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Hepatic artery pseudoaneurysm (HAP) is mostly encountered secondary to trauma or iatrogenic causes. HAP associated with cholangitic liver abscess is a rare complication. We present a case of gallstone disease and choledocholithiasis who developed moderate cholangitis and a liver abscess. A small HAP was detected incidentally on a biphasic CT done to evaluate the biliary system. Repeat CT after management with endoscopic retrograde cholangiopancreatography and antibiotics showed resolution of cholangitic abscess with spontaneous thrombosis of HAP.

Comparative data on percutaneous catheter drainage (PCD) vs EUS-guided drainage (EUS-D) for management of symptomatic walled-off-necrosis (WON), specially infected WON with/without organ failure(OF) is limited.Patients with symptomatic WON were divided into two groups of PCD and EUS-D, depending on the modality of drainage. Resolution of OF, adverse events, and other outcome measures were recorded. The two modalities were compared among infected WON sub-cohort and also degree of solid component (SC).218 patients (175 males; 80.3%) were included who underwent either PCD (n = 102) or EUS-D (n = 116). Clinical success was significantly higher in the EUS-D group (92.1% vs 64.6%; p 0.0001) and even for infected WON (n = 128) (p = 0.004), with higher (p = 0.007) and faster (p 0.0001) OF resolution. Other outcome measures including mortality were significantly higher in the PCD group. Among subgroups, PCD with40% SC had the worst clinical success/OF resolution rates, while EUS-D with40% SC had the best outcomes.EUS-D should be preferred over PCD in the management of WON, infected or otherwise, for higher clinical success, and higher/faster resolution of OF. PCD should be avoided in WON with40% SC.

Background Although abdominal pain is one of the major criteria to diagnose acute pancreatitis (AP) there are no standardized guidelines to treat this troublesome symptom in the hospital setting. Aim To conduct a meta-analysis, to assess the efficacy of non-opioids vs opioids for pain management in AP. Methods We searched the medical literature through May 2021 to identify randomized controlled trials (RCTs) that examined the efficacy of opioids with non-opioids in AP pain management. Efficacy was reported as odds ratio (OR) with 95% confidence intervals (CIs) of each comparison tested. Results We identified 7 eligible RCTs, containing 389 patients. No significant difference in terms of pain intensity at day 1 (OR 0.82, 95% CI -2.55 to 4.19) was found between opioids and non-opioids. Non-opioids has a significantly high risk of supplementary analgesic use compared to opioids (OR 3.87, 95% CI 1.25 to 12.04). However, this significance is not seen when comparing non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol to opioids (OR 1.67, 95% CI 0.73 to 3.82) after excluding trials with Procaine. Opioids did not show a significant increase in the complications of pancreatitis, nausea and vomiting, sedation, and deaths when compared with non-opioids. Conclusions We found non-opioids especially NSAIDs and paracetamol can provide adequate pain relief in patients with AP with no change in supplementary analgesic use and adverse events when compared to opioids. Further research is needed to optimize the use of non-opioids along or in combination with opioids for better pain control in AP patients.

Background and study aims Endoscopic dilation is first-line management for benign esophageal strictures (ES). Depth of involvement of the esophageal wall on endosonography using high frequency mini-probe (EUS-M) may predict response to dilation. This study evaluated EUS-M characteristics to predict response of ES to endoscopic dilation. Patients and methods EUS-M was used to measure the total esophageal wall thickness (EWT), involved EWT, percentage of involved wall and layers of wall involved in consecutive patients of benign ES. After a maximum of five sessions of endoscopic dilation, the cohort was divided into responders and refractory strictures. EUS-M characteristics were compared for underlying etiology as also between responders and refractory strictures. Results Of the 30 strictures (17 females, age: 47.16 ± 15.86 yrs.) 13 were anastomotic, eight corrosive, seven peptic and 2 others. Corrosive strictures had the highest involved EWT and percentage of involved wall (3.51 ± 1.36 mm; 76.38 %) followed by anastomotic (2.73 ± 1.7 mm; 65.54 %) and peptic (1.39 ± 0.62 mm; 40.71 %) (P = 0.026 and 0.021 respectively). After five dilations, 22 were classified as responders and eight as refractory. Wall involvement > 70 % had a greater proportion of refractory strictures (P = 0.019). Strictures with involved EWT of ≥ 2.85 mm required more dilations (P = 0.011). Fewer dilations were required for stricture resolution with only mucosal involvement compared to deeper involvement such as submucosa and muscularis propria (2.14 vs. 5.80; P = 0.001). Conclusion EUS-M evaluation shows that corrosive and anastomotic strictures have greater depth of involvement compared to peptic strictures. Depth of esophageal wall involvement in a stricture predicts response to dilation.

