6 patients 3 survived (50%). All patients were below 40
years. Etiology of ALF was hepatitis A (n= 4), yellow phosphorous (n=1)
and seronegative hepatitis (n=1). In the surviving patients immunosup-
pression was given for a mean of 22 months and was gradually with-
drawn. None required graft hepatectomy. Sepsis was cause of death in 2
patients whereas brain death in 1. High preoperative ammonia (>200) and
non-hepatitis A etiology were predictors of mortality in APOLT patients.
Conclusions APOLT can be offered to ALF patients especially with hep-
atitis A etiology and preoperative ammonia levels <200.
Keywords Liver transplantation, Acute liver failure
226
Etiology, clinical profile and outcome in patients with portal vein
thrombosis
Jithin James, Ramachandran T M, Srijith K
Correspondence- Jithin James-jithinjames87@gmail.com
Department of Gastroenterology, Government Medical College, Medical
College Road, Kozhikode 673 008, India
Introduction A regional data on common causes for portal vein thrombo-
sis and to know its prognosis and outcome helps in better understanding
of disease and in management. This study was undertaken to determine
etiological factors, clinical characteristics, complications, and outcome in
patients with portal vein thrombosis.
Methods A cohort study of 40 patients with diagnosis of portal vein
thrombosis was conducted. A pre structured proforma was used for col-
lection of data. Patients were followed up for 6 months from the time of
diagnosis.
Results Study population was grouped into three strata: C-PVT, non-
malignant cirrhotic PVT; N-PVT, non-malignant non-cirrhotic PVT and
M-PVT, malignant PVT. N-PVT patients were younger at the time of
diagnosis compared to patients with C-PVT or M-PVT (p<0.01). Most
common cause of PVT was cirrhosis liver followed by malignancy.
Abdominal pain was a common complaint in N-PVT and M-PVT but
less frequent in C-PVT (p<0.05). Ascites (p<0.001), splenomegaly
(p<0.05), esophageal varices (p<0.001) and jaundice (p<0.01) were more
prevalent in C-PVT and M-PVT than in N-PVT. In 80% of patients
diagnosis was established by means of Doppler ultrasound.
Anticoagulation therapy was administered to 60% of patients and was
more common in N-PVT patients (92.3%) than in those with C-PVT
(52.9%) or M-PVT (30%) (p<0.01). Out of the 31 patients for whom
results of recanalization were available 51.6 % had complete/partial re-
canalization during 6 month follow-up. Seventy-five percent of patients
with recanalization had received anticoagulation. Recanalization was
seen in 69.2% of patients in N-PVT group, 50% of patients in C-PVT
group (p<0.05). Sixty percent of patients in the M-PVT group and 17.6%
patients in the C-PVT group died during follow-up.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusion Partial or complete recanalization was more frequent in pa-
tients treated with anticoagulation therapy. The prognosis is variable and
highly dependent on underlying disease.
Keywords Portal vein thrombosis, recanalization, anticoagulation.
227
Study of clinical profile and predictors of mortality in spontaneous
bacterial peritonitis in cirrhosis of liver
Pankaj Nawghare, Jayant Sakale*, Saurabh Bansal, Sameet Patel,
Partha Debnath, Siddhesh Rane, Shubham Jain, Sanjay Chandnani,
Pravin Rathi
Correspondence- Pankaj Nawghare-pankaj9ghare21@gmail.com
Department of Gastroenterology, Topiwala National Medical College
and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai
Central, Mumbai 400 008, India, * Department of Medicine,
Government Medical College, Nagpur 440 009, India
Introduction Spontaneous bacterial peritonitis (SBP) is a very common
bacterial infection in patients with cirrhosis and ascites which requires
prompt recognition and treatment. This study was carried out to identify
and understand the clinical profile of SBP, about causative organisms and
different mortality indicators in SBP in cirrhotic.
Methods Study was conducted at tertiary care center. All consecutive
patients with cirrhosis with ascitic fluid TLC >250 cells /mm3 were
included.
Results Forty population were enrolled with 20% were female.
Majority of patients were in age group 40-50 years. Mortality
was more in males (25%) than female (7.5%). Alcohol was pre-
dominant etiology for cirrhosis (85%). Most common presenting
complaint was abdominal pain (82.5%) followed by abdominal
distention (60%) but both were not significantly associated with
mortality. Altered sensorium and reduce urinary output on admis-
sion was associated with increase mortality (p<0.05). On exami-
nation presence of jaundice, grade 3 ascites and WHC >2 was
associated with increase mortality (p<0.05). There was significant
association between the degree of hyperbilirubinemia and mortal-
ity (p=0.017). Though ascitic fluid albumin < 1 gm is strongly
associated with SBP, its association with mortality was not sig-
nificant. Association of ascitic fluid TLC, sugar and SAAG were
also not significant with mortality. Most common organism iso-
lated was E coli. Etiology of cirrhosis didn’t affect mortality.
There was less mortality in patients responding to the treatment
on day 3 (p=0.001). Most of patients belongs to Child-Pugh class
C. Mean MELD score was 24.57 ± 8.45. A highly significant
association was found between MELD score and Child-Pugh
score with mortality.
Conclusion Spontaneous bacterial peritonitis is often a fatal com-
plication of cirrhosis. Early diagnosis is critical for successful
treatment. With use of various mortality indicator response can
be predicted.
Key word Cirrhosis, SBP
228
A study of frailty in patients with liver cirrhosis and impact of nutri-
tional intervention on frailty
Ajay Kumar Jain, Mohit Jain, Shohini Sircar, Arun Singh, Amit Joshi,
Sumit Singh
Correspondence- Mohit Jain-drmohitmd@gmail.com
Department of Gastroenterology, Choithram Hospital and Reasearch
Center, 14, Manik Bagh Road, Indore 452 014, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction It has been seen that commonly used scores to predict prog-
nosis in cirrhosis are CTP and MELD, however these scores failed to
capture the effects of muscle wasting, malnutrition, and functional decline
that are present in most decompensated cirrhotic patients, and contribute
to excess mortality in this population. Recent Studies have shown that
frailty index does have an added role in prognostication of these patients.
So, we aim to determine prevalence of frailty in patients of chronic liver
disease and to assess the effects of nutritional intervention at 8 and 12
weeks in this patient population.
Methodology This is a prospective non-randomized interventional study
for 18 months in patients of cirrhosis. All patients did balance, chair
stands and gait speed (SPPB- short physical performance battery) at base-
line, 8 and 12 weeks respectively. All patient underwent nutritional as-
sessment at baseline and specific dietary advice was given to achieve
protein intake of 1 gm/kg body weight and 30 to 35 K. Cal/Kg body
weight per day.
Results Total 340 patients of cirrhosis were screened for frailty, among
them 173 patients were recruited based on inclusion and exclusion
criteria. Prevalence of frailty in this cohort of patients (n=173) was
34.6% (60/173). Out 173 patients 78 patient completed follow-up at 8
and 12 weeks. At baseline out of 78 patients 34 (43.6%) were frail (SPPB
< 10). After nutritional intervention 15 (44.1%) and 19 (55.8%) patients
showed significant improvement in frailty index (SPPB>10) at week 8
and 12 respectively.
Conclusion This study suggest that about one third of cirrhotic patients
are frail at presentation. Nutritional intervention does help in improving
frailty which possibly could improve prognosis in this patient population.
Keywords Frailty, Chronic liver disease, Nutrition
229
Spectrum of non-alcoholic fatty liver disease in adult Type 2 diabetes
mellitus patients
Nitesh Pandey
Correspondence- Nitesh Pandey-niteshkumarshashi@gmail.com
1
Delhi University, Delhi, India, and 2Department of Medicine, Lady
Hardinge Medical College, Connaught Place, New Delhi 110 001, India
Background Non-alcoholic fatty liver disease (NAFLD) is an overlooked
complication of type 2 diabetes mellitus (T2DM) one of the most com-
mon cause of chronic liver disease worldwide.
Aim To study the proportion of NAFLD in T2DM patients. To measure
the grade of liver fibrosis using fibroscan and to calculate Bazick’s and
NAFLD fibrosis score (NFS) and compare both the scores for advanced
liver fibrosis vis a vis fibroscan.
Method One hundred diagnosed between 35-65 yrs of age were included
and patients with alcohol intake in past 2 years >140 gm and >70 gm in
male and female respectively per week, known liver disease, history of
hepatotoxic drug intake, on insulin therapy, ascites and pregnancy were
excluded. NAFLD was diagnosed as; fatty liver grade 1, 2, 3 using ultra-
sonography, transamniitis (AST, ALT >35 IU/L), and fibrosis by
fibroscan (F0-F4) and advanced fibrosis was considered as F3 (8.7-
10.2) and F4 (≥10.3). Bazick’s score and NAFLD score were calculated
and compared vis-a-vis fibroscan for advanced fibrosis.
Results One hundred T2DM patients (69 female/31 male) in age group of
35-65 years enrolled in LHMC, 84 (84%) T2DM patients were identified
as having NAFLD. 61% patients had fatty liver, 43% had transamniitis
and 60% patient had fibrosis, 23% patient had advanced fibrosis by
fibroscan. As per prevalence of advanced fibrosis was 41% and by NFS
score it was 50%. The diagnostic accuracy for advanced fibrosis was
found to be 61% and 55% in our study for Bazick’s and NFS score
respectively. The specificity, sensitivity, NPV and PPV for Bazicks score
was 90%, 56.8%, 47.7% and 93.2% respectively, for NAFLD score it was
98%, 51%, 85% and 95% respectively.
S73
Conclusion NAFLD was very common among T2DM patients.
Advanced fibrosis was present in about a quarter of T2DM patients.
Both Bazick’s and NAFLD fibrosis score were not good for predicting
advanced liver fibrosis.
Keywords NAFLD, T2DM, Advanced fibrosis
230
Jaundice in pregnancy: Analysis of etiological factors and maternal
and fetal outcome
Vani Malhotra,
Correspondence- Vani Malhotra-drparveenmalhotra@yahoo.com
Department of Medical Gastroenterology, Post Graduate Institute of
Medical Sciences, Medical Road, Rohtak 124 001, India
Introduction Jaundice is a common medical disorder with high maternal
mortality and morbidity, acute viral hepatitis being the commonest cause
of jaundice in pregnancy.
Aims and Objectives To assess the etiological factors associated with
jaundice and its maternal and fetal outcome in pregnancy.
Methods Prospective observational study over one year in pregnant fe-
male presenting with jaundice in pregnancy. A detailed history was taken,
and all the females were subjected to routine and special investigations
like liver function tests, viral markers, coagulation profile and
hepatobiliary sonography. Maternal and fetal outcomes were assessed
and noted in prestrcured. Performa and analyzed by using Chi-square a
with p-value of < 0.05 as significant.
Results Mean age of the patients was 24.12±4.12. Acute viral hepatitis
(47.1%) and ICP (35.4%) were the commonest cause of jaundice.
Seventy percent of women delivered vaginally and about 30% delivered
by cesarean section. Complications were hepatic encephalopathy, ICU
stay, thrombocytopenia and requiring ventilator support. Three patients
expired as a result of hepatic encephalopathy. Preterm delivery was ob-
served in 41.4 % patient.
Conclusion Jaundice in pregnancy should be promptly diagnosed, inves-
tigated and appropriate management should be provided to prevent ad-
verse maternal and fetal complications.
Keywords Jaundice, Acute viral hepatitis, Hepatic encephalopathy,
Thrombocytopenia
231
Loss of sphingosine-1-phosphate predicts severe intrapulmonary
shunting and hepatopulmonary syndrome in patients with cirrhosis
Sukriti Baweja, Preeti Negi, Arvind Tomar, Anupama Kumari, Swati
Thangriyal, Rakhi Maiwall, Shiv Kumar Sarin
Correspondence- Shiv Kumar Sarin-shivsarin@gmail.com
Department of Molecular and Cellular Medicine, Institute of Liver and
Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Hepatopulmonary syndrome (HPS) is a serious complication
of cirrhosis. sphingosine-1-phosphate (S1P): bioactive lipid, maintains
the vascular tone and potent vasoconstrictor and may be selectively in-
volved in complications of HPS. We investigated the role of S1P in
severity of HPS in cirrhosis patients and its association with systemic
inflammation.
Methods HPS was diagnosed by intra pulmonary vascular dilata-
tions (IPVDs) as assessed by sline contrast echocardiography and
oxygenation defect confirmed by arterial blood gas (ABG) analy-
sis. Fifty-four cirrhosis patients; 22 with HPS (Gr. A) and 32
without HPS (Gr. B), and 10 healthy controls (Gr. C) were in-
cluded. Plasma levels of S1P, nitric oxide (NO), TNF-α, IL-1β
were measured and also immune profiling for immune cells in
S74
peripheral blood by flow cytometry and the gene expression of
iNOS, eNOS, S1P receptors, S1P kinases by qPCR.
Results The plasma S1P levels were significantly low in Gr. A compared
to Gr. B (10.9±4.2 vs. 51.3±19.2 ng/mL; p=0.0129) and Gr. C (107.2
±20.1; p<0.05). In Gr A compared to B, the TNF-α (35.6±18.2 vs. 4.5
±1.2 pg/mL; p=0.05) and NO (18.23±2.1 vs. 8.45±1.6 μmol/L; p=0.048)
levels were higher, however with comparable IL-1β levels. A progressive
decline in S1P levels from mild to severe intrapulmonary shunting in Gr.
A patients (mild 8.8± 4.8; moderate 6.4±1.3; severe 1.6±0.2 ng/mL;
[p=0.056 mild vs. severe]) and was able to predict severe HPS with
AUROC of 0.72; p=0.03; with cut off levels <1.4 ng/mL. Patients in
Gr. A than B showed elevated levels of IL-17 producing Th17 cells
(4.5%±2.2 vs. 0.5%±0.01; p=0.000) which directly correlated with low
levels of S1P (r2>0.3; p=0.00). mRNA levels of iNOS, eNOS, S1PR3
were >6-fold high and SPHK1 levels lower in Gr. A than B (p<0.05).
Conclusion Depletion of S1P levels in cirrhosis with HPS can predict the
severity of intrapulmonary shunting. Supplementing S1P may be a po-
tential drug for reducing the intrapulmonary shunting in HPS.
Keywords Hepatopulmonary syndrome, Cirrhosis, Sphingosine-1-phos-
phate, Vasodilation,
232
Use of entecavir in Indian patients of chronic hepatitis B, experience
of a tertiary care centre
Revathy M S, Ajay Kandpal, Sumathi B, Chitra S, Manimaran M,
Sathya G
Correspondence- Ajay Kandpal-kandykilroy@gmail.com
Department of Medical Gastroenterology, Government Stanley Medical
College, Chennai 600 001, India
Background Entecavir is now readily available in Government hospitals
in India. However, there is less data on how it has affected the viral
markers in Indian patients of chronic hepatitis B.
Aim To study effects of entecavir treatment in virological and serological
profile of chronic hepatitis B patients and monitor side effects in study
period.
Methods One hundred chronic hepatitis B patients were included in the
study and treated with entecavir (0.5 mg/day) in our hospital. Baseline
values were recorded. Periodic follow-up was done and virological re-
sponse, biochemical response and serological conversion rate were
assessed at weeks 24, 48 and 96.
Results Mean age was observed to be 42 years. A male preponderance
was observed with 80%of the patients being male. At baseline, 92% of the
patients were HbsAg positive and 10% HbeAg positive, the mean hepa-
titis B virus DNA was6.162 log10 IU/mL. The rates of achieving positive
virological response increased significantly over the follow-up period of
96 weeks. Loss of HBsAg was recorded in 4.35% (4/92 HBsAg positive)
patients at 24 weeks and 8.7% (8/92 HBsAg positive) patients at 96
weeks. A significant clearance of HbeAg and seroconversion to anti-
HbeAg was recorded in 30% (3/10 HbeAg positive) patients gradually
over the treatment duration. Overall, the treatment with entecavir was
well tolerated, and no major adverse event was recorded during the study
period.
Conclusion Entecavir monotherapy in Indian clinical practice was well
tolerated and resulted in a rapid and significant reduction in viral load.
Both virologic and serological response are seen with longer duration of
therapy.
Keywords Entecavir, Hepatitis B, Seroconversion
233
Study of alcohol abstinence and relapse in alcohol related liver
disease
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Neeraj Nagaich1, Radha Sharma2
Correspondence- Neeraj Nagaich-drneerajn@gmail.com
1
Department of Gastroenterology, Fortis Escorts Hospital, Jawahar Lal
Nehru Marg, Sector 5, Malviya Nagar, Jaipur 302 017, India, and 2RUHS
College of Medical Sciences, Kumbha Marg, Sector 11 Road, Pratap
Nagar, Jaipur 302 033, India
Objectives Prospective and retrospective study of 451 patients with alco-
hol use disorders was done with an intent to assess various factors affect-
ing remission and relapse and improve outcome for individuals with
alcohol dependence and liver disease.
Methods Patients with ethanol related liver disease and alcohol de-
pendence were enrolled after their presentation in gastroenterology
clinic and followed thereafter at 1, 3, 6, and 12 months. Patient
assessment and relevant investigations were done. Semi structured
clinical interviews, the symptom checklist 90-revised (SCL90-R),
addiction severity index (ASI), the Beck Depression inventory
(BDI) were recorded. High-risk alcoholism relapse scale-based
score was calculated. 2 Patients were reassessed at six and twelve
months to determine treatment outcome (abstinence status and du-
ration of continuous abstinence). Data were coded, validated and
analyzed using descriptive statistics.
Results A majority of the sample 70 percent (n=315) had significant
psychiatric symptoms at intake: 22 percent (n=70) presented with depres-
sive symptoms, 17 percent (n=15) with anxiety symptoms, and 41 percent
(n=192) with combined depressive and anxiety symptoms. Forty percent
of patients who presented with combined depression and anxiety symp-
toms were abstinent at six months. These patients had worse prognosis
than less symptomatic cohort at intake, including those who presented
with depression symptoms alone; in the latter group, 60 percent were
abstinent at six months.
Conclusions Concurrent depression or anxiety symptoms low education,
lack of motivation for abstinence had a significant negative predictive
effect on treatment outcome. Craving was noted as most common cause
for relapse in alcohol dependent patients. Higher relapse rate was seen in
concomitant opioid dependence, high risk’ situations, previous relapses
positive predictors were more number of coping strategies, principally
adaptive ones. There is significant association between age at first drink,
age at dependence, duration of dependence, other co-morbid diagnosis of
patients and relapse.
234
Osteodystrophy in non-cholestatic liver cirrhosis
Gireesh Dhaked, Anubhav Jain, Gaurav Gupta, Sandeep Nijhawan
Correspondence- Gaurav Gupta-kumarggauravpgi@gmail.com
Department of Gastroenterology, Sawai Man Singh Medical College, J L
N Marg, Jaipur 302 004, India
Background Alterations of bone metabolism in patients with chronic
liver diseases (CLD) represent an important complication. This pa-
thology is represented by osteoporosis or osteopenia. Thus the pres-
ent study was undertaken to look for BMD T-score in CLD patients
and degree of improvement with supplementation with calcium
(1000 mg) + vitamin d (500 IU)+ bisphosphonate (4 mg zoledronic
acid intravenously).
Methods Prospective longitudinal case-control study conducted in the
department of gastroenterology, SMS Medical College, Jaipur. Patients
evaluated with DEXA scan at baseline and at 6 months. The degree of
reduced BMD will be co-related with CTP, MELD, BMI, and MAC.
Results A total of 90 patients were screened, 77 patients (85.5 %) had
hepatic osteodystrophy. Twenty-four (31 %) has osteoporosis rest had
osteopenia. Mean age, BMI, CTP score, MELD score, alkaline phospha-
tase of patients were 44.8 years, 23.32 kg/m2, 8.45, 19.8, 166.9 IU/mL
respectively. Alcohol (73%) was the most common etiology. Most of
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
them were male 97.4% with the mean of Dexa score t value at the lumbar
spine and femur neck were 2.1 and 1.66 respectively. Patients taking
diuretics had a significant reduction in t score (p <0.05) and lower T score
correlated with lower BMI and Lower MAC. To date, a total of 47 pa-
tients followed for 6 months. Twenty-nine out of 47 the patient was
analyzed for change in the DEXA score. On six-month follow-up mean
Dexa score t value at the lumbar spine and femur neck were 1.87 and 1.49
respectively, which was significant improved from baseline (p-value
<0.05).
Conclusion Hepatic osteodystrophy is very common in non-cholestatic liver
cirrhosis. Degree of fall in BMD co-relates with fall in BMI and MAC and
not with MELD and CTP score. To date results of the follow-up, study is
suggestive of significant improvement with medical intervention.
Keywords Dual emission X-ray absorption, Bone mineral density, MAC
235
Phyllanthin regulates expression of NFKB/PI3K/AKT pathway in
animal model of non-alcoholic fatty liver disease: A preliminary
study
Manu Mehta, Ajay Duseja, Sarika Gupta*
Correspondence- Ajay Duseja-ajayduseja@yahoo.co.in
*
Department of Biosciences and Biotechnology, Banasthali Vidyapith,
Jaipur, India, and Department of Hepatology, Postgraduate Institute of
Medical Education and Research, Chandigarh 160 012, India
Introduction Mechanism of protection of liver injury by Phyllanthin is not
clear. Dysregulation of PI3K/AKT pathway contributes to the develop-
ment of non-alcoholic fatty liver disease (NAFLD). Aim of the present
study was to evaluate if the hepatoprotective effect of Phyllanthus niruri
in a mice model of NAFLD is related to the regulation ofNFKB/PI3K/
AKTpathway.
Methodology Control male C57BL/6 mice were given normal chow diet
(group A). Group B mice were fed methionine-choline deficient diet
(MCDD) for 4 weeks to make NAFLD model. Control as well as
MCDD mice were also administered plant crude extract i.e. Phyllanthus
niruri (200 mg/kg) (group C and group D). Control as well as MCDD
mice were also administered commercially available product Phyllanthin
(2 mg/kg) (group E and group F). Real time PCR expression of NF-KB,
AKT, PI3K and IRS-1 genes was studied, and relative expression was
calculated using 2-Ct method. β-actin was used as reference gene. Data
analyzed using one-way ANOVA.
Results There was significantly increase in mRNA expression of NF-KB
(4.78±2.04 vs. 1.06±0.40; p<0.0001), AKT (5.89±2.63 vs. 1.12±0.60;
p<0.0001), PI3K (2.20±1.07 vs. 0.66±0.23; p<0.0001) and IRS (4.63
±2.36 vs. 1.10±0.50; p=0.001) in group B in comparison to group A.
Plant extract (group D) significantly down regulated the expression of
AKT (0.90±0.17 vs. 5.89±2.63; p<0.0001), NF-KB (0.84±0.29 vs. 4.78
±2.04; p<0.0001), PI3K (0.69±0.25 vs. 2.20±1.07; p<0.0001) and IRS
(1.41±1.08 vs. 4.63±2.36; p=0.003) in comparison to group B.
Commercial available phyllanthin (group F) also significantly downreg-
ulated expression of AKT (1.04±0.39 vs. 5.89±2.63; p<0.0001), NF-KB
(0.99±0.45 vs. 4.78±2.04; p<0.0001), PI3K (0.78±0.36 vs. 2.20±1.07;
p=0.001) and IRS (1.69±2.09 vs. 4.63±2.36; p=0.015) in comparison to
group B.
Conclusion The results of our study demonstrate that the
hepatotoprotective effect of crude extract of P. niruri in a mice model of
NAFLD is related to the regulation of NFKB/PI3K/AKT pathway.
Keywords Fatty liver, NASH, Hepatic steatosis, Phyllanthin, Mice model
236
COVID-19 presenting with direct hyperbilirubinemia and multi-
organ failure
S75
Amey Sonavane, Deepak Gupta, Aabha Nagral, Shankar Bhanushali,
Rahul Deotale, Divya Kuckian, Gunadhar Padhi, Aklesh Tandekar,
Suvadeep Sen, Tushar Parmar
Correspondence- Amey Sonavane-amey_max@yahoo.com
Department of Gastroenterology, Hepatology and Liver Transplantation,
Apollo Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur,
Navi Mumbai 400 614, India
Background SARS-CoV-2 can infect liver cells with resultant hepatitis.
Furthermore, drug hepatotoxicity, immune-mediated inflammation and
pneumonia-associated hypoxia can contribute to liver injury and failure.
We describe an interesting case of COVID-19 infection presenting with
significant direct hyperbilirubinemia, mild hepatitis, and multi-organ
dysfunction.
Case Report A 34-year-old gentleman presented with acute high grade
fever followed by increasing jaundice. He was admitted with altered
sensorium, hypotension, and anuria. There was no history of previous
admissions, drug intake, alcohol consumption or liver disease in the past.
He was intubated, ventilated, volume resuscitated, initiated on sustained
low efficiency dialysis and inotropes. Blood investigations revealed he-
moglobin 8.1 gm%, total leukocyte count 12,310/mm2, platelet count
54,000/mm2 and serum creatinine 6.3 mg/dL. Serum total bilirubin was
21.8 mg/dL with direct bilirubin being 16.93 mg/dL. Serum alanine trans-
aminase and aspartate transaminase levels were 107 U/L and 36 U/L
respectively. International normalized ratio, serum gamma glutamyl
transpeptidase, albumin and alkaline phosphatase levels were normal.
Serology tests for viral hepatitis A, B, C and E were negative. Tests for
malaria, dengue, leptospirosis, cytomegalovirus and Epstein-Barr virus
were negative. Antinuclear antibody and anti-smooth muscle antibody
were negative. Serum immunoglobulin G and ceruloplasmin was normal.
Blood tests for hemolysis returned negative. Serum ferritin was 445.7 ng/
mL, serum triglyceride was normal and serum fibrinogen was 753 mg/dL.
Serum interleukin 6 and C-reactive protein was significantly elevated. He
responded to intravenous steroids and supportive management. Inotropes
were stopped, acute kidney injury recovered, fever subsided, and he was
extubated uneventfully. Serum bilirubin gradually declined to 3.4 mg/dL
and patient was discharged uneventfully after 14 days.
Conclusion SARS-CoV-2 can cause mild elevation in serum bilirubin.
However, significantly elevated serum bilirubin is an extremely rare pre-
senting feature of COVID-19, thus widening our knowledge about the
known spectrum of disease.
Keywords COVID-19, SARS-CoV-2, Hyperbilirubinemia, Liver injury
237
Intolerance to penicillamine treatment needing discontinuation in
Wilson’s disease: A retrospective audit
Biswa Ranjan Patra, Mohd. Irtaza, Sanjay Kumar, Praveen Kumar Rao,
Sridhar Sundaram, Aditya Kale, Aniruddha Phadke, Akash Shukla
Correspondence- Akash Shukla-drakashshukla@yahoo.com
Department of Medical Gastroenterology, Seth G S Medical College and
KEM Hospital, Parel, Mumbai 400 012, India
Background There is scant data about serious adverse events with d-
Penicillamine (DPN) resulting in discontinuation of the drug. We aimed
to audit penicillamine related severe adverse effects in patients with
Wilson’s disease requiring drug withdrawal.
Methods A retrospective audit of prospectively maintained data-
base of patients diagnosed with Wilson’s disease registered in the
Liver Clinic at a tertiary care center between December 2006-
January 2020 was done. Demographic parameters and details of
treatment were noted. We analyzed side effects related to DPN
treatment, subsequent therapies following the discontinuation of
medication and the reasons for discontinuation.
S76
Results A total of 118 patients with Wilson’s disease, were included in the
study. 101/118 (85.6 %) patients were started on DPN and 11 patients (9.3
%) on combination therapy of DPN and zinc, while another six patients
(5.0%) received only zinc. Serious side effects were seen in 28/112 patients
(25.0%) over a study duration of 860 person years. The most common side
effect was bone marrow suppression seen in 16/28 (57.1%) and proteinuria
in 7/28 (25%). Two patients developed paradoxical neurological deteriora-
tion following DPN administration. Elastosis perforans serpingosa was seen
in one patient. DPN was discontinued temporarily in 25/28 patients. In three
patients, side effects improved with reduction of dose. Fifteen out of 25
patients were switched to zinc monotherapy, and two to trientine.
Reintroduction of DPN with lower dose was attempted in 8 patients out
of which 4 tolerated without reappearance of adverse effects.
Conclusion DPN treatment is associated with significant adverse effects
mainly related to blood, kidney, and skin, with 1 per 30 person-years.
Temporary stoppage of drug with reintroduction at lower dose is an
effective and safe option.
Keywords Wilsons, Penicillamine, Intolerance
238
Performance of non-invasive tools to stratify patients with chronic
liver disease for risk of future variceal bleeding
Sanchit Sharma, Samagra Agarwal, Srikant Mohta, Ankur Bhardwaj,
Deepak Gunjan, Shiv Sarin*, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, and
*
Director, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj,
New Delhi 110 070, India
Introduction Multiple non-invasive tools (NITs) are validated in compen-
sated advanced chronic liver disease (cACLD) for identifying those at
low-risk of varices needing treatment (VNTs) but their role in stratifying
risk of variceal bleeding (VB) is unclear. The present study assessed the
performance of NITs to stratify risk of VB in cACLD, and their utility for
initiating primary prophylaxis.
Methods In this retrospective multicentre analysis, patients with cACLD
were classified at baseline using endoscopy (high-risk vs low-risk/no
varices) and different NITs (high-risk vs. low-risk for VNTs) like
Baveno-VI, expanded Baveno-VI, platelet-MELD, platelet-albumin and
ANTICIPATE platelet criteria. Follow-up data for future VB was collect-
ed. Rates of VB in different risk subgroups of endoscopic classification
and NITs were calculated. Decision curve analysis was conducted to
assess net benefit of initiating primary prophylaxis for VB based on
different NITs versus endoscopic classification.
Results One thousand two hundred and eighty-four patients of cACLD of
different etiologies were included. All NITs predicted VNTs with good
accuracy at baseline. Ninety-eight (7.6%) patients developed VB over 20
(9-35) months with 22% events in those with low-risk/no varices at baseline
endoscopy. All NITs adequately risk-stratified future VB risk. Low-risk
Baveno-VI subgroup developed no VB, while low-risk subgroups of
ANTICIPATE, platelet-albumin and expanded Baveno-VI criteria suffered
4%, 8% and 13% of VB respectively. NITs were superior to endoscopy for
deciding need for pharmacotherapy when threshold for initiating treatment
for VB was kept below 3% while endoscopy was superior beyond it.
Conclusion NITs stratify risk of future VB with good accuracy. NITs may
be superior to endoscopy in initiating prophylaxis if threshold for initiat-
ing treatment is low.
Keywords Variceal bleeding, Baveno-VI criteria, Varices needing treat-
ment
239
Chylous ascites caused by histoplasmosis: A case report
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Akash Mathur, Ankur Yadav, Vinita Agrawal, Manoj Jain, Uday C
Ghoshal
Correspondence- Uday C Ghoshal-udayghoshal@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of
Medical Sciences, Lucknow 226 014, India
Background Chylous ascites results from blockage of abdominal lym-
phatics by malignancy, trauma, surgery, and infections. A patient present-
ing with chylous ascites due to histoplasmosis is presented.
Case report A 53-year-old female with undifferentiated connective
tissue disorder and hypothyroidism presented with a 3-month histo-
ry of anasarca initially responding transiently to prednisolone and
diuretics. However, ascites and anasarca recurred along with breath-
lessness. 25-year-old ago, she received anti-tubercular drugs (ATD)
for tubercular lymphadenitis. Examination revealed cervical lymph-
adenopathy, right-sided pleural effusion (confirmed on chest radiog-
raphy) and ascites. Echocardiography did not reveal pericardial ef-
fusion. Investigations: Hb 14.7 gm/dL, serum total protein and al-
bumin 4.1 and 2.3 g, respectively; 24-h urinary protein: 118 mg.
Endoscopic duodenal biopsy (for possible protein-losing enteropa-
thy) was unremarkable. Pleural and ascitic fluids were milky white,
had low serum ascitic fluid albumin gradient with high triglyceride
(437 mg/dL). A contrast-enhanced CT showed bilateral pleural ef-
fusion, ascites, and subcutaneous edema (1 A, B). Cervical lymph
node aspiration cytology showed necrosis, no granuloma but acid-
fast bacilli (Ziehl-Neelsen stain). As she did not respond to 1-mo
ATD, histopathology of an excisional biopsy of the cervical lymph
node was done, which showed necrosis, effaced nodal architecture
and capsulated fungal elements in histiocytes suggesting histoplas-
mosis (1 C). A rectal biopsy also showed histoplasmosis (1 D).
Serology for the human immunodeficiency virus was negative.
With a diagnosis of histoplasmosis, liposomal amphotericin B was
started.
Conclusion This rare patient highlights the need for increasing awareness
of physicians about histoplasmosis, especially in immunocompromised
subjects and the lesson that all acid-fast organisms are not tubercule
bacillus.
Keywords Chylous ascites, Ascites, Histoplasmosis
240
An insight into age and gender-wise differences in individual and
clusters of metabolic syndrome in fatty liver
Bhargav V Y, Mayank Jain*, Alen Tom, Shweta D, Karthikeyan M U,
Anusha B, Preetam Arthur, Chandan Kumar Kedarisetty, Thamarai
Selvan S, Jenit Osborn**, Jayanthi Venkataraman
Correspondence- Bhargav V Y-varanasi.b4@gmail.com
*Department of Gastroenterology, Arihant Hospital and Research Centre,
283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India, **Department
of Medical Gastroenterology, PSG Institute of Medical Sciences and
Research Center, Off Avanashi Road, Peelamedu, Coimbatore 641 004,
India, and Sri Ramachandra Medical College and Research Institute,
Chennai 600 116, India
Introduction Metabolic syndrome (MS) refers to a clustering of metabolic
risk factors with different phenotype combinations. The objective is to
determine MS prevalence in men and women above and below 45 years
in fatty liver (FL).
Methods Nine hundred and ninety subjects registered in master health
check during December 2018 to December 2019. USG abdomen and
MS (waist circumference (WC), blood pressure, diabetes status, S. tri-
glyceride, and S. HDL) parameters were collected. Known case of chron-
ic liver disease with various etiologies were excluded (alcohol, HBV,
HCV).
Statistical Analysis Unpaired t-test and chi-square test were performed; p
0.05 taken as significant.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Results Three hundred and one had a normal ultrasound, 478 had Grade I
fatty liver, Grade II 152 and Grade III 59. In both men and women, with
increase in grades of the fatty liver there is an increased incidence of all
metabolic syndrome components. MS was significantly high in FL (p
.0005), especially Grade I. A significant increase in MS components were
seen above the age of 45 years for both men and women. Beyond 45
years, DM (p .0005) and HT (p .0001) in men; and DM (p value .0005),
HTN (p value .0001) and TG (p value .037) in women were significant.
Below 45 years, WC in women (p value .018); HTN (p value 0.12) and
TG (p value .0005) in men were significant. WC + DM were the major
MS clusters seen in both men and women, > and < 45 years. MS showed
no statistical difference in the 2 genders >45 years.
Conclusion MS in women increases significantly beyond 45 years of age.
Waist circumference and DM are the robust clusters of MS.
Keywords Metabolic syndrome, Fatty liver
241
A randomized placebo controlled trial of Tadalafil for erectile dys-
function in patients with cirrhosis
Rakesh Jagdish, Ahemad Kamaal, S M Shasthry, Rakhi Maiwall, Ashok
Choudhury, Ankur Jindal, Vinod Arora, Rajan V, Ankit Bhardwaj,
Guresh Kumar, Manoj Kumar Sharma, Shiv Kumar Sarin
Correspondence- Rakesh Jagdish-dr.rkj.kapil@gmail.com
Departments of Hepatology and Epidemiology, Institute of Liver and
Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Background Erectile dysfunction (ED) is an ignored problem with high
prevalence among patients with cirrhosis. Tadalafil has been shown to be
effective for ED in non-cirrhotic population. However, there are no pla-
cebo controlled randomized controlled trials (RCTs) using Tadalafil for
treatment of erectile dysfunction (ED) in cirrhotic patients. This study was
planned to evaluate the efficacy and safety of Tadalafil in treatment of ED
in patients with cirrhosis.
Methods A total of 140 cirrhotic males with ED (age, 45.5 ± 8.2 years;
CTP-A [56.4%]/B [43.6%]; etiology, alcohol 45%, NASH 30%, viral
18.6%) were randomized into Tadalafil 10 mg daily (n=70) and placebo
(n=70) arm for 12 weeks. ED was assessed with International Index of
erectile function (IIEF) questionnaire (ED diagnosed if EF domain score
was <25). Other assessments included quantitative androgen deficiency
in the aging male (qADAM) questionnaire; generalized anxiety disorder 7
(GAD-7) questionnaire; patient health questionnaire (PHQ-9); Karnofsky
performance score (KPS) and hepatic vein pressure gradient (HVPG)
measurement. Primary outcome was proportion of patients having an
increase in more than 5 points in EF score.
Results Increase in more than 5 points in EF score was seen in 62.82% in
Tadalafil arm (n=44/70), vs. 30% cases in placebo arm (n=21/70)
(p<0.001). As compared to placebo, patients taking Tadalafil had signif-
icant improvements in orgasmic function domain, intercourse satisfaction
domain, overall satisfaction domain, anxiety (GAD 7) score, depression
(PHQ 9) score, functional impairment (KPS) score and HVPG. There
were no significant differences in side effect profile between groups
(2.7% in Tadalafil vs. 1.7% in placebo, p=0.154).
Conclusion Tadalafil significantly improves ED, quality of life and
HVPG in CTP-A and B patients with liver cirrhosis, without any major
side effects.
Keywords Erectile DCLD, Tadalafil, GAD 7, PHQ9, HVPG, qADAM
242
Comparison of the efficacy and safety of plasma exchange compared
to standard medical therapy in patients with severe drug induced
liver injury - A randomized controlled trial (NCT04015570)
Satyam Sinha, Meenu Bajpai, Vinod Arora, S K Sarin
S77
Correspondence- Satyam Sinha-satyamsinhacmc5@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1,
Vasant Kunj, New Delhi 110 070, India
Background Drug-induced liver injury (DILI) carries a mortality of 10%
to 14%. Except withdrawal of the offending drug, there are limited ther-
apeutic options. Plasma exchange has been used to treat antibody-
mediated diseases and is likely that removal of toxic metabolites by ther-
apeutic plasma exchange (TPE) can improve outcomes in severe DILI.
Aim To study the efficacy and safety of plasma exchange compared to
standard medical therapy (SMT) in patients of severe DILI.
Methods Thirty patients with severe DILI, diagnosed based on history
and liver biopsy (n-24, 80%) and graded for the severity as by DILIN
were randomized to receive SMT arm (Gr A, n=14) or TPE+SMT arm
(Gr B, n=16). Normal volume TPE was done on alternate days for min-
imum of 3 sessions.
Results Of 30 patients, 20 (66.6%) were males with mean age of 40.8+13
yr. Complementary and alternative medicines (CAMs) were the
commonest cause of DILI (n=10, 33%). Twenty-eight-day mortality
was comparable in both groups (13.3% [4/30], 14.2% [n=2] in Gr. A
and 12.5% [n=2] in Gr. B [p=0.56]). Significant reduction was seen in
bilirubin and bile acid levels and INR in the TPE arm as compared to the
SMT arm at day 7 (Table1). These trends were maintained, and bilirubin
levels reduced by 77.7% at day 28 (p<0.002) and the bile acid levels by
68.2%% at day28 (p<0.001). The levels of IL-6/TNF-α/ IL-1β also sig-
nificantly reduced following each session of TPE (p<0.002). A total of 53
sessions of TPE, mean of 3.02 sessions per patient and a median of 1.1
plasma volume were processed (range: 0.6-2.0) per session.
Hypocalcemia (59.2%) and alkalosis (42.9%) were the major adverse
events.
Conclusion TPE is very effective in reducing the high bilirubin and bile
acid levels and inflammatory markers and may lead to early resolution in
patients with severe DILI
Keywords Drug-induced liver injury (DILI), Therapeutic plasma ex-
change (TPE)
243
Efficacy and safety of early transjugular intrahepatic portosystemic
shunt (ETIPS) compared with large volume paracentesis in the man-
agement of cirrhosis with recurrent ascites: A randomized controlled
trial
Vinay Kumar B R, Ankur Jindall, Vinod Arora, Amar Mukund, Shiv K
Sarin
Correspondence- Vinay Kumar B R-drvinaybr@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1,
Vasant Kunj, New Delhi 110 070, India
Background Refractory ascites is associated with poor survival outcome.
Transjugular intrahepatic portosystemic shunt (TIPS) decompresses por-
tal system, reduces ascitic refilling, but with complications. Poor outcome
is likely due to delayed intervention. We investigated whether early TIPS
(eTIPS, before ascites becomes refractory) would help in better control of
ascites, reduced development of new complications and improved
survival.
Methods Total 47 patients (M: F-41:6) with recurrent ascites (2 LVPs in
last 3 months) were randomized to receive LVP (Gr. A, n=24) or eTIPS
(Gr. B, n=23) satisfying inclusion criteria and followed up at month 1, 3,
6 and 12. Primary endpoint of the study i. e. transplant-free survival at 12
months and secondary endpoints like overall survival, and complications
analyzed.
Results Among the patients who were randomized, all baseline character-
istics were comparable (mean CTP – 8.3 ± 1.49 and 8.9±1.19, MELD
score of 13.6±3.5 and 14.9±2.82 respectively). The mean portal pressure
gradient reduction was 15.7±3.8 in the Gr. B. Significantly more patients
S78
in Gr. B had resolution of ascites (14 (61%) vs. 6 (26%); p=0.03) with
lesser requirement of diuretics (11 [48%] vs. 4 [18%]; p<0.05) as com-
pared to Gr. A, with Gr. A more often developed diuretic related AKI (14
[61%] vs. 10 [47%]; p<0.05) at 6 months and hospital re-admission rates
(at least >1 admission – 16 [68%] vs. 6 [25%]; p=0.008) and significant
increase in MELD score +2.619 (0.636-2.8); p=0.05). The occurrence of
HE (12 [53%] vs. 10 [45%]; p=0.2), handgrip strength (change from
baseline 1.8 ± 0.37 vs. 2.1 ± 0.41; p=0.7) and infections (7 [30%] vs. 4
[17%]; p=0.4) were not different between groups. Overall, 8 patients died
by 6 months of enrolment (2 in Gr. B and 6 in Gr. A; p=0.03) and 2
patients underwent transplant in Gr. A and none in Gr. B. There was no
difference in occurrence of between the two groups.
Conclusion Early TIPS in comparison to repeated LVP showed better
survival, without any significant increase in occurrence complications.
Keywords eTIPS, Survival, Recurrent ascites
244
Bioenergetic dysfunction of monocytes is associated with an in-
creased incidence of sepsis and mortality in acute-on-chronic liver
failure
Rakesh Kumar Jagdish, Deepanshu Maheshwari, Dhananjay Kumar,
Ashini Kumar Hidam, Deepika D, Nidhi Nautiyal, Meenu Bajpai, Rakhi
Maiwall, Anupam Kumar, Shiv Kumar Sarin
Correspondence- Rakesh Jagdish-dr.rkj.kapil@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1,
Vasant Kunj, New Delhi 110 070, India
Introduction Functional exhaustion of monocyte phagocytic function has
been shown to be associated with increased susceptibility to infection and
sepsis in acute-on-chronic liver failure (ACLF). We investigated the
pathobiology of compromised phagocytic functions of monocytes in
ACLF.
Method Monocytes were isolated from peripheral blood mononuclear
cells of ACLF (n=34) patients at hospitalization and of healthy controls
(HC, n=6). Energy metabolism of freshly isolated monocytes was
determined.
Results Compared to HC, monocytes of ACLF patients (mean age 43
years, M: F 16:1, MELD 30, 61.76% alcohol) showed significant de-
crease in oxygen consumption rate (OCR) and extracellular acidification
rate (ECAR) at baseline, indicating significant defect in both glycolysis
(p<0.001) and OXPHOS (p<0.001) in ACLF (Fig. 1A). Real time mea-
surement of change in OCR during sequential treatment of cells with
oligomycin, the FCCP (H+ ionophore), and Antimycin-A/rotenone
showed significant decrease in ATP linked (p<0.01), proton leak
(p<0.01), maximum (p<0.0001) and spare reserve respiration capacity
(p<0.0001), suggesting multilevel defects in mitochondrial energy me-
tabolism of monocytes. Compared to HC, ACLF monocytes showed
decreased phagocytic capacity (p<0.0001 (Fig. 1B). Inhibition of mito-
chondrial ATP production by oligomycin, but not glycolysis showed
significant (p<0.001) decrease in the phagocytic capacity of healthy
monocytes (Fig. 1C). This indicates that mitochondrial ATP fuels the
phagocytic function of monocytes and its compromised production se-
verely impairs phagocytic potential of monocytes in ACLF. Among the
ACLF group, patients with sepsis at the time of presentation had a sig-
nificant (p<0.0001) decrease in maximum respiration and ATP linked
respiration (p<0.0001) in monocytes as compared to ACLF without sep-
sis (Fig. 1D). ACLF patients with significantly low maximum (p<0.001)
and ATP linked cellular respiration (p=0.01) showed increased 28 day
mortality.
Conclusions Defects in mitochondrial energy metabolism compromise
the phagocytic capacity of monocytes, which contributes to development
of sepsis and increased short- term mortality in ACLF patients.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Keywords ACLF, Monocyte energetics, Sepsis, Cellular respiration,
Functional exhaustion
245
A randomized controlled trial (RCT) of efficacy and safety of
hemoperfusion or plasma exchange compared to standard medical
therapy in patients with acute-on-chronic liver failure
Vinay Kumar B R, Rakhi Maiwall, Ashok Choudhury, Meenu Bajpai,
Jaswinder Singh Maras, Guresh Kumar*, Shiv K Sarin
Correspondence- Vinay Kumar B R-drvinaybr@gmail.com
Department of Hepatology, and *Epidemiology, Institute of Liver and
Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India
Introduction Acute-on-chronic liver failure (ACLF) has high 28-day mor-
tality of 30% to 40%. Exaggerated hepatic necrosis, inflammation and
immune response lead to early organ failure and mortality. We aimed to
remove high levels of toxic bile acids, bilirubin, and metabolites from
circulation and to modulate the immune mechanisms.
Methods Total of 32 ACLF patients with ACLF with bilirubin >12 mg/dL
and INR > 1.5 without any infection or extrahepatic organ failure, were
randomized into 3 groups; standard treatment SMT (Gr A, n=11), SMT
with hemoperfusion (Gr B, n=11) and SMT with plasma-exchange (Gr C,
n=10).
Results The baseline characteristics were comparable (mean age 50.2±
11.5, 44 ± 12 and 47±12.3 yr., male 10:9:8, baseline bilirubin 21.7±7,
26.9±6.1 and 27.6±8.8 mg/dL, bile acid levels 131±7, 126.8±11 and 138
±10.8 mg/dL, MELD score 29±4.2, 28±3.5 and 31.4±3.4, AARC score
9.5 ±1.8, 8.9±1, 10±0.92). There was no statistical difference in survival
SMT vs. HA vs. PE (89%, 0, 89% and 63.3 %, 90%, 72%, respectively)
at day 7 and 28 (p=0.12). In comparison with Gr. A, Gr. B had signifi-
cantly lower incidence at day 7 and 28 of new onset sepsis (27%, 10%,
20% and 45.5%, 20%, 36%) and AKI (27%, 0%, 11% and 45%, 10%,
27%) respectively. In comparison with Gr A, B and C, there was (3.5 and
2.5-fold, p=0.03) and (1.64 and 1.4- fold, p=0.18) reduction in bilirubin
and bile acids which were associated with improved survival. Further,
bile acid profiling identified persistent increase in cholic acid, glycocholic
acid, chenodeoxycholic acid, taurochenodeoxycholic acid,
tauroursodeoxy cholate and lithocholic acid (p<0.05), amongst the survi-
vors specially in Gr. B. In comparison to SMT, intervention arms showed
significant change in the metabolites of energy metabolism (p<0.05).
