The Indian Network of Drug-Induced Liver Injury: Etiology, Clinical Features, Outcome and Prognostic Markers in 1288 Patients.

BACKGROUND: Etiology of and outcomes following idiosyncratic drug-induced liver injury (DILI) vary geographically. We conducted a prospective study of DILI in India, from 2013 to 2018 and summarize the causes, clinical features, outcomes and predictors of mortality. METHODS: We enrolled patients with DILI using international DILI expert working group criteria and Roussel Uclaf causality assessment method. Follow-up was up to 3 months from onset of DILI or until death. Multivariate logistics regression was carried out to determine predictors of non-survival. RESULTS: Among 1288 patients with idiosyncratic DILI, 51.4% were male, 68% developed jaundice, 68% required hospitalization and 8.2% had co-existing HIV infection. Concomitant features of skin reaction, ascites, and encephalopathy (HE) were seen in 19.5%, 16.4%, and 10% respectively. 32.4% had severe disease. Mean MELD score at presentation was 18.8 ± 8.8. Overall mortality was 12.3%; 65% in those with HE, 17.6% in patients who fulfilled Hy's law, and 16.6% in those that developed jaundice. Combination anti-TB drugs (ATD) 46.4%, complementary and alternative medicines (CAM) 13.9%, anti-epileptic drugs (AED) 8.1%, non-ATD antimicrobials 6.5%, anti-metabolites 3.8%, anti-retroviral drugs (ART)3.5%, NSAID2.6%, hormones 2.5%, and statins 1.4% were the top 9 causes. Univariate analysis identified, ascites, HE, serum albumin, bilirubin, creatinine, INR, MELD score (p < 0.001), transaminases (p < 0.04), and anti-TB drugs (p = 0.02) as predictors of non-survival. Only serum creatinine (p = 0.017), INR (p < 0.001), HE (p < 0.001), and ascites (p = 0.008), were significantly associated with mortality on multivariate analysis. ROC yielded a C-statistic of 0.811 for MELD and 0.892 for combination of serum creatinine, INR, ascites and HE. More than 50 different agents were associated with DILI. Mortality varied by drug class: 15% with ATD, 13.6% with CAM, 15.5% with AED, 5.8% with antibiotics. CONCLUSION: In India, ATD, CAM, AED, anti-metabolites and ART account for the majority of cases of DILI. The 3-month mortality was approximately 12%. Hy's law, presence of jaundice or MELD were predictors of mortality.

Accuracy of Leukocyte Esterase Reagent Strip (LERS) test for rapid bedside screening of spontaneous bacterial peritonitis: An observational study.

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm3) and positive culture. Usually fluid analysis and culture take time and precious hours are lost in starting therapy. Leukocyte Esterase Reagent Strips (LERS) have consistently given a high negative predictive value (>95% in the majority of the studies). AIMS AND OBJECTIVES: Aim was to evaluate the diagnostic utility of leukocyte esterase reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values. METHODOLOGY: The study was carried out on 64 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm3 was considered positive). RESULTS: Of the 64 patients SBP was diagnosed in 17 patients, 47 patients were negative for SBP by manual cell count. At cut off of 2+; sensitivity to diagnose SBP was 100%; specificity of 94%; PPV being 57% and NPV of 94%. at the cut off level of 3+; sensitivity decreased down to 76%; specificity increased to 100%; PPV of 100% and NPV of 93.75%. Overall accuracy at 2 + and 3 + was respectively 94.5% and 93.75%. CONCLUSION: In this study we have found good sensitivity and specificity for the prompt detection of elevated polymorphonuclear neutrophil count. A negative test result excludes SBP with a high degree of certainty. Thus, it represents a convenient, inexpensive, simple bedside screening tool for SBP diagnosis.

Correlation of Computed Tomography of Colonic Wall Thickening with Colonoscopy.

