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Foreign bodies in common bile duct (CBD) are rare. Obstructive jaundice in patients who have undergone cholecystectomy may be due to a variety of causes. Common causes of obstruction in these cases are residual stones, inflammatory or ischaemic strictures following CBD injury during cholecystectomy or malignant strictures. Foreign bodies in the bile duct in these post cholecystectomy patients are known but reported very rarely. Clinical features and biochemistry of these patients are no different than those due to other causes mentioned above. Imaging studies will show obstruction due to stones or sludge or narrowing but may not give conclusive diagnosis of a foreign body. Endoscopic ultrasound is helpful in these cases as it shows a hyperechoic foreign body within the stone if the substance is a metallic clip. In our current case series, we are presenting eight such cases with post cholecystectomy foreign bodies, in the form of materials used for ligating or clipping the cystic duct before transection during cholecystectomy, or a mistakenly left behind gauze piece, migrating into the bile duct and forming a nidus for stone formation and causing CBD obstruction. To conclude, if a patient presents with biliary obstruction with a history of cholecystectomy, the possibility of foreign body in the CBD must be considered as a possible differential diagnosis.

Background : : Having a clean esophagus is an integral part of the peroral endoscopic myotomy (POEM) procedure for ensuring safety and success. Conventional preparation is a tricky, because there is no defined definite timeline of fasting for the different types of achalasia. The present study introduces a simple yet effective preparation of esophageal clearance. Methods : : All patients who underwent POEM were included. Patients were stratified in novel and conventional preparation groups by a random selection. In the novel preparation, the cases were maintained on lukewarm water and carbonated drink followed by nil per oral (NPO) prior to the procedure. In conventional preparation, the controls were maintained on clear liquid followed by NPO. Success rate of preparation and procedure related outcomes were compared using independent t tests and chi-squared tests. Results : : A total of 150 patients (male 54.0%; mean age 41.2 ± 15.5 years) were included in the study. Known baseline and clinical factors which could affect esophageal clearance were evenly distributed between the two groups. Novel preparation had provided absolute esophageal clearance (97.3%) without the requirement of pre-POEM endoscopic cleaning. Moreover, Novel preparation demonstrates several advantages over the conventional preparation: decreased anesthesia aspiration risk (P < 0.0001), reduced preoperative hospitalization (P < 0.0001), and hospital stays (P < 0.005). Conclusion : : Evidently, the novel preparation is very simple, efficient, safe and appropriate for all types of achalasia. Moreover, novel preparation provides absolute esophageal clearance without requiring prolonged period of liquid diet, fasting and pre-POEM endoscopic cleaning.

Background : : To assess the usefulness of endoscopic pancreatography without contrast agents and efficacy of transpapillary intervention for pancreatic duct (PD) rupture in chronic pancreatitis. Methods : : We retrospectively analyzed all cases of chronic pancreatitis with ductal rupture causing ascites, effusions and pseudocysts. We performed magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde pancreatography (ERP) without contrast. Results : observed based on the possibility of wire crossing the leak or not and their resolutions were noted. Results : : We performed ERP in 1,324 patients. Ductal disruptions in 321/1,324 (24.2%). We divided cases into two groups. Group 1 involves disruptions causing ascites in 60 cases (18.7%) and effusions in 34 cases (10.6%), and group 2 involves pseudocysts in 227 cases (70.7%). In group 1, 82 patients (87.2%) experienced successful cannulation of PD. Leak crossed in 70 (74.5%) with complete resolution in all. Leak did not cross in 12 cases of which 8 (8.5%) installed stents resolved while four (4.3%) did not resolve. In group 2, 219 (96.5%) PD cannulated. Leak did not cross but stents put in cyst (176, 77.5%). Complete resolution occurred without infection. Leaks were crossed in 43 (18.9%); complete resolution, 14 (32.6%). Complete regression was not achieved in 19 (8.3%). Eight cysts were not resolved (3.5%). Transmural drainage was done. Infection was noted in 2 cases (0.9%). Sites of leak in pseudocysts were jenu & body, 167 (73.6%); tail, 60 (26.4%). We recorded pancreas divisum in 24/321 (7.5%). ERP failed in 20 (6.2%). Three were managed medically (1.3%), 5 with distal pancreatectomy (2.2%), 4 with lateral pancreatico jejunostomy (1.8%), and 8 with transmural drainage (3.5%). Conclusion : : PD rupture in chronic pancreatitis can be managed transpapillary, without any contrast during ERP. In majority, endosonography aspiration and transmural drainage are needed only when transpapillary fails. Leak from tail responded better than those from proximal duct with ERP.

The coexistence of an esophageal leiomyoma with an achalasia cardia is extremely rare and poses a diagnostic dilemma as the clinical presentation of an esophageal leiomyoma strongly resembles to an achalasia cardia. Moreover, at most of the time, an esophageal leiomyoma exist with absence of leiomyoma specific symptoms or findings. It could be the reason why the diagnosis of esophageal leiomyoma is missed while the patient has the coexistence of the both. Here, we present a case series of an unusual coexistence of an esophageal leiomyoma with achalasia in three patients who were presented with dysphagia and had an initial diagnosis of achalasia. Even endoscopic evaluation couldn’t reveal esophageal leiomyoma; it became apparent during the peroral endoscopic myotomy.

