key: cord-0028814-v0of8l28
authors: nan
title: 62nd Annual Conference of the Indian Society of Gastroenterology, February 10th – 13th, 2022, Pune
date: 2022-03-21
journal: Indian J Gastroenterol
DOI: 10.1007/s12664-021-01234-z
sha: f365bc687e1bf7ecaf8bc9a1f89a32919f316d2f
doc_id: 28814
cord_uid: v0of8l28

nan

Introduction Duodenum plays an important role in digestion, enteroinsular signalling, and glucose homeostasis. However, the nature and quantity of duodenal flora, permeability, perfusion, and inflammation have not been assessed in patients with type-2 diabetes mellitus. The aim is to study the quantitative and qualitative aspect of duodenal and fecal bacterial flora in patients with hyperglycemia in comparison to normoglycemic subjects along with measurement of duodenal perfusion, permeability and inflammation. Method A study cohort of 33 hyperglycemic (HbA1c >5.6 % and fasting plasma glucose >110 mg/dL) and 21 normoglycemic subjects was recruited as per protocol approved by institutional ethics committee after informed consent. The paired sampling of endoscopic duodenal biopsy and stool were obtained and analyzed. Microbial analysis was performed using 16S rRNA sequencing with both qualitative and quantitative PCR. Duodenal tissue oxygen saturation was measured using an FDA approved tissue oximeter (T-Stat, Spectros). Serum zonulin was measured using ELISA. The Luminex assay was performed to assess IFN-γ, IL-1β, TNF-α, IL-8, IL-4, IL-5 and IL-10 as markers for inflammation. Results Bacterial counts normalized to biopsy DNA content were almost three-fold higher in the hyperglycemic group (1100) compared to the normoglycemic group (p=0.04). Increasing duodenal bacterial load was associated with increased zonulin levels. The qualitative microbial analysis using 16S rRNA sequencing showed enrichment of pathogenic flora such as Proteobacteria with reduction of probiotic bacteria like Akkermansia muciniphilia. Hyperglycemic subjects showed reduced mucosal tissue oxygen saturation, increased total leukocyte count and reduced IL-10 levels. Duodenal microbiome showed greater inter-Introduction Limited replicative potential of hepatocytes (Hep) is a major limitation of cell therapy in patients with liver failure. Biliary organoids (BO) derived from intrahepatic bile ducts differentiate into both hepatocyte and cholangiocytes in vitro. We studied the effects of intrahepatic transplantation of BO and Hep in CCl4induced liver injury mice models by histology and RNA sequencing of the transplanted liver lobes. Methods Mice Hep were isolated by collagenase perfusion. Intrahepatic mice bile ducts were used to isolate and culture BO on matrigel. Rat livers were decellularized and solubilized to make DCL. Mice models of 3-week liver injury were prepared by CCl4. Well-characterized BO and Hep mixed with DCL were transplanted into subcapsular left lateral mice liver lobes. CCl4 mice given DCL alone were sham group. 2-week post-transplantation, transplanted liver lobes were collected from all the study groups and studied by histology and RNA-seq on Illumina Hiseq 2500 with 2X150 paired-end chemistry. Results Cultured Hep were positive for Alb while BO showed positivity for Krt19 in vitro. Post 3-week CCl4 injections, mice developed a grade 2 fibrosis. After 2-weeks of cell transplantation in CCl4 mice, BO livers had increased PCNA-positive cells as compared to both sham and Hep groups (p< 0.0001). Among the top 20 differentially expressed genes in RNA seq, an upregulation of genes involved in cell cycle progression was observed in BO livers as compared to sham. Hepatocyte differentiation genes, Hnf4a, Bmp4, Foxa3 etc were upregulated in both Hep and BO livers than sham. Serum albumin was significantly increased in both Hep and BO mice and these groups also showed a significant resolution of fibrosis as compared to sham. Conclusion During chronic liver injury, transplanted BO are differentiated into functional hepatocytes in vivo, indicating that they may serve as an efficient cell therapy for restoring hepatic insufficiency. Keywords Biliary organoids, Cell therapy, Hepatocytes, Chronic liver injury 020 GMCSF modulates myeloid derived suppressor cells and Tregs activity in decompensated cirrhotic patients with sepsis Introduction Alcohol associated liver disease (ALD) is a major global clinical problem with high morbidity and mortality. The aims of the study were to identify the liver proteome and fecal microbiome at peak injury and during disease progression at early and late stages of ALD and second to correlate these interactions in order to better understand the pathogenesis of ALD. Methods Male C57BL/6N mice were fed with the control or ethanol Lieber-DeCarli diets for 12 weeks to induce ALD. To capture the events occurring during early and late disease progression, mice were sacrificed after 4, 8 and 12-weeks, respectively. Moreover, peak injury was achieved by a combination of alcohol and thioacetamide-(TAA), which resulted in more severe liver damage. Fecal microbiota was assessed using 16s rRNA. Proteome linked to liver steatosis, injury and intestinal barrier integrity were evaluated by LC-MS. Results Histology of liver sections revealed wide regions of necrosis and liver damage by 12 weeks, with loss of normal villus structure in the ileal epithelium of intestine. Mice exposed to alcohol and given TAA displayed a pericellular pattern of liver fibrosis, enhanced steatosis, and neutrophil infiltration, comparable to human alcoholic hepatitis. At peak liver injury Introduction Endovascular interventions for Budd-Chiari syndrome (BCS) have gradually come to the forefront of management of this rare disease. However, such procedures carry the risk of restenosis which is difficult to diagnose clinically. Our aim was to quantify liver stiffness measure (LSM) changes after endovascular intervention for BCS and evaluate whether liver LSM changes predict restenosis after endovascular intervention. Methods BCS patients who underwent endovascular intervention and had at least two LSM values available after intervention were included. DLSM was the difference between LSM estimated at the last and second last hospital visit. In patients with restenosis, two LSM values before restenosis were included. DLSM% was calculated as the ratio of DLSM to the LSM at second last visit and expressed as a percentage. Odds ratio Introduction Alcohol liver disease (ALD) is associated with gut bacterial dysbiosis and increased gut permeability. Pregnane X receptor (PXR), a ligand activated nuclear receptor has been implicated in transcriptional regulation of intestinal barrier integrity and inflammation. We investigated whether intestinal PXR expression plays a role in gut microbiota homeostasis affecting hepatic function in a mouse model of ALD. Methods Male C57BL/6N mice were fed with the ethanol Lieber-DeCarli diet for 12 weeks to induce ALD. Fecal microbiota was assessed using 16s rRNA followed by fecal metabolome analysis. Intestine and liver tissue proteome analysis were evaluated by LC-MS/MS. Results Chronic ethanol feeding in mice changes the gut microbiota composition and promotes microbial dysbiosis with altered fecal metabolites associated to fatty acid amides. Long-term ethanol exposure resulted in loss of normal villus structure of the ileac epithelium and proteomic analysis of intestinal tissue revealed decrease in anti-oxidative, tight junction proteins and increase in inflammation/injury linked proteins (FC<1.5, p<0.05). Chronic EtOH feeding increased ALT/AST and liver injury in mice. Moreover, EtOH-exposure in mice showed downregulation of proteins such as Cyp3a11 (FC<1.5, p<0.05) important for xenobiotic/bile acid detoxification linked to PXR. Short chain fatty acid producing bacteria such as Chlorobaculum and Lachnospira were decreased in EtOH and positively correlated (r>0.7, p<0.05) with the PXR proteins involved in tight junctions and PPAR signaling. Coriobacterium and Galenea, the secondary bile acid-producing bacteria correlated negatively with the downregulated protein Apoa1 and Cyp1a2 involved in drug metabolism and AMPK signaling pathway (r<0.7, p<0.05) in EtOH fed mice. Conclusion Long-term EtOH consumption promotes disruption in intestinal PXR expression. The identified bacterial families correlate with PXR linked proteins and pathways suggesting an important role of nuclear receptors in tissue injury which could be explored as therapeutic targets to prevent dysbiosis leading to advance stage of alcoholic liver diseases. Keywords Gut microbiome, Liver injury, Nuclear receptor, Hepatic proteome, Intestinal proteome 031 Prolonged detection of SARS-CoV-2 RNA in extracellular vesicles in nasal swab RT-PCR negative with liver disease patients Introduction Malnutrition in chronic pancreatitis (CP) has prognostic value and there is limited data on the prevalence, predictors of malnutrition in CP and its effect on Quality of life (QoL). Methods A retrospective study was conducted in patients with CP to assess the prevalence of malnutrition as per the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multivariable-adjusted regression was used to identify independent predictors of both malnutrition and global QoL. Results A total of 297 patients were included and the most common etiology of CP was idiopathic (75%) and alcohol (25%). The prevalence of malnutrition was 46.4% as per GLIM criteria. On univariate analysis, the risk of malnutrition was significantly higher in alcoholic etiology (p=0.001), current alcohol consumption (p=0.001), smokers (p<0.001), those having higher cumulative days of pain in last 6 months (p<0.001) and lower daily calorie intake (p =0.019). On multivariate analysis, malnutrition was independently associated with current alcohol consumption (Odds ratio: 3.22, p=0.017), current smokers (OR: 2.23, p=0.042) and those having higher cumulative days of abdominal pain (OR: 1.01, Introduction Endoscopy is an invasive procedure used for diagnosis and treatment of gastrointestinal disease. Nursing Care Practice and Documentation of those activities is necessary to provide quality care and evaluate the patient progress to ensure patient safety during endoscopy. Methods A descriptive study was conducted after formal approval and ethics clearance at Endoscopy Unit of Institute of Liver and Biliary Sciences. Prospectively, 240 events of Nursing Care Practice was observed using Observation Checklist. Retrospectively, from Nursing Records of the period January 2019 to December 2019, documentation (n=717) followed by nursing personnel, was retrieved using Data Abstraction Form, with the help of Abstraction Manual. Results At the end triangulation is done for both the studies, the researcher discovered the similar findings which had not practice and documented are past medical/surgical history (65.4%, 97.6%), Procedure explanation (98.8%, 97.4%) during pre-procedure care. Level of consciousness (55%, 96%), skin assessment (99.6%, 99.6%) and adverse events (92.9%, Introduction Outcome of endoscopic dilatation in corrosive esophageal stricture is less known. This study aims to determine the outcome of dilatation in patients with corrosive esophageal stricture. Methods All the patients who attended to our hospital with corrosive esophageal stricture from 2019-2021 were included in the study. Endoscopic dilatation with graded Savary-Gilliard dilator was performed as the first line treatment. Outcome of dilatation was considered favorable when patients were able to swallow solid without intervention at least six months after successful dilatation. Failure of dilatation was defined as one of the following: complete luminal stenosis, inability to perform safe dilatation, perforation, and inability to maintain adequate luminal patency. Surgery or repeated dilatation was indicated in failed dilatations. Results Of 43 patients, 4 lost follow-up, 31 (72%) had failed dilatation (4 having esophageal replacement procedure, 22 continue repeated dilatation, and 5 unfit for surgery). Of 118 sessions of dilatations, eight out of 43 patients (18.6%) had perforations. There was no dilatation-related mortality. All the 4 patients with surgery had good swallow outcome at 6 months post-surgery. Conclusion Majority of patients with corrosive esophageal stricture were refractory to dilatation. Esophageal dilatations were ultimately failed in about three-fourth of the patients. Background Sigmoid esophagus and/or megaesophagus are considered as an advanced stage in the natural history of achalasia cardia. The role of per oral endoscopic myotomy (POEM) in these subset of patients is emerging. Methods We performed a systematic review and metanalysis to study the efficacy of POEM in advanced achalasia cardia with sigmoid and megaesophagus. A literature search in PubMed and Embase was done from inception till 03/08/2021 to look for studies reporting exclusively on the role of POEM in advanced achalasia cardia with sigmoid and/or megaesophagus. The random effect method with inverse variance approach was used for the computation of pooled prevalence. For two groups' analysis of continuous outcome standardized mean difference was used as the summary measure. Results Eleven studies with 428 patients were included for analysis. Introduction Esophageal strictures can present with dysphagia, hold-up sensation, weight loss. Etiologies include benign causes like peptic stricture, post corrosive stricture, post radiation stricture, eosinophilic esophagitis, post anastomotic stricture and malignancies. Savary-Gillard dilatations are a commonly used treatment modality for strictures in resource poor settings. This study aims to assess the efficacy and safety of Savary-Gilliard dilatations. Methods The medical records of patients who underwent Savary-Gilliard dilatation at our hospital between September 2018 to August 2020 were analyzed .The indication for dilatation, grade of dysphagia prior to and after the procedure, post procedural events like significant pain causing prolonged observation, bleeding or perforation were analyzed. Results A total of 265 Savary-Gilliard dilatations were done in over a period of 2 years. The indication for dilatation in 125 cases was a malignant growth which were excluded from the study. Among the benign 140 cases, the most common indication for SG dilatation was post-radiotherapy stricture which was seen in 63 patients. This was followed by post cricoid web in 38 patients, corrosive stricture in 17 patients, peptic stricture in 15 cases, anastomotic site stricture seen in 7 cases. Ninety percent of patients had an improvement in dysphagia over 2 grades. In the 14 patients who did not improve-the etiology of stricture was corrosive stricture in 8 patients, anastomotic stricture and post radiation stricture in 3 patients each. The complications noted in our study included-post procedural pain in 8 % patients. No significant bleeding or perforation was observed. Conclusion Savary-Gilliard dilatation is an effective technique for the management of benign esophageal strictures with very low complication rates. Outcomes are better in patients with simple strictures when compared to complex strictures. Keywords Savary-Gilliard, Stricture, Dysphagia Background Gastroesophageal reflux disease (GER) is commonly seen in patients post peroral endoscopic myotomy (POEM) for achalasia. But the factors associated with the development of GER are explored to a lesser extent. Methods Consecutive patients of either sex aged ≥18 years, diagnosed to have achalasia cardia who underwent POEM over 18-month period were included. All patients underwent 24-h esophageal pH monitoring, highresolution manometry and esophagogastroduodenoscopy at baseline and 3 months in addition to filling a GERDQ questionnaire. The pre and post and intra operative parameters were noted. Post POEM GER was defined as per Lyon Consensus. Results A total of 51 patients (58.8% males) with a mean (SD) age of 40.5 (13.7) years, underwent POEM during the study period out of which 41 (80.4%) completed the 3-month follow-up. At baseline, the mean Eckardt score was 7.2 (1.2), 80 % had type 2 achalasia. Post POEM, mean Eckardt score was 1.48 (0.96), (p<0.05). Post POEM, abnormal AET was seen in 8/41 (20%) as per Lyon. Six (14.6%) had LA grade C esophagitis and 5 (12.1%) were symptomatic i.e. GERDQ score ≥8. On univariate analysis: Fall in IRP >/=20 mmHg from baseline (at 3 months), manometric length of LES segment </=2.5 cm post POEM, length of gastric myotomy (>2 cm) and sling fiber involvement during POEM were predictors of GER, while on multivariate analysis only manometric length of LES, long gastric myotomy, sling fiber involvement were independent predictors of GER.

Introduction Noncardiac chest pain (NCCP) is defined as recurrent episodes of retrosternal pain or discomfort that is diagnosed after excluding nonesophageal causes such as cardiac, musculoskeletal, pleural and pulmonary disorders. Aim of this study was to evaluate the various esophageal abnormalities in NCCP. Methods This was a prospective observational study which included adults (18-65 years) with NCCP. Known cases of pulmonary or pleural diseases, on NSAIDs, history of chest trauma, esophageal or gastric surgery were excluded. All patients underwent UGI endoscopy and esophageal biopsy to rule out eosinophilic esophagitis (EE) . If both endoscopy and biopsy were normal these patients underwent high resolution esophageal manometry (HRM) and those with normal HRM underwent 24hour impedance pH monitoring. Result Sixty patients were included (33 [55%] male and 27 [45%] females) in this study with mean age of 41.8 +/-13.38 years. Twelve (20%) patients were diagnosed as EE, 16 patients (26.6 %) had esophageal motility disorders (8 ineffective motility, 4 achalasia cardia, 2 small hiatus hernia with EGJ outflow obstruction and one each of Jackhammer esophagus and DES). Fourteen (23.3%) patients were of gastroesophageal reflux disease (GERD), eleven patients (18.3%) were having esophageal hypersensitivity and remaining 7 (11.6%) were diagnosed as functional chest pain. Conclusion HRM and impedance pH metry are important diagnostic tools for accurate diagnosis of NCCP in patients with normal endoscopic and esophageal biopsy findings. GERD were present in 23.3% and 26.6% had esophageal motility disorder. After this step-up approach only 30% were found to have esophageal hypersensitivity and functional chest pain, who will be requiring different modalities of treatment. Keywords Non cardiac chest pain, HRM, 24-hour Impedance pH monitoring Introduction Sebaceous glands are derived from the ectoderm. Ectopic sebaceous glands (ESG) have been reported in various other ectopic sites including lips and mouth, eyes, orbits, palms and soles, salivary glands, tongue, and larynx. Esophagus is derived from the endoderm and presence of ectopic sebaceous gland is very rare. We report a case of ESG in the esophagus. Case Report A 38-year-old gentleman, presented with history of heartburn, regurgitation and abdominal bloating of 8 months duration. There is no history of smoking or alcohol intake. He has no prior comorbid illness and is not on any medications. Clinical examination was unremarkable. BMI was 23. He has been on intermittent empirical proton pump inhibitors despite which he has not had any clinical improvement. Upper GI endoscopy done revealed presence of multiple yellowish-white plaques measuring 5 mm each and was resistant to flushing. Possibility of candida esophagitis or eosinophilic esophagitis was considered, and biopsies were taken. Microscopic examination revealed presence of fragments of hyperplastic stratified squamous epithelium with sub-mucosa showing mature sebaceous glands arranged in lobules. There were no features of fungal organisms, eosinophilic esophagitis, dysplasia or malignancy. There are only 52 case reports of ESG described in the English literature and its clinical significance is not known. Conclusion ESG in the esophagus is a benign lesion and is very rare. It has to be considered as a differential diagnosis in patients with yellowishwhite plaques in the esophagus. Keywords ESG -ectopic sebaceous glands 053 Study of endoscopic prevalence, clinical, demographic and histological characteristics of heterotopic gastric mucosa in the cervical esophagus and its association with Barrett's esophagus and hiatus hernia Cyril Alex, Benoy Sebastian, Anil Jose Correspondence -Cyril Alex -cyril_alex@yahoo.com Department of Gastroenterology, Medical Trust Hospital, Mahatma Gandhi Road, Pallimukku, Kochi 682 016, India

