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Background There is limited literature on the role of percutaneous transhepatic biliary drainage (PTBD) as an adjunct to endoscopic retrograde cholangiopancreatography (ERCP). This study evaluates the role of PTBD in patients with failed ERCP or post-ERCP cholangitis. Methods Retrospective evaluation of clinical and intervention records of patients with biliary obstruction referred for PTBD following failed ERCP or post-ERCP cholangitis was performed. The cause of biliary obstruction, baseline serum bilirubin, white blood cell (WBC) count, serum creatinine, and procalcitonin were recorded. Technical success and clinical success (resolution of cholangitis, reduction in bilirubin levels, WBC count, creatinine, and procalcitonin) were assessed. Results Sixty-three patients (35 females, mean age 51.4 years) were included. Indications for ERCP included malignant causes in 47 (74.6%) cases and benign causes in 16 (25.4%) cases. Indications for PTBD were failed ERCP in 21 (33.3%) and post-ERCP cholangitis in 42 (66.7%). PTBD was technically successful in all patients. Clinical success rate was 68.2% in the overall group. Mild hemobilia was noted in five (7.9%) patients. There were no major complications or PTBD related mortality. Cholangitis and acute kidney injury resolved following PTBD in 63.1% and 80% of the patients, respectively. Total serum bilirubin reduced by 47.8% and 69.4% after one week and one month of the PTBD, respectively. The average fall in procalcitonin was 5.17 ng/mL after one week of the PTBD. Conclusion PTBD is an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis.

Inflammatory bowel disease (IBD), once considered a disease of the Western hemisphere, has emerged as a global disease. As the disease prevalence is on a steady rise, management of IBD has come under the spotlight. 5-Aminosalicylates, corticosteroids, immunosuppressive agents and biologics are the backbone of treatment of IBD. With the advent of biologics and small molecules, the need for surgery and hospitalization has decreased. However, economic viability and acceptability is an important determinant of local prescription patterns. Nearly one-third of the patients in West receive biologics as the first/initial therapy. The scenario is different in developing countries where biologics are used only in a small proportion of patients with IBD. Increased risk of reactivation of tuberculosis and high cost of the therapy are limitations to their use. Thiopurines hence become critical for optimal management of patients with IBD in these regions. However, approximately one-third of patients are intolerant or develop adverse effects with their use. This has led to suboptimal use of thiopurines in clinical practice. This review article discusses the clinical aspects of thiopurine use in patients with IBD with the aim of optimizing their use to full therapeutic potential.

The Gallbladder Reporting and Data System (GB-RADS) ultrasound (US) risk stratification is proposed to improve consistency in US interpretations, reporting, and assessment of risk of malignancy in gallbladder wall thickening in non-acute setting. It was developed based on a systematic review of the literature and the consensus of an international multidisciplinary committee comprising expert radiologists, gastroenterologists, gastrointestinal surgeons, surgical oncologists, medical oncologists, and pathologists using modified Delphi method. For risk stratification, the GB-RADS system recommends six categories (GB-RADS 0–5) of gallbladder wall thickening with gradually increasing risk of malignancy. GB-RADS is based on gallbladder wall features on US including symmetry and extent (focal vs. circumferential) of involvement, layered appearance, intramural features (including intramural cysts and echogenic foci), and interface with the liver. GB-RADS represents the first collaborative effort at risk stratifying the gallbladder wall thickening. This concept is in line with the other US-based risk stratification systems which have been shown to increase the accuracy of detection of malignant lesions and improve management. Graphical abstract: [Figure not available: see fulltext.].

Aim of the study This study aimed to evaluate the outcomes of patients with unresectable gallbladder cancer (GBC) with hilar involvement and cholangitis undergoing percutaneous transhepatic biliary drainage (PTBD). Material and methods This retrospective study comprised consecutive patients with unresectable GBC with cholangitis who underwent PTBD. The procedures were categorized as unilateral or bilateral. Bilateral PTBD was classified as simultaneous or sequential. The mean reduction in bilirubin at two weeks was recorded. Complications and mean overall survival were also recorded. Results Thirty-three patients (mean age 54.5 years, 12 males) were included. Thirty patients underwent unilateral drainage. Sequential drainage of the contralateral system was performed in 11 patients. Simultaneous bilateral PTBD was performed in 3 patients. PTBD was technically successful in all patients. Mean reduction in bilirubin was 41.5% in the unilateral group. The fall of bilirubin in the simultaneous bilateral PTBD group was 39%. The mean follow-up duration was 36.5 days. No major complications were encountered. At the last follow-up, 7 patients were alive. The mean overall survival was 34.6 days. Conclusions Patients with unresectable GBC and cholangitis frequently require bilateral drainage. However, prospective studies should be performed to evaluate whether a sequential or simultaneous PTBD should be performed.

Evaluation of a combination of antibiotics as an adjuvant therapy in acute severe ulcerative colitis (ASUC). Patients with ASUC were randomized to either infusions of placebo or intravenous ceftriaxone and metronidazole in addition to standard care. Primary outcome was response on day three according to Oxford���s criteria. Secondary outcome measures included changes in partial Mayo score, CRP levels, fecal calprotectin (day three), and need for second-line therapy, hospital stay, and mortality (day 28). Fifty patients (25 in each group, median age: 33 years, 23 males) were included. The number of patients with fulminant disease in the antibiotic group were 16 (64%) as compared to 7 (28%) in the standard of care group. Complete response on day three was attained by 7 (28%) in the antibiotic and 6 (24%) standard of care group (p = 1.00). Three patients from the antibiotic group underwent colectomy and three received intravenous cyclosporine whereas four patients in the standard of care group received cyclosporine (p = 0.725). There was no significant difference in change in CRP, Partial Mayo score, and fecal calprotectin between the two groups on day three. Combination of intravenous ceftriaxone and metronidazole did not improve outcomes in ASUC. Acronym: AAASUC trial Registration Number: CTRI/2019/03/018196 and NCT03794765

Hepatobiliary disorders are common in pregnancy and pose a management challenge. Minimally invasive interventional radiological (IR) techniques allow safe and effective management of these disorders. However, the available literature is scarce. Radiological interventions in this group of patients mandate a clear understanding of the risks of radiation to the fetus. The IR physician involved in the care of these patients should be aware of the measures to minimize the exposure to ionizing radiation. Additionally, the risk-benefit ratio should be clearly defined in a multidisciplinary discussion involving IR physicians, obstetricians, and gastroenterologists. This review is an effort to address issues related to the application of IR procedures for hepatobiliary disorders in pregnant patients.

