Comparison of gastric emptying time between breast-fed and formula milk-fed infants less than 6 months old, using gastric ultrasound-An observational study.

BACKGROUND: Fasting before elective anesthesia care is a standardized practice worldwide. The aim is to decrease the risk of aspiration leading to pulmonary complications such as aspiration pneumonitis during anesthesia care. There are different guidelines for elective preoperative fasting in children. However, there is insufficient literature measuring gastric emptying time after breast milk or formula milk feeding in infants. OBJECTIVE: This study used gastric ultrasound to determine the gastric emptying time for breast milk and formula milk in children below 6 months of age. We also compared the calculated gastric volumes among breast-fed and formula milk-fed based on Schmitz's and Spencer's formula. MATERIALS AND METHODS: This prospective observational study was conducted at a tertiary care center in India between November (2017-2019). A total of 52 infants less than 6 months of age were recruited. The study population was divided into two groups (breast-fed and formula milk-fed) of 26 patients each. Ultrasound was used to measure the antral cross-sectional area of the stomach and to calculate the gastric volume using the two classical formulas (Schmitz and Spencer's). Gastric emptying was reported when the bull's eye appearance of the gastric antrum was seen or when the antral cross-sectional area was less than 3.07 cm2. RESULTS: The number of breast-fed children whose antral cross-sectional was greater than 3.07 cm2 (cut-off value for aspiration risk) beyond 1 h was 14/26 (53.84%) while none (0) children went beyond 3 h. The number of formula-fed children whose antral cross-sectional was greater than 3.07 cm2 beyond 1 h was 17/26 (65.38%) while one child (3.84%) went beyond 3 h. Using Schmitz's formula, mean (SD) gastric emptying times were 0.35 ± 0.68 h (95% CI 0.35 ± 0.185, range 0.165-0.535) for breast-fed patients and 0.35 ± 0.69 h (95% CI 0.35 ± 0.188, range 0.162-0.538) for formula-fed patients, and were thus neither clinically nor statistically different (p = .73) Using Spencer's formula, the mean gastric emptying times were 0.12 ± 0.33 h (95% CI 0.12 ± 0.09, range 0.03-0.21) for breast-fed patients and 0.04 ± 0.20 h (95% CI 0.04 ± 0.05, range -0.01 to 0.09) for formula-fed patients, and were also neither clinically nor statistically different p = .13. CONCLUSION: In our series, the gastric emptying times in breast-fed and formula-fed infants less than 6 months old were similar. Our results support the fasting guidelines of the European Society of Anaesthesiology and Intensive Care 2022, that is, 3 h for breastfeeding and 4 h for formula milk feeding. In addition, this shows that the Schmitz's and Spencer's formulae used to calculate the gastric volume based on ultrasound measurement of the antral cross-sectional area are not comparable in infants less than 6 months.

Percutaneous radiological interventions of the portal vein: a comprehensive review.

The portal vein is the largest vessel supplying the liver. A number of radiological interventions are performed through the portal vein, namely for primary pathologies of the portal vein, for inducing liver hypertrophy or to treat the sequelae of portal hypertension among others. The routes used include direct transhepatic, transjugular, and, uncommonly, trans-splenic and through subcutaneous varices. Portal vein embolization and transjugular intrahepatic portosystemic shunt are among the most common portal vein interventions that are performed to induce hypertrophy of the future liver remnant and to treat complications of portal hypertension, respectively. Other interventions include transhepatic obliteration of varices and shunts, portal vein thrombolysis, portal vein recanalization, pancreatic islet cell transplantation, and embolization of portal vein injuries. We present a detailed illustrative review of the various radiological portal vein interventions.

Pancreatic hemorrhage contributes to late mortality in patients with acute necrotizing pancreatitis.

OBJECTIVES: The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality. METHODS: In a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention. RESULTS: Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45-68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1-5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7-9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4-6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2-3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7-25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001]. CONCLUSION: Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.

Utility of Hepatic 2D Shear-Wave Elastography in Monitoring Response to Image-Guided Intervention in Children With Chronic Budd-Chiari Syndrome: A Prospective Study.