Heterotopic gastric mucosa of proximal esophagus (HGMPE) or inlet patch is the presence of gastric columnar mucosa in the upper esophagus. Until recently these lesions were mostly considered non-pathogenic and were usually neglected. Of late the role of inlet patch in various disorders like globus, chronic cough, dysphagia etc. are increasingly being noted. Dramatic resolution of troublesome symptoms like chronic globus sensation and cough following ablation of these lesions albeit in small studies, points to a need to study them more closely. The study was undertaken in a tertiary care centre in Kerala over a 1-year period. A total of 2791 patients were enrolled in this study who met the inclusion criteria. The demographic data and the clinical profile were documented, and an upper GI endoscopy was performed and a dedicated effort to look for inlet patches were made using narrow band imaging (NBI) and slow withdrawal in all patients. Paired antral and inlet patch biopsies were taken to analyze the histological type of inlet patch, presence of dysplasia and H. pylori. The study detected 66 cases of inlet patch with a prevalence rate of 2.36%. Laryngopharyngeal reflux symptoms were the predominant symptom found in 54.54%. Globus sensation had a positive association with the presence of inlet patch while dyspepsia and dysphagia failed to show significant correlation. The histopathological analysis showed cardia type mucosa as the predominant type of inlet patch and there was no dysplasia or malignancy detected. There was a positive correlation between the presence of H. pylori in inlet patch and antral biopsy. Taken together a recommendation for avoiding routine biopsies of inlet patches detected during endoscopy is suggested. The presence of inlet patch also had statistically significant association with the presence of endo-Introduction Current gold standard for the diagnosis of gastroesophageal reflux disease (GERD) is 24-h pH-metry. However, 24-h pH-metry fails to detect non-acidic reflux. There has been concern on sensitivity of 24-h pH-metry monitoring alone (both catheter-based and BRAVO capsule) compared to 24-h impedance monitoring, especially, if gastric acid secretion is low due to reduced parietal cell mass, Helicobacter pylori induced gastric atrophy and antisecretory therapy. Accordingly, we aimed to analyse the diagnostic ability of 24-h pH-metry as compared to 24-h impedance monitoring in relation to gastric acid levels for patients offantisecretory therapy. Methods A retrospective analysis of prospectively collected data of 9 1 p a t i e n t s w i t h s u s p e c t e d G E R D r e f e r r e d t o t h e G I Pathophysiology and Motility Laboratory for 24-h pH impedance study was done. Results Among 91 patients (56 [61.5%] males), 73 (80.2%) had confirmed GERD either by pH-metry alone (10 [11%.0]), impedance monitoring alone (25 [27.5%]) or both (38 [41.8%] ). Reflux of gastric contents was detected by pH-metry and impedance monitoring in 48 (52.7%) and 63 (69.2%) of patients respectively (p=0.022). Among 48 patients, who were diagnosed with GERD by pH-metry, 12 (13.2%) had reflux in supine posture, 4 (4.4%) had reflux in upright posture while 32 (35.1%) had reflux in both positions. Among 63 patients diagnosed with GERD by impedance monitoring, 5 (5.5%) had reflux in supine posture, 13 (14.3%) had reflux in upright posture, while 45 (49.5%) had reflux in both positions. The mean gastric pH in patients of GERD detected by pH-metry alone (2.34±1.36), impedance monitoring alone (2.02±1.59) and both (1.57±0.91) were comparable (p=0.247). The percentage time of gastric pH <4 in patients of GERD detected by pH-metry alone (82.47±22.30), impedance monitoring alone (82.62± 27.23) and both (91.42±11.68) were also comparable (p=0.228). Conclusion 24-h impedance monitoring picks up GERD more often than 24-h pH-metry with comparable gastric acid levels in patients who are not on antisecretory therapy. Keywords Gastroesophageal reflux disease, 24-h pH impedance metry, Reflux Esophageotracheal fistula is a rare condition, and in most cases such fistulas are caused by malignant disease or emergency endotracheal intubation. approximately 50% of acquired TOFs are secondary to mediastinal malignancy. Iatrogenic tracheoesophageal (TE) fistula is a rare diagnosis that has high morbidity and mortality and requires a high index of suspicion. In our case, patient is a 26-year-old male, with no premorbid illness presented with a history of fever and headache since 2 months, altered sensorium since 10 days. There was no history of trauma, chest pain, palpitations, breathlessness, sore throat. No history of foreign body aspiration, ingestion of toxic substances or any surgical procedure in the past. On CNS examination, patient was drowsy but arousal, moving all four limbs. Patient was started on anti-tubercular drugs. Post insertion of nasogastric tube, bubble were seen coming out from the Ryle's tube. CT thorax done showed tracheoesophageal fistula. Esophagogastroduodenoscopy (EGD) confirmed tracheoesophageal fistula. Metallic stent was placed. Feeding jejunostomy was done. Patient improved symptomatically. Metallic stent was removed after 3 months. Patient is tolerating orally. Keywords Tracheoesophageal fistula, Iatrogenic, Ryle's tube, Tubercular meningitis Background Functional dyspepsia is an umbrella term referring to patients with postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). Aim To study the clinical and endoscopic characteristics of patients with dyspepsia who underwent upper gastrointestinal endoscopy at our centre. Methods This is a retrospective analysis of prospectively maintained database of patients who underwent upper gastrointestinal endoscopy between May 2019 and April 2021. We included all patients >18 years who underwent endoscopic evaluation for dyspeptic symptoms for >4 weeks duration as per Rome IV criteria. We excluded patients with alarm symptoms, antibiotic use, use of proton pump inhibitors or H 2 receptor antagonists and upper gastrointestinal malignancy. Data recorded were age, sex, use of alcohol or tobacco, co-morbid diseases, clinical diagnosis with duration and endoscopic findings. Statistical analysis-Chi square test, Student's t test, Kruskal-Wallis test. A p-value of < 0.05 was considered significant.

Results Two hundred and thirty-four patients satisfied the study criteria. They were sub-classified as-EPS (18, 7.7%); PDS (116, 49.6%) and overlap of EPS + PDS (100, 42.7%). Organic dyspepsia (duodenal erosions, duodenal ulcer, erosive esophagitis) were noted in 15% cases. H. pylori infection was detected in 114 cases (48.7%). Prevalence of Introduction Patients with functional dyspepsia (FD) have poor healthrelated quality of life (HRQOL) . Indian data on this subject is lacking. Also, there is non-availability of a validated disease-specific questionnaire to assess HRQOL in Hindi speaking dyspeptics. We aimed to develop and validate a reliable translation of the Short-Form Nepean Dyspepsia Index (SF-NDI) in Hindi and assess the impact of FD on HRQOL in Indian patients. Methods Cross-cultural adaptation of English version of SF-NDI, translation to Hindi, and adaptation of Hindi version was performed using standard procedures. English and Hindi versions were assessed against SF-36, examining for internal consistency, test-retest reliability, and validity. Results Total 211 FD patients (144 Hindi speaking, 67 English speaking) were enrolled (mean age 40.8 ±11.7 years; male: female=115:96). Median total SF-NDI scores for both languages were 38.75 and 40.0 respectively. Test-retest reliability intraclass correlation coefficients were 0.85 (Hindi) and 0.89 (English). Internal consistency evaluation revealed Cronbach's α coefficient of 0.79-0.86 (Hindi) and 0.78-0.89 (English). SF-NDI subscales showed moderate to good correlation with various domains of SF-36 (content validity). There was a significant (p<0.001) decline of HRQOL for patients with severe dyspepsia relative to those with mild dyspepsia (construct validity). On multivariate analysis, factors independently associated with HRQOL were duration of symptoms and dyspepsia severity. Conclusion Both English and Hindi versions of SF-NDI are reliable and valid for HRQOL assessment in Indian FD patients and will be useful in future epidemiological and clinical studies. Indian FD patients have poor HRQOL, being worse in those with severe dyspepsia and a longer duration of symptoms. Keywords Epigastric pain syndrome, nausea, post-prandial distress syndrome Background Mucormycosis is a life-threatening disease. Rhinocerebral involvement is most common. Gastrointestinal (GI) involvement is uncommon of which stomach involvement is most common. We encountered 2 patients with post corona virus disease (COVID) gastric mucormycosis. Case 1 A 73-year-old male presented with massive upper gastrointestinal bleed and shock. Patient was admitted 20 days back for COVID pneumonia and was treated with remdesivir, steroid and anticoagulants. During day 10 of COVID illness patient developed anterior wall myocardial infarction for which PTCA with drug eluting stent was placed and Aspirin, ticagrelor and dabigatran started. After hemodynamic stabilization, upper GI endoscopy was done which revealed large necrotic gastric ulcer, biopsy suggestive of mucormycosis. Patient was treated with liposomal amphotericin B. On day 6 patient rebled, repeat upper GI endoscopy revealed large gastric ulcer with visible vessels, hemostasis was achieved by hemoclip application. Reevaluation after 5 weeks showed clean based ulcer with granulation. Patient developed acute myocardial infarction on day 56 of GI bleed and succumbed to it. Case 2 A 56-year-old male presented with massive upper gastrointestinal bleed and shock. Patient was admitted 1 month back for COVID pneumonia and was treated with remdesivir, steroid and anticoagulants. After hemodynamic stabilization, upper GI endoscopy was done which revealed large necrotic gastric ulcer, biopsy suggestive of mucormycosis. Patient was treated with Amphotericin B deoxycholate. On day 12 patient had large volume hemetmesis with hypotension, upper GI endoscopy showed active bleed from ulcer base and a visible vessel, was controlled with difficulty by injection adrenaline, gold probe coagulation, hemoclip application and coagulation of vessel head by coag-grasper. Follow-up upper GI endoscopy done after 1.5 months showed healing of ulcer, with healthy granulation tissue. Henoch-Schönlein purpura (HSP), also known as immunoglobulin A vasculitis (IgA) vasculitis, is a systemic vasculitis which is the most common vasculitis in children. IgA vasculitis formerly called Henoch-Schönlein purpura (HSP) is the most common form of systemic vasculitis in children. Ninety percent of cases occur in the pediatric age group. In contrast to many other forms of systemic vasculitis, IgA V is selflimited in the great majority of cases. The disease is characterized by a tetrad of clinical manifestations: ? Palpable purpura in patients with neither thrombocytopenia nor coagulopathy ? Arthritis/arthralgia ? Abdominal pain ? Renal disease The incidence in adults varies from 3.4 to 14.3 cases per million. The classic triad of symptoms include purpuric rash, arthritis and abdominal pain. First Description Dr. William Heberden, a London physician, described the first cases of Henoch-Schönlein purpura (HSP) in 1801. In describing HSP, Heberden wrote of a 5-year-old boy who "…was seized with pains and swellings in various parts…He sometimes had pains in his belly with vomiting's and the urine was tinged with blood. Presently, the skin of his leg was all over full of bloody points" (purpura). The young boy suffered all four disease hallmarks of HSP: arthritis, gastrointestinal involvement, kidney inflammation, and purpura. Johann Schönlein (1837) and Edouard Henoch (1874) reported additional cases decades after Heberden. They recognized that the disorder often followed upper respiratory tract infections and was not always self-limited, sometimes progressing to serious kidney involvement. We present a case of a 45-year-old female with small vessel vasculitis (HSP) who presented with recurrent episodes of abdominal pain, followed by classical symptoms with an identified postinfectious etiology. Keywords HSP; RASH; Abdominal pain 066 Comparative study of non-invasive C12 urea breath test with stool antigen test and histopathology for diagnosis of Helicobacter pylori Swati Rajput 1 , Prashant Chauhan 1 , Rohit Gupta 2 , Itish Patnaik 2 , Devna Chaudhary 1 , Kiran Meena 1 , Anissa Atif Mirza 1 , Satyavati Rana 1 Correspondence -Satyavati Rana -svrana25@hotmail.com Departments of 1 Biochemistry, and 2 Gastroenterology, All India Institute of Medical Sciences, Virbhadra Road, Shivaji Nagar, Sturida Colony, Rishikesh 249 203, India

Background and Aim Endoscopic biopsy with histopathological diagnosis of H. pylori is gold standard but remains an invasive procedure. Radiolabeled C14 urea breath test is invasive, and C13 urea breath test needs costly instrument. Hence, this study was planned to compare and validate sensitivity and specificity of non-invasive C12 urea breath test with stool antigen test and histopathology for H. pylori detection in endoscopic gastric biopsies which is an invasive method. Methods Ninety-seven adult patients with gastritis were enrolled. They were advised to stop proton pump inhibitors 2 weeks and antibiotics 6 weeks before test. Non-invasive C12 urea breath test was done using HELIC ABT Reader. On same day, stool for antigen test by ELISA and gastric biopsy for H. pylori detection by histopathology were taken. Special Warthin's stain specific for H. pylori detection was done. Sensitivity and specificity of C12 urea breath test was calculated against stool antigen test and histopathology of H. pylori. Results were analyzed using Statistical Package for the Social Sciences (SPSS) version 22. Results Out of 97 patients, 58 were males. Twenty-seven patients out of 97 were positive in both urea breath test and histopathology, 23 positives only in urea breath test. Thus, 27 patients were true positive, 23 false positive, 47 true negative and 0 false negative. Sensitivity and specificity of urea breath test against histopathology is 100% and 67.14% with positive predictive value 54%, negative predictive value 100% and accuracy 76.29%. Sensitivity and specificity of urea breath test against stool antigen test is 100%. This is interim data of an ongoing study. Conclusion This study shows that non-invasive urea breath test is 100% sensitive and specific to stool antigen test and 100% sensitive to detect H. pylori by histopathology. Therefore, it can replace invasive endoscopic histopathology and unpleasant stool antigen tests for detection of H. pylori. Keywords Urea breath test, H. pylori, Histopathology Introduction Microbiomes have been known to inhabit the human gut since time immemorial. While some are beneficial for us, others may in turn cause gastroduodenal diseases. The aim of this study was to find out abundance of gut microbiota in various gastroduodenal diseases in accordance with HP (Helicobacter pylori) status. Methods In this study, raw data from 15 participants which underwent proper physical examination, was obtained having GERD, gastritis and duodenal ulcer (DU). Using urease PCR test, the data was categorized as HP (+ and -) and 16S rRNA gene sequencing was done for meta-analysis. Finally, library preparation and quality purified read was obtained data was analyzed for results. Results At phylum level, for HP (+) among DU and gastritis patients, proteobacteria (87.2 % and 72.6 %, respectively) had highest abundance followed by firmicutes (6.7% and 14.2 %, respectively), whereas, in GERD, firmicutes (41.01%) had a dominance followed by proteobacteria (23.6%). On the other hand, in HP (-) category, Proteobacteria was dominant in all three diseases i.e. GERD, DU, gastritis (94.2%, 46.8% and 63.25%, respectively) trailed by firmicutes in GERD, DU, gastritis participants (2.68%, 21.03%, 24.94% respectively). Thermi (0.85%) phyla were abundant only in DU participants having HP (+). At species level, H. pylori was the most abundant in all categories (GERD= 32.31%; DU= 89.44% and gastritis= 86.54%), whereas in HP (-), Helicobacter pullorum was dominantly abundant in GERD and gastritis (44.9% and 23.9% respectively) and Corynebacterium sp. (24.5%) had higher rate in DU. Conclusion As clearly evident, there exists a symbiotic relation between gut microbiota and HP status in the host. According to the analyses, proteobacteria has the most abundance in the diseases considered, regardless of HP status. Keywords Microbiome, Gastro duodenal diseases, Helicobacter pylori 071 White light endoscopic findings of gastric and duodenal mucosa in Helicobacter pylori infected patients: Cross sectional observational study in a tertiary hospital of south India

Correspondence -Debapratim Routh -debapratimraja@gmail.com Institute of Medical Gastroenterology, Madras Medical College, Near Park Town Station, Park Town, Chennai 600 003, India

Background and Aims Helicobacter pylori (H. pylori) infection causes variety of upper gastrointestinal tract diseases. Successful eradication can prevent H. pylori associated diseases. H. pylori infection can be diagnosed by various non-invasive tests, but they have some limitations including high false negative results. Now a days endoscopy plays an important role for diagnosis of various gastric and duodenal lesions. This paper provides preliminary study on endoscopic features associated with H. pylori infection in gastric and duodenal mucosa. Methods It is a cross sectional observational study carried out from April 2021 to September 2021 at Medical Gastroenterology Department of Madras Medical College. Total, 200 biopsy proven for H. pylori, patients were enrolled for endoscopic correlation. Endoscopic images of stomach and duodenum were recorded and biopsy specimens were collected as per Sydney protocol, stained by H-E staining and examined using a light microscope. Results After proper evaluation as per inclusion and exclusion criteria total 100 patients (55 male and 45 female, 40 patients above 40 year of age and 60 patients were below 40 years) were diagnosed H. pylori by biopsy and were correlated with endoscopic findings. Most common endoscopic finding was spotty redness (38.5%) followed by enlarged gastric mucosal fold (20.5%), least common findings are erosions (2%) and multiple dots (1%).

Conclusion This finding may aid cost effective management of H. pylori infection. But additional studies with larger sample sizes and more diverse populations are required to establish the association of endoscopic features with H. pylori infection. Keywords Helicobacter pylori, Endoscopy, Biopsy 072 Effect on gut microbiota due to lifestyle factors and gastrointestinal disease, among the north Indian patients Introduction Various lifestyle factors, including diet, age, alcohol and gastrointestinal diseases status have individually been proven to alter the host's gut microbial, in an increasing number of studies, and have been separately linked to various diseases. However, studies examining the influence of the microbiome of patients in North India considering multiple factors, are scarce. Hence this research effort is directed towards lessening that gap, by examining on the basis of diet, the overlap of age, alcohol, and gastrointestinal disease. Methodology Human tissue biopsy samples of 19 individuals were collected in which 13 were non-vegetarian, 6 vegetarian, three alcoholic, 16 non-alcoholic, 8 with gastroesophageal reflux disease (GERD), 5 duodenal ulcer (DU) patients and 5 with gastritis. 16s rRNA was then used to analyze the samples as well as library quality and sequencing. Results It was found that, across all lifestyle factors, Prevotella Melaninogenica, belonging to the phylum Proteobacteria was present in the top 10 species in omnivores, barring those that drank alcohol. In vegetarians, Corynebacterium sp., was highly abundant across all factors, with its phylum Actinobacteria being in the top three, except for in DU samples, and Hemophilus parainfluenzae (Proteobacteria), also one of the ten most abundant species. The only time there was an obvious similarity in the microbial composition of the two diets was in the alcoholics, where Streptococcus sp. was found to be most abundant in omnivores (18.10%), and second most abundant in vegetarians (14.01%). Conclusions Streptococcus sp. also causes gastric degradation, indicating that despite diet influencing the health of the host, an alcoholic host will majorly face the same repercussions. Prevotella Melaninogenica was also mainly high in omnivores and has been linked to an increase in gastric cancer risk. Keywords Gastrointestinal disease, Dietary status, Gut microbiome 073 Isolated gastric Crohn's disease with pyloric stenosis -An unusual initial presentation Introduction Crohn's disease (CD) is a heterogeneous disorder with multifactorial etiology, including genetic factors, environmental insults, and intestinal microbiota, characterized by chronic, segmental and trans mural inflammation that affects the gastrointestinal tract and may involve any segment of the oral cavity up to anus. Isolated stomach involvement is very unusual presentation accounting for less than 0.7% of all gastrointestinal Crohn's disease. Case A 17-year-old male presented to our department with recurrent postprandial vomiting, epigastric discomfort, and unintentional weight loss over 3 months. No history of any bleed, fever, loose stools, cough, or jaundice. Per abdomenmild epigastric tenderness. Per rectal examinationnormal.

Investigations CBCmicrocytic hypochromic anemia, RFT, LFT, S. amylase, viral markers, Erect AXR, CXRnormal. CECT abdomenno abnormality detected. UGI endoscopy -Circumferential nodulo-ulcerative mass seen in antropyloric region with narrowing of pyloro-duodenal opening. Histopathological examination of biopsy from the lesion revealed noncaseating granuloma with superficial ulceration. Colonoscopy revealed normal colon up to 15 cms of terminal ileum. CT enterography was normal tuberculosis, H. pylori and sarcoidoses were excluded by appropriate investigations, and a diagnosis of gastric Crohn's disease was made. Patient underwent CRE balloon dilation of the pylorus and was put on oral steroids and azathioprine for maintenance. Patient showed remarkable response at 8-week follow-up with complete resolution of symptoms and started to gain weight as well.

Conclusion Symptoms of pyloric obstruction as a manifestation of isolated gastric Crohn's disease are extremely unusual in clinical practice, awareness of which would facilitate early appropriate investigations and treatment. Balloon dilatation followed by oral steroids and immunomodulators is an effective way to manage such cases. Keywords Gastric Crohn's, Balloon dilatation, Steroids 074 High prevalence of virulent Helicobacter pylori with low clarithromycin resistance in patients with dyspepsia from Odisha Vinaykumar Hallur 1 , Manas Panigrahi 2 , Mukund Sable 3 , Manaswini Ghosh 1 , Srujana Mohanty 1 , Suvendu Purkait 2 , Ashok Praharaj 1 Correspondence -Vinaykumar Hallur -vinay118@gmail.com Departments of 1 Microbiology, 2 Gastroenterology, and 3 Pathology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar 751 019, India

Background The outcome of Helicobacter pylori (HP) infection depends at least partly virulence factors and its eradication as preventive measure against gastric cancer has been advocated by some guidelines. Universal eradication or use of failing antibiotic can add fuel to the antimicrobial resistance pandemic. Hence, there is need to identify candidates at risk for gastric cancer and antimicrobial resistance in HP for rational management. Such candidates could be identified by studying the association of virulence factors with clinical outcome. As this data is lacking from Odisha, India this study was undertaken. Methods One hundred and thirteen consecutive dyspeptic patients attending our centre were subjected to endoscopy to obtain tissue which was subjected to culture and antibiotic susceptibility, histological examination, molecular detection of HP, virulence typing (cagA, EPIYA typing, vacA, vacA s1/s2, vacA m1/m2 and babA2) by conventional PCR and identification of clarithromycin resistance by real time PCR. Cultures isolates were subjected to antibiotic sensitivity using e strips as per EUCAST guidelines.

