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Aims and Objective Mortality by gastric variceal bleeding can reach up to 30%. Gastric varices can be treated by either direct endoscopic glue or endoscopic ultrasound (EUS) coiling + glue injection. Now, enough data show that EUS coil + glue is an effective option for large varices. However, it is a costlier option than direct endoscopic glue injection. In our study, after putting the coil under EUS guidance, direct endoscopic glue injection is done with a 21G sclerotherapy needle. Since the EUS needle was not used for the glue injection, it can be reused for up to three cases for deployment of the EUS coil, hence reducing the cost of the whole procedure. In short, our study aims to find the safety and efficacy of a cost-effective method of EUS coiling + glue injection in a cohort of the Indian population.

Aim and Objective Endoscopic ultrasound-guided liver biopsy (EUS-LB) is now increasingly being used across the globe as a method of liver tissue acquisition. This method is widely accepted by many professionals as it can overcome many shortcomings of percutaneous liver biopsy and transjugular liver biopsy. The aim of the study is to obtain the adequate and optimal biopsy rate associated with EUS-LB.

Abstract The relationship between ammonia and liver-related complications (LRCs) in acute-on-chronic liver failure (ACLF) patients is not clearly established. This study aimed to evaluate the association between ammonia levels and LRCs in patients with ACLF. The study also evaluated the ability of ammonia in predicting mortality and progression of LRCs. The study prospectively recruited ACLF patients based on the APASL definition from the ACLF Research Consortium (AARC) from 2009 to 2019. LRCs were a composite endpoint of bacterial infection, overt hepatic encephalopathy (HE), and ascites. A total of 3871 cases were screened. Of these, 701 ACLF patients were enrolled. Patients with LRCs had significantly higher ammonia levels than those without. Ammonia was significantly higher in patients with overt HE and ascites, but not in those with bacterial infection. Multivariate analysis found that ammonia was associated with LRCs. Additionally, baseline arterial ammonia was an independent predictor of 30-day mortality, but it was not associated with the development of new LRCs within 30 days. In summary, baseline arterial ammonia levels are associated with 30-day mortality and LRCs, mainly overt HE and ascites in ACLF patients.

Background and Objectives: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a minimally invasive and reliable non-surgical technique for the diagnosis of gastrointestinal lesions. The present study aimed to evaluate the spectrum of lesions encountered in the gastric subepithelium on EUS-FNA at a tertiary care center. Materials and Methods: Archival data of all patients undergoing EUS-FNA for gastric submucosal lesions over a period of 5 years was retrieved. Patient demographics, clinical presentation, and EUS findings were recorded along with the FNA results. Results: A total of 78 EUS-FNA samples were analyzed. Material was adequate in 62 cases (79.48%) and inadequate in 16 cases (12.82%) patients due to scant cellularity. Of the adequate samples, 34 (43.5%) were reported as neoplastic while 20 (25.64%) were non-neoplastic, and 8 (10.25%) were reported as suspicious of a neoplasm. In the neoplastic category, the predominant diagnosis was of spindle cell neoplasm comprising gastrointestinal stromal tumor (13), benign neural tumor (03), leiomyoma (02), and spindle cell tumors (03). The latter could not be categorized further due to a lack of IHC material. The next common diagnosis was adenocarcinoma (06) followed by neuroendocrine tumor (02) and poorly differentiated carcinoma (01). The non-neoplastic lesions included non-specific pathology (15), inflammatory lesions (08), and one case each of tuberculosis, pancreatic rest, and Brunner gland hamartoma. Cell blocks for ancillary testing were available in 54 cases (65.23%) and follow-up was available in 42 cases (53.84%). Conclusion: EUS-FNA is a good modality for the diagnosis of gastric submucosal lesions with a high diagnostic yield.

Background and Aims Impacted stones in the bile duct are difficult to extract, and are predictor of failure of conventional endoscopic retrograde cholangiopancreatography techniques including mechanical lithotripsy and large balloon dilatation. Intracorporeal lithotripsy may be an effective technique for these stones. The aim of this study is to report the efficacy and safety of intracorporeal laser lithotripsy for impacted stones in the bile duct. Method This study is retrospective analysis of prospectively collected data. Patients with impacted stones in the bile duct underwent cholangioscopy with spyglass DS system and laser lithotripsy. Outcome measures were proportion of patients with complete clearance of bile duct after the first session, number of sessions required for complete clearance, and the complications. Results Forty-three patients (27 female) with mean age of 56.12 ± 15.16 years underwent digital cholangioscopy and laser lithotripsy. Mean bilirubin value was 1.8 ± 1.6 mg/dL, 20 (46.51%) patients had single stone, 35(81.39%) patients had only bile duct stones, and 8(18.61%) patients had additional stones in cystic duct or intrahepatic biliary radical. Mean size of largest stone was 16.2 ± 4.4mm. Average duration of the procedure was 69.11 ± 28.12minutes, and complete clearance was achieved in 41/43 (95.34%) patients after the first session. Mean number of sessions required for complete clearance was 1.02 ± .26. Postprocedure cholangitis occurred in one patient. Conclusion Intracorporeal laser lithotripsy is an effective and safe modality for the clearance of impacted bile duct stones.

