Impact of the Timing of Percutaneous Catheter Drainage following Endoscopic Drainage on Outcomes in Acute Necrotizing Pancreatitis.

Background The role of dual-modality drainage of walled-off necrosis (WON) in patients with acute pancreatitis (AP) is established. However, there are no data on the association of clinical outcomes with the timing of percutaneous catheter drainage (PCD). We investigated the impact of the timing of PCD following endoscopic drainage of WON on clinical outcomes in AP. Materials and Methods This retrospective study comprised consecutive patients with necrotizing AP who underwent endoscopic cystogastrostomy (CG) of WON followed by PCD between September 2018 and March 2023. Based on endoscopic CG to PCD interval, patients were divided into groups (≤ and >3 days, ≤ and >1 week, ≤ and >10 days, and ≤ and >2 weeks). Baseline characteristics and indications of CG and PCD were recorded. Clinical outcomes were compared between the groups, including length of hospitalization, length of intensive care unit stay, need for surgical necrosectomy, and death during hospitalization. Results Thirty patients (mean age ± standard deviation, 35.5 ± 12.7 years) were evaluated. The mean CG to PCD interval was 11.2 ± 7.5 days. There were no significant differences in baseline characteristics and indications of CG and PCD between the groups. The mean pain to CG interval was not significantly different between the groups. Endoscopic necrosectomy was performed in a significantly greater proportion of patients undergoing CG after 10 days ( p = 0.003) and after 2 weeks ( p = 0.032). There were no significant differences in the complications and clinical outcomes between the groups. Conclusion The timing of PCD following endoscopic CG does not affect clinical outcomes.

Outcomes of Self-expandable Metal Stents in Patients With Unresectable Gallbladder Cancer Undergoing Percutaneous Biliary Drainage.

Background: Biliary obstruction in gallbladder cancer (GBC) is associated with worse prognosis and needs drainage. In patients with biliary confluence involvement, percutaneous biliary drainage (PBD) is preferred over endoscopic drainage. However, PBD catheters are associated with higher complications compared to endoscopic drainage. PBD with self-expandable metal stents (SEMS) is desirable for palliation. However, the data in patients with unresectable GBC is lacking. Materials and methods: This retrospective study comprised consecutive patients with proven GBC who underwent PBD-SEMS insertion between January 2021 and December 2022. Technical success, post-procedural complications, clinical success, duration of stent patency, and biliary reinterventions were recorded. Clinical follow-up data was analysed at 30 days and 180 days of SEMS insertion and mortality was recorded. Results: Of the 416 patients with unresectable GBC, who underwent PBD, 28 (median age, 50 years; 16 females) with PBD-SEMS insertion were included. All SEMS placement procedures were technically successful. There were no immediate/early post-procedural complications/deaths. The procedures were clinically successful in 63.6% of the patients with hyperbilirubinemia (n = 11). Biliary re-interventions were done in 6 (21.4%). The survival rate was 89.3 % (25/28) at 30 days and 50% at 180 days. The median follow-up duration was 80 days (range, 8-438 days). Conclusion: PBD-SEMS has moderate clinical success and 6-months patency in almost half of the patients with metastatic GBC and must be considered for palliation.

Imaging Diagnosis and Management of Fistulas in Pancreatitis.

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Frequent guidewire passage into the pancreatic duct is an independent risk factor for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among high-risk individuals: A post-hoc analysis of a randomized controlled trial data.

OBJECTIVES: To systematically evaluate the patient and procedural risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among patients receiving rectal indomethacin. METHODS: Data from a randomized controlled trial (RCT) of high-risk patients undergoing ERCP who received rectal indomethacin with or without topical epinephrine was evaluated. PEP was defined based on the consensus criteria. Pancreatic stenting was excluded to avoid confounding results with the role of epinephrine spray. Multivariable logistic regression analysis was used to identify patient and procedural risk factors for PEP. RESULTS: Among 960 patients enrolled in the RCT, the PEP incidence was 6.4%. An increased risk of PEP was seen with age <50 years and female gender (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.35-4.26), malignant biliary stricture(s) (OR 3.51, 95% CI 1.52-8.10), >2 guidewire passes into the pancreatic duct (PD) (OR 2.84, 95% CI 1.43-5.64), and pancreatic brush cytology (OR 6.37, 95% CI 1.10-36.90), whereas a decreased risk of PEP was seen with contrast- over guidewire-assisted cannulation (OR 0.14, 95% CI 0.02-0.99) and the use of lactated Ringer's (LR) over other fluid types (OR 0.52, 95% CI 0.27-0.98). There was a significant trend between the number of guidewire passes into the PD and PEP risk (P = 0.002). CONCLUSIONS: More than two guidewire passes into the PD and pancreatic brush cytology increased while the use of LR decreased the risk of PEP among high-risk patients receiving rectal indomethacin. Pancreatic stent placement and/or LR should be considered in patients with >2 guidewire passes into the PD.

Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy.

Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.

Neutrophil-lymphocyte Ratio Predicts Clinical Response to Percutaneous Transhepatic Biliary Drainage in Acute Cholangitis.

Background: Predicting response to biliary drainage is critical to stratify patients with acute cholangitis. Total leucocyte count (TLC) is one of the criteria for predicting the severity of cholangitis and is routinely performed. We aim to investigate the performance of neutrophil-lymphocyte ratio (NLR) in predicting clinical response to percutaneous transhepatic biliary drainage (PTBD) in acute cholangitis. Patients and methods: This retrospective study comprised consecutive patients with acute cholangitis who underwent PTBD and had serial (baseline, day 1, and day 3) TLC and NLR measurements. Technical success, complications of PTBD, and clinical response to PTBD (based on multiple outcomes) were recorded. Univariate and multivariate analysis was performed to identify factors significantly associated with clinical response to PTBD. The sensitivity, specificity, and area under the curve of serial TLC and NLR for predicting clinical response to PTBD were calculated. Results: Forty-five patients (mean age 51.5 years, range 22-84) met the inclusion criteria. PTBD was technically successful in all the patients. Eleven (24.4%) minor complications were recorded. Clinical response to PTBD was recorded in 22 (48.9%) patients. At univariate analysis, the clinical response to PTBD was significantly associated with baseline TLC (P = 0.035), baseline NLR (P = 0.028), and NLR at day 1 (P=0.011). There was no association with age, the presence of comorbidities, prior endoscopic retrograde cholangiopancreatography, admission to PTBD interval, diagnosis (benign vs. malignant), severity of cholangitis, organ failure at baseline, and blood culture positivity. At multivariate analysis, NLR-1 independently predicted the clinical response. Area under the curve of NLR at day 1 for predicting clinical response was 0.901. NLR-1 cut-off value of 3.95 was associated with sensitivity and specificity of 87% and 78%, respectively. Conclusion: TLC and NLR are simple tests that can predict clinical response to PTBD in acute cholangitis. NLR-1 cut-off value of 3.95 can be used in clinical practice to predict response.

Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis.

PURPOSE: It is recommended to drain the pancreatic fluid collections later in the course of the acute necrotizing pancreatitis (ANP). However, earlier drainage may be indicated. We compared early (≤ 2 weeks) vs. late (3rd to 4th week) percutaneous catheter drainage (PCD) of acute necrotic collections (ANC). MATERIALS AND METHODS: This retrospective study comprised ANP patients who underwent PCD of ANC. The diagnosis of ANP was based on revised Atlanta classification criteria and computed tomography performed between 5 and 7 days of illness. Patients were divided into two groups [1st 2 weeks (group I) and 3rd-4th weeks (group II)] based on the interval between the onset of pain and insertion of catheter. The technical success, clinical success, complications, and clinical outcomes were compared between the two groups. RESULTS: One hundred forty-eight patients (74 in each group) were evaluated. The procedures were technically successful in all patients. The clinical success rate was 67.6% in group I vs. 77% in group II (p = 0.069). The incidence of complications was significantly higher in group I (n = 12, 16%) than group II (n = 4, 5.4%) (p = 0.034). These included 15 minor (11 in group I and 4 in group II) and one major complication (group I). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. 5 patients, p = 0.031). CONCLUSION: Early PCD is as technically successful as late PCD in the management of ANC. However, early PCD is associated with higher surgical rate and higher incidence of complications.

MTBDRplus and MTBDRsl for simultaneous diagnosis of gastrointestinal tuberculosis and detection of first-line and second-line drug resistance.

