Investigation of Environmental Factors as a Key Progression in the Treatment of Fatty Liver Disease: A Study Protocol.

Background Fatty liver disease (FLD) is currently a global health problem associated with environmental and metabolic diseases. In addition to air pollution, chemicals, and dietary choices, metabolic problems can also contribute to the development of FLD. However, in order to understand this situation, environmental conditions need to be investigated comprehensively. Materials and methods This study used a scientific method to assess the environmental factors that play a role in FLD. Individuals from different ethnic backgrounds will be recruited as participants to increase diversity in the sample. The survey will include questions on food, exposure to air pollution, finances, and cultural practices. Statistical analysis will be conducted to further reveal environmental changes and factors that affect FLD, leading to a better understanding of environmental factors that cause FLD in the population. Results The study will significantly identify the environmental factors, such as diet, physical activity, exposure to pollutants, etc., that influence the progression and treatment outcomes of FLD.  Conclusion This study will demonstrate that environmental factors influence the occurrence of FLD.

Navigating the swells: A case report of hereditary angioedema.

Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent episodes of localized edema caused by a deficiency or dysfunction of C1 inhibitor (C1-INH). This case report presents the clinical features, diagnostic evaluation, and management of a 23-year-old man with HAE. We discuss the challenges of diagnosing and treating this condition, emphasizing the importance of early recognition and appropriate therapeutic interventions.

An Uncommon Encounter: A Comprehensive Case Report of an Advanced Esophageal Neuroendocrine Carcinoma.

Esophageal neuroendocrine carcinomas (E-NECs) are rare malignant tumors with unknown etiology and pathogenesis. The aggressive nature of E-NECs coupled with a tendency to metastasize and no available treatment guidelines lead to poor prognosis. Here, we report a case of a 65-year-old, previously healthy female who presented with difficulty in swallowing solids, burning sensation over the epigastric region, weight loss (>10%), and altered bowel habits for the last three months. Contrast-enhanced CT (CECT) thorax revealed asymmetric mid-esophageal wall thickening with lymphadenopathy and metastasis in both hepatic lobes. Esophageal endoscopy revealed a large circumferential ulcero-proliferative mass and umbilicated lesions. A histopathological examination revealed small cells with scant cytoplasm and pleomorphic, hyperchromatic nuclei with prominent nuclear molding, and extensive necrosis. Immunohistochemistry revealed positivity for synaptophysin, chromogranin A, and CD56. Ki-67 index was 53%. These findings suggested poorly differentiated, small cell type, high-grade E-NEC. Chemotherapy with cisplatin (30mg/m2) + irinotecan (60mg/m2) was initiated. However, following two chemotherapy cycles, the patient succumbed.

Challenges of Diagnosis: Periampullary Mass-Induced Obstructive Jaundice in a Young Woman.

Periampullary cancers, which include pancreatic adenocarcinoma, ampullary cancer, distal cholangiocarcinoma, and duodenal cancer, present diagnostic and management challenges due to their aggressive nature and nonspecific symptoms. We describe a case of a female patient, age 20, who had obstructive jaundice brought on by a periampullary tumor. Despite difficulties in diagnosis and treatment, including failed endoscopic retrograde cholangiopancreatography (ERCP), the patient underwent a successful pancreaticoduodenectomy (Whipple's resection), and subsequent immunohistochemistry revealed adenocarcinoma with a mixed immunophenotype expressing duodenal and pancreatic markers. This example emphasizes the significance of taking young patients' periampullary tumors into account, the difficulties in diagnosing them, and the possibility of effective surgical surgery throughout this age range.

Herpes Simplex Virus Esophagitis in an Immunocompetent Patient: A Case Report.

Even though it is rare, herpes simplex virus (HSV) esophagitis has a significant adverse impact on immunocompromised people, such as those with HIV, cancer patients receiving chemotherapy or radiation to the neck, and recipients of transplants receiving immunosuppressive treatments. This makes a high level of clinical suspicion necessary for a precise diagnosis and successful treatment. Although rare, its occurrence in immunocompetent patients poses unique challenges for diagnosis and therapy. A 68-year-old woman with HSV esophagitis presented with severe symptoms, including odynophagia and hematemesis. Endoscopy revealed "volcano-like" ulcers; after confirmation of HSV-1 infection, treatment with acyclovir, esomeprazole, and sucralfate led to symptom resolution within a week and complete healing in three months. This case underscores the importance of considering HSV esophagitis in the differential diagnosis of esophageal ulcers in immunocompetent patients, emphasizing the need for early diagnosis and antiviral therapy for effective treatment.