Conclusion Artificial liver support in the form of hemoperfusion and
plasma exchange, can safely be used and improve the bile acid and met-
abolic profile of ACLF patients.
Keywords Acute-on-chronic liver failure (ACLF), Bile acids, Metabolites
246
Comparison of efficacy and safety of transjugular intrahepatic
portosystemic shunt (TIPS) and SX-Ella Danis metal stent (SEMS)
in the management of refractory variceal bleed in cirrhotics- A ran-
domized controlled trial (NCT-03827681)
Sushrut Singh, Rakhi Maiwall, Ashok Choudhury, Ankur Jindal, Guresh
Kumar, Shiv Kumar Sarin
Correspondence- Sushrut Singh-singhsushrut86@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1,
Vasant Kunj, New Delhi 110 070, India
Introduction Refractory variceal bleed carries a high morbidity and mor-
tality in cirrhosis. TIPS (decompresses the high portal pressure) and.
esophageal SEMS (compresses varices locally) are used for managing
such bleeds; though the efficacy of the two has not been compared.
Aim We compared efficacy and safety of SEMS and TIPS in management
of refractory variceal bleed.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Methods Altogether, 46 cirrhotics with refractory variceal bleed were
randomized to either SEMS (Gr. A, n=23) or emergency TIPS (Gr. B,
n=23). Patients with portal vein thrombosis, HCC and <18 >70 years
were excluded. Primary endpoint was 6 week survival and secondary
end-points included prevention of re-bleeding for 5 days and develop-
ment of complications and 3 month survival.
Results Patients in Gr A and B (age [51.2±13.6 vs. 53.9±11.5 yr], p=0.4),
MELD score (17.3±3.4 vs. 18.6±3.6, p=0.2), baseline HVPG (21.3±3.7
vs. 20.8 ±4.8 mmHg, p=0.69) were comparable. Six-week survival in Gr.
A was significantly lower in Gr A (12/23 [52.2%]) than B (19/23 [82.6%]
p=0.027). In Gr A than B, higher very early rebleed (between 48 to 120
hrs) as well as early rebleed (6-42 days) [(26% vs. 4.3%, p=0.04) and
(21.7% vs. 0%, p=0.04) respectively] were witnessed. Time to reversal of
shock was shorter in Gr. B (8.9±3.7 hrs) than A (32 ±9.6 hrs, p<.001),
with shorter ICU (13.9±4.9 vs. 7.6±3.1 days, p<0.001) stay and fewer
packed cell units required (4.6 vs. 1.9, p=0.001). More patients in Gr A
than B developed sepsis (43.5% vs. 8.7%, p=0.004) and AKI (39.1% vs.
13%, p=0.04), without differences in frequency of ischemic hepatitis
(13% vs. 17.4%, p=0.6) and hepatic encephalopathy (39% vs. 52%,
p=0.3). Patients in Gr A had significant worsening of liver functions
and higher MELD (24±3.9 vs. 19±3.7, p<0.01) than Gr. B at 6 weeks,
with lower 3 month survival (39.1% vs. 69.5%, p=0.038).
Conclusion Emergency TIPS is more effective and safe as compared to
esophageal SEMS for management of refractory variceal bleed in
cirrhosis.
Keywords Variceal bleed, SEEMS, TIPS
247
Addition of testosterone therapy to nutrition and structured exercise
is superior to nutrition and structured exercise alone in improving
sarcopenia in men with cirrhosis: A randomized controlled trial
Sushrut Singh, Ashok Choudhury, Jaya Benjamin, Guresh Kumar, Shiv
Kumar Sarin
Correspondence- Sushrut Singh-singhsushrut86@gmail.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1,
Vasant Kunj, New Delhi 110 070, India
Background Sarcopenia has been shown to be a marker of poor long-term
outcomes in advanced cirrhosis. Nutrition supplementation and exercise
are the only current approaches for such patients.
Aims and Objectives We compared nutrition and structured exercise
(NEx) to NEx with addition of testosterone (NExT) in improvement of
sarcopenia.
Methods Altogether, 102 cirrhotic patients with sarcopenia were random-
ized to receive either nutrition and structured exercise with addition of
intramuscular testosterone undeconate 1000 mg every 4 weeks with
(NExT, group A, n=50) or only structured exercise and nutrition (NEx,
group B, n=52). The primary end-point was increase in appendicular lean
mass index (APLMI) by 10%, using dual-energy X-ray absorptiometry
(DEXA) and bio-electrical impedance.
Results The mean age, MELD score and CTP score and distribution of
patients [Gr A : Child A, B, C 9 (14.06%), 42 (65.6%) and 13 (20.3%)
and Gr. B: 10 (15.8%), 41 (65.1%) and 12 (19.04 %) p =0.952], baseline
serum testosterone levels were comparable. Significantly more patients
achieved primary end-point in Gr. A than B (66% vs. 25%, Odds ratio
5.82 (95% C.I. 2.47-13.74), and had higher ASMI than control group [7.3
±0.25 vs. 6.90 ±0.21, p<0.01] at the end of 6 months. Patients in the NexT
group had better hand grip strength, 6 minute walk distance and lower
TNF alpha levels, lower serum ammonia (68.5±13 vs. 90.32±28 μg/dL p
<0.05) and higher serum testosterone levels (p<0.001). 38% patients in
the NexT arm had improvement in fraility category compared with 13.5%
in the NEx arm (p<0.001). During the 6 months, hospitalization was
required by 8 (16%) in NExT and 18 (34.6%) patients in NEx group
(p=0.03).
S79
Conclusions Administering testosterone to men with cirrhosis, irrespec-
tive of baseline serum testosterone levels, significantly increases their
muscle mass, bone mass and improves fraility, with reduction in fat mass
and need and duration of hospitalization.
Keywords Sarcopenia, Cirrhosis, Testosterone
248
Incidence and clinical outcome of hyponatremia in patients with
acute-on-chronic liver failure
Manasa Alla, Vinod Arora, Guresh Kumar, Shiv Kumar Sarin
Correspondence- Vinod Arora-vinod_ucms@yahoo.com
Department of Hepatology, Institute of Liver and Biliary Sciences, D 1,
Vasant Kunj, New Delhi 110 070, India
Background Hyponatremia is an important predictor for mortality and
outcome in patients with cirrhosis. Incidence of severe hyponatremia
(serum sodium <125 meq/l) and its correlation with various clinical out-
comes has not been studied in (ACLF) patients.
Methods A retrospective analysis of the electronic data 3,880 patients
with APASL ACLF was taken from 2009-2020. Hyponatremia catego-
rized as moderate (125-130), severe (< 125 meq/l). Patients with serum
sodium <125 mEq/L were evaluated at baseline, 7, 14 and 28 days. 20%
albumin was given to such patients, but no diuretics or vaptan were given.
The incidence of acute kidney injury (AKI), hepatic encephalopathy
(HE), GI bleed was evaluated at baseline and day 7, 28 day survival
determined.
Results Of 3880 ACLF patients, 3043 patients (mean age 44.8 ±12.56 years)
had complete and serial data of serum sodium and were analyzed . At baseline
moderate hyponatremia (125-130 mEq/l) was present in 1229/3043 (40.4%)
and severe hyponatremia (< 125mEq/l) in 491/3043 (16.7%) patients. AKI at
baseline (serum creatinine≥1.5 mg/dL) was significantly more in patients with
severe hyponatremia compared to moderate hyponatremia (200/491 [40.7%]
vs. 250/1221 [20.4%], p=0.001). Patients with severe hyponatremia had a
greater persistence of AKI (98/491 [19.95%] vs. 108/1221 [8.8%], p=0.001)
and encephalopathy (51/491 [10.4%] vs. 90/1221 [7.3%], p=0.05) at day 7.
Patients with serum sodium < 125 mEq/L had a greater need of ICU admis-
sion (102/491 [20.7%] vs. 146/1221 [11.95%], p=0.001). On multivariate
analysis, serum sodium was predictive of mortality at day 7 (HR 1.08, 95%
CI 1.03-1.14s, p= 0.001) and 28 (HR 2.06, 95% CI 1.32-2.01, p= 0.001). 7-
day mortality (79/491 [16.08%] vs. 121/1221 [11.95%], p=0.0005) and 28-
day (120/491 [24.4%] vs. 228/1221 [18.7%], p=0.008).
Conclusion Serum sodium < 125 meq/L at baseline may be an indepen-
dent predictor for mortality in ACLF and associated with various adverse
clinical outcomes and treatment options remain an important therapeutic
option in improving outcomes.
Keywords Hyponatremia ACLF
Pancreas
249
Interim analysis of clinical and autoimmune features in drug-
induced Liver Injury
Rahul Deshmukh, Shubham Jain, Sanjay Chandnani, Ravi Thanage,
Partha Debnath, Siddhesh Rane, Pravin Rathi
Correspondence – (Rahul Deshmukh- drdeshmukhrahul@gmail.com)
Department of Gastroenterology, Topiwala National Medical College,
Mumbai 400 008, India
Introduction To differentiate between immune-mediated drug-induced
liver injury (DILI) and autoimmune hepatitis (AIH) may be difficult.
DILI has features similar to other liver diseases including AIH. Present
S80
study aims to characterize clinical and autoimmune features of DILI by
complementary and alternative medicine (CAM).
Methods Data from 31 DILI patients was analyzed. Patients were inves-
tigated for levels of immunoglobulin G (IgG), antibodies to nuclear anti-
gen (ANA), anti-smooth muscle (ASMA), and anti–liver-kidney micro-
somal antibody (anti-LKM). We calculate autoimmune score based on
increase in levels of IgG, ANA, SMA, and anti-LKM (assigned values of
0, 1+, or 2+). We categorize patients based on type of injury.
Results Of the 31 cases 12 were males and 19 were females with a median
age of 50 years (range 20-75 years). All patients had jaundice on presen-
tation. Fever, rash, itching, and eosinophilia was present in 29%, 7%,
32%, and 26% patients. Mode of presentation was acute hepatitis in
71% (22/31) and ACLF in remaining 29% (9/31). In majority of patients
(80%) cause of DILI was CAM. The median duration of drug intake was
90 days (range 15-730 days). Of the 31 cases, 65% had hepatocellular
injury and 19% had severe injury, of which 37% were males and 63%
were females. On presentation 29% of cases had increased levels of IgG,
29% had increased levels of ANA, 22% had increased levels of SMA. A
phenotype of autoimmunity (autoimmune score ≥2) was seen in 48% of
cases, of which 33% were males and 66% were females. Mean RUCAM
score was (4.6±1.6). Liver biopsy was available in 6 patients. 4/6 (66%)
patients had marked interface activity and remaining 2/6 (33%) had mild
activity.
Conclusion We found that most cases of DILI due to CAM had hepato-
cellular injury. Almost half of cases had features of autoimmunity.
Females were more affected than males.
Keywords CAM, Autoimmune, DILI
250
Role of endoscopic ultrasonography and magnetic resonance
cholangiopancreatography in idioathic acute pancreatitis
Tuhin Mitra, Vinod Kumar Dixit, Sunit Kumar Shukla, Dawesh Prakash
Yadav, Piyush Thakur, Ravikant Thakur
Correspondence- Tuhin Mitra-mitra_tuhin@yahoo.co.in
Department of Gastroenterology, Institute of Medical Sciences, Banaras
Hindu University, Varanasi 221 005, India
Introduction Approximately 10% to 30% of patients with acute pancrea-
titis do not have an established etiology after routine investigations and
are labelled as having idiopathic acute pancreatitis (IAP). Establishing the
etiology in such patients will prevent recurrences and evolution to chronic
pancreatitis. Endoscopic ultrasonography (EUS) and magnetic resonance
cholangiopancreatography (MRCP) typically are used to diagnose IAP
when conventional methods fail but their exact role has not been
determined.
Methods A prospective study of patients admitted initially with diagnosis
of IAP to department of gastroenterology in a tertiary care centre was
done. These patients underwent MRCP and EUS at least 4 weeks after an
episode of acute pancreatitis. The etiological results of EUS and MRCP
were compared and analyzed with various clinical variables using suitable
statistical tests.
Results A total of 31 patients with IAP were included. EUS and/or MRCP
were able to establish at least one etiology in 17 of our patients (54.8%).
The diagnoses revealed were gallbladder (GB) microlithiasis, GB sludge,
choledocholithiasis, pancreas divisum, pancreatic adenocarcinoma,
intraductal papillary mucinous neoplasm and anomalous pancreatobiliary
union. Comparing the diagnostic accuracy of both the modalities, EUS
(14/31) was able to diagnose more cases than MRCP (8/31). The EUS
yield was lower in patients who had a previous cholecystectomy (12.5%
vs. 56.5%; p=0.03).
Conclusion EUS and MRCP are useful techniques in the etiological di-
agnosis of IAP and should be considered complimentary rather than com-
petitive investigations. EUS is better for establishing a possible biliary
etiology and MRCP for an anatomical alteration in pancreatobiliary ducts.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
251
Pancreatic tuberculosis with obstructive jaundice masquerading as
malignancy
Ronak Ajmera, Premashish Kar, Ashish Garg, Rishabh Kothari, Anant
Chauhan, Subhasish Mazumder
Correspondence- Subhasish Mazumder-subhasish.dr@gmail.com
Department of Gastroenterology and Hepatology, Max Super Speciality
Hospital, W-3, Near Radisson Blu Hotel, Sector 1, Vaishali, Ghaziabad
201 012, India
Pancreatic tuberculosis (TB) is rare form of extra-pulmonary TB even in
endemic countries like India with literature only reported as case reports
or very small case series. Also pancreatic TB has varied clinical presen-
tation from incidental pancreatic mass detected on imaging to abdominal
pain mimicking pancreatitis. We report a case of pancreatic TB who
presented to us with jaundice, abdominal discomfort, weight loss and
palpable gallbladder. He had long history of loss of weight, abdominal
discomfort for 1 year and hence there was low suspicious of malignancy.
On USG abdomen he had pancreatic mass lesion compressing distal CBD
with upstream biliary system dilatation. He underwent whole body PET-
CT which revealed FDG avid heterogenous enhancing mass lesion in-
volving neck and body of pancreas with enlarged necrotic lymph nodes in
paratracheal, hilar, peripancreatic, periportal, paraaortic, aortocaval
lymph nodes. The findings of PET-CT were more in favor of infective
or lymphoproliferative disease. Patient underwent endoscopic ultrasound
guided FNA from pancreatic mass and lymph node which were positive
for mycobacterium tuberculosis by NAAT (nucleic acid amplification
test). Patient underwent ERCP and plastic stent was placed in CBD.
Patient was started on antitubercular drugs once LFT improved. Patient
was symptomatically better after receiving ATT. Hence clinicians must
keep in mind pancreatic TB in patients with obstructive jaundice due to
pancreatic mass lesion.
252
SPINK 1 genetic mutation in chronic pancreatitis ‘a single center
survey’
Subhra Sulipta Jena, Girish Kumar Pati, Kanishka Uthansingh,
Pradeep Mallick, Manas Kumar Behera, Jimmy Narayan, Debakanta
Misra, Manoj Kumar Sahu
Correspondence- Girish Kumar Pati-pati.drgirishkumar@gmail.com
Department of Gastroenterology, IMS and SUM Hospital, Bhubaneswar
751 003, India
Introduction Chronic pancreatitis is known to be a complex problem
occurring due to several genetic and clinical risk factors. There are already
several studies revealing the genetic mutation and their association with
clinical risk factors in chronic pancreatitis in different geographic regions,
but unfortunately there are no genetic studies on chronic pancreatitis from
this part of coastal India.
Aim This study was carried out with an aim to find out the genetic defect
of Serine protease inhibitor Kazal-type 1 (SPINK1) gene in chronic pan-
creatitis patients from this part of coastal eastern India and also their
demography and presentations to be evaluated.
Method Consecutive 20 chronic pancreatitis patients attending the
Dept. of Gastroenterology of IMS and SUM Hospital, Bhubaneswar
were enrolled in this study and evaluated. Two mL of venous blood
was collected from each of the patients and the DNA was isolated
by salting out method. The genetic defect was evaluated by poly-
merase chain reaction – restriction fragment length polymorphism
(PCR-RFLP) method. Demography and clinical presentations of all
the cases were also evaluated.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Result The mean age of presentations of study participants was
33.9±1.089 years. Most of the cases were female i.e. 55% were
female. The RFLP result showed that 60% of the patients were
genetically heterozygote, whereas 40% patients were genetically
mutants for SPINK1. Most of the cases presented with abdominal
pain. Most of the cases in this study were nonalcoholic and
nonsmoker.
Conclusion This study is unique of its kind as it is the first genetic pilot
study from this part of coastal eastern India which evaluated the genetic
defects in chronic pancreatitis patients. Further genetic studies with larger
number of sample size may be carried out in future to validate our find-
ings.
253
Clinical profile, management and outcomes associated with pancre-
atic ascites - Our experience from Western India
Mayur Gattani, Pratik Sethiya, Shamshersingh Chauhan, Meghraj Ingle,
Saiprasad Lad, Gaurav Singh, Kailash Kolhe, Harshad Khairnar, Pooja
Chandak, Akash Shukla, Vikas Pandey
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Department of Gastroenterology, Lokmanya Tilak Muncipal Medical
College and General Hospital, Sion, Mumbai 400 022, India
Introduction Pancreatic ascites is a well-recognized sequelae of pancrea-
titis and is associated with significant morbidity and mortality. We stud-
ied the clinical profile, management and outcomes of patients with pan-
creatic ascites.
Methods This retrospective study investigated 35 patients seen over
a period of 5 years with pancreatic ascites who underwent magnet-
ic resonance cholangiopancreatography (MRCP) and/or endoscopic
retrograde cholangiopancreatography (ERCP). Management strate-
gies included conservative therapy, endotherapy and surgery.
Results Thirty-five patients (male=29; 82.9%) were included.
Associated pancreatic fluid collections (PFC) were documented
in 31/35 (88.6%) patients. MRCP demonstrated a leak in 18/35
patients (51.4%) and ERCP did it in 21/30 patients (70%). Most
common leak site on ERCP was in body in 13/30 (43.3%) pa-
tients followed by head in 5/30 (16.7%) and tail in 3/30 (10%)
patients. Stent was placed beyond the leak in 18/21 (85.7%) pa-
tients. In 9/30 patients (30%) no leak was found, thus stent was
placed empirically. Sphincterotomy was done in 23/30 (76.7%)
patients. Endotherapy was successful in 25/30 patients (83.3%)
amongst which 8 % had recurrence. Only conservative therapy
was successful in three patients amongst which two had recur-
rence. Site of ductal leak (p=0.008), sphincterotomy (p=0.033)
and stent bridging the leak site (p=0.004) were the factors signif-
icant for success of endotherapy. Extensive necrosis >30%
(p=0.022) and presence of intraductal calculi (p=0.049) were as-
sociated with failed endotherapy. Mortality was seen in 1/35
(2.8%) patients.
Conclusions In this study, clinical profile of pancreatic ascites usually
involved more severity of pancreatitis and associated PFC. Success rate
in management and outcome of pancreatic ascites is high for endotherapy
and low for conservative therapy. Combining pancreatic sphincterotomy
with transpapillary stenting and stent bridging the leak site increases
efficacy of endotherapy.
254
Is plasma osteopontin a novel biomarker in prognostication of acute
pancreatitis?
Gautham Morupoju
Correspondence- Gautham Morupoju-m.gautham36@gmail.com
S81
Department of Medical Gastroenterology, Nizam's Institute of Medical
Sciences, Punjagutta, Hyderabad 500 082, India
Introduction Osteopontin (OPN) is an important mediator of inflamma-
tion. Its role has not been established for prediction of mortality and
complications in acute pancreatitis (AP).
Aim To assess the utility of plasma OPN level on day of admission as
early predictor of severity and mortality in AP and compare it with ad-
mission C-reactive protein (CRP), procalcitonin (PCT) and prognostic
scores like Ranson’s, APACHE II, BISAP and mCTSI.
Methods Sixty-one consecutive patients of AP presenting within 5 days of
symptom onset and 20 age and sex matched healthy controls were pro-
spectively enrolled. Admission OPN, CRP and PCT levels were estimat-
ed and prognostic scores of AP calculated. These patients were followed
till discharge or death. The association of biomarker levels and prognostic
scores with severity and mortality was analyzed and utility compared by
receiver operator characteristics (ROC) curve analysis.
Results Sixty-one patients (M:F=48:13), age (mean±SD=34.47±13.62
years) were studied. Common cause was alcohol (n=34) (55.74%).
Forty-eight (78.6%) patients had mild/moderate and 13 (21.3%) had se-
vere AP. Infected pancreatic necrosis (IPN) and death was observed in 2
(3.4%) and 3 (4.9%) respectively. Mean plasma OPN level on admission
for patients and controls was 13.04±3.79 ng/mL and 4.75±1.45 ng/mL
respectively. There was no statistically significant difference in OPN
levels in mild vs. severe pancreatitis (p=0.464), IPN vs those without
IPN (p=0.404) and survivors vs. non-survivors (p=0.404). On ROC curve
analysis, Ranson’s score had the highest whereas OPN had the least area
under the receiver operator curve (AUROC) for predicting severity and
mortality of 0.974 and 0.954, 0.576 and 0.345 respectively in that order.
Conclusion Admission OPN is a suboptimal prognostic marker of AP.
Larger studies are required to assess its utility in AP.
255
Diabetes is frequent after an episode of acute pancreatitis: A prospec-
tive, tertiary care centre study
Wahid Akbar, Zaheer Nabi, Jahangeer Basha, Rupjyoti Talukdar, Manu
Tandan, Sundeep Lakhtakia, Radhika Chavan, Chandrakant Koutarapu,
D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-
3-661, Somajiguda, Hyderabad 500 082, India
Background Acute pancreatitis (AP) is a known risk factor for the devel-
opment of new onset diabetes and prediabetes (NODAP). The severity of
AP may correlate with the development of NODAP. However, the results
in published studies are conflicting. In this study, we aim to determine the
incidence and risk factors for the development of NODAP after AP.
Methods In this prospective study, patients diagnosed with AP between
March 2019 to May 2019 were followed at 3 months, 6 months and 12
months. Patients with pre-existing diabetes or prediabetes were excluded
from the study. The primary outcome of the study was the incidence of
NODAP at 1-year which was evaluated using fasting blood glucose, oral
glucose tolerance test and HbA1c. The secondary outcomes included risk
factors for the development of NODAP.
Results A total of 86 confirmed cases (males 66, mean age 35.5±11.7
years) with AP were enrolled during the study period. The etiologies of
AP included alcohol 31 (36%), gallstones 17 (19.8%), post ERCP (3.5%),
others (40.7%). The proportion of patients with necrotizing pancreatitis,
moderately severe and severe AP were 67.4%, 59.3% and 15.1%, respec-
tively. Overall, diabetes and pre-diabetes developed in 10.46% and
23.25% patients, respectively. NODAP was more common in patients
with necrotizing pancreatitis (>30% necrosis) as compared to interstitial
pancreatitis (42.9% vs. 17.9%, p=0.044). NODAP was significantly more
frequent in patients with moderately severe and severe pancreatitis as
S82
compared to mild AP (42.2% vs. 9.1%, p=0.004). NODAP was signifi-
cantly higher in those requiring a drainage intervention (59.5% vs. 9.1%,
p=0.0001). The mean stay in ICU was significantly higher in patients who
developed NOD (11±3.38 vs. 4.6±3.17 days, p=0.003).
Conclusions NODAP is common after an episode of AP. Severe pancreatitis,
presence of necrosis, requirement of drainage and prolonged ICU stay are the
risk factors for the development of NODAP in patients with AP.
256
A rare case of acute pancreatitis in a known primary sclerosing
cholangitis with ulcerative colitis
Avinash Reddy Boojala, Vaishnavi Priyaa C, Aravind A
Correspondence- Avinash Reddy Boojala-avinashreddyboojala
@yahoo.com
Department of Digestive Health and Diseases, Government Kilpauk
Medical College, Chennai 600 010, India
Introduction Primary sclerosing cholangitis (PSC) is a rare disease asso-
ciated with IBD with an incidence of 0.4-2 per 100,000. Acute pancrea-
titis may occur secondary to drug intake in the treatment of IBD. Here we
present a very rare case of probably idiopathic acute pancreatitis in a
patient of PSC and ulcerative colitis in remission.
Case Nineteen-year-old male presenting initially with anemia, bleeding
PR, pruritus and fatigue and weight loss. Past, family history and exam-
ination unremarkable. On evaluation, Hb 9.8, T. bilirubin 2.1 mg/dL,
direct- 1.3 mg/dL, ALP- 359, SGOT- 107, SGPT- 118, GGT- 69 IU/L.
Viral markers- negative. USG s/o hepatomegaly, dilatation of CBD.
Colonoscopy ulcerations and diffuse erosions, edema, loss of vascularity
till mid transverse colon. HPE s/o active phase of ulcerative colitis. UGI
scopy-normal. MRCP: IHBR, CHD, CBD dilated with multiple areas of
dilatation and narrowing consistent with PSC. ANA strong positive
(+++), homogenous anti DsDNA, p ANCA, anti LKM, SMA, SLA- all
negative. IgG total- 2330 (700-1600 mg/dL). AMA- positive. IgM, IgG4-
normal. Tumor markers CA 19-9, CEA-normal. Liver biopsy shows
sparse lymphocytic infiltrate in rows between cells insinuating the sinu-
soids and areas of fibrosis suggestive of PSC.
Patient responded to treatment with mesalamine, UDCA and iron and vitamin
supplementation and IBD remission achieved. He presented with severe pan-
creatic type abdominal pain with s. amylase 308U/L and USG s/o pancreatitis
after one year of remission of IBD which was managed conservatively.
Conclusion Acute pancreatitis in the absence of PD abnormality or in-
criminating drugs is extremely rare in the setting of IBD with PSC and
needs an extensive genetic and familial work up of the disease and also
follow-up for development of chronic pancreatitis or pancreatic malig-
nancy apart from the routine surveillance of IBD and PSC.
257
A study of pancreatic exocrine insufficiency in early onset idiopathic
chronic pancreatitis
Gauri Kumbhar, Rajesh Sanjeevi, Anuradha Chandramohan, Rajeeb
Jaleel, Reuben Thomas Kurien, Ebby George Simon, Amit Kumar
Dutta, A J Joseph, Sudipta Dhar Chowdhury
Correspondence- Sudipta Dhar Chowdhury-sudiptadharchowdhury
@gmail.com
Department of GI Sciences, Christian Medical College Hospital, Vellore
632 004, India
Introduction Early onset idiopathic chronic pancreatitis (EOICP) is a
common form of chronic pancreatitis in India. The present study was
done with an aim to identify the prevalence of pancreatic exocrine insuf-
ficiency (PEI) in EOICP.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Methods This is an ongoing prospective study in a tertiary care hospital
initiated in August 2018. Baseline data as regards demographic variables,
duration of disease, pain, diabetes mellitus, steatorrhea, body mass index
(BMI), medication use, CT parameters were recorded. PEI was evaluated
by faecal elastase-1 assay (FE-1). Patients with FE-1 <100 μg/gm were
labelled as having PEI.
Results A total of 100 patients with EOICP were included. Mean
age of onset was 24.5 (SD 6.03) years and 46% were females.
The average disease duration was 6 (SD 4.8) years. Pain abdomen
was present in 98%. The mean BMI was 21.04 (SD 3.61) kg/m2.
Calcifications were noted in 61 (75%) patients, mean main pan-
creatic duct (MPD) diameter was 7.59 (SD 5.01) mm, mean pan-
creatic thickness was 13.97 (SD 5.53) mm. PEI was identified in
75% of patients. Except for duration of disease, there was no
correlation between PEI and sex, age of onset, and diabetes
mellitus. We evaluated the association between morphological pa-
rameters identified at CT scan with PEI. There was a significant
association between MPD diameter, parenchymal width and PEI.
However, there was no association between presence of calcifica-
tion and PEI. Fifty percent patients were on enzyme supplements.
Among the patients not on enzymes, subclinical PEI was identi-
fied in 18 (48.65%) patients.
Conclusions This study shows that there is high prevalence of PEI in
patients with EOICP. Disease duration significantly correlates with the
presence of PEI. Pancreatic morphological changes correlate with
presence of PEI, indicating PEI may be manifestation of disease
progression. Substantial proportion of patients off enzyme supple-
ments had subclinical PEI, therefore all patients need to be tested
for PEI.
258
Recurrent acute pancreatitis due to Type 1 C1-Esterase inhibitor
deficiency
Avnish Seth, Mahesh Kumar Gupta
Correspondence- Avnish Seth-avnish.seth@fortishealthcare.com
Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research
Institute, Sector - 44, Opposite HUDA City Centre, Gurugram 122 002,
India
Background Hereditary angioedema due to C1-esterase inhibitor (C1-
INH) is a rare cause of pain abdomen. We present a patient with recurrent
acute pancreatitis (RAP) due to C1-INH deficiency.
Case Report Sixteen-years female was hospitalized with epigastric pain
with back radiation for one day. Pain was severe, band-like, associated with
vomiting and relieved partially on stooping forward. There was history of
similar episodes for last 4 years requiring repeated hospitalization. BP was
100/60 mmHg, pulse 100/minute and epigastric tenderness present. Blood
counts and LFT were normal, amylase/lipase 2300 U/L/1825 U/L. CECT
scan abdomen showed haziness of margins of pancreas with mild peri-
pancreatic stranding and no calcification. Evaluation over last 4 years at
various centers for RAP including serum calcium and trigylerides, ultra-
sound abdomen (x4), CT scan, MRI with MRCP and EUS (x 3) were
normal. On direct questioning there was history of angioedema of lips,
hands, and limbs since early childhood, forcing her to skip school due to
swollen lips and colicky pain abdomen. There was no such family history.
Side-viewing endoscopy revealed edema and boginess of ampulla of Vater.
She was discharged after 48 hours following improvement with IV fluids
and symptomatic treatment. C1-INH level was 164 mg/L (range 275-400),
C4 8 mg/dL (range 10-40) and C1q 7.2 mg/dL (range 5-8.6). She was
diagnosed as C1-esterase inhibitor deficiency, Type 1 and managed with
oral Danazol built up to 400 mg daily. There was reduction in number and
severity of episodes of angioedema and pain abdomen, but she developed
mild hirsutism, weight gain and acne and Danazol was reduced to 100 mg
daily and she continues to do well at one year.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusion History of angioedema and C1-INH deficiency should be
considered in the check-list of evaluation for RAP. Treatment with
Danazol results in amelioration of symptoms.
259
Spectrum and sensitivity patterns of bacterial isolates from infected
pancreatic necrosis managed by exclusive percutaneous catheter
drainage
Ashok Kumar, Kshitiz Saran, Rohit Gupta, Itish Patnaik, Anand Sharma
Correspondence- Ashok Kumar-drashok.sgpgims@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Virbhadra Road Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Introduction Infected pancreatic necrosis (IPN) is associated with high
mortality. Information is limited about bacterial infections in IPN man-
aged exclusively with percutaneous catheter drainage (PCD). This study
aimed to determine the spectrum and antibiotic sensitivity patterns of
bacterial isolates from IPN exclusively managed by PCD.
Methods The database of 156 consecutive acute pancreatitbs patients,
hospitalized between May 2018 to April 2020, was analyzed for culture
results and antibiotic sensitivities of bacterial isolates from IPN patients
exclusively managed by PCD.
Results Thirty patients (age-39.3 yeas, 80% male) with pancreatic necro-
sis were exclusively managed by PCD; 23 (76.7%) had IPN (43 positive
cultures). Six (20%) patients had extra pancreatic infections (9 positive
cultures-blood [5], urine [3], tracheal aspirate [1]). Monomicrobial and
polymicrobial infection were seen in 10 (43.4%) and 13 (56.5%) IPN
cases, respectively. The commonest isolates were Escherichia coli
(56.5%), Klebsiella sp. (43.4%), Pseudomonas aeruginosa (39.1%).
Other isolated organisms were MRCoNS, Acinetobacter (8.6% each);
Serratia, Morganella, Burkholderia, Citrobacter, Enterococcus faecalis,
Proteus (4.3% each). On antibiotic sensitivity, most bacteria were sensitive
to beta-lactams and carbapenems; Escherichia coli -meropenem (76.9%),
piperacillin-tazobactam (69.2%); Klebsiella -colistin (50%); Pseudomonas -
gentamicin (88.8%), cefepime (77.7%), piperacillin-tazobactam (77.7). Pan-
resistant organisms grew from six (14%) PCD fluid samples (Klebsiella,
Escherichia coli -2 each; Pseudomonas, Acinetobacter-1 each) and two
(22.2%) extra pancreatic sites (blood- Klebsiella, urine- Pseudomonas). IPN
patients had higher organ failures (43.5% vs. 28.6%) and mortality (17.4% vs.
14.3%) than sterile pancreatic necrosis.
Conclusion Bacterial infections were common (76.6%) in pancreatic ne-
crosis exclusively managed by PCD. Escherichia coli, Klebsiella, and
Pseudomonas were the most common isolates. Most bacteria were sen-
sitive to beta-lactams and carbapenems. IPN was associated with an in-
creased probability of organ failure and mortality.
260
Prevalence of sarcopenia and it’s impact on patients with chronic
pancreatitis
Premkumar K, Debapratim Routh
Correspondence- Premkumar K-drpremgastro@gmail.com
Department of Medical Gastroenterology, Institute of Medical
Gastroenterology, Madras Medical College, Poonamallee High Road,
Park Town, Chennai 600 003, India
Background Objective and aims: Malnutrition and changes in the body com-
position are common complications of chronic pancreatitis. We measured the
prevalence of sarcopenia and it’s impact on chronic pancreatitis patients. The
aims of the study were 1) to determine the prevalence of sarcopenia in chronic
pancreatitis 2) to determine risk factors associated sarcopenia 3) to determine the
association between sarcopenia and quality of life and 4) to determine the
association between sarcopenia and hospitalization in chronic pancreatitis.
S83
Methods This was a cross sectional study conducted on 100 pa-
tients diagnosed with chronic pancreatitis from October 2019 to
August 2020. Quality of life was measured by the Brazilian ver-
sion of the short form-36. Patients were classified according to
conventional anthropometrics, hand grip strength, timed up and
timed go test, body mass index (BMI) and biceps, triceps,
suprailiac and subscapular skinfold thickness using the appropriate
methods. The primary outcome of sarcopenia was defined accord-
ing to EWGSOP criteria. Several parameters including alcohol,
smoking, exocrine pancreatic insufficiency and pain related symp-
toms were analyzed for their association with sarcopenia.
Statistical tests included the Chi-square, Mann-Whitney and spear-
man correlation tests with the significance level set at p value less
than .05.
Results Amongst 100 patients enrolled in the study, median age
was 55.5 years; 68 % were men; 72 % had alcoholic etiology.
Smokers were 67%. Prevalence of sarcopenia was 31%. An ab-
normal low BMI (<18.5 kg/m2) was seen in 30.2% and 57.6%
had normal BMI (18.5-25 kg/m2) and 9.6% had BMI in over
weight/obese range (>25 kg/m2). Sarcopenia was significantly as-
sociated with exocrine pancreatic insufficiency, alcoholic, smoking
and pain related symptoms on univariate analysis. Four skin fold
thicknesses were also positively correlated with multiple domains
of scale used to asses quality of life. Recurrent hospitalization and
complications related to chronic pancreatitis were also higher in
sarcopenic group compared with their counterparts.
Conclusion Sarcopenia is common complication in chronic pancreatitis
patients and associated with adverse health related outcomes.
261
Glycemic status of patients following acute pancreatitis
Arun Solanki, Shubha Immaneni, Premkumar K, Murali R, Chezhian
Annasamy
Correspondence- Shubha Immaneni-gastroshubha@gmail.com
Department of Medical Gastroenterology, Madras Medical College, Near
Park Town Station, Park Town, Chennai 600 003, India
Introduction Changes in glycemia status over time have never been in-
vestigated comprehensively in patients after acute pancreatitis. The pri-
mary aim was to determine the incidence of new-onset prediabetes and
new-onset diabetes after acute pancreatitis over 9 months of follow-up in
a prospective cohort study. The secondary aim was to identify fluctua-
tions of glycemia levels during follow-up.
Methods This was a prospective cohort study conducted on patients with
a prospective diagnosis of acute pancreatitis and non-diabetic based on
the American Diabetes Association criteria were followed up every 3
months up to 9 months after hospital discharge from October 2019 to
August 2020 at Madras Medical College. Incidence of new-onset predi-
abetes and diabetes over each follow-up period was calculated.
Multinomial regression analyses were conducted to investigate the asso-
ciations between a wide array of routinely available demographic, anthro-
pometric, laboratory and clinical factors.
Results A total of 100 patients without diabetes were followed up. The
cumulative incidence of new-onset prediabetes and diabetes was 20% at 6
months after hospitalization and 28% over 9 months of follow-up. Three
discrete groups were identified based on HbA1c levels: normal-stable
glycemia (40%), moderate stable glycemia (54%), and high-increasing
glycemia (6%).
Conclusion This study of changes in glycemia showed that at least one
out of five patients develops new-onset prediabetes or diabetes at 6
months of follow-up and more than two out of ten patients in 9 months.
Early detection of changes in blood glucose metabolism following an
attack of acute pancreatitis will help to reduce the burden of new-onset
diabetes after acute pancreatitis.
S84
262
A case of acute pancreatitis with normal serum amylase and lipase
value
Jayanta Paul
Correspondence- Jayanta Paul-dr.jayantapaul@gmail.com
Department of Gastroenterology, Desun Hospital, Desun More, 720,
Eastern Metropolitan Bypass, Golpark, Sector I, Kasba, Kolkata
700107, India
Introduction There are several causes of acute pancreatitis (AP). In clin-
ical practice, AP is diagnosed by presence of acute pain abdomen, ele-
vated serum amylase and lipase value (> 3 times of upper limit of normal)
and ultrasonographic (USG) findings of acute pancreatitis but in only
25% to 50% of patients with acute pancreatitis, pancreas is visualized in
ultrasonography. Abdominal pain is the cardinal symptom which occurs
in about 95% of cases of AP. Few studies showed that prevalence of
alcohol induced pancreatitis is higher than gallstone induced pancreatitis
but other study showed opposite result.
Methods/Results In this case, 44 years gentleman was presented with
acute pain abdomen, normal serum amylase and lipase value and no
pancreatic abnormality in abdominal USG. After diagnosis of elevated
serum triglyceride, computed tomography (CT scan) of abdomen was
done to exclude hypertriglyceridemia induced AP. CT scan abdomen
showed features of acute pancreatitis.
Conclusion Patient with acute pain abdomen and normal serum amylase
and lipase value do not exclude acute pancreatitis. Serum lipid profile
including triglyceride should be advised in every patient with acute pain
abdomen to exclude hypertriglyceridemia induced acute pancreatitis.
Keywords Acute pancreatitis, USG abdomen, High serum triglyceride
263
A case of successful treatment by conservative management of
laparostoma in operated case of necrotising pancreatitis with necro-
tizing colitis
Nisarg Chovatiya, Devendra Chaudhary, Mukesh Pancholi
Correspondence- Nisarg Chovatiya-nishu1971994@gmail.com
Department of General Surgery, Government Medical College and New
Civil Hospital, Opp. Income Tax Department Office, Majura Gate, Surat
395 001, India
Background Closure of the abdomen has always been a challenging task
especially in the emergency setting with presence of bowel edema,
hemoperitoneum, peritonitis, fecal contamination or intra-abdominal in-
fection. So following infection or due to tension give away of midline
laparotomy wound sutures and formation of laparostoma is not uncom-
mon. We here report a case of such laparostoma formed following the
give away of midline laparotomy wound suture following intraabdominal
infection and tension over suture and successful management of
laparostoma conservatively leading to spontaneous closure of
laparostoma.
Case presentation A 22-year-old male patient underwent the exploratory
laparotomy with right hemicolectomy with pancreatic necrosectomy with
end ileostomy formation for necrotising pancreatitis with necrotizing en-
terocolitis with two ascending colon perforation. There was wound gap in
midline laparotomy wound with gross pyoperitoneum with pus coming
out through abdominal drains. There was evident sheath gap and
laparostoma formation. We managed the patient conservatively.
Continuous draining of pyoperitoneum through laparostoma for around
a month was done leading to epithelialization and spontaneous closure of
laparostoma. Patient was discharged. Eleven months after discharge pa-
tient was operated for stoma closure through laparotomy and out of a
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
surprise bowels were healthy without adhesions to each other or to ab-
dominal wall.
Conclusion Conservative management of laparostoma wound with regu-
lar dressings involving betadine and metronidazole wash prior to every
dressing to drain pyoperitoneum not only prevented suspected mortality
from immediate 2nd hit in the form of re-operation but also took care of
intra-abdominal infection prevented the inter-bowel adhesions.
Keywords Laparostoma, Conservative management, Regular dressing,
Spontaneous closure
264
Case series of rare pancreatic space occupying lesions
Rithu Sebastian, Abraham Koshy, Roy J Mukkada, Antony Paul
Chettupuzha, Shelley C Paul, Pradeep George, Maya Peethambaran,
Thara Prathap, Pushpa Mahadevan
Correspondence- Rithu Sebastian-rithudec3@gmail.com
Departments of Radiology, Hepatology, Pathology, and Pediatric
Gastroenterology, Lakeshore Hospital and Research Centre, NH 47
Byepass, Nettoor, Maradu, Ernakulam 682 040, India
A wide spectrum of benign and malignant diseases can produce a mass in
the head of the pancreas. It can be solid (ductal adenocarcinoma, chronic
pancreatitis, endocrine tumor) or a cystic lesion (cystic neoplasm, true
cyst or pseudocyst). We present two cases of pancreatic actinomycosis
and one case of pancreatic tuberculosis.
Case 1 A 79-year-old lady known case of diabetes mellitus, systemic
hypertension, chronic kidney disease and chronic calcific pancreatitis
presented with history of fever for 2 weeks. There was history of EUS
FNAC of pancreatic abscess in 2016. Ultrasound guided FNAC pancreas
showed dense inflammatory cell infiltrate and actinomycotic colonies
with Splendore Hoeppli phenomenon.
Case 2 A 67-year-old male known case of chronic calcific pancre-
atitis presented with recurrent episodes of abdominal pain. EUS
FNAC done from pancreatic head mass showed occasional clumps
of basophilic filamentous bacteria surrounded by Splendor-
Hoeppli and a background of acute inflammatory cells suggestive
of actinomycosis.
Case 3 A 75-year-old male presented with loss of appetite and weight loss
since 1 month. CT abdomen showed a well defined multiloculated cystic
lesion abutting the neck of pancreas with multiple rim enhancing lesions
in the splenic parenchyma. He underwent EUS which showed a cystic
SOL in the pancreas with thick contents and splenic abscess. FNB was
done which showed large size caseating granulomas composed of
epitheloid cells and Langhans’s giant cells with occasional acid fast ba-
cilli. He was initiated on ATT.
Conclusion There are only thirteen reported cases of pancreatic actino-
mycosis to the best of our knowledge. A history of previous pancreatic
surgery or stenting was frequently reported. Both our patients had previ-
ous EUS FNAC done. Pancreatic tuberculosis is also a rare presentation.
Keywords Pancreas, Actinomycosis, Tuberculosis
265
Systematic review and meta-analysis: Is there any role of antioxidant
therapy for pain in chronic pancreatitis
Srikant Mohta, Namrata Singh, Deepak Gunjan, Amit Kumar, Anoop
Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Gastroenterology and Human Nutrition, and Neurology,
All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110
029, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction Chronic pancreatitis is an irreversible disease with increased
oxidative stress. The therapeutic role of antioxidants for pain reduction in
chronic pancreatitis (CP) however is debatable. We conducted a system-
atic review and meta-analysis to ascertain their role in pain relief, their
effect on quality of life in CP and associated adverse events.
Methods On literature review, we found 668 articles, seven of which were
included. Only randomized controlled trials (RCT) were included. Two
reviewers extracted the data and assessed the risk of bias. Pain was ana-
lyzed by visual analogue scale (VAS) and pain free participants. Results
are expressed as standardized mean difference (SMD) or risk ratio (RR)
with accompanying 95% confidence intervals and analysis was per-
formed with fixed or random effects model according to heterogeneity.
Adverse events and quality of life (QoL) were also assessed.
Results Twelve articles and four articles were eligible for qualitative and
quantitative analysis respectively. The four included studies had a total of
352 participants. Pain reduction as measured by visual analogue scale was
not significantly different in the antioxidant group compared to placebo
(SMD=-0.14 [95% CI=-0.44-0.17]; p=0.38). Number of pain free partic-
ipants were also similar (OR= 1.59 [0.97-2.59]; p=0.06). Antioxidants
were not associated with increased adverse events (OR=2.59 [CI=0.77-
8.69]; p=0.12). Qualitative analysis for effect on quality of life did not
suggest any significant improvement with antioxidants.
Conclusion There was no significant pain reduction or change in quality
of life in patients of CP with use of antioxidants. This makes their routine
use in management of CP questionable.
Keywords Antioxidants, quality of life, pain
266
A study on the prevalence of sarcopenia in chronic pancreatitis, CT
based assessment at a tertiary center in South India
Damodar Krishnan, Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Medical Gastroenterology, Sri Ramachandra Institute of
Health and Research Center, Chennai, India and Sri Ramachandra
Institute of Higher Education and Research, Chennai 600 116, India
Introduction Patients with chronic pancreatitis (CP) are at an increased
risk of sarcopenia and was associated with increased hospitalization rates
and mortality. CT is considered a valuable tool for the assessment of
skeletal muscle mass and sarcopenia. We aim to determine the prevalence
of sarcopenia using segmented skeletal muscle area, investigate risk fac-
tors associated with sarcopenia, and to derive the cut-off value of psoas
muscle cross-sectional area (CSA) and muscle thickness for the diagnosis
of sarcopenia using segmented skeletal muscle area as the reference
method.
Methods Retrospective data on patients' demographic and disease char-
acteristics were collected from medical records during the last 5 years. CT
from the archives was taken and CSA of the psoas muscle was deter-
mined by manual encircling the outer surface of the muscle and muscle
thickness as 2 points transverse diameter, normalized to stature, taking
skeletal muscle index as a reference of sarcopenia (defined as SMI < 41.3
cm2/m2 for males and <34.cm2/m2 for females).
Results A total of 133 chronic pancreatitis patients were included, pre-
dominantly males 82% (n=109) with mean age of 40.67. CT assessment
showed 51.1% of the patients having sarcopenia based on skeletal muscle
index. Alcohol as etiology was noted in 54% of sarcopenic patients,
PERT usage was noted in 61.76%, and diabetes in 51.47% in sarcopenic
patients. Psoas muscle thickness and CSA showed significant association
with SMI. Optimal psoas muscle thickness cut off for diagnosing
sarcopenia was 23.78 mm/m for males and 21.11 mm/m for females
and psoas CSA cut off 3.49 cm2/m2 for males and 2.40 cm2/m2 for
females.
