An Open-Label Randomized Controlled Trial Comparing Effectiveness of Aggressive Hydration Versus High-dose Rectal Indomethacin in the Prevention of Postendoscopic Retrograde Cholangiopancreatographic Pancreatitis (AHRI-PEP).

BACKGROUND: Although rectal administration of nonsteroidal anti-inflammatory drugs is recommended as the standard pharmacologic modality to prevent postendoscopic retrograde cholangiopancreatography (ERCP) post-ERCP pancreatitis (PEP), vigorous periprocedural hydration (vHR) with lactated Ringer's solution (LR) is emerging as an effective prophylaxis modality for PEP. There has been no head-to-head comparison between these 2. STUDY: This was a single-center, randomized, open-label, noninferiority, parallel-assigned, equal allocation, controlled clinical trial in a tertiary care hospital. Consecutive adults referred for ERCP, satisfying predefined inclusion criteria, underwent simple randomization and blinded allocation into 2 groups. Those allocated to vHR received intravenous LR at 3 mL/kg/h during procedure, 20 ml/kg bolus immediately afterward, and then at 3 mL/kg/h for another 8 hours. Those randomized to rectal Indomethacin received only per-rectal 100 mg suppository immediately post-ERCP. Assuming PEP of 9% in Indomethacin arm and noninferiority margin of 4%, we calculated sample size of 171 patients in each arm for 80% power and α-error 5%. Primary outcome was incidence of PEP, within 1 week, as defined by Cotton's criteria. All analysis were done by intention-to-treat. RESULTS: Between October, 2017 to February, 2018, 521 patients were assessed. In all, 352 were enrolled, 178 randomized to vHR, and 174 to per-rectal Indomethacin. Baseline details and ERCP outcomes were not different between 2 groups. PEP occurred in 6 (1.7%) overall, with 1 (0.6%) in hydration arm, and 5 (2.9%) in indomethacin arm; an absolute risk reduction of 2.3% (95% confidence interval: 0.9%-3.5%) and odds ratio of 0.19 (95% confidence interval: 0.02-1.65). Three patients developed severe PEP, all receiving indomethacin. CONCLUSIONS: vHR with LR is noninferior to postprocedure per-rectal Indomethacin for PEP prevention (ClinicalTrials.govID:NCT03629600).

Indian Outpatients with Idiopathic Chronic Pancreatitis Have Catastrophic Healthcare Expenditure, Malnutrition, Anxiety/Depression and Work-Impairment.

INTRODUCTION: There is paucity of data regarding economic burden, employment affection, psychological and nutritional status of CP patients, of non-alcoholic etiology, especially during their periods of stable disease, i.e., without any complications and/or recent endoscopic/surgical interventions. METHODS: In a prospective cohort study, conducted in outpatient clinic of a tertiary-care hospital, 66 consecutive adults with Idiopathic CP (± diabetes) and 152 matched (by age, socioeconomic status and monthly income) healthy controls were assessed for: (1) healthcare expenses in previous month by recall (catastrophic if > 40% of income); (2) nutritional status by anthropometry and food frequency questionnaire; (3) psychological status by Hospital Anxiety and Depression Scale (HADS); and (4) work-impairment by work productivity and activity impairment questionnaire: general health (WPAI-GH). CP patients were again reassessed for the above parameters after 6 and 12 month, respectively. RESULTS: Seventy-six percent CP patients (vis-à-vis 0% controls) had catastrophic healthcare expenditure. Forty-nine percent of CP patients(vis-à-vis 0% controls) met their healthcare expenses by either selling assets or obtaining loans at high-interest or from charitable donations. CP patients had lower BMI, were more likely to be malnourished and had a lower calorie intake vis-à-vis controls (median (IQR) recommended daily allowance (RDA): 71(19)% vs 97(23)%; [p < 0.0001]). Their median HADS Anxiety and depression scores were significantly higher than controls. Thirty-one (47%) CP patients were employed vis-a-vis 102 (67%) controls (p = 0.006); they had significantly higher work impairment. After one year, there was improvement in some of these above parameters in CP patients. CONCLUSION: Idiopathic CP outpatients had catastrophic healthcare expenditure, malnutrition, abnormal psychological scores and work-impairment vis-à-vis healthy controls. Some of these parameters improved on follow-up.

