Role of ultra-high definition endoscopy (endomicroscopy and endocytoscopy) and real-time histologic examination in inflammatory bowel disease: Scoping review.

OBJECTIVES: Confocal laser endomicroscopy (CLE) and endocytoscopy (EC) are ultra-high definition (HD) imaging modalities that enable real-time histological assessment. Although existent for nearly two decades, their role in current clinical decision making in inflammatory bowel disease management is not well defined. METHODS: We searched PubMed using keywords ("confocal" OR "CLE" OR "endocytoscopy") AND ("IBD" OR "inflammatory bowel" OR "Crohn*" OR "Crohn's" OR "colitis ulcerosa" OR "ulcerative colitis") between 2005 and March 2023. We identified 52 studies for detailed review. RESULTS: Confocal laser endomicroscopy was useful in real-time assessment of histologic inflammation and dysplasia characterization in both ulcerative colitis (UC) and Crohn's disease. Although CLE was associated with higher per-biopsy yield for UC-associated neoplasia (UCAN), the benefit was offset by higher procedure time, frequent equipment failure, and conflicting results on incremental yield over chromoendoscopy. Assessment of barrier dysfunction by CLE did not correlate with disease/endoscopic activity but could predict major adverse outcomes. The implications of residual CLE abnormalities in endoscopic remission remain uncertain. Ex vivo binding of labeled biologics can help in predicting biologic response in UC. EC can discriminate mucosal inflammatory cells by morphology and allows assessment of histologic activity. EC combined with pit pattern was better than pit pattern alone for UCAN. Artificial intelligence-assisted EC in UCAN needs further study. CONCLUSION: Ultra-HD imaging in inflammatory bowel disease can be useful in assessment of UCAN, barrier dysfunction, predicting histologic remission, and biologic response. Future controlled studies are warranted to define the role of these novel technologies in clinical decision making.

Impact of Demographic, Clinical and Psychosocial Variables on Drug Adherence and Outcomes in Indian Patients With Inflammatory Bowel Disease: Cost is not the Only Factor!

BACKGROUND AND AIMS: Barriers to drug adherence in the developing world are multifactorial and under evaluated. We aimed to evaluate predictive factors of medication adherence in Indian patients with inflammatory bowel disease (IBD) and association of adherence with quality of life (QOL) and relapse free remission. MATERIALS AND METHODS: Adherence was assessed in consecutive IBD patients using a self-administered survey questionnaire including Morisky Medication Adherence Scale together with interview and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) to assess QOL. Logistic regression analysis was used to identify variables correlating with adherence, Cox proportional hazards method used for variables associated with relapse and Kaplan-Meier survival curve used for comparing relapse free remission in adherent and nonadherent. RESULTS: A total of 467 consecutive outpatients (279 ulcerative colitis, 188 Crohn's disease, mean age 38.6 y) were mostly on mesalazine 439 (94%) or thiopurines 213 (46%). Self-reported nonadherence was noted in 236/467 (51%). Disease remission was associated with medication adherence [P=0.003, odds ratio (OR): 1.75, 95% confidence interval (CI): 1.21-2.52]. Medication-related factors like high dosing frequency (>3/d) (OR: 0.39, P=0.005) and concomitant non-IBD medications (OR: 0.44, P=0.007) were associated with nonadherence. Psychosocial factors associated with nonadherence were lack of drug information (OR: 0.30, P<0.001), feeling depressed (OR: 0.43, P<0.001), comorbidities (OR: 0.47, P=0.005), doubts about efficacy (OR: 0.49, P=0.001) and perceived poor QOL (OR: 0.61, P=0.01). High-cost perception was associated with nonadherence in univariate analysis (OR: 0.47, P<0.001) but lost significance on multivariate analysis (OR: 0.68, P=0.07). Physician imparting disease information (OR: 2.5, P=0.14) and physician reinforcement (OR: 1.8, P=0.049) were associated with adherence.Adherence was associated with improved QOL (SIBDQ, R=0.724). Nonadherence was associated with >3-fold risk of recurrence within 2 years (hazard ratio: 3.89, 95% CI: 2.74-5.52, P<0.001). CONCLUSIONS: Nonadherence is common in Indian IBD patients but adherence is associated with improved QoL and lower probability of relapse. Psychosocial and medication-related factors are important determinants of adherence compared with demographic or clinical variables and should be addressed.