BACKGROUND. Image-guided interventions for Budd-Chiari syndrome (BCS) reduce hepatic congestion, thereby reducing liver stiffness. Liver stiffness measurement (LSM) by means of ultrasound may provide a noninvasive marker for assessing treatment response. OBJECTIVE. The purpose of this study was to assess, with attention to changes in LSMs in patients with disease recurrence, the utility of 2D shear-wave elastography (SWE) for monitoring response to image-guided intervention in children with BCS. METHODS. This prospective study included children with chronic BCS and planned image-guided intervention. Color Doppler ultrasound (CDUS) and 2D SWE were performed at baseline; 24 hours, 1 month, and 3 months after intervention; and every 3 months thereafter or when recurrence was clinically suspected. Eighteen children underwent liver biopsy at intervention for fibrosis staging according to the Metavir criteria. Disease recurrence was diagnosed with CDUS. Statistical evaluation was performed by means of nonparametric tests. RESULTS. A total of 32 children (28 boys, four girls; mean age, 9 years; range, 3-14 years) were included. The median LSM at baseline was 43.7 (interquartile range [IQR], 33.0-65.4) kPa, at 24 hours was 22.5 (IQR, 16.8-32.0) kPa, at 1 month was 18.7 (IQR, 14.2-32.0) kPa, and at 3 months was 16.7 (IQR, 11.5-22.5) kPa (p = .001 for all postintervention time points vs baseline). Nine (28.1%) patients had a recurrence at a mean of 4 months after intervention. In one patient with recurrence, LSM was higher at 24 hours (52.3 kPa) than at baseline (44.2 kPa). In the other eight patients with recurrence, LSM was increased at recurrence compared with the prior postintervention LSM (median absolute increase, 11.0 [IQR, 6.1-24.4] kPa). Fibrosis stage was not significantly correlated with baseline LSM (r = 0.11 [95% CI, -0.37 to 0.54]; p = .51) or LSM 24 hours after intervention (r = 0.39 [95% CI, -0.11, 0.73]; p = .11). CONCLUSION. LSMs decreased significantly after image-guided intervention for chronic BCS in children, exhibiting a maximal decrease 24 hours after intervention. Disease recurrence was typically associated with an increase in LSM compared with the patient's prior measurement. CLINICAL IMPACT. LSM obtained with 2D SWE may serve as a useful quantitative adjunct to CDUS in monitoring children with chronic BCS for disease recurrence after percutaneous interventional treatment.

Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance.

Objective: To study the use of serial ultrasound gastric residual volume (GRV) measurements in predicting feed intolerance in critically ill patients. Patients and methods: This study was conducted in various intensive care units (ICUs) of All India Institute of Medical Sciences, New Delhi. Forty-three critically ill patients aged more than 18 years were studied for a total of 130 enteral feeding days. Gastric residual volume was obtained by calculating the antral cross-sectional area (CSA), which is the product of anteroposterior (AP) and craniocaudal (CC) diameters of gastric antrum obtained using ultrasound in the right lateral decubitus position. A baseline measurement was done before the initiation of the enteral feed and termed GRV0, the ultrasound scanning was repeated every 1 hour for the first 4 hours and termed GRV1, GRV2, GRV3, and GRV4, respectively, and the patients were watched for feed intolerance. The receiver operating characteristic (ROC) curves were constructed to correlate the GRV at each time with feed intolerance. Results: The data from 43 medical and surgical critically ill patients were analyzed. Out of 130 feeding days, 13 were noted to be feed intolerant. Gastric residual volume at the end of the fourth hour of feed, that is, GRV4 was the best predictor of feed intolerance with 99.3% area under the curve (AUROC), sensitivity of 99%, specificity of 99.3%, and 95% CI, 0.89-0.98 followed by GRV3, with AUROC of 96% and sensitivity and specificity of 92.3 and 96%, respectively, with 95% CI, 0.92-0.99. How to cite this article: Ankalagi B, Singh PM, Rewari V, Ramachandran R, Aggarwal R, Soni KD, et al. Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance. Indian J Crit Care Med 2022;26(9):987-992.

Noninvasive Staging of Liver Fibrosis Using 5-Minute Delayed Dual-Energy CT: Comparison with US Elastography and Correlation with Histologic Findings.