INTRODUCTION: Computed Tomography of abdomen frequently shows bowel wall thickening with different grades and characteristic of thickening. The correlation of bowel wall thickening (BWT) with endoscopic findings is not well described in Indian population. Therefore we did this study to determine the correlation of BWT with endoscopic findings. METHODS: Its Prospective single center study with 85 Consecutive patients with age group more than 12 years with CT scan abdomen showing bowel wall thickening were included in the study. Colonoscopy was done subsequently within a span of 15 days with appropriate bowel preparation. Colonoscopic correlation was done in relation to site, degree and characteristic of thickening. Biopsies were taken at the site of visible abnormalities on endoscopy and from normal appearing mucosa in case of strong suspicious of disease. RESULTS: Total of 85 (37 men) consecutive symptomatic patients with colonic wall thickening on computed tomography underwent colonoscopy. The mean age group was 34.2 (SD±17.35) years. Endoscopy was normal in 20 patients (24%) and abnormal in 65 patients (76.5%). Patients with mild thickening were more likely to have normal endoscopy than those with moderate/severe thickening (19 versus 1 patient; p<0.001). The abnormality rate was similar across different bowel segments (left vs right side; 85.7% versus 76.5%, p< 0.57). Out of 65 patients with endoscopic abnormality, 41 (62.12%) had tuberculosis, 10 (15.16%) had malignancy. Most common cause of IC thickening was secondary to tuberculosis (n=40, 95.2%). CONCLUSION: A proportion of patients with thickening on CT scan, especially mild, may have normal colonoscopy. Patients should be counseled about the same prior to colonoscopy. However, colonoscopy should be done to rule out abnormality even when CT shows mild thickening.

Predictors of 1-month and 3-months Hospital Readmissions in Decompensated Cirrhosis: A Prospective Study in a Large Asian Cohort.

INTRODUCTION AND AIM: Considered as a healthcare quality indicator, hospital readmissions in decompensated cirrhosis predispose the patients and the society to physical, social and economic distresses. Few studies involving North American cohorts have identified different predictors. The aim of this study was to determine and validate the predictors of 1-month and 3-months readmission in an Asian cohort. MATERIAL AND METHODS: We prospectively studied 281 hospitalised patients with decompensated cirrhosis at a large tertiary care public hospital in India between August 2014 and August 2016 and followed them for 3 months. Data regarding demographic, laboratory and disease related risk factors were compiled. We used multivariate logistic regression to determine predictors of readmission at 1-month and 3-months and receiver operating curves (ROC) for significant predictors to obtain the best cut-offs. RESULTS: 1-month and 3-months readmission rates in our study were 27.8% and 42.3%, respectively. Model for End stage Liver Disease (MELD) score at discharge (OR:1.24, p < 0.001) and serum sodium (OR:0.94, p-0.039) independently predicted 1-month and MELD score (OR:1.11, p-0.003), serum sodium (OR:0.94, p-0.027) and male gender (OR:2.19, p-0.008) independently predicted 3-months readmissions. Neither aetiology nor complications of cirrhosis emerged as risk factors. MELD score >14 at discharge and serum sodium < 133 mEq/L best predicted readmissions; MELD score being a better predictor than serum sodium (p - 0.0001). CONCLUSIONS: High rates of early and late readmissions were found in our study. Further, this study validated readmission predictors in Asian patients. Structured interventions targeting this risk factors may diminish readmissions in decompensated cirrhosis.

Risk factors for inflammatory bowel disease: A prospective multi-center study.

INTRODUCTION: Environmental risk factors have been associated with inflammatory bowel disease (IBD). With rising incidence, it is important to know risk factors associated with IBD in our population. This study was aimed to evaluate risk factors for IBD from western India. METHODS: This was prospective, multi-center case-control study which included 1054 patients with IBD of which 765 (72.5%) were ulcerative colitis (UC) and 289 (27.4%) Crohn's disease (CD). Asymptomatic individuals without a history of any major illness served as controls. The questionnaire containing risk factors for IBD was given to patients and control group. Odds ratio and 95% confidence interval were calculated for each variable. RESULT: Significant numbers of patients with CD were from rural area. Rural environment (OR 1.071, 0.82-1.38 and OR 1.441, 1.02-2.02), higher education (OR 1.830, 1.52-2.19 and OR 1.519, 1.16-1.97), professional by occupation (OR 1.754, 1.46-2.09 and OR 1.293, 0.99-1.67), annual family income >100,000 Indian national rupees (OR 2.185, 1.52-3.13 and OR 4.648, 3.10-6.95), history of appendectomy (OR 3.158, 1.71-5.80 and OR 3.158, 1.71-5.80), and family history of IBD (OR 4.510, 2.19-9.25 and OR 3.972, 1.58-9.96) were the risk factors for UC and CD, respectively. Vegetarian diet was protective factor for UC (OR 0.29, 0.27-0.39) and risk for CD (OR 1.179, 0.88-1.57). Smoking and chronic alcoholism were not found to be the risk factors. CONCLUSION: This study highlights association between socioeconomic, dietary factors, appendectomy, and family history as risk factors for IBD.

