Prognostic Role of Tumor Budding and Worst Pattern of Invasion in Lymph Node Metastasis and Disease-Free Survival in Oral Squamous Cell Cancer Patients: Result from Central India's Regional Cancer Centre.

Aim: To study the role of pattern of invasion, tumor budding and other clinicopathological parameters in determining the risk of nodal metastases and disease-free survival in oral squamous cell cancer patients. Method: The data of 90 patients with oral squamous cell carcinoma who underwent surgery as their primary modality of treatment were retrospectively analysed. Predictive significance of clinicopathological parameters was assessed with Univariate analysis with Fisher exact test and unpaired t-test. The factors which were significant on Univariate analysis were then analysed with multivariate analysis using logistic regression model to find independent predictors. P value < 0.05 was considered significant. Disease free survival analysis was performed using Kaplan-Meier method and comparison done using the log-rank test for each group. Result: The age of the patients ranged from 22yrs to 72 years with male predominance (81.1%). The most common site of involvement was buccal mucosa. Significant factors predicting nodal metastases on univariate analysis were site (p = 0.031), grade (p = 0.012), T stage (p = < 0.001), Depth of invasion (p = < 0.001), perineural invasion (p = < 0.001), lymphovascular emboli (p = 0.018), tumor budding (p = < 0.001), pattern of invasion (p = < 0.001) and stroma (p = 0.037). On multivariate analysis tumor budding (p = 0.016), depth of invasion (p = 0.016) and perineural invasion (p = 0.044) were predictive of nodal metastasis. A statistically significant difference in 3year disease free survival was seen in infiltrative pattern of invasion and tumor budding which showed a p-value of 0.0372 and 0.0489 respectively. Conclusion: Based on the findings of the present study and review of previous articles tumor budding, worst pattern of invasion, host lymphocyte response should also be included in routine histopathology reporting of OSCC.

Leuconostoc, a masquerading pathogen in oral cancer patient: A rare case report.

Osteoradionecrosis is the most common cause of mandibular osteomyelitis. Here we are reporting a case of osteomyelitis of the mandible caused by Leuconostoc mesenteroides spp cremoris. The frequency of Leuconostoc infections are under reported mainly due to its difficult identification. Non pathogenic organism like leuconostoc can cause infection in the immunocompromised and should warrant proper microbial identification and adequate targeted treatment to manage the patients.

Non-alcoholic fatty liver disease in polycystic ovarian syndrome in Indian women.

Non-alcoholic fatty liver disease (NAFLD) is a frequent occurrence in polycystic ovarian syndrome (PCOS). We studied the frequencies and characteristics of NAFLD in PCOS women. We compared various methods of detection of advanced fibrosis/cirrhosis. One hundred and forty women with PCOS and seventy controls, matched for age, were evaluated for the presence of NAFLD. Anthropometric variables, serum levels of aminotransferases, glucose, lipids and transient elastography were done. Thirty-six percent of the NAFLD patients had abnormal aminotransferases. In women presenting to an infertility clinic, NAFLD was higher in both obese and non-obese PCOS women, being present in 117 (83.6%) of PCOS cases and 32 (45.7%) of non-PCOS controls (p< .001). Fibroscan is helpful in evaluating for liver fibrosis in patients with NAFLD.Impact StatementWhat is already known on this subject? Polycystic ovarian syndrome (PCOS) has been associated with many long-term health complications including endometrial cancer, diabetes, hypertension and metabolic syndrome. The association of PCOS with NAFLD has been suggested. NAFLD is recognised as a leading cause of liver dysfunction which can progress to long-term sequel of cirrhosis.What do the results of this study add? In this study, asymptomatic women seeking treatment of infertility were screened for presence of NAFLD. The study shows a high prevalence of NAFLD in young Indian women. The prevalence was significantly higher in women with PCOS than non-PCOS women.What are the implications of these findings for clinical practice and/or further research? The findings of the study suggest that all infertile women, especially those with PCOS, should be screened for NAFLD. This will help in early identification and management of this condition and to avoid long-term consequences of liver dysfunction and cirrhosis. PCOS is an independent risk factor for the development of NAFLD in obese women. Liver ultrasound, serum levels of transaminases clinch the diagnosis. Short of liver biopsy, non-invasive tests like Fibroscan and NAFLD fibrosis score are useful to assess the stage of fibrosis.

Gastric secretion in patients with caustic ingestion: A prospective study.