Introduction Eosinophilia can arise due to numerous conditions including allergy and infections. It can also be an incidental finding; but identification and assessment of associated organ is essential. The case A 55-year-old male presented with loss of appetite, vomiting, heartburn and unexplained weight loss since two months. His laboratory parameters for blood counts, renal function test and liver parameters were normal except for low albumin (1.9 g/dL) and eosinophilia (900/μL). His stool occult blood was positive. Esophagogastroduodenoscopy (EGD) showed mild erythema (antrum), pyloroduodenal ulceration with exudates. Rapid urease test for H. pylori was positive. Colonoscopy showed diverticuli in sigmoid and descending colon with inflammatory patches in terminal ileum, cecum and descending colon. Biopsy showed moderate ileitis and nonspecific colitis. Gene expert was negative for mycobacterium tuberculosis. Biopsy specimen of pylorus epithelial lining showed few parasites of Strongyloides stercoralis. He was initially prescribed anti-H pylori therapy, fexofenadine, esomeprazole, probiotics, multivitamin, and advised to consume protein rich diet. At follow-up (2 weeks), patient was treated with Ivermectin 12 mg once a week for 2 weeks. Patient was advised to wear shoes to avoid contact with infected soil in endemic areas. The patient responded well to treatment, a follow up EGD (4 months) revealed no significant ulcers in the stomach, and stool culture was negative.

Introduction There is regional variation in the eradication rates of Helicobacter pylori (H. pylori) regimens depending on the local antibiotic resistance patterns. Data from Odisha, where prevalence of H. pylori and peptic ulcer disease is still high is lacking. The aim of this study was to compare the efficacies of standard triple therapy, sequential therapy, and quadruple therapy in eradicating Helicobacter pylori infection in this region. Methods A total of 304 H. pylori positive patients were randomized to receive one of the three regimens (standard triple therapy [n=102], sequential therapy [n=101] or quadruple therapy [n=101]). Eradication rate was assessed by H. pylori stool antigen test. Results Seventy-one, seventy-one and sixty-nine patients completed the follow-up in the standard triple therapy group, sequential therapy group and quadruple therapy group respectively. The eradication rates of standard triple therapy, sequential therapy, and quadruple therapy was 93%, 94.4%, and 97.8%, respectively. Conclusion Fourteen days of standard triple therapy, ten days of sequential therapy and fourteen days of bismuth-based quadruple therapy are equally efficacious in eradicating H. pylori and all the regimens have Introduction Gastric microbial composition may be influenced by redox perturbations where microbiome may be a passive bystander or induce oxidative stress and related pathology, like H. pylori. We aim to decipher microbial signatures of redox perturbation for the quantitative assessment of mucosal health. Methods Gastric mucosal tissue biopsy is obtained from 10 peptic ulcer and 10 non-ulcer dyspepsia patients and subjected to 16s RNA gene sequencing. Using abundance correlation mapping, a microbial redox spectrum is deduced based on oxygen requirement/tolerance and the presence of the enzymes catalase (Cat) and oxidase (Ox). A simple redox index of mucosal health based on top two predominant Ox+, Cat+ aerobes and Ox-, Cat-anaerobes is conceived. Results The oxidative end of redox spectrum was populated by Ox+, Cat+ aerobes namely, H. pylori, S. mizutaii and T. fusca. These three species had an inverse correlation with the abundance of anaerobes and Ox-, Cat+ aerobes. The abundance of most of the anaerobes was positively correlated with each other except for the aerotolerant Clostridium intestinale. The ratio of the top two Ox+, Cat+ aerobes (H. pylori, S. mizutaii) and top two Ox-, Cat-anaerobes correlated with the tissue oxidation-reduction potential (ORP), Shannon and Species richness indices.

Introduction Gastritis cystic profunda (GCP) is a rare condition characterised by presence of cystic dilatation of gastric glands in basal mucosa and submucosa of the stomach. It commonly occurs in patients with history of gastric surgery at gastroenterostomy sites. Few case reports have noted its development in an unoperated stomach as well. Here we report a case of GCP in a patient who had not undergone any gastric surgery.

A78-year-old gentleman presented with complaints of anorexia, weight loss of 4 kgs since 2 weeks and non-bilious vomiting since 10 days. Past medical history was unremarkable. He had no history of gastric surgery. Upper GI endoscopy revealed a thickened nodular lesion with irregular surface 2 x 1.5 cms in the body of the stomach along the greater curvature. Histopathological examination of the lesion revealed multiple dilated cystic gastric glands lying in the deeper mucosa and between distorted muscularis mucosae fibres with no evidence of dysplasia. Review of literature GCP is considered a benign lesion. GCP may present as elevated lesions in gastroscopy and should be differentiated from early gastric cancers. Most cases of GCP in an unoperated stomach are secondary to changes caused by prolonged chronic inflammation and ischemia. Injury to the muscularis mucosae caused by gastric surgery or suturing Methods This was a prospective observational study conducted on 70 patients with UGI bleed over a period of 18 months. At admission, baseline blood investigations included measurement of serum lactate levels, and calculation of UCR, Glasgow-Blatchford score (GBS), Rockall and AIMS65 scores. These were correlated with the primary (inpatient and thirty-day mortality) and secondary outcomes (need for ICU stay, requirement of blood transfusion, re-bleeding and need for endoscopic/surgical/ radiological interventions). Results In this study the mortality rate was found to be 11.4% (8 patients). Mean lactate levels were significantly higher in the non-survivor group (91.61 mg/dL) in comparison to the survivors (32.96 mg/dL). Elevated lactate levels (>40 mg/dL) was found to be a better predictor of mortality (area under ROC curve 0.85, p<0.0.1), when compared to Rockall, GBS and AIMS65 scores with a sensitivity of 90% and a specificity of 79%. However, UCR was a poor predictor of mortality. On analysis of secondary outcomes, a serum lactate of >40 mg/dL at admission was associated with increased length of ICU stay (3.06 days, p<0.01), increased requirement of blood transfusions (2.63 units, p-0.01), increased requirement of inotropic support and endoscopic interventions. UCR was not found to have any significant association. Conclusion Our study shows that serum lactate levels is useful in predicting in-hospital and thirty-day mortality in patients with UGI bleed. However, UCR showed no similar benefit. Lactate levels can be incorporated into the existing risk stratification scores for better prediction and timely intervention, in patients with UGI bleed. Keywords Gastrointestinal hemorrhage, Lactic acid, Urea, Creatinine Corona virus disease 2019 (COVID-19) pandemic has affected more than 2.5 billion people claiming more than 5 million lives worldwide. During the second wave of this pandemic in India nasopharyngeal mucormycosis was found to complicate the disease however mucormycosis of the gut has been rarely reported. We present a case of gastric mucormycosis in an 82-yearold gentleman who presented with a massive post-covid upper gastrointestinal (UGI) bleed. He was initially diagnosed with moderate COVID-19 and was treated with oral prednisolone for 21 days. One month after he recovered from COVID-19 pneumonia he presented to us with a massive UGI bleed. His UGI endoscopy was suggestive 7.8 cm large gastric ulcer extending from the gastroesophageal junction. Biopsy showed largely ulcerated stomach mucosa with necrotic debris containing Periodic Acid Schiff positive fungal hyphae suggestive of mucormycosis. Contrastenhanced computed tomography of the abdomen was also consistent with the diagnosis. He was planned for surgery but because of his age, he denied surgery and was managed conservatively with intravenous pantoprazole infusion and amphotericin B. After the initial 13 days, because of worsening renal function amphotericin B was stopped and he was started on posaconazole which was continued for 3 months. On follow-up endoscopy, his ulcer healed and subsequently resolved after 3 months. Gastric mucormycosis is a rare but potentially lethal fungal infection with mortality of up to 54% in immunocompromised patients. Most of the literature suggests early anti-fungal with surgical debridement or gastrectomy for gastric mucormycosis with necrosis, angio-invasion, or extensive disease. This is a rare case of mucormycosis. Our patient highlights an unusual cause of post-COVID GI bleed which was successfully managed with antifungal therapy only despite having a large necrotic ulcer. Awareness of this complication is essential for its early diagnosis and appropriate management. Keywords COVID-19 pandemic, Covid Asscociated Mucormycosis, Upper GI bleed, Gastric mucormycosis 081 Spectrum of primary gastric lymphoma in India: A series of thirty patients Akash Mathur 1 , Uday C Ghoshal 1 , Sushil Kumar 2 . Neeraj Kumari 2 , Narendra Krishnani 2 Correspondence -Uday C Ghoshal -udayghoshal@gmail.com Departments of 1 Gastroenterology, and 2 Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, India Primary gastric lymphoma (PGL) is uncommonly reported from India. Since gastric neoplasm (GN) is a relatively less common in northern India, PGL is also considered uncommon. During a 12-y period (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) , data of GN in a teaching institute were retrospectively analyzed to know (i) the frequency of PGL among patients with GN, (ii) its clinical profile, (iii) the diagnostic procedures needed, and (iv) frequency of Helicobacter pylori (H. pylori) among them. 30/324 (9.2%) patients (age 56-y, range 25-72, 73.3% male) with GN had PGL. Forty percent had H. pylori infection (2/3 tests positive). Presentations included dyspepsia (9, 30%), gastric outlet obstruction (n=7, 23.3%), upper gastrointestinal bleeding (n=5, 16.7%), dysphagia (n=4, 13.3%), malignant ascites (n=3, 10%) and other (n=2, 6.7%). H. pylori infection was present in seven (23.3%), twelve (40%), and 21/29 (72.4%) patients by RUT and histopathology, and positive anti-H. pylori IgG serology, respectively. Using any two of three test positive criteria, H. pylori was detected in 12 (40%) patients. Though in 60% PGL was diagnosed on endoscopic biopsy, in 40%, surgical resection was required. The endoscopic and surgical diagnosis groups were comparable in age (53.4-y vs. 52.7-y), sex (male 77.8% vs. 66.7%), H. pylori infection (38.9 vs. 16.7%), presentation with dyspepsia (38.9 vs. 16.7%), organic symptoms (61.1 vs. 83.3%) and need for repeated Introduction Primary gastric actinomycosis is a rare, chronic, progressive, suppurative disease characterized by formation of multiple abscesses, draining sinuses, and abundant granulation and dense fibrous tissue [1] . It should be considered in the differential diagnosis of radiologic and gastroscopic diffuse gastric wall thickening and submucosal tumor-like or infiltrative lesions, particularly in patients with history of abdominal surgery or trauma. A high level of suspicion is needed for diagnosis. The presence of sulfur granules strongly suggests a diagnosis but not pathognomonic for the disease [2] [3] [4] . Methods A 52-year-old female presented with severe abdominal pain for 5 days with no medical comorbidities. No history of abdominal trauma. History of tubectomy 32 years ago and hysterectomy 17 years ago. Gastroscopy showed antral ulcer with edematous mucosa. Mucosal biopsy suggestive of chronic nonspecific gastritis with focal ulceration. Contrast enhanced computed tomography (CECT) abdomen showed illdefined heterogeneously enhancing exophytic soft tissue lesion approximately 4.2 x 3.5 x 3.3 cm seen arising from antrum of stomach. Mild circumferential wall thickening seen in involved segment of antrum. Inflammatory changes seen in surrounding fat. Results On endoscopic ultrasound (EUS) evaluation there is well defined lesion measuring 2.9 x 2.3 cm in antrum of stomach no active doppler uptake. No lymphadenopathy. Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected. EUS guided fine needle aspiration (FNA) from stomach lesion on Hematoxylin and Eosin-stained slide showing basophilic filamentous organism with adjacent neutrophilic inflammation and Gomori Methenamine silver (GMS) stain showing silver positivity morphologically consistent with Actinomyces. She was treated conservatively with long duration of penicillin antibiotic. Conclusion EUS can aid in taking biopsies for histological evaluation to avoid morbidity and mortality due to unnecessary surgery, usually as Background The prevalence of celiac disease (CD) is estimated to be around 1% in northern India, but it is much lower in southern India. This disparity in prevalence is thought to be due to dietary differences. Objective To determine the yield of routine duodenal biopsies in patients with suspected CD in tertiary care centre in Tamil Nadu. Study design Retrospective study, and patients from January 2018 to June 2021 were included. Methods Patients with iron deficiency anemia (<12 gm/dL in women and <13 gm/dL in men with low mean corpuscular volume [MCV] and ferritin), chronic diarrhea (>4 weeks) and significant weight loss (>5% in 6 months) or a combination of these symptoms are included. Results A total of 448 patients are included in the study, 206 (45.9%) males, and 242 (55.1%) females. With mean age was 47.2 years in males, and 44.56 years in females. The predominant symptoms are, only anemia in 383 (85.4%), only diarrhea in 29 (6.4%), anemia + diarrhea in 21 (4.6%), with rest of the combination of symptoms in minority. Scalloping of the duodenal mucosa observed in 15 (3.3%) patients, but none of these patients have features of CD on microscopy. Biopsy features of CD are seen in four patients, three of them came with only anemia and one with only diarrhea. All the patients had normal duodenal endoscopy, but HPE were suggestive of celiac with Marsh stage 3. The overall yield of duodenal biopsy for all symptoms is 0.89%, patients with only anemia 0.78%, and patients with only diarrhea is 3.44%. Conclusion Even in a targeted group of patients with CD symptoms, the yield of duodenal biopsy is very low. Patients who have only diarrhea have a better yield than patients who have only anemia. Keywords Celiac disease, South India, Anemia Introduction Systemic lupus erythematosis (SLE) is a complex autoimmune disorder with multisystem involvement, with a prevalence of 3.2 per 100,000 in India. Lupus enteritis is a vasculitis of the bowel, a rare manifestation with a reported prevalence of 0.2% to 5.8%. Lupus enteritis as the initial manifestation of SLE is rare in literature. Case Summary We report a 28-year-old female, with a history of thrombocytopenia detected during her 2nd pregnancy, for which she was given oral steroids, and a history of cholelithiasis with choledocholithiasispost cholecystectomy with CBD exploration, who presented to our OPD with complaints of watery diarrhea, colicky abdominal pain, and vomiting since 4 weeks and abdominal distension since 1 week. General examination revealed signs of dehydration, pallor, pedal edema and signs of postural hypotension. Abdominal examination revealed epigastric tenderness and shifting dullness. Investigations showed normocytic normochromic anemia (hemoglobin -7.2 g/dL), hypoalbuminemia (2.9 g/dL) and proteinuria (24 hour urine albumin -734 mg/24 hour). Blood and stool studies were negative for infection. Ascitic fluid analysis revealed low SAAG high protein ascites. CECT abdomen revealed diffuse mucosal edema of stomach, small and large intestine, and right mild hydroureteronephrosis. Esophagogastroduodenoscopy and colonoscopy revealed edematous mucosa in the stomach and throughout the colon. Further workup revealed ANA +ve; low complement levels (C3 -10 and C4 -20) and anti-dsDNA +ve. Based on the ACR criteria she was diagnosed with SLE. She was treated with Methylprednisolone pulse for 3 days, followed by Cyclophosphamide, because of multisystem involvement. Her symptoms resolved with the treatment. She was asymptomatic during follow-up after 1 month. Conclusion Lupus enteritis as the presenting feature of SLE is rare and the diagnosis requires a high index of clinical suspicion, combining clinical, biochemical, and imaging features. Though lupus enteritis is steroid-responsive, our patient required Cyclophosphamide because of multisystem involvement.

Keywords Lupus enteritis, Abdominal pain, Chronic diarrhea, Systemic lupus erythematosis, Ascites

Introduction Eosinophilic enteritis is a rare entity characterized by eosinophilic infiltration of the small intestine. Clinical features of this condition depends on the site of involvement of the intestinal wall and includes malabsorption, failure to thrive, bloody stools and ascites. Rarely it may be severe enough to result in small bowel obstruction. Case report A 38-year-old female with no significant medical history presented with complaints of periumbilical, episodic, colicky abdominal pain of 5 years duration accompanied by vomiting and weight loss. Her workup included a hemoglobin of 12.2 gm/dL, total counts of 7800 cells/ mm 3 with eosinophilic predominance. Imaging showed features of acute small bowel obstruction secondary to ileal stricture. Patient underwent an explorative laparotomy. Intraoperative findings included multiple ileal strictures in distal 100 cm with grossly dilated proximal small bowel. Small bowel resection with reanastomosis was done. Histopathology of the resected specimen showed marked transmural eosinophilic infiltrate of the small bowel suggestive of eosinophilic enteritis. Patient was started on low dose steroid along with dietary advice. Patient improved symptomatically and is currently asymptomatic. Discussion Since its discovery in 1937 by Kaijser et al. approximately 280 cases of eosinophilic gastroenteritis have been reported in literature. Pathogenesis of this condition is not clearly understood. Current theories implicate hypersensitivity reactions in its development. Endoscopic appearance is nonspecific and do not aid in diagnosis. Mild symptoms are managed conservatively. More severe symptoms are managed with a course of corticosteroids. If small bowel obstruction is suspected surgical evaluation should be promptly pursued as was in the case of our patient. Conclusion With this case, we wish to highlight a rare etiology that should be kept in the differential when evaluating patients with intestinal obstruction and eosinophilia. Keywords Eosinophilic enteritis, Obstruction, Steroid 088 Duodenal tuberculosis -A rare site of a common disease Introduction Tuberculosis is a worldwide health problem, with a high incidence in developing countries. Duodenal tuberculosis is very rare, with few cases reported in the literature. We report a case of duodenal tuberculosis in a 29-year-old male patient. Case Details The patient presented with persistent dyspeptic symptoms, bloating and epigastric discomfort of one week's duration, following which an upper GI endoscopy was done. A 1 x 0.5 cm nodule was seen in the first part of duodenum. Histopathologically, epithelioid granulomas with giant cells and necrosis were seen with acid fast bacilli (AFB). Retrospectively, the patient revealed that he had taken anti-tubercular drugs for four months in 2018 for tubercular lymphadenitis. Discussion The reported incidence of gastroduodenal tuberculosis is 0.5 %. The possible causes of the rareness of duodenal tuberculosis may be gastric acid, rapid transport of micro-organisms, sparse lymphoid follicles in the wall, and integrity of duodenal mucosa. Duodenal involvement may be endogenous, exogenous or both. The exogenous type may cause duodenal involvement due to the compression by enlarged peri-duodenal lymph nodes, while the endogenous type may show ulcerative, hypertrophic or ulcerative-hypertrophic lesions. Conclusion Duodenal tuberculosis is easy to be misdiagnosed as an ulcer or inflammatory bowel disease. Although the sensitivity of AFB staining is low, it should remain an important part of the diagnostic evaluation of mucosal biopsies. Wrong diagnosis often leads to wrong treatment or serious complications due to delayed treatment. Thus, it is of great significance for patients that diagnosis be made through optimal imaging and histological analysis. Keywords Tuberculosis, Duodenum, Endoscopy, Biopsy

A common disease at an uncommon site-isolated jejunal tuberculosis, a rare presentation Sanjo John, A R Akhilandeswari Correspondence -A R Akhilandeswari -sanjojohnmavely@gmail.com Department of Medical Gastroenterology, Government Peripheral Hospital, 3rd Avenue, Anna Nagar, Chennai 600 102, India

