Novel application of lumen-apposing metal stent for management of malignant recto-sigmoid stricture with fistula.

Video 1Demonstration of novel application of lumen-apposing metal stent for management of a malignant recto-sigmoid junction stricture with fistula.

Magnetic resonance elastography (MRE) outperforms acoustic force radiation impulse (ARFI) in predicting oesophageal varices in obese NAFLD cirrhosis.

PURPOSE: Liver stiffness measurement (LSM) by transient elastography has been shown to underperform in high-risk varices (HRVs) prediction in obese non-alcoholic fatty liver disease (NAFLD) compensated cirrhosis (CC). LSM by magnetic resonance elastography (MRE) and acoustic force radiation impulse (ARFI) has been shown to be useful in prediction of oesophageal varices (EVs), but has limited evidence in obese NAFLD-CC. METHODS: Obese patients with NAFLD-CC who underwent MRE and ARFI for LSM and endoscopy for screening of varices were enrolled. Performance of MRE and ARFI for predicting EVs or HRVs was evaluated using area under receiver operating characteristics (AUROC) curves and regression analyses were performed for predictor variables. RESULTS: One hundred eight patients [mean age 54.7 ± 9.6 years, median BMI, 28.5 (26.4-30.0) kg/m2. 72.2% diabetics, 45.4% hypertensive] were enrolled. Fifty-two (48.1%) had no varices, while 29 (26.8%) and 27 (25%) had low-risk varices (LRVs) and HRVs, respectively. MRE-LSM was higher in patients with LRVs (p = 0.01) or HRVs (p = 0.001) against those without varices. ARFI-LSM did not differ significantly between those without and with LRVs or HRVs (p > 0.05 for all). There was a low correlation between ARFI-LSM and MRE-LSM in the overall cohort (r = 0.19). Only platelet count (PC) [0.98 (0.97-0.99)] and MRE-LSM [1.8 (1.26-2.79)] were predictors of HRVs. At a cut-off of 4.75, MRE showed a sensitivity of 96.3%. Model combining MRE-LSM with PC had a diagnostic AUROC of 0.77 and 0.76 for EVs and HRVs. CONCLUSION: In obese NAFLD-CC, MRE-LSM is significantly higher in patients with varices. MRE combined with PC predicts EVs and HRVs with better accuracy than ARFI.

Definitive Role of Contrast-enhanced Endoscopic Ultrasound (EUS) in the Diagnosis of Hepatocellular Carcinoma With Non-diagnostic Cross-sectional Imaging: A Case Report.

The diagnosis of hepatocellular carcinoma is usually centered around cross-sectional imaging (CSI) modalities. However, in some instances focal hepatic lesions may be missed on CSI. Endoscopic ultrasound (EUS) has an evolving role in hepatology and have been shown to be useful in diagnosing focal lesions with advantages of tissue acquisition. We report a case hepatitis B-related cirrhosis presenting with acute decompensation, wherein EUS was used to identify HCC and perform tissue acquisition as CSI was non-diagnostic.

Psoas Muscle Index: A Simple and Reliable Method of Sarcopenia Assessment on Computed Tomography Scan in Chronic Liver Disease and its Impact on Mortality.

Objectives: Psoas muscle parameters have been proposed as a simple and quick method for sarcopenia assessment. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle on computed tomography and its impact on mortality. Methods: One hundred and fifty patients (75 cirrhotics, 75 subjects) were assessed for psoas muscle on CT scan. Psoas muscle index (PMI) was calculated as 'total psoas muscle area/(height of subject)2'. Cut off values for sarcopenia diagnosis were derived from local subjects (n = 75) who did not have cirrhosis/other causes of sarcopenia. Results: Sarcopenia assessed by PMI was seen in 36% (n = 27) of the cirrhotics. Sarcopenia was significantly higher in patients having Child-Pugh C. Ascites, hepatic encephalopathy (HE) and gastro-intestinal bleed were seen in 48%, 18.7% and 24%, respectively. Sarcopenia was significantly associated with ascites and HE (P < 0.05). Out of the 75 cases, 53 cases completed the follow-up period of 1 year. Among the 20 cases who had sarcopenia, 35% (n = 7) succumbed to liver-related illness during 1 year follow-up, and out of the 33 cases without sarcopenia, only 6% (n = 2) died. The association of sarcopenia and 1 year mortality was statistically significant (P = 0.01). Conclusions: The PMI, a simple method for sarcopenia assessment detected sarcopenia in 36% of cirrhotics. Patients with sarcopenia had a significantly higher 1 year mortality rate and appropriate prognostication of such patients is needed.