Endoscopic Palliative Treatment for Duodenal and Biliary Obstruction in Advanced Periampullary Malignancy.

Unresectable periampullary malignancies can lead to concomitant duodenal and biliary obstructions, significantly affecting patient quality of life. Effective palliation of these obstructions is crucial for symptom management and improving patient outcomes. Endoscopic techniques provide a minimally invasive approach to address these complications. This report presents a case where endoscopy was successfully used to palliate both duodenal and biliary obstructions in a patient with advanced periampullary malignancy. Endoscopic retrograde cholangiopancreatography was attempted to relieve the biliary obstruction caused by periampullary malignancy; however, the procedure was subsequently abandoned and the patient ultimately underwent percutaneous transhepatic biliary drainage. Furthermore, the use of an endoscope for duodenal stenting to restore gastrointestinal continuity was done. The patient experienced significant symptomatic relief and improved quality of life post-procedure. This case underscores the utility of endoscopic interventions in managing complex obstructions due to advanced malignancies.

A Comprehensive Review on the Efficacy and Safety of Vonoprazan in the Management of Gastric Acid-Related Diseases.

Gastric acid-related diseases, including gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and Helicobacter pylori (H. pylori) infection, present significant clinical challenges due to their prevalence and potential for severe complications. Effective management of these conditions is essential for symptom relief, mucosal healing, and prevention of complications. This review aims to evaluate the efficacy and safety of vonoprazan, a novel potassium-competitive acid blocker (P-CAB), in the treatment of gastric acid-related diseases and to compare it with traditional proton pump inhibitors (PPIs). A comprehensive analysis of clinical trials and studies was conducted to assess the effectiveness of vonoprazan in managing GERD, PUD, and H. pylori infection. The safety profile of vonoprazan was also reviewed, and comparisons were made to PPIs and other gastric acid suppressants. Vonoprazan demonstrates superior and more consistent acid suppression than PPIs, resulting in rapid and sustained symptom relief and mucosal healing. Clinical trials have shown its efficacy in treating GERD, PUD, and H. pylori infection, with higher eradication rates for H. pylori when used in combination therapies. The safety profile of vonoprazan is favorable, with fewer adverse effects and drug interactions compared to PPIs. Vonoprazan offers a promising alternative to traditional PPIs for the management of gastric acid-related diseases. Its unique mechanism of action and superior efficacy make it a valuable option for patients requiring effective and reliable acid suppression. Further research is warranted to explore its potential in broader clinical applications and to establish long-term safety data.

Comparative Prognostic Value of the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS) in Supratentorial and Infratentorial Stroke Patients in Western India.