BACKGROUND: Caustic ingestion can lead to structural changes in the upper gastrointestinal tract. However, there are limited data on the effect of caustic ingestion on gastric secretion. This study was planned to determine the changes in gastric acid output in patients with caustic ingestion. METHODS: It was a prospective study done at a tertiary care center in northern India. Twenty consecutive patients in chronic phase of caustic ingestion were evaluated for the study. The gastric secretory function was estimated in the basal state and following pentagastrin stimulation. These results were compared with normal values for our laboratory. RESULTS: The mean age of the included patients (n = 20) was 27.35 ± 2.96 years and 14 patients were male. Sixteen (80%) patients had a history of acid ingestion. Patients with caustic ingestion had significantly lower mean gastric acid secretion (0.8 ± 0.4 mEq/h vs. 4 ± 0.4 mEq/h; p < 0.001) compared to controls. After pentagastrin stimulation, the mean gastric juice volume (31.8 ± 6 mL/h vs. 62.3 ± 11.7 mL/h; p < 0.01) and acidity (15.3 ± 5.1 mEq/L vs. 39.6 ± 9.3 mEq/L; p < 0.001) increased in patients with caustic ingestion, but were lower than those in control subjects. Patients with a lower esophageal stricture (n = 6) had decreased maximum acid output (0.62 ± 0.32 mEq/h vs. 6.05 ± 0.55 mEq/h; p < 0.05) compared to patients with stricture in the upper or middle esophagus. CONCLUSION: Caustic ingestion is associated with reduced gastric juice volume and acid output. Patients with stricture in the lower one third of the esophagus are at a higher risk of hypochlorhydria compared to patients with stricture in either the upper or middle esophagus.

Hypotension in the first week of acute pancreatitis and APACHE II score predict development of infected pancreatic necrosis.

BACKGROUND: Hypotension and intestinal mucosal ischemia lead to bacterial translocation from the gut lumen into systemic circulation. AIM: The purpose of this study was to determine the strength of association between different types of organ failure (OF): hypotension (cardiovascular system failure), renal failure, respiratory failure, CNS failure and coagulopathy in the first week of acute pancreatitis (AP) and the subsequent development of infected pancreatic necrosis (IN). METHODS: Consecutive patients with AP were evaluated for OF and its severity in the first week of hospital admission. Modified multiple organ failure score (MOFS) was used to identify and grade severity of OF. MOFS of ≥2, lasting for more than 48 h was defined as OF. Occurrence of IN (isolation of bacteria in necrosectomy specimen or image guided fine needle aspiration of pancreatic necrosis) was compared between groups with and without OF. RESULTS: Of the 81 patients, mean age was 40.1 ± 14.4 years and 55 were males; 60 (74 %) patients had OF and 13 (16 %) patients had IN. Occurrence of IN was not significantly different between patients with OF (18.3 %) and without OF (14.3 %), p = 0.48. However IN occurred in 10 % of patients without and 33.7 % patients with hypotension, p = 0.01. The rest of the organ systems analyzed did not show any significant difference in occurrence of infected necrosis. On multivariate analysis independent predictors of occurrence of IN were hypotension (odds ratio, OR 2.5, p < 0.001) and APACHE II score at 24 h of hospital admission (OR 4.77, p < 0.001). CONCLUSION: Hypotension in the first week of AP and APACHE II score predict development of IN.

Implementation of the Asia-Pacific guidelines of obesity classification on the APACHE-O scoring system and its role in the prediction of outcomes of acute pancreatitis: a study from India.

AIMS: We studied the role of obesity and the Acute Physiology and Chronic Health Evaluation (APACHE) O score in predicting the outcome in patients with acute pancreatitis (AP) using the Asia-Pacific obesity classification. METHODS: Two hundred eighty AP patients were classified into three different groups, normal weight [body mass index (BMI) = 18.5-22.9 kg/m(2)], overweight (BMI = 23-24.9 kg/m(2)) and obese (BMI > 25 kg/m(2)), according to the Asia-Pacific obesity classification. For all patients APACHE II scores and modified APACHE O (i.e., APACHE Oap) scores that included a factor for obesity were calculated. The patients were managed using a standard protocol, and the outcome measures were compared for different obesity groups. RESULTS: Of the 280 patients (mean age 40.7 years), 46.8% were normal weight, 29.6% overweight and 23.6% obese. Forty-six (16.4%) patients underwent surgery, and 61 (21.8%) patients died. Patients with higher BMI had worse radiological indices of severity, more infected necrosis (p < 0.001), more persistent organ failure (p < 0.001) and higher requirement for percutaneous drain insertion (p = 0.04), surgery (p = 0.008) and mortality (p < 0.001). The area under the curve for predicting mortality was 0.879 for APACHE II and 0.886 for APACHE Oap; at a cutoff of 8.5, the APACHE II score had a sensitivity of 88.2% and specificity of 68.7%, and APACHE Oap 90.2 and 64.0%, respectively. CONCLUSIONS: BMI ≥ 23 kg/m(2) was an important predictor of a severe disease course and fatal outcome in patients with AP. However, the predictive accuracy of APACHE Oap for mortality was similar to APACHE II.