COVID-19 vaccine-associated myositis - a case report.

Myositis is one of the uncommon adverse events following COVID-19 vaccination, and its mechanism is still unclear. A strong clinical suspicion and further evaluation are important not only for early diagnosis and management but also for better understanding of the unprecedented effects of this novel vaccine. We present a case of myositis following the first dose of the ChAdOx1 nCoV-19 Corona Virus Vaccine, evidenced by serology and MRI.

Management of Refractory Variceal Bleed in Cirrhosis.

Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endoscopic treatment has reduced the mortality of variceal bleeding from 50% to 10-20%. The refractory variceal bleed is either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standard medical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metal stents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling. In cases where endoscopic variceal ligation (EVL) has failed and the variceal bleeding continues, temporary measures like balloon tamponade can be used to achieve hemostasis and as a bridge to definitive measures. SEMS being in use for refractory bleed is preferred over balloon tamponade due to the reduced complication rate. The shunting procedures are highly effective in reducing portal pressure and represent the gold standard for uncontrolled variceal bleeding. The surgical shunts, as well as nonshunt surgeries such as devascularization have become less popular with the increasing use of minimally invasive techniques like TIPS. TIPS have high success rates in controlling refractory variceal bleeding. The mortality rate is greater in high-risk patients undergoing salvage TIPS, and hence, pre-emptive TIPS should be considered in these patients. BRTO is an interventional radiologic procedure used in the management of bleeding gastric and ectopic varices. The availability of gastrorenal or splenorenal shunts is required for the BRTO procedure, which helps to reach and obliterate the cardiofundal varices through the femoral or jugular vein approach. The EUS guided coiling and glue injection have shown promising results, and further randomized controlled trials are required to establish their efficacy for refractory variceal bleeding.

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures.

BACKGROUND/AIMS: Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group. METHODS: This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events. RESULTS: Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events. CONCLUSION: FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.

Acute exogenous lipoid pneumonia: Unusual presentation as cavitating lung disease with pneumothorax.

Acute lipoid pneumonia is quite uncommon and is associated with oily or lipid contents within the alveoli. Exogenous lipoid pneumonia due to kerosene poisoning, manifests with a wide clinical spectrum ranging from subtle chemical pneumonitis to marked severe pulmonary and systemic inflammation. We present an interesting case of an adult male with kerosene poisoning. He manifested with severe cavitating lung disease. In addition, he developed spontaneous pneumothorax. Both cavitating lung disease and pneumothorax are unusual manifestations of acute exogenous lipoid pneumonia and perhaps follow severe lung injury following high volume kerosene exposure.

Kinetics of Covid-19 antibodies in terms of titre and duration among healthcare workers: A longitudinal study.

Background Most individuals with Covid-19 infection develop antibodies specific to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the dynamics of these antibodies is variable and not well-studied. We aimed to determine the titres of naturally acquired antibodies over a 12-week follow-up. Methods We recruited healthcare workers who had tested positive on a specific quantitative reverse transcription-polymerase chain reaction (qRT-PCR) for SARS-CoV-2, and then tested for the presence of immunoglobulin G (IgG) antibody against the same virus at baseline and again at 6 and 12 weeks. The antibody titre was determined by a semi-quantitative assay based on signal/cut-off ratio. Healthcare workers with antibody positivity were divided into those with high titre (ratio ≥12) and low titre (<12). Their demographic details and risk factors were surveyed through a Google form and analysed in relation to the antibody titres at three time-points. Results Of the 286 healthcare workers, 10.48% had high antibody titres. Healthcare workers who had tested positive by qRT-PCR and those who had received the Bacille Calmette-Guérin (BCG) vaccination or other immune-boosters had a higher frequency of high antibody titres. While there was a significant decline in antibody titres at 6 and 12 weeks, 87.46% of individuals positive for IgG antibody persisted to have the antibody even at 12 weeks. Conclusion Healthcare workers who tested positive for SARS-CoV-2 on qRT-PCR had a high positivity for the specific antibody, which continued to express in them even at 12 weeks. Further follow-up is likely to enhance our understanding of antibody kinetics following SARS-CoV-2 infection.