Background Acute coronary syndrome is the most common cause of mortality; cerebral vascular accident ranks second. Stroke is the fourth most common cause of disability worldwide, with nearly 20 million people suffering a stroke every year around the world and an estimated five million dead. Slightly more than 85.5% of stroke-related deaths take place in developing countries. In short, blockage (thrombus or emboli) and decreased blood supply for cerebral tissues lead to a stroke that permanently damages brain tissue. A stroke is clinically defined as rapidly developing clinical symptoms of focal cerebral dysfunction lasting >24 hours or leading to death, as characterized by the World Health Organization (WHO). Objective The present study was designed to compare the efficacy of the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS) in determining the prognosis of supratentorial and infratentorial stroke. Methods This observational prospective study was performed on over 100 patients admitted to Bharati Hospital, Sangli, who had cerebrovascular accidents from February 2018 to June 2019. Eligibility criteria were adults more than 18 years of age with clinical and computed tomography/magnet resonance imaging (CT/MRI) evidence consistent with acute stroke. Trauma and concomitant supra- and infratentorial strokes were excluded. GCS and NIH stroke scale scores were measured daily, and scores were noted on the first and last day of hospitalization. Statistical analysis was done using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States), including mean, standard deviation, paired t-test, and Chi-square test. Results Out of 100 patients, 77% had suffered supratentorial strokes, and thus the other 23% had infratentorial strokes. Alcohol consumption was associated with a higher risk of infratentorial strokes, while smoking was linked to a higher risk of supratentorial strokes. Diabetes and hypertension did not differ statistically between the two groups. Compared to patients with supratentorial strokes, those who suffered from infratentorial strokes had a greater death rate and less favorable recovery results. Patients with supratentorial strokes who recovered completely or partially showed considerable improvements in their GCS scores, but patients with infratentorial strokes showed minimal to no improvement. On the other hand, the NIHSS score significantly improved in patients who achieved both complete or partial recovery and no improvement or mortality in both supratentorial and infratentorial stroke. NIHSS is preferred over GCS because it provides a better insight into morbidity and neurological outcomes of both types of strokes in comparison with GCS, which is more useful in predicting mortalities. Conclusion According to this study, supratentorial strokes were more common, whereas infratentorial strokes had a worse prognosis. Alcohol ingestion and smoking may have an impact on the location of a stroke. Compared to GCS, the NIHSS score provided a more thorough evaluation of stroke recovery, indicating its potential for better patient care.

Post-Endoscopy Parotid Swelling: A Rare Complication.

Parotid gland swelling, or parotitis, typically associated with infectious causes, can uncommonly result from non-infectious factors such as mechanical trauma following endoscopic procedures. We present a case of a 46-year-old female with liver cirrhosis who developed right parotid swelling shortly after undergoing endoscopy for evaluation of gastrointestinal symptoms. The patient's clinical course, imaging findings, and successful resolution with conservative measures are detailed. The etiology of post-endoscopy parotid swelling is multifactorial, involving potential mechanisms such as mechanical trauma, salivary gland dysfunction, infection, ductal obstruction, or allergic reactions to medications. Diagnosing this rare complication requires a comprehensive clinical evaluation, including a detailed history, symptom assessment, and imaging studies such as ultrasound. Management involves a combination of symptomatic relief, identification, and treatment of the underlying cause, emphasizing the importance of early recognition to prevent complications. In our case, warm compression provided pain relief, and the swelling subsided without the need for medical or surgical intervention. Regular follow-up evaluations and imaging studies are crucial to assess treatment response and ensure the resolution of the swelling. This case contributes to the limited literature on post-endoscopy parotid swelling, emphasizing the significance of recognizing and managing this rare complication promptly. Healthcare professionals should be vigilant, and further research is encouraged to better understand its pathophysiology and optimize management strategies in order to improve patient outcomes.

Acute Necrotizing Pancreatitis Presenting as Gastrocolic Fistula: A Rare Occurrence.

Tissue necrosis and ischemia are hallmarks of acute necrotizing pancreatitis, which frequently results in fatal infections. In this case, we describe a man in his 40s who had diffuse pain in the abdomen, intractable vomiting, diarrhoea, and intermittent fever. His abdominal computed tomography revealed acute pancreatitis with peripancreatic fluid collection, gastric perforation, and fistula formation between the greater curvature of the stomach and transverse colon. His upper gastrointestinal (GI) endoscopy confirmed a gastrocolic fistula.

Unusual cause of massive upper gastrointestinal bleeding: a pancreatic arteriovenous malformation.

CONTEXT: Upper gastrointestinal bleeding is one of the most common emergencies in gastroenterology. The common causes of the upper gastrointestinal bleeding include peptic ulcer disease, gastric erosive mucosal disease and portal hypertension. Gastrointestinal arteriovenous malformation is a less common cause of gastrointestinal bleeding and these arteriovenous malformation are most commonly located in the large and small intestine. Pancreatic arteriovenous malformation is a rare condition in which there is tumor-like formation or vascular anomaly built up via an aberrant bypass anastomosis of the arterial and venous systems in the pancreas. Splenic artery is most commonly involved (42%), followed by gastroduodenal artery (22%) and small pancreatic arteries (25%). Clinically it may present as gastrointestinal hemorrhage which is occasionally fatal. Other presentations are abdominal pain, pancreatitis, duodenal ulcer, jaundice, and portal hypertension. CASE REPORT: We present a rare case of pancreatic arteriovenous malformation presenting as massive upper gastrointestinal bleeding. CONCLUSION: Since early surgery is a life saving treatment for such cases, hence, a high index of suspicion should be maintained especially when massive bleeding is detected from the medial wall of second part of duodenum.