Endoscopic ultrasound (EUS)-guided drainage is the preferred treatment of pancreatic fluid collections (PFC). However, the choice of the stent for EUS-guided drainage in critically ill PFC cases with infected walled-off necrosis (WON) and/or organ failure (OF) remains unknown.Between January 2018 and December 2019, consecutive patients with symptomatic PFC subjected to EUS-guided drainage using biflanged metal stents (BFMS) or double-pigtail plastic stents (DPPS) were compared for technical success, clinical success, duration of the procedure, need for intensive care unit stay, duration of intensive care unit stay, ventilator need, resolution of OF, the duration for resolution of OF, complications, need for salvage percutaneous drainage or surgery and mortality. A subgroup of patients having infected WON with/without OF were analyzed separately.Among 120 patients (84.6% males) with PFC (108 WON, 22 pseudocyst) who underwent EUS-guided drainage, there was no difference in outcome parameters in BFMS and DPPS groups. Among patients with WON, clinical success was significantly higher (96.2% vs. 81.8%, P=0.04), with significantly shorter hospital stay (6 vs. 10 d) and procedure duration (17.18±4.6 vs. 43.6±9.7 min, P0.0001) in the BFMS group. Among patients with infected WON with/without OF, the clinical success was significantly higher (100% vs. 73.9%, P=0.02), and the duration of the procedure was significantly lower (16.28±4.4 vs. 44.39±10.7, P0.0001) in BFMS compared with DPPS group.EUS-guided drainage of WON using BFMS scores over DPPS. In patients having infected WON with/without OF, BFMS may be preferred over DPPS.

Background Percutaneous catheter drainage (PCD) is effective initial strategy in the step-up approach of management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD and develop a predictive model. Method and materials In a prospective observational study between July 2016 and Nov 2017, 101 consecutive AP patients were treated using a “step-up approach” in which PCD was used as the first step. We evaluated the association between success of PCD (survival without necrosectomy) and baseline parameters viz. etiology, demography, severity scores, C-reactive protein (CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography (CT) [percentage of necrosis, CT severity index (CTSI), characteristics of collection prior to PCD (volume, site and solid component of the collection), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion (fall in IAP, reduction in volume of collection). Results Among 101 patients, 51 required PCD. The success rate of PCD was 66.66% (34/51). Four patients required additional surgical necrosectomy after PCD. Overall mortality was 29.4% (15/51). Multivariate analysis showed percentage of volume reduction of fluid collection (p = 0.016) and organ failure (OF) resolution (p = 0.023) after one week of PCD to be independent predictors of success of PCD. A predictive model based on these two factors resulted in area under curve (AUROC) of 0.915. Nomogram was developed with these two factors to predict the probability of success of PCD. Conclusion Organ failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD outcomes in patients with fluid collection following AP

Background and Aim Chronic alcoholism and nutrition play an important role in liver and pancreatic diseases. To compare drinking habits and nutritional data in patients with alcoholic liver disease (ALD) and alcoholic pancreatitis (ALP). Methods Clinical, anthropometric, dietary intake, laboratory, and imaging data were recorded in consecutive patients of ALD and ALP. Results In 150 patients of ALP (n = 76) and ALD (n = 74), the age of starting alcohol consumption (19.03 ± 3.78 vs 18.0 ± 2.59 years) and the mean amount of alcohol consumed per day (165.63 ± 87.99 vs 185.50 ± 113.54 g; P = 0.230) were similar. Patients with ALD consumed alcohol on a daily basis more frequently (90.5 vs 72.3%; P = 0.003) and had a longer duration of alcohol intake (21.6 + 0.2 vs 14.5 + 6.9 years; P