Endovascular management of massive hemoptysis due to covid-19 related pulmonary artery pseudoaneurysm: A rare entity.

Pulmonary artery pseudoaneurysms are rare causes of massive hemoptysis, even less common in setting of COVID-19 pneumonia. We describe and discuss an index case of cavitating COVID-19 pneumonia complicated by a pulmonary artery pseudoaneurysm without concomitant pulmonary thromboembolism. The patient presented with severe hemoptysis and was managed by endovascular coil embolization. Good technical and clinical success was achieved with complete resolution of hemoptysis.

Quantification of Liver Fat by MRI-PDFF Imaging in Patients with Suspected Non-alcoholic Fatty Liver Disease and Its Correlation with Metabolic Syndrome, Liver Function Test and Ultrasonography.

BACKGROUND: Magnetic resonance imaging (MRI)-estimated proton density fat fraction (PDFF) has emerged to be a promising tool in quantification of liver fat. Aim of this study was to quantify liver fat using MRI-PDFF in patients with suspected non-alcoholic fatty liver disease (NAFLD) and to correlate it with the presence of metabolic syndrome (MetS), ultrasonography (USG) and liver function test (LFT). METHODS: We included 111 consecutive patients who were suspected to have NAFLD on the basis of clinical, laboratory or USG findings. A 3 Tesla Phillips MRI machine was used with a software named "mDixon Quant" for quantification of the liver fat. RESULTS: MRI-PDFF revealed hepatic steatosis grading as Grade 0 in 31 patients (28%), Grade I in 40 (36%), Grade II in 19 (17.1%) and Grade III in 21 patients (18.9%). MetS patients had higher proportion of advanced steatosis (Grades II and III) as compared to those without MetS (P < 0.001). ALT (alanine transaminase) was found to be significantly elevated (>1.5 times) in the patients with advanced steatosis as compared to patients with Grades I and 0 fatty liver on MRI-PDFF (P < 0.001). The Kappa measure of agreement between USG and MRI-PDFF was found to be 0.2, which suggests a low level of agreement between the two tests. CONCLUSION: MetS patients have higher proportion of advanced steatosis (Grades II and III) at MRI-PDFF as compared to those without MetS. Patients with advanced steatosis at MRI-PDFF had higher proportion of abnormal LFTs as compared to those with Grades 0 and I hepatic steatosis. There was a dis-correlation between MRI-PDFF and USG in the evaluation of NAFLD.

Efficacy and safety of cholangioscopy guided laser lithotripsy for difficult bile duct stones - A prospective study from a tertiary care centre in Eastern India.

BACKGROUND AND STUDY AIMS: Endoscopic sphincterotomy combined with endoscopic papillary balloon dilatation, mechanical lithotripsy or both, are effective modalities for the ex- traction of difficult common bile duct (CBD) stones. However, approximately 5-15% of cases are still difficult to treat. In the present study, we have evaluated the safety and efficacy of single- operator cholangioscopy guided laser lithotripsy (LL) for difficult to treat CBD stones. PATIENTS AND METHODS: Consecutive patients undergoing LL for the extraction of difficult CBD stones were enrolled in the study. The primary outcomes were related to the efficacy of the procedure in terms of ductal clearance and safety in terms of complications. RESULTS: During the 36 months, 764 patients presented for biliary stone extraction. Most of the patients, 683 (89.4%), had a successful stone extraction with standard techniques. Thirteen patients (1.7%) were not suitable for endoscopic therapy or did not consent for endoscopic therapy, and were referred directly for surgical treatment. Sixty-seven patients (8.8%) were included in the study. Cholangioscope was able to reach the stone in all the cases but one. Complete ductal clearance was achieved in 61 (91%) patients. Complications were encountered in 8 (11.9%) patients. All patients were asymptomatic at one-month of follow-up. CONCLUSION: LL is a highly effective and safe procedure with minimal and transient complications.

