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Introduction: IgG4-related disease (IgG4-RD) is a rare disease entity in India. We aimed at studying the clinical profile of IgG4-RD of gastrointestinal tract (GIT) from our centre, while systematically reviewing data from India. Methods: Retrospective review of IgG4-RD of GIT was done using electronic medical records between January 2013 and July 2022. Literature search was done for studies of IgG4-RD of the GIT reported from India from 2000 till January 2023. Case series, case reports of IgG4-RD of GIT and case reports describing GIT with multi-organ involvement were included in the review. Primary outcome measure was response to treatment. Secondary outcome measure was relapse after remission. Results: Thirty-one patients were included with 71% (22/31) having autoimmune pancreatitis. The diagnosis was achieved on surgical specimen in 35% (11/31) patients. Steroid was given to 64% (20/31) patients with remission achieved in 70% (14/20) patients. Four patients exhibitted response to prolonged course of steroids with maintenance azathioprine. Relapse was seen in four (20%) patients who achieved remission. Of 731 articles screened, 48 studies (four case series and 44 case reports) were included in the literature review. Of 95 patients described, steroids were given to 65.2% (62/95), while surgery was done in 33.6% (32/95). Remission was seen in 96.6% (85/88) with relapse occurring in 11.4% (10/88) patients on follow-up. Conclusion: One-third patients of IgG4-RD of GIT are diagnosed after surgery. Response to steroids is good with relapse occurring in up to 12% patients. [ABSTRACT FROM AUTHOR]

Background/Aims: Proximal biliary plastic stent migration (PSM) remains a challenging complication. The study aims at determining the PSM rate, retrieval outcomes and factors associated with PSM. Methods: Endoscopy database was analyzed from January 2016 to January 2021 to identify 1137 patients, who underwent stent removal or repeat endoscopic retrograde cholangiopancreatography (ERCP). Demography, methods of stent retrieval, outcomes and complications were noted. Logistic regression was performed to determine risk factors for PSM. Propensity score matching was done in a 1:1 manner using age, sex, comorbidities and indication to assess endoscopy-related factors. Clinical trial registration done (CTRI/2022/02/040516). Results: PSM was noted in 74 (6.5%) cases. Stent retrieval was successful in 94.59% (70/74) of cases. A balloon catheter (46/74) was commonly used. Technical failure was due to an impacted stent (2) and stent above the stricture (2). Complications were seen in 2.7% of cases. On multi-variate regression, sphincteroplasty at index ERCP (Odds ratio [OR] = 5.68, 95% confidence interval [CI] = 2.7–11.89), stent length < 10 cm (OR = 8.53, 95% CI = 3.2–22.47), 7-Fr stent (OR = 18.25, 95% CI = 6.5–50.64), dilated bile duct (mean diameter- 9.2 ± 3.94 mm) (OR = 0.384, 95% CI = 0.18–0.72) and delayed ERCP by > 3 months from index ERCP (OR = 15.28, 95% CI = 8.1–28.49). After performing propensity score matching for age, sex, comorbidities and indication to determine endoscopy-related factors, 7-Fr stent size (OR 3.495; 95% CI-1.23–9.93) and duration of indwelling stent for more than three months (OR-3.37; 95% CI-1.646–6.76) were significantly associated with proximal stent migration. Conclusion: Proximally migrated straight stents can be successfully retrieved using standard accessories. The use of 7-Fr size stent, stents indwelling for more than three months, sphincteroplasty at index ERCP, stent length < 10 cm and dilated bile duct were associated with increased risk of proximal migration of straight biliary plastic stents. After propensity score matching, the use of 7-Fr size stents and stent indwelling for over three months were endoscopy-related factors associated with proximal migration. [ABSTRACT FROM AUTHOR]