Background and Aims External pancreatic fistula occurring in the setting of disconnected pancreatic duct syndrome leads to significant morbidity, often requiring surgery. The aim of this study is to report a new technique of endoscopic ultrasound (EUS)-guided rendezvous and tractogastrostomy in patients with disconnected pancreatic duct syndrome and external pancreatic fistula. Methods This study is retrospective analysis of the data of the patients with external pancreatic fistula who had undergone EUS-guided rendezvous and tractogastrostomy. Internalization of pancreatic secretions was performed by placing a stent between tract and the stomach. Technical success was defined as placement of stent between the tract and the stomach. Clinical success was defined as removal of external catheter and absence of peripancreatic fluid collection, ascites or external fistula at 3 months after the tractogastrostomy. Results Four patients, all male, with median age of 33.5 years (range: 29–45), underwent EUS-guided tractogastrostomy. Technical and clinical success was 100%, without any procedure related complication. External catheter could be removed in all the patients. During the median follow-up of 10.5 months (range: 8–12), two patients had stent migration and peripancreatic fluid collection, which were managed by EUS-guided internal drainage. Conclusions EUS-guided rendezvous and tractogastrostomy are a safe and effective technique for the treatment of external pancreatic fistula.

Background A variation in the measurement of ABO antibody titer has been seen among different laboratories due to lack of standardization. In our study, we aim to evaluate automated ABO isoagglutinin titer measurements by erythrocytes magnetized technology (EMT) and compare with conventional tube technique (TT). Methods We performed ABO isoagglutinin titration on samples received in a reference laboratory during a period of 2 months. A total of 134 tests for immunoglobulin G (IgG) titer and 116 for immunoglobulin M (IgM) for anti-A or anti-B were included in the study. Samples were processed for ABO isoagglutination titers by both TT and EMT by QWALYS-3 (DIAGAST, France). Microsoft Excel was used to compile data, for all calculations, and to draw graphs and plots. The number and percentage of cases within ±1, ±2, or ±3 titer difference (TT-EMT) were calculated. Results Median titers and their ranges obtained by EMT were higher or equal to those by TT for all IgM and IgG ABO-antibodies in all blood group (BGs), except anti-A IgM in (BG) O that was lower by EMT (32 [4:128]) than TT (48 [8:256]). One twenty one (121/134, 90.3%) cases of IgG titer showed an agreement by both methods (within ± one titer difference). One hundred seven cases (107/116, 92.2%) for IgM titer were within one titer difference by both the methods. Conclusion Results of titration by EMT-based automated instrument QWALYS-3 and conventional TT may vary by one titer dilution in the majority of cases. Use of consistent method for patient management is, therefore, advised.

Hepatocellular carcinoma (HCC) is the eighth-most frequent cause of cancer mortality in India. The staging system most often used for treatment decisions in India is the Barcelona clinic liver cancer (BCLC) system. However, this staging system is often criticised for several reasons, such as heterogeneity of patient prognosis in each BCLC stage, limited guidance on expanding the role of liver transplantation (LT), no recommendation on combination therapies, no guidance on downstaging and limited treatment options for late presenters (stages C or D). Hence, we propose a simplified five-step algorithm for making treatment decisions for HCC patients in India. This algorithm incorporates evidence-based treatment allocations based on the step-by-step assessment of major prognostic and treatment-related parameters. The five steps of the algorithm are – Step 1: assessment of performance status, Step 2: assessment of extrahepatic spread and macrovascular invasion, Step 3: assessment for living donor LT, Step 4: assessment for the eligibility of liver resection and Step 5: assessment for appropriate locoregional therapy. Each of these steps does not require any separate investigations, and the initial workup for the diagnosis of HCC (dynamic computed tomography/magnetic resonance imaging and routine laboratory tests) would suffice in this five-step algorithm. We hope that this algorithm will not only simplify the management approach to HCC patients in India, but also it will bring uniformity in the treatment protocol for HCC in India.