Introduction Tuberculosis (TB) can affect any organ system. Intestinal TB constitutes 1% to 3% of TB worldwide. The most common site of gastrointestinal (GI) involvement are the ileum and ccum. Concomitant jejunal TB is usually seen at the terminal stages of extensive bowel involvement. Isolated jejunal involvement, without bowel involvement elsewhere is rare. Case Report A 29-year-old male presented with periumbilical abdominal pain since 2 years, bilious vomiting 1 to 2 hours after food intake since 3 weeks. He had loss of appetite and loss of weight. No fever, cough. General examination was normal. ESR-72. Baseline investigations were normal. Viral markers-negative. Chest X-ray was normal. Barium meal study revealed focal dilatation of distal ileal loops. USG abdomen showed dilated, fluid filled bowel loops in right iliac fossa with sluggish peristalsis. CT enterography showed long segment mild circumferential bowel wall thickening with significant luminal narrowing involving mid/distal jejunal loops and significant dilatation of proximal jejunal loops. Mild adjacent fat stranding and few mesenteric lymph nodes enlarged, largest measuring 12 mm. VOGD was normal. carcinoembryonic antigen (CEA)-negative. Patient underwent diagnostic laparoscopy and resection anastomosis. Histology showed granulomatous inflammation with Langhans giant cells. The possibility of tuberculosis was considered and started on category 1 ATT. Patient improved symptomatically with treatment. Discussion The normal GIT physiology propels food from small intestine, limiting the contact period of the bacilli with jejunal mucosa. The immunocompetancy of the patient also checks the bacillary invasion. Vague symptoms and nonspecific investigations make the early diagnosis of intestinal TB challenging. Conclusion Gastrointestinal TB can present at uncommon sites. Isolated jejunal TB is rare and a high degree of suspicion should prompt the clinician to think of TB in jejunal lesions even in immunocompetent individuals. Keywords Tuberculosis, Granulomas, Jejunum 090 Assessment of intestinal failure and insufficiency in patients with celiac disease Mahendra S Rajput 1 , Alka Singh 1 , Ashish Chauhan 1 , Shubham Prasad 1 , Vikas Jindal 1 , Sanjay Kumar 2 , Saroj K Sinha 2 , K S Madhusudan 3 , Rajesh Khadgawat 4 , Sanjayn K Agarwal 5 , Vineet Ahuja 1 , Govind K Makharia 1 Correspondence -Govind K Makharia -govindmakharia@gmail.com 1 Departments of Gastroenterology and Human Nutrition, 3 Radiology, 4 Endocrinology, and 5 Nephrology, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India, and 2 Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background Intestinal failure/insufficiency has been defined and graded mainly in relation with short bowel syndrome. Diffuse mucosal disease of intestine such as celiac disease (CeD) also leads to intestinal failure/ insufficiency which further secondarily leads to other target organ failure. It is also believed that patients with potential CeD have no significant disease. Patients and Method Fifty-one consecutive treatment naïve patients with CeD and potential CeD underwent intestinal and extraintestinal failure/ insufficiency assessment. The severity of clinical manifestations was assessed using Gastrointestinal Symptom Rating Scale (GSRS) and Celiac Symptom Index (CSI). Intestinal mucosal absorption was assessed using d-Xylose and enterocyte mass using plasma citrulline level estimation. Objectively, intestinal insufficiency was defined if d-Xylose excretion was <5 gm/25 gm/5 hr and/or if plasma citrulline was <30 μMol/L. Secondary, five extraintestinal organ insufficiency/failure were defines as follows; short stature (as linear growth failure), BMI (as nutritional status), anemia (hematological failure), osteopenia and osteoporosis (bone health failure) and sarcopenia (muscle mass failure). Results Intestinal insufficiency/failure was present in 90.7% and 100% patients with CeD and potential CeD respectively. Overall, 39 and 8 patients with CeD and potential CeD had one or more secondary organ failure/insufficiency. Secondary organ failure were present as short stature in 21.6%, anaemia in 78.4%, osteopenia and/or osteoporosis in 54.3%, sarcopenia in 36.4% and low BMI in 43% patients. Amongst patients with CeD, 7.8% had no organ failure, 17.6% had one, 33.3% had two and 42.2% had three or more secondary organ failure. All patients with potential CeD (n=8) had ≥1 organ insufficiency or evidence of primary intestinal failure. Conclusions In not only patients with CeD, but also those with potential CeD have evidence of intestinal failure/insufficiency, which further leads to secondary target organs failure/insufficiency. It is thus essential to identify these diseases early in course before irreversible changes set in other organs. Keywords Celiac disease, Intestinal insufficiency, Intestinal failure 091 Gastrointestinal tract involvement in patients of potential celiac disease beyond small intestine -An early proof Introduction IgA anti-tissue transglutaminase-2 antibody (anti-TG2 Ab) deposits in the tissue have been used as evidence of involvement of both intestinal and extraintestinal organs in patients with celiac disease (CeD). We have recently shown the involvement of the esophagus, stomach, and colon in a subset of patients with CD using anti-TG2 Ab deposits. Whether extra-small intestinal organs are affected in patients with potential CeD is not known. Methods Nine patients with potential CeD and 27 age and gendermatched patients with irritable bowel syndrome (IBS) were recruited as cases and controls, respectively. Mucosal biopsies were collected from the esophagus, stomach, duodenum, and rectosigmoid regions in cases and controls. All biopsies were evaluated for histological changes, and they were subjected to dual-color immunohistochemical staining for identifying IgA anti-TG2 Ab deposits at various sites. Results IgA anti-TG2 Ab deposits were observed in significantly higher numbers of patients with potential CeD at all sites than in patients with IBS ( Conclusion The presence of anti-TG2 Ab deposits in organs other than the small intestine such as the esophagus, stomach, and colon suggests the involvement of these extraintestinal organs even in patients with potential CeD. Keywords Celiac disease, Potential celiac disease, Immuno-histochemistry, IgA tTG mucosal deposits 092 Prediction of villous atrophy based on anti-tissue transglutaminase antibody titre Introduction The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) 2020 guidelines proposes that IgA anti tissue transglutaminase (tTG) antibody titre ≥ 10 times the upper limit of normal (ULN) and a positive anti endomysial antibody on second sample is sufficient for diagnosis of celiac disease (CeD ) in children and duodenal biopsy is not warranted. Studies have suggested that antibody ≥ 10 times can be applied in symptomatic adult CeD but it has not been widely adopted in standard guidelines. Our aim is to determine the fold rise in anti-tTG antibody levels that is predictive of small intestinal villous atrophy (Modified Marsh grade 2 and 3) in adults and to determine the accuracy of anti-tTG antibody level ≥10 times ULN in predicting small intestinal villous atrophy (Modified Marsh grade 2 and 3) diagnostic of CeD. Methods Retrospective analysis of 641 adults with CeD assessed in the specialist CeD clinic at AIIMS, New Delhi from 2009 to 2021 who had a serum IgA anti-tTG test and duodenal biopsy within 6 weeks of each other and naivety to a gluten-free diet. Results Only 42.28% of patients had ≥ 10-fold rise in anti-tTG antibody titre. More than equal to 10-fold rise in anti-tTG antibody titre predicts villous atrophy Modified Marsh grade 2 and 3 with a specificity of 100% and 94% and positive predictive value of 100% and 98% respectively. Prediction of villous atrophy modified marsh grade 3 has 100% specificity and positive predictive value at ≥ 13-fold rise in anti-tTG antibody titre.

Conclusion Biopsy is essential in more than 50% of adults with CeD who have ≤ 10-fold rise in anti-tTG antibody titre. However, patients with anti-tTG antibody titre ≥ 10 fold have high predictive value for diagnosing CeD. Keywords anti-tTG antibody, Duodenal biopsy, ESPGHAN

Retrospective analysis of diagnostic yield and therapeutic outcomes of double balloon enteroscopy -A single center experience Introduction Double balloon enteroscopy (DBE) is an effective endoscopic tool for diagnosis and treatment of small bowel diseases. This study is a retrospective analysis of consecutive patients undergoing DBE at our centre.

Methods The data of all patient's undergoing DBE was retrospectively analyzed between April 2019 to August 2021. The indications, diagnostic yield and therapeutic outcomes were analyzed. Result A total of 118 patients (Mean age 49.46 years, range 18-80 years, 85 males) underwent 130 DBE procedures (63 via antegrade and 67 via retrograde approach) in the study period. Indications for DBE were chronic pain abdomen, obscure GI bleeding, chronic diarrhea and recurrent vomiting in 50.8%, 24.50%, 17.80% and 6.70% respectively. The overall diagnostic yield was 69.7% and the diagnostic yield in indications of chronic pain abdomen, obscure GI bleeding, chronic diarrhea and recurrent vomiting were 75%, 68%, 59% and 80% respectively. Among therapeutic procedures, 12 patients underwent 16 sessions of argon plasma coagulation for angiodysplasias. Follow-up data was available for 9 patients. Overt bleeding resolved and hemoglobin levels stabilised in 5 patients (42%) with mean follow-up of 8 months (range 2 to 12 months). One patient with liver cirrhosis had acute bleeding due to mid ileal ectopic varix which was controlled with glue injection. Two patients underwent DBE assisted endoscopic retrograde cholangiopancreatography (ERCP) for hepaticojejunostomy (HJ) stricture, one patient underwent CRE balloon dilatation and biliary stenting for benign HJ stricture, another patient underwent bilateral biliary stenting for malignant HJ stricture. Conclusion Double balloon enteroscopy is useful tool for diagnosis and treatment of small bowel diseases and provides opportunity for biliary intervention in surgically altered anatomy. Keywords Balloon assisted enteroscopy, Stricture dilatation, APC Objective Compliance to guidelines in making of a diagnosis, dietary counselling and follow-up of patients with celiac disease (CeD) varies markedly amongst physicians. We therefore conducted a questionnairebased survey to assess the pattern of practice of the diagnosis, dietary counselling, and follow-up of patients with CeD in India. Methods A questionnaire including 30-questions was developed based on review of literature, group discussions and expert group meetings. The web-based questionnaire was administered through social media (WhatsApp) to 18 groups comprising of 2980 adult patients with CeD. Of them, 970 (32.5%) responses were received and responses from 955 patients (females:611 [63.9%], medianage:21years, inter quartile range:12-35 years) were finally included. Results While 679 (71.1%) patients were diagnosed based on a combination of blood tests and upper gastrointestinal endoscopy and biopsy, 214 (22.4%) based on blood test alone and 62 (6.5%) based on endoscopic examination for diagnosis. After diagnosis, 875 (91%) patients were counseled initially by the physician and only 585 (61%) were referred to a dietician for dietary counselling. In majority, the time spent by doctors and dietitians during first 81atient81d81s was between 10-20 minutes only. After first counseling, 191 (20%) and 355 (37.3%) patients did not visit the doctor and the dietitian, respectively. Only 515 (53.8%) patients were getting their anthropometric parameters checked at every follow-up visit and one-fourth (n=232, 24.3%) of patients were self-monitoring their serological parameters. The adherence to diet was not monitored by the dietitian in 495 (51.8%) patients. Conclusion The practice of the diagnosis, dietary counselling, and followup of patients with CeD in India is not as per the standard guidelines. Most of the patients are not referred to a dietitian. There is a need to reinforce the guidelines for proper care and management of patients with CeD. Keywords Counselling, Gluten-free diet, Celiac disease, Follow-up 095 Histo morphological study of duodenal nodules in first part of duodenum in 104 patients in a tertiary care center in south India Introduction Duodenal nodules in first part of duodenum are frequently noted as an incidental finding in many patients undergoing upper gastrointestinal scopy for other indications such as dyspepsia. The aim was to evaluate histology and character of this nodules. Methods This is a retrospective study of 104 patients who had nodules in first part of duodenum either single or multiple during routine endoscopy procedures done between January 2019 to July 2021 which are biopsied. The morphology and its histopathology was analyzed. Results The mean age of presentation is 52 years. Out of 104 patients, 64 (61.53%) were males and 40 (38.46%) were females. Single nodule was seen in 41 (39.4%) patients. Multiple nodules were seen in 63 (60.5%) patients. On histological evaluation, Brunner hyperplasia was noted in 46 (44.2%) patients. No significant changes were noted in 43 (41.3%) patients. Neuroendocrine tumor was diagnosed in 15 (14.4%) patients. Fourteen patients of diagnosed neuroendocrine tumor had single 5-10 mm sized nodule in the anterior wall. One patient had multiple nodules in duodenum of size 1-2 mm with one predominant nodule of 8 mm size which was neuroendocrine tumour on biopsy. Conclusion There is high incidence (34.1%) of neuroendocrine tumor in single nodules. Single nodules are much less likely to represent duodenitis unlike multiple nodules and in fact they have significant neoplastic potential mandating biopsy whenever they are found. Keywords Duodenal nodule, Neuroendocrine tumor, Endoscopy

Introduction Chronic non-bloody diarrhea is attributed to functional or organic disease. The latter category may present with malabsorption syndrome. Indian data largely focussed on the etiological spectrum of MAS in adults. Data from south India suggest tropical sprue (TS) is the commonest cause of MAS, whereas northern India data suggests celiac disease and TS are leading causes. Aim The aim of the study was to evaluate the etiological spectrum of chronic organic non-bloody diarrhea in northern India. Methods This prospective observational study was done at a tertiary care corporate hospital in north India. Patients ≥ 18 years presenting with chronic non bloody diarrhea of > 4-week duration, from the period of July 2020 to July 2021 were enrolled for the study. Patients with irritable bowel syndrome (IBS) and other functional disorders were excluded. Results During the study period, 69 patients presented with chronic nonbloody diarrhea which was organic in nature. The mean age of the patients (56.5% males) was 49 ± 16 years. A definite etiological diagnosis was made in 68 (98.5%) patients. The median duration of diarrhea was 6 months. Inflammatory bowel disease (IBD) (CD-29 and UC-3) accounted for 32 of the 68 (46%) cases making it the predominant cause. Gastrointestinal (GI) infection comprising of giardiasis, human immunodeficiency virus (HIV) and TS accounted for 10 cases (14.5%). Adult celiac disease was diagnosed on the basis of revised European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria seen in 6 patients (9%). Notably, GI malignancies manifesting as chronic non-bloody diarrhea was seen in 4 cases (6%). Pancreatic disease (chronic pancreatitis -3, NET-2) accounted for 5 patients (7%). Conclusion Our data suggest that IBD (Crohn's disease) is the predominant cause of chronic organic non-bloody diarrhea in adults, followed by GI infections. Our study differs from previous studies which suggested that celiac disease and TS are the leading causes of chronic diarrhea and malabsorption in India. Keywords Chronic Diarrhea, Non bloody, IBD Introduction Chronic diarrhea is one of the most common gastrointestinal symptoms and may lead to severe protein energy malnutrition and its attendant complications. We present a case report of a middle aged male presenting with chronic diarrhea and malabsorption secondary to common variable immunodeficiency (CVID). It is a primary immunodeficiency disorder characterized by reduced immunoglobulin serum levels and absent or impaired antibody production with variable involvement of GIT. Case Report A 46-year-old male presented with small bowel type diarrhea associated with significant weight loss since 1 year. He also had a h/o multiple hospitalization for recurrent pulmonary infections. Primary evaluation revealed iron deficiency anemia and elevated ESR. Celiac serology, hydrogen breath test and stool for ova and cysts were negative. Serum immunoglobulins were low, with significantly reduced levels of IgG (17.2 mg/dL) and IgA (<10 mg/dL). UGIE revealed nodularity in D2 with histopathology suggestive of reactive lymphocytosis and no evidence of atypical cells. Abdominal imaging showed edematous small bowel loops with changes of bronchiectasis on HRCT chest. Hematology and pulmonology opinion were taken, and he was initiated on antibiotics by pulmonology team for LRTI. He was also initiated on treatment with rifaximin and probiotics, but the response was suboptimal. In view of recurrent pulmonary infections and chronic diarrhea leading to compromised quality of life, he was started on intravenous immunoglobulins once in 2-4 weeks with the aim of maintaining IgG trough levels between 400-500 mg/dL. 1 month after initiation of immunoglobulins there was a significant improvement in his symptoms. Keywords Chronic diarrhea, CVID, Immunoglobulins Aim The exact role of soluble apoptosis-related mediators in celiac disease is still not fully understood. It is possible that serum sFas-sFasL may have a role in the pathogenesis of celiac disease. In this study, we assess the circulating soluble Fas and Fas ligand levels in celiac disease. Methods The study included 50 newly diagnosed celiac disease adults and 25 non-celiac adults as control. The circulating sFas and sFasL levels were assessed by ELISA kits. All duodenal mucosal histological parameters were evaluated, classified, and graded histological lesions according to the criteria proposed by our group. The serum sFas and sFasL levels and duodenal histological results were then analyzed using appropriate statistical methods. Results The mean age of 50 adults with celiac disease was 31.28 ± 12.83 (range, 15-62) years, with a M:F :: 1:1. In adult celiac disease mean serum sFas was significantly lower (p <0.001) than non-celiac control. However, mean serum sFasL was significantly higher (p=0.018) than non-celiac control. One way ANOVA indicated no relationship between grade of duodenal mucosal damage and concentration of serum sFas. On the other hand, One way ANOVA indicated a statistically significant relationship between different grades of duodenal mucosal damage and sFasL. In case of patients presenting with recurrent fungal, bacterial as well as mycobacterial diseases, T cell defect should also be suspected in addition to B cell defect. In such cases, the option of bone marrow transplant is a viable option and to an extent curable. However, in cases of nonrespondent to IVIG in B cell defect, other viable options including Rituximab may be tried. In case of this patient, it is very unlikely for combined disorder to present at such age, however X linked disorder may present at adolescent age. Keywords SCID, Chronic diarrhea, Giardia, Fungal infections Introduction Celiac disease is a long-term immune disorder that primarily affects the small intestine. The occurrence of liver impairment in CD is well established and must be regarded as one of the various extraintestinal presentations of gluten-sensitive enteropathy. However data is still insufficient and only a few studies had been done on the evaluation of celiac disease in patients already with liver cirrhosis. Thus, we did performed an observational study to determine the prevalence of celiac disease in patients with liver cirrhosis Methodology This observational study has been undertaken in the Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Prayagraj. Cases has been selected from the patients who are attending Gastroenterology OPD or admitted in the ward. Result Total of 134 patients were included in our study. Out of which 89 were male as compared to 45 females. More than 50% were in the age group of 30-50 years. Out of total 4 patients had celiac disease and 6 had non-specific duodenitis consistent with Marsh 1 stage. Conclusion This study showed that CD was present in 2.9% of cirrhotics which is more than 2 times the prevalence in general population. This study also concluded the presence of nonspecific duodenitis in 4.5% of the study population which frequency was similar to that of general healthy population. Keywords Cirrhosis, Celiac disease, Non-specific Duod Background Small bowel bleeding poses a diagnostic and therapeutic challenge. With the advent of newer device assisted enteroscope, diagnostic and therapeutic enteroscopy has become easy to perform. Here we present a case of massive, small bowel bleeding where a novel endoscopic collagen spray was used to achieve hemostasis. Methods Novel motorized spiral enteroscope and endoscopic collagen spray (Hemoseal spray, Shalili) were used. Case Report A 26-year-old gentleman, presented with bleeding per rectum on and off. At presentation he was in shock with hemoglobin 0.6.g/ dL. He was resuscitated. Endoscopy and colonoscopy were normal. CT visceral angiography showed enhancing wall thickening in distal jejunum/proximal ileal loop, possible Crohn's disease. Novel motorized spiral enteroscopy showed multiple large ulcers with ooze of blood in distal jejunum and proximal ileum. Hemoclip was applied to a visible vessel and novel endoscopic collagen spray was applied to the entire extent of bleeding. He stabilized and recovered. He is currently on treatment of Crohn's disease on follow-up. Conclusion Endoscopic collagen spray can be used as an additional hemostatic agent for diffuse bleeding in extensive ulcers in the small intestine safely. Small bowel malignancies are relatively rare, accounting for only 2% of all gastrointestinal cancers and 40-60 times less frequent when compared with colon cancer. Among small bowel tumors, most malignancies arise from the ileum, followed by the duodenum and jejunum. Adenocarcinoma of duodenum is an uncommon tumor, which is frequently delayed in diagnosis as its symptoms and signs are non-specific.