Dynamic nature of organ failure in severe acute pancreatitis: the impact of persistent and deteriorating organ failure.

BACKGROUND AND AIMS: In acute pancreatitis (AP), patients with persistent organ failure [POF, duration of organ failure (OF) ≥48 h] and transient organ failure (TOF, duration of OF <48 h) have different outcomes. We have compared the clinical course and outcome of patients with severe AP (SAP) with TOF and POF in the first week of hospitalization as well as the impact of change in the OF score in the first week on patient outcome. METHODS: Consecutive patients with SAP were evaluated for OF and its dynamics during the first week of hospitalization. The modified multiple organ failure score (MOFS) was used to identify OF, grade its severity and monitor its progression. The clinical course and outcome of patients were studied. RESULTS: Of 114 patients, mean age 39.2 ± 13.7 years, 37 (32.5%) patients had no OF, 34 (29.8%) had TOF and 43(37.7%) had POF. Patients with POF had the higher infected necrosis, increased requirement for percutaneous drain placement, surgery and higher mortality as compared with those with TOF. The odds ratio for mortality with persistent and deteriorating OF was 26.2 [confidence interval (CI) 5.1-134.9] compared with only persistent OF. CONCLUSION: The dynamics of OF in the first week of SAP predicts the clinical course and outcome. Persistent and deteriorating OF indicates a poor outcome.

Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm.

BACKGROUND: Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment. AIM: To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts. METHODS: Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21-38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts. RESULTS: All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients. CONCLUSIONS: Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

Non-fluoroscopic endoscopic ultrasound-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis.

BACKGROUND AND AIM: Endoscopic treatment of pancreatic necrosis is less invasive than surgery but is a technically demanding procedure. The aim of the present study was to retrospectively evaluate the safety and efficacy of endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis (WOPN) without the use of fluoroscopy. METHODS: Over the last 24 months, 20 patients (16 men) with symptomatic non-bulging WOPN were treated endoscopically at Department of Gastroenterology, PGIMER, Chandigarh, India.The WOPN was transmurally approached using a linear echoendoscope and the tract dilated over the wire and multiple stents and a nasocystic drain were placed. RESULTS: All 20 patients had acute severe pancreatitis and the etiology of pancreatitis was alcohol in 12, gallstones in six and idiopathic in two patients. All patients were symptomatic with pain and six patients had fever and presented 5 to 16 weeks after an acute episode.The size of WOPN ranged from 5 to 16 cm.All 20 patients had marked improvement with radiological resolution noted in 19 patients and only one patient required direct endoscopic necrosectomy. One patient with multiple WOPN had a large peripherally located WOPN that did not resolve after transmural drainage and required an additional percutaneous drainage. One to seven endoscopic sessions were required and all these patients had complete resolution within 6 weeks.There were no complications of the procedure.There has been no recurrence of symptoms in these patients over a median follow up of 14 months. CONCLUSION: EUS-guided transmural drainage of non-bulging WOPN without the use of fluoroscopy appears to be safe and effective.

Clinical presentation and outcome of endoscopic therapy in patients with symptomatic chronic pancreatitis associated with pancreas divisum.