Outcome of sequential dilatation in achalasia cardia patients: a prospective cohort study.

BACKGROUND: Sequential increment of balloon diameter for endoscopic pneumatic dilatation is a protocol that is used for symptomatic relief in achalasia cardia. However, most of the studies evaluating its effectiveness are retrospective in nature. This study intended to look into the efficacy of the above protocol in a prospective fashion. METHODS: Consecutive patients of achalasia cardia (n = 72) attending gastroenterology department were subjected to graded dilatation with 30, 35, and 40 mm pneumatic balloon and followed up (median 48 weeks; range: 4-96 weeks) with Eckardt score. Efficacy was assessed by proportion of patients achieving and maintaining clinical remission (Eckardt score ≤ 3) without requiring surgery during follow-up. RESULT: Overall 91% of patients (60 out of 66 with follow-up data) remained symptom free without requirement of surgery. Proportion of type 3 achalasia patients was significantly higher in the group requiring surgery compared to those who did not (p = 0.005). Threshold of 12 mm Hg in 4-week post-dilatation integrated relaxation pressure noted to predict future requirement of surgery in type 3 achalasia patients with sensitivity and specificity of 75% and 85%, respectively. Major adverse events requiring in-patient management were 2.9% with perforation noted in 1.9%. CONCLUSION: A sequential increment of balloon diameter for pneumatic dilatation in achalasia is an effective mode of therapy to achieve and maintain clinical remission in achalasia. The incidents of adverse events are low in this approach. Type 3 achalasia patients are more likely to require surgery despite sequential dilatation.

Transcriptome analysis identifies putative multi-gene signature distinguishing benign and malignant pancreatic head mass.

BACKGROUND: Most often, the patients with pancreatic diseases are presented with a mass in pancreatic head region and existing methods of diagnosis fail to confirm whether the head mass is malignant or benign. As subsequent management of the disease hugely depends on the correct diagnosis, we wanted to explore possible biomarkers which could distinguish benign and malignant pancreatic head masses. METHODS: In order to address that gap, we performed a case-control study to identify genome-wide differentially expressed coding and noncoding genes between pancreatic tissues collected from benign and malignant head masses. These genes were next shortlisted using stringent criteria followed by selection of top malignancy specific genes. They subsequently got validated by quantitative RT-PCR and also in other patient cohorts. Survival analysis and ROC analysis were also performed. RESULTS: We identified 55 coding and 13 noncoding genes specific for malignant pancreatic head masses. Further shortlisting and validation, however, resulted in 5 coding genes as part of malignancy specific multi-gene signature, which was validated in three independent patient cohorts of 145 normal and 153 PDAC patients. We also found that overexpression of these genes resulted in survival disadvantage in the patients and ROC analysis identified that combination of 5 coding genes had the AUROC of 0.94, making them potential biomarker. CONCLUSIONS: Our study identified a multi-gene signature comprising of 5 coding genes (CDCA7, DLGAP5, FOXM1, TPX2 and OSBPL3) to distinguish malignant head masses from benign ones.

Frey Procedure Combined with Biliary Diversion for the Treatment of Chronic Pancreatitis-Related Biliary Obstruction: Impact of the Types of Diversion.

BACKGROUND: Frey procedure (FP) has become the standard of treatment for patients with painful chronic pancreatitis and inflammatory head mass. Biliary diversion (BD) is necessary when there is persistent biliary obstruction after adequate head coring. The aim of the present study was to assess the impact of types of biliary diversion on short-term outcome and rates of stricture recurrence. METHODS: All the patients, who underwent FP combined with BD between August 2007 and July 2017 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India, were retrospectively reviewed. The types of BD performed were choledochojejunostomy (Group A) or opening of the CBD in the resection cavity (Group B). RESULTS: During the study period, 36 patients underwent FP with BD. Choledochojejunostomy was performed in 21 patients and opening of the CBD in the resection cavity in 15 patients. Preoperative characteristics and early surgical outcomes were comparable except the postoperative stay which was longer in those who underwent choledochojejunostomy (p = 0.044). Pain control was similar. Over a median follow-up of 72 months, five patients in the Group B developed stricture recurrence which was significantly higher than those of Group A (p = 0.008). CONCLUSION: Choledochojejunostomy combined with FP achieves efficient BD with a lower rate of restricture compared with opening of the CBD in the resection cavity.