Introduction With the advancements in diagnostic and therapeutic upper gastrointestinal endoscopy (UGIE), clear mucosal visualization is essential to ensure optimal outcomes. Though routinely followed in Japan and Korea, pre-endoscopic preparation is seldom used in India. We evaluated the efficacy of a pre-endoscopic drink of N-acetylcysteine (NAC) and simethicone in improving mucosal visibility during UGIE. Patients and Methods This study was a retrospective, investigator blind study with a case–control study design. Cases included patients who received a pre-endoscopy drink of NAC and simethicone in 100 mL water administered 10 to 30 minutes prior to UGIE. Controls only had mandatory fasting for 6 to 8 hours prior to UGIE. Propensity score matching was done to ensure comparability between the groups. Digital images were taken at six standard landmarks during UGIE and stored. A blinded investigator subsequently analyzed the images and rated the mucosal visibility on a 3-point scale. The difference in the mean mucosal visibility between the cases and controls was compared. Results Mean mucosal visibility during UGIE was significantly better using NAC with simethicone as compared with no preparation at esophagus (1.14 [0.37] vs. 1.47 [0.62], p < 0.05), gastric fundus (1.10 [0.30] vs. 1.55 [0.64], p < 0.05), gastric body (1.22 [0.50] vs. 1.62 [0.73], p < 0.05), gastric antrum (1.13 [0.37] vs. 1.47 [0.62], p < 0.05), and duodenal bulb (1.13 [0.34] vs. 1.33 [0.56], p < 0.05). In distal duodenum, though visibility improved with NAC with simethicone, the difference was insignificant. There were no adverse events related to the pre-endoscopy drink. Conclusion A pre-endoscopy drink of NAC with simethicone can significantly improve mucosal visibility during UGIE. It is safe, cheap, easily available and maybe considered for routine utilization for ensuring optimal endoscopic outcomes.

INTRODUCTION: Basophilia can help stratify cases of chronic myeloid leukemia (CML) into different phases and monitor response to therapy and has a significant prognostic value. It helps differentiate patients of CML from those with leukemoid reaction. Basophil counts (BCs) given by automated hematology analyzers are often not reliable. Analysis of peripheral blood picture therefore holds its importance in these cases. In this study, we aim to compare the BC in patients with suspected CML using two automated analyzers with manual microscopy. MATERIALS AND METHODS: Two hundred and sixty-nine ethylenediaminetetraacetic acid samples identified as suspected CML run on Beckman Coulter UniCel DxH 800 and Sysmex XN-1000 were analyzed for BC microscopically on Giemsa-stained peripheral smear slides by two pathologists. The mean of basophil counts obtained microscopically was considered to be standard. They were compared with BC given by automated counters using correlation analysis and Bland Altman plots. RESULTS: The age of the patients ranged from 4 to 89 years, with a male-to-female ratio of 1.2:1 (148 males; 121 females). BC obtained among both analyzers did not correlate (r2 = 0.14). Results of microscopically counted basophils correlated well among two pathologists (r2 = 0.92). Bland–Altman plots showed a mean bias of 2.2% and 2.4% by XN-1000 and DxH 800, respectively, when compared with manual counts. In the frequency distribution analysis, XN-1000 missed all 10 cases with BC >20% whereas DxH 800 missed 3/10 cases with BC >20%. In addition, in the 10%–20% range of BC, XN-1000 identified 6/22 cases whereas DxH 800 identified 12/22 cases. In the 5%–10% range of BC, XN-1000 identified 59/78 cases whereas DxH 800 identified only 43/78 cases. CONCLUSION: With lower BC, Sysmex XN-1000 and, at higher BC, Beckman Coulter DxH 800 showed better performance. However, BC from none of the analyzers can be used alone without consideration of the microscopic results. All smears should be manually counted for basophils in cases of suspected CML because of its importance in clinical management.

Objectives To investigate the association between coagulation parameters and severity of anaemia (moderate anaemia: haemoglobin (Hb) 7–9.9 g/dL and severe anaemia: Hb

A case of multifocal non-Hodgkin's (Diffuse large B cell type) lymphoma of colon in a patient with ulcerative colitis is described. The patient was a 69-year old male treated with azathioprine and methotrexate for ulcerative colitis for 2 years. He was admitted with loose stools and hematochezia. Colonoscopy revealed two deep ulcers in ascending colon and a large ulcer in rectum. Biopsy from both the sites revealed atypical large lymphoid cells, which were CD20 positive. A whole body PET-CT scan showed disease localized to colon with bone marrow examination showing no evidence of lymphoma. The patient was given chemotherapy cycles and recovered well.