Non-invasive assessment of liver fibrosis in alcoholic liver disease.

AIM OF THE STUDY: To assess the severity of fibrosis in patients with alcoholic liver disease (ALD) by a non-invasive method (transient elastography - TE). MATERIAL AND METHODS: A cross sectional study was conducted on 130 cases of ALD over a period of 2 years. Upper gastrointestinal (GI) endoscopy and transient elastography were done. Liver fibrosis was staged with the METAVIR system and severity of fibrosis was correlated with complications, duration of alcohol abuse, aspartate transaminase (AST) to platelet ratio index (APRI) and Child-Turcotte-Pugh (CTP) score. To establish the relationship between various parameters, Spearman's correlation coefficient (r) and their associated probability (p) were used. RESULTS: Distribution in 130 patients according to the METAVIR stage (median liver stiffness measurement [LSM]) was: F0: n = 16 (5.08 kPa); F1: n = 19 (6.6 kPa); F2: n = 9 (9.3 kPa); F3: n = 26 (16.3 kPa) and F4: n = 60 (50.5 kPa) (p < 0.0001). Liver stiffness measurement (LSM) score was significantly correlated with CTP score (r = 0.492, p < 0.0001), APRI (r = 0.435, p < 0.0001), duration of alcohol consumption (r = 0.816, p < 0.0001), presence of ascites (r = 0.756, p < 0.0001), presence of esophageal varices (r = 0.567, p < 0.0001), and presence of variceal bleeding (r = 0.383, p < 0.0001). CONCLUSIONS: TE is an inexpensive and non-invasive modality to assess the severity of liver fibrosis in ALD. It can be used as a good screening tool to identify patients with cirrhosis without the use of invasive liver biopsy, enabling better prognostication for the development of complications.

Dysphagia aortica: Emerging role of endoscopic ultrasound (with videos).

Dysphagia can occur due to extrinsic compression on esophagus. Dysphagia due to intrathoracic vascular causes is rare. Most reported cases of vascular etiology are due to dysphagia lusoria. Dysphagia due to any anomaly of aorta is called dysphagia aortica. In an emergency setting, endoscopic ultrasound (EUS) has been found to be superior and more sensitive for detection of abdominal aortic aneurysms over conventional radiological methods. We present a series of four cases of dysphagia aortica where the diagnosis was made by endoscopic ultrasound.

Non-invasive aspartate aminotransferase to platelet ratio index correlates well with invasive hepatic venous pressure gradient in cirrhosis.

BACKGROUND: Hepatic venous pressure gradient (HVPG) is the best recommended tool to measure portal pressure, but is invasive. HVPG helps in prognosticating cirrhosis and predict its complications. Aminotransferase to platelet ratio index (APRI) is a simple non-invasive marker of hepatic fibrosis. We aimed to correlate APRI with HVPG and to determine the usefulness of APRI in predicting complication of cirrhosis. METHODS: APRI and HVPG were measured in consecutive patients of cirrhosis aged 18 to 70 years. Spearman's rho was used to estimate their correlation; a cut-off value of APRI to predict severe portal hypertension (HVPG > 12 mmHg) was determined. RESULTS: This study, conducted between August 2011 and December 2014, included 277 patients, median age 51 (range: 16-90) years, 84% males. Etiology of cirrhosis was alcohol in 135 (49%), cryptogenic/nonalcoholic steatohepatitis (NASH) in 104 (38%), viral in 34 (12%), and others in 4 (1%). Median Child-Turcott-Pugh (CTP) and model for end-stage liver disease (MELD) scores were 7 (5-11) and 11 (6-33), respectively. Median HVPG was 17.0 (1.5-33) mmHg and median APRI was 1.09 (0.21-12.22). There was positive correlation between APRI and HVPG (Spearman's rho 0.450, p < 0.001). The area under the receiver operating characteristic (ROC) curve of APRI for predicting severe portal hypertension was 0.763 (p < 0.01). Youden's index defined the cut-off of APRI for predicting HVPG > 12 mmHg was 0.876 with a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 71%, 78%, 94%, 38%, and 73%, respectively. APRI also correlated well with CTP, variceal size, bleeding status, ascites but not with MELD. CONCLUSIONS: APRI score of 0.876 has an acceptable accuracy to predict severe portal hypertension (HVPG > 12 mmHg). High APRI also correlated with severity of cirrhosis and its complications. Thus, APRI may be used as a simple, bedside, non-invasive, and inexpensive tool for evaluating portal hypertension and complications of cirrhosis.

