Experience of Performing Hepatic Interventional Radiological Procedures in a Tertiary Care Hospital in Odisha: A Case Series.

Introduction: During last few decades, radiological interventions have played crucial role in the management of the patients with chronic liver diseases. Various procedures including transjugualar intrahepatic portosystemic shunt (TIPS), transjugular liver biopsy (TJLB), transarterial chemoembilization (TACE)/transarterial radioembolization (TARE), balloon retrograde transvenous obliteration (BRTO) and plug-assisted retrograde transvenous obliteration (PARTO) are being performed safely and have significantly improved clinical outcomes in these patients. The technical and clinical success depend on appropriate patient selection along with thorough knowledge and experience to perform these procedures. On the other hand, few adverse events may also be associated with these procedures. The intervention radiologist and hepatologists should identify and treat these complications at the earliest so as to improve outcome of the patient. Materials and methods: About 25 hepatic intervention radiology procedures were performed in our center from January 2022 to 2023 May. Among these we have selected five patients who underwent TACE/TIPS/DIPS in our institute. We have selected these cases as in each of these cases we encountered some interesting outcomes/complications which were managed successfully. Results: The first case describes 33-year-old male with POEM syndrome and Budd Chiari Syndrome (BCS) who underwent TIPS and immediately had blockade of the stent. The second case is of a 43 years old male having BCS, refractory ascites with umbilical and inguinal hernia. The third case is of a 40 years old female with decompensated cirrhosis who underwent TIPS for portal hypertensive gastropathy. The fourth case is of a 51-years' female with decompensated cirrhosis with sarcopenia. Finally, the fifth case describes 24-year-old female with BCS and hepatocellular carcinoma. In this article we discuss the procedure and clinical course of the patients following the procedure. Conclusion: Hepatic radiological interventions though widely used can be associated with unusual albeit life threatening complications. Appropriate patient selection and thorough knowledge of procedure along with early diagnosis and management of these complications are key to obtain satisfying long term outcomes.

Combination of antimicrobials for non-specific isolated terminal ileal abnormalities - A randomized clinical trial.

BACKGROUND AND AIM: Non-specific isolated terminal ileum abnormalities (NSITIA) namely erosions, ulcer and nodularity are frequent findings on ileal examination during colonoscopy. Their clinical significance and management are uncertain. METHODOLOGY: A pilot randomized clinical trial comparing combination antimicrobial therapy (oral Rifaximin 550 mg twice daily for two weeks; Albendazole 400 mg orally as a single dose; Tinidazole 1 gm twice daily for three days i.e. Group A) with symptomatic treatment (Group B) was performed in patients with NSITIA, which was diagnosed on the basis of colonoscopy and histopathology features. The primary outcome measure was mucosal healing on follow-up ileocolonoscopy at three months of randomization. Additionally, clinical, endoscopic and histological findings were noted at baseline and after a follow-up of three months. RESULTS: Total 60 patients with NSITIA were randomized. The most prevalent symptoms were abdominal discomfort (n = 37, 61.6%), diarrhea (n = 25, 41.6%) and constipation (n = 24, 40%). The incidence of ulcers, nodularity and erosions were (n = 18, 62.1%), (n = 8, 27.6%) and (n = 3, 10.34%) in group A and (n = 18, 58%), (n = 9, 29%), (n = 4, 13%) in group B, respectively. After a mean follow-up duration of 3.36 ± 0.27 months, both groups showed comparable resolution in clinical symptoms (n = 24, 92.4% vs. n = 24, 88.8%, p = 0.954), ileocolonoscopic findings (n = 23, 88.5% vs. n = 22, 81.5%, p = 0.765) and histological characteristics (n = 20, 76.5% vs. n = 19, 70.4%, p = 0.806). CONCLUSION: The clinical, endoscopic and histopathological remission occurs in most patients with NSITIA. The use of antimicrobials including antibiotic, antiprotozoal and anthelminthic therapy did not have any impact on the rate of mucosal healing in these patients. Our study is a pilot study and has some limitations such as small sample size and lack of complete small bowel workup in all patients, which leaves a possibility of undetected ulcers proximal to the terminal ileum. CLINICAL TRIAL REGISTRATION: This study has been registered in India's clinical trial registry under the registration number CTRI/2020/02/023459 ).

Unusual Presentation of Systemic Lupus Erythematosus in a Young Male: A Case Report.