Coronavirus disease 2019 (COVID-19) is a new infectious disease that has spread rapidly throughout the world. The disease is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the Coronaviridae family. Though the pulmonary involvement is a major cause of morbidity and mortality, involvement of the gastrointestinal tract, liver, and pancreas has been explained in these patients. The literature is rapidly changing because of influx of new information with every passage of time. The most common hepatic presentation is mild elevation of aspartate transaminase and alanine transaminase, which does not require specific treatment. Occasionally, patients can have severe liver injury. Because of underlying predisposing factors such as diabetes mellitus, hypertension, and obesity, patients with nonalcoholic liver disease may be at risk of severe disease. Patients with decompensated liver disease may also be vulnerable to severe disease. Behavior of SARS-CoV-2 in patients with chronic hepatitis B and C, autoimmune hepatitis, primary sclerosing cholangitis, and primary biliary cirrhosis is yet to be seen. The prevalence and severity of COVID-19 patients with the aforementioned diseases may be different. The effect of SARS-CoV-2 on an underlying liver disease is not known. COVID-19 may complicate the peritransplant period and throw new challenges in these patients. Drugs used to treat severe COVID-19 may cause liver injury and may have an effect on the underlying disease activity. Both hepatic and pancreatic involvement is related to the severity of COVID-19 disease. Serum amylase and lipase levels may be elevated in patients with severe COVID-19 disease. The involvement of pancreatic islet cells may lead to deranged blood sugar levels and potentially predispose to future diabetes mellitus. There are many unknown facts that will unfold with the passage of time.

Lateral duodenal wall perforation occurring during endoscopic retrograde cholangiopancreatography (ERCP) due to scope trauma is large and usually treated by surgery. With advances in endoscopic instrumentation, interest in treating these complications using endoscopic devices has increased. Over-the-scope clip (OTSC) which has higher compression force and can approximate large perforations is being increasingly used for the closure of gastrointestinal fistulae and perforations. We recently used OTSC for treating duodenal perforations which occurred during ERCP in two elderly patients. Both these patients had comorbid conditions and were high risk for surgery. Perforations were immediately identified during endoscopy and were closed with OTSC. Both patients had uneventful further course and were discharged successfully. These cases highlight the usefulness of OTSC for the management of endoscopic duodenal perforations.

Self expandable metal stent (SEMS) are widely used in patients with gastric outlet obstruction. Stent migration can occur in these patients, and is an important issue, which needs to be addressed. We used a novel technique for prevention of migration of gastric stent in an 80 year old female. Patient presented with recurrent vomiting due to gastric outlet obstruction by a growth in the antrum. SEMS was placed for palliation of symptoms. A nylon thread multiloop and through the scope clips were used to fix the SEMS with the gastric wall. The technique was used successfully to prevent the migration of SEMS.

Severe alcoholic hepatitis has very high short term mortality and corticosteroids have been the mainstay of treatment for decades. Patients with Lille score >0.45 are considered non-responders to steroids and have poor outcome. Recently Orthotopic Liver Transplantation (OLT) is being increasingly used as rescue treatment for these patients, without waiting for 6 months of abstinence. Liver transplant is the only rescue treatment which can potentially provide long term benefit for patients who are steroid non-responders. However, with scarcity of organs being a concern, all patients of severe alcoholic hepatitis cannot be chosen for transplantation in an arbitrary way. There is a need for development of predictive tools and objective protocols to select patients who can justify the use of precious liver grafts. With a stringent criteria for selection of patients receiving the graft, liver transplantation in severe alcoholic hepatitis can become a viable rescue therapeutic option conferring significant survival advantage of both short- and long-term basis. The optimal criteria for selection will also prevent misuse of the liver donor pool as well as to prevent mortality in salvageable patients. Further research needs to be done to identify subset of patients which are at low risk of recidivism and also cannot be managed with pharmacotherapy alone. We reviewed the current knowledge on role of OLT in patient with acute severe alcoholic hepatitis in the present review.

Objective: Endoscopic ultrasound (EUS)-guided biliary drainage is evolving as an alternative technique in patients with failed endoscopic retrograde cholangiopancreatography. The objective of this study was to find out the outcome of EUS-guided choledochoduodenostomy in patients with malignant mid and lower end biliary obstruction with inaccessible papilla presenting at our center. Methods: The present study was a single-center prospective observational study. Data of all the patients who underwent choledochoduodensotomy from January 2014 to December 2015 were recorded. Outcome measures were technical success and clinical success. Technical success was defined as successful placement of stent in the biliary system; clinical success was defined as 50% reduction in bilirubin at 2 weeks. Complications during the procedure and follow-up were recorded. Results: A total of 10 patients underwent EUS-guided choledochoduodenostomy. Cause of biliary obstruction was pancreatic cancer in eight patients, two patients had carcinoma gallbladder with mid-common bile duct (CBD) block due to compression by metastatic lymph nodes, and one patient had ampullary carcinoma. Mean bilirubin value was 16.4 mg/dL (±3.2 mg/dL). Technical and clinical success were 100% and 90%, respectively. No immediate procedure-related complication was noticed. Two patients had stent migration during the follow-up. Conclusion: EUS-guided choledochoduodenostomy is an effective and safe alternative for rescuing biliary drainage in patients with mid and lower end malignant CBD block with inaccessible papilla.