Wilkie's syndrome also known as superior mesenteric artery syndrome (SMAS) is an uncommon cause of upper gastrointestinal tract obstruction due to the compression of the duodenum by the superior mesenteric artery. It is commonly due to loss of fatty tissue as a result of a various debilitating conditions leading to acute angulation between superior mesenteric artery and aorta. The exact prevalence of SMAS remains unclear, however, the rate has been estimated to be 0.013 and 0.3%, based on barium studies. The present study describes a case of duodenal adenocarcinoma occurring in a 44-year-old man, who presented with features of intestinal obstruction secondary to Wilkie's syndrome. This is the second case report in the world where a patient of small bowel adenocarcinoma masquerading as Wilkie's syndrome. This case highlights the importance of considering the possibility of SMAS in patients presenting with upper gastrointestinal obstruction caused by intestinal carcinoma. Keywords Superior mesenteric artery syndrome, Duodenal adenocarcinoma and small bowel obstruction Introduction Small bowel bleeding arising distal to ampulla and proximal to ileocecal valve contributes to 5% to 10% of all gastrointestinal (GI) bleed. Capsule endoscopy has enabled the evaluation of previously inaccessible small bowel pushing "true obscure GI bleeding" into oblivion. There are limited data of utility of capsule endoscopy from the tropics. Methods A retrospective analysis of prospectively collected database from December 2003 to April 2020 of patients presenting to a tertiary care academic medical center with suspected small bowel bleeding was done. Capsule endoscopy was done for 352 patients and descriptive analysis of data was done comparing patients with overt and occult GI bleed. Introduction Terminal ileitis is an important entity in India but its etiology and diagnostic approach is poorly defined. Role of complete small bowel evaluation in these patients is still a dilemma. In this study we evaluate the role of capsule endoscopy in these patients. Methods All consecutive patients with terminal ileitis were prospectively included in this observational study conducted from November 2019 to August 2021. All symptomatic patients with terminal ileitis underwent both CT enterography and capsule endoscopy. Results Total 25 patients were included in this study. There were 10 males and 15 females. Most common symptoms were pain abdomen and diarrhea. On evaluation, 2/25 patients (8%) had specific findings on histopathological examination, one had tuberculosis and one had eosinophilic enteritis. Capsule endoscopy showed additional lesions in 4/25 (16%) patients, 2 had deep ileal ulcers and 2 had skip lesions which help in labeling them as IBD-Crohn's. These patients had long standing non resolving symptoms. Colonoscopic findings and histopathology in these patients were non-contributory. These 4 patients were started on specific treatment of Crohn's and showed good clinical response. CT enterography showed skip lesions in only one of these four patients and was non-contributory in rest 24 patients. Conclusion Capsule endoscopy was helpful in changing the diagnosis in 16% patients of terminal ileitis in our study. Capsule endoscopy findings can help in establishing the etiology of isolated terminal ileal ulcers even when histopathology and CT enterography were non-contributory. Keywords Terminal ileitis, Capsule endoscopy, Crohn's disease, CT enterography 105 Impact of delay in the diagnosis on the severity of celiac disease Introduction Celiac disease (CeD) has now become global disease with worldwide prevalence of 0.67%. Despite being a common disease, CeD is often not diagnosed and there is a significant delay in the diagnosis. We reviewed the impact of the delay in the diagnosis of CeD on the severity of CeD. Methods We reviewed records of 409 consecutive patients with CeD (January 2012-January 2021) following in Celiac Disease Clinic. In many of patients, the duodenal biopsies had already been done before reporting to us, hence data of 311 patients having complete data set was finally analyzed. We extracted the specific data including the time of onset of symptoms, time to diagnosis from the onset of the symptoms, symptoms, and the fold-rise in anti-tissue transglutaminase antibody (IgA anti-tTG Ab) and severity of villous abnormalities as assessed using modified Marsh classification. Results The median duration between the onset of symptoms and the diagnosis of CeD was 36 months (interquartile range 12-72 months). A longer delay in the diagnosis of CeD from the onset of symptoms was associated with lower body mass index, lower hemoglobin, higher fold rise in IgA anti-tTG titres and higher severity of villous abnormalities.

Introduction Acute upper gastrointestinal bleeding is a life-threatening emergency which requires hospitalization, evaluation and endoscopic treatment. In this case report, we present a successful endovascular repair of infra renal aortic aneurysm presenting as hematemesis. Case Report A 65-year-old female, known case of rheumatic heart disease on oral penicillin prophylaxis presented to emergency department with 4 episodes of hematemesis and melena associated with giddiness. Upon arrival, she was pale and was hemodynamically unstable with hypotension and tachycardia. Fluid resuscitation and blood transfusion was started. After stabilization bed side endoscopy was negative for bleeding source. Colonoscopy was done which revealed multiple non-bleeding colonic diverticula and melenic stools. In view of obscure gastrointestinal bleed, contrast enhanced computed tomography abdomen with angiography which showed infra renal aortic aneurysm of 30 x 37 x 55 mm with partial thrombosis eroding the 2nd part of duodenum. Vascular surgery opinion sought, and endovascular aneurysm repair (EVAR) was planned. ENDERVANT 16 x 16 x 82 cms stent graft deployed in aneurysm under fluoroscopic guidance. She tolerated the procedure well and she had no further episodes of hematemesis/melena at 3 months follow-up. Conclusion Infrarenal aortic aneurysm presenting as hemetemesis is very rare. High degree of clinical suspicion is essential to make a correct diagnosis and early treatment, which is crucial for the prognosis of these patients. Keywords Abdominal aortic aneurysm, Endovascular aneurysm repair She received 1-unit PRBC in view of severe anemia. Colonoscopy showed altered blood, small diverticulum in left sided colon and AVM noted in right sided colon APC done along with small internal hemorrhoid. CT abdomen angiography subtle hypodensities in descending colon and terminal ileum. Esophagogastroduodenoscopy (EGD) suggestive of small hiatus hernia. She had persistent drop in HB hence relatives brought the patient to our institute. Patient on arrival had history of recurrent anemia with multiple hospital admission. Patient had complaints of abdominal pain, melena with intermittent hematochezia, loss of appetite, weight loss, pedal edema. on examination patient had pallor, pitting pedal edema, cachexia. Patient was then investigated further found to have severe iron deficiency anemia; low hemoglobin hence transfused 2-pint PRBC. Additionally, patient had very low albumin hence albumin was given. Patient was posted for colonoscopy which revealed AVM for which APC was done. Repeat EGD revealed antral gastritis and hiatus hernia. As the bleeding was persistent CT angiography was done which revealed a hyperdense artifact in distal ileum? foreign body. Single balloon enteroscopy was done which revealed video capsule stuck in distal ileum along with local ulceration and stricture, capsule was retrieved.

Introduction Withdrawal of thiopurines after remission has been shown to be associated with an increased risk of relapse in patients with inflammatory bowel disease (IBD). However, long-term data on thiopurine withdrawal is limited especially from developing countries where the cost of long-term therapy poses a significant burden on patients. Methods We retrospectively analyzed data of patients with IBD on thiopurine monotherapy who had stopped and were not on any other immunomodulator or biologics at the time of stopping thiopurines. All these were in clinical remission at the time of withdrawal. Results Among 1264 patients of IBD who were treated with thiopurines, a total of 461 patients had to stop thiopurine because of various reasons. Among these, 218 (UC=179; CD=39) patients were in clinical remission and were continued on mesalamine. Overall, 36.7% (n=80) had relapsed after a median duration of months of 20 months (IQR: 9-49). There is no difference in relapse rate between UC and CD (39.6% vs. 23%). The overall cumulative probabilities of relapse were 17%, 34%, and 44% at the end of 1, 3, and 5 years respectively. The relapse rate was numerically low in patients who had stopped azathioprine after at least 24 months of therapy (31.9% vs. 44.1%, p=0.051). On univariate Cox regression analysis, female sex (HR: 1.6 [1.0-2.6], p=0.02) and short duration of therapy with thiopurines (HR: 1.02 [1.01-1.02 ], p=0.004) before withdrawal were associated with increase risk of relapse. Conclusion Though thiopurine withdrawal is associated with an increased risk of relapse, a significant proportion of patients maintain well even after stopping thiopurines. We need further studies to identify this specific group of patients to avoid adverse events associated with long-term thiopurine therapy. Keywords Inflammatory bowel disease, Azathioprine, Relapse Introduction Sweet's syndrome (SS) is a rare extraintestinal manifestation of Crohn's disease (CD) with <50 case reports. We describe a case of CD associated SS with a dramatic response to steroids. Results Thirty-two-year-old housewife, presented with recurrent periumbilical colicky pain and skin lesions for 2 years. Pain was associated with intermittent, non-bilious, large volume vomiting's but without abdominal distention or obstipation. The skin lesions involved palms and soles, initially macular and erythematous which evolved into elevated pus filled bulllae. There was no history of fever or joint pains. CT abdomen showed thickening, heterogenous enhancement and narrowing of antrum. Endoscopy showed large ulcer along pylorus with evidence of gastric outlet obstruction (GOO). Symptoms were transiently relieved with pantoprazole and domperidone but recurred necessitating gastrojejunostomy (GJ). Three months later, the GOO symptoms recurred, and endoscopy showed stomal ulcers and stenosis with patent GJ loops. Revision Roux-en-Y GJ provided short lasting symptom relief for 4 months. CT showed jejunal stricture, which was resected, and histopathology showed crypt distortion and transmural inflammation. Diagnosis of CD was made, and with prednisolone (40 mg/day), GOO symptoms resolved. After overlap with azathioprine (100 mg/day), steroids were tapered off. Patient discontinued azathioprine and GOO symptoms and skin lesions reappeared (Fig. 1) . Skin biopsy showed neutrophilic infiltrate and a diagnosis of SS was made (Fig. 2) . A pulse of intravenous hydrocortisone was given, which lead to dramatic resolution of skin lesions over one week (Fig. 1) . Conclusion The Sweet syndrome is characterized by fever, leukocytosis, painful papules or nodules of the skin, and a diffuse neutrophilic infiltrate. It is commonly found in 30-60-year females (women to men ratio 4:1). It recurs in one-third of patients. First-line treatments include systemic corticosteroids, potassium iodide, colchicine, and topical corticosteroids. Keywords Crohn's disease, Inflammatory bowel disease, Sweet syndrome 110 Prevalence of anti-tissue transglutaminase serology in community population and patients with irritable bowel syndrome: Two kits comparison Anam Ahmed, Alka Singh, Ashish Chauhan, Mahendra Singh Rajput, Vikas Jindal, Vineet Ahuja, Govind K Makharia Correspondence -Govind K Makharia -govindmakharia@gmail.com Department of Gastroenterology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029. India

Background Anti-tissue transglutaminase-2 antibody (TG2) based serology are the cornerstone of diagnosing celiac disease (CeD), with a reported sensitivity of 98%. However, a few small, single-centre studies have questioned their sensitivity in clinical practice. Moreover, there are variation in TG2 antigens in commercial kits, with cut-offs determined by using small, poorly defined populations. We compared the variations in diagnostic performance of two immnunoglobulin IgA-TG2 assays in community population and patients with irritable bowel syndrome (IBS) at two different time periods. Methods A total of 6210 adults from defined community and 406 patients with IBS from outpatient department of Gastroenterology, AIIMS, New Delhi were enrolled under the study during 2013 and 2019 respectively. Diagnosis of patients with IBS was done on the basis of Rome IV criteria. Serum samples were drawn from all recruited subjects after taking informed consent. For both the cohorts, IgA-TG2 was measured by 2 commercially available ELISA assays i.e. Quanta Lite h-tTG IgA, Inova Diagnostic, USA and Aeskulisa tTG-A New Generation, Germany. Results For Quanta Lite assay, the seropositivity for patients with IBS and community population were 0.5% (2/400) and 1.5% (92/6210) respectively. However, for Aeskulisa assay, the seropositivity for patients with IBS and community population were 10.2% (41/400) and 8.9% (556/ 6210) respectively. Out of 556 participants from community, which were positive by Aeskulisa assay, 441 reported as negative serology from Quanta Lite assay. Conclusion The diagnostic performance of IgA-TG2 varies markedly between 2 different kits. Therefore, a single IgA-TG2 assay may not adequately rule out CeD and further confirmatory tests should strongly be considered. Keywords Celiac, Aeskulisa, Tissue-transglutaminase, Irritable bowel syndrome Introduction The novel 2019 corona virus disease , which is caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in Wuhan, China, in December 2019. Although efforts to recognize and manage SARS-CoV-2 infections have focused primarily on respiratory complications, some patients with COVID-19 infection may experience gastrointestinal manifestation of this disease. Arterial thrombosis, though less common in comparison with venous thrombosis, has also been documented in patients with COVID-19. Arterial thrombotic complications include stroke, acute limb ischemia, renal infarcts, and, rarely, mesenteric ischemia. Methods This is a retrospective analysis of mesenteric ischemia in COVID-19 patients (April to June 2021). Their clinical parameters, imaging findings and outcome were analyzed. Results All patients presenting in emergency for mesenteric ischemia were analyzed, and it was noticed that 8 of the 10 patients were males. Nine had SMA thrombosis, 1 IMA thrombosis. Seven were operated. Among them 2 expired. Four (40%) did not have any comorbidities. Mean leukocyte, neutrophil, and platelet levels were within the normal range, while the lymphocyte level was near the lower limit. C-reactive protein and D-dimer was raised in all patients. The mean levels of international normalized ratio, platelet, and activated partial thromboplastin time were above the limits. Conclusion The presence of hypercoagulation status in critical COVID-19 patients should be observed closely, and anticoagulation therapy to be considered in selected patients. Serious arterial thrombotic events might occur in COVID-19. Clinicians should be aware of the life-threatening situation in COVID-19 patients. For optimal management of these patients, understanding of various systemic manifestations and complications of SARS-CoV2 is vital. Keywords Acute mesenteric ischemia, SMA thrombosis 112 Efficacy of budesonide in management of functional dyspepsia (defined by Rome IV) associated with duodenal eosinophilia Adinath Wagh 1 , Chetan Bhatt 2 , Shobna Bhatia 2 Correspondence -Adinath Wagh -Adinath185wagh@gmail.com 1 Departments of Gastroenterology, and 2 Gastroenterology, Hepatology and Pancreatobilliary Sciences, Sir H N Reliance Hospital, Girgaon, Mumbai 400 008, India

Background Duodenal eosinophilia is recognized as an important factor in pathogenesis of functional dyspepsia. Oral budesonide has been used for treatment of eosinophilic esophagitis. Its use in eosinophilic duodenitis has not been evaluated. Aims To study the efficacy of oral budesonide in functional dyspepsia with duodenal eosinophilia. Methods This prospective observational study was done in 270 consenting adults with dyspepsia. Seventy-two patients with FD who had >22 eosinophils/hpf on duodenal biopsies (age 39.93+12.8 years; 39 men) were included. Patients received oral budesonide (9 mg/day for 4 weeks, and tapered to 6 mg/day and, then 3 mg/day for 4 weeks each) along with PPI +/-prokinetic. Patients filled out Leeds dyspepsia questionnaire (LDQ), Short form Nepean dyspepsia index (SF-NDI) and 7 point Likert scale/Global Symptom Outcome Score (GOS) at presentation, and at 3 months. Treatment response was defined as 5-point reduction in Leeds questionnaire, 2-point reduction in SF-NDI and drop in GOS score to either no or minimal severity (scores of 1 or 2 at end of 3 months treatment). The protocol was approved by the IRB. Statistical analysis: P value <0.05 was considered significant. Results Fifty-one patients had epigastric pain (EPS), and 21 had postprandial distress syndrome (PDS Background Gastrointestinal mucormycosis, a rare fatal fungal infection in an immunocompromised host, commonly affects the stomach. Case Report A 46-year-old female with long-standing diabetes mellitus, hypothyroidism, and hypertension, presented with a 3-month history of fecal discharge per vagina. She reported having intermittent loose stools, mixed with blood and mucus for 1.5 years. Based on the evaluation and unsuccessful treatment with anti-tubercular drugs elsewhere, Crohn's disease was diagnosed, and Adalimumab biosimilar started; however, the response was partial. Examination revealed: pallor and large perianal tags. Investigations: Hb 9.4 g/dL, total serum protein, and albumin 5.5 and 2.8 g/dL, respectively. A computerized tomography (CT) scan with rectal contrast showed inflammatory involvement of the rectum and sigmoid along with a rectovaginal fistula. A magnetic resonance (MR) enterography showed a loss of haustrations in the transverse colon with a prominent vasa recta in the sigmoid colon. Colonoscopy showed loss of vascular pattern with pseudopolyps in the terminal ileum, IC valve, cecum, ascending, transverse, descending, sigmoid colon, and rectum; a fistulous opening was seen in the rectum. Descending and sigmoid colon biopsies revealed crypt distortion, mononuclear cell infiltrates in lamina propria, exudate with broad aseptate fungal hyphae suggesting mucormycosis. The serology for the human immunodeficiency virus was negative. With a diagnosis of colonic mucormycosis with fistulising Crohn's disease, liposomal amphotericin B was started, but the patient succumbed. Conclusion This rare patient highlights the need for increasing awareness about fungal infestations as a cause of disease flare in patients with inflammatory bowel disease. Keywords Crohn's disease, Mucormycosis, Inflammatory bowel disease Introduction A number of mechanisms predisposes patients with chronic pancreatitis (CP) to small intestinal bacterial overgrowth (SIBO). Frequency of SIBO among patients with CP has been reported to vary between 0% and 92%. However, previous studies had limitations including high heterogeneity, inclusion of post-surgical patients with altered anatomy and inclusion of studies using lactulose hydrogen breath test (LHBT) for diagnosis of SIBO, which as several limitations. Methodology An extensive literature search of specified databases was performed using a predefined search strategy for studies evaluating the SIBO in patients with CP. After exclusion of studies not fulfilling the predefined inclusion criteria or those meeting the exclusion criteria data were extracted for meta-analysis on prevalence of SIBO in those with and without CP and also among those with CP with or without alcoholic etiology, exocrine insufficiency and diabetes. Results Among studies shortlisted for the analysis, SIBO was more commonly diagnosed in patients with CP compared to controls (Odds ratio [OR] 5.6; 95% confidence interval [CI] 2.7-11.5). However, there was no difference in frequency of SIBO among alcoholic as compared to nonalcoholic CP (OR 0.90 [95% CI 0.5-1.7]). SIBO was 2.4 (95% CI 1.4-4.2) and 2.7 (95% CI 1.4-4. 2) times more common among those with diabetes and pancreatic exocrine insufficiency, respectively. Conclusions Patients with CP have SIBO more commonly as compared to controls and the risk is more in patients with endocrine and exocrine insufficiency than those without and does not depend on etiology of CP. Background Small bowel bleeding poses a diagnostic and therapeutic challenge. With the advent of newer device assisted enteroscope, diagnostic and therapeutic enteroscopy has become easy to perform. Here we present a case of massive, small bowel bleeding where a novel endoscopic collagen spray was used to achieve hemostasis. Methods Novel motorized spiral enteroscope and endoscopic collagen spray (Hemoseal spray, Shalili) were used. Case Report A-26-year-old gentleman, presented with bleeding per rectum on and off. At presentation he was in shock with hemoglobin 0.6.g/ dL. He was resuscitated. Endoscopy and colonoscopy were normal. CT visceral angiography showed enhancing wall thickening in distal jejunum/ proximal ileal loop, possible Crohn's disease. Novel motorized spiral enteroscopy showed multiple large ulcers with ooze of blood in distal jejunum and proximal ileum. Hemoclip was applied to a visible vessel and novel endoscopic collagen spray was applied to the entire extent of bleeding. He stabilized and recovered. He is currently on treatment of Crohn's disease on follow-up. Conclusion Endoscopic collagen spray can be used as an additional hemostatic agent for diffuse bleeding in extensive ulcers in the small intestine safely. Use of broad-spectrum antibiotics in these patients may be associated with subsequent increase in Clostridioides difficile infection (CDI) Methods Retrospective analysis of cases with CDI detected between January and April 2021 in patients with Results Over the period of last 4 months (January 2021 to April 2021), the author encountered eight cases of CDI in patients who underwent treatment for COVID -19. In the previous 2 years (2019-2020), only one case of documented CDI was noted at our centre. A, all patients were above 45 years of age and predominantly females. All patients had one or more comorbid states. All patients had severe COVID-19 infection and required prolonged hospital stay. Broad spectrum antimicrobials, steroids, proton pump inhibitors and remdesivir were used in these patients. Six patients presented within one month of discharge from COVID care facility while two were diagnosed during hospital stay. The symptoms of CDI included-profuse diarrhea (8,100%), abdominal distention (2, 25%), anorexia (2, 25%) and nausea (2, 25%). Diagnosis was confirmed by stool test for C. difficile toxin assay in all cases and sigmoidoscopy showing pseudomembranes in 6 cases. One case had toxic megacolon and another case was on ventilation with inotropic support. All patients were started on antibioticsmetronidazole and vancomycin. Six cases who presented post discharge improved with treatment and were doing well on follow-up at 1 month.