Terlipressin has stood the test of time: Clinical overview in 2020 and future perspectives.

Vasoactive drugs form the mainstay of therapy for two of the most important complications of liver disease: hepatorenal syndrome (HRS) and acute variceal bleed (AVB). With cumulative evidence supporting the use in cirrhosis, terlipressin has been recommended for the management of HRS and AVB. However, owing to the safety concerns, terlipressin was not approved by food and drug administration (FDA) until now. In this review, we discuss the pharmacology and the major practice-changing studies on the safety and efficacy of terlipressin in patients with cirrhosis particularly focusing on existing indications like AVB and HRS and reviewing new data on the expanding indications in liver disease. The references for this review were identified from PUBMED with MeSH terms such as "terlipressin," "hepatorenal syndrome," "varices, esophagal and gastric," "ascites" and "cirrhosis." Terlipressin, a synthetic analogue of vasopressin, was introduced in 1975 to overcome the adverse effects of vasopressin. Terlipressin is an effective drug for HRS reversal in patients with liver cirrhosis and acute-on-chronic liver failure. There is documented mortality benefit with terlipressin therapy in HRS and AVB. Adverse effects are common with terlipressin and need to be monitored strictly. There is some evidence to support the use of this drug in refractory ascites, hepatic hydrothorax, paracentesis-induced circulatory dysfunction and perioperatively during liver transplantation. However, terlipressin is not yet recommended for such indications. In conclusion, terlipressin has stood the test of time with expanding indications and clear prerequisites for clinical use. Our review warrants a fresh perspective on the efficacy and safety of terlipressin.

Acute Intermittent Porphyria Presenting with Posterior Reversible Encephalopathy Syndrome: A Rare Cause of Abdominal Pain and Seizures.

Acute intermittent porphyria (AIP) is an acute neurovisceral porphyria caused due to inherited deficiency of porphobilinogen deaminase (also called hydroxymethylbilane synthase) (HMBS) in the heme biosynthesis pathway. AIP is rarely associated with posterior reversible encephalopathy syndrome (PRES), which is a clinicoradiological condition caused by the failure of the posterior circulation to autoregulate, resulting in cerebral edema, headaches, nausea, and seizures. AIP should be considered when a patient presents with unexplained abdominal pain and seizures. This association is important because drugs used in the management of seizures may worsen an attack of AIP. This case report describes a young woman who presented with AIP and PRES with seizures. HOW TO CITE THIS ARTICLE: Sarala Kumari D, Murthy NLN Arumilli, Siva Kumar Reddy L, Nageshwar Reddy D, Motor R. Acute Intermittent Porphyria Presenting with Posterior Reversible Encephalopathy Syndrome: A Rare Cause of Abdominal Pain and Seizures. Indian J Crit Care Med 2020;24(8):724-726.

Association of vascular endothelial growth factor (VEGF) gene polymorphism and increased serum VEGF concentration with pancreatic adenocarcinoma.

UNLABELLED: BACKGROUND &AIM: Pancreatic cancer is related to high mortality rate. The vascular endothelial growth factor (VEGF) has a strong influence in tumor-related angiogenesis having association with the grade of angiogenesis and the prognosis of different solid tumors including pancreatic cancer. The present study was aimed to analyze the genotype and haplotype distribution of VEGF gene single nucleotide polymorphisms (SNPs), -460T/C, +405G/C, +936C/T, in patients with pancreatic adenocarcinoma from South India, and the effect of these SNPs on serum VEGF level. METHODS: Total 80 patients with pancreatic adenocarcinoma and 87 controls were recruited. The genotype of VEGF gene polymorphisms was determined in both patients and controls using polymerase chain reaction-restriction fragment length polymorphism method. The serum VEGF protein was estimated by standard enzyme-linked immunosorbent assay. RESULTS: The genotype, +405G/G of VEGF gene showed a significant association with the patients with pancreatic adenocarcinoma (P = 0.012, Odds ratio: 2.133), whereas no significant difference was found in the genotype distribution of SNPs, -460C/T and +936C/T between patient and control groups (P > 0.05). Serum VEGF level was found to be significantly high in patients (1315.10 pg/Ml, SD ± 230.79) when compared to controls (591.35 pg/mL, SD ± 92.48) (P < 0.0001), which showed a strong genotype-phenotype correlation between genotype +405G/G and serum VEGF level. Further, the haplotype C-G-T showed a strong association with the disease, and no specific haplotype was associated with increased serum VEGF level. CONCLUSION: The polymorphism, +405G/C but not -460T/C and +936C/T, of VEGF gene is strongly associated with pancreatic adenocarcinoma, and this SNP has significant influence on serum VEGF level.