Conclusion Psoas muscle CSA measured on a standard axial CT slice can
be used as a surrogate for muscle mass in patients with CP. Used in
S85
combination with clinical risk factors, including exocrine pancreatic in-
sufficiency and opioid treatment, the method provides a clinically useful
means for the detection of sarcopenia in this context.
Keywords Chronic pancreatitis, Sarcopenia, Skeletal muscle index, Psoas
muscle thickness
267
Endoscopic ultrasound guided drainage of critically ill patients with
walled off necrosis: Which stent to choose?
Gaurav Muktesh, Jayanta Samanta, Jahnvi Dhar, Roshan Agarwala,
Balaji Bellum, Anupam K Singh, Saroj K Sinha, Vikas Gupta, Hemanth
Kumar, Rakesh Kochhar
Correspondence- Gaurav Muktesh-gauravmuktesh@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Introduction Endoscopic ultrasound guided drainage is the preferred
treatment of pancreatic fluid collections (PFC).
Methods Between January 2018 and December 2019, consecutive pa-
tients with symptomatic PFC subjected to EUS guided drainage using
bi flanged metal stents (BFMS) or double pig tail plastic stents (DPPS)
were compared for technical success, clinical success, duration of proce-
dure, need for ICU stay, duration of ICU stay, ventilator need, resolution
of organ failure (yes/no), duration for resolution of organ failure, need for
necrosectomy, need for salvage percutaneous drainage (PCD), complica-
tions, need for surgery and mortality. A subgroup of patients having
systemic inflammatory response syndrome (SIRS) and/or organ failure
were analyzed separately.
Results Among 130 patients (84.6% males) with PFC (108 WON, 22
pseudocyst) who underwent EUS guided drainage there was no differ-
ence in outcome parameters in BFMS and DPPS groups in the entire PFC
cohort. Amongst patients with WON, clinical success was significantly
higher (93.7% vs. 80%, p=0.039), duration of hospital stay (5 days vs. 10
days, p=0.028) and duration of procedure significantly lower (15.94±7.2
vs. 42.40±11.2 minutes, p= 0.0001) in BFMS compared to DPPS group.
Amongst patients with SIRS and/or organ failure the duration of proce-
dure was significantly lower (15.36±6.8 vs. 40.56±10.0, p=0.0001) in
BFMS compared to DPPS group.
Conclusion EUS guided drainage in WON using BFMS scores over
DPPS. In patients having SIRS and/or organ failure, BFMS may be pre-
ferred over DPPS.
Keywords Biflanged metal stent, Double pigtail plastic stent, Organ failure
268
Majority of patients with chronic pancreatitis are deficient in calorie
intake and is associated with inflammation and pain
Anoop Saraya, Sumaira Qamar, Namrata Singh, Srikant Gopi, Deepak
Gunjan
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition Unit, All India
Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Actual energy intake and its deficit in patients with chronic
pancreatitis (CP) and association with inflammation and pain pattern are
not well studied.
Methods Pre-tested, open ended, semi-qualitative food frequency
proforma was used for diet assessment. Total energy (kcal) requirement
(TER) was calculated by adding: resting energy expenditure (REE) by
Harris-Benedict equation, 30% REE (increased metabolism) and 5%
REE (diet-induced thermogenesis). Based on consumption of dietary en-
ergy, patients were divided in to: group 1 <90% and group 2 ≥90% TER.
Based on pain characterization in last 3 months, patients were divided into
S86
three groups: continuous, intermittent and no pain. Serum inflammatory
markers (quantitative C-reactive protein [Qcrp] and interleukin-6 [IL-6])
was assessed by ELISA kits.
Results A total of 107 patients (males-82) with mean age 31.2
±11.1 years were included. Mean TER was 1901±279 kcal/day
and mean energy intake was 1741±575 kcal/day in whole cohort,
whereas energy intake was 1437±399 kcal/day in group 1 (n=68
[63%]) vs. 2271±432 kcal/day in group 2 (n=39 [36%],
[p=0.0001]). Group 1 had an average 503±366 kcal deficit/day,
elevated IL-6 (median:1.5 [0.22-15 pg/mL], p=0.039) and CRP
(median: 2.38 [0.02-41 mg/mL], p=0.0447) compared to group
2. Patients having continuous pain (n=17) had significantly lower
energy intake (1381±602) vs. intermittent (1793± 526) vs. no pain
1832± 582) and higher qCRP 2.1 (0.4-15) pg/mL, compared to
intermittent 1.8 (0.01-11) pg/mL and no pain (1 [0.02-29] pg/mL,
[p=0.0267]), similar results were seen for IL-6 (0.0665).
Percentage of energy from macro nutrients was similar in both
groups. There was no difference in frequency of diabetics/non-
diabetics (p=0.970) and patients with steatorrhea/no steatorrhea
(p=0.951) in group 1 and 2.
Conclusion Two third patients with CP are 1/4th daily energy deficient in
their diet. Also patients with higher inflammation and continuous pain are
more likely to have low calorie intake.
Keywords Energy deficit, Inflamation and energy deficieny, CP and en-
ergy intake
269
Differential location of growth factors and pancreatic stellate cell
activation in chronic pancreatitis
Srikant Mohta, Pooja Goswami, Prasenjit Das, N R Dash, Namrata
Singh, Deepak Gunjan, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Gastroenterology and Human Nutrition, Gastrointestinal
Surgery, and Pathology, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India
Introduction Parenchymal fibrosis in chronic pancreatitis is mediat-
ed by various inflammatory cytokines and growth factors. It is
characterized by activation of pancreatic stellate cells and start
expressing smooth muscle actin (α-SMA). Normal pancreas has
predominantly quiescent stellate cells in periductal and
perivascular locations and does not express α-SMA. So, we
wanted to study the immunohistochemistry (IHC) expression pat-
tern of α-SMA, platelet derived growth factor (PDGF-BB) and
transforming growth factor (TGF-β) in the resected specimen of
chronic pancreatitis.
Methods A total of 20 biopsies from resected specimen of chronic pan-
creatitis were included. The expression was measured as compared to
control biopsies (breast carcinoma as a positive control for PDGF-BB
and TGF-β, and appendicular tissue for α-SMA), and scored based on
a semi-quantitative system based on staining intensity and percentage of
positive cells was used for objective scoring, which value varies from 0-
15. This scoring was done separately for acini, ducts, stroma and islet
cells.
Results (Table 1 and Fig. 1) All the patients had undergone surgery for
refractory pain and median duration of symptoms was 48 months (IQR).
On IHC, α-SMA was not expressed in the acini, ducts or islets but had
high expression in the stromal regions (vs. acini, ducts and islet, p<0.01).
PDGF-BB was expressed in the acini, ducts and stroma but has highest
expression in islet cells (vs. stroma, p<0.01). TGF-β1 was also expressed
maximally in islet cells; however, the distribution amongst all locations
was statistically similar.
Conclusion α-SMA expression in the pancreatic stroma is an indi-
cator of concentration of activated stellate cells in the stroma, a site
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
for genesis of fibrosis under the influence of growth factors in the
local milieu.
Keywords Stroma, Extracellular matrix, Growth factors
270
Clinical profile of acute pancreatitis in tertiary care centre
Niranjan N K, Murali R, Prem Kumar K, Shubha I, Chezhian A
Correspondence- Murali R-muraligastro@gmail.com
Department of Medical Gastroenterology, Institute of Medical
Gastroenterology, Madras Medical College, Near Park Town Station,
Park Town, Chennai 600 003, India
Introduction Acute pancreatitis is thought to be a local inflammatory
process involving premature intracellular activation of digestive enzymes
within acinar cells leading to auto digestion of the tissue that can progress
to involve distant organs. AP was one of the most common diseases in
gastroenterology. Practical understanding of etiology and severity will
accommodate in advocate the appropriate treatment.
Method It’s a retrospective observational study carried out over a period
of 1 year from September 2019 to August 2020 at Medical
Gastroenterology Department ward of Madras Medical College of all
acute pancreatitis patients, with regards to demographics and etiology.
Results Data collected from 120 patients was initially assessed for isola-
tion of etiology by using specially self designed etiology assessment
form, severity based on Atlanta severity assessment scale (ASAS).
Treatment was given according to institute protocol and outcome was
measured in terms of length of stay in hospital. Out of 60 patients 48
(40%) patients with alcohol, 66 (55%) with alcohol and smoking, 6 (5%)
with gallstones. On severity assessment 84 (70%) patients were mild and
36 (30%) were moderate. On measurement of outcomes 46 (38.3%) pa-
tients were better, 50 (41.6%) patients were moderate, and 14 (11.6%)
patients were poor control.
Conclusion We conclude that alcohol is the predominant cause
acute pancreatitis and smoking adds to the risk. Evaluating cause,
severity and management based on the standard guidelines are
found to be the safe and effective management of AP to reduce
the hospital stay.
Keywords Acute pancreatitis, ASAC, Alcohol, Gallstone
271
Diagnostic performance of cytology, tumor markers and molecular
(KRAS and GNAS) testing in pancreatic cystic lesions: Experience
from a tertiary care centre in India
Ravi Kumar Sharma, Surinder Singh Rana, Radhika Srinivasan,
Rithabhra Nada, Rajesh Gupta
Correspondence- Surinder Singh Rana-drsurinderrana@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Background Asymptomatic pancreatic cystic lesion (PCLs) are now be-
ing increasingly diagnosed because of widespread use of cross-sectional
imaging modalities. There is a clinical dilemma to diagnose it correctly as
PCLs are complex group of lesions from benign, premalignant to malig-
nant and data from India on these tumors is scarce.
Methods Consecutive with PCLs seen in our unit from July 2015-
September 2019 were prospectively enrolled and underwent endoscopic
ultrasound (EUS) and EUS guided cyst fluid aspiration. Air dried slides
were sent for cytological evaluation. Cyst fluid CEA, CA19.9, CA72.4,
CA125, VEGF were performed by using ELISA and KRAS (exon 2,
codon 12 and 13) and GNAS (exon 8, codon 201) mutation analysis were
performed by using Sanger sequencing. The final diagnosis was based on
histopathology of resected specimen or confirmation in aspirated cyst
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
fluid, or clinical diagnosis with no significant growth on follow-up of >6
months.
Results Hundred consecutive patients (Mean age 49.15±15.9 years, 59 fe-
males) with PCLs were enrolled and 94 patients underwent EUS FNA, mean
cyst size was 4.23±2.8 cm. On EUS single cyst were found in 92 patients
and multiple in 8 patients, location of cyst was 46 in head and uncinate, 27 in
body and 35 in tail of pancreas. On cytopathology 23 patients were identified
positive for malignancy and 63 patents were found negative for malignancy,
5 patients were false negative and 3 were inconclusive. Mean CEA level at
>45.0 ng/mL showed sensitivity of 88.5% and specificity 96.8%, p=<0.001
to differentiate mucinous and non-mucinous cysts. KRAS exon 2 mutation
was positive in 14 patients at codon 12. While KRAS codon 13 and GNAS
exon 8 codon 201 was negative in all cases.
Conclusion CEA is helpful in differentiation of mucinous and non-
mucinous cyst and KRAS gene mutation is helpful in differentiation of
malignant and non-malignant cyst.
Keywords Pancreatic cystic lesion-PCL
272
Outcomes of minor papilla endotherapy for pancreatic divisum in
patients with recurrent acute pancreatitis
Amol Vadgaonkar, Prabha Sawant, Gaurav Patil, Ankit Dalal, Amit
Maydeo
Correspondence- Amol Vadgaonkar-vadu169@gmail.com
Department of Gastroenterology, Baldota Institute of Digestive Sciences,
Global Hospitals, 35, Dr. E Borges Road. Opp Shirodkar High School,
Parel, Mumbai 400 012, India
Background Pancreatic divisum (PD) is the likely cause of abdominal pain in
5% to 10% of patients with recurrent acute pancreatitis (RAP). The outcomes
for endotherapy in these patients remains currently unexplored in India.
Methods This is a prospective observational study of RAP patients who
underwent endotherapy for PD from June 2018 - May 2020. RAP was
defined as >2 episodes of acute pancreatitis (AP) without underlying chronic
pancreatitis (CP). PD was diagnosed based on MRCP and/ or EUS. At
ERCP, minor papilla guidewire cannulation followed by over the wire
sphincterotomy was done. A dorsal duct stent (5-Fr) was placed short-term
for 1 month. All patients were followed up at 1, 6, and 12 months’ post
sphincterotomy. Pain was assessed by visual analogue score (VAS). The
outcomes included technical and clinical success, pain relief and
complications.
Results A total of forty-one patients, male = 34 (82.9%); with a mean
(SD) age of 29 (11) years were analyzed. Median episodes of RAP prior
to endotherapy were 3 (range 3-6). All patients underwent minor papilla
sphincterotomy with placement of 5Fr stent and PD stenting (technical
success 100%). The clinical success of endotherapy in complete PD was
20/27 (74%), in incomplete divisum 8/14 (57.1%). The mean (SD) length
of hospitalization was 3 (1) days. Complications included stenosis of the
sphincterotomised minor papilla (n=4), Post ERCP pancreatitis (n=3),
sphincterotomy bleed (n=2) and stent migration (n=1). At 12 months, 7
(17.1%) had features suggestive of early CP. Twenty-six (63.4%) patients
underwent repeat ERCP with sphincterotomy and pancreatic ductal
stenting. The VAS score reduced significantly from baseline as compared
to 1, 6 and 12 months (p<.001).
Conclusions Endotherapy with minor papilla sphincterotomy and pancre-
atic duct stenting looks appropriate as initial therapy in symptomatic
complete PD and non-responders may need additional interventions.
Keywords Pancreatic divisum, Minor papilla endotherapy, Pancreatic
stenting, Endoscopic retrograde cholangiopancreatography
273
MiR-30b modulates inflammatory response by targeting RIP-140 in
pancreatic tumor
S87
Bharti Garg, Nidhi Singh, Safoora Rashid, Surabhi Gupta4, Deepak
Gunjan, N R Dash, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Background miRNAs are known to skew the immune responses towards
development of pancreatic cancer. Upregulation of receptor interacting
protein (RIP-140) exacerbates inflammatory events and facilitates the
tumorigenesis of pancreatic ductal adenocarcinoma. In this report, we
evaluated whether any down regulated microRNA 30b in pancreatic can-
cer patients orchestrates RIP-140 mediated inflammation with the pro-
gression of the disease.
Methods Target scan and PicTar algorithm was used to predict the
miRNAs target in RIP-140. N=50 PDAC patient and healthy volunteers
were accrued in this study. Taqman assay and SYBR green based qRT
PCR was done to validate the expression of miRNAs and their target,
respectively, in pancreatic patient tissues and their serum samples.
Inflammatory markers (TNF-α, IL-1β and IL-6) levels in serum was
detected by ELISA. Infiltration of M1 (CD80+ and CD86+) and M2
macrophage markers (CD204+ and CD163+) in tumor samples was elu-
cidated by flow cytometry. In Invitro setting, CD45+ cells were co cul-
tured with panc-01 cells in transwell system and miR-30b was over
expressed in panc-01 to see the effect of miR30b on inflammatory
response.
Results miRNA-30b was remarkably found to be down regulated in
PDAC samples and pancreatic cancer human cell lines showing upregu-
lation of RIP-40. Low levels of miRNA-30b enhanced the expression of
inflammatory markers in serum samples. In addition to that we also found
more infiltration of M2 macrophages in tumor samples. Invitro over ex-
pression of miRNA-30b in panc-01 reversed these effects when co cul-
tured with CD45+ cells.
Conclusion Our data suggested miR-30b as a plausible target for RIP-
140. Low levels of miR-30b and high RIP-140 expression levels both
predicts dismal prognosis via increasing inflammation in PDAC patients.
Taken together, these findings implicated that over expression of miR-
30b may suppress inflammation through suppressing RIP-140 expression
highlighting that miR-30b may serve as therapeutic agent in the treatment
of PDAC.
Keywords miRNA, RIP-140 (receptor interacting protein), inflammation,
M1/M2 macrophages, pancreatic cancer
274
Evaluation of point of care urine trypsinogen dipstick for diagnosing
acute pancreatitis in an emergency unit
Amar Simha, Atul Saroch, Navneet Sharma, Ashok K Pannu, Deba P
Dhibar, Harjeet Singh, Vishal Sharma
Correspondence- Atul Saroch-atulsaroch@gmail.com
Department of Internal Medicine, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Introduction Abdominal pain is most frequent presenting symptoms in
emergency medicine department. Diagnosis can be as subtle as acute
gastritis to mesenteric insufficiency a life-threatening condition. Acute
pancreatitis is one of the diseases presenting with symptom of severe
abdominal pain. Here in this study we will assess diagnostic accuracy
of newly introduced urine trypsinogen dip stick, point of care test for early
diagnosis of acute pancreatitis.
Method This diagnostic accuracy study was performed in emergency unit
of one of tertiary care hospital of north India. Consecutive patient with
abdominal pain duration of less than and equal to seven days and fulfill-
ing inclusion criteria were recruited in this study. Urine trypsinogen dip
stick test was performed in all patient and diagnostic accuracy (sensitivity
and specificity) were calculated.
S88
Result Total 187 patient were recruited, out of which 90 were cases (acute
pancreatitis) while 97 were control (non-pancreatitic cause of abdominal
pain). Sensitivity and specificity of urine trypsinogen dip stick test for
diagnosis of acute pancreatitis 67.8% and 90.7% respectively, further
subgroup analysis in patient of duration of pain less than and equal to 3
days, sensitivity and specificity approach to 72.7% and 91.8% respective-
ly. Positive and negative likelihood ratio is 6.10 and 0.36 (≤ 7 days), 8.9
and 0.3 (≤3 days) respectively. In patient with acute severe pancreatitis
diagnostic sensitivity of UTDT is 82%.
Discussion With advantage of bed side point of care testing and better
sensitivity/specificity in early days of abdominal pain (<3 days), urine
trypsinogen dip stick test will be boon to the resource limited setting
where health infrastructure for conducting biochemical test (serum amy-
lase and lipase) is not available.
Keywords Acute pancreatitis, Point of care test, Urine trypsinogen dip-
stick test (UTDT)
275
Endoscopic removal of proximally migrated pancreatic duct stents:
Techniques and their outcome
Sachin H J, Surinder Singh Rana
Correspondence- Surinder Singh Rana-drsurinderrana@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Objective Proximal migration of pancreatic stents is an uncommon,
but significant problem that poses risk of pain and pancreatitis. It is
a challenging situation to the endoscopist, necessitating surgical
retrieval in 10% of cases. We describe our experience with endo-
scopic removal of different stents with different methods (namely
use of grasping forceps, Spy-glass, EUS guided extrusion), compli-
cations, and outcome.
Methods A retrospective review of the last 10 years for pancreatic duct stent
removal procedures done at our unit was done. The size, type, status (intact
or fragmented) and position of migrated stents, the status of PD (pancreatic
duct), the method utilized, and the number of sessions needed for extrac-
tion, success, complications, and need for surgical retrieval were studied.
Results Sixteen patients (mean age 39.52 years, 13 [81%] males) with
migrated proximal stents were studied. Two (12.5%) patients had
fragmented stents and rest 14 (87.5%) had whole migrated stents in situ,
all of them being of straight type. Fourteen (87.5%) patients had dilated PD.
Most (n=10 [62.5%] p=0.022) of them had a stent of 5F size, and most of
them were 10 cm (n=10 [62.5] p=0.001) in length. Most of stents were
positioned in the genu (n= 8 [50%] p=0.105) and were retrieved mostly
with grasping forceps (n=8 [50%] p=0.035). Stents could be removed in 13
(81.25%) patients and retrieval was successful in a single session (n=6
[37.5%]) in the majority. Among the two patients with fragmented stent
both of them could be removed, albeit, in one of them, the distal fragment
remained in the tail. Two patients reported post-procedure pain (n=2
[12.5%]) and 1 patient needed surgical retrieval.
Conclusion In the hands of an expert endoscopist, endoscopic retrieval of
proximally migrated stents using a combination of techniques and accesso-
ries is safe and effective. Surgery is rarely needed for stent removal.
Keywords Migrated pancreatic duct stent, Endoscopic removal,
Outcomes
276
Renal artery Doppler and clinico-radiological profile of acute kidney
injury in acute pancreatitis
Surinder Rana, Nikhil Bush, Pankaj Gupta, Ravi Sharma, Rajesh Gupta
Correspondence- Surinder Rana-drsurinderrana@gmail.com
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Background Acute kidney injury (AKI) in acute pancreatitis (AP) is as-
sociated with poor prognosis. There is lack of data on renal Doppler
findings in patients with AKI due to AP.
Methods Thirty-six patients (41.2±13.79 years; 30 M) of AP with AKI
and thirty-nine patients (42.1±12.8 years; 28 M) of AP without AKI were
prospectively recruited. All patients underwent renal ultrasound and
Doppler analysis at the level of the intra-renal arcuate arteries. RI values
between 0.6-0.7 were considered normal. A comparative analysis of de-
mographic, clinical, radiological, and renal Doppler variables was done.
Results 19.4%, 33.3% and 47.2% of the AKI patients presented in AKIN
stages 1, 2 and 3 respectively. Patients with AKI had significantly higher
frequency of anemia, hypoalbuminemia, lung injury, hypotension, in-
creased lactate, raised procalcitonin, IAH, multiorgan and persistent or-
gan failure with higher mean severity scores (SIRS, BISAP, MMS,
APACHE II, MCTSI) in comparison to those without AKI. Need for
intervention, duration of hospitalization and mortality (30.5% vs. 7.6%,
p-value 0.008) were also higher in the AKI group. Oliguric AKI was
present in 22 (61.1%) and dialysis was needed in 18 (50%). On multivar-
iate logistic regression, high initial creatinine value was a significant
predictor of the need for dialysis (p-value 0.047, OR-1.9, 95% CI 1.00-
3.75). Renal ultrasound revealed increased cortical echogenicity in 22
(61%) patients, compared to none in those without AKI (p<0.05). Peak
systolic velocity and resistive indices at the upper, middle and lower poles
of bilateral kidneys were comparable between the two groups and no
significant differences were noted in their mean values. Among 31 pa-
tients with abnormal resistive indices in bilateral kidneys (41.3%), 25
(33.3%) had values <0.6 while 6 (8%) had values > 0.7. 4.
Conclusions AKI is associated with poor prognosis in AP. There are no
significant alterations in renal Doppler parameters in patients of AP with
AKI.
Keywords Acute kidney injury, Acute pancreatitis, Renal artery doppler,
Resistive index
277
Exclusive percutaneous catheter drainage for infected pancreatic ne-
crosis: Outcome and predictors of mortality
Ashok Kumar, Kshitiz Saran, Rohit Gupta, Itish Patanik
Correspondence- Ashok Kumar-drashok.sgpgims@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Virbhadra Road Shivaji Nagar, near Barrage, Sturida Colony, Rishikesh
249 203, India
Introduction Infected pancreatic necrosis (IPN) is associated with high
mortality. A proactive percutaneous catheter drainage (PCD) strategy
may lead to decreased systemic inflammation and improved outcomes,
but the information is limited about exclusive PCD management (without
necrosectomy) for IPN.
Methods This study aimed to determine the outcomes of exclusive PCD
interventions for IPN patients. The database of 156 consecutive acute
pancreatitis patients, hospitalized between May 2018 to July 2020, was
analyzed for outcomes of exclusive PCD management (without
necrosectomy) for IPN.
Results Thirty patients with pancreatic necrosis were exclusively man-
aged by PCD; 25 (83.3%) survived and 5 (16.7%) died. The survivors
and non-survivors had a similar mean age (37.7 ± 11.3 vs. 47.6 ± 14.8
years, p 0.10), male patients (84 vs. 60%, p 0.22), mCTSI (9.28±1.40 vs.
9.20 ± 1.79, p 0.96), degree of necrosis (20:68:12 and 20:40:40 for <30%,
30-50%, >50% necrosis, respectively, p 0.29), infected necrosis (76 vs.
80, p 0.85) and drug resistant bacteria (72 vs. 80, p 0.64).
However, non-survivors group had fewer alcoholic pancreatitis (0 vs.
64%, p 0.03), higher BISAP score (2.6 ± 0.6 vs. 1.7± 0.7, p 0.02), more
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
patients with multiple organ failures (80 vs. 0%, p 0.00); shorter pain
onset to hospitalization (9.2 ± 8.1 vs. 27.9 ± 22.3 days, p 0.03) and pain
onset to PCD placement interval (20.6 ± 7.6 vs. 39.1 ± 20.8 days. p 0.02),
more number of PCDs per patient (1.8 ± 0.8 vs. 1.5 ± 0.9, p 0.33), lower
fall in SIRS post PCD (0.6 ± 0.6 vs. 1.7 ± 0.45, p 0.00), shorter PCD
dwell time (17.2 ± 6.5 vs. 41.2 ± 38.8 days, p 0.01).
Conclusion For IPN, exclusive PCD management has a high success rate
(83.3%). Etiology, severity of pancreatitis, and multiple organ failures are
associated with higher mortality.
Keywords Acute pancreatitis, Infected pancreatic necrosis, Percutaneous
catheter drainage
278
Outcomes of extracorporeal shock wave lithotripsy in chronic pan-
creatitis with pancreatic duct calculi
Harshal Gadhikar, Mangesh Borkar, Nisarg Patel, Amol Bapaye,
Ashish Gandhi
Correspondence- Harshal Gadhikar-gadhikarhp@gmail.com
Department of Gastroenterology, Deenanath Mangeshkar Hospital and
Research Center, Pune 411 004, India
Introduction The removal of large pancreatic calculi is challenging and
ESWL followed by ERCP is standard of care. We assessed overall out-
comes including pain relief, ductal clearance, recurrence, and safety fol-
lowing ESWL.
Methods Prospective observational study of symptomatic CP patients with
PD calculi (head and body) undergoing ESWL from August 1918-March
2020 was conducted. Patients were evaluated using X-ray, fluoroscopy,
USG, CT scan, EUS/MRCP. Number required for calculi fragmentation,
pancreatic ductal clearance, efficacy, and safety of ESWL was studied. Pain
was assessed using visual analogue scale (VAS). Non-visualization of cal-
culi on fluoroscopy was taken as the end point for ESWL. Patients were
followed up for 6 months W.R.T. pain relief and complications.
Results Total of 128 patients; male 89 (69.5%) with a mean age 40.7
(16.1) years were included. Abdominal pain was present as the only
symptom in 122 (95.3%), while steatorrhea along with pain was present
in 6 (4.7%). Diabetes was present in 64 (50%). Fifty-seven (44.5%)
patients required between 1- 5 ESWL sessions, 49 between 6-10 and 22
required >=11 sessions. The mean (SD) ESWL sessions in these patients
were 7.2(4.2). Mean (SD) VAS pre-ESWL was 4.3(1.75). At 3 months,
113(88.3%) patients had VAS of 0. At 6 months 126 (98.4%) had VAS
score of 0 (p<.001). ERCP, sphincterotomy +/- pancreatic duct stenting
was done in 112 (87.5%) patients. ERCP failed in 6, was refused by 5 and
lost to follow-up in 5 patients. Complete ductal clearance was achieved in
118 (92.2%), whereas partial was in 10 (8.8%). 37 (28.9%) had PD
stricture. Twenty-four (18.7%) patients had minor complications like er-
ythema of skin (14.8%) and cutaneous pain (3.9%), while only 1 (0.8%)
had serious complication of acute pancreatitis. Six (4.7%) patients had
stone recurrence after ESWL during 6 months follow-up period.
Conclusions ESWL is safe and effective modality in CCP patients with
PD calculi with good success rates.
Keywords Pancreatic calculi, Extracorporeal shockwave lithotripsy, Safety
279
Endoscopic transpapillary management of pancreatic duct disrup-
tion at a tertiary care center in Northern India
Shreya Butala, Samir Mohindra, Gaurav Pandey, Vivek Saraswat
Correspondence- Vivek Saraswat-profviveksaraswat@gmail.com
Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of
Medical Sciences, Lucknow 226 014, India
Introduction Pancreatic duct disruption occurring as complication of
acute necrotizing pancreatitis (ANP), traumatic pancreatitis (TP), chronic
S89
pancreatitis (CP), pancreatic malignancies, present with peripancreatic
fluid collections (PFC), pancreatic ascites (PA), pancreatic pleural effu-
sion (PPE) or external pancreatic fistulae (EPF) after percutaneous drain-
age (PCD).
Methods Retrospective review of patients undergoing ERCP between
January 2010 to July 2020 for AP or CP complicated by PFC, PA, PPE
or EPF was done. Pancreatic duct (PD) disruption was defined partial if
upstream PD was visualized or complete if it was not visualized. Clinical
success was defined as resolution of collection and removal of
percutaneous catheter within 2 weeks of ERCP without the need of sec-
ond intervention.
Results Sixty-nine patients (54 male, mean age 28 years) with PD disrup-
tion( EPF - 22, PFC with ductal communication -21, PA -15, PA+PPE -6,
PPE -5) were included. Etiology was ANP- 32 (46.4%), TP-9 (13%), CP-
28 (40.6%). PD cannulation was successful in 61 patients (88.4%).
Transpapillary stents were placed in 51 (73.91%). PD disruption was
successfully bridged by a stent in 21 (30.4%) patients. Stents were not
placed in 18 (failed cannulation-8, leak within 3cm from papilla-3, non-
delineation of MPD-3, stricture or stone-4). Clinical success was achieved
in 42/69 (60.8%) patients. Median duration for resolution of leak after
ERCP was 10 days in patients with clinical success vs. 48.5 days in
failure group (p-0.001). Median PCD duration after ERCP was shorter
in transpapillary stent group (12 vs. 60 days, p-0.005). Three patients
developed post-sphincterotomy minor bleeding, two had mild pancreati-
tis. On univariate analysis, chronic pancreatitis, partial PD disruption,
bridging of leak by stent and transpapillary stenting were associated with
clinical success.
Conclusion Endoscopic transpapillary management of PD disruption is
safe and effective therapy for pancreatic ductal leaks and leads to early
resolution of leak.
Keywords Pancreatic duct disruption, Endoscopic transpapillary management
280
Pancreatic bed hemorrhage contributes to late mortality in patients
with acute necrotizing pancreatitis
Anshuman Elhence, Saransh Jain, Soumya Jagannath Mahapatra,
Rahul Sethia, Varun Teja, Shivam Pandey, Kumble Seetharama
Madhusudhan, Pramod Kumar Garg
Correspondence- Pramod Kumar Garg-pgarg10@gmail.com
Departments of Biostatistics, Gastroenterology and Human Nutrition
Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
110 029, India, and Jainamshree Hospital, E5, 47, Near Bagheera
Apartment, E-5, Arera Colony, Bhopal 462 016, India
Introduction Frequency, risk factors of hemorrhage, and impact on sur-
vival of pancreatic bed hemorrhage into (peri)pancreatic necrotic collec-
tions in patients with acute pancreatitis (AP) are not well studied.
Methods All consecutive patients with AP from January 2015 till
March 2020 admitted in a tertiary care academic centre were included
prospectively to study frequency, risk factors of hemorrhage, and impact
on survival of pancreatic bed hemorrhage. Patients with significant pan-
creatic hemorrhage were managed according to a predefined protocol.
Primary outcome was the effect of pancreatic hemorrhage on in-
hospital mortality. Secondary outcomes were risk factors of hemorrhage.
Results Of a total of 363 patients admitted during the study period,
33 (9.04%) patients developed pancreatic hemorrhage during their
hospital stay. The cause of hemorrhage were arterial
pseudoaneurysm in 21 patients and unlocalized in 12 patients.
Radiographic angioembolization was done in all patients with
suspected arterial bleed which failed in 3 patients. Surgery was
required in 10 patients for persistent bleeding including 7 patients
with unlocalized bleeding source. Median time from onset of AP to
bleed was 59 (45-68) days. On Cox proportional hazard analysis,
persistent organ failure (HR 2.3 [1.1-5.1], p=0.03), use of large
S90
bore (20 Fr or above) catheter for initial drainage (HR 3.9 [1.7-9.1],
p=0.001) and extensive (>50%) necrosis (HR 3.1 [1.4-6.9],
p=0.005) were significantly associated with risk of pancreatic hem-
orrhage. In-hospital mortality in patients with hemorrhage was 22/
33 (66.7%) vs. 81/330 (25%) in no hemorrhage group (p <0.001).
Hemorrhage into pancreatic bed was an independent predictor of
mortality (OR 5.1 [CI 1.7-14.1], p=0.002) in addition to extensive
(>50%) necrosis, persistent organ failure, and infection with multi/
extreme drug resistant organisms.
Conclusion Pancreatic hemorrhage occurred in 9% of patients with AP
and was an independent predictor of mortality.
Keywords Acute pancreatitis, Organ failure, IPN. Bleeding
281
Alcohol etiology and not poor dietary intake determines sarcopenia
in chronic pancreatitis
Srikanth Gopi, Deepak Gunjan, Divya Madan, Namrata Singh,
Madhusudhan K S, Anoop Saraya
Correspondence- Anoop Saraya-ansaraya@yahoo.com
Departments of Radiodiagnosis, Gastroenterology and Human Nutrition
Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
110 029, India
Introduction Sarcopenia is associated with increasing morbidity and mor-
tality in various chronic disease. Chronic pancreatitis (CP) is a chronic
inflammatory disease with various complications and sarcopenia is not
well studied in these patients. We aimed to study the prevalence of
sarcopenia in chronic pancreatitis and its association with pain severity,
complications, dietary intake, exocrine and endocrine insufficiencies.
Methods A prospective observational single center study was conducted
from February 2019 to August 2020. All consecutive chronic pancreatitis
patients were included, and exclusion criteria was age <18 or >60 years,
associated other co-morbidities and history of pancreatic surgery. The
sarcopenia was assessed by measuring skeletal muscle index at L3 level
and gender specific skeletal muscle index cut offs were taken (<37.3 cm2/
m2 for males and <26.7 cm2/m2 for females). All these patients were
assessed for clinical details, anthropometry, body composition by
bioimpedance analysis, hand-grip strength, 6-meter gait speed and dietary
intake.
Results A total of 194 patients (66.5% were males) with mean age
of 36±11 years were included in the study. The prevalence of
sarcopenia was 22.2% and it was more common in alcohol-
related CP than other etiologies (58.1% vs. 24.5%, p=0.001). On
multivariate analysis, only alcoholic CP was significantly associat-
ed with sarcopenia (OR=3.25 [CI:1.14-0.09], p=0.028). There was
a non-significant trend of lower BMI in sarcopenic CP (OR=1.46
[CI:0.98-2.17], p=0.061). There was no statistical significant dif-
ference between sarcopenia and non-sarcopenia groups in endo-
crine deficiency (38.4% vs. 39.5%, p=0.894), exocrine insufficien-
cies (82.8% vs. 69.8%, p=0,060), mean hand grip strength (32.93
±17.4 kg vs. 30.3±15.2 kg, p=0.364), mean 6 m gait speed (1.11
±0.18 m/s vs. 1.11±0.17 m/s, p=0.988), daily calorie intake (1477
±706 Kcal vs. 1657±577 Kcal, p=0.104) and median CRP levels
(1.93 vs. 1.04 mg/L, p=0.246), respectively.
Conclusion Sarcopenia is common in chronic pancreatitis and alcoholic
CP has higher chances of developing sarcopenia.
Keywords Sarcopenia, Chronic pancreatitis
Endoscopy
282
Granulomatous pharyngitis - A diagnostic dilemma for an
endoscopist/otolaryngologist
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Avinash Balekuduru, Mandalapu Narendra Babu, Shruthi Sagar
Bongu, Satyaprakash Bonthala Subbaraj
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S
Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru
560 054, India
Introduction Endoscopy showing posterior pharyngeal wall lesion with-
out histological confirmation can make the diagnosis and treatment chal-
lenging. We here with present a case of granulomatous pharyngitis.
Case Report A 41-year-old male from Middle East, presented with pain-
less progressive dysphagia to solids and hoarseness of voice for 8 years
duration. He was operated at multiple hospitals for thickened posterior
pharyngeal wall. Otolaryngeal examination revealed scarred soft palate,
perforated anterior nasal septum, floppy epiglottis and vocal cord palsy.
He had gastrostomy tube placed for nutrition. Endoscopy with balloon
dilation was done for posterior pharyngeal wall ulceration, and
hypopharyngeal stricture (Fig. 1A, C). He had an inspiratory stridor. On
image enhanced endoscopy intrapapillary capillary loops type III-IV were
noted on pharyngeal wall (Fig.1A, B). Biopsies were obtained which
showed non-specific granulomatous tissue. Immunohistochemistry stain-
ing revealed positivity for CD-20, CD-3 and LCA and was negative for
CD-56 (Fig.1D). He underwent tracheostomy for stridor. There was
no apparent evidence of either tuberculosis or Crohn’s disease. Other
causes of granulomatous pharyngitis such as syphilis, sarcoidosis,
autoimmune diseases, Wegener's granulomatosis, viral serology or
Klebsiella rhinoscleromatis were excluded. Chest radiograph and
computed tomography of neck did not reveal any abnormality.
Diagnosis of midline granulomatous disease was made. He was treat-
ed with mycofenalate mofetil, hydroxychloroquine and tapering dose
of prednisolone. He had speech and swallowing physiotherapy. He
was able to resume to oral feeds. He is on follow-up for 3 months
and his disease has not progressed.
Conclusion Isolated midline granulomatous disease is rarely reported and
should be considered in the differential diagnosis of pharyngeal diseases.
283
Spectrum of foreign body ingestion at a tertiary care center
Manish Kumar, Anurag Mishra, Arpan Jain, Ashok Dalal, Ujjwal
Sonika, Siddharth Srivastava, Ajay Kumar, Sanjeev Sachdeva, B C
Sharma
Correspondence- Manish Kumar-drtomarmanish@gmail.com
Department of Gastroenterology, GB Pant Hospital, 1, J L N Marg, New
Delhi 110 002, Indi
Introduction Foreign body ingestion is common in pediatric age group.
This study was conducted with the aim to identify the most common age
group, types and locations of foreign bodies.
Methods A retrospective study was conducted in G B Pant Hospital,
Delhi from October 2015 to December 2019. All patients presented to
the hospital with a history of foreign body ingestion during this time
period were included. The data were analyzed using descriptive statistics.
Results Total 170 cases of foreign body ingestion were encountered.
These included 68.8% males and 31.1% females with a median age of
5 yrs. Though foreign body ingestion was accidental in all children of less
than 15 yrs of age, it was either intentional (5.2%) or secondary to esoph-
ageal stricture (4.1%) or denture (3.5%) in adults. In majority of the cases,
foreign bodies were located in the stomach, 55.8% followed by esopha-
gus, 25.2%. The most common type of foreign body was a coin, 58.2%.
Foreign bodies passed spontaneously in 7%. In rest of the patients endo-
scopic removal was attempted and was successful in 97.4%.
Complications were seen in 10% cases. Ulceration at the foreign body
site being the most common, 7.6%.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141 S91

Conclusion Foreign body ingestion is common in pediatric age group
particularly among children less than five years old. Special attention is
needed to prevent foreign body ingestion in this age group. In our study,
coins are the commonest foreign body found, and stomach the
commonest location.
284
Comparison between Glasgow-Blatchford score and complete
Rockall score for predicting clinical outcome among patients with
upper gastrointestinal bleed
Jigar Patel, Ankur Jain, Kaushal Vyas, Sushil Narang
Correspondence- Jigar Patel-jskap1992@gmail.com
Department of Medical Gastroenterology, Sardar Vallabhbhai Patel
Institute of Medical Sciences (SVPIMS), Riverfront Road, Ellisbridge,
Ahmedabad 380 006, India
We report a similar case of iatrogenic gastric perforation after partial
splenectomy which is closed with endoscopic clips.
Case Report A 48-year-old female presented with complaints of
high grade fever, left upper quadrant pain and loss of appetite
for 2 weeks. After laboratory and imaging studies patient was
diagnosed to have splenic abscess for which she underwent partial
splenectomy.
Post operatively after 4 days when patient is allowed to take orally, food
particles are noted in drain. 10 mL methylene blue was given through NG
tube, dye was seen draining through drains. Gastroenterology reference
was given for upper gastrointestinal endoscopy which revealed small
2 cm full thickness defect in stomach wall on the greater curvature at
the junction of body and fundus thus diagnosis of gastric fistula is made.

Introduction The two commonly used risk scoring systems to categorize

patients with upper gastrointestinal bleed (UGIB) into high-risk and low-
risk subgroups include the Complete Rockall scoring (CRS) system and
the Glasgow-Blatchford scoring (GBS) system. The present study aimed
to compare CRS and GBS systems for predicting clinical outcomes of
patients of UGIB.
Methods Two hundred patients with the age >18 years who pre-
sented with UGIB in the emergency department of SVPIMSR,
were enrolled in the study. Patients with past history of variceal
bleeding and those who received any treatment before admission
were excluded. Diagnostic endoscopy was performed for all As repeat surgery carries greater risk and morbidity endoscopic
assigned patients. Relevant clinical and laboratory parameters closure of gastric defect was planned. After taking consent ovesco
were also recorded. In addition, the cases were followed for any clip was applied with suction technique and patient was stable
episode of rebleeding and 1-month mortality. The outcomes of post procedure. Patient improved subsequently tolerated oral feeds
UGIB were categorized as need for endoscopic intervention and and discharged after 4 days.
ICU admission, 1-month mortality, rebleeding episode. CRS and
GBS systems were calculated for each patient. A receiver operat-
ing characteristic (ROC) curve by using areas under the curve
(AUC) was used for statistical comparison. P-value less than
0.05 was considered statistically significant.
Results GBS was better than CRS system to predict need of en-
doscopic intervention (AUC: 0.927 v/s 0.822; p value <0.0001).
However CRS system was better than GBS to predict outcome
(treated or death) (AUC: 0.997 vs. 0.768; p value <0.0001. There
was no statistically significant difference between GBS and CRS
systems to predict need of ICU admission (AUC: 0.845 vs. 0.851;
p value= 0.8354) and rebleeding at 1 month (AUC: 0.749 vs.
0.728; p value= 0.6063).
Conclusion We found that Glasgow-Blatchford Score is better to predict
need of endoscopic intervention, while the Complete Rockall Score is
better for 1-month mortality prediction. There was no statistically signif-
icant difference between both scoring systems to predict need of ICU
admission and rebleeding at 1 month.

Conclusion Endoscopic closure is preferred in acute small perforations

285
Endoscopic closure of gastric defect
C Revanth Reddy
Correspondence- C Revanth Reddy-revanthreddy1990@gmail.com
Department of Gastroenterology, Government General Hospital, Kurnool
Medical College, Budhwarpet Road, Budhawarapeta, Kurnool 518 002,
India
Introduction Incidence of gastrointestinal perforations are increasing due
to increase in number of therapeutic procedures (EMR, ESD, POEM,
NOTES).
which are <2 to 3 cm due to high success rate (90%), minimally invasive
procedure and short hospital stay. OTSC (over the scope clips) is a new
device for the closure of GI defects so it should be an essential component
of endoscopic arsenal.
286
Comparison of endoscopic ultrasound guided fine needle aspiration
with endoscopic ultrasound guided fine needle biopsy for solid gas-
trointestinal lesions: A randomized crossover single centre study
Shivaraj Afzalpurkar, Vijay Rai, Nikhil Sonthalia, Gajanan Rodge,
Rachit Agarwal, Bhavik Shah, Mahesh Goenka
S92
Correspondence- Shivaraj Afzalpurkar-drshivaraj62@gmail.com
Department of Gastroenterology, Institute of Gastrosciences and Liver,
Apollo Gleneagles Hospital, 58, Canal Circular Road, Kadapara, Phool
Bagan, Kankurgachi, Kolkata 700 054, India
Introduction Endoscopic ultrasound guided fine needle aspiration (EUS
FNA) is limited to diagnosis by cytopathology alone while the core his-
tologic tissue can be procured by EUS guided fine needle biopsy (FNB).
Majority of the studies comparing EUS FNA and FNB are done in dif-
ferent lesions and/or patients and in different sessions with hardly any
studies comparing both the modalities in a single lesion. The purpose of
this study was to compare the results of EUS-FNA and FNB performed at
the same site in a single session.
Methods Consecutive patients with solid gastrointestinal lesions referred for
EUS evaluation were randomized to undergo EUS-FNA and FNB using 22G
needles with three and two passes respectively. In one group EUS FNA was
done followed by EUS FNB, in second EUS FNB followed by EUS FNA.
Results We included 50 patients (62% males, 38% females) with the
mean age of 56.58 ± 14.2 years and mean size of the lesions being 2.6
(± 2) cm. The Kappa agreement with final diagnosis for FNA and FNB
was 0.841 (almost perfect agreement) and 0.61 (substantial agreement)
respectively. The sensitivity, specificity, PPV, NPV, diagnostic accuracy
and tissue adequacy of FNA vs. FNB was 85.19% vs. 62.96%, 100% vs.
100%, 100% vs. 100%, 85.19% vs. 69%, 92% vs. 80% and 98% vs. 80%
respectively in comparison with final diagnosis. The overall adverse
events were noted in 14% patients which included self-limited bleeding
(6%), hypotension (4%) and mild acute pancreatitis (4%).
Conclusion Both EUS-FNA and FNB are very safe. EUS FNA is better
than EUS FNB in terms of sensitivity, diagnostic accuracy and tissue
yield. However, the specificity and positive predictive value were equally
good for both the modalities. There was no significant difference whether
EUS FNA was performed first or FNB.
287
Foreign bodies (FBs) in colon- Surprises that are never planned
Avinash Balekuduru, Narendra Babu Mandalapu, Satyaprakash
Bonthala
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S
Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru
560 054, India
Introduction Endoscopic removal of ingested foreign bodies is well doc-
umented. But removal of FBs in colonoscopy not well documented. We
present 3 cases of FBs which were managed by colonoscopy.
Case Report - Case 1 A 52-year-male presented to us with constipation
for 3 days. He used to have anal eroticism with traditional sex toys. But he
tried an infant feeding bottle on a tinder date, which he pushed it in too far
and could not remove the bottle. The bottle was noted at recto-sigmoid
junction on fluoroscopic spot image. Colon-fluoroscopic trans-anal re-
trieval attempts with snare forceps were futile. A CT followed by mini-
laparatomy and sigmoid incision were made for FB removal. He was
referred to psychiatry for perversion disorder and to prevent recurrences.
Case 2 A 27-year-old female presented with pelvic pain for 18 months
duration. Computed tomography (CT) abdomen and pelvis showed an
intrauterine device (IUD) perforating the sigmoid colon without pelvic
collections. Sigmoidoscopy revealed displaced IUD at 30 cms from anal
verge. Using foreign body forceps and gentle manipulation, IUD was
removed under fluoroscopic guidance. Fistulous opening was closed
using through the scope clips. Postoperative period was uneventful
Case 3 A 14-year-old male, presented to us after 5 days of accidental
history of nail ingestion. He had serial abdominal radiographs which
revealed a stuck nail in the left lumbar region without any pneumoperi-
toneum. Colonoscopy was done in fluoroscopic room without bowel
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
preparation. Nail was noted to be embedded in the stool near the hepatic
flexure without any pneumoperitoneum. It was removed using foreign
body forceps under colon-fluoroscopic guidance. Follow-up spot image
on fluoroscopy did not reveal any complication.