BACKGROUND Response to antitubercular therapy (ATT) is often used to differentiate intestinal tuberculosis (ITB) from Crohn's disease. Role of non-invasive biomarkers to predict mucosal response to ATT is unclear. MATERIALS AND METHODS A prospective study to compare faecal calprotectin and serum C-reactive protein (CRP) levels at diagnosis, 2 and 6 months of ATT in patients with suspected ITB started on ATT was done. The patients were eventually divided into two groups: ITB or alternative diagnosis (OTH). Decline of calprotectin and CRP levels was used to compute area under the receiver operating characteristic (AUROC) to predict mucosal healing at 2 months. RESULTS Thirty-seven patients (mean age: 34.95 ± 16.35 years, 23 males) were included and 28 (75.67%) were diagnosed as ITB while nine (24.32%) had alternative diagnosis (OTH). The median faecal calprotectin values of ITB and OTH groups at baseline, 2 months and 6 months were 216 and 282 µg/g (P = 0.466), 43 and 216 µg/g (P = 0.003), and 26 and 213 µg/g (P < 0.001), respectively. The median CRP values at baseline, 2 months and 6 months were 18 and 30 mg/L (P = 0.767), 4.7 and 15 mg/L (P = 0.025), and 3 and 10.85 mg/L (P = 0.068), respectively. The AUROC of percent decline in faecal calprotectin and serum CRP at 2 months for mucosal healing were 0.8287 [95% confidence inteval (CI) 0.6472-1] and 0.6018 (95% CI 0.4079-0.7957), respectively. CONCLUSION Faecal calprotectin can help in assessing response to therapy in suspected ITB patients started on empirical ATT.

Gallbladder (GB) wall thickening is a relatively common finding on imaging. While there are clear recommendations for the management of gallstones, GB wall thickening presents a significant challenge. Despite advances in radiological as well as endoscopic techniques, the ability to characterize GB wall thickening is still limited.This review summarizes the currently available literature on various imaging investigations to characterize GB wall thickening. This review also summarizes the differences between benign and malignant GB wall thickening based on available imaging modalities. Transabdominal ultrasonography is the first-line investigation for evaluation of GB wall thickening. However, further characterization requires additional imaging tests. Magnetic resonance imaging (MRI) with the use of gadolinium and diffusion-weighted sequence is the preferred modality for GB wall characterization.The accurate characterization of GB wall thickening is a challenging task. The available imaging criteria allow differentiation of benign and malignant GB wall thickening with moderate accuracy. The advanced imaging techniques, including contrast enhanced ultrasound, contrast-enhanced endoscopic ultrasound, and shear wave elastography, continue to evolve. There is a need for a well-designed reporting system for GB wall thickening to ensure uniformity of reporting of imaging tests, especially in regions with a high prevalence of GB cancer.

The amount of intra-abdominal fat on CT correlates positively with the severity of acute pancreatitis (AP). The objective of the study was to evaluate a fat-modified CT severity index (FMCTSI) and compare its performance with MCTSI. For this retrospective study, 99 patients with AP who underwent contrast-enhanced CT between 3 and 7 days after pain onset were divided into a training cohort (n = 75) and a validation cohort (n = 24). MCTSI was calculated. The total adipose tissue (TAT), visceral adipose tissue (VAT), and total to visceral fat ratio (TVFR) were computed using semi-automatic software. These parameters were given a score of 1–3. FMCTSI was calculated by adding the fat score to MCTSI. Concordance for diagnosing the severity of AP was assessed. Areas under receiver operating characteristic curves (AUC) for predicting clinical outcomes were compared between FMCTSI and MCTSI. The diagnostic performance of the FMCTSI in the validation cohort was also evaluated. In the training cohort, our proposed FMCTSI performed better than MCTSI for all the outcome parameters. The highest concordance for the severity of AP was achieved for VAT-MCTSI. For all outcome parameters, the highest AUC was seen for TVFR-MCTSI. In the validation cohort, the FMCTSI achieved diagnostic performance similar to the training cohort with the highest AUC for TVFR-MCTSI. FMCTSI is a better CT index than MCTSI for predicting the severity and clinical outcomes of AP. Among the various FMCTSI parameters, TVFR-MCTSI is the best performer.

Percutaneous catheter drainage (PCD) performed pro-actively for collections in acute pancreatitis (AP) is associated with better outcomes. However, there are only a few studies describing this protocol. We aimed to evaluate an aggressive PCD protocol. Consecutive patients with AP who underwent PCD with an aggressive protocol between January 2018 and January 2019 were included. This protocol involved catheter upsizing at a pre-specified interval (every 4–6 days) as well as drainage of all the new collections. The indications and technical details of PCD and clinical outcomes were compared with patients who underwent standard PCD. Out of the 185 patients with AP evaluated during the study period, 110 (59.4%) underwent PCD, all with the aggressive protocol. The historical cohort of standard PCD comprised of 113 patients. There was no significant difference in the indication of PCD and interval from pain onset to PCD between the two groups. The mean number of catheters was significantly higher in the aggressive PCD group (1.86 ± 0.962 vs. 1.44 ± 0.667, p = 0.002). Additional catheters were inserted in 54.2% of patients in aggressive group vs. 36.2% in the standard group (p = 0.006). Length of hospital stay and intensive care unit (ICU) stay were significantly longer in the standard PCD group (34.3 ± 20.14 vs. 27.45 ± 14.2 days, p

Background: In Punjab, esophageal carcinoma has been reported as leading cancer in rural population. Reason for this high incidence of esophageal carcinoma in this region is unknown. The life style of people in Punjab is different from those of other areas in India. Therefore, the risk factors contributing to esophageal carcinoma in Punjab may also be different than the other parts of India. There are no previous studies on risk factors for high incidence of esophageal carcinoma in this region. Use of pesticides is much higher in Punjab state. Also there is no evidence available for association of use of pesticides/fumigants in occurrence of esophageal carcinoma. Hence this study is planned to identify the risk factors, especially the role of chemical toxicity (Pesticides/fumigants/heavy metals) associated with development of esophageal carcinoma among inhibitants of Punjab. Methods: A case-control design will be used to identify potential risk factors associated with development of carcinoma esophagus in Punjab. Cases will be recruited from PGIMER, Chandigarh, Population based cancer registry Mansa, Sangrur, SAS Nagar and Punjab Cancer control cell. For each esophageal cancer case 2 controls will be selected after matching for gender, age and area of residence. A pre designed questionnaire, including demographic characteristics, family cancer history, personal medical history, height, weight, life-style (habits such as smoking, tobacco chewing, alcohol drinking, etc.), dietary habits, fumigants and pesticide usage and practices etc, will be used. Urine samples will be taken for the analysis of pesticide metabolites. Heavy metals analysis will be done in water samples. Oral health will be examined for mucosal changes as well as for oral hygiene. Discussion: This study will results in identification of risk factors for high occurrence of esophagus carcinoma in Punjab, so that measures for early detection, prevention and control of esophagus carcinoma could be initiated.