Hepatic involvement in systemic lupus erythematosus (SLE) is common but described infrequently. Liver is usually never the primary organ to be affected in lupus. Again hepatic involvement probably does not carry much prognostic importance though it may correlate with lupus activity. We here report a case of 21-year-old man with no prior comorbidity or addiction who presented to us with acute hepatic illness with jaundice. He also had malar rash and arthralgia. Viral markers were negative. Antinuclear antibody and anti-double-stranded DNA (dsDNA) were strongly positive. Liver biopsy was consistent with autoimmune hepatitis, whereas skin biopsy was suggestive of SLE. He had a brisk and complete recovery with prompt use of immunosuppressive agents (corticosteroids and azathioprine). Cyclophosphamide was started latter in view of lupus nephritis. This is probably the fourth reported case of SLE presenting as acute hepatic illness with jaundice.

Hyper-eosinophilic syndrome: An uncommon cause of chronic abdominal pain in an elderly male.

Hypereosinophilia is defined as an absolute eosinophil count of ≥1.5 × 109/L, and its presence with involvement of at least one organ system defines the hypereosinophilic syndrome. It may occur with parasitic infestation, connective tissue disorder or rarely in clonal disorders such as eosinophilic leucaemia. Organ systems that may be involved include the cardiovascular, central nervous, respiratory and gastrointestinal systems. In the latter, a wide spectrum of clinical presentation may be seen from trivial, to debilitating or rarely fatal. We report an elderly male with a history of bronchial asthma, obstructive sleep apnoea and food allergy who presented with chronic abdominal pain and weight loss. Abdominal examination and routine evaluation were essentially normal other than a peripheral hyper-eosinophilia. We witnessed a brisk and lasting response to an elimination diet and corticosteroids.

Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure.

Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.

Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis.

Acute liver failure (ALF) is an infrequent, unpredictable, potentially fatal complication of acute liver injury (ALI) consequent to varied etiologies. Etiologies of ALF as reported in the literature have regional differences, which affects the clinical presentation and natural course. In this part of the consensus article designed to reflect the clinical practices in India, disease burden, epidemiology, clinical presentation, monitoring, and prognostication have been discussed. In India, viral hepatitis is the most frequent cause of ALF, with drug-induced hepatitis due to antituberculosis drugs being the second most frequent cause. The clinical presentation of ALF is characterized by jaundice, coagulopathy, and encephalopathy. It is important to differentiate ALF from other causes of liver failure, including acute on chronic liver failure, subacute liver failure, as well as certain tropical infections which can mimic this presentation. The disease often has a fulminant clinical course with high short-term mortality. Death is usually attributable to cerebral complications, infections, and resultant multiorgan failure. Timely liver transplantation (LT) can change the outcome, and hence, it is vital to provide intensive care to patients until LT can be arranged. It is equally important to assess prognosis to select patients who are suitable for LT. Several prognostic scores have been proposed, and their comparisons show that indigenously developed dynamic scores have an edge over scores described from the Western world. Management of ALF will be described in part 2 of this document.

Unusual Cause of Recurrent Cholangitis: Gossypiboma.

Gossypiboma refers to a retained surgical sponge that can occur after any type of surgery. Though it is a rare complication of surgery, the retention of surgical sponges still occurs. We report a case of a 70-year-old woman who presented with recurrent upper abdominal pain and fever. She had a prior history of cholecystectomy and choledochoduodenostomy. Magnetic resonance cholangiopancreatography showed a filling defect in common bile duct. However, during endoscopic retrograde cholangiopancreatography and common bile duct clearance, clumps of woven fibres were removed suggestive of gossypiboma.

Outcomes of Endoscopic Dilation in Patients with Esophageal Anastomotic Strictures: Comparison Between Different Etiologies.

BACKGROUND AND AIMS: This retrospective study was aimed at assessing the efficacy of endoscopic dilation for esophageal anastomotic strictures, and to compare response between caustic anastomotic strictures (CAS) and non-caustic anastomotic strictures (NCAS). MATERIALS AND METHODS: Patients with anastomotic strictures (enrolled during January 1996-December 2015) were analyzed. Short- and long-term outcomes of dilation, in terms of clinical success, refractory, and recurrent strictures were compared between NCAS and CAS. Patients with refractory and recurrent strictures were managed with adjunctive therapy including intralesional steroids. Factors predicting refractoriness at start of dilation and reasons for more than ten lifetime dilations were also evaluated. RESULTS: Of the 142 patients, 124 (mean age-44.02; males-74) underwent dilation. Clinical success was achieved in 113 (91.3%) patients requiring a median [Interquartile range (IQR)] of 4 (2-10) sessions. The number of dilations to achieve clinical success, refractory strictures, and recurrent strictures, and the use of adjunctive therapy were significantly higher for CAS than for NCAS. Intralesional steroid use decreased periodic dilation index (PDI) significantly in CAS. Caustic etiology and starting dilation diameter of < 10 mm were found to be predictors of refractoriness, with the former alone being an independent predictor of more than ten lifetime dilations. No patient had free perforation; however, five required revision surgery. CONCLUSION: Patients with CAS fared worse than those with NCAS in terms of number of dilations, refractoriness, recurrence of strictures, and need of adjunctive therapy. Endoscopic dilation can successfully ameliorate dysphagia due to anastomotic strictures in a majority of patients.