Do additional colonoscopic biopsies increase the yield of Mycobacterium tuberculosis culture in suspected ileo-colonic tuberculosis?

BACKGROUND: Isolation of Mycobacterium tuberculosis on culture is vital for differentiating intestinal tuberculosis (ITB) from Crohn's disease (when histology is not diagnostic) and for diagnosis of multidrug-resistant tuberculosis. The current yield of TB culture (< 50%) from colonoscopic biopsy tissue is not satisfactory. AIM: To determine whether more colonoscopic biopsies can increase the yield of TB culture in patients with ITB. METHODS: In this prospective study, in patients who underwent colonoscopy for suspected ITB, four biopsies were taken (container 1) followed by an additional four biopsies (container 2) for TB culture, from involved regions. The culture was done using Mycobacterium Growth Indicator Tube (MGIT) 960. A final diagnosis of ITB was made if TB culture was positive, there was unequivocal histological evidence of TB, or there was unequivocal evidence of TB elsewhere in the body, in the absence of another diagnosis. RESULTS: Of 182 patients enrolled (mean age 37.5 [SD 17.2] years; 93 [51.5%] women), 70 (38.4%) were finally diagnosed to have ITB. MGIT culture was positive in 29 (41.4%), 27 (38.5%), and 37 (52.8%) of 70 patients from containers 1, container 2, and combined eight biopsies, respectively. The incremental yield of eight biopsies was 11.4% (95% confidence interval [CI] 5.1 to 21.3%) as compared to container 1 and 14.3% (95% CI 7.1 to 24.7%) as compared to container 2. CONCLUSION: Additional four (total eight) colonoscopic biopsies improved the yield of TB culture positivity over four biopsies by 11.4% to 14.3%, to 52.8%; this increase is clinically useful.

Difficult colonoscopy: air, carbon dioxide, or water insufflation?

BACKGROUND/AIMS: This study aimed to compare tolerance to air, carbon dioxide, or water insufflation in patients with anticipated difficult colonoscopy (young, thin, obese individuals, and patients with prior abdominal surgery or irradiation). METHODS: Patients with body mass index (BMI) less than 18 kg/m2 or more than 30 kg/m2, or who had undergone previous abdominal or pelvic surgeries were randomized to air, carbon dioxide, or water insufflation during colonoscopy. The primary endpoint was cecal intubation with mild pain (less than 5 on visual analogue scale [VAS]), without use of sedation. RESULTS: The primary end point was achieved in 32.7%, 43.8%, and 84.9% of cases with air, carbon dioxide and water insufflation (P<0.001). The mean pain scores were 5.17, 4.72, and 3.93 on the VAS for air, carbon dioxide, and water insufflation (P<0.001). The cecal intubation rate or procedure time did not differ significantly between the 3 groups. CONCLUSIONS: Water insufflation was superior to air or carbon dioxide for pain tolerance. This was seen in the subgroups with BMI <18 kg/m2 and the post-surgical group, but not in the group with BMI >30 kg/m2.

Anemia in patients with ulcerative colitis in remission: A study from western India.