Conclusion Colonoscopy with unprepared bowel, grasped FB maintained
in the center of the visual field with close monitoring on fluoroscopy can
be effective in FB removal in colon.
288
A retrospective single blinded study comparing efficacy of
prucalopride when used as an adjunct with polyethylene glycol in
bowel preparation in patients of constipation
Gaurav Kumar Singh, Saiprasad Lad, Pratik Sethiya, Mayur Gattani,
Shamsher Singh Chauhan, Swapnil Walke, Kailash Kolhe, Mit Shah,
Vikas Pandey, Akash Shukla, Meghraj Ingle
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Department of Gastroenterology, Lokmanya Tilak Municipal Medical
College and General Hospital, Sion, Mumbai 400 022, India, and
Department of Gastroenterology, Seth G S Medical College and KEM
Hospital, Mumbai 400 012, India
Background Colonoscopy is currently gold standard for visualizing colonic
mucosa. Presence of constipation is generally associated with poor bowel
preparation. We compared effect on colonic cleansing when prucalopride
was used as adjunct with polyethylene glycol in patients of constipation.
Methods A retrospective, single blinded controlled study was conducted
in outpatient of a tertiary care centre. One seventy patients with constipa-
tion were enrolled in two groups of who took only polyethylene glycol
(PEG) and other of prucalopride (2 mg one day prior to endoscopy) plus
polyethylene glycol (PEG+) for bowel preparation. They underwent co-
lonoscopy by a single blinded experienced endoscopist. Bowel prepara-
tion quality was reported by Boston bowel preparation scale (BSS) prior
to washing or suctioning. The groups were analyzed for bowel prepara-
tion quality and side effects in either groups based on preformed
questionnaire.
Results Both groups were comparable in view of mean age and male
female ratio. Diabetes was comparable in either group (14- PEG, 13 in
PEG+) with 70 patient having functional constipation in both groups.
Mean BSS IN PEG group (5.33+/- 1.43) was slightly higher than peg+
GROUP (5.16 + 1.37) although not statistically significant (p value=.44).
The side effects of preparation used like nausea, vomiting, abdominal
discomfort, headache was higher in peg+ group than peg group although
not statistically significant. Post procedure questionnaire suggested pa-
tient preferring peg more than the peg plus prucalopride combination (21
vs. 8) (p value <.001).
Conclusion We conclude addition of prucalopride has no additional ben-
efit when used in combination with polyethyleneglycol in bowel prepa-
ration in patients of constipation. It may rather lead to noncompliance and
inferior bowel preparation in view of increased side effect of nausea,
vomiting, bloating, abdominal discomfort and headache.
289
The early endoscopist gets the worm and the later one reports the
findings of the endoscopy
Avinash Balekuduru, Gajendra R, Satyaprakash Bonthala Subbaraj
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S
Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru
560 054, India
Introduction Soil-transmitted helminths (STH) consist of Ascaris,
Trichuris, and hookworm which affect nearly 1.7 billion people
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
globally1. The retrospective study is aimed to investigate the characteris-
tics of the worms detected in an endoscopic unit from January 2015 to
December 2019.
Methods and Results Among 31,913 procedures, 45 hookworms, 3 each
of hydatid and strongyloidiasis, 2 ascaris, 2 enterobius, one each of
fasciolopsis, and taenia saginata were noted. Among them 36 (63%) were
asymptomatic. Twelve patients of hookworm had presented with iron
deficiency anemia with duodenal erosions on endoscopy. Three patients
with hydatid cyst in liver presented with obstructive jaundice and required
bile duct clearance. All the patients with strongyloidiasis presented with
malabsorption and diarrhea. One patient with fasciolopsis presented with
protein losing enteropathy and vomiting of worms. Patients with
enterobius had perianal itching. Stool examination was positive only in
7 (12%) of patients. All the patients received either cyclical albendazole
(15mg/kg), praziquantel (25 mg/kg) or Ivermectin (200 μg/kg). All the
patients were advised regular anthelminthic treatment, health education,
sanitation, personal and familial hygiene.
Conclusions Endoscopy is a useful diagnostic approach for intestinal parasitic
infections even for asymptomatic patients with negative stool examinations.
References
1. Parija SC, Chidambaram M, Mandal J. Epidemiology and clinical
features of soil-transmitted helminths. Trop Parasitol. 2017;7:81-5.
290
Therapeutic endoscopic retrograde cholangiopancreatography in
patient of carcinoma gallbladder with situs inversus
Raghav Singhal, Mohnish Kataria
Correspondence- Raghav Singhal-raghavsag08@gmail.com
Department of Gastroenterology, Maharishi Markandeshwar Institute Of
Medical Science (MMIMS), Mullana University Road, Mullana 133 207,
India
Situs inversus is a congenital anomaly associated with various visceral
abnormalities. We present a case of 40-year-old female with painful pro-
gressive cholestatic jaundice and cholangitis of three months duration
associated with significant weight loss. Examination revealed deep jaun-
dice with hard, tender lump in left hypochondrium. USG and MRI abdo-
men showed situs inversus with large mass arising from gallbladder neck
involving primary biliary confluence and dilated intrahepatic biliary rad-
icles. Endoscopic retrograde cholangiopancreatography (ERCP) was car-
ried out successfully despite situs inversus maintaining the patient in
prone position. In conclusion, ERCP can be safely performed in usual
position with minor modification of endoscopic manoeuvres.
291
Symptomatic heterotopic gastric mucosa in distal esophagus: A case
report
Mahesh Kumar Gupta, Mahesh Gupta, Avnish Seth
Correspondence- Mahesh Gupta-guptamahesh1982@gmail.com
1
Department of Gastroenterology and Hepatobiliary Sciences, Fortis
Memorial Research Institute, Gurugram, India
Background Heterotopic gastric mucosa (HGM) in esophagus is com-
monly noted as an inlet patch at endoscopy. We describe a rare patient
with symptomatic distal esophageal HGM.
Case Report Forty-year-male presented with retrosternal pain, heart-
burn and marked odynophagia for 4 weeks. There was no history
of ingestion of antibiotics, foreign body or corrosive. There was
no history of fever or weight loss. Clinical examination was un-
remarkable. Endoscopy showed abrupt circumferential transition to
salmon pink mucosa at 35 cm from incisors. From 35 cm to
41 cm there were areas of polypoid edematous thickening with
S93
few superficial ulcers of 1-3 mm. Squamous epithelium was vi-
sualized at NBI from 41 cm to the Z-Line at 43 cm with no
hiatus hernia. Biopsy from 35 to 41 cm showed gastric mucosa
with parietal cells without dysplasia. Blood counts and biochem-
istry were normal and serology for CMV and HIV were negative.
Contrast enhanced CT scan showed circumferential mural thick-
ening of 7 mm involving distal esophagus with associated polyp-
oid thickening of 26 mm x 6 mm along right lateral wall. He was
managed with proton pump inhibitors (PPI) and prokinetics and
improved over two weeks. Follow-up endoscopy at 3 months
demonstrated healing of ulcers. There was no resolution of pol-
ypoid lesion. He remains well on maintenance PPI.
Conclusion Symptomatic heterotopic gastric mucosa in distal
esophaguscan be differentiated from Barrett’s esophagus by presence of
squamous epithelium distally. Inflammatory mass lesions may develop
and mimic esophageal malignancy. Symptoms due to acid production
may be prominent and respond to PPI.
292
Lockdown due to COVID-19 and its impact on endoscopy and upper
gastrointestinal bleeding - A single centre study
Shruti Sagar Bongu, Avinash Balekuduru
Correspondence- Avinash Balekuduru-avinashbalekuduru@gmail.com
Department of Gastroenterology, M S Ramaiah Hospitals, B E L M S
Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru
560 054, India
Introduction and Aim COVID-19 pandemic was declared on 11/03/2020
and required Indian government to implement intermittent lockdown to
contain the disease from 24/03/2020. Aim of the study was to investigate
the effects of lockdown on acute upper gastrointestinal bleeding (UGIB)
at our centre.
Methods Records of all the UGIB patients who had undergone endoscopy
at our institution during the 3 months- April, May and June in years 2019
(n =1175) and 2020 (n = 554) were retrospectively reviewed and com-
pared. All the procedures were performed by enhanced personal protec-
tive equipment.
Results Of the 1729 patients (mean age + SD :61.7±12.7 years, 85 %
males) during the two study periods, 64 (3.7 %) had UGIB. Hemetemesis
was the most common presenting symptom in 60% of patients. The
proportion UGIB among the total endoscopies done was significantly
higher during the lockdown period compared to the previous year 5.4%
to 2.8% (p value = 0.009). The frequencies of UGIB variceal and non-
variceal showed the decline in variceal and increase in non-variceal bleed-
ing due to lock down from 38% to 20% and 62% to 80% respectively but
this was not statistically significant. The decline was more marked for
need for endotherapy- as 70% to 30% in nonvariceal bleeding (p value
0.010). There was no mortality among the subjects.
Conclusions National lockdown resulted in a decrease in the total number
of endoscopies as well as the number of UGIB. The proportion of endos-
copies done for UGIB during the lockdown was significantly.
Establishing standard safety protocol for endoscopy during the pandemic
will ensure safety of patients and health care workers.
293
Colonoscopic instillation of cola for clearance of fecaloma in
megarectum and sigmoid megacolon
Avnish Seth, Gur Simran Kaur, Mahesh Kumar Gupta, Rinkesh Bansal,
Neha Choudhry
Correspondence- Avnish Seth-avnish.seth@fortishealthcare.com
Department of Gastroenterology and Hepatobiliary Sciences, Fortis
Memorial Research Institute, Gurugram 122 002, India
S94
Background Fecaloma is organized hardened stool, usually impacted in
rectum and sigmoid colon. Cola, with a pH of 2.5 due to carbonic acid
and bubbles of carbon dioxide has been effective in dissolving gastric
phytobezoars. We describe colonoscopic instillation of Cola for clearance
of fecaloma in a patient with megarectum and sigmoid megacolon.
Case report Seventy-two-year-old lady, bed-ridden with co-morbidities,
presented with constipation and progressive abdominal distension for six
months. There was history of infrequent passage of small amount of
liquid stool without blood or mucus. Physical examination revealed ill-
defined, firm, non-tender pitting mass occupying the hypogastrium, left
iliac, left lumbar, umbilical and epigastric regions of abdomen. Rectal
examination revealed normal anal tone and impacted stool, some of
which was removed manually. X-ray abdomen revealed fecal loaded
and grossly dilated rectum and sigmoid colon. CT scan showed grossly
distended sigmoid colon (12.7 cm) and rectum, loaded with stool.
Repeated sodium phosphate enemas and oral polyethylene glycol were
unsuccessful in clearing the stool. Colonoscopy revealed grossly dilated
rectum and sigmoid colon with large amount of solid fecal matter few
superficial sterocoral ulcers. The option of surgery was refused by the
family. Following informed consent, 1000 mL of Cola was instilled into
the sigmoid colon during colonoscopy. Over the next three hours she
passed explosive stool with expulsion of more than 3 litres of fecal matter.
The abdominal distension decreased and repeat plain CT scan showed
remarkable decrease in the fecal loading. She refused further evaluation
and was discharged. A few weeks later, she was subjected to ileostomy
with a possibility of idiopathic megarectum with sigmoid megacolon and
remains lost to follow-up.
Conclusion Colonoscopic instillation of Cola may be used for clearance
of large fecaloma refractory to oral and rectal medication.
294
Life threatening gastrointestinal bleeding due to thrombocytopenia
and megakaryocytic blast crisis as presenting symptom of myelopro-
liferative disorder - A case report
Sushant Sethi, Akash Dobhada, Kailash Mohitey, Rajat Khandelwal
Correspondence- Sushant Sethi-drsushant2004@yahoo.co.in
Department of Gastroenterology, Apollo Hospitals, India
Introduction Myeloproliferative disorders commonly present as unex-
plained anemia or cytopenias. Overt gastrointestinal (GI) bleeding as an
index presentation for underlying hematological malignancy is unusual.
Recently we encountered a case of GI bleeding which turned out to have
underlying chronic myeloproliferative disorder.
Case summary A 57-year-old male, presented with chief complaints of
generalised weakness, decreased appetite and loss of weight for last 6
months along with evening rise of temperature for 1 month. Clinical
examination revealed pallor, generalized lymphadenopathy and an en-
larged firm spleen. Investigation showed low hemoglobin, high reticulo-
cyte count, raised TLC and low platelet count with peripheral smear
showing promyelocytes and metamyelocytes. Stool occult blood was
positive. Imaging showed hepatosplenomegaly with multiple enlarged
intraabdominal lymph nodes. UGI endoscopy showed a bleeding gastric
polyp which was removed by snare polypectomy. Colonoscopy revealed
internal hemorrhoids to which sclerosant polidocanol was injected.
Patient was doing well when he developed painless hematochezia 6 to
7 times a day. Sigmoidoscopy showed rectal oozing, APC was done,
hemostasis achieved. After lymph node and bone marrow biopsy, cyto-
genetic tests, hematopathologist diagnosed chronic myeloproliferative
disorder with megakaryocytic blast crisis. During admission patient de-
veloped malena and UGI endoscopy showed diffuse mucosal oozing to
which hemoseal application was done to achieve hemostasis. Despite
management with multiple transfusions, IV immunoglobulins and IV
steroids, patient developed bilateral frontotemporal subdural hemorrhage
and succumbed.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusion The reported incidence of hemorrhagic complications in he-
matological malignancies ranged from 3% to 53%, and resulting deaths
ranged from 14% to 24%. In another similiar study it was found that 16 %
of patient deaths occur due to major bleeding from gastrointestinal or
intracranial hemorrhage. In autopsy finding of MDS patients, it was
found that 25 % had evidence of major gastrointestinal bleeding and so
must be foreseen when clinical signs are suggestive.
295
Utility of GeneXpert-Mtb/Rif for the diagnosis of intestinal tubercu-
losis in patients with ileocolonic ulcers.
Cyril Alex, Benoy Sebastian, Sunil K.Mathai, Anil Jose, Mary George,
Sajith Sebastian, Santhosh R, Sujith James, Swaran Kumar
Correspondence- Benoy Sebastian-benoygastro@gmail.com
Department of Gastroenterology, Medical Trust Hospital, Mahatma
Gandhi Road, Pallimukku, Kochi 682 016, India
Introduction Diagnosis of intestinal tuberculosis is challenging with con-
ventional methods due to the paucibacillary nature of the disease and the
close similarity it shares with IBD-Crohn’s. Newer PCR based rapid tests
like GeneXpert could aid in differentiating and diagnosing intestinal
tuberculosis.
Methodology We performed a retrospective hospital record-based study
of 39 patients with ileal/colonic ulcers suspected to have ITB on which
testing of intestinal tissue for Xpert MTB/Rif was performed. The patients
were divided into two groups, a group with a positive diagnosis of intes-
tinal tuberculosis and another group with other alternative diagnosis.
Result Out of the 39 patients studied, 29 (74.35%) patients were male and
10 (25.64%) were female with a mean age of 45.51 yrs. A total no of 12
patients had a positive geneXpert test, of which 7 patients were diagnosed
to have intestinal tuberculosis based on clinical suspicion and histological
features and were started on ATT.2patients with negative genexpert were
also started on AKT. The sensitivity and specificity was 71.4286% (95%
confidence interval 30.2561% to 94.8876) and 78.125% (59.5582% to
90.055%) respectively, while the negative predictive value and positive
predictive value of GeneXpert-Mtb/Rif for diagnosis of ITB was
92.5926% (74.247% to 98.7065%) and 41.66% (16.4993% to 71.40%)
respectively.
Conclusion Gene Xpert/MTB may be used as a diagnostic tool to help
differentiate between intestinal tuberculosis and other causes of
ileocolonic ulcers.
296
Endoscopy in lockdown
Noopur Mehta, Vaibhav Somani, Niranjan Banka
Correspondence- Noopur Mehta-noopurrmehta@gmail.com
Department of Gastroenterology, Bombay Hospital and Medical
Research Centre, MumbI 400 020, India
Introduction There is significant decrease in gastrointestinal (GI) endos-
copies during the COVID-19 pandemic due to travel restrictions and
concerns of infection amongst doctor, staff and patients. Even emergency
endoscopies have been deferred due to fear of SARS-CoV-2 infection.
Aim Aim of this study is to analyse the indications and safety of GI
endoscopy during lockdown period.
Methods We did retrospective analysis of the prospectively maintained
data of endoscopic procedures performed from 24/03/2020 to 29/08/
2020. The data was analyzed for indication of procedure in terms of
urgency (emergent, urgent and routine) and de-novo development of
SARS-CoV-2 infection in endoscopy department staff, doctors and
patients. Pre-procedural COVID testing was not mandatory in our
department. Thorough history of exposure was taken and triage was
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
done before the procedure. All the procedures were done wearing
level three personal protective equipment. Standard scope cleaning
process was followed after each procedure and a gap of 15 minutes
was maintained in between procedures. Post procedure, patients
were followed up telephonically on every third day and inquired
about development of symptoms of SARS-CoV2 infection.
Patients who tested negative before the procedures were excluded
from the study.
Results A total 274 of various GI endoscopic procedures were performed
over a period of 159 days. Indication wise 48% were emergency proce-
dures, 31% were urgent and 21% were routine. Seven emergency bedside
procedures were performed in COVID positive patients. Throughout the
study period none of the endoscopy staff, consultants and residents were
tested COVID-19 positive, or exhibited any signs or symptoms of the
disease. None of the patients developed symptoms of SARS-CoV-2 in-
fection till 14 days post procedure.
Conclusion GI endoscopy in lockdown, is not a daunting task. It can be
safely performed without pre-procedural COVID testing and should not
be delayed because of non-availability of the test.
297
Profile of pediatric patients undergoing upper gastrointestinal endos-
copy: A single centre experience
Gautam Nath, Shivaram Prasad Singh, Dinesh Meher, Prajna Anirvan,
Pankaj Bharali, Mrinal Gogoi
Correspondence- Gautam Nath-gautamnath7@gmail.com
Department of Gastroenterology, S C B Medical College, Cuttack 753
007, India
Background and Aim Upper gastrointestinal endoscopy (UGIE) is an
important procedure for diagnosis and management of GI problems.
There is scanty data on endoscopic findings in children from India. The
Department of Gastroenterology at SCB Medical College performs the
largest number of endoscopies in children from coastal eastern India. The
present study was conducted to analyze the findings of UGIE in children
and assess its utility.
Methods This retrospective study was conducted in the Department of
Gastroenterology. Endoscopy records of patients below 14 years were
obtained from departmental records for the duration May 2016 to
February 2020. Data were analyzed to ascertain the common indications
for UGIE and document the common GI diseases diagnosed by UGIE in
this region.
Results Seven hundred and eighty-seven endoscopies were performed in
children during 2016-2020, out of which 62.13% were males and 37.87%
females. Upper GI bleeding (UGIB) was the commonest indication for
endoscopy (34%) followed by vomiting (14.36%), pain abdomen
(13.3%), dyspepsia (11.8%), anemia 74 (9.4%) and foreign body inges-
tion (5.7%). Other indications like chronic diarrhea (for duodenal biopsy),
corrosive ingestion etc. constituted the rest (11.3%). Out of the total 268
cases of upper GI bleeding, 168 (62.7%) were males and 100 (37.3%)
were females. Variceal bleeding was the most common cause of UGIB
(60.8%) followed by ulcer bleeding (13.05%), gastric erosions bleeding
(11.9%), malignancy (1.1%) and Mallory-Weiss tear (0.74%). In 12.3%
cases no upper GI source of bleeding could be identified.
Conclusions UGIE is very useful in evaluation of GI problem in children.
UGIB is the commonest indication for UGIE. Variceal bleeding accounts
for about two thirds of UGIB in children, while one eighth of children
bled from ulcer. Other common indications for UGIE are vomiting, pain
abdomen, dyspepsia and anemia.
298
Colonoscopy for acute lower gastrointestinal bleed in the pediatric
population: Single tertiary care center experience
S95
Mohammad Irtaza, Sridhar Sundaram, Praveen Kumar Rao,
Biswaranjan Patra, Akash Shukla
Correspondence- Sridhar Sundaram-drsridharsundaram@gmail.com
Department of Gastroenterology, Seth G S Medical College and KEM
Hospital, Parel, Mumbai 400 012, India
Introduction There is paucity of data on acute lower gastrointestinal bleed
(LGIB) in the pediatric population with no previous data from India. We
aimed to retrospectively audit endoscopy findings in patients less than 18
years of age, presenting with acute lower GI bleed.
Method Retrospective review of endoscopy database at Department of
Gastroenterology at a tertiary care centre from Western India between
June 2017 until June 2020 was done. Patients with age =18 years with
acute LGIB, who underwent colonoscopy within 7 days of onset of bleed
were included. Demographic details, endoscopic findings and complica-
tions were noted.
Results Fifty-three patients were included in study (male-67%, Mean
age=12 years, range:-1-18 years). Most common endoscopic findings
were polyps in 21 (39.6%), colitis in 12 (22.6%), SRUS in 6 (11.3%)
and hemorrhoids in 3 (5.6%) patients. Eight (15.1%) patients had normal
colonoscopy in whom cause remain unidentified on further evaluation.
However, no repeat episode was documented on a follow-up of 30 days.
Most common location of polyp was rectum (68%). Two patients had
multiple polyps. All patients underwent successful polypectomy.
Pathology reported juvenile polyps in 19 patients. Out of 12 colitis pa-
tients, 3 were diagnosed as inflammatory bowel disease, while 9 had
acute infective colitis which resolved completely with conservative man-
agement. Patients with infectious colitis had higher incidence of fever
(55% vs. 0%), lesser incidence of previous similar events (22% vs.
66%). There was no difference between bleed severity, anorexia, and
weight loss amongst those with or without infectious colitis. Those with
polyps were younger than those without (8.4 vs. 14.3 years, p=0.000).
Males were more likely to have polyps (p=0.014). No complications
occurred in this cohort of patients.
Conclusions Polyps are the most common cause of acute lower GI bleed-
ing in patients =18 years of age followed by colitis. Polyps were more
common in younger male children.
299
Clinical profile of patients with gastric variceal bleed and outcomes
of cyanoacrylate glue injection- Single center experience
Veera Abhinav Chinta, Ganesh P, Shanmuganathan S, Koushik A K,
Anand T K
Correspondence- Veera Abhinav Chinta-veeraabhinav.chinta@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Institute of
Higher Education and Research, Chennai 600 116, India
Background Gastric variceal bleed is a complication of liver cirrhosis that
causes significant morbidity and mortality. there is substantial variability
in prevalence due to the differences in patient characteristics. With ad-
vancement of endoscopic techniques, cyanoacrylate injection has become
the most accepted intervention.
Aim To identify the clinical profile of gastric variceal bleeding and also
determined the outcomes of cyanoacrylate glue injection in relation to
primary hemostasis and rebleeding.
Methods This is a prospective observational study of 42 patients who
were diagnosed with bleeding gastric varices from October 2018 to
January 2020 at SRMC. Patients who underwent glue injection were
included and were followed up for 3months for complications.
Results Patients has mean age of 55 years with male predominance of 76.2%.
The main etiology is alcohol related cirrhosis in 15 patients (35.7%), melena is
main presenting symptom 35.7%. Sarin classification of gastric varcies GOV1
seen in 14 patients (33.3%), GOV2 seen in 18 patients (42.9%), IGV1 seen 7
patients (16.7%) and size of varix ranges from 5 mm-10 mm in 71.4% and
S96
>10 mm in 28.5% of patients. 64.3% of patients requiring ICU admissions and
61.9% were requiring blood transfusion. All 42 patients underwent Glue in-
jection and 100% achieved primary hemostasis. 45.2% patients required both
glue and EVL banding. The volume of glue required varied among patients
0.5ml in 30.9%, 1 mL in 40.4%, 1.5 mL in 21.4% and 2 mL in 7.14%. The
incidence of rebleeding is seen in 5 patients (11.9%), of which 4 patients
(9.5%) required Re-Glue injection and 2 patients (4.8%) required BRTO.
complications like gastric ulceration, sepsis and embolism were not seen.
Conclusion Bleeding gastric varices were mainly seen among in 5th and
6th decade. Melena is the most common presentation. Cyanoacrylate
injection is an effective modality in achieving primary hemostasis how-
ever there is still remains a significant of rebleeding.
300
Fully covered stent using novel Shim technique to prevent migration
in benign non stricturing esophageal diseases
Deepakkumar Gupta1, Amey Sonawane2, Aabha Nagral2, Shanker
Bhanushali2, Rahul Deotale2
Correspondence- Deepakkumar Gupta-dkgt@rediffmail.com
Department of Gastroenterology, Apollo Hospitals, Plot # 13, Parsik Hill
Road, Sector 23, CBD Belapur, Navi Mumbai 400 614, India
Introduction In benign non stricturing esophageal disease for example leak,
fistula or perforation the use of fully covered stent is a modality of treatment.
However, its use is limited due to its high rate of migration and embedment. We
use a novel technique of using a proximal release stent and using a silk thread
anchored to the proximal end of the stent tied to it before release and then
moved through the nose and attached to ear lobe with tape (Shim technique).
Aim To determine the risk of migration and efficacy in using Shim tech-
nique in benign non stricturing esophageal disease.
Methods Patient undergoing fully covered stenting for benign non struc-
turing disease over last 24 months were included in this study. Success of
deployment and duration of procedure was collected from records.
Migration was identified by serial X-ray and also dislodgement of the
silk thread tied to the ear lobe. Stent embedment, difficulty in removal of
stent and successful closure of leak/fistula was retrieved from records.
Results Fully covered esophageal stent with Shim technique was used in
total five cases. 2 Boerhaves syndrome, 1 Post Esophagectomy cervical
leak, 1 aortoesophageal fistula, and 1 post balloon dilatation perforation
were managed. Stent were placed by experienced endoscopist under guid-
ance of fluoroscopy. Stent deployment were successful in all 5 cases and
anchored by Shim technique. Migration happened only in one case of
Boerhaves syndrome within 72hours and patient succumbed post-surgery
to mediastinitis. In aortoesophageal fistula the patient succumbed to
mediastinitis 4 weeks post stent placement. The stent was removed at 4-
6 weeks in other cases with complete healing of leak or perforation seen.
Conclusion Fully covered SEMS using Shim technique in benign esophageal
nonstricturing disease has good efficacy with minimal migration rate.
301
Effectiveness of low volume split-dose versus same day morning poly-
ethylene glycol regimen for adequacy of bowel preparation in pa-
tients undergoing colonoscopy: A single blinded randomized con-
trolled trial
Venkata Anudeep K, Pazhanivel Mohan, K Senthamizh Selvan, Deepak
Chellan, Abdoul Hamide
Correspondence- Pazhanivel Mohan-dr.pazhani@gmail.com
Department of Gastroenterology, Jawaharlal Institute of Postgraduate
Medical Education and Research, Dhanvantri Nagar, Gorimedu,
Puducherry 605 006, India
Background Adequacy of bowel preparation is the key for successful
colonoscopy which depends on the bowel cleansing regimen. The timing
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
of administration of polyethylene glycol (PEG) for colonoscopy has
evolved from previous day evening to the currently recommended split
dose regimen. Consumption of entire or portion of PEG on the previous
day can interfere with work and sleep. Hence, this single blinded random-
ized trial was conducted to evaluate the efficacy, tolerability, and accept-
ability of same-day PEG compared to low volume split-dose PEG for late
morning colonoscopy.
Methods A total of 384 patients were randomized to 192 each in same-
day [SD] and split-dose [SPL] groups. Both the groups received 10 mg
bisacodyl. SD group took two litres of PEG between 5AM and 7AM on
the day of colonoscopy. SPL group took one litre of PEG between 6PM
and 7PM on the preceding day and another litre between 6AM and 7AM
on the day of colonoscopy. The adequacy of bowel preparation was
assessed using Boston Bowel Preparation Scale (BBPS). Tolerability
was scored by recording symptoms of nausea, vomiting, bloating, and
abdominal pain. Acceptability was based on overall satisfaction, willing-
ness to repeat the preparation and interference with sleep.
Results The median (IQR) BBPS in SD group was 8(3) while in the SPL
group was 6 (3) and this difference was statistically significant (p<0.001).
Similarly, a significantly higher proportion in SD group (86%) achieved
adequate bowel preparation (BBPS ≥6) compared to SPL group (73.4%)
(p=0.002). There was no significant difference in tolerability, overall
satisfaction (p=0.33) or willingness to repeat same regimen (p=0.37)
between the groups. Patients in SPL group had more sleep interference
before colonoscopy (54% vs. 14.5%, p<0.001).
Conclusion The same day PEG was more effective than split dose in
achieving an adequate bowel preparation with added advantage of lesser
interference with sleep before colonoscopy.
302
Gastrointestinal endoscopy in infants: A single center experience
Harpreet Kaur Chhabra, Areesha Alam, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, Era Lucknow Medical College and Hospital
(ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background Gastrointestinal (GI) endoscopic procedure in infants is an
evolving diagnostic and therapeutic tool in management of GI disorder of
infancy.
Aim The present study aimed to evaluate the diagnostic role of endoscopy
done in infants suffering with diverse GIT symptoms.
Methods This is a retrospective descriptive hospital-based study, conduct-
ed from January 2017 to October 2019 in Pediatric Gastroenterology Unit
of a tertiary care hospital. All infants (> 1 month old and ≤1 year of age)
who underwent GIT endoscopic procedure during the study period were
included. Following data were collected from hospital database and pa-
tients record sheets: basic demographic data, preliminary diagnosis, indi-
cation for endoscopy, procedure done, endoscopic finding, complica-
tions, and final diagnosis.
Results A total of 126 infants (104 males, 22 females) of which 34.9% were
below 6 months were enrolled in the study. Mean age was 6.69±3.3 months.
Mean duration of symptoms was 21.6±16.3 days. Recurrent vomiting
(30.9%) was found to be the most common indication for endoscopic eval-
uation followed by melena (17.5%), hematemesis (15.9%) and chronic diar-
rhea (13.5%). Upper GI endoscopy was performed in 108 infants and lower
GI endoscopy in 35 infants. Mucosal inflammation (eosophagitis; 31.7%,
gastritis; 22.2%, duodenitis; 13.5%, proctosigmoiditis; 23% and colitis;
7.9%) was the most common finding in infants who presented with different
GI symptoms. Varices were noted in 12.7% and polyps in 4.8% of cases.
Other findings were ulcer, foreign body, esophageal stricture and gastric
outlet obstruction. Nine out of 39 infants (23%) who presented with recurrent
vomiting had a negative endoscopy. No complications occurred either due to
procedure or sedation.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Conclusions Pediatric gastrointestinal endoscopy is a high-end, informa-
tive, diagnostic and therapeutic procedure in infants done in very few
centre across India. Endoscopy helped in comprehensive evaluation and
in depth management of various GI disorders in infants.
303
Endoscopic removal of giant rectal polyp in a child- A case report
Gunjan Makkar, Shrish Bhatnagar, Geetika Srivastava
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, Era Lucknow Medical College and Hospital
(ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Solitary pedunculated Juvenile rectal polyps (JP) are a recognized
cause of painless rectal bleeding in preschool age children however
Giant juvenile polyps (greater than 30 mm) are exceedingly rare in
children.
A 10-year-old boy with prior history of something coming out of
rectum for one year presented with sudden onset of massive painless
hematochezia. On evaluation a giant rectal polyp measuring 3 x 3 x
2 cm was found and removed endoscopically. Histological evalua-
tion revealed juvenile adenomatous polyp. To best of our knowl-
edge only few case reports are available where a giant rectal polyp
has been removed endoscopically in pediatric age group.
Keywords Polyp, Giant, Endoscopy
304
Endoscopic radial incisional stricturotomy using flushknife followed
by balloon dilatation of a benign esophageal anastomotic stricture: A
case report
John Christopher Onilla, James Crisfil Fructuoso Montesa
Correspondence- John Christopher Onilla-onillajc@gmail.com
Department of Internal Medicine - Section of Gastroenterology and
Digestive Endoscopy, Manila Doctors Hospital, Philippines
Introduction Esophageal strictures develop from various etiologies;
peptic strictures from gastroesophageal reflux disease (GERD),
caustic ingestion, anastomotic stricture from previous surgery.
Benign esophageal strictures are usually managed with dilation
using Savary-Gilliard or balloon dilatation. There are a small group
of patients with refractory or recurrent stenosis for which alternative
treatment modalities may be required. There are only a few reports
of the use of needle knife for incisional therapy to manage esopha-
geal anastomotic stricture.
Methods Presentation: This is a case report of a 45-year-old male, known
to have recurrent esophageal anastomotic stricture after colon interposi-
tion, managed with repeated mechanical dilation who had progressive
dysphagia 4 weeks from the previous dilatation.
Results The patient underwent radial incision stricturotomy using
Flushknife (Fujifilm) followed by CRE balloon dilatation with no com-
plications. He was discharged stable with no recurrence of symptoms on
follow-up after 2 months.
Conclusion Endoscopic incisional stricturotomy using Flushknife follow-
ed by CRE balloon dilatation is a safe and effective modality for the
treatment of anastomotic stricture provided it is done in a tertiary hospital
by an experienced therapeutic endoscopist.
Keywords Case report, Incisional stricturotomy, Esophageal anastomotic
stricture
305
Study of gastric mucosal changes and Helicobacter pylori prevalence
in patients with metabolic syndrome
S97
Swapnil Patil, Bhumika Vaishnav
Correspondence- Bhumika Vaishnav-bhumika.dholakia@gmail.com
Department of General Medicine, Dr. D Y Patil Medical College,
Hospital and Research Centre, Sant Tukaram Nagar, Pimpri Colony,
Pimpri-Chinchwad 411 018, India
Introduction Helicobacter pylori (HP) has been implicated as a causative
agent in many non-gastrointestinal diseases like insulin resistance, car-
diovascular disorders and diabetes mellitus. Metabolic syndrome (MetS)
refers to cluster of diabetes and cardiovascular factors including raised
blood pressure, low HDL levels, elevated serum triglycerides (TG) levels,
obesity and hyperglycemia. Lifestyle and dietary changes have been at-
tributed to high prevalence of MetS. However, they don’t justify all the
MetS cases and hence study of alternative emerging risk factors is neces-
sary. The current study was undertaken to ascertain if any relationship
exists between the GI mucosal changes, HP infection and various com-
ponents of metabolic syndrome.
Methodology Cross-sectional, prospective study done between June 2018
to January 2020 in Maharashtra, India. Total 100 patients who came for
UGIE were studied out of which 58 patients had MetS. Gross mucosal
changes in the stomach were noted and biopsies were taken from the body
and the antrum of the stomach and sent for histopathlogy examination for
detection of HP. P value of <0.05 was taken as statistically significant.
Results Out of total 58 patients with MetS 18 were males (31.03%) and 40
were females (68.97%). Average age was 49.81 ± 11.10 years. HP infec-
tion was found in 31 out of 58 patients with MetS which was statistically
significant. Chronic superficial antral gastritis was the common finding in
39 patients (67.25%). Presence of HP infection positively correlated with
higher abdominal obesity (WC), fasting blood glucose levels and Serum
TG levels (p<0.05).
Conclusion HP colonization of gastric mucosa may predispose patients to
develop MetS. High blood sugar levels, abdominal obesity and high
triglyceride levels in MetS were associated with HP infection. Thus,
eradication of HP infection may reduce prevalence of metabolic syn-
drome and in turn the prevalence of cardiovascular disorders in the
patients.
Keywords Helicobacter pylori, Metabolic syndrome, Upper gastrointes-
tinal endoscopy
306
Comparison of risk scores for predicting mortality in patients pre-
senting with acute upper gastrointestinal bleed
Damodar Krishnan, Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Medical Gastroenterology, Sri Ramachandra Institute of
Health and Research Center, Chennai 600 116, India
Introduction Gastrointestinal (GI) bleeding results in 5% of admissions to
an emergency department (ER), with mortality rates ranging from 2% to
15%. Early identification of patients at high risk of death could allow
targeted management with early interventions that may improve out-
comes. Various risk scores have been developed for risk stratification
Glasgow- Blatchford score (GBS), Pre-Endoscopy and Rockall score,
AIM-65, and the recently proposed ABC (age, blood parameters, co-
morbidities) score. We aim to compare these various risk scores for
predicting mortality.
Methods Retrospective data of patients admitted to ER with acute upper
GI bleed during the last 2 years (2018-2020) have been collected from
medical records including clinical assessment and lab parameters, wheth-
er the patient required endoscopic therapy; surgical procedures; radiolog-
ical intervention; blood transfusion; and mortality.
Results Total of 112 patients were included in the study. Mean age of
study population was 53.71 and male predominant with 83.92% (n=94).
76.79% presented with hematemesis and 23.21% with melena. Major co-
S98
morbidities included ischemic heart disease (10.71%), cirrhosis (25%)
and malignancy (2.68%). 45.3% belonged to ASA category 3 and
25.6% in ASA 2and 28.6% in ASA 1 category. Endoscopic findings
included normal in 1%, erosive changes in 20.5%, gastric/duodenal ulcers
in 25.6%, variceal bleed in 40.18% and tumor bleed in 0.04%.
Endoscopic treatment was done in 46.42% and surgery was undertaken
in 0.08%. Mortality was 9.82% (n=11). Based on AUROC, AIM-65
scored over other scores in predicting mortality (AUROC [95% CI]
0.91 [0.85 to 0.97]; p<0.001), GBS 0.82 (0.71-0.93) p 0.001, Pre-
Rockall 0.76 (0.63-0.89) p 0.005, Rockall 0.89 (0.82-0.97) p<0.001,
ABC 0.79 (0.65-0.90) p 0.003.
Conclusion BP, heartrate, BUN, INR, and albumin showed a significant
association with mortality. Risk scores with albumin have better mortality
prediction. AIM-65 scored over other risk scores in predicting mortality
even better than post endoscopy Rockall score, hence can be used to
stratify patients early in the emergency room to prevent mortality.
Keywords Upper GI bleed, GBS, Rockall, AIMS-65, ABC score
307
Effect of sucralfate plus proton pump inhibitors combination versus
PPI alone on post EVL band ulcers; A single-centre prospective ran-
domized study
Hameed Raina, Anukalp Prakash
Correspondence- Hameed Raina-hameedraina49@gmail.com
Department of Gastroenterology and Hepatology, Paras Hospital, Phase-
I, Paras Hospitals, C-1, Sushant Lok Road, Sector 43, Gurugram 122 002,
India
Background/Aim Endoscopic band ligation (EBL) is a universal treatment
of large esophageal varices with red colour signs or active bleeding.
However, it is complicated with post band ulcers. Proton pump inhibitors
plus sucralfate combination is commonly used in post band ligation to
prevent it or their bleeding. However, not much literature is available to
support it. This study aimed to find the same.
Methods It was a comparative single-blind randomized study. Eligible
patients were randomized into a proton pump inhibitor plus sucralfate
group (Group A) and a proton pump inhibitor alone group (Group B)
after EBL. Check endoscopy was done after two weeks.
Results Two hundred and ten patients, 105 in each group, were evaluated.
The baseline demographic and lab parameters were comparable in both
the arms. On an average, there were 2.19±0.07 number of ulcers in Group
A and 3.76±0.63 number of ulcers in Group B (p< 0.005). The mean size
of the largest ulcer was 1.02 ± 0.42 cm in Group A and 2.10 ± 0.67 cm in
group B (p<0.05). Post EVL bleeding was present in ten (9.5%) of pa-
tients in Group A and twelve (11.4%) in Group B patients with p=0.63.
(low albumin [<2.8 mg/dL] was significantly associated with the forma-
tion of multiple ulcers on b-variate analysis with OR of 7.7 (95% C: 1.58-
42.99).
Conclusions The sucralfate plus PPI is more effective than PPI alone in
reducing the occurrence, number, and size of band ulcers. Low albumin
as an independent host predictor for multiple ulcer formations
Keywords Esophageal varices, Endoscopic band ligation; Band ulcers;
Sucralfate, Proton pump
308
Metabolic outcomes of endoscopic sleeve gastroplasty in patients
with obesity
Shivaji Thakare, Prabha Sawant, Gaurav Patil, Ankit Dalal, Amit
Maydeo
Correspondence- Shivaji Thakare-dr.shivaji21@gmail.com
Baldota Institute of Digestive Sciences, Gleneagles Global Hospitals,
Mumbai 400 012, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Background Endoscopic sleeve gastroplasty (ESG) is a restrictive endo-
scopic bariatric procedure. In our study, metabolic outcomes of ESG were
studied.
Methods In this prospective observational study, we studied the effectiveness
of ESG in patients undergoing ESG at our center from June 2018 to May 2020.
Patients with BMI ≥28 kg/m2 were included. Anthropometric and laboratory
parameters were noted at baseline and postoperatively at 6, 12 and 18 months.
The primary outcomes included percent of total weight loss (%TWL) and
percent of extra weight loss (% EWL) at 6, 12 and 18 months. Secondary
outcomes included changes in metabolic and laboratory parameters after ESG.
Results A total of 74 patients, 65 (87.8 %) females with mean (±SD) age
of 43.1±9.8 years were included. The baseline BMI (kg/m2) was 36.76 ±
6.1. The mean % TWL was 17.9 ±5.2 and 20.4 ±5.9, 21.45±6.1 at 6, 12
and 18 months, respectively. The % EWL was 44.2±13.5, 49± 14.2 and
51.4±15.1 at 6, 12 and 18 months, respectively. At the end of 12 months,
there was a statistically significant reduction seen in levels of metabolic
parameters like systolic blood pressure (p<0.001), waist circumference
(p<0.001), glycylated hemoglobin (p<0.001), SGOT/SGPT (p<0.001),
and serum triglycerides (p<0.001). Total cholesterol and LDL levels also
reduced from baseline but were not significant. Among adverse events,
nausea was seen in 38 (51.3%) patients, moderate to severe abdominal
pain in 20 (27%) patients, perigastric serous collection (size 2 cms) in 3
(4%) patients and intraoperative bleed in 5 (6.7%) patients were seen.
Conclusions ESG appears safe and effective minimally invasive tech-
nique in treating obesity at our center. ESG showed favorable changes
in metabolic outcomes with sustainable weight loss up to 18 months.
Keywords Obesity, Endoscopic sleeve gastroplasty, Metabolic
outcomesv
309
Efficacy of EUS-guided tissue acquisition in the absence of an on-site
pathologist
Balaji Musunuri, Shiran Shetty, Ganesh Bhat, Ganesh Pai C
Correspondence- Balaji Musunuri-balajimbmc@gmail.com
Department of Gastroenterology, Kasturba Medical College, Manipal
Academy of Higher Education, Manipal 576 104, India
Introduction EUS-guided tissue acquisition has been widely used to ob-
tain tissue for the diagnosis of gastrointestinal (GI) lesions with good
accuracy and safety, but the diagnostic yield remains highly variable.
Hence, we intend to study these outcomes in the absence of on-site
cytopathologist.
Methods A retrospective analysis of patients who underwent EUS-FNA
for upper GI lesions from September 2018 to March 2020. EUS-FNA had
been performed by 2 experienced endosonographers, using the fanning
technique with 22-G franseen design needle from Boston Scientific with-
out on-site cytopathologist. Specimens were analyzed through cell blocks
and thread biopsies by an experienced pathologist and were categorized
into adequate and diagnostic or non-diagnostic.
Results A total of 176 patients were taken into study; male 108 (61.4%)
with mean age of 53.6 ± 15.5 years. The lesions were grouped into those
arising from pancreas in 110 (62.5%), lymph nodal lesions in 28 (15.9%),
bile duct lesions in 16 (9.1%), and the rest in 22 (12.5%) of patients. The
mean size of the lesions was 2.8±1.5 cms. The average number of passes
was 2.35 ± 0.9. There were no complications observed during or post
procedure. The overall adequacy rate of the tissue specimen was 92% for
both smears and/or biopsy specimen. The adequacy rate was highest for
pancreatic lesions at 95.5%, followed by bile duct lesions (93.7%), lymph
nodal lesions (89.3%) and lowest among submucosal epithelial lesions at
77.7%. Among the adequate samples, malignancy was confirmed in
60.49% and benign pathology was seen in 39.5%.
Conclusion EUS guided tissue acquisition by experienced
endosonographer yields high adequacy rates and is safe and cost effective
in the absence of on-site pathologist at resource limited settings.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Keywords EUS-FNA, EUS-guided tissue acquisition, Tissue adequacy
310
Endoscopic N-butyl cyanoacrylate (NBC) glue injection in manage-
ment of gastric variceal bleeding: A tertiary care center experience in
eastern part of India
Rakesh Kumar Barik, Haribhakti Seba Das, Chittaranjan Panda, Saroj
Kanta Sahu, Subhasis Pradhan, Reshu Khandelwal, Dinesh Meher,
Gautam Nath, Prajna Anirvan, Pankaj Bharali, Mrinal Gogoi
Correspondence- Rakesh Barik-rakeshkumarbarik.88@gmail.com
Department of Gastroenterology, S C B Medical College, Cuttack 753
007, India
Aim Endoscopic glue injection is recommended as first-line treatment for
bleeding gastric varices (GV). However, there is limited data with this
method in eastern India. Our aim was to analyze efficacy and safety of
endoscopic glue injection for treatment of gastric variceal bleeding.
Methods We prospectively studied 463 portal hypertension patients from
December 2017 to December 2019 at Gastroenterology Department,
SCB Medical College, Cuttack. Bleeding GV underwent injection of
one to three mL of glue in one sitting and repeat injections were admin-
istered after two to three weeks whenever required. Patients were evalu-
ated in terms of primary hemostasis, recurrent bleeding, complications
and in-hospital mortality.
Results Thirty-five bleeding GV patients underwent glue injection. Male:
female, 19:16 (54%:46%). Causes of varices–cirrhosis 18 (51%), EHPVO
15 (43%), noncirrhotic portal hypertension 1 (3%), Budd-Chiari syndrome
1 (3%). Out of 35 patients, 22 had GOV2, 12 had IGV1 and one had IGV2.
Twenty-three patients had large varices and 12 had medium sized varices.
Initial hemostasis was achieved in 33 (94%) patients. During follow-up,
bleeding recurred in 6 (17%) patients. Median time to rebleed was 60 days
(15-180 days). Five patients underwent repeat glue therapy for rebleeding
and all five patients had achieved homeostasis after injection glue. One
patient was referred for shunt surgery. The average volume of glue injected
per session was 2 (0.2) mL per patient. The average amount of glue needed
per patient was 2.5±1 mL. For 10 patients, repeated sessions of glue injec-
tions were given to achieve gastric variceal obliteration. Three patients had
mild abdominal pain and one patient had mild fever. There was no distant
embolization and channel block or damage to lens of the endoscopes noted
during these procedures.
Conclusion Endoscopic glue injection is safe and effective in achieving
hemostasis of bleeding GV and their eradication.
Keywords n-butyl cyanoacrylate, Gastric varices, Variceal bleed
311
Endoscopic retrograde cholangiopancreatography in pediatric pa-
tients performed by experienced endoscopists from a tertiary care
center in western India
Akash Shukla, Aditya Kale, Mohit Aggarwal, Sridhar Sundaram, Manish
Dodmani, Abhijeet Karad, Nitinkumar Ramani, Aniruddha Phadke
Correspondence- Akash Shukla-drakashshukla@yahoo.com
Department of Gastroenterology, Seth G S Medical College and KEM
Hospital, Parel, Mumbai 400 012, India
Introduction There is sparse data from India about indications, technical
success, safety and outcomes of endoscopic retrograde
cholangiopancreatography (ERCP) in the pediatric population.