Feasibility and efficiency of a new 22G core needle: a prospective comparison study.

BACKGROUND AND STUDY AIMS: Histological examination of core tissue samples may have advantages over cytology in endoscopic ultrasound (EUS)-guided sampling. We aimed to evaluate the feasibility and efficiency of a new 22G core biopsy needle. PATIENTS AND METHODS: Consecutive patients with a pancreatic mass lesion or peri-intestinal lymphadenopathy sequentially underwent fine needle biopsy with both a newly developed 22G core needle (the FNB needle) and a standard 22G fine needle aspiration (FNA) needle, in randomized order. RESULTS: In 144 patients, mean age 48 years (± standard deviation [SD] 14; range 18 - 82), with 145 lesions (mean lesion size 39 ± 15 mm, range 15 - 99), EUS-guided sampling was technically feasible with both needles in all patients. Mean number of passes to obtain sufficient tissue was 1.2 ± 0.5 with the core needle vs. 2.5 ± 0.9 with the standard needle (P < 0.001). FNB specimens were adequate for evaluation in 125 (86.2 %) vs. 127 (87.6 %) with FNA (P = 0.72). Among 139 patients available for follow-up, FNB provided a correct diagnosis in 110 (79.1 %) and FNA in 112 (80.6 %) (P = 0.73). Sensitivity, specificity, positive and negative predictive values, and accuracy for diagnosis of malignancy were 90 %, 100 %, 100 %, 93 %, 96 % for FNB and 77 %, 100 %, 100 %, 85 %, 92 % for FNA, respectively (P > 0.05). CONCLUSION: FNB with the new 22G core needle was technically feasible, efficient and comparable to FNA with a standard needle. The core needle required fewer passes to provide an adequate sample, offering potentially shorter procedure time.

Management of Pancreatic Duct Stones: Extracorporeal Approach.

Stone clearance with extracorporeal shock wave lithotripsy is a safe and effective procedure for large pancreatic calculi not extractable by the standard endoscopic retrograde cholangiopancreatography techniques. In properly selected patients, this minimally invasive approach should be offered as the first line of therapy instead of surgery. Complete stone clearance can be achieved in three-fourths with long-term pain relief in two-thirds of patients. Re-intervention is required in less than half of the patients. Future studies should compare the extracorporeal approach with intraductal lithotripsy using the pancreatoscope.

Inflammatory bowel disease (IBD) in rural and urban India: results from community colonoscopic evaluation of more than 30,000 symptomatic patients.

Background: Traditionally, infectious diarrhoea has been the major cause of lower GI symptoms across the developing world. Increasing urbanization has been implicated for the rising IBD cases despite very limited data in the rural setting. We aimed to assess the relative proportion of IBD and other intestinal diseases among symptomatic patients from rural and urban India. Methods: Patients with lower GI symptoms attending urban out-patient clinics and/or specially conducted mobile rural health camps were evaluated using basic laboratory parameters, abdominal ultrasound and colonoscopy. Data including patient demographics, symptom profile, rural/urban residence and final diagnosis were analyzed. Current data was compared with previous rural survey in 2006. Findings: Of 32,021 patients investigated, 30,835 with complete dataset [67% male; 21% (6362) rural median 44 years:6-78 years] were included. Predominant symptoms were chronic abdominal pain (55%), change in bowel habit (45%), rectal bleeding (16%), chronic diarrhoea (13%), un-intended weight loss (9%) and anaemia (3%). Final diagnoses included IBD: (1687; 5.4%; 2.2% ulcerative colitis (UC), 3.2% Crohn's disease, CD), intestinal tuberculosis (364; 1.2%), infective colitis (1427; 4.6%), colorectal cancer (488; 1.6%) and polyps (2372; 7.7%). Proportions of UC (2.1% rural, 2.3% urban, p = 0.66) and CD (3.5% rural, 3.1%,urban, p = 0.12) were similar in both groups. There was no rural-urban divide in the relative proportion of other intestinal diseases. Interpretation: IBD accounts for more than 5% of patients presenting with lower GI symptoms, a rate that is higher than that of infectious colitis. The proportion of IBD cases was not different between the rural and urban populations. These data appear to indicate the changing disease prevalence patterns in India that require further research. Funding: The study was funded by Leona M. and Harry B. Helmsley Charitable Trust.