Comparison of tumour and serum specific microRNA changes dissecting their role in pancreatic ductal adenocarcinoma: a meta-analysis.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is considered as one of the most aggressive cancers lacking efficient early detection biomarkers. Circulating miRNAs are now being considered to have potency to be used as diagnostic and prognostic biomarkers in different diseases as well as cancers. In case of cancer, a fraction of the circulating miRNAs is actually derived from the tumour tissue. This fraction would function as stable biomarker for the disease and also would contribute to the understanding of the disease development. There are not many studies exploring this aspect in pancreatic cancer and even there is not much overlap of results between existing studies. METHODS: In order to address that gap, we performed a miRNA microarray analysis to identify differentially expressed circulating miRNAs between PDAC patients and normal healthy individuals and also found two more similar datasets to perform a meta-analysis using a total of 182 PDAC patients and 170 normal, identifying a set of miRNAs significantly altered in patient serum. Next, we found five datasets studying miRNA expression profile in tumour tissues of PDAC patients as compared to normal pancreas and performed a second meta-analysis using data from a total of 183 pancreatic tumour and 47 normal pancreas to detect significantly deregulated miRNAs in pancreatic carcinoma. Comparison of these two lists and subsequent search for their target genes which were also deregulated in PDAC in inverse direction to miRNAs was done followed by investigation of their role in disease development. RESULTS: We identified 21 miRNAs altered in both pancreatic tumour tissue and serum. While deciphering the functions of their target genes, we characterized key miR-Gene interactions perturbing the biological pathways. We identified important cancer related pathways, pancreas specific pathways, AGE-RAGE signaling, prolactin signaling and insulin resistance signaling pathways among the most affected ones. We also reported the possible involvement of crucial transcription factors in the process. CONCLUSIONS: Our study identified a unique meta-signature of 21 miRNAs capable of explaining pancreatic carcinogenesis and possibly holding the potential to act as biomarker for the disease detection which could be explored further.

Outcome of surgery for recurrent pyogenic cholangitis: a single center experience.

BACKGROUND: Although, recurrent pyogenic cholangitis (RPC) is prevalent in several parts of India, there is paucity of published literature from India. The aim of this study was to report on the short and long-term outcomes of surgery for RPC. METHODS: All the patients, who underwent surgery for RPC between August 2007 and February 2016 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. RESULTS: Of the total 94 patients, 66 (70%) were women. The median age at presentation was 40 years. Left lobe was solely involved in 49% of patients. Left hepatectomy was performed in 23/44 (52%) patients who underwent liver resection. Thirty two postoperative complications developed in 27 patients (29%). Complete stone clearance was possible in 83% of patients after primary surgery. Over a median follow up of 36 months, seventy one of 87 patients (81%) remained free of stones. Recurrent cholangitis occurred 10 of 87 patients (11%). CONCLUSIONS: Surgery plays an important role in the management of RPC achieving excellent short and long-term outcomes.

"Normal" liver stiffness measure (LSM) values are higher in both lean and obese individuals: a population-based study from a developing country.