Methods Retrospective analysis of the prospectively maintained endo-
scopic database was performed to identify paediatric patients (age
</=18 years) from January 2017 to September 2020 who underwent
ERCP at Gastroenterology Department of Seth GSMC and KEM hospi-
tal. Demographics and details about the procedure including indication,
S99
type of sedation, cholangiopancreatogram findings, type of endotherapy
done, technical and functional success as well as complications were
noted. All procedures were done using standard duodenoscopy
(Olympus TJF-Q180V) by experienced operators (experience of more
than 300 ERCP procedures with selective cannulation rate of more than
95%).
Results Seventy-two procedures were done in 56 patients during the study
period (Mean age 13 years; range:3-17 years; 60% male). ERCP for
biliary and pancreatic diseases was performed in 20 (35.7%) and 36
(64.2%) cases respectively. ERCPs were done for choledocholithiasis
11 (55%), bile duct injuries/leaks 4 (20%), biliary strictures 3 (15%),
choledochal cyst 2 (10%), and chronic pancreatitis 22 (61.1%), pancreatic
duct injuries/leaks 6(16.6%), pancreas divisum 4 (11.1%), recurrent acute
pancreatitis 3 (8.3%), anomalous pancreatobiliary union 1 (2.7%)
amongst biliary and pancreatic indications respectively. General anesthe-
sia, total intravenous anesthesia and endoscopist directed sedation was
given in 26 (36.2%), 41 (56.9%) and 5 (6.9%) procedures respectively.
No sedation related adverse events were noted. Cannulation was success-
ful in 35 (83.3%) pancreatic and 25 (86.2%) biliary procedures respec-
tively. In 10 (13.8%) procedures, pre-cut sphincterotomy was done for
cannulation. Technical success in 63 (87.5%) and functional success in 62
(86.1%) procedures. Reasons for failure include failed cannulation 6
(8.3%) and failed guidewire passage across stricture 4 (5.5%). There
was no correlation between technical failure and age, sex or type of
ERCP. Complications include mild post ERCP pancreatitis and bleeding
in 3 (4.1%) and 1 (1.3)% cases respectively.
Conclusion ERCP is safe and effective for evaluation and management of
various biliary and pancreatic diseases in children.
Keywords ERCP, Pediatric patients
312
Epidemiology and clinical profile of endoscopic retrograde
cholangiopancreatography patients in tertiary care hospital in
South India
Chaitanya Katragadda, Revathy M S, Sumathi B, Manimaran M, Chitra
S, Satya B
Correspondence- Chaitanya Katragadda-chaitan.katragadda@gmail.com
Department of Medical Gastroenterology, Government Stanley Medical
College, Chennai 600 003, India
Introduction and Aim Endoscopic retrograde cholangiopancreatography
(ERCP) is universally established modality in evaluation and treatment of
suspected biliary and pancreatic diseases. The aim of this study is to
evaluate our experience in ERCP and to study the etiology, indications
and findings of ERCP and complications of the procedure.
Methods This is a retrospective study carried out in the Department of
Medical Gastroenterology at Govt. Stanely Medical College, Chennai.
All the patients who underwent ERCP from January 2020 till August
2020 were included in the study. Etiology, indications, findings of
ERCP and procedure related complications were assessed in these
patients.
Result Records of 73 consecutive patients who underwent ERCP
were analyzed, out of which 46 (63%) were males and 27 (37%)
were females. Most common indications were choledocholithiasis
(61.6%), biliary stricture (13.6%) and periampullary growth
(9.5%). Other less common etiologies were portal biliopathy
(4.1%), head of pancreas mass (2.7%), cholangiocarcinoma
(2.7%), pancreatic duct stricture (1.3%), duodenal growth (1.3%)
and traumatic bile duct injury (1.3%). In choledocholithiasis, single
stone was found in 22 (48.8%), multiple stones were found in 10
(22.2%) and sludge was seen in 13 (28.8%) patients. Black pigment
stones were seen in 78% and yellow cholesterol stones seen in 22%.
Periampullary diverticulum was noted in 6 (8.2%). Sphincterotomy
was performed in 44 (60.2%) patients. Biliary cannulation failed in
S100
5 patients and stone retrieval failed in 1 patient. Post ERCP pancre-
atitis was seen in 2 (2.7%) patients.
Conclusion The most common indication for ERCP was choledocholi-
thiasis followed by biliary stricture and periampullary growth. In choled-
ocholithiasis single stone and black pigment stones were common.
Sphincterotomy was the most common procedure performed.
Keywords ERCP, Choledocholithiasis, Pigment stones, CBD stricture,
Sphincterotomy
313
Early pre-cut fistulotomy reduces the fluoroscopy time and radiation
dose in patients with difficult biliary cannulation
Harshal Mandavdhare
Correspondence- Harshal Mandavdhare-hmandavdhare760@gmail.com
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160 012, India
Background Role of pre-cut fistulotomy in reducing fluoroscopy time and
radiation dose in difficult selective biliary cannulation is unknown.
Methods This is a prospective randomized controlled trial where patients
with difficult biliary cannulation were randomized into 2 groups, viz,
Group I -Early pre-cut fistulotomy after difficult biliary cannulation at 5
minutes and Group II- Late pre-cut fistulotomy after failure of conven-
tional methods of selective biliary cannulation for 15 minutes. We com-
pared the success rates of selective biliary cannulation along with fluo-
roscopy time and radiation dose, the complication rates, need for repeat
Endoscopic retrograde cholangiography (ERC) and need for other inter-
ventions in early and late pre-cut fistulotomy.
Results Of the 130 eligible patients screened, 40 patients were random-
ized. The technical success was comparable between early and late group.
The ERC time was less and the fluoroscopy time and radiation dose were
significantly less in the early group (4 minutes [3, 6] vs. 15 minutes [8,
28], p=0.001) and (1.35 mGy [0.90, 1.63] vs. 2.40 mGy [1.58, 3.25],
p=0.010) respectively. In the late group, 60 % required need for rescue
pre-cut fistulotomy. One patient from late group developed PEP while 1
from early developed perforation. Three needed other interventions due to
failed second attempt.
Conclusion Early pre-cut fistulotomy has comparable technical success
and reduces the time and dose of fluoroscopy as compared to late pre-cut
fistulotomy for difficult biliary cannulation.
Keywords Pre-cut, Fistulotomy, Fluoroscopy, Radiation dose
314
Efficacy, safety and medium term outcomes of endoscopic full thick-
ness resection and various defect closure techniques for gastrointes-
tinal tumors
Muppa Indrakeela Girish, Amol Bapaye, Parag Dashatwar
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar
Hospital and Research Center, Pune 411 004, India
Background Endoscopic full-thickness resection (EFTR) is a minimally
invasive NOTES technique described to achieve resection of epithelial
tumors extending deeper than the mucosa or associated with significant
submucosal fibrosis and subepithelial tumors (SET). This study reports
our experience with EFTR and various defect closure techniques.
Methods Retrospective observational study included 42 patients. Patients
found to have either SET or epithelial tumor on gastrointestinal endosco-
py during evaluation of various gastrointestinal symptoms. Pre-procedure
EUS, CT scan in all. Resultant defects were closed using various
methods-TTSC or OTSC, endoscopic suturing, clip and loop. Follow-
up assessments include endoscopy and CT scan.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Results This study comprised 42 patients, 30 male, 12 females. Mean age
56. 3 years (19-83). Layer of origin (EUS)- GIST (18) and leiomyoma (5)
arising MP, NET (7) – SM and MP. Mean EFTR procedure time -
162 min (range 20 – 424). Mean resection specimen size - 3.0 cm. R0
resection 28/33, margin positive 5/33, morcellation 6/33. Mean defect
closure time -17.9 mins (2-50 mins). Closer methods-TTSC 19,
endoloop+TTSC-6 Padlock-3, padlock+TTSC – 2, padlock+ endoloop
+ TTSC- 1, Padlock + Apollo overstitchendosuture-1, Omental patch +
TTSC-2, Ovesco clip - 2, Apollo overstitch endosuture - 2. Histology
GIST – 18 (46.1%, low grade – 17, high grade - 1), NET- 7 (17.9%,
WHO grade- grade 1- 4 , grade 2 - 3), leiomyoma- 5 (12.8%),
Schwannoma-3 (7.6%), gastric duplication cyst - 1 (2.5%), ectopic pan-
creas 1 (2.5%), neurofibroma - 1 (2.5%), parietal cell hyperplasia-1
(2.5%), adenomatous proliferation with high grade dysplasia-1 (2.5%),
hyperplastic granulation tissue-1 (2.5%).Two adverse events- laceration
and perforation. Follow-up – 3 months - 100% no residual lesions,1-3 yrs
-60-80% no residual lesions, after 3 yrs 56% asymptomatic and no resid-
ual lesions.
Conclusion EFTR with various defect closure techniques appears to be
safe, effective for various GI neoplastic lesions.
Keywords EFTR, SET, Closer techniques
315
Concomitant endoscopic fundoplication after per oral endoscopic
myotomy (POEM + F) for prevention of post gastroesophageal reflux
- Medium term results
Parag Dashatwar, Amol Bapaye, Siddharth Dharamsi
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar
Hospital and Research Center, Pune 411 004, India
Background and Aim Peroral endoscopic myotomy (POEM) is an
established treatment for achalasia cardia (AC), however post-POEM
gastroesophageal reflux (GER) remains a significant problem.
Concomitant endoscopic fundoplication following POEM (POEM+F)
is a recently described technique to reduce post-POEM GER. This sin-
gle-center study reports short and medium-term outcomes of
POEM+F.
Methods Retrospective analysis of prospectively maintained data-
base of patients subjected to POEM+F. Abstracted data included
demographics, achalasia type, pre-POEM Eckardt score (ES), prior
therapy and follow-up. All patients were subjected to POEM+F.
Follow-up was at 3-monthly intervals for one-year. Follow-up as-
sessments included post-POEM ES, GerdQ score, EGD findings –
wrap integrity and esophagitis and pH studies. GER was defined
according to the Lyon consensus guidelines.
Results Twenty-five patients were subjected to POEM+F, mean age (SD)
– 40.13 (13.66) years, 12 females. POEM+F technically successful in 23/
25 (92%) patients. Significant dysphagia improvement seen in all 25
(mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respective-
ly, p< 0.05). Mean total procedure and mean fundoplicationtime (SD)
was 115.6 (27.2) and 46.7 (12.4) minutes respectively. Procedure times
significantly reduced after initial 5 cases. Median follow-up was 12-
months (IQR 9 – 13). At follow-up, conclusive GER on the basis of
abnormal EAET was seen in 2/18 (11.1%) patients. On ITT analysis, an
intact wrap was found in 19/23 (82.6%) patients. Grade A erosive esoph-
agitis with normal EAET was seen in additional 4/22 (18.1%) and was of
borderline significance. GerdQ scores remained high in one patient with
abnormal EAET. Two (8%) minor delayed adverse events required no
additional intervention.
Conclusions POEM+F is safe and reproducible. Incidence of post-
POEM+F GER is lower than that after traditional POEM. These results
are maintained at medium-term follow-up.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Keywords POEM F, GERDQ, EAET
316
Safe guarding ourselves with bare minimum in resource constraints
setting against COVID-19 our experience in tertiary care center
Muppa Indrakeela Girish, Amol Bapaye, Mangesh Borkar, Sachin
Palnitkar, Harshal Gadhikar, Rajendra Pujari, Lalit Shimpi, Suhas Date
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar
Hospital and Research Center, Pune 411 004, India
Background SARS-CoV-2/Novel Corona Virus-19 (COVID-19) has be-
come a global pandemic. COVID-19 can be easily transmitted in an
endoscopy suite, there is high risk of infection during endoscopic proce-
dures. Adequate protection of HCP is utmost important.
Methods Retrospective study who underwent endoscopic procedures dur-
ing COVID-19 pandemic. Patients were pre-screened and risk was cate-
gorized into urgent (GI bleed, urgent feeds, biliary sepsis) and semi-
urgent (GI cancers, ERCP for hepatobiliary pancreatic cancers, EUS for
diagnosis of malignant conditions) for endoscopic procedures according
to APSDE guidelines. Prior to procedure hemogram, chest X-ray, CRP
done to all patients. HCW’s used modified PPE (cap, mask, shield, gown,
gloves). Anesthesia preference- TIVA (midaz, fentanyl, propofol), GA
with intubation. Gap between each procedure 20-30 mins. Divided our
clinical force into two teams and followed the rotation policy on weekly
basis. Procedures were performed in positive pressure rooms with air
conditioning settings- MTR power 5.5KW, fan TSP-626Pa, fan speed -
1198 RPM, Disch vol -11.6m/s, motor frame size-132S-4, efficiency–
89.4% and nearly 30 mm of W.C positive pressure.
Results Four hundred and sixty-seven patients (70.9%; male =312
[66.8%]; median age = 57) underwent endoscopy procedures- from
March 20th to June 20th, 2020. One hundred and ninety (40.7%) patients
had one or more comorbidities with hypertension being commonest co-
morbidity in 142 (28%) patients. Commonest symptom was GI bleed in
121 (25.91%) patients. Five hundred and seven procedures, 274 (54%)
diagnostic, 233 (46%) -therapeutic. Interventions ERCP – 85 (36.5%),
EUS – 7 (3%), esophageal stenting-9 (3.9%), PEG- 22 (9.4%), EVL-35
(15%) 6 (1.2%) died during hospitalization following terminal illness.
Follow-up of patients according to different procedures 2 weeks – 1
month did not develop covid -19 symptoms and were not detected
positive.
Conclusions Proper precautions there was no event of cross COVID-19
viral transmission between healthcare workers and patients. Judicious use
of basic tests we followed will help in resource constraints settings like
peripheral hospitals and nursing homes.
Keywords: Covid 19, Endoscopy , Risk Stratification
317
Closure with composure! tracheoesophageal closure- Novel endo-
scopic technique
Ashish Gandhi, Amol Bapaye, Balasaheb Pawar, Mangesh Borkar
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Department of Gastroenterology, Shivanand Desai Center for Digestive
Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune
411 004, India
Tracheoesophageal fistula (TEF) can either be congenital or acquired,
etiology being benign or malignant. Acquired TEF in adults can be severe
and life threatening especially when complicated with recurrent aspira-
tions. Spontaneous closure of TEF is rarely encountered and require
stenting or surgery as the modalities of addressing TEF. Endoscopy can
be a quick and convenient modality to address such fistulas averting the
S101
need of prolonged and invasive surgeries. Experience with occluder de-
vices has been less however. We present our experience of HARTER
Lifetech ASD septal occluder device to tackle TEF.
TEF closure using an HARTER Lifetech ASD occluder was practiced
electively on 1 patient who presented with chronic cough. Endoscopy
revealed TEF of 6-7 mm diameter located 26 cm from incisors. Edge of
fistula was fulgurated using APC probe. Under combined endoscopy and
bronchoscopy guidance, HARTER Lifetech ASD septal occluder device
placement was done. We used HARTER Lifetech ASD septal occluder
device with waist size of 12 mm, proximal disc size of 22 mm (esopha-
geal end) and distal disc size 26 mm (tracheal end). Procedure was toler-
ated well. Post procedure patient developed Pneumothorax which re-
quired drainage. Follow-up bronchoscopy after 2 weeks showed occluder
device in situ with no airway lumen compromise. At follow-up visit after
1 month, there was significant relief in cough. Barium swallow revealed
no further leak. Follow-up endoscopy showed in-situ device. Patient was
started on semi-solid diet which is being tolerated well.
In this case report (video), TEF closure with novel endoscopic technique
using HARTER occluder device requires simple manipulations and is a
well tolerated procedure.
Keywords Tracheoesophgeal fistula, ASD closure, HARTER Lifetech
318
Study of endoscopic findings in upper gastrointestinal bleeding in
tertiary care centre
Zameer Ahamed, Chitra S, Manimaran M, Sathya G, Sumathi B, M S
Revathy
Correspondence- Zameer Ahamed-zameer.343@gmail.com
Department Medical Gastroenterology, Stanley Medical College, 1, Old
Jail Road, Chennai, 600 001, India
Introduction and Aim Acute gastrointestinal (GI) bleeding is a life
threatening emergency that remains a common cause of hospital-
ization worldwide. The etiology of acute upper GI bleed varies
with each geographical region. Early recognition and appropriate
management protocols, significantly reduces morbidity and mor-
tality. Study aimed endoscopic findings in patients with acute
upper GI bleeding.
Methods This was a retrospective study conducted in a tertiary care centre
in Government Stanley Medical College and Hospital, Chennai. In this
study we analyzed the records of consecutive patients admitted with
upper GI bleeding over period of 8 months from January 2020 to
August 2020.
Results We analyzed 194 consecutive patients diagnosed with acute up-
per GI bleeding, 151 (77.1%) patients were males and 43 (22.9%) were
females, mean age of presentation was 45 and plusmn; 5.2 years. On
etiological association shown history of alcohol use disorder 105
(54.1%), smoking 45 (28.3%), analgesic abuse 14 (7.2%) and on anti-
platelet drugs 10 (5.1%). On endoscopic evaluation esophageal varices
101 (52.6%), esophagitis 32 (16.4%), duodenal ulcer 28 (14.4%), gastric
ulcer 18 (9.2%), Mallory-Weiss tear 5 (2.5%) and normal endoscopic
finding was seen in 10 (5.1%) of patients.
Conclusion The present study reported that portal hypertension as the
most common cause of upper G bleeding followed by peptic ulcer dis-
ease. The most common endoscopic lesions reported were esophageal
varices, followed by esophagitis and duodenal ulcer.
319
Measures to contain exposure to endoscopy department staff during
the COVID-19 pandemic while providing quality care- A clinical
audit from a large volume tertiary center
S102
Amol Bapaye, Mangesh Borkar, Muppa Indrakeela Girish, Sachin
Palnitkar, Harshal Gadhikar, Rajendra Pujari, Suhas Date, Lalit Shimpi
Correspondence Amol Bapaye - amolbapaye@gmail.com
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar
Hospital and Research Center, Pune 411 004, India
Background SARS-CoV-2, global pandemic, causes aerosol borne viral
illness (COVID-19). GI endoscopy, an aerosol generating procedure,
carries high-risk for transmission. Despite several guidelines, protecting
healthcare workers (HCW) and patients from cross transmission remains
a challenge. This study elaborates measures implemented at a high-
volume tertiary center to reduce transmission risk and also discusses
outcomes.
Methods Since pandemic began, department functioning was as per mod-
ified APSDE guidelines. Elective endoscopy procedures stopped, only
emergency and semi-emergent procedures scheduled. Important differ-
ences from guidelines– routine COVID testing not employed, triage
protocol– history of symptoms/exposure, blood count including differen-
tial count, CRP, chest X-ray within 48 hours of scheduled procedure. All
HCWs used modified-PPE (cap, mask, face shield, surgical gown,
gloves). All procedures performed under propofol/GA with endotracheal
intubation. Departmental staff divided into two working groups by week-
ly rotation to avoid simultaneous exposure of all. Air-conditioning set-
tings modified to reduce positive pressure and improve ventilation.
Minimum 30-min-interval between procedures. Social distancing norms
enforced in patient waiting/recovery areas.
Results During 3-month period (March’20-June’20), 467 patients (70.9%
male, mean age 57 years) underwent 507 endoscopic procedures vs. 2110
procedures in preceding 3-months (22.9% of regular workload). One
hundred and ninety (40.7%) patients had associated comorbidities.
Indications for endoscopy– GI bleed–121 (25.9%), severe abdominal
pain–89 (19%), suspected cancer–128 (27.4%), obstructive jaundice
and cholangitis–67 (14.3%), others–253 (54.1%). Two hundred and
seventy-four (54%) diagnostic, 233 (46%) therapeutic procedures.
Therapeutic– ERCP–85 (36.5%), EUS–7 (3%), feeding access including
esophageal/enteral stent– 9 (3.8%), treatment for GI bleed–35 (15%). Six
(1.2%) patients died during hospitalization due to non-COVID
causes. Follow-up as per protocol– no occurrence of COVID
symptoms in any patients at 2 weeks post procedure, none detect-
ed positive. No HCWs developed COVID symptoms or tested
positive during 3-month period.
Conclusions This audit demonstrates low incidence of cross transmission
of SARS-COV-2 between patients and HCWs by using measures listed
above. At reduced workload of 25% of normal, department could serve
patients in need of emergency/semi-emergency endoscopic intervention.
Keywords Covid 19, Endoscopy, Triage
Motility Disorders
320
Evaluation of esophageal motor function in patients with gastro-
esophageal reflux using multiple rapid swallows
Mayank Jain, Vinodini Agrawal
Correspondence- Mayank Jain-mayank4670@rediffmail.com
Department of Gastroenterology, Arihant Hospital and Research Centre,
283- a, Gumasta Nagar, Scheme 71, Indore 452 009, India
Background Multiple rapid swallow (MRS) is a complementary test per-
formed during high resolution esophageal manometry.
Aims To assess the MRS findings in patients with gastroesophageal reflux
disease (GERD) who have normal peristalsis and minor motility
disorders.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Methods This is a retrospective analysis from a prospectively maintained
database of patients referred for HREM study to our centre. The details
recorded included age, sex, symptoms with duration and upper gastroin-
testinal endoscopy reports. HREM data included basal inspiratory and
expiratory pressures, median integrated relaxation pressure and peristaltic
pattern. Three MRS sequences were recorded per patient. The inhibition
and contraction phases were interpreted for each MRS sequence.
Results A total of 68 patients (38- normal motility, 30 minor motility
disorders) formed the study cohort. Hiatus hernia was commoner in
GERD patients with minor motility disorders (p 0.02). Patients with mi-
nor motility disorders were more likely to have poor peristaltic reserve
than patients with normal peristalsis (p<0.05). MRS patterns in inhibition
and contraction phases are similar in three MRS sequences for patients
with normal peristalsis, while in patients with minor peristaltic disorders,
the inhibition phase is significantly discordant on repetitive MRS swal-
lows. (p 0.049).
Conclusion In GERD patients, those with normal peristalsis are more
likely to have normal MRS pattern. On the contrary, those with minor
peristaltic disorders have a higher incidence of poor peristaltic reserve and
show significant discordance in the inhibition phase of MRS.
321
Bowel habit pattern of patients with self-reported constipation at out
patient department in north east part of Bangladesh
Madhusudan Saha, Bimal Chandra Shil, Mohammed Kamal Uddin
Correspondence- Madhusudan Saha-madhunibedita@yahoo.com
Department of Gastroenterology, North East Medical College,
Bangladesh, North East Medical College, Sylhet, Bangladesh, Sir
Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
Aim This study was designed to see the symptoms and bowel habit pattern
of patients presenting with self reporting constipation at Out Patient
Department in a tertiary care hospital.
Method This study was conducted in out patient Department of gastroen-
terology department in North East Medical College Hospital during
January 2017 to December 2018. Total 228 consecutive patients with self
reported constipation were enrolled in this study. Patients with history of
abdominal surgery, known chronic disease, age below 18 years, pregnant
women, patients using drugs like anti-depressant, anti-psychotic and pa-
tients unwilling to take part in the study were excluded. Demographic
data, symptoms, bowel habit pattern and character of stool were recorded
at in a pre-designed data sheet.
Result Total 228 patients, male 130 (57%), female 98 (43%), age varying
from 18 to 81 years (mean 38.7±15.10) were included. Among them 127
patients (55.7%) had daily bowel motion with frequency one to seven and
101 patients (44.3%) had infrequent stools. Sixteen patients (7.0%), 182
patients (79.8%) and 30 patients (13.2%) had feeling of complete bowel
evacuation all time, days a week and almost never respectively. Among
the patients 127 (55.7%), 29 (12.7%), 06 (2.6%), 02 (0.9%) and 64
(28.1%) complained of hard, soft, semi liquid, liquid and stool of variable
consistency respectively. In this study 159 (63.73%), 21 (9.21%) and 43
(18.85%) patients were regularly taking proton pump inhibitor (PPI), anti-
diabetic drugs and anti-hypertensive drugs respectively.
Conclusion Patient’s perception regarding constipation does not always
match the traditional medical definition. Symptoms like stool consisten-
cy, volume, and feeling of incomplete evacuation are more important to
patients’ perception regarding constipation.
322
Quality of life, prevalence of psychiatric comorbidities and extrain-
testinal functional disorder in patients with functional gastrointesti-
nal diseases
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Abhinav Jain, Himanee Patel
Correspondence- Abhinav Jain-dr.a.j.12320@gmail.com
Department of Gastroenterology, CIMS Hospital, Science City Road,
Science City, Panchamrut Bunglows II, Sola, Ahmedabad 380 060, India
Introduction Functional gastrointestinal disorders (FGID) patients report
poor health-related quality of life (HRQOL) and experience high rates of
psychiatric comorbidity and extraintestinal functional disorders (EIFD).
The data from India on this is sparse.
Methods A hospital based cross-sectional study was carried on out-
patient basis December 2019 to March 2020. Thirty-five patients
with functional gastrointestinal diseases diagnosed on basis of
ROME-IV criteria were identified. A survey was undertaken using
SF-36 questionnaire, hospital anxiety and depression scale and so-
matic symptom scale-8. Prevalence of EIFD and history of function-
al disorders in family were also noted.
Results The most prevalent FGID were functional bloating (28.5%), irri-
table bowel syndrome (IBS) (25.7%) and functional dyspepsia (25.7%).
EIFD were seen in 33 (94.3%) of patients, the commonest being headache
(80%), halitosis (51.42%), and dysguesia (40%). Nearly half (48.6%) the
patients had a history of FGID and/or EIFD among family members.
Anxiety and depression was seen in 13 (37.1%) and 19 (28.6%) patients,
respectively. Eight (22%) patients had both anxiety and depression. The
somatic symptom burden was high and very high in 20% and 34.2%,
respectively. No differences in prevalence of psychiatric comorbidities
was seen with relation to type of FGID. The overall QoL was low with a
mean score of 49.5 (SD 12.5). The domains of QoL with the lowest scores
were role-emotional (mean 19.75 [SD 26.19]), followed by role-physical
(mean 22.50 [SD 29.67]).
Conclusion There is a high prevalence of psychiatric comorbidities like
depression and anxiety, EIFD, family history of functional disorders in
patients with FGID. These patients have a high somatic symptom burden
and a poor QoL.
323
Long-term outcomes of per-oral endoscopic myotomy in esophageal
motility disorders: A large, single centre study
Arun Karyampudi, Zaheer Nabi, Mohan Ramchandani, Rajesh Goud,
Santosh Darisetty, D Nageshwar Reddy
Correspondence- Zaheer Nabi-zaheernabi1978@gmail.com
Department of Gastroenterology, Asian Institute of Gastroenterology, 6-
3-661, Somajiguda, Hyderabad 500 082, India
Background Per-oral endoscopic myotomy (POEM) is an established
modality of treatment in achalasia and non-achalasia spastic motility dis-
orders of esophagus. However, there is limited data on the long-term
outcomes of POEM. In this study, we aim to evaluate the efficacy of
POEM in patients with a minimum follow-up of five-years.
Methods The data of patients who successfully underwent POEM and
completed at least five-years follow-up were analyzed from a prospec-
tively maintained database. The primary outcome of the study was clin-
ical success (Eckardt&le;3) at age; 5-years after POEM. The secondary
outcomes included the prevalence of dysphagia and symptoms of gastro-
esophageal reflux disease (GERD). Multivariate analysis was performed
to analyze the predictors of dysphagia and symptomatic and GERD on
long-term follow-up.
Results Two hundred and twenty-five only; patients (males 129, mean
age 40.7 and plusmn;14.3 years) completed a minimum of 5-years fol-
low-up. The spectrum of motility disorders included idiopathic achalasia
(type I 28.4%, type II 60%, type III 6.2%) and Jackhammer esophagus or
distal esophageal spasm (3.1%). POEM was technically successful in 217
(96.4%) patients. The data for long-term follow-up was available in 201
(89.3%) patients. The median follow-up was 69 months (range 60-81). In
intention to treat analysis (considering technical failures and lost to
S103
follow-up as failures), the overall long-term success was 87.5%, 84.3%
(type I), 91.8% (type II), 78.6% (type III) and 85.7% (Jackhammer
esophagus/ distal esophageal spasm). Clinical success was lower in type
III achalasia (p=0.002). Young age was an independent risk factor for the
development of dysphagia on follow-up (p=0.002). Clinical GERD was
detected in 30.6% patients. On multivariate analysis, female sex, high
Eckardt score at 5-years and dysphagia of any degree were independent
predictors of symptomatic GERD after POEM.
Conclusion POEM is an effective and durable treatment modality for
achalasia and other non-achalasia spastic motility disorders. Clinical
GERD is detected in nearly one-third patients.
324
Spectrum of anorectal manometry and balloon expulsion test find-
ings in patients with chronic constipation at a tertiary care centre in
India
Suresh Chawla, Mohinish Chhabra, Hardeep Singh Dua, Amandeep
Raghuvanshi, Amit Kumar
Correspondence- Mohinish Chhabra-mohinish.chhabra@fortishealthcare.com
Departments of Gastroenterology, Medical Technology and GI
Physiology, Fortis Hospital in Mohali, Sector 62, Sahibzada Ajit Singh
Nagar, Punjab 160 062, India
Background and Aims Constipation is a common problem encountered in
GI practice. The patients referred to tertiary care hospital poorly respond
to laxatives and require a thorough work up for the fecal evacuation
disorder.
Methods Retrospective data of 87 consecutive patients (2017 to 2020)
with chronic constipation (Rome III) referred for ARM and BET was
analyzed.
Results Eighty-seven patients (51.88 ± 19.21 years, 51 males, 36 females)
had history of incomplete evacuation out of which history of digital evac-
uation (n=20), rectocele (n=2), anal fissure (n=5), trauma (n=3), surgery
(n=28), Parkinson (n=1), diabetes (n=9), hypertension (n=4), hypothy-
roidism (n=4) was observed. On ARM, Type 1 dyssynnergia was seen in
n=57, Type 2 and 3 dyssynnergia was present in n=3 patients each. N=52
patients couldn’t expel the Balloon in one minute. Rectal hyposensitivity
was noted in n=47 and hypersensitivity in n=5. mean sensation volume,
urge volume and pain volume was 72.13±52.21, 182.18± 74.75, 242.71
±89.96 cc respectively. Recto anal inhibotory reflex (RAIR) was absent in
n=1, cough reflex was absent in n=12 patients. Mean anal length of the
study population was 3.69 ± 0.77. Biofeedback therapy was effective in
all the patients who underwent it (n=13).
Conclusion Rectal hyposensitivity and Type 1 dyssynnergia were
the most common observations of our study. Hence it is important
to have a thorough workup in patients with chronic constipation
to rule out FED to avoid laxative abuse and multiple doctor visits
as biofeedback therapy shows promising results in such category
of patients.
Keywords Anorectal manometry, FED, Dyssynnergia
325
Effect of moderate aerobic exercises on symptoms of functional dys-
pepsia
Siddhesh Rane, Partha Debnath, Sanjay Chandnani, Prasanta Debnath,
Parmeshwar Junare, Ravi Thanage, Pankaj Nawghare, Bharati
Asgaonkar, Qais Contractor, Pravin Rathi
Correspondence- Siddhesh Rane-sid.6173@gmail.com
Department of Gastroenterology, Topiwala National Medical College
and BYL Nair Charitable Hospital, Dr Anandrao Nair Marg, Mumbai
Central, Mumbai 400 008, India
S104
Introduction Functional dyspepsia is a commonly encountered entity
worldwide and is difficult to treat. Most of the treatment modalities have
low quality evidence for use, except for proton pump inhibitors. Aerobic
exercise has been shown to improve the symptoms but its direct effect on
symptoms has never been studied. Objective was to study the effects of
moderate aerobic exercise on symptoms of functional dyspepsia and to
compare the effect of conventional treatment alone vs. exercise plus con-
ventional treatment.
Methods Out of 112 patients, 72 were randomly divided into controls
(conventional treatment) (n=36) and experimental (aerobic exercise for
30 minutes per session, 5 times a week for 6 weeks with conventional
treatment) group (n=36). Both groups were assessed on day 1 and at the
end of 6 weeks, using Glasgow dyspepsia severity score (GDSS),
Depression anxiety stress scales-42 (DASS 42) and Visual analogue scale
(VAS).
Results Pre-treatment GDSS, DASS 42 and VAS in the experimental
group were significantly different as compared to the post-treatment
scores (p=0.00019, p=0.0002, p=0.00019 respectively). Even in the con-
trol group, pre- and post-treatment GDSS, DASS 42 and VAS scores
were significantly different (p=0.00019, p=0.0002, p=0.00019 respec-
tively). However, on head-to-head comparison of the 2 groups, scores
at the end of 6 weeks were significantly different (p< 0.05), in favor of the
experimental group.
Conclusion Aerobic exercise with conventional treatment is more effec-
tive than conventional treatment alone for functional dyspepsia.
326
Incidence and risk factors associated with development of post infec-
tion irritable bowel syndrome (PI-IBS) - A one-year prospective lon-
gitudinal study
Rishabh Agarwal, Rekha Patil
Correspondence- Rishabh Agarwal-rishabhagarwal90@gmail.com
Department of Internal Medicine, Jawaharlal Nehru Medical College,
KAHER, India
Introduction Post-infection irritable bowel syndrome (PI-IBS) is seen
following an episode of acute gastroenteritis (AGE). There is paucity of
literature in this field with respect to Indian population. This F study aims
to evaluate the incidence of PI-IBS and identify the risk factors associated
with it.
Methods This prospective study was carried out over a period of one year
on AGE patients admitted in KLE Dr. Prabhakar Kore Hospital,
Belgaum. Clinical and demographic characteristics were noted, risk fac-
tors evaluated, and previous or current IBS was ruled out by means of an
IBS questionnaire. The patients were followed up after 6 months to look
for development of IBS (ROME IV criteria).
Results Out of 100 hospitalized AGE patients, one-fourth i.e. 25 devel-
oped PI-IBS after 6 months. Out of these, 18 patients had IBS-D type and
remaining 7 had IBS-C type. The factors significantly associated with PI-
IBS were younger age, longer duration of AGE, depression, abdominal
cramps. On multivariate logistic regression analysis, longer duration of
acute gastroenteritis (>7 days) (p-value=0.0040) and presence of abdom-
inal cramps (p-value=0.0130) were found to be significantly influencing
the development of PI-IBS at 6 months.
Conclusion One fourth of the patients in our study developed PI-IBS after
6 months of AGE episode. Younger age, depression, longer duration of
diarrhea and abdominal cramps were statistically significant risk factors
for development of AGE. Physicians should keep a high suspicion for PI-
IBS, in patients with predisposing risk factors. The possibly involved
molecular mechanisms in the pathogenesis of PI-IBS should be investi-
gated for better understanding of the disease, and to plan and strategize
therapeutic options.
Keywords PI-IBS, Gastroenteritis, Diarrhea, ROME, IBS
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
327
Subtypes of functional constipation based on colonic transit time and
anorectal manometry
Ashish Chand, Mandhir Kumar, Munish K Sachdeva
Correspondence- Ashish Chand-ashishchanddewangan@gmail.com
Department of Gastroenterology, Institute of Liver, Gastroenterology and
Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar,
New Delhi 110 060, India
Chronic constipation is a common complaint in the general population
worldwide as well as in India. It may be idiopathic or secondary.
Idiopathic constipation is classified as functional constipation (FC) and
IBS-C. Proportion of FC among patients of idiopathic chronic constipa-
tion is higher than IBS-C. We studied 100 patients of FC. Majority were
male (70%). Colonic transit time (CTT) was measured by using radio-
opaque markers and anorectal manometry by high resolution water per-
fusion system. Mean age of patient was 41y ±14.7, maximum were in 21-
30 years and 31-40 years of age group. Common complaints were exces-
sive straining (100%), feeling of incomplete evacuation (99%) and block-
age (93%). Straining ≥ 30 min, sensation of blockage, feeling of lumpy
hard stool and manual evacuation is significantly associated with
dyssynergic defecation (p-<0.05). BSFS1 and 2 stool consistency were
reported more by those who had dyssynergia (p <0.05). Solitary rectal
ulcer syndrome was found in 13% of patients and all had dyssynergic
defecation (DD). DD was found in 66 patients. Type 1 DD was most
common 46, found in followed by type 2- 17 and type 4-3 patients. Mean
resting anal and squeeze pressure were found high among patients of DD.
CTT showed slow colonic transit in 25% patients. Sixty percent of pa-
tients with slow transit had BSFS1 or 2.
In conclusion majority of patients of FC who presented to tertiary care
facilities may have defecative disorder or slow colonic transit or a com-
bination of the two because majority had already been treated at primary
health care facilities and had inadequate response whereby were suffering
from refractory constipation.
Keywords Chronic constipation, Functional constipation, Dyssynergic
defecation, Colonic transit time, Anorectal
328
Can maximal anal squeeze pressure predict the diagnosis of
dysynergic defecation during anorectal manometry?
Ajay K Jain, Amit Joshi, Shohini Sirkar, Abhilash Surela, Sudhanshu
Yadav
Correspondence- Amit Joshi-dradjoshirajkot@gmail.com
Department of Gastroenterology, Choithram Hospital and Reasearch
Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction Constipation affects 11% to 18% of adults and is frequently
underreported. A multicentric study in India found the prevalence of self-
reported constipation of about 53%. Pelvic floor dyssynergia or
dysynergic defecation constitutes about half of constipation which can
be diagnosed by anorectal manometry. There-fore we aimed this study to
evaluate the various anorectal manometric parameters like basal anal
pressures, maximal squeeze pressures and rectal sensations in patients
with dysynergic defecation and their utility in predicting the diagnosis.
Methods Present study is retrospective observational study of patients
who underwent anorectal manometry for evaluation of constipation at
the department of gastroenterology, Choithram Hospital and Research
Centre, Indore, M.P. from 1/3/2015 to 31/2/2020. Patients were divided
into two groups: A: Dysynergic defecation group and B: Non-dysynergic
defecation group and various parameters were analyzed and compared
between the two groups with appropriate statistical tests.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Results During the study period 98 patients underwent anorectal manom-
etry for evaluation of constipation. Of these 74 patients (75.51%) had
dysynergic defecation and 24 (24.48%) had normal anorectal manometry
findings. The mean age of presentation was in forth decade (49.28 years)
in dysynergic defecation group (49.28 years) and in fifth (53.20 years)
decade in normal anorectal manometry group. Finger evacuation was
exclusively seen in dyssynergic defecation group (9%, p=0.044). There
was no statistical difference in basal anal pressures between the two
groups. Maximal squeeze pressures were significantly higher in
dysynergic defecation group. No significant differences were seen in
rectal sensations in both the groups.
Conclusions 1) Dysynergic defecation affects in fourth decade with male
preponderance. 2) Use of finger evacuation can clinically distinguish
between dysysnergic defecation and non dysynergic defecation. 3)
Patients with dysynergic defecation have high maximal squeeze pres-
sures. 4) Rectal sensations is not a sensitive manometric parameter to
diagnose dysynergic defecation.
Keywords Dysynergic defecation, Anorectal manometry, Maximal
squeeze pressures, Rectal sensations
329
Physiological management of irritable bowel syndrome with
Psyllium husk: Novel aspects
Pankaj Garg, Sohail Singh Sodhi
Correspondence- Pankaj Garg-drgargpankaj@yahoo.com
Department of Colorectal Surgery, Garg Fistula Research Institute, 1043,
Sector 15, Panchkula 134 113, India and Govt Medical College, Chandi
Path, Sector 32B, Sector 32, Chandigarh 160 047, India
Introduction Psyllium husk is bowel regulator and could work very ef-
fectively in irritable bowel syndrome (IBS) provided it is taken in proper
quantity and with adequate water. This and other physiologic steps
(FEED) were studied.
Methods IBS patients (Rome IV criteria) were prescribed FEED regimen,
(F) - Fiber (Psyllium-Ispaghulla husk), 5 tsf (25 grams) with 500 mL
water/day
(E) - Elevation of feet by small bench (12-16” height) while on toilet-
commode,
(E) - Exercises of abdominal muscles
(D)- Drinking (500 mL) water in morning.
Earlier 5-10 grams of soluble fiber (psyllium) has been studied which
provide only partial relief. Daily fiber requirement is 35-40 grams/day where-
as the intake is <15 grams/day. So, this deficiency of 20-25 grams fiber needs
to be supplemented daily to maximise the relief in IBS patients. Second aspect
is the amount of water taken along with the fiber. Psyllium absorbs water,
takes water to the rectum, thereby making stools softer and bulkier. However,
for this to happen optimally, adequate water must be taken along with the
fiber intake (@25 mL water/gram fiber, 500 mL water with 25 grams fiber/
day). These aspects which markedly increases the efficacy of fiber supple-
ment was ignored by previous studies. Elevating the feet while sitting on toilet
commode straightens the rectoanal canal which by relieving functional ob-
struction makes defecation process easier and less strainful. Drinking water in
morning and doing abdominal wall exercises while sitting on toilet-commode
activate gastrocolic reflex and help in bowel regulation. All these physiolog-
ical steps (FEED) when implemented together, helps to regulate bowel and
provide substantial relief in IBS.
Results In the pilot study, FEED was recommended to 7 patients of IBS
(4-IBS with constipation, 2-IBS with diarrhea, IBS mixed). After 6
weeks, all patients responded well to this physiological treatment and
reported a major relief (>90%) in their symptoms.
Conclusions Physiological (non-pharmacological) treatment (FEED) can
play a major role in the management of IBS. Irritable bowel syndrome,
psyllium husk, physiological management
S105
330
Efficacy of biofeedback therapy in patients with dyssynergic defeca-
tion
Ashish Agarwal, Samagra Agarwal, Deepak Madhu, Abhinav Anand,
Mukesh Ranjan, Saurabh Kedia, Vineet Ahuja, Govind Makharia,
Anoop Saraya
Correspondence- Govind Makharia-govindmakharia@gmail.com
Department of Gastroenterology and Human Nutrition, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Introduction Multiple studies have demonstrated the beneficial effects of
biofeedback therapy for dyssynergic defecation. However, data from
India is limited. This study was planned to assess the efficacy of biofeed-
back therapy for dyssynergic defecation.
Methods In this retrospective analysis from a prospectively maintained
database, all patients with symptomatic dyssynergic defecation who com-
pleted at least six sessions of weekly multicomponent biofeedback ther-
apy between July 2018 and March 2020 were included. Patients with any
structural abnormality in the defection unit, uncontrolled hypothyroidism,
uncontrolled diabetes, and hypercalcemia were excluded. Efficacy of
biofeedback therapy was assessed as the reduction in the modified
Cleveland constipation severity score and global bowel satisfaction based
on visual analogue scale at the end of biofeedback therapy.
Results Fifty-three patients received biofeedback therapy of which, 45
patients (Mean age 41.4+17.1; 73% males) were included in the analysis.
The median duration of symptoms was 5 (IQR: 3-10) years. Thirty-two
(71.1%), 4 (8.9%), 7 (15.6%) and 2 (4.4%) patients had type I, type II,
type III and type IV pelvic floor dyssynergia, respectively. There was a
significant improvement in the median modified Cleveland Constipation
Severity Score with biofeedback therapy (before 7 [IQR:4-9] vs. after 3
[IQR:1-5]; p<0.001). Biofeedback therapy was effective (>25% reduction
in constipation severity score) in 37 (82.2%) patients. 84.4% patients had
satisfactory (>20%) global bowel satisfaction with biofeedback therapy.
Conclusion The study reaffirms that biofeedback therapy is highly effec-
tive in patients having dyssynergic defecation.
Keywords Biofeedback, Pelvic floor dyssynergia, Anorectal
331
To study normal values on high-resolution anorectal manometry in
healthy volunteers in India
Rahul Deshmukh 1 , Sanjay Chandnani 1 , Shubham Jain1, Pratik
Tibdewal2, Nitin Ramani2, Pravin Rathi1, Akash Shukla2
Correspondence – Rahul Deshmukh-drdeshmukhrahul@gmail.com)
1
Department of Gastroenterology, Topiwala National Medical College,
Mumbai 400 008, India, 2Department of Gastroenterology, Seth G S
Medical College, Mumbai 400 012, India
Introduction High-resolution anorectal manometry (HRAM) is used for
determination of anorectal disorder. There are differences in data on effects
of gender and age on anorectal function. The data on normal anorectal
pressure and sensation are sparse. Our hypothesis is that values in Indian
population might be different from others. This study aims: (1) To obtain
normal data sets of anorectal function using HRAM and (2) Influence of
gender and age on anorectal functions in healthy volunteers in India.
Methods In our population healthy volunteers underwent HRAM using a
24-channel water perfused catheter. We determined anorectal pressures,
recal sensation and balloon expulsion time. Measurements were recorded
during rest, squeeze, and push with and without balloon inflation.
Informed consent was taken.
Results HRAM was performed in 93 healthy volunteers of which 29 were
females. Median age was 38 years (ranges: female 18–65 years; male 18–
S106
76 years). Volumes of first sensation (47±28 mL) and (34±17 mL), ur-
gency (114±44 mL) and (98±35 mL) and MTV (maximum tolerable
volume) (162±52 mL) and (154±50 mL) in males and females respec-
tively. Anal canal length (1.86±0.68 cm vs. 2.5±0.68 cm), anal push
residual pressure without inflation (59±21 mmHg vs. 81±22 mmHg)
and first sensation (34±17 ml vs. 47±28 mL) were significantly lower
(p<0.05) in females compared to males. No statistical difference was
found in resting anal pressure, maximum squeeze pressure, push residual
pressure with inflation, urgency to defecate and MTV in males and fe-
males. Mean anal resting (91±29 mmHg) and mean squeeze max pressure
(155±38 mmHg) were lower in >50-year age group compared to <50-
year age group (100±28 mmHg) and (169±45 mmHg) respectively.
Balloon expulsion was failed in 30 (32%) study participants.
Conclusion HRAM parameters anal canal length, anorectal pressure
and volume are influenced by age and gender (significantly low
in females). Results must be interpreted concerning gender and
age-adapted normal values. Anorectal pressure and rectal sensa-
tion are different from other population. Balloon expulsion was
negative in one third at end of 1 minute in our population.
Keywords: Anorectal function, High-resolution anorectal manometry
(HRAM), Healthy volunteers
Pediatric Gastroenterology
332
Presentations, management and outcome of upper gastrointestinal
bleeding in children admitted in a tertiary care endoscopy unit in
South India
Sajith Sebastian, Benoy Sebastian, Sunil K Mathai, Mary George
Correspondence- Sajith Sebastian-drsaseneeruvelil@gmail.com
Department of Medical Gastroenterology, Medical Trust Hospital,
Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
The aim of this study was to find out whether the causes of pediatric upper
GI bleeding to our center and outline their presentations and treatments.
Children presenting to Endoscopy unit of Medical Trust Hospital, Kochi
with upper GI bleeding for a year and half from December 2018 to
June 2019 were evaluated and included in the study after obtaining a
informed consent from the parents. Information retrieved from patient's
records and results of upper GI endoscopy regarding etiology of bleeding,
managements, and the mortality rate were also analyzed.
Results Age distributions of paediatric patients presented with UGI
bleeding shows most common age of presentations were between 2-
5 years of age, followed with 8-12 years both of which occurred in
33.34%. Males presented slightly more with UGIB. Children's pre-
sented with UGIB presented with Melena in 33.4%, hematemesis in
22.22%. Children’s with accidental foreign body ingestions also
present with UGI Bleeding in 11.13%. But none of them presented
with major bleeding with hypotension or required blood transfusion.