Endoscopic ultrasound guided fine-needle aspiration of lymph nodes and solid masses: factors influencing the cellularity and adequacy of the aspirate.

GOALS: To study the factors that influence the cellularity and adequacy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). BACKGROUND: An on-site cytopathology service is preferred during EUS-guided FNA. However, this is not always available. Factors that influence the aspirate cellularity and adequacy have not been well defined in the absence of on-site cytopathology. STUDY: EUS-guided FNA procedures without an on-site cytopathologist from a single center were retrospectively studied. FNA of solid masses and lymph nodes (LN) were included. The FNA cellularity, hemorrhagic content, and endoscopists' assessment of adequacy were analyzed. RESULTS: A total of 166 patients from January 2009 to October 2010 were included. A total of 520 FNA passes were performed. Of the 166 lesions, 70 (42.2%) were solid masses and 96 (57.8%) were LNs. A 22-G needle was used in 72.3% and 25 G in 27.7% of the patients. The median (range) number of FNA passes was 3 (1 to 7) for LNs and 3 (1 to 5) for solid masses. With this, the endoscopists had an accuracy of 92.2% (153/166) for obtaining an adequate aspirate. Of the 166 samples, 4 (2.4%) were acellular, 20 (12.0%) sparsely cellular, 52 (31.4%) moderately cellular, and 90 (54.2%) highly cellular. The 25-G needle had significantly more adequate aspirates than the 22-G needle for solid masses (P=0.011). Also, increasing passes correlated with higher cellularity (P=0.002) and an adequate aspirate (P=0.021). No correlation was found for LN FNA. Lesion size did not influence the cellularity or adequacy (P>0.05). The degree of hemorrhage was not influenced by the needle gauge, number of passes, or lesion size. The diagnostic yield was not affected by hemorrhage in the sample (P>0.05). CONCLUSIONS: EUS-guided FNA obtains a high proportion of adequate aspirates for LNs and solid masses, even without an on-site cytopathologist. Small proportions of inadequate samples still occur. For solid masses, a 25-G needle with at least 3 passes is more likely to provide an adequate aspirate than a 22-G needle and fewer passes. Hemorrhage did not affect the cytopathology's ability to make a diagnosis.

Intraoperative pancreatoscopy with narrow band imaging: a novel method for assessment of resection margins in case of intraductal papillary mucinous neoplasm.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is characterized by intraductal proliferation of neoplastic mucinous cells with a variable extent along the main duct or its branches. The lesion may be continuous or discontinuous. Skip lesions have been described in about 6-19% of cases. Complete resection without leaving behind any skip lesions is important, to such an extent that many groups suggest even total pancreatectomy, a major and morbid surgery. METHODS: A 40 year-male patient with chronic pancreatitis presented with recent-onset diabetes mellitus and weight loss. Ultrasound and computed tomography (CT) scan showed a cystic lesion in the head and uncinate process of pancreas. Peroral pancreatoscopy showed villous projections with dilated tortuous vessel in the head, suspicious of IPMN. The duct beyond pancreatic head could not be visualized and remained unassessed. At pancreatoduodenectomy, pancreatoscopy with narrow band imaging (NBI) was done using flexible pancreatoscope through the cut end of the duct at the neck to assess the duct in the body and tail. RESULTS: Pancreatoscopy with NBI showed a normal-looking resection margin and a skip lesion 1 cm beyond it. The revised resection margin confirmed the skip lesion on frozen section and also that the fresh cut margin was negative. The remaining duct in the body and tail was normal on pancreatoscopy. Total clearance of the disease could be achieved without a major procedure such as total pancreatectomy. CONCLUSIONS: Intraoperative pancreatoscopy, especially with NBI, is a good diagnostic tool for IPMN and also helps in intraoperative decision-making of the resection margins.

Safety and efficacy of terlipressin in acute-on-chronic liver failure with hepatorenal syndrome-acute kidney injury (HRS-AKI): a prospective cohort study.