Objective To evaluate the relationship of mucosa-associated candida (MAC) and disease severity in patients with ulcerative colitis (UC). Methods We prospectively investigated the presence, nature, and quantification of MAC in patients with UC and its relationship with disease severity. Consecutive patients with UC were assessed for clinical, endoscopic, histological features and serum markers of disease severity. All patients underwent mucosal brushing cytology, brushing culture, and biopsy culture for candida growth. MAC was considered present if mucosal biopsy culture grew candida. Candida spp. identification was performed by matrix-assisted laser desorption/ionization. Serum β-D-glucan was measured with a Fungitell assay. Patients with irritable bowel syndrome who had undergone similar investigations were included as controls. Results Ninety-six patients with UC showed evidence of MAC more often than the controls (n = 20) based on biopsy culture (33.3% vs 5.0%, P = 0.011), brush cytology (30.2% vs 5.0%, P = 0.019), and brush culture (36.5% vs 10.0%, P = 0.021). Patients with UC had higher candida colony counts (≥103 CFU/mL) than controls (34.4% vs 5.0%, P = 0.007). Median β-D-glucan values were higher in patients with UC than in controls (103.26 pg/mL vs 66.51 pg/mL, P = 0.011). The UC group with MAC had a higher median total Mayo score, C-reactive protein, fecal calprotectin, β-D-glucan, and histological activity than those without MAC. Conclusions Patients with UC more often show evidence of MAC and a higher candida colony count than controls. The presence of MAC is associated with high disease severity in patients with UC.

Pancreatitis is one of the important medical conditions. Gastrointestinal (GI) complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require a strong clinical suspicion coupled with various imaging features. This review provides an extensive update of the whole spectrum of GI complication of pancreatitis, both acute and chronic, from inflammation, ischemia, and necrosis to obstruction, perforation, and GI fistulae. The focus is on the clinical and imaging features of this less commonly described aspect of pancreatitis., Gastrointestinal complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require strong clinical suspicion coupled with various imaging features.

Background Polymorphisms in thiopurine methyltransferase (TPMT) and Nudix hydrolase-15 (NUDT15) have been implicated as the predominant cause of thiopurine induced leukopenia in the Western countries and East Asia respectively. Exact role of these polymorphisms in South Asian population with inflammatory bowel disease (IBD) is uncertain. Methods We included consecutive patients with IBD who were initiated on thiopurines at a center in North India. The dosage of thiopurines was titrated using regular monitoring of hemogram and liver function tests. Three TPMT polymorphisms (c.238 G > C, c.460 G > A, and c.719A > G) and one NUDT15 polymorphism (c.415 C > T) were assessed. Comparison regarding incidence of leukopenia and maximum tolerated thiopurine dosage was performed between those with wild polymorphism and those with TPMT and NUDT15 polymorphisms, respectively. Results Of the 119 patients (61 males, mean age 36.8 ± 13.5 years), 105 (88.2%) had ulcerative colitis and 14 (11.8%) had Crohn’s disease. Leukopenia was noted in 33 (27.7%), gastrointestinal intolerance in 5 (4.2%) and pancreatitis in 2 (1.6%). TPMT polymorphisms were detected amongst five patients of whom 1 developed leukopenia. NUDT15 polymorphism was noted in 13 patients of whom 7 had leukopenia. The odds of developing leukopenia in TPMT polymorphism were non-significant (0.77, 95% CI:0.0822 to 7.2134, P = 0.819) but were significantly higher in those with NUDT15 polymorphism (3.5933, 1.1041 to 11.6951, P value: = 0.0336). Conclusion NUDT15 polymorphism was more frequent than TPMT polymorphisms and was associated with thiopurine induced leukopenia. However, the tested polymorphisms account for only 24.2% of the risk of thiopurine induced leukopenia.

Hereditary transthyretin (TTR) amyloidosis is a multisystem disorder caused by extracellular amyloid deposition, usually presenting with neurological and cardiovascular involvement. Gastrointestinal involvement, if present, is usually in the form of motility symptoms like diarrhea, constipation, or diarrhea alternating with constipation. Presentations mimicking ulcerative colitis without other system involvement are rare. Here we present a case of a young female from northern India, who presented with blood‐admixed diarrhea without any feature of any other system involvement. She was diagnosed and treated as ulcerative colitis for two years with ambivalent response, although the compliance to therapy was also poor. She was re‐evaluated when she presented with recurrence of symptoms and new onset dysphagia. On evaluation, she was diagnosed as hereditary transthyrtetin related amyloidosis., Amyloidosis can occur as a consequence of inflammatory bowel disease or can mimic inflammatory bowel disease. Hereditary transthyretin (TTR) amyloidosis is hardly ever recognised in the Indian subcontinent. We report a case of TTR amyloidosis occurring in a young Indian girl who also had ulcerative colitis.

Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events. Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded. During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed. PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being

Background and aim Abdominal tuberculosis is an important form of extrapulmonary tuberculosis. Evidence from clinical trials suggests that 6 months of antitubercular therapy (ATT) is sufficient for abdominal tuberculosis. Methods We report real-world experience with 6 months of ATT based on a retrospective analysis of patients with abdominal tuberculosis seen at a large tertiary care hospital in India. Results Of 101 patients, 93 with complete records were included. The mean age was 35.90 ± 14.06 years, and 53 were males (56.98%). A total of 42 patients (45.16%) had intestinal involvement, 24 (25.08%) had peritoneal, 22 (23.65%) had combined involvement, and 5 patients (5.37%) had isolated lymph nodal involvement. Six patients received prolonged ATT. Six patients developed ATT-induced hepatitis. Of 64 patients with intestinal involvement, 45 had stricturing disease (70.3%), of whom 7 (15.5%) required surgery due to refractory symptoms. Overall, there was one death, and eight patients (including one with massive gastrointestinal bleeding) needed surgery. Conclusion Six months of ATT is associated with objective clinical response in most of the patients of abdominal tuberculosis.