BACKGROUND: Anemia is common in patients with active ulcerative colitis. We aimed to study the anemia profile in patients with ulcerative colitis in clinical remission. METHODS: Sixty-four patients with ulcerative colitis and with a clinical Mayo score less than 3 for at least 3 months were evaluated for anemia. Initial screening was done by hemogram and only patients with anemia were evaluated further for the cause of anemia. We also screened a control population for anemia. Patients with mild anemia were given oral iron, moderate anemia were given intravenous iron and severe anemia were given blood transfusion. RESULTS: The mean hemoglobin in ulcerative colitis patients was 11.75 g/dL and in controls was 13.1 g/dL (p=0.011). The prevalence of anemia was 53.1% in the ulcerative colitis patients and 13.3% in the controls (p=<0.001). 58.8% had mild anemia, 29.4% had moderate anemia and 8.8% had severe anemia. Iron deficiency was the most common cause of anemia (70.5%) followed by anemia of chronic disease combined with iron deficiency in 23.5%. Ferritin levels did not correlate with hemoglobin levels. Oral iron increased the hemoglobin by 1.4 g/dL and intravenous iron by 2.2 g/dL at 1 month. CONCLUSION: Anemia was seen in more than half of patients with ulcerative colitis in clinical remission, iron deficiency being the most common cause.

Endoscopic Ultrasonography Can Prevent Unnecessary Diagnostic Endoscopic Retrograde Cholangiopancreatography Even in Patients with High Likelihood of Choledocholithiasis and Inconclusive Ultrasonography: Results of a Prospective Study.

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the initial therapy recommended for patients with high likelihood of choledocholithiasis. To determine whether endoscopic ultrasonography (EUS) can prevent diagnostic ERCPs in patients with high probability of choledocholithiasis and inconclusive ultrasonography (US). METHODS: All patients with high likelihood of choledocholithiasis and negative US underwent EUS. ERCP was performed for the patients who showed a definite stone/sludge on EUS. Patients without choledocholithiasis were followed up for 3 months. The primary outcome was avoidance of diagnostic ERCP. RESULTS: We included 78 patients (51 women; 27 men). Of these, 25 and 7 (total 41%) were diagnosed with choledocholithiasis and sludge, respectively; stone/sludge was removed in 96.9% of the patients. EUS ruled out choledocholithiasis in 38 patients (48.7%). Two of them were found to have choledocholithiasis on follow-up. The sensitivity, specificity, positive and negative predictive value of EUS for detecting choledocholithiasis were 93.9%, 97.3%, 96.9%, and 94.7%, respectively. Unnecessary ERCP was avoided in 57.7% of the patients by using the EUS-first approach. CONCLUSIONS: EUS is a highly accurate and safe procedure. EUS can replace ERCP as the initial investigation in patients with a high probability of choledocholithiasis. It avoids unnecessary ERCP; hence, decreasing related costs and complications.

Drug Induced Liver Injury at a Tertiary Hospital in India: Etiology, Clinical Features and Predictors of Mortality

ABSTRACT Introduction and aims. Drug-induced liver injury (DILI) is rare; however, it is one of the important causes of acute liver failure which results in significant morbidity or mortality. Material and methods. Patients with suspected DILI were enrolled based on predefined criteria and followed up for at least 6 months or until normalization of liver tests. Causality assessment was done by applying the Roussel Uclaf Causality Assessment Method model. Results. We collected data from 82 individuals diagnosed with DILI at our hospital from 2014 through 2015 (41 men; median age, 38 years). The most commonly implicated drugs were antitubercular therapy (ATT) (49%), antiepileptic drugs (12%), complementary and alternative medicine (CAM) in 10%, antiretroviral drugs (9%) and non-steroidal anti-inflammatory drugs (6%). 8 out of 13 deaths were liver related. Also, liver related mortality was significantly higher for ATT DILI (17.5%) vs. those without (2.4%) (P = 0.02). There was no significant difference in overall as well as liver related mortality in hepatocellular, cholestatic or mixed pattern of injury. Laboratory parameters at one week after discontinuation of drug predicted mortality better than those at the time of DILI recognition. On multivariate logistic regression analysis, jaundice, encephalopathy, MELD (Model for end stage liver disease) score and alkaline phosphatase at one week, independently predicted mortality. Conclusion. DILI results in significant overall mortality (15.85%). ATT, anti-epileptic drugs, CAM and antiretroviral drugs are leading causes of DILI in India. Presence of jaundice, encephalopathy, MELD score and alkaline phosphatase at one week are independent predictors of mortality.(AU)

Drug Induced Liver Injury at a Tertiary Hospital in India: Etiology, Clinical Features and Predictors of Mortality.