Terlipressin with albumin, the recommended treatment for hepatorenal syndrome-acute kidney injury (HRS-AKI), is associated with adverse events. Furthermore, the course of AKI in patients with acute-on-chronic liver failure (ACLF) is unknown. We aimed to analyze the safety and efficacy of terlipressin infusion and AKI course in patients with ACLF. We prospectively enrolled consecutive adult patients with ACLF with HRS-AKI (satisfying EASL criteria) treated with terlipressin infusion between 14 October 2019 and 24 July 2020. The objectives were to assess the incidence of adverse events, response to terlipressin, course of HRS-AKI and predictors of mortality. A total of 116 patients were included. Twenty-one percent of patients developed adverse effects. Only 1/3rd of patients who developed adverse events were alive at day 90. Sixty-five percent of the patients responded to terlipressin. Nearly 22% developed recurrence of HRS, and 5.2% progressed to HRS-chronic kidney disease. TFS was 70.4% at day 30 and 57.8% at day 90. On multivariate stepwise Cox regression analysis terlipressin non-response (hazard ratio [HR], 3.49 [1.85-6.57]; P < 0.001) and MELD NA score (HR,1.12 [1.06-1.18]; P < 0.001) predicted mortality at day-90. Patients with ACLF who develop terlipressin related adverse events have dismal prognoses. Terlipressin non-response predicts mortality in patients with ACLF and HRS-AKI.

A Pro-Endocrine Pancreatic Islet Transcriptional Program Established During Development Is Retained in Human Gallbladder Epithelial Cells.

BACKGROUND & AIMS: Pancreatic islet ß-cells are factories for insulin production; however, ectopic expression of insulin also is well recognized. The gallbladder is a next-door neighbor to the developing pancreas. Here, we wanted to understand if gallbladders contain functional insulin-producing cells. METHODS: We compared developing and adult mouse as well as human gallbladder epithelial cells and islets using immunohistochemistry, flow cytometry, enzyme-linked immunosorbent assays, RNA sequencing, real-time polymerase chain reaction, chromatin immunoprecipitation, and functional studies. RESULTS: We show that the epithelial lining of developing, as well as adult, mouse and human gallbladders naturally contain interspersed cells that retain the capacity to actively transcribe, translate, package, and release insulin. We show that human gallbladders also contain functional insulin-secreting cells with the potential to naturally respond to glucose in vitro and in situ. Notably, in a non-obese diabetic (NOD) mouse model of type 1 diabetes, we observed that insulin-producing cells in the gallbladder are not targeted by autoimmune cells. Interestingly, in human gallbladders, insulin splice variants are absent, although insulin splice forms are observed in human islets. CONCLUSIONS: In summary, our biochemical, transcriptomic, and functional data in mouse and human gallbladder epithelial cells collectively show the evolutionary and developmental similarities between gallbladder and the pancreas that allow gallbladder epithelial cells to continue insulin production in adult life. Understanding the mechanisms regulating insulin transcription and translation in gallbladder epithelial cells would help guide future studies in type 1 diabetes therapy.

Common variants in NOD2 and IL23R are not associated with inflammatory bowel disease in Indians.

BACKGROUND AND AIM: Ulcerative colitis (UC) and Crohn's disease (CD) are two major phenotypes of inflammatory bowel disease (IBD) that present with inflammation of the colon or the entire gastrointestinal tract, respectively. Genome-wide association studies have confirmed the role of nucleotide-binding oligomerization domain protein-2 (NOD2) variants and identified several other genes associated with IBD. We investigated whether variants in NOD2 and interleukin-23 receptor (IL23R) are associated with IBD in a well-characterized case-control cohort from southern India. METHODS: We recruited 652 patients (411 UC and 241 CD) using established diagnostic criteria and 442 age-, sex-, and ethnically-matched, normal individuals. By direct sequencing, we screened the complete NOD2 gene and genotyped the R381Q variant in IL23R, and performed an association analysis and genotype-phenotype correlation analysis. RESULTS: The clinical presentation of UC and CD patients did not differ significantly from the Europeans. We observed a monomorphic status for three common disease-susceptible variants, R702W, G908R, and 1007fs in NOD2; three other single nucleotide polymorphisms, P268S, R459R, and R587R, had a comparable minor allele frequency in patients and controls. Compared to Europeans, we found a low frequency (∼1%) of the protective allele at R381Q in IL23R and no statistically-significant association with IBD (odds ratio = 0.87; 95% confidence interval = 0.26-2.86; P>0.05). CONCLUSIONS: Our study suggests that variants in the NOD2 gene and the protective variant R381Q in IL23R are not associated with IBD in Indians. Additional variants in these or other candidate genes might play a major role in the pathophysiology of IBD in Indians.