Introduction Primary amyloidosis of gastrointestinal (GI) tract is a rare presentation. In the GI tract, amyloidosis affects the duodenum most commonly, followed by the stomach and colorectum. GI bleeding due to AL amyloidosis is a rare phenomenon and has been reported in 10% to 40% of patients with GI involvement. GI amyloidosis presents as abdominal pain, gastroesophageal reflux disease-like symptoms, upper or lower GI bleeding, malabsorption, bacterial overgrowth, and diarrhea. Case Report We here present a 66-year-old male known case of coronary artery disease (CAD) on antiplatelets presented with intermittent lower abdominal pain and hematochezia for 3 days. Colonoscopy showed multiple colonic ulcers, biopsy of ulcers showed features of amyloidosis. Biopsy reports were suggestive of secondary amyloidosis (AA type). He had significant proteinuria and renal core needle biopsy revealed mild medial hypertrophy of arteries and arterioles with deposition of extracellular eosinophilic material suggestive of amyloidosis. The presence of lambda light chain restriction by direct immunoflourensce studies favored primary amyloidosis. On further evaluation he was found to have plasma cell dyscariasis and was later started on immunosuppresant medications. Amyloidosis of GI tract presenting as lower GI bleed is a rare entity. Conclusion The clinical presentation and high index of suspicion most essential, when patient has multisystem involvement to detect primary amyloidosis. Biopsy is of utmost importance in guiding the diagnostic evaluation along with other supportive investigations. Though the evaluation with intestinal biopsy alone would have been misleading regarding the type of amyloidosis in our case. On further evaluation, other features suggested towards systemic light chain related amyloidosis such as renal and bone marrow biopsy, guiding appropriate treatment plan. The biopsies of the rectal or small bowel mucosa or renal or biopsy of subcutaneous adipose tissue will help in diagnosis, as it will be positive in many patients with amyloidosis. Keywords Hematochezia, Amyloidosis, Plasma cell dyscariasis Introduction Endoscopic remission is the current treatment target in ulcerative colitis (UC) patients. Literature on adequacy of sigmoidoscopy in comparison to pan colonoscopy in UC patients is sparse. Methods It is an interim analysis of a prospective study of patients diagnosed with UC with disease extent proximal to the sigmoid colon. Twenty adult patients underwent a complete colonoscopy with segmental biopsies. Endoscopic disease activity was graded using Mayo Endoscopic Subscore and the histological grading was done using the Simplified Geboes Score (SGS). The maximum rectosigmoid disease activity was compared with the maximum disease activity in the rest of the colon. Results Endoscopic Correlation: Sigmoidoscopic examination showed good correlation with pan colonoscopic examination for disease severity with a sensitivity of 87.5% and specificity of 75%. The accuracy of sigmoidoscopic examination for pancolonoscopic disease severity was 80% (95% CI -57% to 100%). Histological Correlation Rectosigmoid histological examination for SGS showed good correlation with SGS for biopsies from the proximal colon to diagnose severe pancolonic involvement with a sensitivity of 88.24%, specificity of 33.33% and an accuracy of 80%. Conclusion In patients diagnosed with UC and having disease extent proximal to the sigmoid colon, sigmoidoscopic examination has good correlation with pan colonic examination for grading endoscopic and histological disease severity. A sigmoidoscopic examination is adequate to assess the disease severity in patients with disease extent proximal to the sigmoid colon. Keywords Ulcerative colitis, Simplified Geboes score, Mayo endoscopic subscore Introduction Entamoeba Histolytica is a pathogenic protozoan endemic in the Indian subcontinent and can have protean presentation. Methods We present a case series of 7 patients who presented with isolated bleeding per rectum (PR) in whom intestinal amebiasis was not initially suspected. None of the patients had fever and infectious colitis was not anticipated. Results First case A 7-year-old male child who presented with bleeding PR and was suspected to have a juvenile rectal polyp. Second case A 72-year-old female with ischemic heart disease who presented with bleeding PR and was suspected to have diverticular bleed or bleeding from angioectasia or ischemic colitis. Third case A 69-year-old male who was suffering from COVID-19 infection, was on steroids and developed bleeding PR. Initial diagnosis was ischemic bowel disease. Fourth case A 39-year-old male who presented with isolated bleeding PR. Imaging was suggestive of ileo-colonic tuberculosis or Crohn's disease. Fifth case A 45-year-old male who presented with large quantity bleeding PR. Suspected diagnosis was massive diverticular bleed. Sixth case A 9-year-old male child who presented with bleeding PR and was suspected to have juvenile rectal polyp.

Seventh case A 85-year-old lady who presented with bleeding PR and initial diagnosis was diverticular bleed. Diagnosis was established in all 7 cases after ileo-colonoscopy and histopathology. On colonoscopy, all 7 patients had cecal ulcerations. Three had additional rectal ulcerations, while one had additional terminal ileal ulceration and one had ulcerations throughout the colon including rectum. Histopathology showed typical amebic ulcers with trophozoites of Entameba histolytica. All 7 patients recovered with metronidazole therapy. Conclusions Intestinal amoebiasis can be a great masquerader and should be considered in the differential diagnosis of patients presenting with isolated bleeding per rectum in endemic countries like India. Keywords Intestinal Amoebiasis, Bleeding per rectum, Entamoeba Histolytica 120 Management of irritable bowel syndrome in Indian patients with a fixed-dose combination of mebeverine hydrochloride and chlordiazepoxide Aim To assess the effectiveness and safety of a fixed-dose combination of mebeverine hydrochloride 135 mg and chlordiazepoxide 5 mg in the management of irritable bowel syndrome (IBS) in Indian patients. Methods This was an 8-week, prospective, open-label, observational study. Patients (n=60, age: 18-60 years), newly diagnosed with IBS and having anxiety symptoms (score =18 on Hamilton anxiety rating scale [HAM-A]), who were prescribed the study drug as a part of routine practice were included. The study drug dosage was thrice daily before food. Results All 60 patients completed the study. Patients' mean (SD) age was 37.45 (11.00) years; most were male (73.33%). The mean (SD) irritable bowel syndrome-symptoms severity scores (IBS-SSS) at baseline was 182.72 (84.39). The mean change in IBS-SSS scores from baseline at week 8 (primary endpoint) was -85.50 (82.69), p<0.0001, and at week 4 was -64.70 (58.44), p<0.0001. There was a notable decrease in scores from baseline at week 4 and at week 8 for each of the individual parameters assessed on the IBS-SSS scale (all p<0.0001). The mean (SD) irritable bowel syndrome-36 (IBS-36) score at baseline was 78.33 (41.87) and change from baseline at week 8 was -45.88 (34.92), p<0.0001. At week 8, majority of patients achieved a =50-point improvement in IBS SSS score (73.33%), and a =10-point improvement in IBS-36 score (88.33%). The mean (SD) HAM-A total score was 26.97 (6.72) at baseline and decreased to 10.45 (8.99) at week 8, p<0.0001. Three adverse drug reactions were reported in two patients: nausea in one patient and headache in both patients. All patients and investigators described "good" tolerability to study drug at week 8. Conclusion The fixed-dose combination of mebeverine hydrochloride 135 mg and chlordiazepoxide 5 mg was well tolerated and effective in the management of symptoms related to IBS. Background Status and trends of disease related burden provide valuable information for effectively handling various dimensions of disease management and carving out suitable policy measures. Present study investigates Global Burden of Disease (GBD) 2019 study database to summarize and critically investigate the global burden of IBD. Methods Using Log-Linear growth models, we have presented trends for three decadal data (1990-2019) for age standardized prevalence estimates, incidence estimates, disability adjusted life years (DALYs) and its components: years lived with disability (YLDs) and years of life lost (YLLs). We have also reported IBD related burden measures stratified across 15 macrogeographic regions, Socio-Demographic Index (SDI) based quintiles, gender and age. Results On crude basis, globally the prevalence rate of IBD increased from 62.09 in 1991 to 63.30 in 2019. Age standardized IBD related prevalence and burden measures have shown a significant downward trend over the period of study. There are negative compound annual growth rates of 0.656% and 1.035% for prevalence and burden of disease respectively over the study period. There is a wide variation in burden estimates and their growth rates across regions and SDI based quintiles. Although the contribution of premature mortality to the burden of disease has come down over last 30 years, yet in 2019 it contributed about 56.33% to the disability adjusted life years. Incidence rate of IBD has fallen significantly in the age groups of more than 25 years but the same has remained stable for the age groups of less than 25 years. Australasia and Western Europe have high IBD prevalence and related disease burden, and contrary to global trends, these regions have exhibited significant positive growth trends. Conclusions The findings highlight widespread variations in all IBD related burden measures across regions. For better management of IBD, there is a need for localized research and policy measures. Keywords Inflammatory bowel disease, epidemiology, quality adjusted life years endometriosis. Amyloidosis of gastrointestinal (GI) tract presenting as lower GI bleed is a rare entity. GI bleeding due to AL amyloidosis is a rare phenomenon, and has been reported in 10% to 40% of patients with GI involvement. Case Report A 66-year-old gentlemen with previously diagnosed coronary artery disease on antiplatelets presented with intermittent lower abdominal pain and hematochezia for 3 days. Colonoscopy revealed diffuse linear ulceration and a few deep necrotic ulcers throughout the transverse and descending colon; diffuse erythema and erosions in rectum. Biopsy of ulcers revealed amyloidosis. Initially biopsy was reported as secondary amyloidosis (AA type) since submucosal vessel thickening with salmon red colored material and apple green birefringence with congo red stain were noted. He also had significant proteinuria; renal core needle biopsy revealed mild medial hypertrophy of arteries and arterioles with deposition of extracellular eosinophilic material suggestive of amyloidosis. The presence of lambda light chain restriction by direct immunoflourensce studies favored a revised diagnosis of primary amyloidosis. On further systemic evaluation he was found to have plasma cell dyscariasis and was initiated on immunosuppresants. Amyloidosis of GI tract affects the duodenum most commonly, followed by the stomach and colorectum. GI amyloidosis presents as abdominal pain, gastroesophageal reflux diseaselike symptoms, upper or lower GI bleeding, malabsorption, bacterial overgrowth, and diarrhea.The mechanism of GI bleed in amyloidosis is believed to be due to thickening and calcification of the mesentry, peritoneum and retroperitoneum causing GI ulcers with bleeding. Conclusion A high index of suspicion is necessary to diagnose primary amyloidosis. This case report illustrates the importance of obtaining biopsy in the evaluation of bleeding colonic ulcers. Amyloidosis, being a multisystem disease, its detection in the GI tract should prompt one for careful evaluation of other systems as well. Keywords Hematochezia, Amyloidosis, Colonic ulcers 123 Gaps in optimal use of biologic therapy in inflammatory bowel disease patients at tertiary care centre in developing country-A gap analysis Background and Aims Inflammatory bowel disease (IBD) is chronic relapsing disease requiring life-long therapy. Biologics are often required for induction and maintenance of remission. Treatment discontinuation often occurs. We decided to analyse gaps in optimal use of biologics. Methods Patients eligible for biologic therapy were selected from prospectively maintained IBD database. Coverage gap is a gap between number of patients prescribed biological therapy and number of patients eligible for therapy measured by screening rate and 1st dose received rate. Retention gap denotes difference between the number of patients actually on biologic therapy at a given point to number of patients expected to be on biologic therapy measured by medication possession rate, discontinuation rate. Wellness gap is defined as patients on biologic therapy with remission with or without adequate quality of life as per IBDQ-32 questionnaire. Out of 540 patients, 150 (27.77%) eligible patients with complete record were identified. Screening rate was 100%. First dose received rate was 55.33% (83/150). Sixty-seven (44.66%) cases fall in the coverage gap due to financial constraints (90%), drug non-availability (5%) and 5% selected surgery/clinical trial as option. Out of 83 patients started and maintained on biologics 44 (53.01%) had medication possession rate >80%. Thirty-nine (46.98%) could not be 'retained' in maintenance phase due to financial constraints (20, 51.28%), discontinuation due to remission (10, 25.64%), surgery (6, 15.38%), clinical trial (3, 7.6%) suggestive of 'retention gap'. Out of 44 patients on maintenance, 38 (86.36%) were in clinical remission and 35 (80%) were satisfied and happy as per IBDQ-32 questionnaire. Out of remaining 9 (20%) patients, 6 had response loss and 3 had tuberculosis. Out of 150, 38 (25.33%) were in remission. Thirty-five (23.33%) had good quality of life (QOL). Conclusion Financial constraints and high cost of biologic therapy are responsible for significant coverage and retention gaps. Low cost effective therapies may help to reduce these gaps. Keywords Inflammatory bowel disease, Gap analysis, Biologics

Endoscopic appearance among patients with chronic diarrhea in a urban tertiary care centre Chittuluri Jagadeesh Correspondence -Chittuluri Jagadeesh -doctorjd18@gmail.com Institute of Medical Gastroenterology, Madras Medical College and Rajiv Gandhi Government General Hospital, Poonamallee High Road, Park Town, Chennai 600 003, India

Backgrounds and Aims Chronic diarrhea is defined as abnormal stool weight, consistency and/or frequency, that last for at least four weeks. There are many possible causes of chronic diarrhea. Chronic diarrhea treatment seeks at eliminating the underlying cause, strengthening bowel movements, and treating any problems associated with diarrhea. Endoscopy plays an important role as a chronic diarrhea diagnostic instrument. This paper provides a preliminary study of chronic diarrhea based on endoscopy appearance in adults. Methods A cross sectional study was conducted at Madras Medical College in Chennai. Data of their demographic profiles and endoscopy were recorded from medical record. Results Two-hundred and seventy patients were included in this study from January 2021 -September 2021. Median age was 54 years old (range 19 to 84 years old). The amount of male and female patients doesn't differ. The most common diagnosis of chronic diarrhea is inflammatory bowel disease (67.2%), followed by cancer (22.6%). Among of those patients with cancer, there are 63.6% with rectal cancer and 36.4% with colon cancer. Of those with diarrhea, there are twelve patients with tuberculous colitis who were all patients with human immunodeficiency virus (HIV) infection. The remainder of these patients with chronic diarrhea were radiation colitis with cervical cancer as underlying disease. Conclusion Chronic diarrhea can affect the quality of life and general health considerably. Chronic diarrhea patients generally require some assessment, but in some cases history and physical examination may be adequate to direct treatment. Diet, medicines, and surgery or radiation therapy can be significant causes of chronic diarrhea that can be suspected from history alone. Endoscopy and biopsy is valuable for the diagnosis of chronic diarrhea. Keywords Chronic diarrhea, Endoscopy, Biopsy Introduction Colorectal carcinoma (CRC) is the third most common cancer of gastrointestinal tract in the world. Ninety percent CRC develops are mainly adenocarcinoma. Nerve growth factor (NGF) is significant for the development and phenotypic maintenance of neurons. There is a major utility of NGF in maintenance of visceral integrity. The function of NGF in gastric cancer and ulcerative colitis have been reported but in colorectal carcinoma is still unidentified. Aim Immunohistochemical study of nerve growth factor in myenteric neurons of the colorectal adenocarcinomatous tissues in humans. Methods Thirty specimens collected for this study. Twenty specimens from patients undergoing surgery for colorectal adenocarcinoma in department of gastrointestinal surgery and 10 specimens of normal colonic tissues collected from department of forensic medicine, All India Institute of Medical Sciences, New Delhi. It was approved by the Institutional Ethical Clearance Committee of All India Institute of Medical Sciences, New Delhi. Tissues were processed and 3 μm thick sections used for H&E and immunohistochemistry (anti-NGF antibody: neuronal marker used). Results H&E stained sections showed decrease in the myenteric neurons with increasing grades of colorectal carcinoma and immunohistochemistry showed the increasing expression of anti-NGF antibody with increasing grades of colorectal adenocarcinoma as compared to normal human colonic tissue. Conclusion NGF may have profound effects on enteric neurophysiology and emphasizes the importance of increasing the current understanding in maintenance of enteric nervous system. Keywords Myenteric neurons, Nerve growth factor, Colorectal carcinoma 126 Delayed manifestations of colonic mucormycosis in severe corona virus disease 2019 Ravi Shankar Bagepally, Vijay Rampally Correspondence -Ravi Shankar Bagepally -b_ravishankar@yahoo.com Department of Gastroenterology, Yashoda Hospitals, Alexander Rd, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India Mucormycosis is a rare, devastating fungal infection of humans and usually affects immunosuppressed individuals. The corona virus disease 2019 (COVID-19) pandemic has affected millions of people and caused significant mortality in severely diseased subjects. During the second wave of pandemic in India (2021), Mucormycosis has surfaced as a significant opportunistic infection. Gastrointestinal mucormycosis is rare and the usual presentation is gastrointestinal (GI) bleed. We present two cases of colonic mucormycosis with manifestation of colonic bleed and colonic perforation. Diagnosis of these cases was made by KOH stain on endoscopic biopsies and histopathology at surgery. Both patients had severe COVID infection. Systemic antifungal therapy did not benefit any of the patients. Both patients underwent surgery at a later stage of disease. There could be a significant number of patients with COVID in whom GI mucormycosis might have been overlooked. High suspicious and early endoscopy in COVID patients with bleed, abdominal pain or late onset diarrhea may be helpful in quick diagnosis and probable recovery, if treatment is instituted before it is late.