INTRODUCTION AND AIMS: Drug-induced liver injury (DILI) is rare; however, it is one of the important causes of acute liver failure which results in significant morbidity or mortality. MATERIAL AND METHODS: Patients with suspected DILI were enrolled based on predefined criteria and followed up for at least 6 months or until normalization of liver tests. Causality assessment was done by applying the Roussel Uclaf Causality Assessment Method model. RESULTS: We collected data from 82 individuals diagnosed with DILI at our hospital from 2014 through 2015 (41 men; median age, 38 years). The most commonly implicated drugs were antitubercular therapy (ATT) (49%), antiepileptic drugs (12%), complementary and alternative medicine (CAM) in 10%, antiretroviral drugs (9%) and non-steroidal anti-inflammatory drugs (6%). 8 out of 13 deaths were liver related. Also, liver related mortality was significantly higher for ATT DILI (17.5%) vs. those without (2.4%) (P = 0.02). There was no significant difference in overall as well as liver related mortality in hepatocellular, cholestatic or mixed pattern of injury. Laboratory parameters at one week after discontinuation of drug predicted mortality better than those at the time of DILI recognition. On multivariate logistic regression analysis, jaundice, encephalopathy, MELD (Model for end stage liver disease) score and alkaline phosphatase at one week, independently predicted mortality. CONCLUSION: DILI results in significant overall mortality (15.85%). ATT, anti-epileptic drugs, CAM and antiretroviral drugs are leading causes of DILI in India. Presence of jaundice, encephalopathy, MELD score and alkaline phosphatase at one week are independent predictors of mortality.

Comparison of Tissue Elastography With Magnetic Resonance Imaging T2* and Serum Ferritin Quantification in Detecting Liver Iron Overload in Patients With Thalassemia Major.

BACKGROUND & AIMS: We investigated whether tissue elastography (TE) can be used as an alternative to magnetic resonance imaging (MRI) T2* analysis to determine the degree of iron overload in patients with thalassemia major. METHODS: We conducted a prospective study of 154 patients (99 male; mean age, 12 ± 3.6 years) with thalassemia major requiring chronic blood transfusion and on iron chelator therapy. The study was performed at a tertiary hospital in India from January 2015 through June 2015. We performed routine blood sample analyses, measurements of serum levels of ferritin, and TE within 1 month of MRI T2* analysis of the liver. The Spearman correlation test and linear regression analysis were used to evaluate the correlation between TE liver stiffness measurements and R2* MRI results or serum ferritin levels. RESULTS: The subjects' mean total serum levels of bilirubin, alanine aminotransferase, aspartate aminotransferase, and albumin were 1.4 ± 0.6 mg/dL, 65.0 ± 51.8 IU/L, 62.9 ± 44 IU/L, and 4.2 ± 0.2 g/d, respectively. Mean liver stiffness measurement, MRI T2* (3 T), corresponding MRI R2* (3 T), and ferritin values were 8.2 ± 4.4 kPa, 3.18 ± 2.6 milliseconds, 617.3 ± 549 Hz, and 4712 ± 3301 ng/mL, respectively. On the basis of MRI analysis, 67 patients (43.5%) had mild iron overload, 49 patients (31.8%) had moderate iron overload, and 22 patients (14.3%) had severe iron overload. Fibroscan liver stiffness measurements correlated with MRI R2* values (r = 0.85; P < .001). TE results identified the patients with severe, moderate, and mild iron overload with area under the receiver operating characteristic curve values of 94.8%, 84.5%, and 84.7%, respectively. Liver stiffness measurements greater than 13.5, 7.8, and 5.5 kPa identified patients with severe, moderate, and mild iron overload, respectively; the sensitivity and specificity values were 92% and 93% for severe overload, 82% and 82% for moderate overload, and 73% and 75% for mild overload. No correlation was found between TE results and serum level of ferritin (r = 0.19; P = .11). CONCLUSIONS: Results of TE correlate with those from MRI T2* analysis. TE is cheaper and more available than MRI and might be used to estimate hepatic iron overload, especially moderate to severe overload in patients with thalassemia major who require chronic transfusion.