Background: Both Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT) have been linked to various prothrombotic (PT) conditions. The PT profile in Asians is different from the west and there are no nationwide epidemiological surveys from India. Hence, the present meta-analysis was aimed at analyzing the prevalence of acquired and hereditary thrombophilia among Indian patients with non-cirrhotic PVT and BCS. Methods: A comprehensive literature search of Embase, Medline and Scopus was conducted from January 2000 to February 2022 for studies evaluating the prevalence of various PT conditions in Indian patients with PVT and BCS. Pooled prevalence rates across studies were expressed with summative statistics. Results: Thirty-five studies with 1005 PVT patients and 1391 BCS patients were included in the meta-analysis. At least one PT condition was seen in 46.2% (28.7–63.7) of the PVT patients and 44.9% (37.3–60.7) of the BCS patients. Multiple PT conditions were seen in 13.0% (4.2–21.8) of the PVT patients and 7.9% (3.5–12.4) of the BCS patients. Among PVT patients, hyperhomocysteinemia was the commonest prothrombotic condition (21.6%) followed by protein C (PC) deficiency (10.7%), Janus kinase 2 (JAK-2) mutation (8.5%) and antiphospholipid antibodies (APLA) (7.5%). Among patients with BCS, PC deficiency was the commonest prothrombotic condition (10.6%) followed by methylenetetrahydrofolate reductase (MTHFR) mutation (9.8%), APLA (9.7%) and JAK-2 mutation (9.1%). Conclusion: The PT profile in Indian patients with abdominal vein thrombosis is different from that of the western data with a lower prevalence of PT conditions in patients with BCS. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound (EUS)–guided tissue acquisition (TA) is widely used for various target samples, but its efficacy in gallbladder (GB) lesions is unknown. The aim of the present meta-analysis was to assess the pooled adequacy, accuracy and safety of EUS-TA of GB lesions. Methods: A literature search from January 2000 to August 2022 was done for studies analyzing the outcome of EUS-guided TA in patients with GB lesions. Pooled event rates were expressed with summative statistics. Results: The pooled rate of sample adequacy for all GB lesions and malignant GB lesions was 97.0% (95% CI: 94.5–99.4) and 96.6% (95% CI: 93.8–99.3), respectively. The pooled sensitivity and specificity for the diagnosis of malignant lesions were 90% (95% CI: 85–94; I2 = 0.0%) and 100% (95% CI: 86–100; I2 = 0.0%), respectively, with an area under the curve of 0.915. EUS-guided TA had a pooled diagnostic accuracy rate of 94.6% (95% CI: 90.5–96.6) for all GB lesions and 94.1% (95% CI: 91.0–97.2) for malignant GB lesions. There were six reported mild adverse events (acute cholecystitis = 1, self-limited bleeding = 2, self-limited episode of pain = 3) with a pooled incidence of 1.8% (95% CI: 0.0–3.8) and none of the patients had serious adverse events. Conclusion: EUS-guided tissue acquisition from GB lesions is a safe technique with high sample adequacy and diagnostic accuracy. EUS-TA can be an alternative when traditional sampling techniques fail or are not feasible. [ABSTRACT FROM AUTHOR]

Introduction: Placement of biliary self-expanding metal stents (SEMS) has been effective for palliation of unresectable hilar malignant biliary obstruction. Optimal drainage in hilar obstruction may require placement of multiple stents. Data on multiple SEMS placement in hilar obstruction from India is sparse. Methods: Retrospective review of patients with unresectable malignant hilar obstruction who underwent endoscopic bilateral SEMS insertion from 2017 to 2021 was done. Demographic details, technical success and functional success (decrease in the bilirubin value below 3 mg/dL at four weeks), immediate complications with 30-days mortality, requirement of re-intervention, stent patency and overall survival were studied. Results: Forty-three patients were included (mean age 54.9 years, 51.2% females). Thirty-six patients (83.7%) had carcinoma gallbladder as primary malignancy. Twenty-six patients (60.5%) were metastatic at presentation. Cholangitis was seen in 4/43 (9.3%). On cholangiogram, 26 (60.4%) had Bismuth type II block, 12 (27.8%) had type IIIA/B, 5 (11.6%) had type IV block. Technical success was achieved in 41/43 (95.3%) patients (38, side-by-side SEMS placement; 3, SEMS-within-SEMS in Y fashion). Functional success was achieved in 39 patients (95.1%). No moderate-severe complications were reported. Median post-procedure hospitalization was five days. Median stent patency was 137 days (interquartile range [IQR] 80–214 days). Re-intervention was required in four patients (9.3%) after mean 295.7 days. Median overall survival was 153 days (IQR 108–234 days). Conclusion: Endoscopic bilateral SEMS in complex malignant hilar obstruction has good outcomes in the form of technical success, functional success and stent patency. Survival is dismal despite optimal biliary drainage. [ABSTRACT FROM AUTHOR]