Most common cause of UGIB was gastric and duodenal erosion´s as
par with other studies. No source was identified in 1/3rd of patients
during the initial endoscopy. While one patient had a Dieulafoy's
lesion picked up and managed in subsequent endoscopy.
Conclusion Our findings showed that most common sources of
upper GI bleeding in pediatric patients from our center was due
to gastric and duodenal erosions. We conclude that the causes of
upper GI bleeding in children in our center, a developing country,
are not different from those in developed ones. Various regions of
the world have reports indicating variation in the source, etiology,
cause and approaches for pediatrics GI bleeding. Furthermore,
multicenter studies considering various countries or review articles
investigating the mentioned issues in GI bleeding of children is
essential.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
333
Role of gastrointestinal endoscopy in children with functional ab-
dominal pain
Shrish Bhatnagar, Aashlesha Kritika, Saba Ekta
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital
(ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background and Study Aims Rome 4 criteria has classified pediatric func-
tional abdominal pain (FAP) into 4 variants i.e. functional dyspepsia
(FD), functional abdominal pain not otherwise specified (FAP-NOS),
irritable bowel syndrome (IBS), abdominal migraine (AM). However,
there is lack of information on endoscopy and histopathological findings
in this subset of children. Hence our study was to evaluate the endoscopic
and histopathological findings in children with FAP.
Methods It was prospective observational study. 110 children (aged 4 to
17 years) with diagnosis of FAP according to Rome 4 criteria were en-
rolled from paediatric OPD. All children underwent gastrointestinal en-
doscopy and biopsy.
Results Most of the children belonged to age group 6-12 yrs
(52.7%). Majority of children were girls (n=62, 56.4%). Fifty-
eight (52.7%) children were suffering from FD, 42 (38.2%) children
suffering from FAP NOS, 9 (8.2%) had IBS and 1 child had AM. In
view of small sample size the IBS and AM patient were removed
from statistical analysis. Endoscopic assessment showed 28 (42.3%)
children with FD had significant lesions while it was seen only in 2
(4.8%) children with FAP NOS (p<0.001. Rapid urease test for H
pylori was positive in 30 (51.7%) of children with FD, while only 1
in FAP NOS (p<0.001). Histopathological assessment collaborated
with endoscopic assessment in both the categories. Thirty-five chil-
dren of FD had evidence of mucosal inflammation against only 4
children of FAP NOS group (p<0.001). On follow-up 96.6% chil-
dren with FD improved when given treatment with PPI and
H. pylori (in positive cases).
Conclusion Indian children with functional dyspepsia have evidence
of significant endoscopic and histopathological abnormalities in-
cluding H pylori infection. Hence, we recommend that children with
functional dyspepsia should be subjected to both upper GI endosco-
py and H pylori evaluation while FAP-NOS usually do not require
the same.
334
A challenging case of unusual liver mass in a teenage girl
Viswanathan M S, Anand Khakkar, Satheesh Ramamurthy
Correspondence- Viswanathan M S-vichums@rediffmail.com
Department of Pediatric Gastroenterology, Children's Hospital, India,
Apollo Hospital, Chennai, India
History and Examination A 14-year-old girl presented with intermittent
epigastric pain, vomiting and amenorrhea for 3 months. On examination:
Growth was appropriate, anicteric, tenderness over epigastrium, and sig-
nificant hepatomegaly. Otherwise normal.
Evaluation Hb 11, other CBC normal. LFT - AST-52 u/L, ALT-54
u/L, GGT-95 u/L, Normal bilirubin and synthetic function.
Ultrasound abdomen revealed diffuse right liver lobe mass, other-
wise unremarkable. Alfa-fetoprotein: normal. MRI abdomen: diffuse
right lobe hepatic mass (17.8 cm x 13.3 cm) with compression of
intrahepatic IVC, suggestive of hepatic adenoma. Liver biopsy con-
firmed hepatic adenoma.
Management In the multidisciplinary (MDT) meet options were
discussed. In view of the risk of postoperative acute liver failure following
a complete mass resection and technical surgical challenges it was
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
decided to reduce the size of the mass by embolization in the interim. Two
sittings of selective embolization of tumor branches of right hepatic artery
was done, with 6 months interval. Post embolization syndrome following
first sitting was medically managed, second embolization uneventful.
Tumor significantly reduced to 12.1 cm x 9.8 cm and left lobe enlarge-
ment was noted. Then she underwent surgical excision of the hepatic
adenoma along with right hepatectomy. She recovered well postopera-
tively and remained clinically well at 12 months follow-up.
Discussion Hepatocellular adenomas (HCAs) are extremely rare during
childhood with varying histopathological features. HCA can be sporadic
but is more frequently associated with oral contraceptive use and meta-
bolic liver disease. In our patient there was no history of oral contracep-
tive use, underlying liver disease or genetic predilection. In view of risk of
rupture/bleed we intervened.
Conclusion Hepatic adenoma, particularly large one is extremely rare in
childhood and needs MDT management. Huge adenoma can be success-
fully reduced by selective embolization technique before high risk sur-
gery to achieve optimal postoperative outcome.
335
Button battery ingestion: Experience from a tertiary center
Syed Shafiq, Harshad Devarbhavi, Balaji Gurappa, Mallikarjun Patil
Correspondence- Syed Shafiq-syed.dr.s@gmail.com
Fortis Hospital, Bannerghatta Road, Bengaluru, India, and Department of
Gastroenterology, St. John's Medical College Hospital, Bengaluru, India
Introduction The ubiquitous use of portable electronic devices has result-
ed in an increased incidence of button battery (BB) ingestion in the pe-
diatric population and represents a distinct category of ingested foreign
body due to high morbidity and mortality. The aim of this study is to
report our experience in the management of BB ingestion.
Methods A study involving 56 pediatric patients who presented to our
Hospital Emergency Department with BB ingestion between December
2016 and November 2019. Data with respect to patient age, sex, time of
presentation to emergency department to endoscopic retrieval of BB, the
endoscopic findings, and adverse events if any was collected.
Results A total of 56 patients were enrolled in our study, of whom 33
(59%) were boys and 23 (41%) girls. The mean age was 3.3 years (range
6 months to 13 years). In 10 (17.8%), the BB was beyond the reach of
esophagogastroduodenoscope and passed off spontaneously without any
adverse events while in 27 (48.2%) patients, BB from the stomach was
retrieved without any difficulty. A total of 19 (33.9%) patients had im-
pacted BB. Amongst 9 patients with impacted BB in the cricopharynx,
two went on to develop esophageal stricture needing serial dilatations.
The most serious adverse event occurred in one patient with perforation
and peritonitis needing laparotomy.
Conclusions: A vast majority of the ingested BBs pass off sponta-
neously or require minimal endoscopic intervention. Adverse events
arise when BBs are of a larger diameter (>10 mm) and get impacted
in the esophagus.
Keywords Button battery, Impaction, Endoscopic retrieval, Laparotomy
336
Fatal outcome of perforating lower esophageal button battery in a
child
Shubhika Garg, Taranum Fatima, Areesha Alam, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital
(ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background Impacted button battery (BB) in the esophagus can be fatal
unless managed urgently.
S107
Case characteristics A 2-year-old male child presented with respi-
ratory distress from three weeks. Chest X-ray suggested a radi-
opaque foreign body, which was confirmed to be esophageal BB
during esophagoscopy and subsequently removed. Corrosive na-
ture of BB had perforated the lower esophagus leading to
pyopericardium and pyothorax.
Outcome Inspite of appropriate antibiotics and surgical drainage, child
died of sepsis.
Message Impacted esophageal BB should be removed as an emergency
procedure. Any delay might lead to poor outcome.
Keywords Button Battery, Esophagus, Perforation
337
Safety and efficacy of endoscopic retrograde cholangio-
pancreatography in children: Ten years’ experience from a single
tertiary care center
Syed Shafiq, Harshad Devarbhavi, Mallikarjun Patil
Correspondence- Syed Shafiq-syed.dr.s@gmail.com
Department of Gastroenterology, St. John's Medical College Hospital,
Bengaluru 560 034, India
Introduction The role of endoscopic retrograde cholangio-
pancreatography (ERCP) both as a diagnostic and therapeutic tool is well
established in adults, while there is a paucity of data regarding its safety
and efficacy in the pediatric population. The aim of our study was to
evaluate the outcomes of ERCP in the management of pancreaticobiliary
diseases in children (<18 years) by adult gastroenterologists using stan-
dard duodenoscopes.
Methods Consecutive patients aged 18 years or less who
underwent ERCP from January 2010 to December 2019 were
identified from our endoscopy database. Data pertaining to patient
demographics, indications, success at cannulation of the desired
duct, findings on cholangiopancreatogram, and adverse events if
any were recorded.
Results A> total of 175 ERCP procedures were performed on 159 chil-
dren, aged between 3 years to 18 years with 93 (58.5%) males and 66
(41.5%) females. The most common indications for ERCP were chronic
pancreatitis (CP) with pancreatic duct disruption and/or acute exacerba-
tions (n=93) followed by choledocholithiasis with biliary pancreatitis
(n=41) and with cholangitis (n=4), choledochal cyst (n=12), and traumatic
pancreatic duct disruption (n=10). Less common indications included pan-
creas divisum (n=6), PCC (n=3), hepatic hydatic cyst with biliary commu-
nication (n=2), traumatic liver laceration (n=1), progressive familial
intrahepatic cholestasis with intractable pruritus (n=1), primary sclerosing
cholangitis (n=1) CBD stricture status post-surgery for rhabdomyosarco-
ma (n=1). Cannulation was successful in 95% of the patients. Adverse
events were noted in 4 patients (2.2%), post-ERCP pancreatitis in 3 pa-
tients and one had post-sphincterotomy bleed, all of whom were managed
conservatively. There was no procedure or anesthesia related mortality.
Conclusions ERCP when performed by expert endoscopists is a
relatively safe and effective procedure in children. Our study
shows a predominance of pancreatic over biliary disorders as an
indication for ERCP.
Keywords Endoscopic retrograde cholangiopancreatography, Pediatric,
Chronic pancreatitis, Choledocholithiasis, Pancreatic duct leak
338
Pediatric liver abscess in Covid-19 era- Causal or casual?
Amarinder Oberoi, Naina Chakravarty, Vishrutha Poojari, Sagar
Mehta, Ira Shah
Correspondence- Amarinder Oberoi-amarinderoberoi@gmail.com
S108
Department of Pediatric Gastroenterology and Hepatology, Bai Jerbai
Wadia Hospital for Children, Acharya Donde Marg, Parel, Mumbai
400 012, India
COVID-19 has rapidly spread all over the world. Little is known about
hepatic infections associated or aggravated in pediatric age groups.
Objectives To study the incidence of liver abscess in pediatric patients
between January 2019 to August 2020 and the impact of COVID-19
pandemic on demographics of the same.
Design A retrospective cohort study of 29 patients diagnosed as
liver abscess at a tertiary care Pediatric Centre in India. The patients
presented between January 2019 August 2020. The cases reported
from January 2019 to February 2020 were classified as “Pre-Covid
cases” and the ones there after as “Intra-Covid cases”. Factors as-
sociated with liver abscesses were analyzed by Fischer’s exact test
and Student t test. P value <0.05 was considered significant.
Results Twelve (40%) patients presented in the Intra-covid months
whereas 17 (60%) in the pre-Covid period of which 2 were COVID-19
positive. Boys predominated in the pre-Covid era (59%, n=10) whereas a
female preponderance was seen in the intra-Covid period (68%, n=7)
(p=0.462). Table 1a and 1b depicts the factors associated with liver ab-
scess in the pre- and intra-Covid period. Salmonella typhi was isolated in
the pus culture in one patient while no other aerobic organisms could be
isolated other cases. There was no mortality in our study.
Conclusions Prevalence of liver abscesses was higher in the
COVID-19 era. During the Covid period, the lesions were multiple
and had higher volume of pus requiring pigtail insertion, as well as
longer hospital stay with prolonged duration of intravenous antibi-
otics. Further studies are needed to determine if there is a difference
in the causative organisms during the COVID period, and whether
COVID-19 causes a change in the epidemiological prevalence of
bacterial infections in the community.
Keywords Liver abscess, Children, COVID-19
Surgical Gastroenterology
339
A simple novel concept to conservatively manage refractory spasm in
acute fissure-in-ano: Defecation put on-hold temporarily (DePOT)
Pankaj Garg, Sohail Singh Sodhi
Correspondence- Pankaj Garg-drgargpankaj@yahoo.com
Department of Medical Gastroenterology, Dayanand Medical College
and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India
Introduction Severe spasm and pain in acute fissure-in-ano is primarily
aggravated by defecation. Fissure are usually constipated and the shearing
force of the hard stools aggravates the spasm. Moreover, the ‘narrowed’
anal outlet due to spasm further increases the impact of this shearing
force.
Methods Acute fissure-in-ano patients with refractory spasm were man-
aged by DePOT (defecation is put on-hold temporarily) regimen. This not
only provided immediate pain relief but would also led to earlier resolu-
tion of fissure-in-ano by removing the aggravating factor (defecation
process). While implementing DePOT, the daily requirements of protein,
minerals, vitamins, water, and fats were taken care of. This was done by
liquid diet having zero fiber plus full nutrition (oral rehydration solution
[ORS], vitamin supplementation and protein [whey] supplementation
[50-60 grams/day]). Once these nutritional needs of the patient are taken
care of, then it is not difficult for the patient to sustain on the liquid diet for
a week. An enema is given on the first day of the DePOT regimen to
evacuate the rectum so as to avoid hardening of residual stools already
present in the rectum.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Results DePOT was also prescribed for seven days to four patients of
acute fissure-in-ano with refractory spasm in whom conservative man-
agement was not working (26-year/male, 23-year/female, 34-year/female,
29-year/male). All patients except the third patient, had immediate pain
relief and the acute spasm improved progressively over next 7-10 days.
The third patient had to stop DePOT after 3 days as she developed an
intersphincteric abscess and was operated for the same.
Conclusion The DePOT regimen puts defecation process on hold for a
week by zero fiber, full nutrition, liquid diet. It is a simple, novel, eco-
nomical, safe and easily reproducible concept to provide immediate relief
and helps prevent surgery in acute thrombosed hemorrhoids and acute
fissure with refractory spasm.
Keywords Acute anal fissure, Fissure-in-ano, Defecation
340
Novel non-surgical treatment of intractable bleeding in hemorrhoid
patients on anti-coagulants
Pankaj Garg, Sohail Singh Sodhi
Correspondence- Pankaj Garg-drgargpankaj@yahoo.com
Department of Colorectal Surgery, Dayanand Medical College and
Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India
Introduction Bleeding hemorrhoids can be extremely troublesome in pa-
tients on anti-coagulants/anti-platelet drugs, especially in high-risk elder-
ly patients, who are also unfit for surgery. There is no effective manage-
ment available in such a scenario. Regular rectal enema as conservative
treatment (REACT) is a new non-surgical life-saving concept which was
tried in these patients.
Methods The root causes bleeding (bursting of hemorrhoids) are in-
creased straining, prolonged time spent during defecation and increased
frequency of motions. If these root causes of hemorrhoidal rupture could
be eliminated by converting the act of defecation from an active mecha-
nism to a passive one, then it would be extremely effective in controlling
the bleeding and relieving the symptoms. Regular daily enema does pre-
cisely this. It is like a rectal wash and almost completely removes the need
to strain for defecation. It also decreases the time spent during defecation.
It simply gives time to the torn hemorrhoids to repair themselves, thus
stopping bleeding and diffusing the emergency situation. In the study, the
enema was given once daily for ten days. REACT was repeated if bleed-
ing happened again.
Results REACT was tried in two patients (76 yrs/F, 82/M) who and
presented with persistent bleeding for three weeks due to grade III hem-
orrhoids. Both were on anti-coagulants and had developed anemia (Hb-
6.2, 7.3 gm/dL). Due to associated comorbid conditions (cardiac and
cerebrovascular), the anti-coagulants couldn’t be stopped and surgery
was very high risk. Both the patients were advised REACT with
sodium-phosphate rectal enema for 10 days The bleeding stopped in both
patients within 3 days. Both the patients were doing well after 6 months of
follow-up.
Conclusions REACT is a new, simple, safe, economical, non-surgical,
domiciliary and effective method to stop bleeding in hemorrhoids patients
on anti-coagulants and having associated comorbidities (especially the
patients whose anticoagulants cannot be stopped).
Keywords Hemorrhoids, Bleedings, Anti-coagulants
341
Synchronous esophageal and gastric malignancy presented as gas-
trointestinal bleeding: Curative resection by single sitting endoscopic
sub mucosal dissection
Rohan Maydeo, Pravin Suryawanshi
Correspondence- Rohan Maydeo-rohanmaydeo@gmail.com
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Department of Surgery, MGM Medical College, Aurangabad 431 003,
India
Introduction With the improvement and advancements in endoscopic
imaging, the diagnosis of the synchronous multiple primary early cancers
in esophagus and stomach is increasing, while the traditional surgery for
these malignancies are radical and much more invasive leading to signif-
icant morbidity. With evolving experience, endoscopic submucosal dis-
section (ESD) has become the preferred treatment option of early cancer
in the digestive tract.
Case Summary Sixty-four-year old male, chronic smoker and alcoholic, pre-
sented with history of recurrent melena and severe anemia requiring blood
transfusion. Upper gastrointestinal endoscopy revealed mid esophageal lesion
(Paris 0-IIA) and gastric antral lesion (Paris 0-IIB). On endoscopic biopsy
esophageal lesions was moderately differentiated squamous cell carcinoma
and gastric lesion was intramucosal adenocarcinoma. On endoscopic ultra-
sound esophageal lesion was arising from mucosal layer with intact
muscularis propria (T1a, N0) and gastric lesion was superficial without inva-
sion of the submucosa (T1 N0). Patient underwent ESD of both lesions in
single sitting with complete en-block excision of the lesion. On follow up
check endoscopy at 3 months and 6 months, no evidence of recurrence lesion
was observed.
Conclusion Endoscopic submucosal dissection is a feasible option
for curative resection of early malignancies of the gastrointestinal
tract.
Keywords Early GI malignancy, ESD, Synchronous malignancy
342
Unusual presentation of a large GIST in extraintestinal site: An
intra-operative surprise and challenging diagnostic dilemma
Govind Purushothaman, Jeswanth S
Correspondence- Govind Purushothaman-govindmmc@gmail.com
Department of Surgical Gastroenterology and Liver Transplant, Institute
of Surgical Gastroenterology and Liver Transplantation, Stanley Medical
College and Hospital, No. 1, Old Jail Road, Chennai 600 001, India
Introduction GISTs are rare mesenchymal tumors that can arise in any
part of the GIT. Most of these tumors arise in the stomach and small
intestine. It should be noted that, GISTs that originate from outside of
the GIT, are defined as EGISTs and are usually arise from omentum,
mesentery and retroperitoneum, adjacent, but separate from the stomach
and the intestine. EGIST accounts for 10% of all GISTs.
Case Study Sixty-year-old male presented with left hypochondrial pain
for 1 week with fever and vomiting, no addictions. Examination showed
non tender mass in left hypochondrium, not moving with respiration.
Blood investigations were normal. USG abdomen showed 8*10 cm cys-
tic lesion in epigastrium, abutting inferior margin of liver and distended
gallbladder and cholelithiasis. MRI showed a 15*7.2*8 cm bilobed lob-
ulated thick walled lesion, ? pancreatic pseudocyst in body and tail
projecting anteriorly into lesser sac, wall thickness of 7 mm, with normal
MPD in head and uncinate region, with cholelithiasis. With a preopera-
tive diagnosis of pseudocyst pancreas, patient was planned for
cystogastrostomy. However intraoperatively there was a large
multilobulated cystic lesion, 15*15*20 cm ?arising from tail of pancreas
with areas of hemorrhage inside the lesion along with solid components,
extending from gastric pylorus to splenic hilum abutting stomach poste-
rior wall to transverse mesocolon, suggestive of an extraluminal neo-
plasm. The patient thus underwent distal pancreatectomy along with sple-
nectomy and cholecystectomy (in view of cholelithiasis). Histopathology
report showed gastrointestinal stromal tumor, staining positive for CD
117.
Conclusion We present a case of EGIST which masqueraded as
pseudocyst pancreas on imaging. Other than individual case reports and
small case series on EGIST, the number of cases has been limited. Further
S109
studies on the pathogenesis, behavior, and molecular biology of EGIST
are needed before evidence-based diagnostic or prognostic recommenda-
tions can be made.
Keywords Extra-gastrointestinal stromal tumor incidence
Nutrition
343
Hospital malnutrition and its clinical significance in children with
acute viral hepatitis
Wamique Khan, Shashwat Jha, Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital
(ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Introduction Hospital malnutrition is malnutrition diagnosed at any
time during hospital stay. Hospital malnutrition which depends on
various factors is common in pediatric inpatients as their nutrition-
al status often deteriorates during hospital stay. Acute viral hepa-
titis in children is a major public health problem in both develop-
ing and developed countries .Given the protein catabolism and
higher energy requirement and dietary taboos associated with acute
viral hepatitis, energy intake will probably be inadequate, increas-
ing the risk of hospital malnutrition and its complications. Hence
we planned this study to identify nutritional risk in hospitalized
children with acute viral hepatitis and to evaluate its correlation
with clinical outcome.
Methods This cross-sectional study was conducted for a period of
18 months with a sample size of 70. All admitted children between
6-16 years who were clinically diagnosed as acute viral hepatitis
were included. Nutritional assessment was done at admission, dis-
charge, 2 weeks and 3 months post discharge. Nutritional assess-
ment included W/A;H/A;W/H, and BMI. Nutritional risk screening
was done by PYMS scoring system and on that basis the children
were classified into high, medium and low risk patients. Outcomes
were assessed in two aspects Nutrition and disease related.
Results The mean age of the cases was 10.10±3.71 years with
maximum age of the cases was 16 years and minimum was 5.5
years. At the time of admission and discharge, 37.1% cases were
at high risk, 38.65 were at medium risk and only 24.3% at low
risk. The mean length of hospital stay of high-risk cases was max-
imum 13.23±1.48 days and minimum 4.12±2.12 days in low risk
cases (p<0.001). The mean hospital expenses of high-risk cases
was maximum Rs 3589.62±395.98 (p<0.001).
Conclusions Hospitalized children of acute viral hepatitis with high nu-
tritional risk have significantly higher length of hospital stay and hospital
expenses
344
Combination of sarcopenia and high visceral fat predict poor out-
comes in patients with Crohn’s disease
Gurasis Boparai, Saurabh Kedia, Devasenathipathy Kandasamy, Raju
Sharma, Kumble Seetharama Madhusudhan, Nihar Ranjan Dash,
Pabitra Sahu, Sujoy Pal, Peush Sahni, Rajesh Panwar, Sudheer K
Vuyyuru, Bhaskar Kante, Davesh P Yadav, Venigalla Pratap Mouli,
Govind Makharia, Vineet Ahuja
Correspondence- Vineet Ahuja-vineet.aiims@gmail.com
Departments of Gastroenterology, Gastrointestinal Surgery, and
Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India
S110
Background Sarcopenia and visceral fat independently predict poor out-
comes in Crohn’s disease (CD). However, combined influence of these
parameters on outcomes in unknown. We estimated the prevalence of
sarcopenia and its combined influence with visceral fat on outcomes in
CD.
Methods This retrospective study evaluated skeletal muscle index
(SMI-cross-sectional area of five skeletal muscles normalized for
height), visceral and subcutaneous fat area and their ratio (VF/SC)
on single slice computed tomography (CT) images at L3 vertebrae
in CD patients (CT done between January 2012-December 2015,
patients followed till December 2019). Sarcopenia was defined as
SMI <36.5 cm2/m2 and 30.2 cm2/m2 for males and females re-
spectively. Disease severity, behavior, and long-term outcomes
(surgery and disease course) were compared with respect to
sarcopenia and VF/SC ratio.
Results Forty-four patients (age at onset:34.4±14.1 years, median disease
duration:48 [24–95] months, follow-up duration:32 [12–53.5] months,
males:63.6%) were included. Prevalence of sarcopenia was 43%, more
in females, but independent of age, disease severity, behavior and loca-
tion. More patients with sarcopenia underwent surgery (31.6% vs. 4%,
p=0.01). VF/SC ratio was also significantly higher in patients who
underwent surgery (1.76+1.31 vs. 0.9+0.41, p=0.002), and a cut-off of
0.88 could predict surgery with sensitivity and specificity of 71% and
65% respectively. On survival analysis, probability of remaining free of
surgery was lower in patients with sarcopenia (59.6% vs. 94.1% p=0.01)
and those with VF/SC ratio >0.88 (66.1% vs. 91.1%, p=0.1), and lowest
in those with both sarcopenia and VF/SC>0.88 than those with either or
none (38% vs. 82% vs. 100%, p=0.01).
Conclusion Combination of sarcopenia and high visceral fat predict
worse outcomes in CD than either of two.
345
Refeeding syndrome in a child with celiac disease: A rare entity
Hina Tabassum, Anantika Garg, Pallav Singhal, Sumaiya Shamshi,
Shrish Bhatnagar
Correspondence- Shrish Bhatnagar-drshrishbhatnagar@gmail.com
Department of Pediatrics, ERA's Lucknow Medical College and Hospital
(ELMCH), Hardoi Road, Sarfarazganj, Lucknow 226 003, India
Background Refeeding syndrome is a rare and life-threatening pathology
ascribed in those celiac patients who deteriorated clinically after initiation
of a gluten-free diet (GFD) and had biochemical parameters such as
hypophosphatemia, hypokalemia, hypocalcemia, and hypoalbuminemia.
Case characteristics Four-year-old girl presented with complaint of con-
stipation, abdominal distension, vomiting, failure to thrive and anorexia.
The child was emaciated and weighed 10.3 kg. Had pallor, distended
abdomen but no organomegaly. Upper GI endoscopy was done showing
D2 bald mucosa with scalloping. Duodenal biopsy had Marsh Gr 3c
features. She was diagnosed as celaic disease and was discharged on
GFD with weight gain of 500 g. However, she was readmitted after 12
days with complaint of poor oral intake, diarrhea and pain abdomen. She
had severe dehydration with severe anemia and CHF. On investigation
hypophosphatemia, hypokalemia, hypocalcemiaemia and hypoalbumin-
emia was present suggestive of refeeding syndrome. Patient was managed
in the PICU with IV antibiotics, albumin and PRBC transfusion along
with correction of all metabolic abnormalities as per protocol. Gradually,
her enteral feeding was resumed and was discharged on 12 days, with
weight gain of 2.9 kg, receiving GFD with oral supplementation of cal-
cium and phosphorous.
Message Refeeding syndrome in children with celaic disease is a rare but
known entity. It can result in prolonged hospital stay and even death if not
recognized and treated promptly. Prevention is the key to avoid metabol-
ic, physiologic and multi-organ complications.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Keywords Refeeding syndrome, Celiac disease
346
Clinico-epidemiological profile of patients undergoing feeding proce-
dures in a tertiary care center- A descriptive cross- sectional study
S Rajeevan, A Chezhian, K Premkumar, R Murali, I Shubha
Correspondence- A Chezhian-chezhianannasamy@gmail.com
Department of Medical Gastroenterology, Madras Medical College, Near
Park Town Station, Park Town, Chennai 600 003, India
Introduction Feeding procedures are done when patients are unable to take
adequate nutrition orally. This could be due to gastrointestinal pathologies,
critical illness, encephalopathy, etc. Patients with dysphagia can have oropha-
ryngeal or esophageal pathologies. This study tries to characterise the
clinicoepidemiological profile of patients undergoing feeding procedures in
a tertiary care centre.
Methods Descriptive cross-sectional study conducted in Medical
Gastroenterology Department of Madras Medical College for 1 year du-
ration (September 2019 to August 2020) in 344 patients.
Results Of the 344 patients studied 263 (76.5%) were males and 81
(23.5%) were females. 82% of patients who underwent nasogastric tube
(NGT) insertion and 62.9% of dilatation were males. Feeding procedures
done were (NGT) insertion (66.3%), esophageal dilatation (25.9%),
esophageal self-expanding metal stent (SEMS) (0.6%) and percutaneous
endoscopic gastrostomy (PEG) (0.3%). 7% of patients underwent both
dilatation and NGT insertion. Most of the patients had grade 3 dysphagia
(61.9%). The median age of feeding procedures was 55 years (NGT-58
years; dilatation- 52 years). The most common indications for NGT in-
sertion were carcinoma of oropharynx (46.9%), hypopharynx (29.4%)
and esophagus (10.1%). The most common indications for esophageal
dilatation were carcinoma of esophagus (34.8%) and hypopharynx
(21.3%). Two patients with carcinoma esophagus underwent SEMS.
PEG was done for a case of neurogenic dysphagia. Carcinoma esophagus
affected upper third in 49.6% and middle third in 37.4% cases. Squamous
cell carcinoma (96.9%) was the most common histological variant among
malignancies. Corrosive injuries requiring feeding procedures were main-
ly of Grade 2B (60%) severity.
Conclusion In this study the most common feeding procedure was NGT
insertion. Oropharyngeal cancer and esophageal cancer were the most
common indications for NGT insertion and dilatation respectively.
Squamous cell carcinoma was the most common histological variant in
malignancies. Among corrosive injuries, acid poisoning and grade 2B
injuries were more common.
Keywords Feeding, Dysphagia, Dilatation
Biliary Tract
347
A rare case of obstructive jaundice caused by tuberculosis
Dharmendra Tyagi
Correspondence- Dharmendra Tyagi-drdtyagi89@gmail.com
Department of Gastroenterology, Kurnool Medical College, Budhwarpet
Road, Budhawarapeta, Kurnool 518 002, India
Introduction Extrapulmonary involvement occurs in one fifth of all TB
cases and out of them, 60% have no evidence of pulmonary infection in
chest radiograph or in sputum. Tuberculosis can present as a obstructive
jaundice but it is a very rare entity with only a few cases reported. We are
reporting unusual case of multiple enlarged tuberculous lymph nodes
compressing the common bile duct in the retro pancreatic region and
causing obstructive jaundice.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Case Report A 27-year-old male patient presented as yellowish
discolouration of urine for 5 days with history of clay colored stool.
There was no history of fever, vomiting, weight loss, abdominal pain
and distension. Patient had history of contact with tuberculosis patient.
On physical examination, icterus was present but normal GI examination.
In laboratory investigation, LFT showed the pattern of obstructive jaun-
dice. USG showed CBD dilatation of 9 mm.
MRCP showed cystic lesion at posterior aspect of head of pancreas
with loss of fat plane appearing hyperintense on T2W and STIR
images while hypointense on T1W images. Multiple small cysts
seen in lesion. Size of lesion 29×24×38 mm. This lesion
compressing CBD with diameter 11 mm. So patient kept for EUS
which showed multiple, enlarged, discrete to ill defined, hypoechoic
lymph nodes in per pancreatic and hilar region with few lymph
nodes were matted and these lymph node were compressing the
distal CBD causing proximal CBD dilatation of 8.7 mm with normal
pancreatic duct. EUS guided biopsy was taken which showed gran-
ulomatous lymphadenitis with caseating necrosis indicated tubercu-
lar lymphadenopathy.
Conclusion Isolated peripancreatic tuberculous lymphadenitis is extreme-
ly rare. It is a diagnostic challenge and for that a high index of suspicion is
needed and should be considered in the context of the peripancreatic or
pancreas head mass especially in a young adult.
348
Demographic, clinical, biochemical and microbial spectrum of
cholangitis patients admitted at a tertiary care centre in North India
Arpan Jain, Gaurav Padia, Anurag Mishra, Manish Kumar, Ujjwal
Sonika, Ashok Dalal, Ajay Kumar, Siddharth Shrivastava, Sanjeev
Sachdeva, Barjesh Chander Sharma
Correspondence- Arpan Jain-drjain.arpan@gmail.com
Department of Gastroenterology, Gobind Ballabh Pant Institute of
Postgraduate Medical Education and Research, 1, J L N Marg, New
Delhi 110 002, India
Background Acute cholangitis is the infection of the biliary tree with life
threatening outcomes. The aim was to analyze the clinical profile, micro-
bial spectrum and outcome of patients with cholangitis at our centre.
Methods A prospective observational study of patients who underwent endo-
scopic retrograde cholangiopancreatography (ERCP) for cholangitis (as per
Tokyo guidelines) due to any biliopancreatic disorder from July 2019 to
December 2019. Bile samples collected during ERCP were sent for culture
and sensitivity. The demographic profile, clinical and biochemical profile,
microbial spectrum along with their sensitivity patterns and patient outcome
were studied. The data analysis was done with SPSS 23.
Results A total of 92 patients were included with median age of 49 (Range
15-85 years). Females comprised 73.9% (n=68). Etiology of cholangitis
was mainly benign, most common being choledocholithiasis
(n=42,45.6%). Cholangitis with underlying malignancy was less com-
mon (n=17,18.5%). Charcot’s triad (n=44,47.8%) was more common
than Reynod’s pentad (n= 3,3.3%). Renal failure was the predominant
organ failure (n=14,15.2%) and 12 cases had hypotension at admission (8
patients required inotropic support). Mean leukocyte count was 16876
±6496/mm3, bilirubin and alkaline phosphatase (ALP) levels were 9.60 ±
7.18 mg/dL and 596±471 U/L, respectively. Mean serum procalcitonin
levels were 3.19 ± 1.8 ng/mL. Most frequent organism identified on bile
culture was E. coli (n=35,38%) followed by pseudomonas (n=20, 21.7%)
and Klebsiella (n=7, 7.6%) and was sterile in (n=28, 30.4%) cases. Most
sensitive antibiotic was imipenem followed by tigecycline and piperacil-
lin/tazobactum. Multidrug resistant organisms (n=25, 27.2%) were also
identified. Mean hospital stay was 8 ± 7.6 days, with most cases being
discharged (n=80, 87%) and with mortality in 12 patients.
Conclusion Gram negative organisms were the most frequent cause of
cholangitis with E. coli and pseudomonas being the most common.
S111
Emergence of multidrug resistant organism mandates judicious use of
antibiotics in hospital settings. Cholangitis was more frequent due to
benign etiologies.
349
Impacted distal pancreatic duct calculus causing obstructive jaun-
dice and double duct sign
Gursimran Kaur1, Mahesh Kumar Gupt, Avnish Seth
Correspondence- Avnish Seth-avnish.seth@fortishealthcare.com
Gastroenterology and Hepato-Biliary Sciences, Fortis Memorial
Research Institute, Gurugram 122 002, India
Background Simultaneous dilatation of common bile duct and pancreatic
duct, the double-duct sign, is considered an ominous finding at imaging
and usually suggestive of peri-ampullary malignancy.
Case Report 32-year-old male presented with pain epigastrium and right
upper abdomen with jaundice for 3 days. The pain was severe, exacerbated
with meals and was radiating to the back. There was history of episodes of
similar pain without jaundice for last 3 years. There was no history of fever,
weight loss, alcohol intake, steatorrhea or diabetes. On examination there was
icterus and marked epigastric tenderness. Bilirubin was 6.5 mg/dL, ALT
1450 U/L, GGT 760 U/L, lipase 90 U/L, CA-19.9 58 U/mL. MRCP showed
dilated entire MPD of up to 8 mm with clubbing of side branches and possible
impacted stone at distal end. Bile duct dilated 9 mm with no filling defect.
EUS confirmed double duct sign with changes of chronic pancreratitis with
impacted distal MPD stone and dilated CBD till distal end with no filling
defect. ERCP showed bulky ampulla and of 7 mm diameter impacted stone
was removed from distal PD with needle-knife pre-cut and manipulation. 10F
X 8 cm plastic tannenbaum stent was placed in CBD and 7F X 8 cm
percuflex plastic stent was placed in PD. Pain abdomen and LFT improved
rapidly. Both stents were removed at 3 months and he continues to do well on
medical treatment for chronic pancreatitis.
Conclusion Impacted distal pancreatic duct stone can present with ob-
structive jaundice and double duct sign.
350
IgG4-related sclerosing cholangitis: A great mimicker
Hemant Nayak, Sunil Jee Bhat, Manas Kumar Panigrahi, Subash
Chandra Samal
Correspondence- Hemant Nayak-drhemantnayak@gmail.com
Department of Gastroenterology, All India Institute of Medical Sciences,
Sijua, Patrapada, Bhubaneswar 751 019, India
Introduction IgG4-related sclerosing cholangitis (IgG4 SC) is the biliary
manifestation of IgG4 related disease often in association with autoim-
mune pancreatitis. Here we report two patients of IgG4 SC mimicking
primary sclerosing cholangitis and carcinoma head of pancreas,
respectively.
Case 1 A 16-year-old boy presented with history of recurrent self-limiting
episodes of jaundice and pruritus for last 4 years. liver function tests
(LFT) suggested cholestatic jaundice. Ultrasound abdomen was non-con-
tributory. Magnetic resonance cholangiopancreatography (MRCP) was
characteristic for multiple intrahepatic biliary strictures with beaded ap-
pearance and long segment narrowing in distal segment of common bile
duct (CBD). Serum IgG4 level was raised 227 mg/dL (80-120 mg/dL).
Contrast enhanced computed tomography (CECT) of abdomen revealed
bulky pancreas. After receiving prednisone 40 mg daily for 2 months,
jaundice settled and biliary strictures resolved on repeat MRCP. He is on
maintenance azathioprine 50 mg without any relapse in last 8 months.
Case 2 A 54-years-old woman presented with abdominal pain, weight
loss and anorexia for 2 months. Her physical examination revealed
marked pallor, mild icterus, and left axillary lymphadenopathy.
S112
Laboratory investigations showed pancytopenia, hyperbilirubinemia,
mild transaminitis and elevated alkaline phosphatase. CECT abdomen
revealed bulky pancreas and CBD dilatation. Endoscopic retrograde
cholangiopancreatography (ERCP) revealed distal CBD stricture and
beaded appearance of pancreatic duct in head of pancreas. Serum IgG4
was significantly raised (815 mg/dL). We suspected IgG4 SC. Patient
received oral prednisolone 40 mg for 4 weeks and tapered over next 8
weeks. After 8 weeks, all her symptoms and signs improved. Repeat
ERCP after 2 months revealed complete resolution of pancreatic and
biliary strictures. No relapse was noted till 6 months of follow-up.
Conclusions IgG4 SC is an important treatable disease and it greatly mimicks
other benign and malignant diseases of the pancreato-biliary system.
351
Profile of malignant obstructive jaundice in a tertiary care centre of
West India
Partha Debnath, Rahul Deshmukh, Pankaj Nawghare, Sameet Patel,
Parmeshwar Junare, Ravi Thanage, Sanjay Chandnani, Qais Q
Contractor, Pravin Rathi
Correspondence- Partha Debnath-partha628@gmail.com
Department of Gastroenterology, Topiwala National Medical College, B
Y L Nair Hospital, Mumbai 400 008, India
Introduction Malignant obstructive jaundice is one of the common causes
of referral to a Gastroenterologist. Our study aimed to identify the etiol-
ogy and clinical profile of malignant obstructive jaundice cases in our
center.
Methods One hundred patients with malignant obstructive jaundice over a
period of 1 year (January 2019- February 2020) were studied. The diag-
nosis was based on imaging findings along with cytology/histopathology.
Demographic, clinical, biochemical, Imaging, ERCP, and cytology find-
ings were recorded.
Results Of the 100 patients mean age was 57.47±13.87 years (median age
60 years), 54% of patients were females. The mean duration of symptoms
before diagnosis was 1 month. Cholangiocarcinoma was the commonest
etiology (36%), followed by gallbladder cancer (26%), ampullary carci-
noma (22%), carcinoma head of the pancreas (13%), lymphoma (2%),
and one case of retroperitoneal neuroendocrine tumor with liver metasta-
sis (1%). Clinical profile of patients included jaundice (100%), abdominal
pain (68%), loss of appetite (50%) and weight (40%), fever (27%), ab-
dominal mass (29%), pruritus (20%), vomiting (14%). 64% of patients of
gallbladder cancer had a history of cholelithiasis. Cholangitis was present
in 32% gallbladder cancer, 25% in cholangiocarcinoma, 30% in ampul-
lary carcinoma, 7.7% in carcinoma head of the pancreas. Imaging was
suggestive of type 1 block in 100% patients with ampullary carcinoma
and carcinoma head of the pancreas, and type1, type 2, type 3, type 4
block was seen in (36%/30%/6%/28%) gallbladder cancer, (44%/15%/
0%/41%) of cholangiocarcinoma cases. Advanced stage disease (stage 3
and 4) at diagnosis was seen in 72% of gallbladder cancer, 55.5% in
cholangiocarcinoma, 46.2% in carcinoma head of the pancreas.
Conclusion Cholangiocarcinoma (36%) is the most common etiology of
malignant obstructive jaundice in our center. The majority of the cases
occur in the older age group with slight female preponderance (54%).
Majority of the patients presented in an advanced stage.
352
Endoscopic ultrasound for characterization of distal common bile
duct block- Is it better than MRCP?
Rahul Kakkar, Shraddha Sharma, Naveen Yadav, Sewaram Chaudhary,
Sabir Hussain, Narender Bhargawa, Sunil Dadhich
Correspondence- Rahul Kakkar-kakkarrahul1805@gmail.com
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Department of Medical Gastroenterology, Dr. S N Medical College,
Residency Road, Near Sriram Excellency Hotel, Opposite Petrol Pump,
Sector-D, Shastri Nagar, Jodhpur 342 003, India
Background Endoscopic ultrasound (EUS) is a novel technology which is
being increasingly utilised to visualize the gastrointestinal tract as well as
nearby structures mainly liver, gallbladder, pancreas, biliary tract and lymph
nodes. EUS guided FNAC or biopsy helps to obtain tissue diagnosis. Role of
EUS has now increased from diagnostic tool to therapeutic tool.
Aim To compare the efficacy of EUS with MRCP in the characterisation
of pathology in patients presented with surgical obstructive jaundice
(SOJ).
Methods We have planned a study in our department in patients who
presented with clinical and radiological findings of SOJ. The study in-
cluded 255 patients from January 2019 to July 2020. Both EUS and
MRCP were done in these patients. In case of mass lesions, EUS guided
FNAC was done either from mass lesion or from metastatic lymph nodes,
whichever feasible.
Results The most common pathology was choledocholithiasis (n=110),
followed by pancreatic malignancy (n=57), gallbladder (GB) malignancy
with common bile duct (CBD) involvement (n=45), distal CBD cholan-
giocarcinoma (n=17), ampullary malignancy (n=16), hilar cholangiocar-
cinoma (n=5) and choledochol cyst (n=5). In our study, we found that
EUS is superior than MRCP for the characterization of lesions causing
distal CBD block (sensitivity of EUS and MRCP was 98.9% and 95.8%
respectively) while MRCP is better in case of hilar block (sensitivity of
MRCP and EUS were 94.6% and 83.8% respectively) and both have
equal efficacy in evaluation of mid CBD block (sensitivity of 100% for
both MRCP and EUS).
Conclusions EUS has very high sensitivity and specificity for the char-
acterization of distal CBD lesions in patients presented with SOJ as com-
pare to MRCP. It also has an additional advantage of obtaining tissue for
diagnosis as compare to other diagnostic modalities.
353
Laparoscopic single-stage management of cholecystogastric fistula-
A rare case report and review of literature
Anandkumar Jayaram, Narayan Prasad, Kavya Taranath
Correspondence- Anandkumar Jayaram-anandsgn@gmail.com
Department of General and Minimally Invasive, RMV Hospital, No 138,
RMV 2nd Stage, AECS Layout, Sanjay Nagar, Bengaluru 560 094, India
We hereby present a very rare case report of cholecystogastric fistula in an
elderly female patient, which was managed by laparoscopic single stage
approach. Patient had on and off abdominal pain and bloating sensation.
After thorough investigation, patient was taken up for laparoscopic cho-
lecystectomy for chronic calculous chlecystitis. Intraoperatively, inciden-
tally along with lot of adhesions to the gallbladder there was a
cholecystogastric fistula which was managed by laparoscopic single-
stage approach entirely. We here by present this case, highlighting the
rarity of its incidence, the clinical findings and complications associated,
diagnostic imaging and, the surgical approaches and its technical chal-
lenges in managing such cases and the review of literature as a video
presentation link attached below.
354
Clinical profile of acute cholangitis in tertiary care centre
Shubha Immaneni, Sambit Kumar Bhuyan, Premkumar K, Murali R,
Chezhian Annasamy
Correspondence- Shubha Immaneni-gastroshubha@gmail.com
Department of Medical Gastroenterology, Madras Medical College,
Poonamallee High Road, Park Town, Chennai 600 003, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction Cholangitis defined as inflammation of biliary tract, mostly
caused by bacterial infection and obstruction of bile duct or hepatic duct.
Acute, cholangitis characterized by abdominal pain, jaundice, and fever
(Charcot’s triad) as well as confusion and septic shock (Reynolds’ pen-
tad). This study was to know different etiology of cholangitis patients
attending tertiary care Hospital.
Method It’s a retrospective observational study carried out over a period
of 1 year from September 2019 to August 2020 at Medical
Gastroenterology Department ward of Madras Medical College of all
acute cholangitis patients, diagnosed using updated Tokyo Guidelines,
with regards to demographics and etiology.
Results Total 180 patients diagnosed with cholangitis, 94 were male
and 86 were female, with mean age of 51years. One hundred and
fifty-five (80%) were acute suppurative cholangitis, 22 (12%) were
recurrent suppurative cholangitis, two were primary sclerosing
cholangitis and one was IgG4 related cholangitis. Common causes
of acute cholangitis were choledocholithiasis (57%), CBD stricture
(18%) which includes benign stricture (11%) and malignant stricture
(7%), malignant CBD occlusion (15%) which includes ampullary
tumor (10%), pancreatic tumor (3%) and bile duct tumor (2%).
Other rare causes that leads to acute cholangitis were pancreatitis
3%, EHPVO with portal biliopathy 2%, postoperative bile duct in-
jury 2%, post ERCP 2% and duodenal diverticulum 1%. Out of 88
acute cholangitis patients with choledocholithiasis 39 (25%) were
male and 49 (31%) were female. Severity grading of acute
cholangitis patients were 26% mild, 43% moderate and 32% severe.
Conclusion From this study it is concluded that choledocholithiasis and
CBD stricture were most important cause of acute cholangitis. Early
clinical diagnosis and accurate diagnostic workup including etiology-
oriented imaging is needed for prompt and appropriate management of
cholangitis.
Keywords Acute cholangitis, Choledocholithiasis, CBD stricture
355
Bronchobiliary fistula - A rare complication secondary to portal
cavernomatous cholangiopathy
Tejaswini Tumma, Ramesh Kumar B, Ramanna Macherla
Correspondence- Tejaswini Tumma-tejaswinitumma@gmail.com
Department of Gastroenterology, Osmania General Hospital, Afzalgunj
Road, Afzal Gunj, Hyderabad 500 012, India
Introduction Bronchobiliary fistula is a rare condition consisting of com-
munication between biliary tract and bronchial tree presenting with
bilioptysis and suspicious pneumonia. The management of this condition
is challenging with limited current evidence to date.
Case Report We are reporting a 45 yrs male patient presenting with
complaints of cough with green coloured sputum and shortness of breath
since 2 months. He is a K/C/O portal cavernoma. He had a past history of
right liver lobe abscess with rupture into pleural cavity 4 years back.