Background Normalized iodine concentration (NIC) (ratio of iodine concentration of liver to that of aorta) of liver at delayed dual-energy CT (DECT) may reflect the amount of fibrosis based on the extent of iodine uptake. Purpose To stage liver fibrosis by using 5-minute delayed DECT and compare findings with those of transient elastography (TE), shear-wave elastography (SWE), and histologic examination. Materials and Methods This prospective study included patients with chronic liver disease who were scheduled to undergo multiphase abdominal CT and liver biopsy from January 2017 to September 2018. Fifty individuals being screened as renal donors comprised the control group. Study participants underwent TE, SWE, multiphasic DECT (including 5-minute delayed dual-energy scanning), and liver biopsy. Multiphasic DECT and SWE were performed in the control group. The NIC of the right lobe of the liver (RNIC) was compared with liver stiffness (LS) as measured with TE and SWE and with the METAVIR fibrosis stage (ranging from F0 to F4). Diagnostic performance was assessed by using areas under the receiver operating characteristic curve (AUCs). Results A total of 107 participants (mean age, 35 years ± 12 [standard deviation]; 57 men) and 50 control subjects (mean age, 47 years ± 11; 29 women) were evaluated. The RNIC showed strong correlation with METAVIR stage (Spearman ρ = 0.81, P < .001). The AUC for RNIC with each METAVIR stage ranged between 0.86 (95% CI: 0.76, 0.97) and 0.96 (95% CI: 0.92, 0.99). The cut-off value of RNIC was 0.24 (sensitivity: 85% [86 of 101 participants; 95% CI: 77%, 91%]; specificity: 83% [84 of 101 participants; 95% CI: 42%, 98%]) for stage F1 fibrosis and 0.29 (sensitivity: 84% [67 of 80 participants; 95% CI: 74%, 90%]; specificity: 81% [65 of 80 participants; 95% CI: 63%, 92%]) for stage F2 fibrosis. RNIC correlated well with LS as measured with TE and SWE (Spearman ρ = 0.60 and 0.64, respectively; P < .001). Conclusion Normalized iodine concentration of liver at 5-minute delayed dual-energy CT showed strong correlation with the histologic stages of liver fibrosis and good diagnostic performance in estimating liver fibrosis. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Chandarana and Shanbhogue in this issue.

Immediate and Long-Term Outcomes of Percutaneous Radiological Interventions for Hemorrhagic Complications in Acute and Chronic Pancreatitis.

PURPOSE: To evaluate and compare the immediate and long-term outcomes of radiological interventions for hemorrhagic complications in patients with acute and chronic pancreatitis. MATERIALS AND METHODS: This retrospective study, conducted between January 2014 and June 2020, included all patients with acute and chronic pancreatitis presenting with hemorrhagic complications who underwent angiography and/or embolization. Their clinical, angiographic, and embolization details were evaluated and correlated with procedure success, complications, recurrence, and mortality. The patients were subgrouped into groups A (acute pancreatitis) and C (chronic pancreatitis), and comparisons were made. RESULTS: The study included 141 patients (mean age, 36.3 ± 11.2 years; 124 men), of whom 106 patients had abnormal angiography findings and underwent embolization. Of them, group A had 50 patients (56 lesions) and group C had 56 patients (61 lesions). All the patients in group A had severe acute pancreatitis, with a mean computed tomography severity index of 7.6. The technical and clinical success rates of embolization, complications, recurrence, and long-term outcomes were not significantly different between the groups. Group A had significantly higher mortality due to sepsis and organ failure. Embolic agents did not have any significant association with complications, recurrence, and mortality. After a mean follow-up of 2 years, 72.5% of the patients were asymptomatic, and none had symptoms attributable to embolization. CONCLUSIONS: Success, complications, and recurrence after embolization for hemorrhagic complications were comparable between acute and chronic pancreatitis. Acute pancreatitis was associated with significantly higher mortality. Embolic agents did not significantly influence the outcomes. None had long-term adverse effects attributable to embolization.

Vascular complications of chronic pancreatitis: A tertiary center experience.

INTRODUCTION: Vascular complications such as venous thrombosis (VT) and pseudoaneurysm are not uncommon in patients with chronic pancreatitis (CP). The aim of this study to was to evaluate the prevalence and risk factors for vascular complications in patients with CP. METHODS: A retrospective analysis of a prospectively maintained database of patients with CP presenting from January 2002 to August 2019 was performed. Venous thrombosis and pseudoaneurysm were identified using radiological imaging, and their risk factors were identified using multivariate Cox-proportional hazards. RESULTS: Of 1363 patients with CP, 166 (12.2%) had vascular complications. Isolated VT was present in 132, pseudoaneurysm in 17, and both in 17 patients. They were more commonly seen in males and alcoholic CP (ACP), and less commonly in patients with pancreatic atrophy and calcification. It involved the vessels in the closest proximity to the pancreas, VT most commonly involving the splenic vein whereas pseudoaneurysm most commonly involved the splenic artery. Alcoholic CP [odds ratio (OR) 2.1, p = 0.002], pseudocyst (OR 4.6, p < 0.001) and inflammatory head mass (OR 3.1, p = 0.006) were independent risk factors for VT, whereas ACP (OR 3.49, p = 0.006) and pseudocyst (OR 3.2, p = 0.002) were independent risk factors for pseudoaneurysm. Gastrointestinal bleed occurred in 3.5% patients, and more commonly in patients with pseudoaneurysm than VT (64.7% vs 15.9%), and in patients with ACP in comparison to other etiologies (p < 0.001). CONCLUSION: Vascular complications are a common complication of CP, VT being more frequent than pseudoaneurysm. Pseudocyst and ACP are independent risk factors for the development of vascular complications.