To study the natural course of patients with acute pancreatitis (AP) with acute kidney injury (AKI) and their cytokine profile.Natural course of patients with AP and AKI was studied in 97 individuals. Levels of TNFα, IL-6, IL-10, IL-8 and IL-1β were measured at presentation and at 72 h in patients who developed AKI.Amongst the entire cohort, 16.4% patients developed AKI (persistent AKI - 11 patients, transient AKI - 5 patients). Mortality rate was 25% amongst patients with AKI. Levels of IL-6 (p = 0.035) and IL-8 (p = 0.002) were found to be significantly higher in the AKI group. On multivariate analysis, IL-8 levels at baseline were found to be an independent predictor of AKI. AKI group had significant rise of TNF-α (P 0.001), IL-6 (P 0.001) and IL- 1β (P 0.001) on day 3 whereas persistent-AKI group had significant rise of TNF-α (p = 0.031), IL-6 (p = 0.001) and IL-1β on day 3 and significant decline of IL-10 (p = 0.015). Using a cut-off of 105 pg/ml, IL-8 levels at baseline could predict AKI with a sensitivity of 87.5% and specificity of 59.2%, with area under the curve being 0.744 (p = 0.002).AP patients developing AKI have poor prognosis. IL-8 levels can predict AKI in patients with AP.

The aim was to study the outcomes of acute pancreatitis (AP) patients who were referred from other facilities to a tertiary care centre.Patients with AP were who were referred from other hospitals to a tertiary care centre between April 2013 and September 2019 were studied and their outcomes were analysed. Comparison was made between patients referred early (≤7 days) versus those referred late (7 days).Of the 838 patients seen by us, 650 patients (77.6%) were referred from other centres. Median (interquartile range) onset to admission interval was 5 (4-7) days for those who were referred ≤7 days and was 16 (11-30) for those who were referred7 days. Patients referred beyond 7 days of pain onset had higher rates of development of organ failure (P = 0.007), including acute lung injury (P = 0.008) and acute kidney injury (P = 0.026), infected necrosis (P 0.0001), requirement of endoscopic/percutaneous drainage (P 0.001) and need for surgery (P 0.02) compared to patients who were referred ≤7 days of pain onset. Mortality was however similar in the two groups.Patients with AP referred to a specialized centre with AP early (≤7 days) have better outcomes than those referred late (7 days) from other facilities.

The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than the retroperitoneum has not been systematically studied. To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes. This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated. A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups. Mesenteric collections are frequent in ANP. The other non-retroperitoneal sites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.

Terlipressin is used in the management of variceal bleeding and hepatorenal syndrome. Ischemic complications are rare, but serious adverse effects of terlipressin therapy can be fatal. In this context, we reviewed all the published case reports of terlipressin-induced ischemic complications, and data were collected regarding the part of body affected by ischemic complication, latency, geographical variation, different treatment strategies and their outcome, and other relevant information. After an exhaustive search in different databases, 33 published cases were found. The ischemic complications affected virtually every part of the body. Peripheral gangrene was the most common ischemic complication followed by ischemic complications of more proximal parts such as thigh and abdominal wall. Other parts affected were heart, colon, small intestine, scrotum, etc. Most cases were managed conservatively. Although in few cases, other treatment options were also explored, knowledge of this dreaded complication and different management strategies is necessary for early identification of this adverse effect and early management so as to prevent fatality.