Strongyloides Infection Presenting as Proximal Small Intestinal Obstruction.

Duodenal obstruction is an infrequent but potentially fatal complication of strongyloidiasis infection. Strongyloides stercoralis can clinically manifest in a broad variety of ways and lacks a classic clinical syndrome, which makes the diagnosis of strongyloidiasis difficult. The diagnosis is usually delayed and made by duodenal aspirate, duodenal biopsy, and/or postoperative biopsy specimen of the resection stricture segment. We present a case of partial duodenal obstruction caused by S. stercoralis. A 46-year-old man had presented with repeated bilious vomiting for 12 days. Upper gastrointestinal endoscopy showed ulceronodular mucosa with luminal compromise at the second part of the duodenum. Abdominal computed tomography scan also showed a wall thickening with luminal narrowing of the second and third part of the duodenum. Duodenal mucosal biopsy revealed larval forms of S. stercoralis.

Change in serum levels of inflammatory markers reflects response of percutaneous catheter drainage in symptomatic fluid collections in patients with acute pancreatitis.

BACKGROUND: Percutaneous catheter drainage (PCD) is used as the first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). There are limited data on the effect of PCD on inflammatory markers. AIM: To study the effects of PCD on serum levels of C-reactive protein (CRP), IL-6, and IL-10 and its correlation with the outcome. METHODS: Consecutive patients of AP with symptomatic fluid collections undergoing PCD were evaluated for serum levels of CRP, IL-6, and IL-10 before PCD and at 3 and 7 days after PCD. Resolution of organ failure (OF), sepsis, and pressure symptoms was considered to demonstrate the success of PCD. Changes in levels following PCD were correlated with outcome. RESULTS: Indications of PCD in 59 patients (age 38.9 ± 13.17 years, 49 male) were suspected/documented infected pancreatic necrosis (n = 45), persistent OF (n = 40), and pressure symptoms (n = 7). A total of 49 (83.1%) patients improved with PCD, five patients required surgery, and six died. A significant difference was noted between baseline levels of CRP (P = 0.026) and IL-6 (P = 0.013) among patients who improved compared to those who worsened following PCD. Significant decrease (P < 0.01) of all three markers on day 3 of PCD insertion, with further decrease (P < 0.01) on day 7, was noted. The percentage of the decrease of IL-6 levels on day 3 and of CRP on day 7 correlated with the outcome. CONCLUSION: PCD is associated with a significant decrease in CRP, IL-6, and IL-10 levels. Percentage decrease in IL-6 on day 3 and CRP on day 7 correlated with the outcome of patients managed with PCD.

Arterial pseudoaneurysms in acute and chronic pancreatitis: Clinical profile and outcome.

OBJECTIVE: To evaluate the clinical profile and outcome of arterial pseudoaneurysms (PSA) associated with acute and chronic pancreatitis (CP). METHODS: Records of all patients of pancreatitis from 2010 to 2016 were analyzed retrospectively for the development PSAs; clinical profile and outcome parameters were compared between PSAs associated with acute and CP. RESULTS: Of the 980 patients, 46 (all males, age 39.70 ± 11.78 years) developed PSAs, including 19 of 600 of acute pancreatitis (AP) and 27 of 380 of CP. The most common clinical presentation was bleeding (37, 80.4%). The majority of patients was managed nonsurgically, with endovascular embolization in 31 (67.4%) and percutaneous thrombin injection in 9 (19.6%) patients. Pseudoaneurysms in patients with AP were associated more often with fluid collections (94.7% vs. 55.6%, P = 0.004) with more requirement of surgery compared to patients with CP (15.8% vs. 3.7%, P = 0.033). The pattern of arteries involved with PSAs and outcome was similar in AP and CP patients. CONCLUSION: Arterial PSAs were more commonly associated with CP compared to AP with similar presentations. Associated fluid collections and requirement of surgical intervention were higher in PSAs in patients with AP compared to patients with CP.

Hepatitis A infection related haemophagocytic syndrome: a case report and systematic review.

Haemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome of excessive inflammation and tissue destruction owing to abnormal immune activation. We report an unusual case of haemophagocytosis associated with hepatitis A virus (HAV) infection in a 21-year-old man. This was further complicated by haemolysis secondary to G-6-PD deficiency and fungal sepsis. Our patient was treated successfully with intravenous immunoglobulin (IVIg) and supportive care. A systematic review of all reported cases of HAV associated haemophagocytosis is presented.