Percutaneous biliary drainage is commonly performed procedure after failure of ERCP in patients with biliary obstruction. Failure to internalization can lead to permanent external catheter. In the present case, problem of external biliary catheter was solved with hepaticocholecystogastrostomy. Guidewire from the external drain site could not be passed across the stricture, instead it was entering in the gall bladder. This was used as an opportunity to internalize the catheter. First EUS guided cholecystogastrostomy was performed, followed by placement of stent between right biliary system and the stomach, through the cholecystogastrostomy stent. This led to drainage of right biliary system into the stomach, and the external catheter could be removed.

Histoplasmosis is caused by Histoplasma capsulatum. Like most fungal infections, histoplasmosis is common in immunocompromised patients. In immunocompetent patient, infection is generally asymptomatic and rarely turns into a disseminated form. Addisonian crisis as presentation of disseminated form has been reported in present. Here, we report a case of disseminated histoplasmosis leading to life threatening adrenal crisis and hypercalcemia in an elderly immunocompetent Indian patient. Appropriate diagnosis and anti fungal and steroid treatment lead to dramatic improvement in patient. Histoplasmosis should be considered in a immunocompetent hosts with adrenal involvement.

Background and study aims Although endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) is an established modality for pathological sampling of pancreatic and biliary lesions, limited data are available on the diagnostic value of EUS-FNA for evaluation of gallbladder mass lesions, a common cause of obstructive jaundice. We aimed to evaluate the usefulness of EUS-FNA for diagnosis of gallbladder mass lesions presenting with biliary obstruction. Patients and methods This study was a retrospective analysis of data from patients who had undergone EUS-FNA for gallbladder mass lesions. FNA was performed on either a gallbladder mass, metastatic node or liver lesions. Outcome measures were diagnostic yield of EUS FNA and adverse events. Results From April 2011 to August 2018, 101 patients with gallbladder mass lesions with biliary obstruction underwent EUS-FNA. The final diagnosis was malignancy in 98, benign disease in one, and two patients were lost to follow-up. EUS-FNA confirmed the diagnosis in 89 of 98 patients with malignancy (sensitivity 90.81 %); was false negative in nine of 98 cases with malignancy; and was truly negative in the solitary patient with benign disease (specificity 100 %). Positive predictive value, negative predictive value (NPV), and accuracy were 100 %, 10 %, and 90.90 %, respectively. Two patients had self-limiting pain. Conclusion EUS-FNA is a sensitive tool for evaluation of gallbladder mass lesions presenting with obstructive jaundice. However, because of low NPV, lesions in which FNA is negative should be further evaluated.

Kikuchi-Fujimoto disease (KFD) is a benign, self-limiting disease characterized by histiocytic necrotising lymphadenitis. Though several viral agents or an autoimmune etiology has been proposed as causative, the exact cause remains unknown. It has a female predilection and most commonly seen among young Asian people. Patients usually present with a febrile illness and the presence of lymphadenopathy may provide a clue to diagnosis. The most common site of lymphadenopathy is cervical lymph nodes while intra-abdominal involvement is uncommon. Cases of KFD presenting with intra-abdominal lymphadenopathy have been reported to occur with equal frequency in both sexes. Abdominal tuberculosis, non-Hodgkin’s lymphoma, and systemic lupus erythematosus are close differential diagnoses for this type of presentation. Treatment is mostly supportive as the disease usually resolves spontaneously; steroids are only required in severe cases. We report a 32-year-old male patient of intra-abdominal lymphadenitis that presented as fever of unknown origin (FUO) and diagnosed by excisional biopsy as a case of KFD.

Adenosquamous carcinoma (ASC) of the stomach is a very rare tumor comprising less than 0.5% of all stomach malignancies. Here, we report a case of a 37-year-old male, who presented with upper gastrointestinal bleeding in the form of hematemesis and malena. A subtotal gastrectomy was done in view of massive uncontrolled bleed. Histology showed evidence of ASC of the body and antrum with metastasis to the liver, perigastric lymph nodes and peritoneal and pleural cavity.