UNLABELLED: The liver stiffness measure (LSM) needs to be explored in ethnically and anthropometrically diverse healthy subjects (to derive an acceptable normal range) and also in patients with liver disease. In view of this objective, LSM was performed by transient elastography (TE) using FibroScan in 437 healthy subjects with normal alanine aminotransferase (ALT) levels, recruited from a free-living population of the Birbhum Population Project (BIRPOP; www.shds.in), a Health and Demographic Surveillance System (HDSS), and from 274 patients with liver disease attending the Hepatology Clinic of the School of Digestive and Liver Diseases (SDLD; Institute of Post Graduate Medical Education & Research [IPGME&R], Kolkata, India) including 188 with nonalcoholic fatty liver disease (NAFLD) and 86 with chronic hepatitis of viral and other etiologies. Liver biopsy was performed in 125 patients. The range of normal values for LSM, defined by 5th and 95th percentile values in healthy subjects, was 3.2 and 8.5 kPa, respectively. Healthy subjects with a lower body mass index (BMI; < <18.5 kg/m(2)) had a higher LSM compared with subjects who had a normal BMI; this LSM value was comparable to that of obese subjects (6.05 ± 1.78 versus 5.51 ± 1.59 and 6.60 ± 1.21, P = 0.016 and 0.349, respectively). Liver disease patients without histologic fibrosis had significantly higher LSM values compared with healthy subjects (7.52 ± 5.49 versus 5.63 ± 1.64, P < 0.001). Among the histologic variables, stage of fibrosis was the only predictor for LSM. LSM did not correlate with inflammatory activity and ALT in both NAFLD and chronic hepatitis groups. CONCLUSION: LSM varies between 3.2 and 8.5 kPa in healthy subjects of South Asian origin. Both lean and obese healthy subjects have higher LSM values compared with subjects with normal BMI. Liver stiffness begins to increase even before fibrosis appears in patients with liver disease.

Pancreatic and peripancreatic nodal tuberculosis in immunocompetent patients: report of three cases.

CONTEXT: Pancreatic and peripancreatic tuberculosis in immunocompetent patients is extremely rare. It often mimics pancreatic malignancy. Majority of the cases are diagnosed after an image guided biopsy or after an operation. CASE REPORT: We report three cases of pancreatic tuberculosis in immunocompetent patients. All three cases were diagnosed without laparotomy. Diagnosis was made by contrast enhanced computed tomography or endoscopic ultrasound guided fine needle aspiration of the peripancreatic mass and all three cases were treated successfully with antituberculous drugs. CONCLUSION: Pancreatic and peripancreatic tuberculosis should be considered in the differential diagnosis of a peripancreatic mass when the patient is young, residing in the endemic zone of tuberculosis or had past history of tuberculosis. Extensive necrosis of peripancreatic lymph nodes with rim enhancement further supports the diagnosis of tuberculosis. Every attempt should be made to diagnose the cases before start of therapy to prevent unnecessary operation.

External validation of Chronic Pancreatitis Prognosis Score (COPPS): A prospective cohort study.

BACKGROUND: Prognostic stratification in ChronicPancreatitis(CP) remains suboptimal and cumbersome. Chronic Pancreatitis Prognostic Score(COPPS) was recently developed to predict one-year hospitalisations in CP. AIM: External validation of COPPS in a geographically divergent patient population. METHODS: A single-center prospective cohort study, conducted on out-patients of a tertiary-care hospital. Consecutive adults with CP were assessed for COPPS risk predictors at baseline, similar to the original development cohort, and followed for one-year for: 1)hospitalisations; 2)development of pancreatitis-related complications; and 3)need for endoscopic and/or surgical interventions. Outcomes were compared by Kendall's tau-b(τb) and other statistical tests. Only those who had complete one-year follow-up were included in analysis. RESULTS: There were 177 patients(mean±SD age: 35.9 ± 11.2 years), 116(65%) males and 117(66%) with Idiopathic CP. Despite being younger, with significantly more females and Idiopathic CP, than the original development cohort, our cohort was similar to the latter regarding COPPS severity at baseline. Eight patients died over one-year; 169 were evaluated for outcomes. Increasingly severe COPPS categories correlated with increasing number of hospitalisations(both overall and pancreatitis-related) and increasing number of days spent in hospital(both overall and pancreatitis-related) irrespective of age at symptoms-onset(≤35 vs >35years), etiology(idiopathic vs alcohol) and smoking-status. CONCLUSIONS: COPPS is effective in a geographically distinct cohort having a different case-mix of CP patients(ClincialTrials.gov ID:NCT04907266).

Nonobese population in a developing country has a high prevalence of nonalcoholic fatty liver and significant liver disease.