Background: The present guidelines stratify endoscopic ultrasound-guided tissue acquisition (EUS-TA) as a high-bleeding risk procedure in patients on antithrombotics. However, the data regarding the same are conflicting. Therefore, this meta-analysis aimed to analyze the bleeding event rates associated with EUS-TA in patients receiving antithrombotic therapy. Methods: A literature search from January 2000 to August 2022 was done for studies on EUS-guided TA in patients receiving antithrombotics. The primary outcome was incidence of overall and major bleeding. Pooled event rates across studies were expressed with summative statistics. Results: A total of 12 studies were included in the meta-analysis. The pooled risk of overall bleeding and major bleeding in patients on antithrombotics was 2.0% (0.6–3.4) and 0.8% (0.0–1.6), respectively. In patients taking thienopyridine or anticoagulants, the pooled risk of overall bleeding and major bleeding was 2.4% (0.9–3.9) and 1.7% (0.4–3.1), respectively. Patients on antithrombotics had a higher odd of overall bleeding (OR 2.12, 1.20–3.83) and major bleeding (OR 3.58, 1.11–11.52) compared to controls. The odds of overall bleeding (OR 0.95, 95%CI 0.38–2.42) and major bleeding (OR 1.57, 95%CI 0.45–5.54) were comparable between patients on antithrombotics who continued and those who discontinued it preprocedural. Conclusion: Despite an increase risk of bleeding with EUS-TA in patients on antithrombotics, the pooled incidence remains low. Compared to the previous guidelines stating thienopyridine use as high risk for bleeding, the present analysis showed a bleeding rate of less than 1%. Discontinuing antithrombotics prior to EUS-TA does not reduce the bleeding risk significantly, requiring strict monitoring. [ABSTRACT FROM AUTHOR]

Background: No large studies have addressed the role of endoscopic-ultrasound biliary drainage (EUS-BD) as preoperative biliary drainage (PBD) for malignant extrahepatic biliary obstruction (MEBO). We aimed to discuss the outcomes of EUS antegrade stent placement (EUS-AG) in the preoperative and palliative setting. Methods: Retrospective review of patients who underwent EUS-AG for MEBO between December 2019 and December 2021 was done. Primary outcome measures were technical success and clinical success. Secondary outcome measures were number of days of hospitalization postprocedure, adverse events related to EUS-AG procedure, morbidity related to surgery, and 3-month mortality after surgery. Results: 54 patients underwent attempt for EUS-AG (mean age 54.8 ± 12.1 years; female 44.4%). Most common primary cancer was pancreatic cancer in 42.1% (23/54) patients. Indication was palliative in 34 (62.9%) patients and PBD in 20 (37%) patients. Level of block was distal in 35 (64.8%) and proximal in 19 (35.1%) patients. Technical success of EUS-AG was 88.7% (47/53). Clinical success was seen in 95.7% (45/47) patients. Median number of days of hospitalization postprocedure was 1 day. No procedure-related severe adverse events were seen. Of 20 patients who underwent EUS-AG as PBD, 19 had technical success (95%) with clinical success in 94.5% (18/19). Surgery was performed in 11 patients, of whom 10 patients underwent successful PPPD (one intraoperative liver metastasis). Two patients had Clavein–Dindo III/IV complication post-PPPD, with one mortality within 30 days of surgery. Conclusion: EUS-AG is safe and effective after failed ERCP in both preoperative and palliative setting. [ABSTRACT FROM AUTHOR]