Multiplex Polymerase Chain Reaction for diagnosis of gastrointestinal tuberculosis.

BACKGROUND AND AIM: To evaluate the role of multiplex polymerase chain reaction (PCR) for diagnosis of gastrointestinal tuberculosis (GITB). METHODS: This was a prospective observational study conducted from July 2015 to November 2016 at a tertiary care teaching institution in north India. Fifty individuals with clinically suspected GITB and older than 18 years of age were recruited. Patients underwent radiological investigations, esophagogastroduodenoscopy, or colonoscopy as clinically indicated. Multiple biopsies for tissue diagnosis and PCR were taken. All specimens were subjected to Ziehl Neelsen staining, histopathology, and multiplex PCR using specific primers for genes IS6110, MPB64, and Protein b. The performance of the assay was assessed using a composite reference standard for diagnosis of tuberculosis. It comprised a combination of clinical characteristics and microbiological methods, including smear, Bactenecin (BACTEC) culture, histopathology, and response to antitubercular therapy. RESULTS: A final diagnosis of tuberculosis was made in 32 cases (Duodenal-4, Ileo-colonic-28). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of histopathology for the diagnosis of tuberculosis was 28.12, 100, 100, and 43.9%, respectively. The sensitivity, specificity, PPV and NPV of BACTEC Mycobacteria Growth Indicator Tube (MGIT) culture for the diagnosis of tuberculosis was 9.3, 100, 100, and 38.29%, respectively. The sensitivity, specificity, PPV, and NPV of multiplex PCR for the diagnosis of tuberculosis was 87.5, 100, 100, and 86.2%, respectively. CONCLUSION: Multiplex PCR using specific primers for genes IS6110, MPB64, and Protein b had a higher sensitivity compared to conventional techniques for the diagnosis of GITB.

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

BACKGROUND AND OBJECTIVES: Despite improvement in outcomes of acute pancreatitis (AP), some subgroups remain at increased risk. We studied the impact of onset-to-admission interval to a tertiary care centre on outcomes in AP. METHODS: Retrospective analysis of consecutive patients with first episode of AP admitted between 2009 and 2017 on the basis of onset-to-admission interval: ≤7 days, 8-21 days and >21 days was done. Patients were assessed for severity and managed using a step-up approach. Primary outcome measures were surgical necrosectomy and mortality. RESULTS: Of 745 patients (age 39.26 ±â€¯13.18 yrs, 69% male), 380 (51%) had presented ≤7 days, 229 (30.7%) between 8 and 21 days and 136 (18.3%) >21 days after pain onset. Severe pancreatitis was highest in 8-21 days group (129; 56.3%) followed by ≤ 7 days (166; 43.7%) and >21 days of illness (52; 38.2%).Surgical intervention rates were highest in the 8-21 days group(14%) followed by > 21 days (12.5%) and ≤7 days (6.6%) respectively (p = 0.007). Also, mortality was highest in patients with onset to admission interval of 8-21 days (24%) followed by > 21 days (15.4%) and ≤7 days (14.2%) (P = 0.007). On the multivariate analysis, age, late presentation, and the presence of organ failure were found to predict the mortality. CONCLUSION: Patients presenting between 8 and 21 days after onset perform poorly than those presenting earlier or later than them in terms of severity, organ failure, need for surgery and mortality although organ failure remains the most important determinant of outcome. This data can help in devising guidelines for referral of such patients.

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

BACKGROUND AND OBJECTIVES: Percutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP. METHODS: Consecutive patients of AP with symptomatic ANC or WON undergoing PCD were evaluated. Primary outcome measures were need for additional surgical necrosectomy and mortality. Secondary outcome measures were need for up-gradation of first PCD, need for additional drain, in-hospital as well as total duration of PCD and length of hospital stay. RESULTS: Indications of PCD in 375 patients (258 with ANC and 117 with WON) were suspected infected pancreatic necrosis (n = 214), persistent organ failure (n = 117) and pressure symptoms (n = 44). Need for additional surgical necrosectomy was seen in 14% patients with ANC and in 12% of patients with WON (p = 0.364) and mortality was 19% in patients with ANC as compared to 13.7% in those with WON (p = 0.132). There was no significant difference in the secondary outcome parameters between patients who underwent PCD for ANC or WON. Complications of PCD were comparable between patients with ANC and WON except development of external pancreatic fistula which occurred more often in patients with WON than in those with ANC (24.4% versus 34.2% respectively, p = 0.034). CONCLUSION: Persistent organ failure in more often an indication of PCD in patients with ANC than in WON and suspected infection is more commonly an indication in WON than in ANC. Early PCD is as efficacious and safe as delayed PCD.

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

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