UNLABELLED: There is a paucity of community-based epidemiological data on nonalcoholic fatty liver (NAFL) among nonaffluent populations in developing countries. Available studies are radiological and/or biochemical and lack histological assessment, limiting their strength. We conducted a prospective epidemiological study comprising a 1:3 subsample of all adult (>18 years) inhabitants of a rural administrative unit of West Bengal, India. Subjects positive for hepatitis B virus and/or hepatitis C virus infection and consuming any amount of alcohol were excluded. Diagnosis of NAFL was by dual radiological screening protocol consisting of ultrasonographic and computed tomographic examination of the liver. Transient elastographic examination and liver biopsy were performed in a subset to identify significant liver disease. The risk factors of having NAFL were analyzed. A total of 1,911 individuals were analyzed, 7% of whom were overweight and 11% of whom had abdominal obesity. The prevalence of NAFL, NAFL with elevated alanine aminotransferase, and cryptogenic cirrhosis was 8.7%, 2.3%, and 0.2%, respectively. Seventy-five percent of NAFL subjects had a body mass index (BMI) <25 kg/m(2), and 54% were neither overweight nor had abdominal obesity. The subjects with the highest risk of having NAFL were those with a BMI >25 kg/m(2) (odds ratio 4.3, 95% confidence interval 1.6-11.5). Abdominal obesity, dysglycemia (fasting plasma glucose >100 mg/dL or elevated homeostatic model assessment of insulin resistance), and higher income were the other risk factors. Even having a normal BMI (18.5-24.9 kg/m(2)) was associated with a 2-fold increased risk of NAFL versus those with a BMI <18.5 kg/m(2). CONCLUSION: There is a significant prevalence of NAFL and potentially significant liver disease, including cryptogenic cirrhosis, in this predominantly nonobese, nonaffluent population in a developing country. NAFL will be a major determinant of future liver disease burden in countries of the developing world.

An unusual cause of acute abdomen in adults: giant cystic lymphangioma of the pancreatic head. A clinical case and literature review.

CONTEXT: Cystic lymphangioma of the pancreas presenting as acute abdomen in adults has not been reported before. CASE REPORT: We report the case of a young man who presented with severe pain in the upper abdomen and abdominal swelling. On imaging, he was found to have a giant multiseptate cystic lesion occupying almost the entire abdomen anterior to the pancreas. On exploration, a cystic mass involving the head of the pancreas and densely adherent to the antrum, and the second and third parts of the duodenum was found and a classic Whipple pancreaticoduodenectomy was done. Histology revealed a diagnosis of cystic lymphangioma. CONCLUSION: Cystic lymphangioma is a rare benign tumor of the pancreas and this is the first reported case in an adult presenting with acute abdomen. Though rarely diagnosed preoperatively, this entity should also be considered in the differential diagnosis of cystic lesions of the pancreas. Complete surgical excision is curative.

Capsule endoscopy for obscure gastrointestinal bleeding in the tropics: report from India.

BACKGROUND: Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited. METHODS: Eighty-six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64-month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3±14.1 months) were considered to confirm CE findings. RESULTS: Of 86 patients (aged 54.5±16.3 years, 63 males), 64 and 22 had OGIB-overt and OGIB-occult, respectively. Lesions were equally detected in OGIB-overt and OGIB-occult patients (48/64, 75% vs 18/22, 81.8%, P= ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively. CONCLUSION: CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.

Longer-term outcome of acute pancreatitis: 5 years follow-up.

BACKGROUND AND AIM: Following an index episode of acute pancreatitis, sometimes the inflammation subsides completely, but sometimes inflammation persists and progresses to chronic pancreatitis, which may be or may not be preceded by recurrent acute pancreatitis. Some patients may also develop diabetes mellitus. There is only limited information on the longer-term outcome of patients with acute pancreatitis. The aim of this study was to evaluate the longer-term consequences of acute pancreatitis in the form of the development of recurrent attacks of acute pancreatitis, chronic pancreatitis, diabetes, or pancreatic carcinoma. METHODS: The index study included 122 patients who presented with their first episode of acute pancreatitis. This retrospective, cross-sectional survey was performed 5 years after the index episode. RESULTS: Of the 122 patients, 96 were available for follow-up while 4 were known to have died (one from pancreatic cancer). On reassessment after 5 years, 28 of 96 patients had further episodes of pancreatitis. Fifteen patients were diagnosed as having recurrent acute pancreatitis, 13 patients were diagnosed as having chronic pancreatitis, while 17 developed new-onset diabetes. Recurrent acute pancreatitis was more common in younger patients, while chronic pancreatitis was associated with alcohol abuse and a more severe index episode. The development of diabetes was more common with advanced age. CONCLUSIONS: In this study, a good proportion of patients progressed to chronic pancreatitis and diabetes within 5 years after surviving acute pancreatitis.