Despite the advances in the medical care, tuberculosis (TB) still remains an important health problem. This is particularly relevant to the developing countries as well as the immunocompromised population in the developed world. Multidrug resistance poses another challenge and may be responsible for increasing incidence of TB, to some extent. The respiratory system is the most commonly involved, although any organ system may be affected. Abdominal involvement occurs in 11-12% of the patients with extrapulmonary TB. The clinical features of abdominal TB are nonspecific. Imaging plays an important role in the diagnosis of abdominal TB. Although a few imaging features strongly favour the possibility of TB, abdominal TB is a greater masquerader. In this review, we highlight the entire spectrum of the manifestations of abdominal tuberculosis (excluding the genitourinary involvement) with an emphasis on imaging findings.

Vitamin D plays a key role in gut immunity and maintenance of the mucosal barrier. Vitamin D deficiency (VDD) worsens ulcerative colitis (UC) and its supplementation ameliorates the disease in mouse models. The prevalence and predictors of VDD in UC are not known.Consecutive patients with UC (n = 80) underwent clinical, endoscopic, and histological evaluation to assess the extent, severity using UC disease activity index (UCDAI) score, and duration of illness. An equal number of age and gender-matched healthy adults without any features of inflammatory bowel disease (IBD) living in the same latitude were identified as controls. The serum 25-hydroxy vitamin DThe patients and controls were similar in age and gender (40 ± 11.4 years, 51% male vs. 40 ± 12 years, 51% male; p = 1.000). Median vitamin D levels among patients were lower than the controls (18.1 ng/mL [IQR 14] vs. 32.5 ng/mL [IQR 36]; p 0.001). Patients were more often VDD (56% vs. 40%) or insufficient (34% vs. 9%) and less often sufficient (9% vs. 40%) or optimal (1% vs. 11%), in contrast to controls (p 0.001). Median vitamin D levels were lower in those with UCDAI 6 (15 vs. 21 ng/mL; p = 0.01), having pancolitis (13 vs. 21 ng/mL, p = 0.01), and longer duration of illness 2 years (13.8 vs. 20.8; p = 0.025). Vitamin D levels showed a negative correlation with frequency of stools (rho = - 0.244, p = 0.05), disease duration (rho = - 0.244, p = 0.007) and UCDAI score (r = - 0.348, p = 0.002).VDD is highly prevalent among patients with UC. Patients with longer disease duration, more severe symptoms, and pancolitis are likely to have lower vitamin D levels.

Infra-cardiac tracer activity due to persistent hepatic activity interferes in inferior and infero-septal wall assessment during 99mTc-MIBI SPECT/CT myocardial perfusion scintigraphy (MPS) in evaluation of patients with coronary artery disease. It affects image interpretation with increased study duration. Ursodeoxycholic acid (UDCA) is known to enhance hepatic excretion of bilirubin and bile salts, though its role in enhancing the hepatic tracer clearance in facilitating cardiac imaging is not known. This prospective, randomized double-blind, placebo controlled clinical trial of 120 patients, referred for adenosine stress or viability MPS studies were randomized 1:1 to receive either UDCA or placebo. Outcome was quantitative & qualitative improvement in imaging for better interpretation and to reduce the waiting time for scan. 118 participants (59 ± 11.9 years; 84 men) underwent adenosine stress MPS or viability MPS. Sixty participants had UDCA while 58 had placebo intervention. The study showed significant decrease in liver counts with improved myocardial to liver ratio at 30 and 60 minutes in adenosine stress MPS group, and marginally significant alteration in liver counts at 60 minutes in viability MPS group receiving UDCA, resulting in better images. UDCA intervention in MPS provides early and better image due to faster hepatic tracer clearance.

Background: The relationship between diabetes mellitus and tuberculosis (TB) has received increasing attention, and diabetes may be associated with poor outcomes in pulmonary TB. Clinical relevance of HbA1c measurement in abdominal TB is unknown. Methods: We did a retrospective study of consecutive patients diagnosed with abdominal TB and treated with antitubercular therapy for 6 months. Patients were categorized as those with normal HbA1c (

Purpose Intraabdominal hypertension (IAH) in acute pancreatitis (AP) may reduce tissue perfusion and impair organ function and has been shown to portend poor prognosis. We investigated the computed tomography (CT) findings in patients with AP with IAH. Methods This retrospective study comprised of consecutive patients with AP from June 2016 to June 2018 in whom intraabdominal pressure (IAP) was measured. The patients who underwent a contrast-enhanced CT within 7 days of IAP measurement were included. Using a cutoff of 12 mm Hg for IAP, the patients were divided into IAH and non-IAH groups. Measures of severity and clinical outcome were evaluated. CT parameters were compared between the groups. Results The IAH group comprised of 41 patients, while there were 20 patients in the non-IAH group. The IAH group was characterized by severe disease, increased incidence of organ failure, increased requirement for drainage and surgery, prolonged hospital and intensive care unit stay. The mortality was not significantly different between the two groups. On univariate analysis, the CT features that were found to be significantly different between the two groups were the presence of collection (p = 0.036), the maximum dimension of collection (p = 0.004), volume of collection (p = 0.019), biliary dilatation (p = 0.011), and the presence of moderate-to-severe pleural effusion (p = 0.009). On multivariate analysis, all these parameters except biliary dilatation were found to be statistically significant. Conclusion CT findings in patients with AP may suggest IAH. This can be used as an additional marker for severity of AP.