BACKGROUND AND AIM: Emergence of drug resistance, especially to second-line drugs, hampers tuberculosis elimination efforts. The present study aimed to evaluate MTBDRplus and MTBDRsl assays for detecting first-line and second-line drug resistance, respectively, in gastrointestinal tuberculosis (GITB). METHODS: Thirty ileocecal biopsy specimens, processed in the Department of Microbiology between 2012 and 2022, that showed growth of Mycobacterium tuberculosis on culture were included in the study. DNA, extracted from culture, was subjected to MTBDRplus and MTBDRsl (Hain Lifescience GmbH, Nehren, Germany), following manufacturer's instructions. Their performance was compared against phenotypic drug susceptibility testing (pDST) and gene sequencing. RESULTS: Out of the 30 specimens, 4 (13.33%) were mono-isoniazid resistant, 4 (13.33%) were multidrug resistant (MDR), 2 (6.67%) were pre-extensively drug resistant (pre-XDR), and 2 (6.67%) were mono-fluoroquinolone resistant. The results were 100% concordant with pDST and gene sequencing. CONCLUSIONS: In the wake of growing drug resistance in all forms of extrapulmonary tuberculosis, including GITB, MTBDRplus and MTBDRsl are reliable tools for screening of resistance to both first-line and second-line drugs.

"Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India.

Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.

Contrast-enhanced ultrasound of solid pancreatic head lesions: a prospective study.

OBJECTIVE: To evaluate the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of solid pancreatic head lesions (SPHL). METHODS: This prospective study comprised consecutive patients with SPHL who underwent CEUS evaluation of the pancreas. Findings recorded at CEUS were enhancement patterns (degree, completeness, centripetal enhancement, and percentage enhancement) and presence of central vessels. In addition, time to peak (TTP) and washout time (WT) were recorded. The final diagnosis was based on histopathology or cytology. Multivariate analysis was performed to identify parameters that were significantly associated with pancreatic ductal adenocarcinoma (PDAC). RESULTS: Ninety-eight patients (median age 53.8 years, 59 males) were evaluated. The final diagnosis was PDAC (n = 64, 65.3%), inflammatory mass (n = 16, 16.3%), neuroendocrine tumor (NET, n = 14, 14.3%), and other tumors (n = 4, 4.1%). Hypoenhancement, incomplete enhancement, and centripetal enhancement were significantly more common in PDAC than non-PDAC lesions (p = 0.001, p = 0.031, and p = 0.002, respectively). Central vessels were present in a significantly greater number of non-PDAC lesions (p = 0.0001). Hypoenhancement with < 30% enhancement at CEUS had sensitivity and specificity of 80.6% and 67.7%, respectively, for PDAC. There was no significant difference in the TTP and WT between PDAC and non - PDAC lesions. However, the WT was significantly shorter in PDAC compared to NET (p = 0.011). In multivariate analysis, lack of central vessels was significantly associated with a PDAC diagnosis. CONCLUSION: CEUS is a useful tool for the evaluation of SPHL. CEUS can be incorporated into the diagnostic algorithm to differentiate PDAC from non-PDAC lesions. KEY POINTS: • Hypoenhancement and incomplete enhancement at CEUS were significantly more common in PDAC than in non-PDAC. • Central vessels at CEUS were significantly associated with PDAC. • There was no difference in TTP and WT between PDAC and non-PDAC lesions.

Endoscopic Ultrasound-guided Drainage of Patients With Infected Walled-off Necrosis: Which Stent to Choose?

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage is the preferred treatment of pancreatic fluid collections (PFC). However, the choice of the stent for EUS-guided drainage in critically ill PFC cases with infected walled-off necrosis (WON) and/or organ failure (OF) remains unknown. MATERIALS AND METHODS: Between January 2018 and December 2019, consecutive patients with symptomatic PFC subjected to EUS-guided drainage using biflanged metal stents (BFMS) or double-pigtail plastic stents (DPPS) were compared for technical success, clinical success, duration of the procedure, need for intensive care unit stay, duration of intensive care unit stay, ventilator need, resolution of OF, the duration for resolution of OF, complications, need for salvage percutaneous drainage or surgery and mortality. A subgroup of patients having infected WON with/without OF were analyzed separately. RESULTS: Among 120 patients (84.6% males) with PFC (108 WON, 22 pseudocyst) who underwent EUS-guided drainage, there was no difference in outcome parameters in BFMS and DPPS groups. Among patients with WON, clinical success was significantly higher (96.2% vs. 81.8%, P=0.04), with significantly shorter hospital stay (6 vs. 10 d) and procedure duration (17.18±4.6 vs. 43.6±9.7 min, P<0.0001) in the BFMS group. Among patients with infected WON with/without OF, the clinical success was significantly higher (100% vs. 73.9%, P=0.02), and the duration of the procedure was significantly lower (16.28±4.4 vs. 44.39±10.7, P<0.0001) in BFMS compared with DPPS group. CONCLUSION: EUS-guided drainage of WON using BFMS scores over DPPS. In patients having infected WON with/without OF, BFMS may be preferred over DPPS.

Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology.

The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.

Can serum resistin predict severity of acute pancreatitis?

OBJECTIVE: Acute pancreatitis (AP) is a common disorder with high mortality in severe cases. Several markers have been studied to predict development of severe AP (SAP) including serum resistin with conflicting results. This study aimed at assessing the role of baseline serum resistin levels in predicting SAP. METHODS: This prospective study collected data from 130 AP patients from July 2017 to Nov 2018. Parameters measured included demographic profile, serum resistin at admission, severity scores, hospital stay, surgery, and mortality. Patients were divided into two groups, severe and non-severe AP. The two groups were compared for baseline characteristics, serum resistin levels, hospital stay, surgery and mortality. RESULTS: Among 130 patients, 53 patients had SAP. SAP patients had higher BMI, baseline CRP, APACHE II and CTSI scores (p-value 0.045, <0.001, <0.001 and 0.001, respectively). Both groups had comparable serum resistin levels. Serum resistin levels were also not different for obese and non-obese patients (p-value = 0.62). On multivariate analysis, BMI and high APACHE II score and CRP levels were found to independently predict SAP. CONCLUSION: We found that serum resistin is not a useful marker for predicting the severity of AP and does not correlate with increasing body weight.

Splenic abscess in a tertiary care centre in India: clinical characteristics and prognostic factors.

BACKGROUND: Splenic abscess has been an uncommon entity which is now being encountered more frequently due to increased prevalence of immunodeficiency disorders and chronic illnesses. This study was aimed to audit our experience with splenic abscesses at a tertiary care centre in India highlighting usefulness of an algorithmic approach. METHODS: Retrospective analysis of data of patients (January 2014 to December 2019) with splenic abscess was done. Data were retrieved for clinical characteristics, radiological findings, organism spectra, abscess characteristics, therapeutic measures and clinical outcome. RESULTS: The mean age of the study population (n = 36) was 41.3 ± 19.0 years with 50% males. Comorbidities were identified in 17 (47.2%) patients, with diabetes mellitus being the commonest. Fever and abdominal pain were the most common presenting features. Multiple splenic abscesses were present in 21 (58.3%) patients. Extra-splenic abscesses in liver were seen in five (13.9%) patients while nine (25%) patients had ruptured splenic abscess. Microorganisms were identified in 24 (66.7%) patients, with Salmonella typhi being the commonest (n = 9, 25%) followed by Escherichia coli (n = 7, 19.4%) and Staphylococcus aureus (n = 4, 11.1%). Six patients received only antimicrobials, 24 were managed with percutaneous aspiration or catheter drainage and six required surgery. Five (13.9%) patients died, with highest mortality being seen in those who received only antimicrobial (50%), compared to percutaneous aspiration or catheter drainage (8.3%) and surgery (0%), P = 0.017. CONCLUSION: Using percutaneous aspiration or drainage in conjunction with antibiotics, followed by surgery in non-responder, patients with splenic abscesses can be managed successfully with acceptable mortality.

Outcome of percutaneous drainage in patients with pancreatic necrosis having organ failure.

BACKGROUND: Percutaneous catheter drainage (PCD) is an effective way of drainage in acute pancreatitis (AP) and its role in persistent organ failure (OF) has not been studied. This study assessed the outcome of severe AP managed with PCD. METHODS: We retrospectively analysed outcome of AP patients undergoing PCD for persistent OF with respect to success of PCD, etiology, severity scores, OF, imaging features and PCD parameters. Success of PCD was defined as resolution of with PCD and survived without surgical necrosectomy. RESULTS: Between January 2016 and May 2018, 83 patients underwent PCD for persistent OF at a mean duration of 25.59 ± 21.2 days from pain onset with successful outcome in 47 (56.6%) patients. Among PCD failures, eleven (13.25%) patients underwent surgery. Overall mortality was 31 (37.3%). On multivariate analysis, pancreatic necrosis <50% and absence of extrapancreatic infection (EPI) predicted the success of PCD. Presence of infected necrosis did not affect the outcome of PCD in organ failure. CONCLUSION: PCD improves the outcome in patients with OF even when done early irrespective of the status of infection of necrosis. Therefore, PCD may be considered early in the course of patients with OF.