Ultrasonography in pediatric Budd-Chiari syndrome.

Budd-Chiari syndrome is a vascular pathology of the liver, commonly seen in adults and uncommon in children. Most children with Budd-Chiari syndrome present with ascites, and an etiology is found in only about 50%. Ultrasonography (US) with color Doppler is the main modality used in the diagnosis. US imaging additionally guides radiologic interventions and follow-up after recanalization or shunt procedure. In this pictorial review, we illustrate the findings in pediatric Budd-Chiari syndrome as seen on B-mode and color Doppler US and describe the role of US in guiding percutaneous radiologic interventions, with a brief description of the role of US contrast agent and sonoelastography in this setting.

Diabetes after pancreaticoduodenectomy: can we predict it?

BACKGROUND: There is limited literature about the perioperative factors which can predict endocrine insufficiency after pancreaticoduodenectomy (PD). The primary aim was to correlate percentage pancreatic remnant volume (%RV) after PD in nondiabetic patients with the development of new-onset impaired glucose tolerance/diabetes mellitus (IGT/DM). The secondary aim was to identify the risk factors for new-onset IGT/DM. METHODS: In this prospective study, all consecutive patients with resectable periampullary carcinoma and without IGT/DM were evaluated with fasting and postprandial plasma glucose, HbA1c, insulin, and C-peptide levels preoperatively and at 3 mo postoperatively. After that, all patients were followed up with fasting and postprandial plasma glucose level assessed at 3-mo intervals for 24 mo or till death, whichever occurred earlier. The %RV was determined from computed tomography measurements preoperatively. RESULTS: Of the 50 patients, 11 (22%) patients developed IGT/DM after median follow-up of 32 mo. The patients' with/without IGT/DM were similar in demographic/perioperative variables. The %RV was found to be an independent factor associated with new-onset IGT/DM. A %RV of <48.8% was found to be a predictor of new-onset IGT/DM (sensitivity, 89.7%; specificity, 73.6%). Plasma sugar and glycosylated hemoglobin levels were significantly higher postoperatively after PD than the preoperative levels. Insulin and C-peptide levels were significantly lower after PD, irrespective of new-onset IGT/DM. CONCLUSIONS: The incidence of IGT/DM after PD was 22%, and %RV < 48.8% was found to be a significant risk factor for new-onset IGT/DM. (CTRI/2013/12/004233).

Interventional Radiology in India.

OBJECTIVE: The purpose of this article is to review the status of interventional radiology (IR) in India. CONCLUSION: After a few initial challenges, the specialty of interventional radiology (IR) is well established in most cities in India, where various quality procedures are now regularly performed. The national IR society, the Indian Society of Vascular and Interventional Radiology, is still new, but its collaboration with other international societies will help its progress. Education and training in IR are fast evolving in India, and as more radiologists choose IR as their career, IR is bound to progress.

Colonic Crohn's Disease Is Associated with Less Aggressive Disease Course Than Ileal or Ileocolonic Disease.

BACKGROUND: The literature on disease characteristics of colonic Crohn's disease (CD) is sparse, especially from Asia, where the burden of inflammatory bowel disease is on the rise. The present study aims to describe the disease characteristics of colonic CD, and compare it with that of ileal/ileocolonic disease. METHODS: This retrospective study included adult patients of CD (diagnosed by standard criteria, follow-up duration > 6 months) on follow-up between August 2004 and January 2016. The disease location was classified by Montreal classification. The data were recorded on demographic characteristics, smoking status, disease phenotype, disease course, treatment received, hospitalization and surgeries. RESULTS: Of 406 CD patients, 123 had colonic [mean age (at onset) 30.4 ± 13.2 years, 59.3% males] and 265 had ileal/ileocolonic disease [mean age (at onset) 32.9 ± 13.8 years, 61.5% males] while 18 patients had isolated upper GI disease. The frequency of inflammatory behavior (B1 phenotype; 61.8 vs. 46.4%, p = 0.003), perianal disease (23.6 vs. 4.5%, p < 0.001), and extra-intestinal manifestation (42.3 vs. 30.2%, p = 0.019) was higher in colonic than ileal/ileocolonic CD. Though not statistically significant, requirement of atleast one course of steroid was lower in colonic CD (72.7 vs. 84.2%, p = 0.098). Although there was no difference in the frequency of hospitalization (30.1 vs. 27.1%, p = 0.45), the overall requirement for surgery was significantly lower in colonic CD (17.1 vs. 26.1%, p = 0.032) and patients with colonic disease had a lower cumulative probability of first surgery in the first 10 years of follow-up [Hazard ratio 0.556 (95% CI 0.313-0.985), p = 0.045]. CONCLUSION: Colonic CD was associated with less aggressive disease behavior and lower requirement of surgery as compared to ileal/ileocolonic CD.