Introduction: Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted. Methods: A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL. Results: A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92–0.98], and 0.92 (95% CI 0.85–0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78–0.90) and 0.90 (95% CI 0.79–0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05–1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35–2.90) but comparable specificity (RR 1.02, 95% CI 0.96–1.08) with MRCP. Conclusion: There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP. [ABSTRACT FROM AUTHOR]

Purpose: Most studies identifying risk factors for post-hepatectomy biliary leaks (PHBLs) have relatively small proportions of major hepatectomies. A simplified predictive score to identify high risk patients is necessary in order to investigate the efficacy of mitigation strategies. Methods: A retrospective analysis of a prospectively maintained database of liver resections from a high-volume cancer center was performed. Multivariate regression was utilized for identification of risk factors and development of the predictive score. Results: A total of 862 patients underwent a curative hepatic resection over 10 years, of whom 146 (16.9%) developed a biliary leak; 85 (9.86%), 52 (6.03%), and 9 (1.04%) patients had a grade A, B, and C leak respectively. A biliary-enteric anastomosis [OR 5.1 (95% CI 2.45–10.58); p < 0.001], a central [OR 4.33 (95% CI 1.25–14.95); p = 0.021] or an extended hepatectomy [OR 4.29 (95% CI 1.52–12.12); p = 0.006], liver steatosis [OR 2.28 (95% CI 1.09–4.77); p = 0.027], and blood loss of ≥ 2000 mL [OR 2.219 (95% CI 1.15–4.27); p = 0.017] were identified as independent predictors of a clinically significant biliary leak and were assigned 1 point each to develop the biliary leak score. Clinically significant biliary leaks were seen in 11 (2.79%), 20 (6.38%), 19 (15.4%), 9 (56.3%), and 1 (100%) patients with scores of 0, 1, 2, 3, and 4 respectively (p < 0.001). Conclusion: A biliary-enteric anastomosis, a central or extended hepatectomy, liver steatosis, and blood loss ≥ 2L combined result in a simple predictive score for clinically significant biliary leaks. [ABSTRACT FROM AUTHOR]

Background: Patients with moderate–severe cholangitis require urgent/early biliary drainage and failed endoscopic retrograde cholangiopancreatography (ERCP) warrants use of percutaneous drainage. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved as an effective salvage modality but its safety and efficacy data in moderate–severe cholangitis are limited. Patients and methods: All consecutive moderate–severe cholangitis patients, with failed/technically non-feasible ERCP requiring EUS-BD in two tertiary care centers were included. Baseline laboratory and demographic parameters were documented. Technical and clinical success were primary outcome measures. Additionally, effective biliary drainage, adverse events due to procedure, hospital stay, ICU stay, and mortality were noted. Results: Of the 49 patients (23 male; 46.9%) presenting with moderate/severe cholangitis, 23 (46.9%) had severe cholangitis. The median Charleston comorbidity index was 7.0 (IQR 2.0). Majority had malignant disease (87.8%) and 25 (51.0%) had inaccessible papilla. Technical success was achieved in 48 cases (98.0%), while clinical success with improvement of cholangitis was noted in 44 of 48 cases (91.7%). Effective biliary drainage was noted in 85.4% (41/48) cases. Adverse events in the form of mostly bleeding and bile leak were noted in 5 cases (10.2%) but managed conservatively. Distal obstruction exhibited significantly better clinical success (100% vs. 78.9%; p = 0.02) than hilar obstruction. Severe cholangitis had significantly lower clinical success (81.8% vs. 100%; p = 0.04) than moderate cholangitis. Conclusion: EUS-BD can be a safe and effective alternative option for patients with moderate to severe cholangitis, even with significant pre-morbid conditions, with acceptable adverse events rate. [ABSTRACT FROM AUTHOR]