Isolated pancreatic and peripancreatic nodal tuberculosis: A single-centre experience.

Isolated pancreatic and peripancreatic nodal tuberculosis may mimic pancreatic malignancy and may result in unnecessary surgery. Being a treatable disease, it is desirable to diagnose this condition without a laparotomy. Pancreatic tuberculosis should be considered in the differential diagnosis of a peripancreatic mass if the patient is young, residing in endemic tuberculosis regions, or has had a history of tuberculosis. We report our experience with pancreatic tuberculosis. Over a period of 12 years, we have managed 16 such patients, of whom 10 were diagnosed preoperatively. In six, the diagnosis was only made after extensive surgery. All 16 patients received antitubercular drugs and were well at a median follow-up of 52 months. Although pancreatic tuberculosis can be diagnosed by modern image-guided biopsy in a fair number of patients, if a high index of suspicion is maintained, a laparotomy may still be unavoidable in a subset of patients.

Short- and long-term outcome of Frey procedure for chronic pancreatitis in adults.

OBJECTIVE: To report our experience with Frey procedure (FP) for chronic pancreatitis (CP) in adults. METHODS: Adult patients with CP, who underwent a FP between August 2007 and July 2018, were retrospectively reviewed. RESULTS: Of the total 138 patients, 95 (69%) were male. The median age at operation was 36.5 years. The median pain-surgery interval was 48 months. Alcohol abuse was identified in 64 (46%) patients. The major indication for surgery was disabling pain (94%). There was no postoperative mortality. Postoperative complications developed in 43 (31%) patients. Median postoperative hospital stay was 9 days. Over a median follow-up of 65 months, 84% of patients had complete pain relief. Continuous pain and high preoperative Izbicki pain score were associated with incomplete pain control. New-onset diabetes and exocrine insufficiency developed in 31% and 27% of patients respectively. Longer duration of disease and previous pancreatic surgery were associated with the development of new-onset diabetes after the FP. CONCLUSIONS: Frey procedure is safe with an acceptable perioperative complications and good long-term pain control.

Incretins in fibrocalculous pancreatic diabetes: A unique subtype of pancreatogenic diabetes.

BACKGROUND: Studies evaluating endocrine and exocrine functions in fibrocalculous pancreatic diabetes (FCPD) are scarce. METHODS: Insulin, C-peptide, glucagon, incretin hormones (glucagon-like peptide 1 [GLP-1] and gastric inhibitory peptide [GIP]), and dipeptidyl peptidase IV (DPP-IV) were estimated in patients with FCPD (n = 20), type 2 diabetes mellitus (T2DM) (n = 20), and controls (n = 20) in fasting and 60 minutes after 75 g glucose. RESULTS: Fasting and post-glucose C-peptide and insulin in FCPD were lower than that of T2DM and controls. Plasma glucagon decreased after glucose load in controls (3.72, 2.29), but increased in T2DM (4.01, 5.73), and remained unchanged in FCPD (3.44, 3.44). Active GLP-1 (pmol/L) after glucose load increased in FCPD (6.14 to 9.72, P = <.001), in T2DM (2.87 to 4.62, P < .001), and in controls (3.91 to 6.13, P < .001). Median active GLP-1 in FCPD, both in fasting and post-glucose state (6.14, 9.72), was twice that of T2DM (2.87, 4.62) and 1.5 times that of controls (3.91, 6.13) (P < .001 for all). Post-glucose GIP (pmol/L) increased in all: FCPD (15.83 to 94.14), T2DM (21.85 to 88.29), and control (13.00 to 74.65) (P < .001 for all). GIP was not different between groups. DPP-IV concentration (ng/mL) increased in controls (1578.54, 3012.00) and FCPD (1609.95, 1995.42), but not in T2DM (1204.50, 1939.50) (P = .131). DPP-IV between the three groups was not different. Fecal elastase was low in FCPD compared with T2DM controls. CONCLUSIONS: In FCPD, basal C-peptide and glucagon are low, and glucagon does not increase after glucose load. GLP-1, but not GIP, in FCPD increases 1.5 to 2 times as compared with T2DM and controls (fasting and post glucose) without differences in DPP-IV.