Background There is an emerging role of fungal dysbiosis in the pathogenesis of inflammatory bowel disease. Prevalence of Candida in patients with active ulcerative colitis (UC) and the effect of fluconazole therapy in reducing disease activity of UC are not known. Patients and methods All consecutive consenting patients with active UC defined as Mayo score ≥3 were evaluated for presence of Candida by stool culture and predictors for presence of Candida were identified. Those who had evidence of Candida in the stool were randomized to receive oral fluconazole 200 mg daily or placebo for 3 weeks along with standard medical therapy. Patients were assessed by clinical, sigmoidoscopy, and laboratory parameters at baseline and at 4 weeks. The primary outcome was clinical and endoscopic response at 4 weeks defined by a 3-point reduction in Mayo score. Secondary outcomes were reduction in fecal calprotectin, histologic response, and adverse events. Results Of the 242 patients with active UC, 68 (28%) patients had Candida in stool culture. Independent predictors for presence of Candida in patients with active UC were partial Mayo score of ≥3 and steroid exposure. Among those with Candida on stool culture (n=68), 61 patients fulfilled eligibility criteria and were randomized to receive fluconazole (n=31) or placebo (n=30). Three-point reduction in Mayo score though was numerically higher in the fluconazole group than the placebo group but was not statistically significant [5 (16.1%) vs. 1 (3.33%); P=0.19]. Postintervention median Mayo score was lower in fluconazole than placebo group [4 (3, 5) vs. 5 (4, 6); P=0.034]. Patients in fluconazole group had more often reduction in fecal calprotectin [26 (83.9%) vs. 11 (36.7%); P=0.001] and histologic scores [23 (74.1%) vs. 10 (33.3%); P=0.001] compared with placebo. All patients were compliant and did not report any serious adverse event. Conclusion Candida colonization is found in 28% of patients with UC. Steroid exposure and active disease were independent predictors for the presence of Candida. There was no statistically significant difference in the number of patients who achieved 3-point reduction in Mayo score between 2 groups. However, clinical, histologic, and calprotectin levels showed significant improvement in fluconazole group.

Dear Editor,We read with keen interest the excellent review by Anikhindi et al. regarding the management strategies for inflammatory bowel disease (IBD) in the COVID era [1]. As suggested by the au...

Background Splenic abscess has been an uncommon entity which is now being encountered more frequently due to increased prevalence of immunodeficiency disorders and chronic illnesses. This study was aimed to audit our experience with splenic abscesses at a tertiary care centre in India highlighting usefulness of an algorithmic approach. Methods Retrospective analysis of data of patients (January 2014 to December 2019) with splenic abscess was done. Data were retrieved for clinical characteristics, radiological findings, organism spectra, abscess characteristics, therapeutic measures and clinical outcome. Results The mean age of the study population (n = 36) was 41.3 ± 19.0 years with 50% males. Comorbidities were identified in 17 (47.2%) patients, with diabetes mellitus being the commonest. Fever and abdominal pain were the most common presenting features. Multiple splenic abscesses were present in 21 (58.3%) patients. Extra-splenic abscesses in liver were seen in five (13.9%) patients while nine (25%) patients had ruptured splenic abscess. Microorganisms were identified in 24 (66.7%) patients, with Salmonella typhi being the commonest (n = 9, 25%) followed by Escherichia coli (n = 7, 19.4%) and Staphylococcus aureus (n = 4, 11.1%). Six patients received only antimicrobials, 24 were managed with percutaneous aspiration or catheter drainage and six required surgery. Five (13.9%) patients died, with highest mortality being seen in those who received only antimicrobial (50%), compared to percutaneous aspiration or catheter drainage (8.3%) and surgery (0%), P = 0.017. Conclusion Using percutaneous aspiration or drainage in conjunction with antibiotics, followed by surgery in non-responder, patients with splenic abscesses can be managed successfully with acceptable mortality.

Introduction The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy. Areas covered This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.

Background Some studies have suggested that targeted combination therapy with antibiotics could improve response in active ulcerative colitis, but similar data is not available in acute severe UC (ASUC). Methods We randomised consecutive patients diagnosed with ASUC ( modified Truelove and Witt’s classification) to receive placebo infusions or combination antibiotics (intravenous ceftriaxone and metronidazole) groups. Response as defined by oxford criteria was used to assess response on day three. We also assessed changes in partial Mayo score, CRP levels and reduction in fecal calprotectin at day three. Also, we assessed the need for second line drug therapy, colectomy, length of hospital stay and mortality by day 28. Results Fifty patients were randomised: 25 in each arm (Median age: 33, IQR 25–45, 23(46%) males). Twenty-two patients had extensive disease, while the median disease duration was 24 months. Sixteen patients (64%)in antibiotic arm responded (complete and partial response) at day three while 18 (72%) in the placebo arm responded. Three patients from the antibiotic group underwent colectomy. Three patients in the antibiotic arm received intravenous cyclosporine, whereas four patients in the placebo group received cyclosporine (p=0.725). There was no significant difference in change in CRP, Partial Mayo and fecal calprotectin between the two groups on day three. Conclusions Combination of intravenous ceftriaxone and metronidazole in patients with ASUC neither improved the day 3 response nor reduced the need for second line therapy.

Background Antegrade approach myotomy is usually performed in peroral endoscopic myotomy (POEM) for achalasia cardia. This study assessed the feasibility of retrograde approach as an alternative. Methods This is a retrospective review of a prospectively maintained database of patients undergoing POEM, comparing the 2 techniques of antegrade myotomy (AM) and retrograde myotomy (RM). AM was performed by the conventional technique of proximal to distal myotomy while RM was from the distal end to proximal. The time required for myotomy, complications, and technical nuances were compared. Results Of the 24 cases of POEM, 6 were done by RM and 18 by AM approach. The baseline characteristics, symptomatology, type of achalasia, and preprocedure Eckardt score were similar between the 2 technique arms. The median myotomy time for AM was 21 minute while for RM was 25 minute (P=0.07). Complication rates were similar.Technical issues during RM included: (1) difficulty in visualizing the depth of myotomy; (2) incomplete myotomy requiring back and forth scope adjustment; (3) need for antegrade movement for completion of myotomy; (4) difficulty visualizing the axis of myotomy; (5) added arm strain during posterior myotomy. Conclusion Our study did not find any additional benefit of RM compared with AM approach for POEM.