Impact of COVID-19 on liver transplant recipients-A systematic review and meta-analysis.

BACKGROUND: Immunosuppression and comorbidities increase the risk of severe coronavirus disease-2019 (COVID-19) in solid organ transplant (SOT) recipients. The outcomes of COVID-19 in liver transplant (LT) recipients remain unclear. We aimed to analyse the outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in LT recipients. METHODS: The electronic databases were searched for articles published from 1 December 2019 to 20 May 2021 with MeSH terms COVID-19, SARS-CoV-2, and liver transplantation. Studies reporting outcomes in more than 10 LT recipients were included for analysis. LT vs non-LT patients with COVID-19 infection were compared for all-cause mortality, which was the primary outcome studied. We also evaluated the relation between the timing of COVID-19 infection post-LT (< one year vs > one year) and mortality. FINDINGS: Eighteen articles reporting 1,522 COVID-19 infected LT recipients were included for the systematic review. The mean age (standard deviation [SD]) was 60·38 (5·24) years, and 68·5% were men. The mean time (SD) to COVID-19 infection was 5·72 (1·75) years. Based on 17 studies (I2 = 7·34) among 1,481 LT recipients, the cumulative incidence of mortality was 17·4% (95% confidence interval [CI], 15·4-19·6). Mortality was comparable between LT (n = 610) and non-LT (n = 239,704) patients, based on four studies (odds ratio [OR], 0·8 [0·6-1·08]; P = 0·14). Additionally, there was no significant difference in mortality between those infected within one year vs after one year of LT (OR, 1·5 [0·63-3·56]; P = 0·35). The cumulative incidence of graft dysfunction was 2·3% (1·3-4·1). Nearly 23% (20·71-25) of the LT patients developed severe COVID-19 infection. Before infection, 71% and 49% of patients were on tacrolimus and mycophenolate mofetil, respectively. Immunosuppression was modified in 55·9% (38·1-72·2) patients after COVID-19 infection. INTERPRETATION: LT and non-LT patients with COVID-19 have a similar risk of adverse outcomes.

Visceral adipose tissue visfatin in nonalcoholic fatty liver disease.

BACKGROUND: Visfatin is a novel adipocytokine predominantly expressed and secreted by visceral adipose tissue. It is realized for its multiple functions of central importance in NAD biosynthesis, innate immunity and inflammation. Its phosphoribosyl transferase activity regulates cellular energetics and NAD dependent enzymes such as SIRTUINS. Although its expression in various tissues and circulating levels are documented, visceral visfatin levels in Nonalcoholic fatty liver disease (NAFLD) patients have not been reported. OBJECTIVE: The aim of the present study was to assess visceral adipose tissue visfatin levels in NAFLD. Materials and methods. A total of 115 patients undergoing diagnostic laparoscopy were recruited in the study and categorized into two groups based on standard criteria for NAFLD. Visceral adipose tissue TNF-a, IL-6 and visfatin levels were measured by ELISA. Blood glucose, lipids, liver enzymes and non esterified fatty acids (NEFA) were estimated using standard procedures. Formalin fixed, Hematoxylene Eosin stained liver biopsy specimens were examined for the presence of steatosis and the degree of steatosis was ascertained as per Brunt.s classification. RESULTS: The visceral visfatin level declined significantly (P < 0.001) in all groups of NAFLD as compared to non NAFLD group, while plasma NEFA level increased with progressive steatosis (P < 0.02). Significant increase in TNF a was observed in all groups of NAFLD, while IL-6 increased in NASH only. CONCLUSION: A significant decline in visceral adipose tissue visfatin level was found to be associated with degree of steatosis in NAFLD patients.

Systematic review with meta-analysis: liver manifestations and outcomes in COVID-19.