All ileo-cecal ulcers are not Crohn's: Changing perspectives of symptomatic ileocecal ulcers.

AIM: To investigated clinical, endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy. METHODS: Consecutive symptomatic patients undergoing colonoscopy, and diagnosed to have ulcerations in the ileocecal (I/C) region, were enrolled. Biopsy was obtained and their clinical presentation and outcome were recorded. RESULTS: Out of 1632 colonoscopies, 104 patients had ulcerations in the I/C region and were included in the study. Their median age was 44.5 years and 59% were males. The predominant presentation was lower GI bleed (55, 53%), pain abdomen ± diarrhea (36, 35%), fever (32, 31%), and diarrhea alone (9, 9%). On colonoscopy, terminal ileum was entered in 96 (92%) cases. The distribution of ulcers was as follows: Ileum alone 40% (38/96), cecum alone 33% (32/96), and both ileum plus cecum 27% (26/96). The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon. Based on clinical presentation and investigations, the etiology of ulcers was classified into infective causes (43%) and non-infective causes (57%). Fourteen patients (13%) were diagnosed to have Crohn's disease (CD). CONCLUSION: Non-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region. And if all infections are clubbed together then infection is the most common (> 40%) cause of ulcerations of the I/C region. Cecal involvement and fever are important clues to infective cause. On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers. So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn's.

Endoscopic ultrasound in mediastinal tuberculosis.

BACKGROUND: Tubercular lymphadenitis is the commonest extra pulmonary manifestation in cervical and mediastinal locations. Normal characteristics of lymph nodes (LN) have been described on ultrasonography as well as by Endoscopic Ultrasound. Many ultrasonic features have been described for evaluation of mediastinal lymph nodes. The inter and intraobserver agreement of the endosonographic features have not been uniformly established. METHODS AND RESULTS: A total of 266 patients underwent endoscopic ultrasound guided fine needle aspiration and 134 cases were diagnosed as mediastinal tuberculosis. The endoscopic ultrasound location and features of these lymph nodes are described. CONCLUSION: Our series demonstrates the utility of endoscopic ultrasound guided fine needle aspiration as the investigation of choice for diagnosis of mediastinal tuberculosis and also describes various endoscopic ultrasound features of such nodes.

Imaging of pancreas divisum by linear-array endoscopic ultrasonography.

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. Endoscopic ultrasound (EUS) is often performed to evaluate idiopathic pancreatitis and has been shown to have high accuracy in diagnosis of PD. The different techniques to identify PD by linear EUS have been described differently by different authors. If EUS is done with a proper technique it can be a valuable tool in the diagnosis of PD. The anatomical and technical background of different signs has not been described so far. This article summarizes the different techniques of imaging of pancreatic duct in a suspected case of PD and gives a technical explanation of various signs. The common signs seen during evaluation of pancreatic duct in PD are stack sign of linear EUS, crossed duct sign on linear EUS, the dominant duct and ventral dorsal duct (VD) transition. Few other signs are described which include duct above duct, short ventral duct /absent ventral duct, separate opening of ducts with no communication, separate opening of ducts with filamentous communication, stacking of duct of Santorini and indirect signs like santorinecele. The principles of the sign have been explained on an anatomical basis and the techniques and the principles described in the review will be helpful in technical evaluation of PD during EUS.