COVID-19 prevalence among health-care workers of Gastroenterology department: An audit from a tertiary-care hospital in India.

BACKGROUND AND AIM: In the present coronavirus disease-19 (COVID-19) era, health-care workers (HCWs) warrant special attention because of their higher risk and potential to transmit the disease. Gastroenterology services include emergency and critical care along with the endoscopy procedures, which have aerosol-generating potential. This study was aimed at auditing the COVID-19 impact on HCWs working in the Gastroenterology department of our hospital. METHODS: The COVID-19 status of 117 HCWs was collected using either polymerase chain reaction (PCR) or Immunoglobulin G (IgG) seroassay. COVID-19 positivity was correlated with demographic characteristics, job profile, area of work, and medical history. RESULTS: Thirty-eight HCWs (32.48%) showed evidence of COVID-19 using PCR (23.93%) or only IgG assay (8.55%). Endoscopy technicians (68.75%) exhibited significantly higher (P = 0.003) COVID-19 incidence compared to doctors (20.69%). Those working in the critical care units exhibited a trend toward higher COVID-19 incidence (42.86%). None of the six HCWs who received adequate hydroxychloroquine prophylaxis developed evidence of COVID-19. All the HCWs with COVID-19 disease recovered. However, there was a considerable loss of "man-days." CONCLUSIONS: In our setting, we observed a high COVID-19 risk for HCWs working in the Gastroenterology department, with the highest risk among the endoscopy technicians. A more stringent triaging and pretesting of patients, as well as HCWs, might decrease the risk of COVID-19. Further multicenter studies are needed to evaluate the risk and related parameters.

Seroprevalence of COVID-19 Amongst Health Care Workers in a Tertiary Care Hospital of a Metropolitan City from India.

BACKGROUND: Seroprevalence studies for COVID-19 evaluate the extent of undetected transmission in a defined community, with special significance among health care workers (HCW) owing to their greater exposure and potential to transmit. METHODS: A total of 1122 HCW (approximately 25% of the employees) of a large tertiary care hospital in India were recruited for this cross-sectional study. COVID PCR-positive HCW were excluded. Based on their risk-assessment, participants were grouped into three categories. A questionnaire was administered and they were tested for SARS-CoV-2-IgG antibodies using the chemiluminescence. RESULTS: The overall seroprevalence among workers was 11.94%, which included 19.85% in COVID units, 11.09% in non-COVID units, and 8% in administrative workers (p=0.007). Antibody prevalence was highest in the department of gastroenterology (11.94%), followed by oncology (10.53%), pathology (10.26%), emergency medicine (7.84%) and critical care medicine (7%). Housekeeping staff, food and beverage staff, lab assistants and technicians had higher seroprevalence rate than doctors and nurses (p < 0.0001). HCW with a history of BCG vaccination in childhood and those who received an adequate prophylactic dose of hydroxychloroquine (HCQ) had a lower seroprevalence as compared to those who did not (7.31% vs. 16.8% and 1.30% vs. 11.25% respectively). CONCLUSION: BCG vaccination, HCQ prophylaxis, and the job profile influence the seroprevalence rate in HCW. Seroprevalence rate and follow-up evaluation of its durability may help hospitals to triage their staff at risk, rationalize their placement, prioritize the use of PPE, thereby potentially reducing the risk.

Single-balloon enteroscopy in management of small-bowel disorders.