Renal Vein and Inferior Vena Cava Thrombosis: A Rare Extrasplanchnic Complication of Acute Pancreatitis.

Acute pancreatitis is an inflammatory disorder often associated with various complications. Approximately one fourth of patients with acute pancreatitis develop vascular complications, of which venous thrombosis forms a major group. Extrasplanchnic venous thrombosis is less common, and simultaneous renal vein and inferior vena cava thrombosis is reported only twice. We report a case of alcohol-related acute pancreatitis complicated by simultaneous renal vein and inferior vena cava thrombosis.

Etiology, clinical profile, and outcome of liver disease in pregnancy with predictors of maternal mortality: A prospective study from Western India.

BACKGROUND: The aim of this study is to study the etiology, clinical profile, and prognostic factors related to maternal and fetal health in pregnant patients with liver disease in Western India. METHODS: This study included 103 consecutive pregnant patients with liver dysfunction from August 2013 to July 2015, who underwent regular biochemical tests, viral markers, ultrasound of abdomen, etc. and were followed up for 6 weeks postpartum or until death. RESULTS: Pregnancy-specific causes of liver dysfunction were found in 39 % (40/103) patients. Liver diseases were most frequent in third trimester 69.9 % (72/103). Etiologies in third trimester were viral hepatitis 36.1 % (26/72), pregnancy induced hypertension (PIH) 30.5 % (22/72), intrahepatic cholestasis of pregnancy 11.1 % (8/72), acute fatty liver of pregnancy (2/72), etc. Hepatitis E was the commonest agent among viral hepatitis 71.8 % (28/39). Causes of maternal mortality (n = 25) were hepatitis E 40 % (10/25), PIH 32 % (8/25), and tropical diseases 20 % (5/25). Fetal mortality (n = 31) was 38.7 % (12/31) in hepatitis E. Maternal mortality was significantly associated with presence of jaundice, fever, abdominal pain, oliguria, anemia, leukocytosis, and coagulopathy. Model for end-stage liver disease (MELD) score >21 predicted maternal mortality with 80 % sensitivity and 91 % specificity (area under the receiver operating characteristic curve = 0.878 and p < 0.001). CONCLUSIONS: Liver disease was most common in the third trimester of pregnancy. Hepatitis E was the most common cause of liver disease in pregnant women in western India with significant maternal mortality, predicted by high MELD score.

Post Colonoscopy Ischaemic Colitis in a Patient without Risk Factors for Colon Ischemia: A Case Report.

Ischaemic colitis is the most common form of intestinal ischaemia and is more common in the elderly and in the people having risk factors for colonic ischaemia. Colonoscopy procedure itself is a rare cause of ischaemic colitis. Fewer than 20 cases of ischaemic colitis caused by colonoscopy procedure have been reported in the english literature till date. This patient presented to us within hours of routine colonoscopy with rectal bleeding and lower abdominal pain. On repeat colonoscopy, the patient had mucosal oedema and ulcerations in the descending colon and sigmoid colon. Computed tomography of abdomen and biopsy of the involved segment confirmed ischaemic colitis. The patient recovered with conservative management.

Role of Rectal Diclofenac Suppository for Prevention and Its Impact on Severity of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients.

BACKGROUND: The aim was to study the role of rectal diclofenac in prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and its impact on severity of post-ERCP pancreatitis. METHODS: We conducted a single-center, prospective, open-labeled, randomized trial for evaluating the use of rectal diclofenac in prevention of post-ERCP pancreatitis in high-risk patients. We assessed 526 patients coming for ERCP for different indications. Four hundred patients were eligible for the study. Those not fitting the high-risk criteria and with acute pancreatitis were excluded. These patients were randomized in two groups: 200 patients received rectal diclofenac prior to or during the procedure, while 200 patients received placebos. Serum amylase was measured at 2 and 36 hours. Post-ERCP pancreatitis was defined as serum amylase > 3 times upper limit of normal with associated severe abdominal pain. Severity was graded according to days of hospitalization and complications. RESULTS: Twenty-nine out of 400 (7.2%) patients developed post-ERCP pancreatitis. Six out of 200 (3%) patients in rectal diclofenac group developed post-ERCP pancreatitis compared to 23 out of 200 (11.5%) patients in placebo group. The difference was statistically significant (P = 0.001). All patients (six) in rectal diclofenac group developed mild pancreatitis as compared to severe pancreatitis in four and moderate pancreatitis in five patients in the placebo group. CONCLUSION: Rectal diclofenac prior to or during ERCP in high-risk patients reduces the incidence as well as severity of post-ERCP pancreatitis compared to placebo.