CONTEXT: The results of endoscopic drainage in pancreas divisum with chronic pancreatitis have been debatable. OBJECTIVE: To evaluate clinical presentation and long term results of endoscopic therapy in patients of calcific and non-calcific chronic pancreatitis with pancreas divisum. PATIENTS AND METHODS: Between 1996 and 2011, 48 patients (32 males and 16 females) with chronic pancreatitis and pancreas divisum were treated endoscopically. Patients were considered to have clinical success if they had resolution of symptoms and did not require surgery. RESULTS: All patients presented with abdominal pain and symptoms were present for 36.6 ± 40.5 months. Pseudocyst, diabetes, pancreatic ascites, pancreatic pleural effusion, segmental portal hypertension and steatorrhea were seen in 13 (27.1%), 6 (12.5%), 3 (6.3%), 2 (4.2%), 2 (4.2%) and 1 (2.1%) patients, respectively. Ductal calculi and strictures were noted in 3 (6.3%) and 2 (4.2%) patients, respectively. In 47 patients, an endoprosthesis (5 or 7 Fr) was successfully placed in the dorsal duct. Following pancreatic endotherapy, 45/47 (95.7%) patients had successful outcome. The mean number of stenting sessions required to have clinical success was 2.6 ± 0.9. One patient each had mild post ERCP pancreatitis, inward migration of stent and precipitation of diabetic ketoacidosis. Over a follow up of 2-174 months (median: 67 months), 12 out of 31 patients with pain only and no local complications (38.7%) required restenting for recurrence of pain and none of these patients required surgery. CONCLUSION: Intensive pancreatic endotherapy is safe and effective both in patients with chronic calcific, as well as non-calcific, pancreatitis associated with pancreas divisum. It gives good long term response in patients having abdominal pain and/or dorsal ductal disruptions.

Tubercular versus Crohn's ileal strictures: role of endoscopic balloon dilatation without fluoroscopy.

BACKGROUND: Benign ileal strictures can cause considerable morbidity and they have been conventionally treated with surgery. The aim of this study was to report our experience of endoscopic balloon dilatation (EBD) in patients with terminal ileal strictures because of Crohn's disease and tuberculosis. METHODS: Over the last 8 years, 9 patients (6 males; mean age 39.7±13.2 years) with benign terminal ileal strictures were treated by EBD using a colonoscope and through-the-scope controlled radial expansion balloon dilators. RESULTS: The etiology of benign ileal stricture was Crohn's disease in 5 and tuberculosis in 4 patients. All the patients with Crohn's disease had no or partial response to 4 weeks of steroid therapy and there were no mucosal ulcerations on ileoscopy. Three patients with ileal strictures due to tuberculosis underwent dilatation after completion of the antitubercular therapy (ATT) while one patient required dilatation 3 months after starting ATT. All patients had single ileal stricture with length of stricture ranging from 0.6-1.8 cm. EBD was successful in all 9 patients with a median number of dilating sessions required of 2 (range: 1-5 sessions). Patients with Crohn's disease required more endoscopic sessions as compared to patients with tuberculosis but this difference was not statistically significant (mean number of session being 3.0±1.58 vs. 1.75±0.5 sessions respectively; P=0.1). One patient with ileal tuberculosis had enterolith proximal to the stricture that could be removed with dormia. There were no complications of the endoscopic procedure. CONCLUSIONS: EBD is an effective, safe, and minimally invasive treatment modality for benign ileal strictures.

Endoscopic ultrasound assisted etiological localization in acute pancreatitis.

Hyperparathyroidism is an uncommon cause of pancreatitis and one should look for its telltale evidence on history (renal stone disease) and investigations (hypercalcemia). Endosonography has an upcoming role in the management of acute pancreatitis, especially in the presence of fluid collection. We report a case of parathyroid adenoma related acute pancreatitis complicated with pseudocyst, which was managed with percutaneous drainage and endosonographic localization of the adenoma to the left parathyroid gland. This patient underwent sestamibi scanning, which confirmed its presence and underwent surgical excision of the adenoma. Endosonography should be included in the work up of patients with unclear etiology and thyroids should be routinely scanned for parathyroid adenomas. One should always look outside the box to get clues for diseases inside the box.

Esophageal duplication cyst in an adult masquerading as submucosal tumor.

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

Celiac disease presenting as recurrent pancreatitis and pseudocyst.

CONTEXT: The association between celiac disease and pancreatitis is sparsely reported. Celiac disease may remain asymptomatic or may have atypical features, and its diagnosis in pancreatitis may not be obvious. It is more than mere chance association that explains the occurrence of pancreatitis in celiac disease. Malnutrition, papillary stenosis and immunopathogenetic mechanisms contribute to the development of pancreatitis in a patient of celiac disease. CASE REPORT: We here report one such case that had recurrent acute pancreatitis with pseudocyst formation and negative routine etiological work up. It was on noticing abnormal duodenal mucosa at the time of doing endoscopic cystogastrostomy that the diagnosis of celiac disease was suspected and later proved. CONCLUSION: This report highlights that celiac disease should be considered in the etiological work up of patients with unexplained pancreatitis.