BACKGROUND We performed a meta-analysis to determine diagnostic accuracy of Xpert MTB/RIF for diagnosis of abdominal (intestinal or peritoneal) tuberculosis (TB) in various tissues (intestinal, omental/peritoneal tissue or ascitic fluid). METHODS Electronic databases were searched for observational studies on use of Xpert MTB/RIF in ascitic fluid, peritoneal, or omental tissue for diagnosis of peritoneal and intestinal TB. We calculated the pooled sensitivity, specificity and diagnostic odds ratio of Xpert MTB/RIF for diagnosis of peritoneal TB in comparison to composite reference standard (CRS) and culture, and in comparison to CRS for intestinal TB. RESULTS Twenty-five observational studies were included. The pooled sensitivity and specificity as assessed with peritoneal culture from ascites as an Index test was 64% (95% Confidence Interval [C.I.] 49-76%) and 97% (95% C.I., 95-99%) respectively and with peritoneal CRS was 30% (95% C.I., 22-40%) and 100% (95% C.I., 98-100%) respectively. In the intestinal group, the pooled sensitivity and specificity of Xpert MTB/RIF was 23% (95% C.I., 16-32%) and 100% (95% C.I., 52-100%). The AUC of peritoneal culture and intestinal tissue was 0.935 and 0.499. CONCLUSION Xpert MTB/RIF has modest sensitivity for diagnosis of peritoneal and intestinal tuberculosis but has a good specificity. PROSPERO REGISTRATION CRD42020140545.

Autopsy practice has been an invaluable tool to understand the pathobiology of various disease processes. We herein have given the description of a case of malignant extra-hepatic biliary obstruction secondary to a diffuse large B-cell lymphoma. The patient disease could only be adequately characterized at autopsy in the form of exact origin and subtyping of lymphoma. The autopsy revealed certain unattended and exciting, yet significant pathological findings in the form of portal vein thrombosis, neurolymphomatosis, the exact track of the lymphomatous cells from abdominal to thoracic cavity, and the terminal events which led to the patient’s demise. The plausible clinical correlates of these pathological findings have been discussed. This can serve as a useful clue to the clinicians for managing such cases in the future.

To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP). This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated. One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3–267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively. Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics. • Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.

With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker’s while two had epiphrenic diverticulum. The median symptom duration was 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280 days (range 98–330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.

Gallbladder carcinoma (GBC) is among one of the gastrointestinal malignancies with extremely dismal prognosis. This is due to the advanced stage at presentation. Majority of the patients with GBC are not considered candidates for surgery because of the locally advanced disease or metastases. However, with the accumulating evidence regarding the role of neoadjuvant chemotherapy, there is a need to correctly identify a subset of patients with locally advanced GBC who will benefit maximally from neoadjuvant chemotherapy and will be successfully downstaged to receive curative (R0) surgery. In this context, there is a lack of consensus and different groups have resorted to criteria for locally advanced disease eligible for neoadjuvant chemotherapy based on personal or institutional experiences. Imaging plays a critical role in the evaluation of patients with GBC as it helps stratify patients into resectable and unresectable. Imaging also has the potential to identify patients with locally advanced GBC and hence facilitate neoadjuvant chemotherapy and improve outcomes. In this review, we evaluate the various criteria for locally advanced GBC and the role of imaging in this scenario.

Background Liver function derangements have been reported in coronavirus disease (COVID-19), but reported rates are variable. Methods We searched PubMed and Embase with terms COVID and SARS-COV-2 from December 1, 2019 till April 5, 2020. We estimated overall prevalence, stratified prevalence based on severity, estimated risk ratio (RR), and estimated standardized mean difference (SMD) of liver function parameters in severe as compared to non-severe COVID. Random effect method utilizing inverse variance approach was used for pooling the data. Results In all, 128 studies were included. The most frequent abnormalities were hypoalbuminemia [61.27% (48.24–72.87)], elevations of gamma-glutamyl transferase (GGT) [27.94% (18.22–40.27)], alanine aminotransferase (ALT) [23.28% (19.92–27.01)], and aspartate aminotransferase (AST) [23.41% (18.84–28.70)]. Furthermore, the relative risk of these abnormalities was higher in the patients with severe COVID-19 when compared to non-severe disease [Hypoalbuminemia—2.65 (1.38–5.07); GGT—2.31 (1.6–3.33); ALT—1.76 (1.44–2.15); AST—2.30 (1.82–2.90)]. The SMD of hypoalbuminemia, GGT, ALT, and AST elevation in severe as compared to non-severe were − 1.05 (− 1.27 to − 0.83), 0.76 (0.40–1.12), 0.42 (0.27–0.56), and 0.69 (0.52–0.86), respectively. The pooled prevalence and RR of chronic liver disease as a comorbidity was 2.64% (1.73–4) and 1.69 (1.05–2.73) respectively. Conclusion The most frequent abnormality in liver functions was hypoalbuminemia followed by derangements in gamma-glutamyl transferase and aminotransferases, and these abnormalities were more frequent in severe disease. The systematic review was, however, limited by heterogeneity in definitions of severity and liver function derangements. Graphic abstract Graphical depiction of the summary of meta-analytic findings a) pooled prevalence of abnormalities b) Risk ratio of abnormality in severe versus non-severe COVID-19 c) standardized mean difference (SMD) between severe and non-severe group and d) pooled prevalence for parameters based on severity stratification for bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), albumin, globulin and acute hepatic injury (AHI) . Also estimates for overall/total liver disease (TLD) and chronic liver disease (CLD) amongst COVID-19 patients are depicted in a, b, d. For d) In addition to severity stratification, Overall (all studies for a particular estimate) and combined (only those studies which reported severity) estimates are provided. Electronic supplementary material The online version of this article (10.1007/s12072-020-10071-9) contains supplementary material, which is available to authorized users.

The existing CT indices do not allow quantitative prediction of clinical outcomes in acute pancreatitis (AP). The aim of this study was to develop and validate a revised CT index using a nomogram-based approach. This retrospective study comprised consecutive patients with AP who underwent contrast-enhanced CT between June 2017 and March 2019. 123 CT scans were randomly divided into training (n = 103) and validation groups (n = 20). Two radiologists analyzed CT scans for findings described in modified CT severity index and additional exploratory items (13 items). Seven items (pancreatic necrosis, number of collections, size of collections, ascites, pleural effusion, celiac artery involvement, and liver steatosis) found to be statistically significant were used for development of index. Synthetic minority oversampling technique (SMOTE) was employed to balance representation of minority classes and hence this index was named “SMOTE Application for Reading CT in AcuTe Pancreatitis (SMART-CT index)”. Binomial logistic regression was used for development of prediction algorithm. Nomograms were then created and validated for each outcome. The new CT index had area under the curve (AUC) of 0.79 [95% CI 0.65–0.93], 0.66 (95% CI 0.54–0.77), 0.75 (95% CI 0.65–0.85), 0.83 (95% CI 0.69–0.96), 0.70 (95% CI 0.60–0.81), and 0.64 (95% CI 0.53–0.75) for mortality, intensive care unit (ICU) stay, length of hospitalization, length of ICU stay, number of admissions, and severity, respectively. The AUC of validation cohort was comparable to the training cohort. The novel nomogram-based index predicts occurrence of clinical outcome with moderate accuracy.