BACKGROUND: The incidence of elevated liver chemistries and the presence of pre-existing chronic liver disease (CLD) have been variably reported in COVID-19. AIMS: To assess the prevalence of CLD, the incidence of elevated liver chemistries and the outcomes of patients with and without underlying CLD/elevated liver chemistries in COVID-19. METHODS: A comprehensive search of electronic databases from 1 December 2019 to 24 April 2020 was done. We included studies reporting underlying CLD or elevated liver chemistries and patient outcomes in COVID-19. RESULTS: 107 articles (n = 20 874 patients) were included for the systematic review. The pooled prevalence of underlying CLD was 3.6% (95% CI, 2.5-5.1) among the 15 407 COVID-19 patients. The pooled incidence of elevated liver chemistries in COVID-19 was 23.1% (19.3-27.3) at initial presentation. Additionally, 24.4% (13.5-40) developed elevated liver chemistries during the illness. The pooled incidence of drug-induced liver injury was 25.4% (14.2-41.4). The pooled prevalence of CLD among 1587 severely infected patients was 3.9% (3%-5.2%). The odds of developing severe COVID-19 in CLD patients was 0.81 (0.31-2.09; P = 0.67) compared to non-CLD patients. COVID-19 patients with elevated liver chemistries had increased risk of mortality (OR-3.46 [2.42-4.95, P < 0.001]) and severe disease (OR-2.87 [95% CI, 2.29-3.6, P < 0.001]) compared to patients without elevated liver chemistries. CONCLUSIONS: Elevated liver chemistries are common at presentation and during COVID-19. The severity of elevated liver chemistries correlates with the outcome of COVID-19. The presence of CLD does not alter the outcome of COVID-19. Further studies are needed to analyse the outcomes of compensated and decompensated liver disease.

Recurrent acute pancreatitis and Wirsungocele. A case report and review of literature.

CONTEXT: The association of Santorinicele with pancreas divisum has been well described. There is an increased risk of recurrent acute pancreatitis in patients with pancreas divisum who also have Santorinicele. Focal saccular dilation of the terminal part of the main pancreatic duct has been described as an incidental finding and termed, 'Wirsungocele'. CASE REPORT: We report a case of a 39-year-old male who had recurrent episodes of acute pancreatitis. Laboratory tests, US of the abdomen and CECT of the abdomen confirmed acute pancreatitis. MRCP showed focal saccular dilation of the terminal part of the main pancreatic duct suggestive of Wirsungocele. An ERCP confirmed MRCP findings. An endoscopic pancreatic sphincterotomy was performed and a 5 Fr single pigtail pancreatic stent was placed. The pancreatic stent was removed after 4 weeks. At the 12-week follow-up, the patient was asymptomatic. CONCLUSION: This case report describes the association of Wirsungocele with recurrent acute pancreatitis.

Capsule endoscopy: current status in obscure gastrointestinal bleeding.

Capsule endoscopy (CE) is a safe, non invasive diagnostic modality for the evaluation of small bowel lesions. Obscure gastrointestinal bleeding (OGIB) is one of the most important indications of capsule endoscopy. Capsule endoscopy has a very high diagnostic yield especially if the bleeding is ongoing. This technique appears to be superior to other techniques for the detection of suspected lesions and the source of bleeding. Capsule endoscopy has been shown to change the outcome in patients with obscure gastrointestinal (GI) bleed.

Hemophagocytic Lymphohistiocytosis Masquerading as Acute Liver Failure: A Single Center Experience.

BACKGROUND/AIM: Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening disorder of extreme inflammation and unregulated immune response which require prompt recognition and early introduction of definitive therapy. HLH can present with wide range of hepatic dysfunction ranging from mild elevation of transaminases to liver failure. This study is carried out to describe the clinical and laboratory presentation of HLH. METHODS: Patients who were diagnosed with HLH between January 2013 and December 2015 were retrospectively included in this study. RESULTS: Six patients were diagnosed as secondary HLH with median age of 28.5 years at diagnosis. All patients were presented with history of deep jaundice and high grade fever with pancytopenia and splenomegaly. Underlying diagnosis was viral infections in 4 and probable viral infection in remaining two. Bone marrow hemophagocytosis was present in 3 cases. Three patients were treated with corticosteroids only and one each with corticosteroids with cyclosporine or intravenous immunoglobulin (IVIG) and HLH treatment protocol. One patient died due to acute respiratory distress syndrome (ARDS); another patient died in follow-up due to respiratory failure due to pneumonia. CONCLUSIONS: HLH is rare and potentially life-threatening cause of prolonged fever, jaundice and pancytopenia. Early diagnosis and initiation of specific therapy can improve clinical outcome.