EUS-guided in vivo microdialysis of the pancreas: a novel technique with potential diagnostic and therapeutic application.

BACKGROUND: Microdialysis has been used in vivo to measure dynamic temporal variations in extracellular or interstitial concentrations of non-protein-bound substances that are unstable in the systemic circulation. OBJECTIVE: To evaluate the technical feasibility and possible complications of EUS-guided in vivo microdialysis of the pancreas. DESIGN AND INTERVENTION: Under the guidance of an echoendoscope inserted into the stomach of each dog, the pancreatic parenchyma was punctured by using a 19-gauge needle. A specially developed microdialysis probe threaded through the lumen of the 19-gauge needle was positioned in the pancreas. The probe was constantly perfused with saline solution at a flow rate of 1.0 microL/minute. SETTING: Experiments on 8 beagle dogs. MAIN OUTCOME MEASUREMENTS: The concentration of 5-fluorouracil (5-FU) in the microdialysate was measured at 10-minute intervals, once before and for 8 times after a single (20 mg/kg) bolus intravenous infusion of 5-FU. RESULTS: Following the administration of 5-FU, the concentration of 5-FU in all macrodialysate samples exceeded the cut-off value by more than 100-fold. The 5-FU levels in the microdialysate increased rapidly, peaked by 10 minutes (13.9 microg/mL), and gradually declined thereafter. No local bleeding or accumulation of fluid around the pancreas was observed. LIMITATION: Sampling was unsuccessful in 2 of the 8 dogs because the probe broke while being inserted into the pancreatic parenchyma. CONCLUSION: EUS-guided pancreatic microdialysis is feasible and has multiple potential clinical/therapeutic applications, including monitoring pharmacokinetics focally and detecting novel biomarkers that are unstable or undetectable in the plasma.

Obscure GI bleeding in the tropics: impact of introduction of double-balloon and capsule endoscopies on outcome.

BACKGROUND: Innovative but costly small-bowel enteroscopies, capsule endoscopy (CE), and double-balloon endoscopy (DBE) have revolutionized the management of obscure GI bleeding (OGIB). OBJECTIVE: To measure the impact of these procedures on outcomes of OGIB in a resource-poor setting. DESIGN: Prospective cohort study and comparison with a historical cohort. SETTING: Tertiary-care center in India. PATIENTS: Fifty-three patients with OGIB, diagnosed by American Gastroenterological Association criteria. INTERVENTIONS: DBE and/or CE were performed. Patients were then offered specific treatment and/or hematinics. MAIN OUTCOME MEASUREMENTS: The etiology of OGIB in a tropical country and yield of DBE and/or CE. The number of investigations required, follow-up hemoglobin, rebleeds, and interventions/transfusions needed were compared between the present and historical cohort. RESULTS: Mean age was 46.4 years with hemoglobin (mean +/- standard deviation) of 8.3 +/- 2.3 g/dL at evaluation. OGIB was overt in 33 and occult in 20. They underwent 173 investigations before referral. DBE and/or CE localized the source of bleeding in 43 (yield 81%). Angiodysplasias, tumors, Crohn's disease, intestinal tuberculosis, and hookworm infestation were predominant etiologies. Compared with the historical cohort, DBE and/or CE have reduced the number of investigations per patient, increased the yield of mid intestinal source of OGIB, and reduced the number of surgeries, especially emergency laparotomies. There was no significant alteration in the overall yield, mortality, and rebleeding rates. LIMITATION: Small cohort without economic analysis. CONCLUSIONS: The demographic profile and etiological spectrum of OGIB in the tropics is different. DBE and/or CE have made a favorable impact on management.