Intestinal involvement in Behcet's disease (BD) is uncommon. Differentiating it from close mimics like Crohn's Disease is difficult. Further, in asymptomatic cases, diagnostic challenges posed is still greater. A 17‐year‐old boy had history of recurrent oro‐genital ulcers, papulo‐pustular skin eruptions, ocular lesions and had presented with recent onset perianal abscess. Fecal calprotectin was elevated, and ileo‐colonoscopy showed ileocolonic ulcers of inflammatory nature. Clinical diagnosis of intestinal BD was made. Patients with BD having mucosal lesions may harbor asymptomatic intestinal lesions. Screening them with fecal calprotectin levels and if positive, with subsequent imaging and endoscopic biopsy with timely initiation of appropriate treatment in such asymptomatic cases help to control overall disease activity., Many diseases can cause intestinal granulomas like Crohn's disease and tuberculosis. Behcet's disease is an uncommon cause of intestinal granulomas. Here, we present the case of intestinal Behcet's that closely mimicked Crohn's disease.

Narrow band imaging (NBI) with magnification better visualizes the duodenal microsurface and mucosal vascularity. NBI delineates villous atrophy better than conventional white light endoscopy. This study was conducted to evaluate the diagnostic accuracy of narrow band imaging with magnification (NBI-ME) in celiac disease (CD). In this prospective study, consecutive patients of suspected CD and controls were subjected to tissue transglutaminase antibody test and endoscopic evaluation initially with white light followed by NBI-ME, and biopsies were taken from duodenum. Duodenal villous patterns on NBI were interpreted as normal, blunted distorted, and absent. Severity of villous atrophy was reported according to the modified Marsh criteria. One hundred and twenty-two patients (mean age of 27.53 ± 13.37 years and a male to female ratio of 1:1.26) and 40 controls were studied. The sensitivity and specificity of NBI-ME in predicting villous atrophy were found to be 95.54% and 90%, respectively. The specificity and negative predictive value of NBI-ME in predicting villous atrophy amongst controls was 100% and 97.5%, respectively. Abnormal findings (blunted and absent villous patterns) combined with elevated transglutaminase antibody (> 5-fold) were found to have high accuracy in predicting villous atrophy. NBI with magnification has high sensitivity and specificity in predicting villous atrophy in patients with celiac disease.

Background Opioids and non steroidal anti inflammatory drugs (NSAIDs) are commonly used for pain relief in acute pancreatitis (AP). Opioids carry risk of sphincter of oddi constriction. Although diclofenac prevents post endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis, few reports of diclofenac associated AP are also present. Although, both tramadol and diclofenac are commonly used for pain relief in AP, no study has evaluated their comparative efficacy and safety. Materials and methods Forty-six eligible participants were randomized to either diclofenac or tramadol. Primary objectives of our study were improvement in pain intensity on visual analogue scale (VAS pain score after 1 hr of drug administration) and number of patients requiring supplementary analgesia. The secondary objectives were total number of times of supplementary analgesia requirement, time to significant decrease (33%) in VAS pain score from baseline, number of painful days (VAS pain score >5), VAS pain score on 7th day, side effects, all cause death and complications of pancreatitis between the two groups. Results Although 46 patients were randomized, the final analysis included 41 participants. Five patients were withdrawn from the study (intubation = 3, altered sensorium = 2). No significant difference was seen in terms of VAS score after 1 hr of drug administration, number of patients requiring supplementary analgesic and number of painful days. However, time taken to significant reduction of pain was lower in the diclofenac group (p = .028). Both the agents were comparable in terms of safety. Although complications were less in the diclofenac group, the difference was not statistically significant. Conclusion Both diclofenac and tramadol are equally effective in controlling pain in AP with similar safety profile. Significance There are no studies that have compared the safety and efficacy of two commonly used analgesics for pain relief in patients with AP. We found that both diclofenac and tramadol are equally effective in decreasing the pain associated with AP. There is also no significant difference in the incidence of side effects between both the groups. Hence both diclofenac and tramadol can be used safely and effectively for pain control in AP. Trial registration The trial was registered with clinical trials registry India (Number- CTRI/2018/05/014309).