Prevalence of coeliac disease in healthy blood donors: a study from north India.

BACKGROUND: Blood donor screening can help predict prevalence of coeliac disease in population. METHODS: Between December 2010 and June 2011, healthy blood donors were screened using anti-tissue glutaminase antibodies. Those positive underwent duodenoscopy. Their age, gender, body mass index and haemoglobin and histological changes were recorded. RESULTS: Of the 1610 blood donors screened, 1581 (98.2%) were males. The mean age of donors was 31.51 ± 9.66 years and the mean body mass index was 22.12 ± 4.24 kg/m(2). Nine (0.56%) men were seropositive. Endoscopic features included reduced fold height (9), scalloping (8), grooving (7) and mosaic mucosal pattern (3). Eight had Marsh IIIa changes whilst one had IIIb change. The prevalence of coeliac disease was 1:179 (0.56%, 95% confidence interval 1/366-1/91, 0.27-1.1%). None of the 9 patients had any symptoms. Their mean haemoglobin and body-mass index was similar to rest of the cohort. CONCLUSION: The prevalence of coeliac disease amongst apparently healthy blood donors was 1:179 (0.56%).

Endoscopic management of pancreatic injury due to abdominal trauma.

CONTEXT: There is limited experience with pancreatic endotherapy in patients with pancreatic injury due to trauma. OBJECTIVE: To retrospectively evaluate our experience of endoscopic management of pancreatic trauma. PATIENTS: Eleven patients (10 males and 1 female; mean age: 21.8±11.9 years) with pancreatic trauma. INTERVENTION: Endoscopic therapy. Patients with pseudocyst and a gastroduodenal bulge were treated with endoscopic transmural drainage. Pseudocysts without bulge or patients with external pancreatic fistula were treated with transpapillary drainage. RESULTS: Seven patients (6 males, 1 female) were treated for symptomatic pseudocyst and 4 patients (all males) were treated for persistent external pancreatic fistula. Three patients with external pancreatic fistula had partial disruption of pancreatic duct (head: 2 cases; tail: 1 case) and were successfully treated with bridging pancreatic stent (2 cases) or bridging nasopancreatic drain (1 case) with resolution of external pancreatic fistula in 4 to 6 weeks. Of seven patients presenting with symptomatic pseudocyst (size range: 4-14 cm), two patients were successfully treated with cystogastrostomy and there has been no recurrence over a follow up of 20 and 16 months, respectively. Five patients underwent transpapillary drainage. Three patients had partial disruption and two had complete disruption. In the former, a bridging nasopancreatic drain was placed in one patient and stent in two patients. All three patients had resolution of pseudocyst within 8 weeks and there has been no recurrence over a follow-up of 11 to 70 months. In two patients with complete disruption, non-bridging stent did not resolve the pseudocysts and required surgery. CONCLUSION: Pancreatic injury due to trauma can be effectively treated endoscopically.

Evaluation of fecal myeloperoxidase as a biomarker of disease activity and severity in ulcerative colitis.

BACKGROUND: Subclinical inflammation in ulcerative colitis (UC) can predispose to relapses and biomarkers can detect mucosal inflammation. AIMS: To study the role of fecal myeloperoxidase (FMPO) in assessing disease activity and response to therapy in UC. METHODS: Patients with UC attending our hospital from July 2005 to September 2006 were studied. All patients underwent clinical, endoscopic, and histological assessment for disease extent and severity. Estimation of FMPO levels at baseline and on follow-up was carried out. Age-matched healthy controls were studied for FMPO levels. RESULTS: A total of 55 patients of UC (30 males, 25 females, mean age 38.6 ± 12 years) and 54 age-matched controls (mean age 37.6 ± 13.6 years) were studied. Cases had higher median MPO levels than controls (0.42 [IQR 0.84] vs. 0.06 [IQR 0.12]); (p < 0.001). Cases with endoscopically more severe disease (Gr III & IV; n = 18) had higher median FMPO levels compared to those with milder disease (Gr II, n = 37), [0.075 (IQR 1.315) vs. 0.315 (IQR 0.813); p = 0.02]. The median MPO level in 27 patients was 0.58 [IQR 0.89] units/ml at presentation which on follow-up decreased significantly to 0.18 [IQR 0.42] units/ml (p value 0.002). However, there was no significant association between FMPO and endoscopic extent and histological scores of activity and chronicity. CONCLUSIONS: Fecal MPO is an effective biomarker for assessing disease activity and response to therapy in patients with ulcerative colitis.