Development and validation of visceral fat quantification as a surrogate marker for differentiation of Crohn's disease and intestinal tuberculosis.

BACKGROUND AND AIM: Crohn's disease (CD) and intestinal tuberculosis (ITB) have close phenotypic resemblance. Mesenteric fat (a component of visceral fat [VF]) hypertrophy and fat wrapping, which is visible radiologically as fibrofatty proliferation, is seen more commonly in CD than in ITB. AIM: The present study was conducted to study the role of VF in differentiating CD and ITB. METHODS: Visceral fat area and subcutaneous (SC) fat area were measured on computed tomography in two cohorts (development and validation). VF/SC ratio was also calculated for all patients. In the development cohort, retrospective data collection was carried out for 75 patients with CD and ITB who were on follow-up from January 2012 to November 2014. In the validation cohort, 82 patients were recruited prospectively from December 2014 to December 2015 and were diagnosed as CD or ITB according to standard diagnostic criteria. RESULTS: Visceral fat area and VF/SC ratio were significantly higher in CD patients (n = 42: development, n = 46: validation) than in ITB patients (n = 33: development, n = 36: validation) in both the development (106.2 ± 63.5 vs 37.3 ± 22, P = <0.001; 1.1 ± 0.57 vs 0.43 ± 0.24, P = <0.001) and validation cohorts (102.2 ± 69.8 vs 55.8 ± 44.9, P = 0.01; 1.2 ± 0.68 vs 0.56 ± 0.33, P = <0.001). A cut-off of 0.63 for VF/SC ratio in the development cohort had a high sensitivity (82%) and specificity (81%) in differentiating CD and ITB. Similar sensitivity (81%) and specificity (78%) were seen when this cut-off was applied in the validation cohort. CONCLUSION: The VF/SC ratio is a simple, cost-effective, non-invasive and single objective parameter with a good sensitivity and specificity to differentiate CD and ITB.

Tubercular Intestinal Strictures Show a Poor Response to Anti-Tuberculous Therapy.

BACKGROUND: The literature on resolution of intestinal strictures in patients with intestinal tuberculosis (ITB) after anti-tuberculous therapy (ATT) is sparse and ambivalent. We aimed to assess the frequency of stricture resolution after ATT and its predictors. METHODS: This ambispective cohort study included consecutive ITB patients with strictures who received ATT for ≥6 months and were on regular follow-up between January 2004 and December 2015. Resolution of stricture was assessed at the end of ATT by endoscopy/radiology. RESULTS: Of 286 patients, 128 had strictures, and 106 were finally included (63 males, median age 35 years). The stricture location was distal ileum/ileocecal in 52 (49.1%), colon in 37 (34.9%), ileocolonic in 4 (3.8%), proximal small bowel in 10 (9.4%), and gastroduodenal in 4 (3.8%) patients. Although all patients demonstrated mucosal healing (indicating resolution of active infection), stricture resolution occurred only in 25/106 (23.6%) patients. Symptoms pertaining to stricture (pain abdomen/recurrent SAIO) were present in 104/106 (98%) patients, and after a median of 6 (6-9) months of ATT, these symptoms resolved only in half, 88% (22/25) in patients with stricture resolution and 38% (30/79) in patients with persistent strictures. Colonic strictures had the least resolution (5.4%) followed by proximal small intestinal (20%) and distal ileal/ileocecal (36.5%). Although not statistically significant, stricture resolution was less frequent in patients with multiple strictures, longer strictures (>3 cm), and strictures in which scope was not negotiable prior to ATT. CONCLUSION: Only one-fourth of ITB patients with strictures show resolution of stricture following ATT. The resolution of strictures is dependent on disease location, and majority of them exhibit symptoms pertaining to stricture even after ATT.