Background Percutaneous catheter drainage (PCD) is an effective initial strategy of step-up approach for the management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD Methods This prospective observational study was conducted from July 2016 - Nov 2017. A total of 101 consecutive AP patients were recruited. Step up approach was followed for the management of patients. We evaluated the association between success of PCD ( survival without necrosectomy) and baseline parameters (aetiology, demography, severity scores(SIRS,APACHE II, organ failure),total leucocyte count, C-reactive protein(CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography, percentage of necrosis , CT severity index (CTSI), characteristics of collection before PCD (timing, nature of collection, volume, site, solid component), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion ( fall in IAP, reduction in volume of collection). Results Among 101 patients of AP, 51patients required PCD. The success of PCD 66.66% (34/51). Four patients required surgical necrosectomy after PCD. Mortality was 29.4% (15/51, including 2 deaths after necrosectomy). Multivariate analysis(6 factors included after univariate analysis) showed the percentage of volume reduction of fluid collection (p=0.016) and organ failure (OF) resolution(p=0.023) after one week of PCD predicted success of PCD. A predictive model based two factors resulted in AUROC- 0.915. Internal validation by bootstrapping of 5000 resamples showed AUROC 0.906 & is similar to the original model. Nomogram was developed with above factors to predict the probability of success of PCD((figure 1. Nomogram for predictor of PCD success in managing fluid collection in patients with necrotizing pancreatitis total points line indicates total points obtained from predictors and which is synchronized w) figure 1: Total points line indicates total points obtained from predictors and which is synchronized with probability of PCD success line which indicates probability of PCD success). (table 1). Conclusions Organ failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD in patients with pancreatic fluid collection.

Background Quality of life (QOL) in children with celiac disease (CD) has been sparsely studied. Aims We aimed to study QOL in pediatric CD and the effect of a gluten‐free diet (GFD) in a North Indian population. Methods QOL was assessed at baseline and 6 months after GFD using a pediatric symptom checklist (PSC) score. The effect of GFD was assessed using a CD‐specific questionnaire on domains such as dietary compliance, parental behavior and perceptions, children's feeling, and difficulty identifying gluten‐free foods. Results A total of 60 CD children (age 6.03 ± 0. 42 years, range: 2–12 years, M:F 2:1) were prospectively enrolled. The median PSC score at baseline was 11.5 (2–35), which showed a statistically significant improvement after GFD to 2.5 (0–34) (P

Choriocarcinoma is an aggressive gestational trophoblastic neoplasia known for its widely metastatic potential. However, isolated pancreatic metastasis is an extremely rare occurrence and has not been documented in the English literature to the best of our knowledge. The metastatic deposits in the index case led to widespread hemorrhage and necrosis of the pancreatic parenchyma, causing severe acute pancreatitis. The patient succumbed to her illness before chemotherapy was administered. Thus, we present an autopsy case of a uterine choriocarcinoma with isolated pancreatic metastasis presenting as severe acute pancreatitis in a 27-yr-old woman following a molar pregnancy.

Background & aimsCarcinoembryonic antigen (CEA) is a tumour marker whose role is now being evaluated as a biomarker for early diagnosis of acute coronary syndromes. Its levels may rise even prior to rise of established biomarkers of myocardial necrosis.MethodsSerum CEA concentrations were measured by double sandwich ELISA method in four groups of subjects with STEMI, NSTEMI/UA (24 patients of NSTEMI and 18 patients of unstable angina), stable angina and healthy controls with 42 males between 40 to 60 years of age in each group. Also qualitative Troponin T assay and CPK-MB concentrations measurement was done in groups with STEMI and NSTEMI/UA and correlations between CEA concentrations and Troponin T and CPK-MB were made.ResultsMean serum CEA concentrations were 5.19 ± 0.39, 3.84 ± 0.34, 3.91 ± 1.40, 1.84 ± 0.35 and 2.12 ± 0.40 ng/ml respectively in groups with STEMI, NSTEMI/UA, UA alone, stable CAD and healthy controls respectively. STEMI, NSTEMI/UA and UA patients had significantly higher concentrations than stable CAD and healthy controls (p

Fibrocalculous pancreatic diabetes (FCPD) is a peculiar form of diabetes secondary to chronic pancreatitis and usually affects young individuals. It is mostly seen in the developing countries of the world where protein-calorie malnutrition is prevalent. FCPD has an aggressive course and may be responsible for pancreatic calculi, steatorrhoea and other complications of diabetes as well as makes the patient immunocompromised in the majority of cases. Candida glabrata is an important cause of invasive candidiasis in immunocompromised hosts. Here we report the first case of intra-abdominal and scrotal abscess caused by C. glabrata in a patient suffering from FCPD.