Introduction Data on the prevalence and distribution of colonic polyps in Indian/Asians is limited. To study this, we conducted a retrospective study on 202 polyps out of 7936 colonoscopies. Method The objective was to analyse demographic, clinical, endoscopic and histopathological characteristics of polyps in patients undergoing colonoscopy from 2016 to 2019 at GIPMER, New Delhi. All polyps were removed colonoscopically by polypectomy and specimen were sent for histopathological examination. Parameters like age, gender, symptoms, site, gross morphology, and histological subtypes of polyps were assessed. Result Total 7936 colonoscopies were performed in this period. Polyps were seen in 202 patients. Mean age was 23 years. 72% were males. 82% were below 40 years and 18% were above 40 years of age. 69% polyps were found in rectum. 63% polyps were juvenile, 10% Peutz-Jeghers, 17% adenomatous, 3% inflammatory and 7% others. Mean age of adenomatous polyp was 48 years. 66% polyps were pedunculated. 51% polyps were less than 1 cm. 81% patients presented with bleeding P/R. 78% of adenomatous polyps were dysplastic. Out of adenomatous polyp 44% were tubular, 34% tubulo-villous and 22% villous. Conclusion Frequency of polyps on colonoscopy at our centre was 2.5%. Most common type was juvenile polyp. Polyps were more common in younger age group. Adenomatous polyps were common in middle to old age group. Most polyps were small, pedunculated, and located in rectum. Tubular was most common type of adenomatous polyp. Dysplasia was more common in villous type. Keywords Polypectomy, Peutz-Jeghers, Dysplastic polyp Background and Aims The corona virus disease (COVID) pandemic and countrywide lockdown has had significant impact on patients with inflammatory bowel disease (IBD), with delay in diagnosis, difficulty in access to healthcare and unavailability of drugs. We conducted a telephonic survey to assess this impact. Methods Out of 350, 302 participated in the survey. Demographic data, disease severity at the time of survey, extent of disease, details of therapy and adherence were noted. A validated questionnaire addressing information source, perception of COVID-19 situation, contact with healthcare, adherence to standard precautions was administered telephonically. Results Out of 350 contacted patients, 302 (86.28%) patients participated in the survey. Median age of cohort was 39 years. Ulcerative colitis (UC) constituted 79%, 16% Crohn's disease (CD) and 5% IBD-unclassified. At the time of survey, 86.98% patients with UC were in clinical remission and 75.75% of CD patients were generally well. One hundred and fifteen (38%) cases were nonadherent to therapy due to unavailability of medicines (66.38%), financial constraints (25.21%) inability to reach healthcare facility (3.6%). Disease flare was seen in 14.2% correlated well with nonadherence. Existing drug therapy was switched to alternative drug in 70 (23.17%) cases due to unavailability (74%). Social media (52.3%) and television (40.4%) were the common sources of information about the pandemic. Telemedicine platforms (WhatsApp and telephone) were used by 180 (59.6%) patients for consultation with good acceptance (81.6%). Eighty-seven (28.8%) patients failed to contact healthcare. Apprehension regarding severe Covid infection was noted in 80% while 29% thought that IBD therapy could increase infection risk. Adherence to wearing mask, hand washing, and social distancing was 100%. Conclusion Pandemic resulted in disruption of healthcare visits and medication supply. Majority were concerned about increased risk of COVID-Introduction The novel corona virus disease 2019 (COVID-19) is a potential devastating disease with varying presentation from asymptomatic to critically ill patients. Patients are susceptible to fungal and bacterial infections due to low immunity. Mucormycosis is life threatening fungal disease with propensity to vascular invasion by hyphae, causing ischemic necrosis to tissue it invade. Case Study A 60-year-old male patient presented to us with c/o fever, abdominal pain, hematochezia from 1 day. Patient was treated at some hospital for breathlessness, fever, sore throat 10 days ago and was found to be COVID-19 positive and treated there with meropenem, oseltemavir and hydrocortisone and discharged. Patient again came to our emergency, was admitted. Repeat throat swab was done, found to be COVID-19 positive. Urgent colonoscopy was done s/o giant ulcer with debris and active bleeding in ascending colon, biopsy examination confirmed mucormycosis after confirmation on biopsy Amphotericin was prescribed as per standard dose with gradual improvement in clinical condition. Discussion Patients with COVID-19 has higher level of inflammatory markers such as IL-6, IL -10, with impairment in cell mediated immunity. There is current protocol of using steroids to prevent or treat cytokine storm to prevent further complications, but this leads to increased risk of fungal infections. Mucormycosis causes ischemia and necrosis by hyphae invasion. GI involvement from stomach to rectum can be seen in 5% to 8% of cases. Disease has high mortality and diagnosis is based on biopsy confirmation of typical fungal hyphae from specimen obtained during surgery or endoscopy. Treatment consists of early antifungal with surgical resection of involved part. Conclusion Although GIT Mucormycosis is a rare disease due to decreased immunity. High clinical suspicion with early intervention is required to prevent further complications in COVID-19. Keywords COVID -19, Overuse of steroids, GI mucomycosis Primary signet ring cell carcinoma of the rectum (PSRCCR) is a rare variant of colorectal adenocarcinoma (AC) with incidence of less than 1%, containing > 50% of cells with prominent intracytoplasmic mucin with marked nuclear displacement and molding (signet ring cells) and presents at an advanced stage. The tumor has a distinctive molecular pattern and poor prognosis as it presents as diffuse infiltration and circular thickening of the bowel wall, also called "colonic linitis plastica." Case Report A 20-year-old female born out of nonconsanguineous marriage with hematochezia, pain abdomen since 3 months, tenesmus and loss of appetite since 3 months. There are no affected relatives due to colonic cancer in family. On examination patient is pale. Per abdomen examination was normal except with mild tenderness in left iliac and lumbar region. Investigations Laboratory examination shows Hb:9.1g/dL, MCV:82.1fL, TLC:4100/microL, platelet: 2.11Lakhs, ESR: 40 mm/hr, CRP was negative. Contrast CT abdomen shows homogenous smooth circumferential thickening with enhancement of rectum for length of 8 cm with 24 mm thickness causing luminal narrowing with transverse and descending colon dilatation of 5 cm with evidence of hyperdense linear branching foci noted in right pararectal region likely vascular calcifications extending into rectal wall suggestive of phlebosclerosing colitis. Upper GI endoscopy was normal, but sigmoidoscopy shows presence of circumferential edema, erythema, ulceration, wall thickening, friability and spontaneous bleeding from 5 to 10 cm from anal verge, causing luminal narrowing. Biopsy reveals sheets of signet ring cells, infiltrating into lamina propria with extracellular mucinous material suggestive of poorly differentiated adenocarcinoma, signet ring cell type. Conclusion Primary signet ring cell cancer in young females being rare in rectum with no family history is a distinct entity and imaging evidence of vascular calcifications in mucosal wall with thickening can be a early sign in signet ring cell carcinoma and may indicate poor prognosis Keywords PSRCCR, Vascular calcifications Methods Two hundred consecutive cases of colonoscopy were selected. Patients more than 18 years of age posted for colonoscopy were included and those with history of colonic disease such as inflammatory bowel disease, previously diagnosed adenomas, colorectal cancer, family history of adenomas or colorectal cancer were excluded. The prevalence of polyps detected among colonoscopy was calculated. Polyps were classified according to site, size, number and histopathology. Results Of 200 cases, polyps were detected in 41 patients and of these 31 patients fulfilled criteria for metabolic syndrome. In remaining 159 patients without colonic polyps 29 had metabolic syndrome. Statistical analysis showed prevalence of colonic polyps in sample population at 20%. Polyps were most commonly found in left colon and were predominantly adenomatous in nature. Prevalence of metabolic syndrome was found to be 30%. Also, upon applying Chi-square test for Yates's correction the association between the occurrence of polyps and that of metabolic syndrome is found to be statistically significant (p value =0.00001). Conclusion Our study shows statistically significant association between occurrence of colonic polyps and presence of metabolic syndrome, further multicentric studies are required to validate our finding and to make recommendations for the screening in this population. Keywords Colonic polyp, Metabolic syndrome. Background and Aims This study aims to assess the clinical features and colonoscopic findings in patients with radiation proctitis after radiotherapy for pelvic malignancy. Methods This was an observational cross sectional study conducted in Department of Digestive Health and Disease, attached to Kilpauk Medical College over a period of 1 year. A total of 28 patients above the age of 18 years who received radiotherapy for pelvic malignancies were included in this study. Clinical features and colonoscopic findings were assessed in those patients. Vienna Rectoscopy score (VRS) was used to describe the colonoscopic findings and was compared to the European Organization for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) morbidity score for clinical features. Results A total of 28 patients of age ranging (30-55) were included. Mean interval between radiotherapy and presenting symptoms was 15 months. Sixteen patients had carcinoma cervix and rest had carcinoma endometrium, prostate, and rectum. Twenty-two patients received radiation dose of 45-70 Gy,7 above 70 Gy. The most frequent symptom observed was rectal bleeding in 21 patients, bowel habit change in 4 patients and mucous stools in 3 patients. Colonoscopic findings were congested mucosa in 18 patients, telangiectasia in 8 patients. Ulcerations in 2 patients. Eighteen patients (VRS score >grade 2) had morbidity score greater than grade 2. The VRS significantly correlated with EORTC/RTOG score (p = 0.038). Conclusion In conclusion, rectal bleeding was the most frequent symptom in RT induced proctitis followed by bowel habit change. Congested mucosa and telangiectasias were the most prevalent colonoscopic findings in RT induced proctitis. Vienna rectoscopy scoring significantly correlated with EORTC/RTOG morbidity score. Keywords Radiation, Proctitis, Rectal bleeding 133 Comparative analysis of gene expression in blood and colonic tissue of ulcerative colitis Ajay Oli 1 , Rohit N Maidur 2 , Anita P Javalgi 3 , Preetham S Hurakadli 2 , Palaksha K Javaregowda 1 , Apoorva Jain 1 Correspondence -Ajay Oliajay.moli@gmail.com Departments of 1 Biomedical Science, 2 Gastroenterology, and 3 Patholoy, SDM Research Institute for Biomedical Sciences, Shri Dharmasthala Manjunatheshwara University, 5th Floor, Specialty Block, Manjushree Nagar, Sattur-Dharwad 580 009, India

Background Inflammatory bowel disease (IBD) includes Crohn's disease (CD) and ulcerative colitis (UC) cause gut tissue chronic inflammation, has no cure, and requires life-long therapy. UC is a chronic relapsingremitting disease of the large intestine that is associated with both genetic and environmental risk factors. UC is characterized by inflammation of the mucosa and sub-mucosa, a loss of epithelial barrier integrity, and dysregulated immune responses. Aim The aim of this study is to analyze a gene expression level in a blood sample and the colonic mucosa of UC patients. Methodology We studied a total of 20 patients with a definitive diagnosis of UC and the control group (20 subjects) without endoscopic evidence of intestinal inflammation. Peripheral blood samples and colonic mucosal biopsies were collected by venipuncture and colonoscopy procedures, respectively. Then the total RNA was extracted by using Trizol method and genes, IDO-1, TNFβ, IFNα, IL-6 expression was analyzed by quantitative real-time polymerase chain reaction (qrtPCR). Results The study demonstrated the significant difference in genes, IDO-1, TNF-β, IFNα, IL-6 expression in both blood and tissue biopsies of UC patients as compared to the control. Furthermore, this preliminary study also demonstrated the importance of sample type, blood vs. tissue in studying the biomarkers for diagnosis of UC. Conclusion The expression of marker genes is associated with the clinical course and histological deviations and are of relevance since they define the usefulness of markers in diagnosis of UC. The result indicates the possible involvement of genes, IDO-1, TNF-β, IFNα, IL-6 in pathogenesis of UC. The comparative analysis indicates the similarity in marker gene expression in blood and tissue biopsies of UC patients. Hence, the blood sample could be a potential substitute for tissue biopsies for early diagnosis of ulcerative colitis. Keywords IBD, UC, qRTPCR, Gene expression, mRNA -19) pandemic. There is an overlap of GI symptoms between these two infections. Method We have screened severely ill COVID-19 patients with persistent diarrhea for CDI. Stool assay for GDH and stool enzyme immunoassay for toxin were screening and confirmation test respectively.

Results Among, 32 screened patients, we have identified eleven patients with CDI co-infection. All patients had persistent diarrhea as presenting complaints. However, 6 patients complained of bloody diarrhea. Other clinical features include-fever in 4 patients and abdominal pain in 2 patients. The most commonly used antibiotic was ceftriaxone. Severe CDI was noted in 8 patients. All patients with severe CDI were on steroids. Colonoscopy was done in 7 patients, which revealed erythematous mucosa in all patients, focal pseudo-membrane in 3 patients, and diffuse pseudo-membrane in 1 patient. Histology revealed predominant neutrophilic infiltrate in all patients. Computed tomography was done in 4 patients-all patients had diffuse bowel wall thickening. The accordion sign was seen in 2 patients. All patients received the standard medical line of management. Three patients with mild CDI improved with antibiotics. However, 1 patient succumbed to respiratory complications. Five patients with severe infection succumbed-3 due to C. difficile related complications, one each due to respiratory failure and multi-organ dysfunction. Conclusion CDI in COVID-19 patient may be challenging, and needs high degree of suspicion. Judicious use of antibiotics is advisable in COVID-19 hospitalized patients. Keywords COVID-19, Cl. difficile, Antibiotics

Vitamin-D level in patients of acute severe ulcerative colitis Introduction Vitamin D plays a primary role in calcium, phosphorus and bone metabolism. However, the discovery of vitamin D receptors on lymphocytes, monocytes, and dendritic cells initiated various studies which have highlighted the role of vitamin D in regulating gut mucosal immunity and gut barrier. Ulcerative colitis (UC) is characterized by an inappropriate and exaggerated mucosal immune response to gastrointestinal antigens in genetically susceptible individuals. This study done to detect vitamin-D deficiency in severe ulcerative colitis patients and find any relationship with vitamin-D deficiency and severity of ulcerative colitis. Methods Twenty-five patients of acute severe colitis patients were taken in to study and vitamin-D levels was measured. They were divided in to 4 groups based on vitamin-D level as severe vitamin D deficiency (< 12 ng/ mL), mild to moderate deficiency (12 to 19 ng/mL), insufficiency (20 to 29 ng/mL), and suboptimal levels (29 to 40 ng/mL). Results Out of 25 patients vitamin-D level <12 ng/mL present in 11 (44%) patients, 12-19 ng/mL present in 8 (32%) patients, 20-29 ng/ mL present in 5 (20%) patients and 30-40 ng/mL present in 1 (4%) patients. Conclusion In this study all patients included in the study had vitamin-D deficiency. Further studies required to demonstrate its therapeutic and preventive role in exacerbations of ulcerative colitis. Keywords Vitamin-D, Ulcerative colitis, Immune response 136 Extensive deep vein thrombosis as the initial presentation of colorectal cancer: A case report Introduction Malignancy is a hypercoagulable state. Carcinoma of pancreas, stomach, and lung are commonly associated with venous thromboembolism (VTE). Colorectal carcinoma (CRC) is a very rare cause of VTE with a two year cumulative incidence of 3%. We present a case of extensive unprovoked DVT as the initial presentation of colonic malignancy. Case Summary Fifty-four-year-old male, farmer, with no prior comorbidities or addictions, presented with insidious onset of dull aching pain in left thigh. He had no upper GI or lower GI symptoms. Examination revealed bilateral calf tenderness. Venous doppler was suggestive of extensive DVT of both lower limbs. He was started on warfarin after bridging with heparin. While on adequate anticoagulation, he developed new onset pain in his right arm and was diagnosed to have cephalic vein thrombosis. He was evaluated in view of extensive unprovoked DVT. Thrombophilia workup was negative. Ultrasound abdomen showed multiple hypoechoic focal lesions in both lobes of liver. Upper GI endoscopy was normal. Tumor markers revealed elevated CEA with normal AFP. CECT abdomen showed multiple liver metastases and a short segment circumferential wall thickening of distal transverse colon. Colonoscopy revealed ulceroproliferative growth in mid-transverse colon with luminal narrowing. Histopathology confirmed a colonic malignancy. Discussion There is a synergistic relationship between cancer biology and the clotting system. In colorectal carcinoma, there can be upregulation of the clotting system with tissue factor (TF) being abnormally expressed on tumor cells. TF positivity correlates with TNM stage and hepatic metastasis. Clot formation surrounding metastatic cells in the bloodstream may allow them to escape immune surveillance to form distant metastatic deposits. Our patient had CRC with hepatic metastasis presenting as DVT.

Conclusion In extensive unprovoked DVT, in middle aged men, search for underlying malignancy even if patients do not have any symptom to suggest a colorectal carcinoma. Keywords Colorectal cancer, Deep vein thrombosis, VTE

Comparison of Mayo endoscopic score and ulcerative colitis endoscopic Index of severity score with histological activity in ulcerative colitis Introduction Endoscopic and histological remission are the desirable targets in ulcerative colitis (UC) for achieving better long-term outcomes. The aim of the present study was to compare the correlation of Mayo endoscopic score (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score with histological activity in UC. Methods This is a longitudinal follow-up study conducted between September 2018 and February 2020 including patients with newly diagnosed acute UC or a flare of pre-existing UC. The disease activity was assessed using clinical, colonoscopy (MES and UCEIS) and histopathology (Geboes [GS] and Robarts histopathology index [RHI]) at baseline and at clinical remission. The correlation of MES and UCEIS with histology was done using spearman correlation coefficient at clinical remission. Results A total of 43 patients were studied. The mean age was 36 ± 10 years with a slight male predominance. At clinical remission, 79% (34/ 43) achieved endoscopic remission by MES while 56% (24/43) achieved by UCEIS. Histological remission was achieved by 42% (18/43) and 40% (17/43) by GS (≤12) and RHI (≤3) respectively. There was a weak correlation of MES with both GS (rho=0.312, p=0.04) and RHI (rho=0.375, p=0.01). Correlation of UCEIS with GS was weak (rho=0.327, p=0.03), however there was moderate correlation with RHI (rho=0.44, p=0.003). Conclusion Our study showed that the currently available endoscopic scores (MES and UCEIS) have only a weak to moderate correlation with histological activity. Hence, a biopsy is required to confirm the presence of an underlying inflammation even in those who have endoscopic remission. Keywords Endoscopic activity, Geboes score, Robarts histopathologic index, Ulcerative Colitis Introduction There are many case reports on AV malformations of gastrointestinal (GI) tract. Most of the AVMs of GI tract occur in right side of colon, but it is very rare to observe AVMs in rectum.

Here we report a case of 22-year-old female with past history of pulmonary tuberculosis completed ATT for 6 months presented to our hospital (RGGGH, Chennai) with on and off bleeding per rectum from the age of 11 years, on examination patient had clinical pallor, no other findings, patients' investigation showed Hb 5.1 gm% (severe anemia), initially treated with 3 units of PRBCs. CECT abdomen showed diffuse circumferential wall thickening with submucosal edema noted in rectum (maximum thickness of 2.1 cm). Multiple prominent vessels noted with in the rectal wall showing enhancement in the arterial phase. The inferior mesenteric artery is mildly dilated. The inferior mesenteric vein is dilated and shows early enhancement in arterial phase. colonoscopy showed submucosal tumor like lesion in distal rectum, but not tumor. Ulcer like erosions were observed on elevated lesion. Biopsy from ulcer like erosions showed colonic mucosa with preserved architecture showing ulceration, fibro muscular hyperplasia in lamina propria and scant inflammation with no evidence of dysplasia or malignancy. DSA showed hypertrophied IMA dividing into right and left branches. Large, hypertrophied vessels are noted in rectum on either side with rapid AV shunting from right side. These vessels selectively catheterized and embolized with coils and gel foam to reduce pressure head and bleeding. Control angiogram revealed complete obliteration of flow. Embolization was performed to control bleeding and to avoid surgery. After embolization she was followed up for 4 months in our hospital without recurrence. Conclusion Here we seen a rare case of rectal AVM as a cause of bleeding and was cured by trans arterial embolization. Background Primary colorectal lymphoma (PCL) occurs more commonly in patients with inflammatory bowel disease who are on long-term immunosuppression. However, PCL occurring de novo in an untreated patient with ulcerative colitis is extremely rare. Histologically, non-Hodgkin's lymphoma (NHL) is more common than Hodgkin's lymphoma. The exact etiology is not known, although infection with Epstein-Barr virus may play a role. Case Presentation A 51-year-old man presented to Gastroenterology Clinic with 8 months history of intermittent abdominal pain, fatigue, feeling of a lump in his abdomen, tenesmus bleeding per rectum associated with diarrhea alternating with constipation and significant weight loss. He was diagnosed with ulcerative colitis 8 years back but was lost to follow-up until recently. He initially took 5-ASA since diagnosis for 5 years and never had immunosuppressant during his treatment. MRI abdomen was suggestive of circumferential enhancing mass lesion in the left colon extending from splenic flexure distally for a length of 24 cm and diffuse thickening of the wall of the colon. Colonoscopy biopsy and IHC marker (pan CK negative, CD 45+, CD 20 +and CD 3 highlights T lymphocytes with Ki67 50%) were suggestive of lymphoproliferative disorder. Further IHC marker BCL 2 CD 20 BCL 6 c MYC (focal) was positive and MUM 1 was negative, suggestive of diffuse B cell lymphoma germinal origin. All these findings were suggestive of NHL DBCL (germinal), fulfilling the Dawson criteria for PCL, and after WHO staging he was started on a CHOP regimen with good nutrition supplementation. The patient was followed for 6 months and showed significant improvement. Cytomegalovirus (CMV) colitis is a common occurrence in immunecompromised patients but uncommon in immune-competent patients with usual mild and self-limiting symptoms and rarely gives rise to serious complications. CMV infection is often more severe in immunosuppressive diseases such as immunodeficiency syndrome. Furthermore, patients with cancer, and organ-or bone marrow-transplantation and those undergoing treatment with steroids or chemotherapeutics are more susceptible to CMV. Some of the recent literature report that cases of CMV infection are seen in immune-competent individuals. Serious CMV infection occurs commonly in immunocompromised patient as compared to immunocompetent patient. Colitis is a secondary manifestation to CMV infection and less frequently occurs within a clinical setup. The gastrointestinal tract involvement usually results in gastroenteritis, duodenitis, ileitis, proctitis, or exacerbation of inflammatory bowel disease (IBD). Gastrointestinal involvement is very rare in immunocompetent individuals; however, the commonly involved sites are colon and rectum. Immunocompromised state is associated with latent CMV infection that gets reactivated and also occurs as a primary infection in immunocompetent individuals. Many case reports and series document that comorbidities like diabetes and renal failure in immunocompetent individuals are associated with immune dysfunction. CMV colitis association with Crohn's disease is a very rare occurrence. However, a clear relationship between CMV colitis and ulcerative colitis has been reported in the literature. The chances of morbidity and reported deaths due to CMV in immunocompetent patients were low as compared to immunocompromised patients, but life-threating situations were seen in critically ill and in patients having comorbidities. We aimed to share our experience of CMV colitis in immunocompetent patients. In conclusion, CMV colitis is frequently encountered nowadays even in immunocompetent patients. Colonoscopy findings in our case series showed nonspecific ulcers, so high index of suspicion is required. Histology along with immunohistochemistry and tissue PCR remains the mainstay for diagnosis. Highly effective antiviral treatment has led to improved outcomes over time.