Investigations TSB – 1.61 mg/dL, ALP – 628 IU/L, sputum is positive for
bile pigments. Ultrasound abdomen – portal cavernoma with mild central
IHBrD. Chest X-ray – right lower lobe patchy consolidation. MRCP –
stricture at CHD and CBD level secondary to portal biliopathy with mild
upstream IHBrD. ERCP was done confirming the stricture and on dye
injection leakage of dye into right lower lobe of lung noted.8Fr DPT CBD
stent deployed with free flow of bile noted. Bilioptysis and dyspnea
decreased after stenting and CXR was cleared of patchy consolidation.
Symptoms again recurred after 2 months and patient underwent stent
exchange. Despite improvement for short-time symptoms recurred again.
So patient was referred for surgery. He underwent shunt procedure in
view of portal cavernoma and fistula was identified and closed.
Conclusion Bronchobiliary fistula is a serious complication associated
with high morbidity and mortality and requires high index of suspicion
for diagnosis and requires well planned management strategy.
S113
Keywords Portal cavernoma, Bilioptysis, CHD stricture, Broncho biliary
fistula
356
A case report of rare congenital anomaly of gallbladder and cystic
duct
Jigar Aagja, Manish Chaudhari
Correspondence- Jigar Aagja-jigaraagja@gmail.com
Department of General Surgery, Government Medical College Surat,
Opp. Income Tax Department Office, Majura Gate, Surat 395 001, India
Congenital anomalies of the gallbladder are rare and can be accompanied
by other malformations of the biliary or vascular tree. Anatomical varia-
tions of cystic duct (CD) are frequently unrecognized. It is important to be
aware of these variations prior to any surgical, percutaneous, or endo-
scopic intervention procedures. A phrygian cap is a congenital abnormal-
ity of the gallbladder with an incidence of 4%. A case of calculous cho-
lecystitis with phrygian cap and low insertion of cystic duct along with
pancreatic bead on left posterior part of CHD which was identified on
MRCP. Patient operated as laparoscopic cholecystectomy. This case is
reported for its rarity and difficulty in operating. Postoperative period is
uneventful.
Pharygian Cap, congenital anomaly of GB and CD.
357
A rare case of choledochal cyst with pancreatic divisum and complex
anamolous pancreaticobiliary junction
Bontha Vineesha, Shanmuganathan Subramanyam, Ganesh
Panchapakesan
Correspondence- Bontha Vineesha-bontha.vineesha@gmail.com
Department of Medical Gastroenterology, Sri Ramchandra Institute of
Higher Education And Research, Chennai 600 116, India
A 16-year-old female child with no significant past illness presented to the
outpatient department with 10-day history of abdominal pain and high
colored urine. The pain was localized to the right upper quadrant, associated
with nausea and vomiting and was intermittent, each episode lasting for 3-4
hours. The patient reported normal colored stools. Patient did not report
fever, pale stools or pruritus during the course of illness. Examination was
remarkable for scleral icterus and mild tenderness over the right
hypochondrium. Blood investigations were done, showed cholestatic jaun-
dice (total bilirubin: 2.99 mg/dL, direct bilirubin: 1.63 mg/dL, alkaline
phosphatase: 319 IU/L, alanine transaminase: 204 IU/L, aspartate transam-
inase: 125 IU/L, serum albumin: 4.3 g/dL). Abdominal ultrasonography
showed a normal liver size and echo texture, dilated common bile duct
(1.8 cm) along with dilated intrahepatic biliary radicles. Multiple calculi
were noted in the gallbladder, with wall thickening suggestive of calculous
cholecystitis. An MRCP (magnetic resonance cholangiopancreatography)
was done. The findings were suggestive of a choledochal cyst (type IV a)
along with a complex type of anomalous pancreatobiliary ductal union and
a variant of pancreas divisum with choledocholithiasis. Patient was taken
up for ERCP (endoscopic retrograde cholangiopancreatography) under
general anesthesia. Ampulla was noted deep in 2nd part of duodenum.
Selective bile duct cannulation was done and guidewire was placed into
the right intrahepatic duct. Cholangiogram confirmed the findings of
MRCP. Endoscopic biliary sphincterotomy was done. Balloon trawling
was done to extract CBD stones. Multiple tiny calculi and sludge was
extracted. Biliary stenting was done using a double pigtail stent of size
7Fr. Patient improved symptomatically, and liver functions normalized
over a week. Patient was referred to a specialized center for surgery.
S114
Keywords Choledochal cyst, Pancreatic divisum, Abnormal pancreatico
biliary malunion
358
Preoperative risk factor used for verification of operative grading
system for conversion from laparoscopic cholecystectomy to open
cholecystectomy
Palak Paliwal, Krishnanand Anand
Correspondence- Palak Paliwal-dr.palakpaliwal@gmail.com
General Surgery, L N Medical College and J K Hospital, J K Town Kolar
Road Sector, Sarvadharam C Sector, Bhopal 462 042, India
Introduction Laparoscopic cholecystectomy is the most commonly done
procedure for gallstone disease. Preoperative prediction factors are helpful
to categorize patients and take timely measures. The CLOC score compro-
mises of preoperative variable such as patient demographics, indications for
surgery, ASA grade, admission type and ultrasound findings. The key
aspects of operative grading system (OGS) include: 1) gallbladder appear-
ance and amount of adhesions, 2) degree of distension/contracture of gall-
bladder, 3) ease of access, 4) local/septic complications, and 5) time taken to
identify the cystic artery and duct. OGS grades the difficulty into mild,
moderate, severe and extreme. This study is a prospective observational
study with the aim to predict intraoperative grading score for conversion
from laparoscopic to open cholecystectomy.
Methods This study was done at L N Medical College, Bhopal of 100
patients who underwent laparoscopic cholecystectomy from June 2018 to
June 2020. Inclusion criteria are patient >18 years, giving informed con-
sent, with acute or chronic cholecystitis with cholelithiasis. A comparison
was made between the preoperative risk factors and intraoperative find-
ings based on OGS. The outcome measures are prediction of conversion
from laparoscopic to open cholecystectomy, bile duct injury, intraopera-
tive and postoperative complication and duration of hospital stay.
Result Out of 100 cases, 14 cases were converted into open procedure.
The cases with intraoperative complications like bile leak, bile duct injury
etc were found to be 19. In converted cases, 1 case fell into moderate
grade, 3 into severe grade and 10 into extreme grade. Also, 4 cases
underwent bile duct exploration and repair in the same sitting while 2
cases underwent delayed bile duct exploration. Out of 100 cases, 3 cases
were associated with postoperative complications.
Conclusion Operative grading system provides a better scoring system and
aids the surgeon in making decision in case of difficult cholecystectomy.
Keywords Operative grading system, Preoperative risk factors,
Laparoscopic cholecystectomy, Open cholecystectomy
359
Endoscopic therapy of traumatic bile leaks
P Abdul Samad, Shravan Kumar P, Uma Devi M, Sai Krishna K, Issac
Abhilash M, Kishan N, Sri Ram S, Anirudh K, N S V M Krishna M,
Swapnika G, Abhinay Raja Rao P, Tarun B, Gurunath B, Sivarama
Krishna D
Correspondence- P Abdul Samad-samad.abdul30@gmail.com
Department of Gastroenterology, Gandhi Medical College,
Musheerabad, Secunderabad 500 003, India
Traumatic bile leaks often result in high morbidity and prolonged
hospital stay that requires multimodality management. Data on en-
doscopic management of traumatic bile leaks are scarce. Our study
objective was to evaluate the efficacy of the endoscopic manage-
ment of a traumatic bile leak. We performed a retrospective case
review of patients who were referred for endoscopic retrograde
cholangiopancreatography (ERCP) after traumatic bile duct injury
secondary to blunt trauma (motor vehicle accident or fall from
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
height) for management of bile leaks at our tertiary hospital. Three
patients underwent ERCP for the management of a traumatic bile
leak over a 1-year period. The etiology included blunt trauma from
motor vehicle accident in 2 patients or fall from height accident in 1
patients. Liver injuries were grade III in 1 patient, grade IV in 2
patients. All patients were treated by biliary stent placement, and the
outcome was successful in 3 of 3 cases (100%). The mean duration
of follow-up was 90 days. There were no ERCP-related complica-
tions. In our case review, endoscopic management with endobiliary
stent placement was found to be successful and resulted in resolu-
tion of the bile leak in all 3 patients. Based on our study results,
ERCP should be considered as first-line therapy in the management
of traumatic bile leaks.
360
Prevalence of gallbladder stasis in patients with asymptomatic and
symptomatic gallstones
Tejinder Kaushal, Chhagan Lal Birda, Pankaj Gupta, Raghu Ram,
Dimple Kalsi, Divya Dahiya, Lileswar Kaman, Harshal S
Mandavdhare, Vishal Sharma, Arun Kumar Sharma, Usha Dutta
Correspondence- Usha Dutta-ushadutta@gmail.com
Departments of Gastroenterology, General Surgery, Internal Medicine,
and Radiodiagnosis, Postgraduate Institute of Medical Education and
Research, Chandigarh 160 012, India
Introduction Among patients with gallbladder cancer (GBC), 80%
have gallstones (GS), most of whom are asymptomatic.
Gallbladder (GB) stasis in patients with GS promotes develop-
ment of preneoplastic lesions. The prevalence of GB stasis in
patients with asymptomatic gallstones (AGS) is not known. We
conducted a study to determine the prevalence of GB stasis
among patients with AGS and compare it with symptomatic
GS(SGS).
Methods Consecutive patients with GS were enrolled in a prospec-
tive case-control study after informed consent. Patients with
symptomatic (SGS) and asymptomatic gallstones (AGS) were re-
cruited as cases and controls based on the presence/absence of
biliary symptoms. All patients underwent clinical and ultrasound
assessment at 30 and 60 minutes post-fatty meal for gallbladder
ejection fraction (GBEF). Gallbladder stasis (GBS) was defined as
GBEF <40%. Chi-square and Mann-Whitney U tests were used
for comparison and p< 0.05 was taken as significant.
Results The mean age and gender profile were similar in the SGS (n=50)
and AGS (n=37) groups. Dyspepsia symptom score and biliary symptom
scores were significantly higher in patients with GBS compared to no
GBS (5 [3.25,6] vs. 4 [3,5]; p=0.003) and (32 [0,35] vs. 0 [0,33];
p=0.001) respectively. GBEF at 30 minutes showed a significant negative
correlation with dyspepsia score (-0.230, p=0.03) and biliary symptom
score (-0.216, p=0.04). All the patients with SGS had history of definite
biliary colic with median biliary symptom score of 34 (IQR-32,35).
Median dyspepsia symptom scores were significantly higher in SGS
group compared to AGS (5 [4,6] vs. 3 [2,4]; p<0.001). Median GBEF
at 30 minutes and 60 minutes were significantly higher in patients with
AGS compared to SGS (43.3 [22,61] vs. 28.2 [17,48]; p=0.029) and (47
[33,82] vs. 41 [28,63]; p=0.020) respectively; though both were subopti-
mal. Patients with SGS more often GB stasis than those with AGS (66%
vs. 40.5%, p=0.018).
Conclusions GBEF was significantly lower in patients with SGS com-
pared to AGS. GB stasis was present in 40% of patients with AGS and
66% in patients with SGS. GB stasis was associated with higher dyspep-
sia and biliary symptom scores.
Keywords Gallbladder stasis, Asymptomatic gallstones, Gallbladder ejec-
tion fraction
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
361
Prevalence of H. pylori infection in patients with gallstone disease and
its relationship with gallbladder function
Tejinder Kaushal, Chhagan Lal Birda, Nikhil J Bush, Pankaj Gupta,
Raghu Ram, Priyanka Popli, Divya Dahiya, Lileswar Kaman, Harshal
S Mandavdhare, Vishal Sharma, Arun Kumar Sharma, Usha Dutta
Correspondence- Usha Dutta-ushadutta@gmail.com
Departments of Gastroenterology, General Surgery, Internal Medicine,
and Radiodiagnosis, Postgraduate Institute of Medical Education and
Research, Chandigarh 160 012, India
Introduction Patients with gallstone disease (GSD) are at increased risk
for gallbladder cancer (GBC). H pylori (Hp) has been identified as a
cofactor in the pathogenesis of GBC. Prevalence of Hp in patients with
GSD and its relationship with GB function is not known. This study was
planned to study prevalence of Hp and its relationship to symptom profile
and GBEF in patients with GSD.
Methods Consecutive patients of GSD in a prospective cross-sectional
study between March 2019 to November 2019 were enrolled. All patients
underwent clinical, demographic and ultrasound abdomen assessment for
GS and gallbladder ejection fraction (GBEF). GBEF was calculated after
30 and 60 min of standard fatty meal. Gallbladder stasis was defined as
GBEF<40%. Sera was analyzed for anti H. pylori IgG antibody. Upper
gastrointestinal endoscopy (UGIE) was done to assess for Hp related
changes and biopsies were taken for histopathology and rapid urease test
(RUT). Chi-square and Mann-Whitney U tests were used for comparison
and p value < 0.05 was taken as significant.
Results Patients with GS (n=87) with a mean age of 48.5±14.9 yrs
(F:73.6%) were evaluated. Multiple stones were present in 61%. Mean
GBEF at 30 min was 35±21% and at 60 min was 48±26%. GB stasis was
present in 55.8% (48/87) patients of GS. UGIE showed antral hyperaemia
in 95.4% and duodenitis in 35.3% of the patients. Hp+vity by RUT or
serology, was seen in 40% patients; of which RUT was positive in 75%.
Active Hp infection (RUT +ve) was more often associated with gallblad-
der stasis (45.7% vs. 15.6%, p=0.1); however, it was not significant.
However, active Hp infection was more often associated with very low
GBEF (<30%) (14/27 vs. 7/41, p=0.01).
Conclusion Patients with GS had high overall prevalence (40%) of Hp
infection, of which 75% was active. Active Hp infection was more often
associated with GB stasis.
Keywords Gallbladder stasis, H. pylori, Gallstone disease
Miscellaneous
362
Abdominal gas – Patients’ perception sometimes differ from medical
knowledge
Madhusudan Saha, Bimal Chandra Shil
Correspondence- Madhusudan Saha-madhunibedita@yahoo.com
Department of Gastroenterology, North East Medical College,
Bangladesh, North East Medical College, Sylhet, Bangladesh, Sir
Salimullah Medical College and Mitford hospital, Dhaka, Bangladesh
Aim and Objectives Patients try to correlate varieties of symptoms with
abdominal gas. So, this study was designed to see the patients’ view
regarding abdominal gas and its relation with medically explained
symptoms.
Method Consecutive patients with complain of abdominal gas were included
in this study. Their demographical information and explanation of symptoms
resulting from abdominal gas, they believed were recorded on a predesigned
data sheet. Statistical analysis was done using SPSS 20 version.
S115
Result Total 346 patients, male 239 (69.1%), female 107 (30.9%), age
varying from 17 to 83 years (mean 38.27) were enrolled. Common symp-
toms were bloating (fullness) of abdomen (194, 56.1%), abdominal pain
(164, 47.41%), belching or eructation (149, 43.1%), heart burn (137,
39.6%), anorexia (124, 35.8%), nausea (120, 34.7%), noisy bowel (88,
25.4%), chest pain (79, 22.8%), headache (56, 16.2%), whole body pain
(58, 16.8%), incomplete bowel evacuation (185, 53.5%), excess flatus
(76, 22.4%), movement of gas to different part of body including head
87 (25.1%) and expulsion of hot air from ear, nose and head in 69
(19.9%) patients. Among them 107 (30.9%) patients believed abdominal
gas to be a curable disease with treatment and 222 (64.2%) believed it to
be a relapsing disease even after treatment. And 307 (88.7%) patients
were taking proton pump inhibitor (PPI) as its remedy regularly.
Conclusion Most of the symptoms of patients can be explained by ab-
dominal gas. Again, some patients have a misperception regarding some
symptoms like heart burn, noisy bowel and sense of incomplete bowel
evacuations are also related with abdominal gas. But in some instances
causal relations with patients’ symptoms and abdominal gas could not be
explained by medical knowledge. These difference in perceptions might
be related to their personal thinking and social, cultural, educational,
economic condition.
363
Assessing prevalence of microsatellite instability and Lynch syn-
drome amongst colorectal cancer patients in India
Harsh Sheth3, Abhinav Jain1, Chandni Patel4, Suresh Advani7, Liyana
Thomas7, Mithun Shah8, Pankaj Shah8, Vipul Yagnik6, Avinash Tank2,
Darshan Bhansali1, Manish Gandhi1, Tarang Patel1, Natu Patel1, Ashok
Patel1, Chirag Shah1, Bharat Parikh5, Frenny Sheth4, Jayesh Sheth4,
Sunil Trivedi4,
Correspondence- Harsh Sheth-harsh.sheth@frige.co.in
1
CIMS Hospital, Science City Road, Science City, Panchamrut
Bunglows II, Sola, Ahmedabad 380 060, India, 2 Dwarika Clinic, 301
Shilp Arcade, Jodhpur Cross Road, Satellite, Ahmedaba, 380 015, India,
3
FRIGE's Institute of Human Genetics, Frige House, Jodhpur Gam Road,
Satellite, Ahmedabad 380 015, India, 5 HOC Vendant Hospital, Near, 1st
Floor, Vedanta Institute of Medical Sciences, Lalit Kunj Society Road,
Navrangpura, Ahmedabad 380 009, India, 6 Nishtha Surgical Hospital
and Research Centre, 4th Line, 1st Floor, Kilachand Shopping Centre,
Station Road, Patan 384 265, India, 7 Sushrut Hospital, Mumbai, India,
and 8 Zydus Cancer Hospital, Ahmedabad, India
Microsatellite instability (MSI) and Lynch syndrome (LS) prevalence in
colorectal cancer (CRC) patients is estimated to be 15% and 3% in
European populations. Microsatellite instability (MSI) testing in all
CRC patients is now recommended by NCCN and NICE guidelines to
detect LS patients. However, since prevalence estimates from India are
not available, no such practice guidelines are available in India. We aim to
systematically assess the prevalence of MSI and LS in CRC patient pop-
ulation from India. Venous blood and primary tumor biopsies were pro-
spectively collected and analyzed for MSI using Promega fragment
length analysis assay and BRAF V600E using Q-PCR. Patients with
MSI-high BRAF-negative tumor biopsies were assessed for LS using
germline DNA sequencing of the mismatch repair genes (MLH1,
MSH2, MSH6, PMS2 and EPCAM). Within 1 year of a 3 year study, 62
patients have been recruited with CRC. Average age of recruitment was
51±15 years, 71% were males and ~45% of cancers originated in rectum.
MSI testing in these patients show MSI-high phenotype in 20 patients
(32%). Of these, 17 patients (85%) were negative for BRAF V600E mu-
tation. Germline testing in these patients have shown known and novel
mutations in the MLH1 and PMS2 genes. More than 90% of LS patients
had a mutation in MLH1 gene with highest occurrence of c.156delA
mutation. Ad hoc analysis of the prospective study cohort suggests higher
prevalence of MSI and LS in CRC patient population in India. Analysis of
S116
the entire patient cohort (n=300) in 2022 will provide a robust estimate of
the prevalence of MSI and LS in CRC patients in India. These estimates
would help in formulation of national guidelines for MSI testing, LS
diagnosis and aspirin based chemoprevention strategies of CRC in India.
364
Ingested foreign body in children’s - A single centre study from South
India
Sajith Sebastian, Benoy Sebastian, Mary George
Correspondence- Sajith Sebastian-drsaseneeruvelil@gmail.com
Department of Medical Gastroenterology, Medical Trust Hospital,
Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India
A total of 32 cases of foreign body ingestion in aerodigestivive tract who
underwent endoscopy in Medical Trust Hospital, Kochi between October
2018 until June 2019 were selected for the study. All the cases selected
and studied in detail for age, sex, incidence, type of foreign body, site of
lodgement, presenting symptoms of were noted.
Results A total of 32 children's were included in the study which includ-
ing both male children's (15, 46.87%) and female children's (17, 53.12%).
Gender distribution and Site of foreign body females presented slightly
more commonly following a foreign body ingestion. Of the children s
admitted with symptoms of foreign body ingestion, the most common site
of FB lodgement were in post cricoid and lower esophagus (9.375%).
Others side of impaction were base of tongue, pyriform area, upper
esophagus, stomach and duodenum. No foreign body were seen in
OGD in 13 % of males and 16 % of female children with suspected
foreign body ingestion. Presentation of foreign body ingestion. The most
common presentation was a foreign body sensation or something struck
in the throat after an accidental ingestion which occurred in 43.75 % of
children’s followed by odynophagia and dysphasia occurring in 25% and
21.82% children´s. 15.6% had no complaints on presentation expect his-
tory of foreign body ingestion. Type of foreign body and site of presen-
tation 18.75% presented were impacted coins. other foreign body found
were fish bone, metal pins, batteries, and food impactions.
Conclusions Expert hands and clinical skills are necessary for early and
safe removal. It is necessary to educate the parents about keeping away
the article from reach of children and to observe the activity of child will
prevent the higher incidence of a foreign body in children.
365
In today's era of high resolution-anorectal manometry and magnetic
resonance defecography - Would you still use the finger?
Pratik Sethiya, Mayur Gattani, Shamshersingh Chauhan, Gaurav
Kumar Singh, Saiprasad Lad, Kiran B, Kailash Kolhe, Harshad
Khairnar, Sneha Deshpande, Vikas Pandey, Akash Shukla, Meghraj
Ingle
Correspondence- Meghraj Ingle-drmeghraj@gmail.com
Departments of Gastroenterology, and Radiology, Lokmanya Tilak
Muncipal Medical College and General Hospital, Sion, Mumbai 400
022, India, and Departments of Gastroenterology, Seth G S Medical
College and KEM Hospital, Mumbai 400 012, India
Background Magnetic resonance defecography (MRD) and high-
resolution anorectal manometry (HR-ARM) are advanced tools for defin-
ing pelvic floor anatomy and thus help in detection of dyssynergia.
Digital rectal examination (DRE) is a simple bedside test done on outpa-
tient basis which has also shown to detect dyssynergia in patients with
constipation with high sensitivity. The objective of the study was to
evaluate usefulness of DRE as compared with HR-ARM and MRD as a
marker for detection of dyssynergic defecation (DD).
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Methods Thirty patients of chronic constipation (CC) defined by ROME
IV criteria were enrolled. After ruling out structural causes of constipation
using colonoscopy, all patients were subjected to undergo DRE and sub-
sequently HR-ARM, blinded to DRE findings. MRD was reported by
radiologist who was also blinded to the findings of DRE and ARM.
The diagnostic yield of DRE was compared with that the HR-ARM and
MRD.
Results Dyssnergia was diagnosed on DRE in (24/30) 80%, on ARM (23/
30)76.6%, MRD 26.6% (8/30) of patients. The sensitivity, specificity,
positive predictive value (PPV) of DRE in diagnosing DD were
90.91%, 57.14%, 86.96% respectively with correlation coefficient of
0.452 and p=0.01. Digital maneuvering significantly correlated with
DD on HR-ARM (correlation coefficient of 0.43 and p=0.02) whereas
paradoxical anal sphincter relaxation and DD correlated significantly with
HR-ARM (correlation coefficient of 0.49 and p=0.006). Correlation of
excessive descent on DRE with anorectal descent and rectocele on MR
defecography (correlation coefficient 0.34 p=0.06) and (correlation coef-
ficient 0.33 p=0.07) respectively was not statistically significant.
Conclusion DRE is useful bedside test in diagnosing DD with high sen-
sitivity and PPV compared with HR-ARM. MRD is useful modality in
identifying structural etiology for chronic constipation.
366
Evaluating etiology and clinical profile of infectious causes of febrile
jaundice other than viral hepatitis (A to E)
Chaitanya Teja Annam, Ambika Prasad Mohanty
Correspondence- Ambika Prasad Mohanty-ambika.mohanty1
@kims.ac.in
Department of General Medicine, Kalinga Institute of Medical Sciences,
KIIT University, Campus No:5, KIIT Road, Patia, Bhubaneswar 751
024, India
Background Fever with jaundice is a common entity seen in routine
practice. This manifestation is seen in many individuals infected with
viral hepatitis A to E. Excluding these hepatotropic viruses, many other
pathogens can clinically manifest as fever with jaundice which include
bacteria, protozoa, fungi, and non-hepatotropic viruses.
Aim and Objectives India, being a tropical country, the study aims to
evaluate the tropical and other infectious causes barring viral hepatitis
A to E, which manifest as fever associated with jaundice.
Methods This study includes 60 patients admitted in Kalinga
Institute of Medical Sciences from 2019 who were found to have
febrile jaundice after initial evaluation by liver function tests and
hepatotropic viral markers (HBsAg, anti-HCV IgM, anti HAV
IgM, anti HEV IgM). Routine laboratory parameters, chest X-
ray, ECG was performed in all cases. Appropriate investigations
like specific serological, radiological investigations and cultures
were performed to identify the causal pathogen. Patients infected
with hepatotropic viruses, if associated with any other confound-
ing organisms responsible for their clinical picture were included
in this study.
Results Out of 60 patients, 23 (38.3%) patients were found to have scrub
typhus (4 had associated encephalopathy). Dengue was found in 8
(13.3%) patients (3 had dengue associated with scrub typhus). Malaria
was identified in 5 (8.3%) patients (2 had associated scrub typhus). Four
(6.6%) patients had tuberculosis (2 are on ATT) and 3 (5%) patients had
varicella-zoster clinically. S. typhi was found in 2 (3.3%) patients. K.
pneumonia, E. coli, A. baumannii, B. cepacia, E. feacalis were isolated
in other individuals. Among these 21 patients had associated transaminitis
(elevated AST/ALT >3 times of ULN). Eleven cases had hepatomegaly
and 5 were found to have splenomegaly. Ten cases had septic shock of
which 4 could not be revived. No definitive etiology was found in 10
patients.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
367
Eosinophilic ascites as rare unusual initial presentation of eosinophil-
ic gastroenteritis
Santhosh R, Benoy Sebastian, Anil Jose Kokkat, Mary George, Cyril
Alex, Swaran Kumar, Sujith James
Correspondence- Benoy Sebastian-Santumail18@gmail.com
Department of Gastroenterology, Medical Trust Hospital, Mahatma
Gandhi Road, Pallimukku, Kochi 682 016, India
Thirty-three-year-old male presented with progressive abdominal disten-
sion and discomfort associated with nonspecific abdominal pain of 1
week duration.
Physical examination was unremarkable except for ascites.
Routine labs showed high eosinophilic count with leukocytosis in
hemogram and peripheral smear, AEC-7890 cells/cumm. Stool exam
was nil contributory.
Abdominal sonogram showed moderate to gross ascites, no features of
CLD/portal hypertension. Ascitic fluid cytology and cell block were sug-
gestive of low SAAG high protein ascites, ascitic fluid TC-15,600 cells/
cumm, AEC-13,950 cells/cumm.
Prior to current admission there was also a history of consuming seafood
containing prawns followed by loose stools and pain abdomen for 2 days
which was self-limiting.
EGD showed mild duodenitis. Biopsy from D2, Antrum, esophagus
showed histopathologic evidence of eosinophilic gastroenteritis. CT tho-
rax and abdomen showing diffuse esophagial wall thickening and edem-
atous and thickened small bowel loops. He was treated albendazole, iver-
mectin and PPI. Within a week there was significant improvement in
symptoms. He was not put on steroids as there was clinical improvement
on PPI and antielminthics. There was no ascites on repeat ultrasound scan
of abdomen done two weeks later. He remained asymptomatic even at
one-year follow-up.
Conclusion Eosinophilic ascitis is a rare unusual presentation of
eosinophilic gastroenteritis, usually occurs in serosal involvement.
Mostly ascites is mild and not clinically significant and usually
associated with abdominal pain. Rarely, isolated ascites can be the
initial presentation.
368
A rare case of concurrent primary gastric and bone diffuse large B
cell lymphoma
Chunduri Vikranth, Chunduri Venkata Viswa Vikranth, Ganesh
Panchapakesan, Shanmugnathan Subramanyam
Correspondence- Chunduri Vikranth-chvv.vikranth@gmail.com
Department of Medical Gastroenterology, Sri Ramachandra Institute of
Higher Education and Research (SRIHER), Chennai 600 116, India
Primary bone lymphoma (PBL) is an uncommon clinical entity and a
rare non-Hodgkin's lymphoma presentation. PBL accounts for less
than 5% of malignant bone tumors, 4% to 5% of extranodal lympho-
ma, and less than 1% of all non-Hodgkin's lymphoma.
Primary gastric lymphoma (PGL) is rare cancer, but it is the most com-
mon site for extranodal non-Hodgkin lymphoma. We report a rare case of
concurrent presentation of a bone lymphoma and gastric lymphoma. The
patient presented with a slow-growing swelling around the knee joint for
two years. Positron emission tomography incidentally picked up an FDG
avid lesion in the fundus of the stomach. Tissue specimens of both the
lesions were obtained and conformed to have diffuse large B cell lym-
phoma on histology and immunochemistry. He was followed up with the
oncology department and treated with R-CHOP regimen (rituximab, cy-
clophosphamide, hydroxydaunorubicin, oncovin [vincristine], and
prednisone).
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369
Preoperative successful thrombectomy and thrombolysis of acute
extensive splanchnic venous system and TIPSS thrombosis in a child
with Budd-Chiari syndrome- Creating a window to enable living
donor liver transplantation
Amey Sonavane, Aabha Nagral, Deepak Gupta, Shaji Marar, Vikram
Raut, Ketul Shah, Amruthraj C, Ashok Thorat, Ambreen Sawant, Harshit
Chaksota, Abhijit Bagade, Suresh Vasanth, Darius Mirza
Correspondence- Amey Sonavane-amey_max@yahoo.com
Gastroenterology, Hepatology and Liver Transplantation, Apollo
Hospitals, Plot # 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi
Mumbai 400 614, India
Background Preoperative extensive portal vein (PV) thrombosis can pose
a technical challenge during liver transplantation. Extensive and diffuse
thrombosis of the splanchnic venous system may even necessitate
multivisceral transplantation. We describe the case of a pediatric patient
with Budd-Chiari syndrome (BCS) and decompensated cirrhosis, who
developed extensive acute thrombosis of the portospleno-mesenteric ve-
nous system prior to living donor liver transplantation (LDLT). We used a
combination technique of thrombus aspiration using a novel trans-TIPPS
approach followed by thrombolysis to achieve complete pre-operative
resolution of the thrombus.
Case Report A 10-year-old child with BCS who had underwent a prior
TIPPS, presented with TIPPS thrombosis, ascites, hepatic encepha-
lopathy and hepatopulmonary syndrome (HPS). Two days prior to a
planned LDLT, he developed an acute extensive thrombosis of the
portospleno-mesenteric venous system. As the window for a prompt
LDLT was fast fading due to multiple and recurrent episodes of
decompensation and severe HPS, a decision to perform intervention-
al radiology guided mechanical thrombectomy and thrombolysis was
taken. Using a retrograde right transjugular trans-TIPSS approach,
mechanical thrombus aspiration using a 6F shuttle sheath was per-
formed. This was followed by thrombolysis using tissue plasminogen
activator (tPA). Post procedure, there was near-total recanalization of
all the veins (Fig. 1). He was then started on intravenous tPA and
continuous heparin infusion. This allowed the creation of a brief
window to enable LDLT. Intraoperatively, PV showed complete re-
canalization with a good flow. A triangulated reconstruction of left
hepatic vein to IVC/right hepatic vein and donor left PV to right main
PV was performed. Post LDLT, anticoagulation was continued with
intravenous heparin followed by subcutaneous enoxaparin and oral
warfarin. He was discharged uneventfully.
Conclusion In prudently selected patients, performing an early mechani-
cal and chemical thrombolysis of an extensive acute splanchnic venous
thrombosis can help expedite a planned LDLT.
370
Retrospective study of inflammatory bowel disease unclassified at
tertiary care hospital
Ajay Kumar Oli, Rohit N Maidur, Preetham S Hurakadli, Anita P
Javalgi, Palaksha K Javaregowda, Mallikarjuna Goni
Correspondence- Ajay Kumar Oli-ajay.moli@gmail.com
Department of Biomedical Science, SDM Research Institute for
Biomedical Sciences, Shri Dharmasthala Manjunatheshwara
University, 5th Floor, Specialty Block, SDMCMS&H, Campus,
Manjushree Nagar, Sattur-Dharwad 580 009, India, Department of
Gastroenterology, SDM College of Medical Sciences and Hospital,
Shri Dharmasthala Manjunatheshwara University Dharwad-580 009,
India, Department of Pathology, SDM College of Medical Sciences
and Hospital, Shri Dharmasthala Manjunatheshwara University,
Dharwad 580 009, India, and SDM Research Institute for
S118
Biomedical Sciences, Shri Dharmasthala Manjunatheshwara
University, 5th Floor, Specialty Block, SDMCMS&H, Campus,
Manjushree Nagar, Sattur- Dharwad 580 009, India
Background Inflammatory bowel disease unclassified is allocated to
cases of colitis where endoscopic and histological findings are not ade-
quate to differentiate between ulcerative colitis and Crohn’s disease.
Altered bowel, functional bowel, irritable bowel, esoinophilic colitis
and microscopic colitis in its histological distinct patterns, lymphocytic
colitis, infective colitis, and bacterial colitis are increasing common
causes of non-bloody diarrhea. There appears to be an association with
other autoimmune conditions, and also there is be variability in patient
journey from referral to treatment.
Aim To know the frequencies of unclassified inflammatory bowel
diseases/to evaluate various causes of unclassified inflammatory bowel
diseases.
Methodology It is an observational study. All the cases diagnosed as
IBDU in the department of gastroenterology from the year 2015 to
2019 were included in the study. Cases with incomplete evaluation of
suspected IBDU cases were excluded from the study. Diagnosis of IBDU
was made based on clinical, radiological, endoscopy and histopathologic
findings.
Results Total cases included from study period were 226.These patients
were diagnosed with altered bowel, irritable bowel, functional bowel,
lymphocytic colitis, infective colitis, bacterial colitis and eosinophilic
colitis with 115 (66.86%), 09 (5.23%), 10 (5.81%), 9 (5.23%), 19
(11.04%), 07 (4.06%) and 03 (1.74%) respectively. The average age of
the patients ranged from 17-40 years and many cases were >40 years.
Conclusion Unclassified inflammatory bowel disease is not infre-
quent problem for the gastroenterologist and should be considered
in the evaluation of IBD with clinical features. Extra awareness and
extensive biopsy sampling are required in order to avoid an erroneous
diagnosis purely based on histological mimicry of changes seen in
bacterial colitis and infective colitis.
371
Autoimmune ascites -A diagnostic dilemma
Umashankar U S, Nithin K R, Anand A, Arun N, Akhilandeshwari,
Vaishnavi Priya, Aravind
Correspondence- Umashankar U S-us14us@gmail.com
Department of Digestive Health and Disease, Government Kilpauk
Medical College, Chennai 600 010, India
Abnormal accumulation of fluid within the peritoneal cavity is defined as
ascites. The commonest cause of ascites among Indians’ is cirrhotic portal
hypertension, accounting for 80% of cases. Others includes tuberculosis,
malignancy, heart failure and pancreatic disease. Autoimmune disorders
are rare cause. Here we present a rare case of undifferentiated connective
tissue disorder (CTD) associated ascites.
Case Forty-five-year-female presented with h/o 6 months h/o dry cough,
exertional dyspnoea, and abdominal distension. No h/o jaundice, de-
creased urine output, lower limb swelling. No h/o photosensitivity, oral
ulcers, joint pain, skin tightening. O/E pallor+ CVS, respiratory and CNS
examination was unremarkable. Abdominal examination showed pres-
ence of shifting dullness.
Investigations Hemoglobin 8.4 g%, platelet 7.4 lakhs, LFT A/G reversal
with normal enzymes, viral markers negative, ascitic fluid shows low
SAAG, high protein ascites with normal ADA, and amylase; ascetic fluid
geneXpert and cytology for malignant cells was negative. Normal urine
routine. Thyroid profile-normal, 2D echo-normal. USG abdomen moder-
ate ascites, liver normal echotexture. Portal vein doppler was normal.
CECT abdomen liver normal, moderate ascites, no evidence of malignan-
cy, CA 19.9, CEA, CA125 was normal. Fibroscan normal, UGI scopy
and colonoscopy was normal, HRCT chest- interstitial lung disease (ILD)
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
NSIP pattern. ANA was strongly positive1:1000, anti scl70, anti Ro-52,
anti SS-A positive. Diagnostic laparoscopy no evidence of malignancy or
tuberculosis. Since patient was not fulfilling any diagnostic criteria of
autoimmune disease, a diagnosis of undifferentiated CTD with CTD as-
sociated ILD, CTD associated ascites was made. Patient was started on
hydroxychloroquine and steroids. Patient became symptomatically better
and in follow- up.
Conclusion To the best of our knowledge and review of literature
autoimmune ascites in a patient with undifferentiated CTD with
normal liver and normal cardiac status is unreported. Though rare,
yet treatable autoimmune cause should be kept as a differential
diagnosis.
372
Significant weight loss due to abdominal aortic compression (dia-
phragmatic aortic hiatus syndrome): A rare type of median arcuate
ligament syndrome
Mahesh Kumar Gupta, Rinkesh Kumar Bansal
Correspondence- Mahesh Gupta-guptamahesh1982@gmail.com
Department of Gastroenterology and Hepatobiliary Science, Fortis
Memorial Research Institute, Sector - 44, Opposite HUDA City Centre,
Gurugram 122 002, India
Background Median arcuate ligament syndrome is a rare condition
caused by compression of celiac artery with or without celiac ganglia
by median arcuate ligament (MAL). Most of the patients asymptomatic
due to celiac compression but may present with complaints like bloating,
nausea, vomiting, postprandial epigastric pain, and other non-specific
symptoms.
Case A 37-year-old male with sober personal history, hospitalized
with multiple episodes of severe epigastric postprandial pain and
bilious vomiting over last 2 months. Weight loss of about 10 kg
also present. No other significant past medical history. On clinical
examination hemodynamically stable but mild dehydration present,
rest was normal. His BMI was 21kg/mt2.On per abdomen exami-
nation everything is unremarkable. His laboratory report of
hemogram, renal function tests, liver function tests, lactate, LDH,
iron, C-reactive protein, amylase and lipase within normal limits.
Ultrasound abdomen also normal. CT angiography revealed mod-
erate external compression and luminal narrowing of aorta by the
MAL at the diaphragmatic hiatus. Rest of the aorta and its
branches shows normal contrast opacification. Visualized abdomi-
nal organs and bowel normal. Endoscopy was unremarkable.
Doppler showed reduced flow distal to compression. After in-
formed consent underwent laparoscopic division MAL causing
compression. Normal flow pattern conformed intraoperatively and
postoperatively by doppler. He is asymptomatic and gain 6 kg
weight, with 2 months follow- up period.
Conclusion Diaphragmatic aortic hiatus syndrome is a rare cause and
should be considered in the checklist for evaluation of postprandial pain
and weight loss. Computed tomography angiography is diagnostic.
Laparoscopic resection is curative.
373
Do the patients of COVID-19 with predominant gastrointesti-
nal presentations behave differently from those with classical
presentations?
Manoj Kumar Gupta, Anup Sarkar, Tryambak Samanta, Saubhik
Ghosh, Kalidas Biswas
Correspondence- Manoj Gupta-mkgupta.pintu@gmail.com
Division of Hepatology, Medical Gastroenterology, Medical College,
Kolkata, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Background Lack of clarity remains whether COVID-19 patients with
predominant gastrointestinal complaints differ in basic descriptive param-
eters, natural course and outcome in comparison to those cases with
classical presentations. So, our objective was to determine whether such
difference exist between these two group of patients.
Methods Consecutive patients admitted in Medical College, Kolkata in-
between May 2020 to July 2020 were enrolled. The classification into the
subsets was based on predominant subjective complaints of the patients in
the 1st 5 days of illness. The parameters assessed were age, gender,
presence of comorbidity, symptomatology duration, need of ICU care
and case fatality rate.
Results Of the 678 patients enrolled, 23 (3.4%) subjects complained of
predominant gastrointestinal symptomatology. The mean ± SD of age of
presentation in years (46.9 ± 10.4 vs 53.7 ± 13, p=0.01) and duration of
symptoms in days (7.9 ± 5.3 vs. 10.8±4.7, p=0.004) were significantly
less in patients with gastrointestinal symptoms. The sex ratio and pres-
ence of comorbidity did not differ statistically (p 0.93 and 0.5 respective-
ly). Though ICU care (5.9% vs. 1.3%) and death rate (2.4% vs. 0.4%)
were proportionally higher in patients with classical symptoms, they were
not found to be significant (p>0.05).
Conclusion Our study failed to show any significant difference of out-
come between COVID- 19 patients with classical and gastrointestinal
symptoms, though there was some dissimilarity in demographic and clin-
ical parameters. Further studies in this regard with special emphasis on
background viral genomic aspects need to be done to find out the basis of
any difference, if any which in turn will assist to modify guidelines in
clinical settings for such subset of cases.
374
A rare presentation of abdominal TB - Retroperitoneal mass
Radhika Nittala, Manas Behera, Jimmy Narayan, Debakanta Mishra,
Manoj Sahu, Girish Pati, Ram Gopal Teja K, Srinith Patil, Swarup
Pattnaik
Correspondence- Radhika Nittala-drnradhika@gmail.com
Department of Medical Gastroenterology, IMS and SUM Hospital,
Bhubaneswar 751 003, India
Introduction TB can involve any part of the gastrointestinal sys-
tem. It is the sixth most common type of extrapulmonary tuber-
culosis. Our country has the highest burden in the whole world.
We are reporting a case of a young male who had rare presenta-
tion of abdominal tuberculosis.
Case report A 17-year-old male presented with pain in the right lower
quadrant of abdomen, loss of appetite and weight loss since 2 months and
dysuria since 2 weeks. He had no history of cough, fever, or bowel distur-
bance. He was averagely built and moderately nourished. On general phys-
ical examination, no abnormality was detected, and abdominal examination
revealed mild tenderness in the right iliac fossa. His routine hematological
parameters showed high CRP and ESR with normocytic normochromic
anemia. CECT abdomen showed long segment circumferential thickening
of the terminal and distal ileum with ill defined retroperitoneal mass in right
pelvic wall in close proximity to the ileocecal mesentry, right psoas and
terminal ilem. And this mass was involving right distal ureter resulting in
moderate hydronephrosis. Colonoscopy showed multiple ulcers in the ter-
minal ileum with surrounding edematous and friable mucosa with luminal
narrowing. Biopsy was done from the terminal ileum. FNAC was done
from mass adjacent to the thickened small bowel. Both biopsy and
FNAC showed numerous epitheloid granulomas and multinucleated giant
cells with histiocytes. Further, AKT was started and his symptoms im-
proved. Review USG KUB was done after 1 month, it showed resolution
of hyderonephrosis. The patient is now on ATT and doing well.
Conclusion Tuberculosis can rarely present as retroperitoneal mass with
hydronephrosis. Early suspicion and diagnosis can help in initiating the
treatment early.
S119
375
Clinical profile of gastroenteropancreatic neuroendocrine tumors:
Single center experience in a teritary care center in southern India
Ravindra Kantamaneni, Mukundan S, Prudhvi Krishna Chandolu,
Kartikeyan R K, Nikhil Kenny Thomas, L Venkatakrishnan
Correspondence- L Venkatakrishnan-ravindra.mbbs@gmail.com
Department of Medical Gastroenterology, PSG Institute of Medical
Sciences and Research Center, Off Avanashi Road, Peelamedu,
Coimbatore 641 004, India
Background Gastrointestinal is the commonest site for neuroendocrine
tumors (NET). appendix, ileum, rectum are considered to be common
sites. Majority of tumors have an indolent course. Some of them are
diagnosed incidentally and few have disseminated disease and also pres-
ent as metastatic disease.
Methods We retrospectively analyzed the data in Department of
Gastroenterology, PSG Institute of Medical Sciences and Research,
Coimbatore over a period of 10 years from Jan 2010 to July 2020.
Gastroenteropancreatic NETs were included in the study. Clinical details,
site of tumor, metastasis at the time of diagnosis were reviewed.
Results Our analysis showed a male predominance with ratio of 3:1 with a
mean age of 51.6667±5.56 Of the 12 tumors, the commonest site was
found to be duodenum 4 (33.3%), followed by pancreas 3 (25%) and
stomach 2 (16.6%), appendix, sigmoid colon, ileum were 1 (8.33%) each.
The disease was localized in 4 patients (33.3%) and with metastasis 8
(66.6%). Most of gastric and duodenal NETs were localized where as
pancreatic NETs have metastasis at presentation.
Conclusion This analysis showed gastrointestinal pancreatic NET are not
rare and incidence of these tumors is increased over the past decade due to
availability of higher imaging and increased rate of biopsy.
376
Clinical, endoscopic and histological characteristics of gastrointesti-
nal graft versus host disease and its outcome after allogenic hemato-
poietic stem cell transplantation
Pradipkumar Vekariya, Pazhanivel Mohan, Senthamizh Selvan, Smita
Kayal, Abdoul Hamide
Correspondence- Pazhanivel Mohan-dr.pazhani@gmail.com
Department of Medical Gastroenterology, Jawaharlal Institute of
Postgraduate Medical Education and Research, Dhanvantri Nagar,
Gorimedu, JIPMER Campus, Puducherry 605 006, India
Introduction Graft versus host disease (GVHD) is a common cause of
morbidity and mortality after hematopoietic stem cell transplantation
(HSCT). Skin, gastrointestinal tract and liver are commonly affected in
GVHD. The outcome of gastrointestinal acute GVHD is poor and de-
pends on clinical, endoscopic, or histological severity. We retrospectively
studied the frequency, clinical profile, and outcome of acute gastrointes-
tinal GVHD following allogenic HSCT.
Methods Patients who underwent allogenic HSCT between December
2018 and May 2020 were included. The clinical symptoms, gastroscopy
or colonoscopy findings, histopathology, details of treatment and out-
come of acute gastrointestinal GVHD were analyzed.
Results Eighteen patients underwent allogenic HSCT. A total of 8
(44.4%) recipients developed acute gastrointestinal GVHD. Their
median age was 29.5 years (12-36) with a male preponderance
(n=5). The median duration of onset of GVHD was 41 (17-92) days
after HSCT. All patients received fludarabine and busulfan followed
by GVHD prophylaxis. Six recipients had matched sibling donor, one
had matched unrelated donor and another had mismatched sibling
donor. All except one had 10/10 HLA matching. The symptoms of
nausea, vomiting and anorexia were seen in five; abdominal pain in
S120
two and diarrhea in five recipients. A total of 11 endoscopic proce-
dures were performed: gastroscopy in two, sigmoidoscopy in three
and both upper and lower gastrointestinal endoscopy in three pa-
tients. The endoscopic findings included mucosal edema, erythema,
erosions, ulcerations, and bleeding. The Freiburg endoscopic severity
was grade 4 in two, grade 3 in one, grade 2 in two and grade 1 in six.
Histopathology showed apoptosis of crypt epithelial cells and drop-
out of crypts in four patients. All patients received step-up treatment
using steroids, cyclosporine-A, mycophenolate-mofetil, ruxolitinib
and etanercept. Mortality was observed in four recipients (50%).
Conclusion Gastrointestinal GVHD was observed in about half of our
allogenic HSCT recipients and had a dismal prognosis.