PURPOSE: Although the use of steroids in the management of COVID-19 has been addressed by a few systematic review and meta-analysis, however, they also used data from “SARS-CoV” and “MERS-CoV.” Again, most of these studies addressed only one severity category of patients or addressed only one efficacy endpoint (mortality). In this context, we conducted this meta-analysis to evaluate the efficacy and safety of steroid therapy among all severity categories of patients with COVID-19 (mild to moderate and severe to critical category) in terms of “mortality,” “requirement of mechanical ventilation,” “requirement of ICU” and clinical cure parameters. METHODS: 11 databases were screened. Only randomized controlled trials (RCTs) or high quality (on the basis of risk of bias analysis) comparative-observational studies were included in the analysis. RevMan5.3 was used for the meta-analysis. RESULTS: A total of 15 studies (3 RCT and 12 comparative-observational studies) were included. In the mechanically-ventilated COVID-19 population, treatment with dexamethasone showed significant protection against mortality (single study). Among severe and critically ill combined population, steroid administration was significantly associated with lowered mortality (risk ratio [RR] 0.83 [0.76–0.910]), lowered requirement of mechanical ventilation (RR 0.59 [0.51–0.69]), decreased requirement of intensive care unit (ICU) (RR 0.62 [0.45–0.86]), lowered length of ICU stay (single-study) and decreased duration of mechanical ventilation (two-studies). In mild to moderate population, steroid treatment was associated with a higher “duration of hospital stay,” while no difference was seen in other domains. In patients at risk of progression to “acute respiratory distress syndrome,” steroid administration was associated with “reduced requirement of mechanical ventilation” (single-study). CONCLUSION: This study guides the use of steroid across patients with different severity categories of COVID-19. Among mechanically ventilated patients, steroid therapy may be beneficial in terms of reduced mortality. Among “severe and critical” patients; steroid therapy was associated with lowered mortality, decreased requirement of mechanical ventilation, and ICU. However, no benefit was observed in “mild to moderate” population. To conclude, among properly selected patient populations (based-upon clinical severity and biomarker status), steroid administration may prove beneficial in patients with COVID-19.

Incidence of malaria across the globe has constantly been on a rise, especially the tropics. Hence, it is of utmost importance to know its clinical presentation and complications including rare ones and treat them at the earliest. Spleen is a major organ affected by plasmodium. The changes in spleen because of malaria can range from asymptomatic enlargement to complications, such as splenic infarct, rupture, hemoperitoneum, hypersplenism, torsion, cyst, or abscess formation all of which are life-threatening if not treated. Splenic abscess due to any cause is a serious complication due to high-incidence of morbidity and mortality associated with it. Spleen abscess as a complication of malaria has been rarely described in the literature. We present to you a rare case of splenic abscess due to vivax species of plasmodium which was successfully treated conservatively.

Cardiovascular events are the leading cause of fatal outcome from tricyclic antidepressant (TCA) overdose; cardiotoxicity as dysrhythmias and hypotension. Electrocardiogram (ECG) abnormalities usually precede the development of significant, clinically evident cardiovascular disease, and so the ECG has manifests clinically emerged as a valuable tool in the assessment of TCA toxicity. Cardiac toxicity secondary to TCAs is due mainly to sodium-channel blockade and slowing of phase 0 depolarization of the action potential resulting in slowing of conduction through the His-Punkinje system and myocardium. Sinus tachycardia is the most common manifestation seen, other ECG changes, which are seen are premature ventricular contractions, ventricular tachycardia and fibrillation, supraventricular tachycardia with aberrancy, sinus arrest, idioventricular rhythm, pulseless electrical activity, QRS/QT/PR prolongation, rightward terminal QRS axis, increased amplitude of R aVR , atrioventricular blocks, and uncommonly as bundle branch block. Here, we discuss the ECG alterations as a right bundle branch block in a patient who was intoxicated with amitriptyline.