Gallbladder (GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma (GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities (conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.

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.

Ileocecal thickening (ICT) on imaging could result from diverse etiologies but may also be clinically insignificant. Evaluation of role of combined 2-deoxy-2-fluorine-18-fluoro-d-glucose(18F-FDG)-positron emission tomography and computed tomographic enterography (PET–CTE) for determination of clinical significance of suspected ICT. This prospective study enrolled consecutive patients with suspected ICT on ultrasound. Patients were evaluated with PET–CTE and colonoscopy. The patients were divided into: Group A (clinically significant diagnosis) or Group B (clinically insignificant diagnosis) and compared for various clinical and radiological findings. The two groups were compared for maximum standardized uptake values of terminal ileum, ileo-cecal valve, cecum and overall. Of 34 patients included (23 males, mean age: 40.44 ± 15.40 years), 12 (35.3%) had intestinal tuberculosis, 11 (32.4%) Crohn’s disease, 3 (8.8%) other infections, 1 (2.9%) malignancy, 4 (11.8%) non-specific terminal ileitis while 3 (8.8%) had normal colonoscopy and histology. The maximum standardized uptake value of the ileocecal area overall (SUVmax-ICT-overall) was significantly higher in Group A (7.16 ± 4.38) when compared to Group B (3.62 ± 9.50, P = 0.003). A cut-off of 4.50 for SUVmax-ICT-overall had a sensitivity of 70.37% and a specificity of 100% for prediction of clinically significant diagnosis. Using decision tree model, the SUVmax-ICT with a cut-off of 4.75 was considered appropriate for initial decision followed by the presence of mural thickening in the next node. PET–CTE can help in discrimination of clinically significant and insignificant diagnosis. It may help guide the need for colonoscopy in patients suspected to have ICT on CT.

Objective: To evaluate the sensitivity, specificity, and diagnostic odds ratio (DOR) of Doppler ultrasound, CT, and MRI in the diagnosis of Budd Chiari syndrome (BCS). Methods: We performed a literature search in PubMed, Embase, and Scopus to identify articles reporting the diagnostic accuracy of Doppler ultrasound, CT, and MRI (either alone or in combination) for BCS using catheter venography or surgery as the reference standard. The quality of the included articles was assessed by using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results: 11 studies were found eligible for inclusion. Pooled sensitivities and specificities of Doppler ultrasound were 89% [95% confidence interval (CI), 81–94%, I2 = 24.7%] and 68% (95% CI, 3–99%, I2 = 95.2%), respectively. Regarding CT, the pooled sensitivities and specificities were 89% (95% CI, 77–95%, I2 = 78.6%) and 72% (95% CI, 21–96%, I2 = 91.4%), respectively. The pooled sensitivities and specificities of MRI were 93% (95% CI, 89–96%, I2 = 10.6%) and 55% (95% CI, 5–96%, I2 = 87.6%), respectively. The pooled DOR for Doppler ultrasound, CT, and MRI were 10.19 (95% CI: 1.5, 69.2), 14.57 (95% CI: 1.13, 187.37), and 20.42 (95% CI: 1.78, 234.65), respectively. The higher DOR of MRI than that of Doppler ultrasound and CT shows the better discriminatory power. The area under the curve for MRI was 90.8% compared with 88.4% for CT and 86.6% for Doppler ultrasound. Conclusion: Doppler ultrasound, CT and MRI had high overall diagnostic accuracy for diagnosis of BCS, but substantial heterogeneity was found. Prospective studies are needed to investigate diagnostic performance of these imaging modalities. Advances in knowledge: MRI and CT have the highest meta-analytic sensitivity and specificity, respectively for the diagnosis of BCS. Also, MRI has the highest area under curve for the diagnosis of BCS.

Background Doppler is the screening modality of choice for assessment of patients suspected of Budd Chiari syndrome (BCS). The aim of this study was to compare the diagnostic value of contrast enhanced ultrasound (CEUS) with Doppler in the initial evaluation of patients with BCS. Methods This was a retrospective study of patients with suspicion of BCS who underwent CEUS of the hepatic veins and inferior vena cava between July 2017 and April 2019. CEUS was performed using Sonovue. All patients underwent Doppler evaluation of the hepatic veins and inferior vena cava. The final diagnosis of BCS was based on transvenous or percutaneous digital subtraction venography. The diagnostic accuracy of CEUS was compared with Doppler. Results A total of 19 patients (median age, 30 years; 11 males) were evaluated with CEUS and Doppler. A final diagnosis of BCS was established on digital subtraction venography in 15 patients. CEUS was found to have a 100% sensitivity and 75% specificity. The sensitivity and specificity of Doppler was 100% and 25%. The diagnostic accuracies of CEUS and Doppler were 94.74% and 84.29%, respectively. Conclusion CEUS is a useful adjunct to the Doppler in the initial assessment of patients with BCS. However, further prospective studies must confirm our preliminary observations.

Objective: To compare risk of hepatotoxicity between various regimens for reintroduction of antitubercular therapy (ATT) in patients with previous episode of ATT hepatitis. Methods: We searched various databases (PubMed, Embase, CENTRAL, Scopus, WoS and LILACS) for studies comparing ATT reintroduction regimens using terms ‘drug-induced liver injury’ and ‘antitubercular drugs’ AND ‘reintroduction’. The reintroduction regimens i.e concomitant (all drugs introduced together), sequential (reintroduction of one drug in full dose followed by another) or incremental (one drug in a low dose and then higher dose followed by next drug) were compared using Bayesian approach for network meta-analysis with random-effect model. Cochrane revised tool was used to assess risk of bias in included studies (RoB 2.0). Results: Four randomized studies with 577 patients were eligible for analysis. Compared with concomitant regimen (baseline comparator), incremental regimen appeared to have lower risk of ATT hepatitis (odds ratio [OR] 0.24; 95% CrI 0.017, 1.2) as also the sequential regimen (OR 0.33; 95% CrI 0.033, 1.7). Rifampicin first and isoniazid first reintroduction regimens were similar via-a-vis recurrence of hepatotoxicity. Conclusion: The sequential and incremental regimen may be better than concomitant regimen in reducing risk of ATT hepatitis although the odds did not achieve statistical significance.