377
To study clinicopathological profile of gastrointestinal tuberculosis
and assess treatment response and outcome
Sahil Parmar, Vineet Gupta, Sudhir Gupta, Harit Kothari, Amol
Samarth
Correspondence- Vineet Gupta-guptavintu@gmail.com
Department of Gastroenterology, Government Medical College and
Super Specialty Hospital (SSH), Nagpur 440 009, India
Background Abdominal tuberculosis (TB) is defined as infection of
the gastrointestinal tract, peritoneum, abdominal solid organs and
abdominal lymphatics with Mycobacterium tuberculosis.
Abdominal TB is one of the most common forms of
Extrapulmonary TB. Early diagnosis and initiation of anti-
tuberculous therapy is essential to prevent morbidity and
mortality.
Aims To study clinicopathological profile of gastrointestinal tuberculosis
and assess treatment response and outcome.
Methods This was a hospital based prospective study in
Department of Gastroenterology in a tertiary care referral center
from January 2019 to June 2020. The study variables included
socio-demographic characteristics (i.e. age and sex), clinical pre-
sentation, HIV coinfection, radiological findings, endoscopic find-
ings, Mantoux, ESR, GeneXpert and response rate to anti-
tubercular drugs. Patients were followed at monthly interval in
the intensive phase and then two monthly till the completion of
treatment.
Results Out of total 96 cases, 44 (45.83%) were males and 52
(55.17%). Maximum incidence of GITB was seen in 21-30 years
age group. Abdominal pain (96.72%) was the most common present-
ing symptom. Luminal involvement was seen in 43.05% of patients
out of which ileocecal junction (82.5%) was the most common site
involved. Ascites was seen in 41.66% patients. A positive gene xpert
was reported in 7.5% cases out of total 96 GITB cases. 4.1% patients
develop complications in form of decompensation of cirrhosis and
6.2% in form of hepatitis.
Conclusion Nonspecific features of the abdominal tuberculosis result in
difficulty in establishing diagnosis. A high index of suspicion is therefore
necessary for early diagnosis of abdominal. Neither clinical features nor
laboratory findings are conclusive of GITB, histopathological findings by
themselves provide a gold standard in the diagnosis.
378
Reduction in incidence of corrosive poisoning during this COVID-19
pandemic
Viswanath Donapati, Ravi Shankar Bagepally, Guduru R Srinivas Rao,
Rami Reddy Y, Bharani
Correspondence- Viswanath Donapati-viswanathdr@yahoo.com
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Department of Gastroenterology, Yashoda Hospital, Alexander Road,
Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India
Introduction COVID-19 pandemic is troubling the entire world in most
aspects. One good aspect which we noted was an overall reduction in
poisoning cases particularly corrosive ingestion.
Methods We did a retrospective analysis of the number of poisoning cases
hospitalized at our tertiary care centre from March 2019 till August 2020
with particular reference to corrosive ingestion who underwent endosco-
py. The age group of patients included was above 12 years. We looked at
differences in the incidence of corrosive ingestion before the lockdown
(March 2019-February 2020) and after the lockdown (March 2020-
August 2020).
Results We had 160 cases of poisoning admitted during March 2019 till
February 2020 and of them 35 were corrosive ingestion cases (21.8%).
Fifteen of the 35 were males (42.8%). Five patients of the 35 cases died
(14.3%) due to complications related to corrosive ingestion like renal
failure, sepsis and multiorgan failure. Seven of them (20%) required
feeding jejunostomy. There were 68 cases of poisoning of which 11 were
corrosive cases (16%) from March till August 31. 8 of the 11 cases were
females (72.7%). Two of the 11 patients died (18.1%) due to complica-
tions. Three of them (27.2%) required feeding jejunostomy. There was
considerable reduction of the overall incidence of poisoning and particu-
larly corrosive ingestion. Our hypothesis was that during lockdown peri-
od, there was more family bonding and more emotional stability.
Conclusion There was an overall reduction in number of poisoning cases
particularly corrosive ingestion during this COVID-19 pandemic.
379
Clinic-pathological profile of gastrointestinal stromal tumors - A ret-
rospective study from a tertiary center in South India
Damodar Krishnan, Ganesh Panchapakesan, Shanmughanathan S
Correspondence- Ganesh Panchapakesan-ganesh_dr@yahoo.co.in
Department of Medical Gastroenterology, Sri Ramachandra Institute of
Higher Education and Research, Chennai 600 116, India
Introduction Gastrointestinal stromal tumors (GIST) comprise 1% to 3%
of all malignant gastrointestinal (GI) tumors. GIST is the most common
mesenchymal tumor of the GI tract. GISTs are extremely heterogeneous
from a clinical perspective. We aim to explore the clinical and patholog-
ical profile of all newly diagnosed GIST including clinical presentation,
morphology (gross and microscopic), location of tumors, risk stratifica-
tion and management among patients admitted in a tertiary centre in
South India.
Methods Retrospectively analyzed cases diagnosed as GIST (HPE with
IHC) either by diagnostic biopsy or postoperatively during the past 4
years (2016-2020).
Results During the study period 20 patients fulfilled the inclusion criteria
and data were analyzed. The median age was 56.2 years with a male-
female ratio of 2:1 (14 males and 6 females). The mean age for men
was 58.3 and for women 51.2. Four (20%) patients had metastatic
disease and unresectable or incompletely resected disease. The most
common primary site was small intestine in 10 (50%) patients which
were followed by the stomach in 5 (20%) patients. The most com-
mon site of metastases was liver in 2 (50%) patients. Median tumor
size was 6.2cm (range 5cm -20 cm). Nine (45%) patients had mi-
totic counts of >5/50 HPF. Spindle cell type was the predominant
histological type 80% and CD117 was found to be positive in 14
patients (70%). Nine patients received treatment with imatinib for
more than 6 months and 3 patients who underwent surgery present-
ed with metastasis or recurrence of disease on follow-up.
Conclusion In our study of GISTs, the commonest site of the tumor was
detected to be small intestine followed by stomach, the majority were of
the high-risk malignant category and of pure spindle cell morphology.
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Limited numbers had follow-up after imatinib therapy and showed recur-
rence of the disease.
380
Primary falciform ligament necrosis- An unusual case of abdominal
pain
Arun Dhotra, Anand A, N Arun, Akhilandeshwari, Vaishnavi Priya, Kani
Shaikh, Aravind
Correspondence- Arun Dhotra-arun.dhotra88@gmail.com
Department of Digestive Health and Diseases, Government Kilpauk
Medical College, Chennai 600 010, India
Introduction Falciform ligament, is a broad and thin fold of peritoneum
that divides the liver into left medial and right lateral lobe. It attaches liver
to diaphragm and anterior abdominal wall. Primary or isolated falciform
ligament necrosis is rare entity and often confused with gall bladder
diseases due to its presenting symptoms.
Case A 46-year-old male presented to our hospital with symptoms of pain
upper abdomen which was continuous and dull aching type since 2
months. No history of nausea, vomiting, fever, obstipation or loose mo-
tion. Per abdomen- mild epigastric tenderness. Per rectal examination–
normal.
Investigations CBC, RFT, LFT, S. amylase, viral markers, Erect AXR,
CXR were normal USG abdomen suggestive of acalculous cholecystitis.
UGI endoscopy- normal.
CECT abdomen Non-enhancing heterodense lesion with air pockets not-
ed extending along the falciform ligament to anterior abdominal wall till
umbilical region with surrounding inflammatory changes and minimal
fluid collection. Left branch of portal vein (PV) not visualized- features
suggestive of falciform ligament necrosis and inflammation.
PV Doppler normal.
Surgical gastroenterology opinion taken. Surgical excision of ligament
was done. Postoperative period uneventful. Patient symptoms relieved
and patient is on follow-up.
Conclusion Primary Falciform ligament inflammation and necrosis is a
rare condition. It is difficult to diagnose as it is often confused with other
intra-abdominal pathologies especially gallbladder diseases. CECT abdo-
men should be preferred over USG abdomen for its diagnosis. Surgery is
the treatment of choice. It should be considered as one of the possibilities
in cases presenting with pain abdomen with other common causes ruled
out.
381
GIT and hepatic manifestations of Covid-19 in a tertiary care centre
Pavankumar Evuri, Chezhian Annasamy
Correspondence- Chezhian Annasamy-chezhianannasamy@gmail.com
Department of Medical Gastroenterology, Madras Medical College,
Poonamallee High Road, Park Town, Chennai 600 003, India
Background The clinical syndrome caused by SARS-CoV-2 was called
COVID-19 and became a pandemic from March 2020. Predominant clin-
ical manifestations are fever, dry cough, and dyspnea. Multiple gastroin-
testinal (GI) symptoms, including diarrhea, nausea/vomiting, and abdom-
inal pain, as well as liver enzyme abnormalities have been variably re-
ported. This study aims to comprehensively outline the various GIT and
hepatic manifestations of this virus.
Methods A cross sectional observational study carried out from July 1st to
July 30th at Madras Medical College Hospital, Chennai – a tertiary care
COVID hospital. Data obtained from the RT PCR positive COVID in
patients by selected questionnaire and lab reports, analyzed with regards
to GIT and hepatic manifestations.
S121
Results Out of 118 patients diagnosed to have COVID by RT PCR, 69
were male and 49 female. Mean age 55.6 years. Eighteen (15.2%) have
GIT manifestations. Nine (7.6%) have diarrhea as a most common GI
symptom, 6 (5%) nausea or vomiting, 3 (2.5 %) abdominal pain. Isolated
GI symptoms were reported in 2 patients. Diarrhea presented earlier to
respiratory symptoms in one patient. Fifteen (12.7%) patients have liver
function test abnormalities. SGOT and SGPT both elevated but SGOT
levels more than SGPT in 13 out of 15 patients.
Conclusion Digestive symptoms are not uncommon in patients with
COVID-19 and in some cases digestive symptoms may occur isolated
or earlier to onset of respiratory symptoms. Hence GIT symptoms should
be addressed promptly for early diagnosis and proper management.
Attention should also be paid to monitor regularly liver function during
the course of COVID-19.
382
Normative values of various parameters defining sarcopenia among
Indian adult population
Subham Choudhary, Manav Wadhawan, Prem Kumar Ganesan,
Sugandha Dhawan, Payal Mittal, Ajay Kumar, Amrish Sahney
Correspondence- Manav Wadhawan-manavwadhawan@gmail.com
Department of Radiodiagnosis, Dr B L Kapur Memorial Hospital, 5, Pusa
Road, Near Rajendra Place Metro Station, New Delhi 110 005, India
Introduction Sarcopenia is defined as decrease in muscle mass and func-
tion (performance or strength). Sarcopenic parameters are crucial for pre-
cise diagnosis and management of various medical conditions and must
be formulated as per local population.
Objective To study the quantitative analysis of various sarcopenic param-
eters in Indian population.
Methodology This cross-sectional study was conducted at a super
speciality hospital in New Delhi among 2002 normal Indian indi-
viduals over a period of one year. Normative values for all ab-
dominal muscles and individually for psoas and erector spinae
muscles were measured using the latest software, Tomovision
Slice0matic version5.0 with Alberta protocol. Standardized psoas
muscle thickness (PMTH), psoas muscle index (PMI), erector
spinae muscle index (ESMI), total skeletal muscle index (SMI)
and skeletal muscle radiation attenuation (SMRA) were computed.
Their mutual relationships and correlations between either sex
were determined statistically by applying Pearson’s and student’s
t test.
Results A total of 2002 individuals, including 1308 males and 694 females,
underwent CT evaluation. PMTH (mm/m) was observed to be 15.87±2.67 in
males versus 12.61±2.46 in females (p=0.0001); PMI (cm2/m2) was 6.69
±1.40 in males vs 5.57±1.18 in females (p=0.0001); ESMI (cm2/m2) was
16.5±2.55 in males vs. 14.62±2.6 in females (p=0.0001), SMI (cm2/m2) was
estimated to be 51.00±5.70 in males vs. 43.93±6.05 in females (p=0.0001)
and SMRA was 55.80±3.91 HU in males vs 52.36±3.67 HU in females
(p=0.0001). Cut off values for PMTH, PMI, ESMI, SMI and SMRA for
sarcopenia at L3 vertebral level were observed to be 10.53 mm/m, 3.89
cm2/m2, 11.40 cm2/m2, 39.59 cm2/m2 and 47.98 HU among males and
7.69, 3.20, 9.42, 31.83 and 45.01 among females.
Conclusion Normative values of sarcopenic parameters for either sex
among Indian adult population would enable future studies on sarcopenia
in various medical conditions.
383
Incidental retroperitoneal ancient neurilemmoma- A rare variety of
neurilemmoma
Mukesh Pancholi, Devendra Chaudhri, Divya Sinhar
Correspondence- Mukesh Pancholi-dr_mpancholi@yahoo.co.in
S122
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India
Ancient neurilemmoma are rare variants of tumors which arise from the
peri-neural Schwann cells. These tumors are termed “ancient” because of
the degenerative features such as cyst formation, hemorrhage, calcifica-
tion, and hyalinization are acquired with increasing age in these tumors.
They are benign, slow growing and usually detected only incidentally or
due to local symptoms. Although most schwannomas are benign tumors,
those that are associated with von Recklinghausen disease are malignant
in 5% to 18% of cases. Retroperitoneal schwannomas account for only
0.5% to 5% of all cases and are extremely uncommon. They are well
encapsulated and recurrences following complete surgical excision are
uncommon.
Case Study A 70-year-old Hindu male patient presented with bilateral
lower limb pain, fever and headache. On blood investigations patients
was found to be positive for Falciparum. With normal abdominal exami-
nation, radiological examination was suggestive of an incidental well-
defined heterogeneous mass lesion measuring 4.8 x 4.8 cm is seen along
left anterior surface of left psoas muscle in the left retroperitoneal space.
Preoperative biopsy report was suggestive of predominantly fibro collage-
nous tissue and few benign spindle cells. Exploratory laparotomy and ex-
cision of the retroperitoneal mass was done. Overall histological features
were suggestive of atypical neurilemmoma (ancient neurilemmoma).
Conclusion Retroperitoneal ancient schwannoma is rare variety of
schwannoma with least chance of malignant transformation.
Keywords Ancient, Retroperitoneal schwannoma, Neurilemmoma,
Benign, Excision
384
A case of left diaphragmatic hernia in blunt abdominal trauma
Vedant Wankhede, Manish Chaudhari, Jawansingh Manja
Correspondence- Vedant Wankhede-vedwankhede786@gmail.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India and
Government Medical College and New Civil Hospital, Majuragate, Surat,
India
Background Adult onset diaphragmatic hernia is rare condition with var-
iable manifestation. Majority of adult onset diaphragmatic hernia is asso-
ciated with trauma. Traumatic diaphragmatic injury is known to present
with the wide range of symptoms, and most patients would have some
symptoms due to abdominal organ herniation. These injuries may be left
unrecognized when they occur but often uncovered in days during work
related symptoms. Diaphragmatic hernia is repaired by laparotomy or
thoracotomy or both. Here we present a diaphragmatic hernia in blunt
abdominal trauma presented with chest pain, breathlessness that was
repaired via laparotomy. Operative approach of diaphragmatic defect
closure is given below.
Case presentation A 50-year-male patient came to casualty with 7 day
history of chest pain and breathlessness. It is due to fall down in well 7
days ago while walking on road. Chest X-ray suggestive of left pleural
effusion along with collapsed left lung. Patient is further evaluated in the
form of CT abdomen which confirmed herniation of stomach and large
bowel in left hemithorax. Consolidation of right lower lobe also present.
Conclusion Traumatic injury of diaphragm is rare and for diagnosis re-
quired heigh index of suspicion for diagnosis and late diagnosis result in
wide range of symptom.
Keyword Diaphragmatic, Hernia, Laparotomy
385
Primary mesorectal hydatid cyst in presacral area of pelvis: An un-
usual case of echinococcosis
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Aman Balar, Devendra Chaudhary, Mukesh Pancholi
Correspondence- Aman Balar-aman.animax@gmail.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Hydatid disease is a parasitic infectious disease caused by
Echinococcus granulosus. The parasite can form cysts in any part of the
body with the liver and lung being the most common organs. It can rarely
occur in other organs like the muscle, bone and pelvis. Mesorectal fossa
hydatid cyst is rare. Surgical excision is treatment modality of choice and
accepted to be curative with a very low recurrence.
Case presentation A 48-year-old male presented with complaints of pain
while defecating since 4 months. During clinical examination, abdomen
was soft and nontender, proctoscopic examination was found to be nor-
mal. USG was suggestive of anechoic lesions with multiple septations in
pelvic region. CT scan was suggestive of discrete cystic density lesion
with septations and dependent debris. MRI scan was suggestive of multi-
loculated cystic lesion in mesorectal fossa. There were no such cysts
found in any other organ. Patient received antihelminthic medications
for 1 month before surgery. During surgery the cyst was excised from
mesorectal fossa and was apparent to be hydatid cyst as it contained small
daughter cysts. The cavity of the cyst was irrigated with 3% NaCl as a
scolicidal agent. Preventing spillage of the contents of the cyst and use of
scolicidal agents are mandatory to decrease the rate of recurrence.
Histopathological examination confirmed the hydatid disease.
Postoperatively, the patient was put on albendazole and patient’s symp-
toms disappeared after surgery.
Conclusion We conclude that Echinococcus granulosus can affect any
organ in the body from head to toe, and a high suspicion of this disease is
justified in endemic regions. Moreover, medical treatment should be giv-
en in the preoperative period as well as in the postoperative period for 4-6
weeks but surgical intervention is inevitable.
Keywords Hydatid cyst, Mesorectal fossa, Scolicidal agent
386
A case of post thyroidectomy tracheomalacia in multinodular colloid
goitre with Hashimoto’s thyroiditis
Aditya Baraiya, Devendra Chaudhary, Mukesh Pancholi
Correspondence- Aditya Baraiya-adityabaraiya1@gmail.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Post-thyroidectomy tracheomalacia has been a rare compli-
cation of thyroid surgery. High degree of suspicion is required to diag-
nose such grave complication in order to give timely management.
Acquired tracheomalacia in patient with thyroid mass results from degen-
eration of myoelastic component due to continuous compression/
infiltration by thyroid mass. We here present a case of post-
thyroidectomy tracheomalacia and its successful conservative
management.
Case presentation A 31-year-old female an operated case of right
hemithyroidectomy came with recurrent neck swelling. We suspected
toxic multinodular goitre of residual left lobe. Patient was kept on max-
imum dose of oral anti-thyroid agent yet patient was hyperthyroid. After
10 days of medical management and titration of doses patient was made
near euthyroid and operated for left sided hemithyroidectomy for left lobe
multinodular colloid goitre with intrathoracic extension. Intraoperatively,
thyroid mass found to be grossly displacing trachea and esophagus to-
wards left side, raising concern of possibility of postoperative
tracheomalacia. On completion of surgery patient was given extubation
trial, but due to breathing difficulty and stridor, patient was re-intubated
and kept on T-piece ventilation with oxygen support so we suspected
tracheomalacia and tracheostomy was done. Attempts were made to re-
move tracheostomy tube without success. On 15th postoperative day
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
thyroid profile was suggestive of hypothyroid state so we started supple-
mentation for the same and discharged patient on levothyroxine 25 mi-
crogram OD. On subsequent follow up 1 month after discharge trial to
remove tracheostomy tube was given with success and dose of
levothyroxine was titrated to levothyroxine 50 microgram OD. Patient
is on regular follow-up and euthyroid on levothyroxine supplementation
without any complications.
Conclusion High degree of suspicion for postoperative tracheomalacia in
case of thyroidectomy for large mass and timely diagnosis and man-
agement can avert rare but catastrophic event with necessary
precaution.
Keywords Tracheomalacia, Thyroidectomy, Tracheostomy
387
Successful treatment in case of angiomyolipoma of right kidney abut-
ting IVC with spontaneous bleeding itself
Dharmesh Chauhan, Devendra Chaudhary, Mukesh Pancholi
Correspondence- Dharmesh Chauhan-hip31777@gmail.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Renal angiomyolipoma (AML), also referred to as
renal hamartoma, is a rare solid tumor without malignant charac-
teristics. The inheritance pattern of renal AML is autosomal dom-
inant. Renal angiomyolipoma (R-AML) is a benign mesenchymal
neoplasm that includes smooth muscle cells, adipose tissue and
thick-walled blood vessels in different compositions. It is usually
asymptomatic and found incidentally by routine imaging tech-
niques and rarely becomes symptomatic. The prevalence of R-
AML in the general population is between 0.3% to 3% and fe-
males are 4 times at risk than males . It develops 80% sporadi-
cally and might be a clinical sign of tuberous sclerosis.
Case presentation A 32-year-old, male patient presented to OPD
with abdominal distension and abdominal pain with no history
of trauma. On clinical examination abdominal distension was
present and ballotable mass palpable in right hypochondrium
and lumber region. On ultrasonographic examination approx. 20
x 11 cm sized large well-defined heterogeneous echo texture le-
sion with evidence of multiple hypoechoic areas within. p/o
myolipoma.
On CECT abdomen approx. 12.8*13.6*17.9 cm (AP*ML*SI)
sized well defined soft tissue density lesion with hyperdense com-
ponent (HU +56) (s/o hemorrhage) and fat density component
noted in right suprarenal region with ill defined posterior wall
noted. Superiorly lesion abuts inferior surface of the right lobe
of liver with preserved fat plane. Right adrenal gland not seen
separately from lesion.
Exploratory laparotomy with right side nephrectomy with en mass
removal with large hematoma was done. On histopathological
examination all finding suggestive of angiomyolipoma of right
kidney, immunoreactive for SMA (smooth muscle actin), vimentin
and focally immunoreactive for HMB45.
Keywords Nephrectomy, Angiomyolipoma
388
A rare case of non-traumatic spontaneous acute extradural hemato-
ma in a patient with sickle cell disease
Nilesh Vaniya, Praveen Sharma
Correspondence- Nilesh Vaniya-nilvaniya9@gmail.com
Department of General Surgery, New Civil Hospital, Ring Road, Opp
Stem Cell Hospital, Khatodra Wadi, Majura Gate, Surat 395 001, India
S123
Background Non traumatic spontaneous epidural hematoma is a rare and
often unmentioned complication of sickle cell F. It is often associated
with skull bone infarction. An 18 yrs old boy with sickle cell anemia
who developed persistence headache during a vaso-occlusive crisis.
Brain CT revealed a right frontal extradural hematoma (EDH)
compressing on the brain. No other etiologic factor was identified. A right
frontal craniotomy and evacuation of the hematoma was performed.
Case report An 18-year-old male with sickle cell disease was admitted to
another hospital to receive treatment for headache and vomiting with no
improvement after one day of hospitalization. CT brain revealed a right
frontal extradural hematoma with midline shift. An emergency cranioto-
my with evacuation of extradural hematoma was performed. The patient
was discharged with normal neurological examinations on the fifth post-
operative day.
Results Non traumatic spontaneous EDH is a rare occurrence; in SCD
patients is rarer still. A high index of suspicion is required in the diagnosis
and treatment of EDH in patient with sickle cell anemia. Operative man-
agement is associated with excellent outcomes as demonstrated in our
index patient. It is often associated with skull bone infarction. An
eighteen-year old boy with sickle cell anemia who developed persistence
headache during a vaso-occlusive crisis. Brain CT revealed a right frontal
EDH compressing on the brain. No other etiologic factor was identified.
A right frontal craniotomy and evacuation of the Haematoma was per-
formed and he made good recovery.
Conclusion Spontaneous EDH is a rare occurrence; its occurrence in SCD
patients is rarer still. A high index of suspicion is required in the diagnosis
and treatment of EDH in patient with sickle cell anemia. Operative man-
agement is associated with excellent outcomes as demonstrated in our
index patient.
Keywords Sickle cell disease, Extradural hematoma, Craniotomy, CT
brain
389
Laparoscopic primary acquired lumbar hernia repair with intraper-
itoneal onlay mesh (IPOM) repair approach
Khushbu Badami, Devendra Chaudhari, Mukesh Pancholi
Correspondence- Khushbu Badami-khushbu.badami@gmail.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India
Background Lumbar hernias are rare among all other hernias in which
abdominal contents protrude through a defect in the posterolateral ab-
dominal wall. Hafner et al. stated that general surgeons will get only
one opportunity to repair a lumbar hernia during their lifetime. Lumbar
hernia was first suggested by P. Barbette in 1672 and R.J.C. Garangeot
published a case for the first time in 1731. Since then, only about 300
cases have been reported. We here describe a successful case of laparo-
scopic primary acquired lumbar hernia Repair with IPOM approach in a
65-year-old female patient who had a complain of reducible abdominal
swelling with no other com plains.
Case presentation A 65-year-old female patient presented to OPD with
right sided reducible, gradually progressive abdominal swelling for 2
years, with impulse on coughing, diagnosed as a primary acquired lumbar
hernia. Laparoscopic right lumbar hernia repair with IPOM approach was
done; intraoperatively, all the contents including terminal part of ileum,
ileocecal junction, cecum, appendix , proximal part of ascending colon
with its mesentry were reduced. 6 × 5 cm2 sized defect seen.15 cm2 sized
circular parietex composite pre-placed sutures mesh kept and fixed. There
were no postoperative immediate complications. Patient was discharged
on 4th postoperative day.
Conclusion Laparoscopic lumbar hernia repair is effective as there is
minimal tissue handling with very little dissection of surrounding tissues
with minimal to no postoperative morbidity.
S124
Keywords Lumbar hernia, laparoscopic repair, IPOM approach, parietex
composite pre-placed sutures mesh.
390
Lumbar hernia: Sutureless tensionfree meshplasty
Anuj Mehta, Praveen Sharma
Correspondence- Anuj Mehta-Anujmehta_101@yahoo.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001, India
Introduction Lumbar hernia is an uncommon abdominal wall hernia. It
develop through weakening of posterolateral abdominal wall associated
with Petit’s triangle or Grynfeltt-Lesshaft triangle. In lumbar hernia bow-
el, omentum, or pre-peritoneal fat herniates through the lumbar triangles.
Lumbar hernias have been misdiagnosed as lipomas, muscle strains, fi-
bromas, abscesses, and kidney tumor. It is more common in males be-
tween 50-70 years old and are more frequent on the left side. We here
report a case of such lumbar hernia in which we have done successful
repair through sutureless tensionfree meshplasty.
Methods A 40-year-old male patient with presented with right sided lumbar
region swelling since 2 years. On USG evaluation there was 3 cm defect
noted in anterior abdominal wall in right lumbar region. An open approach
through a posterolateral lumbar incision, content dissected up to the neck of
the sac, extraperitoneal fat excised, herniation was through the superior
lumbar triangle, loose lumbar fascia adjacent to the defect was dissected
enough to create flaps for approximation, fascia was approximated with
interrupted prolene stitches, attenuated muscle layers were dissected by
undermining thereby creating good muscle flap, prolene mesh was placed
over this fascial layer. The muscle flaps were approximated over the mesh.
Results The postoperative recovery was uneventful. The patient has
followed up for six months with no recurrence.
Conclusion Awareness of the anatomy of the lumbar triangles is essential
for prompt diagnosis of lumbar hernias. Repair can be done by both
laparoscopic and open approach. Open sutureless tensionfree meshplasty
is an easy, safe, and effective means of curing this rare surgical condition.
Keywords Lumbar hernia, Sutureless tensionfree meshplasty, Petit's tri-
angle, Grvnfeltt-lesshaft hernia
391
Successful operative management of a rare case of celiac axis neuro-
endocrine tumor
Bhargav Patel, Praveen Sharma
Correspondence- Bhargav Patel-bhargavdnp@gmail.com
Department of General Surgery, Government Medical College, Opp.
Income Tax Department Office, Majura Gate, Surat 395 001. India
Introduction Neuroendocrine tumor (NET) is a rare type of tumor that
arises from neuroendocrine cells. These cells have traits of both nerve
cells and hormone-producing cells and release hormones into the blood in
response to signals from the nervous system. Neuroendocrine tumors can
develop anywhere in the body, but most occur in the digestive tract,
pancreas, rectum, lungs, or appendix. We report a case of excision of
neuroendocrine tumor of celiac axis. The patient's postoperative course
was unremarkable. Excision of the celiac axis tumor may be safely per-
formed in selected patient.
Method A 49 yr/F patient presented with abdominal pain and vomiting
since 3 weeks. On USG evaluation there was 82 x 61 mm2 sized heter-
ogenous echo texture lesion with evidence of minimal vascularity and
foci of calcification noted involving left lobe of liver (p/o neoplastic
etiology). CECT abdomen and pelvis was done afterwards which sug-
gested presence of neuroendocrine tumor of celiac axis. An open ap-
proach through Chevron incision taken, mass of about 7 x 7 cm2 found
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
behind the left lobe of liver, arising from celiac axis. Mass separated from
surrounding structure, excised and sent for histopathological
examination.
Result The postoperative recovery was uneventful. The patient has
followed up for 1 year with no complications.
Conclusion This was the first case operated at our centre for ex-
cision of neuroendocrine tumor involving celiac axis. Open as well
as laproscopic approach can be done, but open approach provides
better safety, visualization with less complications.
Keywords Celiac axis tumor, Neuroendocrine tumor, Abdominal mass
392
Gastrointestinal and hepatic involvement in patients with COVID-19
infection at a tertiary care centre in Northern India: An observation-
al prospective study
Mohammed Ajmal, Manjunath Totaganti, Anirudh Mukherjee, Mukesh
Bairwa, Ajeet Bhadoria, Itish Patnaik, Sahaj Rathi, Anand Sharma, Rohit
Gupta
Correspondence- Rohit Gupta-docgupta1976@gmail.com
Department of Gastroenterology, All India Institute of Medical Science,
Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India
Introduction Since the outbreak of Corona Virus Disease 2019 (COVID-
19) in December 2019, various digestive symptoms have been frequently
reported in patients infected with the virus. The exact magnitude of gas-
trointestinal and liver involvement remains uncertain.
Methods In this descriptive, cross-sectional, study, we enrolled
confirmed patients with COVID-19 who presented from June till
August 2020. All patients were confirmed by real-time PCR and
were analyzed for clinical characteristics, laboratory data, and
treatment. The patients were followed throughout their hospital
stay and their outcomes noted.
Results In the present study, 180 patients including 117 patients with
COVID-19 and full clinical and laboratory data were analyzed. The av-
erage age was 43.4 years (SD±14.9), including 121 men and 59 women.
Most common presentation to the hospital was with fever in 82 patients
(70%), followed by cough (45.3%), dyspnea (37.6%) and sore throat
(25.6%). We found that 17 patients (14.5%) reported a digestive symp-
tom, including diarrhea (10 [8.5 %] cases), vomiting (8 [6.8 %] cases),
and abdominal pain (5 [4.3%] cases). Deranged LFTs in asymptomatic
patients (n=63) were noted with bil >1.2 [5 (7.9%)], AST >45 (19 [30%]),
ALT >40 (23 [36.5%]), ALP >270 (11 [17.5%] and bil>1.2 [17 (14.5%]),
AST >45 (42 [35.9%]), ALT>40 (59 [50.4%]), ALP>270 (27 [23%]) in
symptomatic patients.
Conclusion Digestive symptoms are seen in 15% of patients with
COVID-19 infection. Deranged LFT is common even in asymptomatic
patients, however, abnormal LFTs are more commonly seen in symptom-
atic patients.
Keywords Covid-19, Gastrointestinal, Hepatic
393
A study on pain and palliative management in advanced gastrointes-
tinal tract malignancy
Vivek Joshi, Mahadevan Balakrishnan, Mayank Jain, Madhankumar
Rathnasabapathy, Sitaraman Balajisubramanian, Jayanthi
Venkataraman
Correspondence- Vivek Joshi-vivekjoshi91@gmail.com
Department of Medical Gastroenterology, Arihant Hospital and Research
Centre, Indore 452 009, India, Gleneagles Global Health City, Chennai
600 100, India, and Sri Ramachandra Institute for Higher Education and
Research, Chennai 600 116, India
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
Introduction Pain is highly prevalent in cancer population. One
third of patients with cancer related pain receive inadequate pain
management.
Methods The study was done on patients with advanced and inoperable
gastrointestinal (GI) malignancies at institute of Gastrointestinal and
Hepatobiliary Sciences, Gleneagles Global Health City, Chennai, be-
tween 1st August 2018 to 31st December 2019. Demographic data, lab-
oratory parameters and radiological investigations, baseline visual ana-
logue scale (VAS) score and subjective global assessment (SGA) were
recorded on first contact along with details of medical, endoscopic, and
palliative interventions as performed. Analgesic pain ladder approach was
followed for pain management. Follow-up to assess response was done
using VAS score and SGA at the end of 3 months or death within this
period.
Results Seventy-one patients were included in the study. Most of them
were old aged males. Out of 7 malignancies, hepatocellular carcinoma
(HCC) was the most common tumor (57.8%) in study group. 40.8%
patients had metastatic cancer. Baseline mean VAS score of study popu-
lation was 5.13 ± 2.38 and highest was in carcinoma gallbladder patients
(8.0 ± 2.0). Most patients were having baseline SGA rating B (69%).
Tramadol was the most commonly used analgesic (35.22%) followed
by combination of tramadol and fentanyl (26.76%). the most common
palliation was transarterial chemoembolization (TACE) in HCC (80.5%)
and biliary self-expanding metal stent (SEMS) in carcinoma pancreas
(77.8%). There was statistically significant reduction in VAS score in
HCC (p<0.001), carcinoma pancreas (p=0.009) and colorectal cancer
(CRC) (p=0.022). 15.5% patients moved from SGA rating B to rating
A, 9.9% moved from SGA rating B to rating C, and 9.9% moved from
SGA rating C to rating B.
Conclusion Analgesic pain ladder approach is effective in cancer pain
management. But there is need for patient-tailored treatment for better
outcomes.
Keywords Advanced gastrointestinal malignancy, Pain and palliative
management, Visual Analogue Scale
394
Anti-epileptic drugs and DRESS syndrome- masquerading as extra-
hepatic biliary obstruction
Shodhan Aithal, Rohit Maidur
Correspondence- Rohit Maidur-rohitmaidur@gmail.com
Department of Internal Medicine, SDM College of Medical Sciences,
SDM University, Manjushree Nagar, Sattur Colony, Dharwad 580 009,
India
Introduction Systemic manifestation of adverse drug reaction have been
studied extensively. Anti-epileptic drugs (AED) associated DRESS (drug
reaction with eosinophilia and systemic symptoms) is a known entity.
They are usually idiosyncratic in nature and patients commonly present
to dermatologist due to skin manifestations with associated mortality of
10%. Our study aims to know the pattern of hepatic manifestation and
correlation with drug dosage and duration in DRESS along with associ-
ated morbidity.
Methods Clinical and laboratory parameters of four proven cases of
DRESS syndrome according to RegiSCAR criteria were studied, who
presented to internal medicine and medical gastroenterology department
in a tertiary care hospital.
Results Manifestations were seen across different age groups (2nd, 3rd,
4th and 7th decade) with female preponderance (3 out of 4). Phenytoin
was the common AED with mean dose of 300 mg/day. Duration of AED
usage till clinical manifestation varied from 4 weeks to 2 years. Absolute
eosinophil count was elevated (mean AEC- 2144). Hepatic involvement
in the form of cholestatic hepatitis (3 of 4) and skin rash (2 of 4) were
seen. Two patients had prolonged hospitalization for >1 week and both
had hepatic manifestation necessitating additional workup.
S125
Conclusion Skin rash need not be the presentation in all patients with
DRESS syndrome. It is of idiosyncratic in nature. Patient can present with
fever of unknown origin to internal medicine mimicking infective causes
and masquerading as extrahepatic biliary obstruction (EHBO) to gastro-
enterology, necessitating further workup for the same. Hepatic involve-
ment in DRESS syndrome is associated with prolonged hospitalization
and increased morbidity.
395
Clinical profile of patients with gastrointestinal malignancy at a ter-
tiary care centre in Odisha
Mrinal Gogoi
Correspondence- Mrinal Gogoi-DRMRINALGOGOI@GMAIL.COM
Department of Gastroenterology, S C B Medical College, Cuttack 753
007, India
Background Gastrointestinal malignancies account for significant num-
ber of cases managed in tertiary care centres. Although they are managed
by medical or surgical oncology department, most patients are diagnosed
or seek initial medical attention in gastroenterology department.
Aim This study was done to analyze clinical profile of patients diagnosed
with gastrointestinal malignancies.
Method Detailed clinical information, investigation reports were collected
from all patients admitted and diagnosed with gastrointestinal malignan-
cies between January 2019 to January 2020 were included in the study.
Results Total 650 patients with various gastrointestinal malignancies were
hospitalized in the gastroenterology department. Mean age of presentation
was 48±6 and among them 380 (58.4%) were male. Among various gastro-
intestinal malignancies 26% were diagnosed as carcinoma gallbladder, which
represent the maximum number of cases. Other malignancies include carci-
noma esophagus (5%), carcinoma stomach (14%), carcinoma duodenum
(0.5%), periampullary cancer (5%), carcinoma head of pancreas (11.5%),
cholangiocarcinoma (20%), hepatocellular cancer (5%), carcinoma colon
(8%), carcinoma rectum and rectosigmoid (5%). Most cases of carcinoma
gallbladder presented at late stage with jaundice. In periampullary and
cholangiocarcionoma common presentation was jaundice (78%) and in 20
% cases initial presentation was cholangitis. Hepatocellular cancer patients
commonly presented with jaundice and ascites. Most cases of carcinoma
rectum presented with bleeding per rectum. Among carcinoma stomach
patients 60% cases presented with gastric outlets obstruction.
Conclusion Carcinoma gallbladder is the most common gastrointestinal
malignancy in Odisha with female predominance and usually presented at
advanced stage. Among other malignancies few cases like carcinoma
colon and stomach were detected on screening gastrointestinal endoscopy
for nonspecific gastrointestinal symptoms like loss of appetite, early sa-
tiety and anemia due to chronic blood loss.
Keywords Gastrointestinal malignancies, Carcinoma gallbladder
396
Non-invasive assessment of cardiovascular risk using carotid intima
media thickness in patients with inflammatory bowel disease- Does
non-alcoholic fatty liver disease add on to the risk?
Anju Krishna K, Krishnadas Devadas, Sandesh K, Nidhin R, Ravindra
Pal
Correspondence- Ravindra Pal-docravindrapal@yahoo.com
Department of Medical Gastroenterology, Government Medical College,
Ulloor - Akkulam Road, Chalakkuzhi, Thiruvananthapuram 695 011,
India
Introduction We compared the carotid intima-media thickness test
(CIMT) of patients with IBD and subjects without IBD to know the
association between subclinical atherosclerosis in IBD and the
S126
cardiovascular risk. We also looked at whether NAFLD is an important
factor affecting CIMT in IBD.
Methods Descriptive study on 80 patients with IBD and 80 sub-
jects without IBD conducted in a tertiary care hospital. Subjects
aged more than 55 years, obese individuals, patients already diag-
nosed with cardio/cerebrovascular disease and those with other
chronic inflammatory conditions were excluded. The demograph-
ic, anthropometric and disease related data were recorded.
Baseline blood investigations including CRP and ESR were done.
CIMT was measured using B mode Doppler imaging. Presence of
fatty liver and Shear wave elastography of the liver were assessed.
The quantitative data were compared using students t test and the
qualitative data by Chi square test. Pearson and Spearman corre-
lation was done to find out the factors correlating with CIMT.
Results Age, sex distribution and traditional cardiovascular risks
(hypertension, diabetes and dyslipidemia) were comparable in
both groups. The CIMT was higher in patients with IBD as com-
pared to controls (0.532±0.091 vs. 0.476±0.038, p=.000). On
analysing the factors affecting CIMT in patients with IBD, those
with NAFLD as an extraintestinal manifestation had increased
CIMT (0.561±0.099 vs. 0.490±0.053, p=.000). Age, CRP and ul-
trasound grades of fatty liver had positive correlations with CIMT.
There was no change in CIMT with disease type (UC/CD), extent
of disease, disease activity or severity of disease. Multivariate
regression analysis showed that age and ultrasound grading of
fatty liver (R2=0.576, p=.000) were independent predictors of
CIMT.
Conclusion We found that CIMT, was increased in patients with
IBD as compared to controls. Age and NAFLD were independent-
ly associated with increased CIMT in IBD. Patients with IBD
especially those with NAFLD may require enhanced monitoring
for cardiovascular events.
Keywords Inflammatory bowel disease. Ulcerative colitis. Crohn’s dis-
ease; Carotid intima media
397
Unexplained pain abdomen due to alternative medicines
Ajay Jain, Arun Singh, Sohini Sirkar, Amit Joshi, Sumit Kumar Singh,
Abhilash Surela, Sudhansu Yadav
Correspondence- Arun Singh-arunptsv@gmail.com
Department of Gastroenterology, Choithram Hospital and Research
Center, 14, Manik Bagh Road, Indore 452 014, India
Introduction In last three decades there is increasing use of various
alternative medicines for the treatment of various chronic disor-
ders. These drugs are claimed as wonder drugs for chronic illness.
How-ever many of these drugs contain very high level of heavy
metals including lead and its accumulation leads to abdominal
pain of variable severity. Therefore we planned this study “to
analyze those patients who were consuming these unnamed indig-
enous drugs and presented with severe abdominal pain”.
Methods This is an observational case series of prospectively maintained
data of all patients having unexplained abdominal pain and found to have
an elevated blood lead level from 2011 to 2019. Lead toxicity was diag-
nosed when the blood lead level was more than >25 ug/dL as per the
recommendation of the Centers for Disease Control and Prevention
(CDC). All these patients were further interrogated for chronic diseases
for which they were consuming these alternative medicines.
Result Total sixty-six patients of unexplained abdominal pain from 2011
to 2019 were recruited, out of sixty-six patients, seventeen had elevated
blood lead levels. All seventeen patients had a history of ingestion of
herbal medicines for more than six months. Among these seventeen pa-
tients, six were taking for D.M., one for hypertension, two for arthritis and
remaining eight for infertility, and sexual dysfunction. Basophilic
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
stippling was seen in one patient. Fourteen patients had low hemoglobin
with median value 9.7g/dL. Mean serum blood lead level were 87.1 ug/
dL (range from 26.3-428 ug/dL). None of them required anti-chelating
agent.
Conclusion 1. Lead toxicity because of alternative medicine is not un-
common cause of otherwise unexplained abdominal pain with anemia. 2.
Most of these patients do not require a chelating agent for the
treatment. 3. There is an urgent need to bring these alternative
medicines under strict regulations for displaying its constituents
and their concentration.
Keywords Alternative medicines, Lead toxicity, Pain abdomen
398
Preventive role of hepatitis C and B oral antiviral drugs in Covid-19
infection
Parveen Malhotra
Correspondence- Parveen Malhotra-drparveenmalhotra@yahoo.com
Department of Medical Gastroenterology, Post Graduate Institute of
Medical Sciences, Medical Road, Rohtak 124 001, India
Introduction Researchers have suggested role of antiviral drugs for treat-
ment of Corona Viruses which includes anti-HIV drugs and oral antivirals
for hepatitis C and B like velpatasvir, sofosbuvir, daclastavir, ledipasavir
and tenofovir.
Aims To determine the prevalence of Covid-19 infection in patients taking
oral antiviral drugs for hepatitis C and B and the number of patients who
developed Covid-19 infection while being on treatment with above
antivirals.
Methods There were two groups which were followed for six months.
The first group included those patients who were on treatment for hepa-
titis C and B since 1st March, 2020. The second group included patients
who developed Covid-19 infection while being on oral antiviral drugs for
hepatitis C and B.
Result First group included 3100 patients of hepatitis C who were on
sofosbuvir 400 mg and daclastavir 60 mg or sofosbuvir 400 mg and
velpatasvir 100 mg and 600 chronic hepatitis B patients who were on
tablet tenofovir 300 mg, since 01.03.2020 till 30.09.2020, none devel-
oped Covid-19 infection. In second group, out of 30,000 confirmed
Covid-19 infection in above duration, four patients were found to be
positive for hepatitis C, out of them two completed their treatment one
year back and two were yet to start treatment. Hence, practically none was
on oral antiviral drugs for hepatitis C when got Covid-19 infection. Only
two patients developed Covid-19 infection while on tenofovir for chronic
hepatitis B.
Conclusion This study can be taken as indirect evidence of efficacy of
above oral antivirals in Covid-19 infection which has to be confirmed on
larger clinical trials.
Keywords Velpatasvir, Sofosbuvir, Daclastavir, Ledipasavir, Tenofovir,
Hepatitis C, Hepatitis B, Covid-19, Oral antivirals
399
Safeguarding ourselves with bare minimal in resource constraints
setting against Covid -19 our experience in tertiary care center
Muppa Indrakeela Girish, Amol Bapaye, Mangesh Borkar, Sachin
Palnitkar, Harshal Gadhikar, Rajendra Pujari, Suhas Date, Lalit Shimpi
Correspondence- Amol Bapaye-amolbapaye@gmail.com
Deenanath Mangeshkar Hospital and Research Center, Pune, India, and
Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar
Hospital and Research Center, Pune 411 004, India
Background SARS-CoV-2/Novel Corona Virus-19 (COVID-19) has be-
come a global pandemic. COVID-19 can be easily transmitted in an
Indian J Gastroenterol (December 2020) 39 (Suppl 1):S1–S141
endoscopy suite, there is high risk of infection during endoscopic proce-
dures. Adequate protection of HCP is utmost important.
Methods Retrospective study who underwent endoscopic procedures dur-
ing COVID-19 pandemic. Patients were pre-screened and risk was cate-
gorized into urgent (GI bleed, urgent feeds, biliary sepsis) and semi-
urgent (GI cancers, ERCP for hepatobiliary pancreatic cancers, EUS for
diagnosis of malignant conditions) for endoscopic procedures according
to APSDE guidelines. Prior to procedure hemogram, chest X-ray, CRP
done to all patients. HCW’s used modified PPE (cap, mask, shield, gown,
gloves). Anesthesia preference- TIVA (midaz, fentanyl, propofol), GA
with intubation. Gap between each procedure 20-30 mins. Divided our
clinical force into two teams and followed the rotation policy on weekly
basis. Procedures were performed in positive pressure rooms with air
conditioning settings- MTR power 5.5 KW, fan TSP-626Pa, fan speed -
1198RPM, Disch vol -11.6 m/s, motor frame size-132S-4, efficiency–
89.4% and nearly 30mm of W.C positive pressure.
Results Four hundred and sixty-seven patients (70.9%; male =312
[66.8%]; median age = 57) underwent endoscopy procedures- from
March 20th to June 20th 2020. One hundred and ninety (40.7%) patients
S127
had one or more comorbidities with hypertension being commonest co-
morbidity in 142 (28%) patients. Commonest symptom was GI bleed in
121 (25.91%) patients. Five hundred and seven procedures, 274 (54%)
diagnostic, 233 (46%) -therapeutic. Interventions ERCP – 85 (36.5%),
EUS – 7 (3%), esophageal stenting-9 (3.9%), PEG- 22 (9.4%), EVL-35
(15%) 6 (1.2%) died during hospitalization following terminal illness.
Follow-up of patients according to different procedures 2 weeks – 1
month did not develop Covid-19 symptoms and were not detected
positive.
Conclusions Proper precautions there was no event of cross COVID-19
viral transmission between healthcare workers and patients. Judicious use
of basic tests we followed will help in resource constraints settings like
peripheral hospitals and nursing homes.
Keywords Covid 19, Risk stratification, PPE
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