Background : Plugged percutaneous liver biopsy, though has been in use for many years, is being used more frequently in patients in whom percutaneous liver biopsy is contraindicated due to proven or probable bleeding tendencies. We report our experience with this procedure, its indications, efficacy, and complications in Indian population over 2 years. Methods: A retrospective study of 127 consecutive patients who had undergone plug liver biopsy from April 2017 to May 2019 was done from the database maintained in our department. The indications, technical success, complications, and impact of histological diagnosis on the management of those patients were evaluated. Results: A total of 127 biopsies were performed of which 68 were males and 59 were females, aged between 7 and 73 years. No procedures were abandoned; however, 13 cases needed ultrasonography (USG) guidance because of small size of the liver or presence of right perihepatic fluid. Out of 127 biopsies, none of the samples was inadequate and yielded adequate tissue for histopathological diagnosis. Seven patients required repeat study only because underlying liver disease was suspected clinically and the previous biopsy report had turned out to be normal. Histopathological examination in our study showed autoimmune hepatitis in 61, cirrhotic changes either hepatitis B virus (HBV) or hepatitis C virus (HCV) related in 40, veno-occlusive disease in 3, cholestatic disease in 2, and Wilson's disease in 2 patients. The remaining 19 were normal. Complications occurred in 3 patients — arterioportal fistula, pneumothorax, and inadequate coiling causing mild hemoperitoneum. Conclusion: Percutaneous liver biopsy followed by plugging of the tract with coils is a safe, easy, and effective method in patients with underlying bleeding tendencies, minimal ascites, and small liver. [ABSTRACT FROM AUTHOR]

Background and aims: Budd Chiari syndrome (BCS) commonly affects adolescents and adults. With improved survival, important quality-of-life parameters such as sexual life and fertility become more relevant. This study was aimed to assess the gonadal function in male patients with BCS and the effect of treatment on gonadal function. Methods: Thirty male patients with newly diagnosed BCS were prospectively assessed for the presence of gonadal dysfunction. Erectile function was assessed using standardized International Index of Erectile Function questionnaire (IIEF). Follicular stimulating hormone (FSH), luteinizing hormone (LH), sex hormone-binding globulin (SHBG), estradiol, total testosterone (TT), calculated free testosterone (cFT), calculated bioavailable testosterone (cBT), sperm count, and sperm motility were compared at baseline and at 6 months of treatment for the assessment of gonadal function. Results: Sixteen (53.3%) out of 30 patients were sexually active at the time of study and 5/16 (31%) had erectile dysfunction. Hypogonadotropic hypogonadism (HH) was the most common pattern seen in 50% cases followed by hypergonadotropic hypogonadism (HyH) in 23% cases. 27% patients had eugonadism. At 6 months of treatment, 60% of patients in HH group became eugonadal as compared to only 14% in HyH group. Proportion of patients with erectile dysfunction reduced (5/16 vs 1/16) after 6 months of therapy. The improvement in sperm count and sperm motility was not significant. Conclusion: Gonadal dysfunction is common in male patients with BCS. HH remains the most common type of hypogonadism BCS and the type which improves significantly after treatment. [ABSTRACT FROM AUTHOR]

Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management. [ABSTRACT FROM AUTHOR]

Thiopurines (azathioprine [AZA] and 6-mercaptopurine [6-MP]) are one of the main therapies for the management of inflammatory bowel disease (IBD), commonly being used as steroid-sparing agents for the maintenance of remission [[1]]. Reply We appreciate the interest expressed by Giri et al. in our recent work evaluating the long-term effectiveness and safety of first-line low-dose azathioprine-allopurinol co-therapy (LDAA) in 166 patients with inflammatory bowel disease (IBD) [[3]]. [Extracted from the article]