Background Liver transplantation is the only curative option for patients with decompensated cirrhosis; however, many patients die while awaiting transplantation. Granulocyte colony-stimulating factor (GCSF) has shown promising results in improving outcomes in patients with advanced liver disease. We evaluated the efficacy of GCSF in patients with decompensated cirrhosis in an open-labeled randomized-controlled trial. Methods Consecutive patients with decompensated cirrhosis were randomized to receive either GCSF 300 μg twice daily for 5 days plus standard medical therapy (SMT) (GCSF+SMT group) or SMT alone (SMT alone group). Outcomes were assessed at 6 months from randomization. Results A total of 126 patients [median age: 53 (range: 31-76) years, 85% men] received GCSF+SMT and 127 patients received SMT alone. Baseline characteristics were similar in both the groups. The 5-day GCSF therapy did not lead to any significant adverse effects. At 6 months, in the GCSF+SMT group, 17 patients had died and nine were lost to follow-up, whereas in the SMT-alone group, 30 patients had died and 11 were lost to follow-up. By intention-to-treat analysis, cumulative survival was significantly higher in the GCSF+SMT group (79 vs. 68%; P=0.025). Also, significantly more patients (66%) showed improvement or stability in the Child-Turcotte-Pugh score at 6 months in the GCSF+SMT group compared with the SMT-alone group (51%, P=0.021). Conclusion GCSF therapy improves survival and clinical outcome in patients with decompensated cirrhosis. It may be useful in patients awaiting transplantation to prevent worsening during the waiting period. Further studies are needed to explore whether repeated periodic GCSF courses can further increase the survival and decrease the need for liver transplantation.Clinical trial registered at https://clinicaltrials.gov vide NCT02642003.

Introduction: Chronic Pancreatitis (CP) is a progressive inflammatory disorder characterised by recurrent episodes of severe abdominal pain. Experimental studies demonstrated protective effects of statins in pancreatic fibrosis. Aim: To assess impact of simvastatin therapy on the severity of pain in patients with idiopathic CP or recurrent acute pancreatitis. Materials and Methods: This prospective, single centre and open-label study included patients with idiopathic CP and recurrent acute pancreatitis, depending upon inclusion and exclusion criteria. Patients were treated with either simvastatin (40 mg per day) (Group-A; n=25) or standard therapy (protonpump inhibitor and antioxidant therapy) (Group-B; n=25). Severity of the pain was assessed using a Visual Analogue Score (VAS) at the start of treatment and at 12-month of treatment. Results: Between June 2017 and August 2017, a total of 50 patients, age ranging from 18 years to 54 years, were included in the study. The study population predominantly included male patients (n=38). The intensity of pain in patients of Group-A reduced significantly (p=0.0001) from 8 (range 6-10) at baseline to 2 (range 0-9) after 12 months of the treatment. There was significant reduction in the intensity of pain in Group-B also {7 (range 6-10) at baseline vs. 5 (range 0-7); p=0.0001}. However, the reduction of VAS score was significantly higher in Group-A as compared to Group-B at 12-month follow-up {6 (range-1-8) vs. 3 (range 0-6); p=0.032}. Conclusion: Simvastatin treatment improved severity of pain in patients with CP or recurrent acute pancreatitis at 12-month follow-up. However, large randomised trials are needed to replicate these findings.

Background Non-selective beta-blockers (NSBBs) are recommended for prophylaxis of first variceal bleeding in patients of cirrhosis with large esophageal varices. However, the data is conflicting whether NSBBs can also prevent growth of small esophageal varices to large size. Aim To perform a meta-analysis of the randomized clinical trials comparing NSBBs with placebo for prevention of development of large esophageal varices in patients of cirrhosis with small esophageal varices. Methods The PubMed, EMBASE, Science Direct, and Cochrane library databases were searched for relevant papers. A meta-analysis was performed using risk ratios (RRs) with 95% confidence interval (CI) as the effect sizes. Results Overall, 314 trials were initially retrieved from the database searches, of which five randomized controlled trials were included in the meta-analysis. The incidence of development of large varices (RR = 0.91, 95%CI: 0.29–2.86; P = 0.87) was similar between NSBB and placebo groups. However, the heterogeneity among studies was significant (P Conclusion The results of this meta-analysis indicate that NSBBs are not effective in preventing growth of small varices and may lead to significant adverse effects. Hence, NSBBs should not be recommended for cirrhotic patients with small varices.

Eosinophilic gastrointestinal disorder (EGID) is a spectrum of gastrointestinal disorders with eosinophilic infiltration of gut without any known cause for such tissue eosinophilia. Eosinophilic gastrointestinal disorders can be sub grouped as eosinophilic esophagitis, eosinophilic gastroenteritis, and eosinophilic colitis. The least frequent manifestation of EGIDs is eosinophilic colitis. We present a case of 51-year-old male patient who presented with chronic painless large bowel diarrhea with a rare diagnosis of eosinophilic colitis.