JAK2V617F Mutation in Patient with Splanchnic Vein Thrombosis.

Splanchnic vein thrombosis is an uncommon life-threatening form of venous thrombosis. It is one the common complication among MPN's. In the western studies the prevalence of JAK2V617F mutation among SVT patient is high and ranges from 7 to 59%. The frequency of this mutation among Indian SVT patients is heterogenous. This was a prospective case control study. A total 52 cases of SVT and 40 controls were screened for JAK2V617F mutation along with other routine thrombophilic risk factors. Out of total 52 cases, 10 had BCS, 2 had MVT and rest 40 were of PVT/EHPVO. The JAK2V617F mutation was seen in two cases and not in controls. Among the thrombophilic markers, heterozygous FVL mutation, PC, PS and presence of APA were seen in 2, 3, 1 and 3 cases respectively. In addition, eight cases also showed deranged risk factors (5 inherited and 3 acquired), however the repeat testing was not performed due to loss of follow up. Among controls, one person showed presence of APA and one person showed multiple thrombophilic risk factor deficiency. JAK2V617F mutation was observed in 3.8% among north Indian SVT patients. The frequency of mutation is on the lower side as compared to the available Indian data. The other thrombophilia markers (both inherited and acquired) are more frequent (18%) and patients should be routinely screened for these thrombophilia markers.

Delayed referral increases the need for surgery and intervention in patients with acute pancreatitis.

BACKGROUND: The aim was to study the outcomes of acute pancreatitis (AP) patients who were referred from other facilities to a tertiary care centre. METHODS: Patients with AP were who were referred from other hospitals to a tertiary care centre between April 2013 and September 2019 were studied and their outcomes were analysed. Comparison was made between patients referred early (≤7 days) versus those referred late (>7 days). RESULTS: Of the 838 patients seen by us, 650 patients (77.6%) were referred from other centres. Median (interquartile range) onset to admission interval was 5 (4-7) days for those who were referred ≤7 days and was 16 (11-30) for those who were referred >7 days. Patients referred beyond 7 days of pain onset had higher rates of development of organ failure (P = 0.007), including acute lung injury (P = 0.008) and acute kidney injury (P = 0.026), infected necrosis (P < 0.0001), requirement of endoscopic/percutaneous drainage (P < 0.001) and need for surgery (P < 0.02) compared to patients who were referred ≤7 days of pain onset. Mortality was however similar in the two groups. CONCLUSION: Patients with AP referred to a specialized centre with AP early (≤7 days) have better outcomes than those referred late (>7 days) from other facilities.

Diagnostic accuracy of Doppler ultrasound, CT and MRI in Budd Chiari syndrome: systematic review and meta-analysis.

OBJECTIVE: To evaluate the sensitivity, specificity, and diagnostic odds ratio (DOR) of Doppler ultrasound, CT, and MRI in the diagnosis of Budd Chiari syndrome (BCS). METHODS: We performed a literature search in PubMed, Embase, and Scopus to identify articles reporting the diagnostic accuracy of Doppler ultrasound, CT, and MRI (either alone or in combination) for BCS using catheter venography or surgery as the reference standard. The quality of the included articles was assessed by using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS: 11 studies were found eligible for inclusion. Pooled sensitivities and specificities of Doppler ultrasound were 89% [95% confidence interval (CI), 81-94%, I2 = 24.7%] and 68% (95% CI, 3-99%, I2 = 95.2%), respectively. Regarding CT, the pooled sensitivities and specificities were 89% (95% CI, 77-95%, I2 = 78.6%) and 72% (95% CI, 21-96%, I2 = 91.4%), respectively. The pooled sensitivities and specificities of MRI were 93% (95% CI, 89-96%, I2 = 10.6%) and 55% (95% CI, 5-96%, I2 = 87.6%), respectively. The pooled DOR for Doppler ultrasound, CT, and MRI were 10.19 (95% CI: 1.5, 69.2), 14.57 (95% CI: 1.13, 187.37), and 20.42 (95% CI: 1.78, 234.65), respectively. The higher DOR of MRI than that of Doppler ultrasound and CT shows the better discriminatory power. The area under the curve for MRI was 90.8% compared with 88.4% for CT and 86.6% for Doppler ultrasound. CONCLUSION: Doppler ultrasound, CT and MRI had high overall diagnostic accuracy for diagnosis of BCS, but substantial heterogeneity was found. Prospective studies are needed to investigate diagnostic performance of these imaging modalities. ADVANCES IN KNOWLEDGE: MRI and CT have the highest meta-analytic sensitivity and specificity, respectively for the diagnosis of BCS. Also, MRI has the highest area under curve for the diagnosis of BCS.