Background and Aim Clinical significance of ileocecal thickening on computed tomography (CT) is uncertain. We conducted this prospective study to determine the clinical relevance of ileal and/or cecal thickening on CT. Methods All patients with ileocecal thickening on CT were prospectively evaluated with ileocolonoscopy, biopsy, and other relevant investigations. Results Fifty patients (29 males, mean age 36.8 ± 13.21 years) were studied. Thirty nine (78%) patients presented with abdominal pain. On CT, 46 (92%) had a thickened wall of terminal ileum, 25 (50%) cecum, and 21 (42%) of both cecum and ileum. The mean wall thickness of ileum and cecum on CT was 7.23 + 3.2 mm and 5.5 + 3.1 mm, respectively. Final diagnosis was tuberculosis in 24 (48%) patients, Crohn's disease (CD) in 10 (20%), and adenocarcinoma in 1 patient. Colonoscopy demonstrated abnormal findings in 41 patients (82% patients with mucosal ulcerations being most common (n = 20 (40%). Of 15 (30%) patients with ileocecal bowel wall thickening, 4 (8%) patients had normal colonoscopy and histopathology (incidental ileocecal wall thickening), and in the remaining 11 patients, histopathology showed non-specific findings and these patients were asymptomatic without any specific treatment on last follow up ranging from 3 to 24 months. Involvement of cecum with ileocecal junction, ascending colon involvement, peri-ileocecal stranding, and long-segment stricture was significantly more common in patients with underlying disease as compared to nondiseased patients (P < 0.05). Conclusion A majority of patients with ileocecal wall thickening on CT have an underlying disease and should be further investigated by ileocolonoscopy and biopsy.

Thickened gastric folds (TGF) are not an uncommon finding on radiological imaging or endoscopy. It is an enigmatic condition requiring a systematic approach with correlation between clinical, laboratory, radiological, endoscopic, and histological parameters to reach a final diagnosis. It has a varied number of differential diagnosis and reaching the final diagnosis is often challenging even to an astute clinician. Findings on endoscopy are similar and biopsy results often equivocal. Differentiating between benign and malignant conditions is challenging. Routine pinch biopsy usually does not sample deep enough to get an adequate tissue sample, and other methods of biopsy may be required. Newer modalities, such as endoscopic ultrasound (EUS) and EUS‑guided sampling, are helpful in differentiating benign from malignant causes. At times, exploratory laparotomy and full‑thickness biopsy may be required for final diagnosis. In this review, we discuss the various differentials of TGF, with special emphasis on how to approach a case of TGF.

Chylous ascites is an uncommon entity and infectious etiology is the most common cause in developing countries. However, recently, whether there is any change in trend of etiologies in developing countries is not known. In this study, a retrospective analysis of the data of cases of atraumatic chylous ascites was conducted. Twelve patients of atraumatic chylous ascites with a mean age of 35 years were studied and 6 of them were males. The mean duration of symptoms was 9.6 months and the clinical presentation was abdominal distension (12 cases), pain abdomen (10 cases), loss of appetite and weight (9 cases), peripheral lymphadenopathy (4 cases) and fever (3 cases). Etiologies were tuberculosis (3 cases), malignancy (2 cases), radiotherapy related (2 cases), pancreatitis related (2 cases), lymphatic malformation (2 cases) and multifactorial (1 case). Eight improved with conservative measures, 2 were lost to follow up and 2 died. Our outcomes found infectious etiology still as the most common cause of atraumatic chylous ascites. Benign treatable causes could be managed successfully with conservative measures while malignant etiology had a poor prognosis. Underlying etiology determines the outcome in atraumatic chylous ascites.

Background Literature on the diagnosis of abdominal cocoon using computed tomography (CT) outside the setting of continuous ambulatory peritoneal dialysis is sparse. Methods We did a retrospective analysis of contrast enhanced CT done for patients treated for abdominal cocoon. The clinical features, radiological findings, underlying etiology and outcomes were recorded. Results Of the 22 patients analyzed, 19 had tuberculosis, 2 had malignancy and 1 was idiopathic. The basis of diagnosis of cocoon was CT in 18 and CT and surgery in 4. Types 1, 2 and 3 cocoon were found in 3 (13.63%), 6 (27.27%) and 13 (59.09%) respectively. The bowel findings were clumped loops in 21 (95%), inter-bowel fluid in 13 (59%), bowel wall thickening/enhancement in 6 (27%) and stricture in 1 (5%). Peritoneal thickening and nodularity were seen in 14 (64%) and 2 (9%) while omental thickening, nodularity and mass in 9 (41%), 5 (21%) and 1 (5%). Cauliflower sign was seen in 14 (64%), concertina pattern in 5 (23%) and Bottle Gourd sign in 6 (23%) patients. Of 12 with imaging done during episode of IO, 11 (92%) had cauliflower sign, 4 (80%) had concertina appearance and 6 (100%) had bottle gourd sign. Post treatment weight gain with anti-tubercular therapy was seen in 14 (63.63%), resolution of ascites in 12 (54.54%) and 2 patients had complete resolution of cocoon on repeat imaging. Conclusion CT is a valuable tool for pre-operative diagnosis of abdominal cocoon. The classical described signs are seen more frequently in patients with IO.

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.

Thrombotic Thrombocytopenic Purpura (TTP) is a poorly understood entity involving multiple organs and having grave prognosis if not treated promptly. Acute pancreatitis (AP) is a rare cause of TTP and TTP is also a rare complication of acute pancreatitis. TTP is induced in AP by poorly understood mechanism, which involves multiple pathways apart from only ADAMTS13 deficiency. Here, we report a case of a 32-year-old male who developed acute pancreatitis due to chronic alcoholism. He developed signs of TTP from Day 4 of his onset of pain. High clinical suspicion and prompt initiation of plasmapheresis was associated with good outcome. In this case report, we have discussed details of our case and the different mechanisms involved in pathogenesis of TTP in AP and their outcome with prompt management.