A Rare Case of Solitary Peutz Jeghers Type Hamartomatous Duodenal Polyp with Dysplasia!

Solitary Peutz Jeghers (SPJ) type hamartomatous polyp is a rare and separate entity from classic Peutz Jeghers syndrome (PJS). A hamartomatous polyp without associated mucocutaneous pigmentations, any other gastrointestinal polyp or a family history of PJS is diagnosed as a SPJ type polyp. We described a case of 22-year-old young man in whom solitary duodenal polyp was incidentally detected and resected. Histopathological examination revealed PJ type hamartomatous polyp with foci of adenomatous and moderate dysplastic change. Very few cases of solitary duodenal PJ type hamartomatous polyps with malignant transformation have been reported. They can be treated with endoscopic or surgical resection. Endoscopic ultrasound can give an idea about the depth of involvement. This is a rare case of duodenal solitary PJ polyp with dysplasia in a young patient.

Gastric lipoma: an unusual cause of dyspeptic symptoms.

Gastric lipomas are rare tumours accounting for 2-3% of all benign gastric tumours. These are usually submucosal in origin but in rare cases may be subserosal in origin. Although a majority of gastric lipomas are asymptomatic and usually detected incidentally, occasionally these can cause abdominal pain, dyspeptic disorders, obstruction, invagination and haemorrhages. In the literature, only 200 cases of gastric lipomas have been reported so far. We report a case of a 56-year-old female with a submucosal symptomatic gastric lipoma presenting with disabling dyspeptic symptoms.

An open-label randomized control study to compare the efficacy of vitamin e versus ursodeoxycholic acid in nondiabetic and noncirrhotic Indian NAFLD patients.

BACKGROUND/AIM: The study was carried out to compare the efficacy of Vitamin E versus Ursodeoxycholic acid (UDCA) in nondiabetic nonalcoholic fatty liver disease (NAFLD) patients. PATIENTS AND METHODS: We randomized 250 non cirrhotic and non diabetic NAFLD patients diagnosed on ultrasound, with raised alanine aminotransferase (ALT) level. (>40 IU/L), to receive Vitamin E 400 mg twice a day (Group A) or UDCA 300 mg twice a day (Group B) for 52 weeks. Lifestyle modification to achieve at least 5% weight reduction and subsequent weight control and regular exercise was advised to both groups. The primary study endpoint was normalization of ALT. Secondary endpoints were the proportion of patients with reduction in ALT, relative reduction in the NAFLD Fibrosis score (NFS), symptomatic improvement and tolerability. RESULTS: One hundred and fifty patients received UDCA as compared to 100 patients receiving Vitamin E. The treatment groups were comparable at entry with regard to age (44.1 vs 42.4 years), gender (67% vs 63% female), risk factors for nonalcoholic steatohepatitis, hypochondriac pain, serum liver biochemistries, and NAFLD Fibrosis score. The primary endpoint was achieved in 21 (14%) and 19 (19%) of patients in Group A and Group B, respectively (P = 0.2). The proportion of patients with reduction in ALT (56% vs 63%, P = 0.2), symptomatic improvement (78% vs 67%, P= 0.058), reduction in the NFS (44% vs 47%, P= 0.69), and tolerability (98% vs 95%, P= 0.2) were similar between Group A and Group B, respectively. CONCLUSION: UDCA is an effective and safe alternative to Vitamin E in nondiabetic-noncirrhotic Indian NAFLD patients.