BACKGROUND: Device-assisted enteroscopy including single-balloon enteroscopy (SBE) allows direct visualization of the small bowel and has good safety and efficacy in experienced hands. Our study is aimed to share our single-centre experience of SBE in diagnosing and treating small-bowel disorders. METHODS: We reviewed the prospectively collected data (from December 2016 to December 2019) of 180 consecutive anterograde and/or retrograde procedures. Analysis of baseline characteristics, endoscopic findings, and diagnostic and therapeutic rates was done. RESULTS: SBE was done in 158 patients with a median age of 55 years (range, 13-94 years) for suspected small-bowel lesions. Dual enteroscopy (anterograde plus retrograde) was done in 22 patients (13.92%). The indication for the procedure was obscure gastrointestinal bleeding in 129 (71.66%), chronic unexplained abdominal pain in 20 (11.11%), suspected small-bowel abnormality in the form of narrowing and/or mass on imaging in 10 (5.5%), chronic diarrhea in 9 (5%), unexplained iron deficiency anemia in 9 (5%), and retained capsule in 2 (1.11%). The most common finding was ulcer, which was noted in 45 (25%) patients followed by stricture in 8 (4.44%) and both ulcers and strictures in 6 (3.33%) patients. SBE was normal in 61 (33.88%) patients. SBE gave a diagnosis in 66.11% while in 28.43% cases, therapeutic intervention was done. Minor complications like bleeding were noted in 3 patients and mild acute pancreatitis in 2 patients. Jejunal perforation requiring surgical intervention was noted in 1 patient. CONCLUSION: SBE is a safe and effective procedure in diagnosing and treating small-bowel diseases.

Assigning computed tomography involvement score in COVID-19 patients: prognosis prediction and impact on management.

OBJECTIVE: Chest CT can provide a simple quantitative assessment of the extent of the parenchymal opacities in COVID-19 patients. In this study, we postulate that CT findings can be used to ascertain the overall disease burden and predict the clinical outcome. METHODS: In this prospective study undertaken from March 28, 2020, until May 20, 2020, 142 patients with CT features suggestive of viral pneumonia, and positive RT-PCR for COVID-19 were enrolled. A dedicated spiral CT scanner was used for all COVID-19 suspects. CT features were reported as typical, indeterminate, or atypical for COVID-19 pneumonia. A CT involvement score (CT-IS) was given to each scan and assigned mild, moderate, or severe category depending on the score range. The patients were followed up for at least 15 days. RESULTS: Ground glass opacity was present in 100% of the patients. There was a significant association between CT-IS and the final outcome of the patients. A statistically significant increasing trend of mortality and requirement of critical medical attention was observed with the rising value of CT-IS in COVID-19. CONCLUSION: The severe CT-IS score group has a high mortality. The CT-IS score could be valuable in predicting clinical outcome and could also be useful in triage of patients needing hospital admission. In situations where healthcare resources are limited, and patient load high, a more careful approach for patients with higher CT-IS scores could be indispensable. ADVANCES IN KNOWLEDGE: CT-IS is a simple quantitative method for assessing the disease burden of COVID-19 cases. It can be invaluable in places with limited resources and high patient load to segregate patients requiring critical medical attention.

A rare peritoneal egg: Case report with literature review.

The occurrence of peritoneal loose bodies has been known for hundreds of years. Although rarely, they attain a diameter of more than 5 cm and are then named "giant" peritoneal bodies (gPLBs). Even these huge peritoneal bodies are generally symptom free, but may be linked with chronic symptoms like abdominal pain or discomfort. Many a times, these gPLBs are misinterpreted as intraabdominal tumors or foreign bodies and unnecessary surgical interventions are carried out. We report a rare case of a 75-year-old male, who presented to our tertiary care center emergency department with history of chronic intermittent abdominal discomfort with acute diarrhea and peri-anal pain. Contrast enhanced computed tomography of the abdomen and pelvis revealed round to oval mass in the pelvis measuring 6.2 cm × 5.8 cm. On laparoscopy, a hard, free floating object with the appearance of a boiled egg could just be scooped out from the pelvis. The postoperative pathological examination revealed laminated strands of hyalinized fibro collagenous tissue with central fat necrosis confirming the diagnosis of gPLB. Postoperative period was uneventful. Peritoneal bodies are rare intraabdominal bodies which are either detected incidentally or present with vague symptoms and require interdisciplinary management.