Aggressive Percutaneous Catheter Drainage Protocol for Necrotic Pancreatic Collections.

BACKGROUND: Percutaneous catheter drainage (PCD) performed pro-actively for collections in acute pancreatitis (AP) is associated with better outcomes. However, there are only a few studies describing this protocol. AIM: We aimed to evaluate an aggressive PCD protocol. METHODS: Consecutive patients with AP who underwent PCD with an aggressive protocol between January 2018 and January 2019 were included. This protocol involved catheter upsizing at a pre-specified interval (every 4-6 days) as well as drainage of all the new collections. The indications and technical details of PCD and clinical outcomes were compared with patients who underwent standard PCD. RESULTS: Out of the 185 patients with AP evaluated during the study period, 110 (59.4%) underwent PCD, all with the aggressive protocol. The historical cohort of standard PCD comprised of 113 patients. There was no significant difference in the indication of PCD and interval from pain onset to PCD between the two groups. The mean number of catheters was significantly higher in the aggressive PCD group (1.86 ± 0.962 vs. 1.44 ± 0.667, p = 0.002). Additional catheters were inserted in 54.2% of patients in aggressive group vs. 36.2% in the standard group (p = 0.006). Length of hospital stay and intensive care unit (ICU) stay were significantly longer in the standard PCD group (34.3 ± 20.14 vs. 27.45 ± 14.2 days, p < 0.001 and 10.46 ± 12.29 vs. 4.12 ± 8.5, p = 0.009, respectively). There was no significant difference in mortality and surgery between the two groups. CONCLUSION: Aggressive PCD protocol results in reduced length of hospital stay and ICU stay and can reduce hospitalization costs.

Radiation dose from computed tomography in patients with acute pancreatitis: an audit from a tertiary care referral hospital.

BACKGROUND: There is a limited data on the radiation dose from computed tomography (CT) in patients with acute pancreatitis (AP). The present study evaluated the radiation dose from CT scans in patients with AP. MATERIAL: A retrospective review of CT reports of patients with AP was conducted. The type of CT scan (non-contrast vs. single-phase vs. biphasic CT) was recorded. The mean number of CT scans and cumulative radiation dose was calculated. The indications and abnormalities on biphasic CT scans were recorded. The radiation doses between different types of the scan were compared. RESULTS: 495 CT studies in 351 patients were evaluated. In patients (n = 78, 22.2%) undergoing multiple CT scans, mean number of CT scans per patient and mean radiation dose were 2.64 ± 1.18 (range 2-9) and 24 ± 15 mSv (range 8.3-79.8 mSv), respectively. The mean radiation dose was significantly greater in patients with modified CT severity index ≥ 8 (n = 63) [25.08 mSv vs. 18.96 mSv, (P = 0.048)]. 61 (12.32%) biphasic scans were performed. A definite indication for a biphasic CT scan was identified in 20 (32.7%) patients. Arterial abnormalities were detected in 6 (9.8%) patients undergoing CT for defined indication. Mean radiation dose in this group was 13.26 ± 7.64 mSv (range 3.42-38.27 mSv) which was significantly greater than the single venous phase scan (7.96 ± 3.48 mSv, P < 0.001). CONCLUSION: There is a potential for substantial radiation exposure from CT scans to patients with AP. Patients with severe AP and those undergoing biphasic scans have significantly higher radiation exposure. Hence, routine arterial phase acquisition should be avoided.