Keywords CMV colitis, Immunecompetent, Histology, Colonoscopy Introduction Fecaloma is a large mass of organized hardened feces causing impaction, usually in rectum and sigmoid colon. Management includes digital evacuation, use of clearance enema, oral laxatives or, as described by us, colonoscopic instillation of Coca-Cola. We present use of intralesional injection of Coca-Cola for evacuation of large rectal fecaloma refractory to other treatment modalities. Case Report Eighty-one-year-old male with long standing constipation, presented with inability to pass stool and severe pain in rectum for one month and difficulty in passing urine for one day. Examination of abdomen was unremarkable. Per-rectal examination revealed rounded 10 cm diameter hard non-pitting fecaloma in rectum that could not be crushed. Abdominal X-ray and NCCT scan confirmed presence of solid stool with distension of rectum and sigmoid colon. Attempts at clearance of stool with conventional methods were unsuccessful. At colonoscopy (Olympus CF-H180AL), large mobile fecaloma was noted in distal rectum with presence of solid fecal matter in proximal rectum and sigmoid colon. Following informed consent, two liters of Coca-Cola was instilled with 50 mL syringe through the working channel of colonoscope into descending and sigmoid colon, leading to evacuation of stool, but the rounded fecaloma was retained in the rectum. 50 mL of Coca-Cola was then injected into the fecaloma with 21-G endoscopic sclerotherapy needle. After 5 minutes, the hard fecaloma could easily be crushed against the sacrum and was successfully evacuated digitally. Conclusion Colonoscopic intralesional injection of Coca-Cola followed by manual removal is effective for removal of rectal fecaloma refractory to conventional treatment. Keywords Fecaloma, Colonoscopic removal, Colonoscopic injection Coca-Cola 142 Assessment of thiopurine metabolites 6-MMP and 6-TGN ratio in inflammatory bowel disease patients on thiopurine therapy Introduction The enzyme TPMT methylates 6-Mercaptopurine (6-MP) to 6-Methylmercaptopurine (6-MMP) thereby preventing accumulation of active metabolite 6-Thioguanine (6-TGN). In many individuals there is a preferential conversion to 6-MMP resulting in increased 6-MMP/6-TGN ratio (>11). These individuals are known as shunters who may accumulate hepatotoxic 6-MMP and may exhibit thiopurine resistance. Aim We reviewed 6-MMP/6-TGN ratio retrospectively in inflammatory bowel disease (IBD) patients undergoing thiopurine metabolite analysis at our center. Methods The data from July 2015-August 2021 (n=309) was reviewed to identify patients with 6-MMP/6-TGN ratio >11. The patients were then sorted based on therapeutic 6-TGN range of 235-400 pmoles/8x10^8 RBCs and 6-MMP cut off <5700 pmoles/8x10^8 RBCs. Results A 6-MMP/6-TGN ratio of >11 was obtained in 20 IBD patients wherein 14 had moderate elevation (11-20) and 6 had >20. Nine of these had 6-MMP above the cut off however only 1 patient with 6-MMP level of 3132 pmoles/8x10^8 RBCs had hepatotoxicity. All these patients had active disease and were on thiopurine dose of >1 mg/kg body weight (1.06-3.27 mg/kg) except 1 who was on 0.46 mg/kg. Inspite of the high dose 50% (n=10) had sub therapeutic 6-TGN suggesting preferential formation of 6-MMP. Thiopurine dose was reduced in 7 patients and allopurinol was added in 4 of them. Though subsequent metabolite analysis is not performed in any of them a clinical improvement subsequent to Allopurinol addition was noted in all. Thiopurine was discontinued only in one 64Y/F on a dose of 2.36 mg/kg presenting with leucopenia. She had increased ratio, 6-TGN and 6-MMP. Other patients are being followed up in the OPD. Conclusion In our study cohort 6.5% of patients have a high 6-MMP/6-TGN ratio. These shunters may not respond to an increase in thiopurine dose. Hence a metabolite level based objective therapeutic management can be beneficial for optimal disease control. Keywords Inflammatory bowel disease, Shunters, 6-MMP/6-TGN ratio 143 Utility of adalimumab and anti-adalimumab estimation in management of inflammatory bowel disease Mihika Dave 1 , Alpa Dherai 2 , Devendra Desai 3 , Bhamini Keny 2 , Valentina D'Cruz 2 , Dhanashri Shetty 2 , Tester Ashavaid 2 Correspondence -Devendra Desai -dr_ddesai@hindujahospital.com Departments of 1 Research, 2 Clinical Chemistry and Immunology, 3 Gastroenterology, P D Hinduja Hospital and MRC, S V S Marg, Mahim, Mumbai 400 016, India Introduction Availability of Adalimumab (ADA) biosimilars in India has remarkably helped in management of our patients with inflammatory bowel disease (IBD). Benefit of level-based dose optimization of anti-TNF agents is well documented. However, to apply the same for ADA biosimilar, the available assays need to be assessed prior to estimation. Aim We aimed to validate the commercial kits for estimation of an ADA Indian Biosimilar Mabura and assess its clinical efficacy for measurement of serum ADA and antibodies to Adalimumab (ATA) levels in IBD patients. Methods Commercially available ELISA kits was validated for precision, accuracy, recovery and specificity of Mabura and ATA estimation. Trough ADA and ATA levels were done in 15 and 7 patients respectively. Therapeutic ADA was considered as >7.5 μg/mL as per AGA guidelines while >10 ng/mL of ATA was considered significant. The levels were correlated with dose, disease activity and concomitant azathioprine therapy. Results A dose of 40 mg every 2 week and per week was prescribed in 13 and 2 patients respectively. ADA <7.5 ug/mL and ATA <10 ng/mL was obtained in 3 patients with active IBD. In these patients increasing dose frequency to 40 mg/week may help in disease control. Five of our patients had severe disease of which 3 had ADA~10 ug/mL suggesting that higher therapeutic target would be required amongst our patients. Two patients showed primary nonresponse (PNR) and had ADA of~15 ug/ mL. Concomitant thiopurine therapy was prescribed in 13 patients however no correlation could be established due to small size. None of our patients had developed ATA and hence timely dose optimization will help to achieve desired therapeutic outcome. Conclusion Kits need to be validated thoroughly prior to biosimilar and antibody estimation. Level based dosing would help in identifying PNRs and also optimize the dosing frequency to obtain desired therapeutic outcome. Keywords Inflammatory bowel disease, Biosimilar (Adalimumab), Therapeutic drug monitoring Introduction Portal vein thrombosis and mesenteric vein thrombosis can be caused by various thrombophilic states. But thrombosis as a part of underlying hypereosinophilic states like eosinophilic colitis is among the rarest of presentations. Case Scenario A 46-year-old male, with no prior comorbidities, had presented to our hospital with chronic epigastric dull aching pain and constipation for the past 6 months. There was no obstructive symptoms. He was evaluated elsewhere with ultrasound abdomen and upper GI endoscopy but no diagnosis could be made. Physical examination revealed, moderately built and moderately nourished patient. His vitals were stable. Abdominal examination was normal. His routine blood investigations revealed significantly high eosinophil counts (absolute eosinophil count [AEC] -2600). His ultrasonography abdomen showed absent flow in the right branch of portal vein portal vein. He underwent CECT abdomen, which showed portal vein thrombosis (PVT) and the superior mesenteric vein thrombosis. Patient was worked up for thrombophilic states and hypereosinophilia. He also underwent colonoscopy for chronic constipation. Colonoscopy was normal but biopsy revealed eosinophilic colitis, with more than 60 eosinophils/HPF. Subsequent work up for other thrombophilic states and hypereosinophilia were negative. Hence PVT was attributed to the hypereosinophilic state caused by the 120atient120d120s120 colitis. He was started on anticoagulation with heparin and steroids. After 2 week of treatment, his abdominal pain reduced and the AEC came down to 800. A repeat CT abdomen and colonoscopic biopsy after 3 months showed, complete recanalization of the portal vein and the superior mesenteric vein and the resolution of 120atient120d120s120 colitis. Conclusion Eosinophilic colitis can rarely present as a portal vein thrombosis due to hypercoagulable state caused by hypereosinophilia. Introduction Abdominal bloating is a common complaint in patients with functional and organic bowel disease. Rifaximin, a non-absorbable antibiotic, has been tried for the treatment of this disease. We performed a systematic review and meta-analyses on the available literature to study the efficacy of rifaximin in abdominal bloating and distension in patients with functional gastrointestinal disorders (FGID). Methods We accessed four database (MEDLINE, Embase, SCOPUS, and Web of Science) to identify randomized placebo-controlled trials that utilized rifaximin for abdominal bloating or distension in patients diagnosed with FGID. We excluded observational studies, studies including patients with organic bowel disorders such as inflammatory bowel disease, or when rifaximin was given for another indication such as HE. Results A total of 1426 articles were available. 813 articles were screened for eligibility after removing duplicates. Thirty-four articles were selected for full-text review. Finally, ten articles (nine full-texts and one abstract; 3326 patients) were included in the analysis. Rifaximin was administered in doses ranging from 400 to 1650 mg per day for one to two weeks. Rifaximin therapy led to higher likelihood of improvement in symptoms of bloating (44.6% vs. 34.6%, RR 1.22, 95% CI 1.11, 1.35; n=2401 patients) without significant heterogeneity. Further analysis for this outcome showed that doses less than 1200 mg/day were similar to placebo (p=0.09). Bloating was measured using different scales across studies (including Likert scale, VAS, IBS-SSS; n= 7 studies). Rifaximin led to greater reduction in bloating scores compared to placebo (SMD -0.3, 95% CI -0.51, -0.1, p=0.04) but carried significant heterogeneity (I2 =61.6%, p for heterogeneity = 0.01). Conclusion Rifaximin therapy at doses of 1650 mg/day for 2 weeks led to an increased likelihood of improvement in bloating and distension as well as reducing subjective severity of these symptoms in patients with FGID. The protocol was registered on PROSPERO. Keywords Irritable bowel syndrome, Rifaximin, Bloating Introduction Multiple primary malignant neoplasms are defined as two or more unrelated primary malignant tumors that originate from different organs and occur in the body at the same time or one after another. A 67-year-old male presented with complaints of dull aching type of diffuse abdominal pain since 1-week, high-grade fever associated with chills and rigors in the last 10 days, excessive straining while defecation associated with the reduced caliber of stools for the period of past one month, and significant weight loss of 15 kg in 3 months. On general examination, pallor and firm non-tender lymph nodes were noted in bilateral upper, mid-cervical, and inguinal areas. Abdomen examination showed tenderness in the left iliac fossa and splenomegaly. On working up patient had normocytic normochromic anemia with Hb of 8.7 with normal total counts. PET CT done showed enlarged lymph node with increased FDG uptake in bilateral cervical, posterior triangle, supraclavicular, paratracheal, and inguinal. FDG avid circumferential thickening in the sigmoid colon. Multiple FDG avid hypodense lesions in the liver. Cervical lymph node biopsy showed non-Hodgkin lymphoma-peripheral T cell lymphoma NOS type. Colonoscopy done showed normal rectum and a friable circumferential ulcer proliferative growth noted in sigmoid colon 20 cm from anal verge causing severe luminal narrowing, scope could not be negotiated further. Colon biopsy revealed moderately differentiated adenocarcinoma with adjacent areas of high-grade dysplasia and focal areas of necrosis. Liver biopsy showed adenocarcinoma of the livermetastatic. Bone marrow biopsy showed Reactive marrow with myeloid hyperplasia. Final Diagnosis NHL-peripheral T cell type and Adenocarcinoma of sigmoid colon with liver metastasis. Discussion The synchronous occurrence of a solid tumor with a hematological malignancy is extremely rare, but even more so is the synchronous presentation of colorectal carcinoma and lymphoma, which has been estimated at 0.0002%. Keywords Background Fecal microbial transplantation (FMT) has been shown to be efficacious in patients of ulcerative colitis (UC). There is large knowledge gap in number of FMT sessions required for the response and timing of response to FMT. Methods In this single centre (centre: All India Institute of Medical Sciences, New Delhi; duration: August 2019 -March 2020) study, patients with mild-moderate UC who were refractory to conventional therapy were subjected to FMT. Patients received up to 7 sessions of freshly prepared FMT once a week, administered colonoscopically (30 -50 grams of stool). Clinical assessment using SCCAI (simple clinical colitis activity index) was done at each follow-up FMT session till 7 weeks. Clinical remission was defined as SCCAI ≤ 3 and response as decrease in SCCAI scores by 3 points. Results Thirty patients with UC (mean age-33.4±10.82 years, 63.6% males, median disease duration-48.5 months, 53.3% left side colitis, 46.7 % pancolitis, median SCCAI at baseline-7) were included, of which 18 (60%) had clinical response, and 16 (53.3%) had clinical remission. There was no difference in baseline demographic, clinical, endoscopic and laboratory features between responders and non-responders ( Table 1) . Total of 181 FMT sessions were performed, of which 19, 4, 1, 2, 3, and 1 patients' received 7, 6, 5, 4, 3 and 2 FMT sessions respectively. Median SCCAI at 8 weeks in responders was 1 (0-5) ( Table 2) . Median time to achieve clinical response and remission was 1 and 2 weeks respectively. Conclusion Patients with mild to moderate ulcerative colitis refractory to conventional therapy achieved clinical response to FMT as early as 1 week. Studies including large number of patients are required to assess the requirement for the number of FMT sessions to achieve clinical response and remission. Keywords Ulcerative colitis, Dysbiosis, Fecal microbiota transplantation, Clinical response, Clinical remission 148

Introduction Cytomegalovirus (CMV) is ubiquitous latent persistent viruses which is commonly seen in immunosuppressed status. Since the beginning of corona virus disease 2019 (COVID-19) epidemic, reactivation of latent infection secondary to rampant use of steroids/ immunomodulators has been increased. We draw attention to reactivation of latent infections like CMV while treating severe COVID-19 pneumonia. We present a case series of CMV and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coinfection that manifested with hemorrhagic enterocolitis. This complication may have developed because of synergistic pathophysiologic mechanisms related to COVID-19 infection including T lymphocyte depletion and immune response dysregulation and use of corticosteroids. Method This is a retrospective case series of 5 consecutive CMV colitis patients who had COVID-19 infection (covid antibody positive) and have received steroids during the course of COVID-19 treatment. Diagnosis was made through tissue CMV PCR. Patients were treated with ganciclovir and surgical intervention as a lifesaving procedure as and when required.

Result Five patients were included in the case series. The patients were of age group between 41-74 years with median age of 57 years. Four (80%) were males and 20% were females. Three (60%) of patients had severe covid pneumonitis and 80% of patients have received high dose steroids. Eighty percent have presented with massive gastrointestinal (GI) bleed. Median duration between onset of COVID-19 and diagnosis of CMV colitis were 35 days. All patients have received Gancyclovir and 1 patient underwent right hemicolectomy. Out of 5, 1 (20%) patient went leave against medical advice and 1 patient (20%) succumbed to CMV colitis. Conclusion This case series highlights the importance of keeping a high index of suspicion and providing the correct diagnosis and treatment of CMV Colitis in COVID-19 infection. In COVID-19, the use of immunosuppressive therapy should be justified while being alert for signs and symptoms of CMV reactivation and other opportunistic infections. Background Biologic agents are highly effective in patients with inflammatory bowel disease (IBD). However, they are expensive and are associated with primary and secondary non-response and side effects. Aim To study the proportion of patients with IBD in whom biologics are indicated, how many receive them, how many discontinue them, and the factors that limit their use. Methods Two hundred and fifty consecutive patients with IBD were enrolled prospectively between June 2020 and June 2021. Demographic data, disease characteristics, and treatment details were noted. Numbers needing biologics, who discontinued them, and reasons for discontinuation were noted. Results Two hundred and fifty patients (111 women) included 131 patients with ulcerative colitis (UC), 116 with Crohn's disease (CD), and three with IBD-undifferentiated. Mean age was 39.6 years (SD 16.0). Median duration of UC was 10 years (Q3-Q1 interquartile range [IQR] 9) and of CD 8 years (IQR 8). Biologics were indicated in 73 (29.2%) but only 58 (UC 20, CD 38) received them; 11 patients were unwilling, 2 had financial constraints, one had recurrence of Hodgkin's lymphoma, and one expired before initiation. Indications in these 58 included: fistulising disease (18), stricturing disease (13), non-response to conventional drugs (11), acute severe UC (10), and steroid-dependent (5) or steroidrefractory (1) UC. Forty-two patients received infliximab, 22 adalimumab, and three vedolizumab. Twenty-five (43.1%) patients discontinued biologics; reasons included unwillingness to continue (6), primary non-response (5), secondary loss of response (3), physician decision (2), non-affordability (2), reactivation of tuberculosis (2), remission (2), and infliximab-induced psoriasis, metastatic carcinoma of colon and pancytopenia (1 each). Conclusion Biologics were indicated in about a fourth of our patients with IBD, more than previously described from India. This indicates changing IBD phenotype in India. They were discontinued in a large proportion of patients (43.1%), due to unwillingness to continue, non-response, and side effects. Patient education may reduce discontinuation. Keywords Crohn's disease, Ulcerative colitis, Treatment

Minimal risk of lymphoma despite long-term use of azathioprine in patients with inflammatory bowel disease: A longitudinal cohort analysis from northern India Mukesh Ranjan 1 , Bhaskar Kante 1 , Sudheer Vuyyuru 1 , Peeyush Kumar 1 , Sandeep Mundhra 1 , Rithvik Golla 1 , Raju Sharma 2 , Prasenjit Das 3 , Peush Sahni 4 , Govind K Makharia 1 , Saurabh Kedia 1 , Vineet Ahuja 1 Correspondence -Vineet Ahujavinnet.aiims@gmail.com Departments of 1 Gastroenterology and Human Nutrition, 2 Radio Diagnosis, 3 Pathology, and 4 Gastrointestinal Surgery, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Background Thiopurines are widely used to maintain remission in both ulcerative colitis (UC) and Crohn's disease (CD). Reported effectiveness and tolerability rates have been variable across studies. Moreover, there are only sparse data in the Asian population regarding the long-term efficacy and safety of azathioprine (AZT). Methods Records of 5351 patients followed up at IBD clinic, All India Institute of Medical Sciences, New Delhi from 2004-2020 were evaluated retrospectively. Azathioprine efficacy was defined as no requirement of surgery, hospitalizations, anti-TNFs agents, and minimum steroid (≤1 course in 2 years) requirement on follow-up. Safety was evaluated in terms of long-term adverse events and the development of malignancy. Results Of 5351 patients with IBD, 1093 who received AZT for > 3 months (UC=788 [proctitis-1.9%, left sided colitis-44.9%, pancolitis-53.1%], CD=305 [inflammatory-42.6%, 125atient125d125s-46.9%, fistulizing-10.5%]) were included (60.8%-males, mean age at disease onset-31.69±12.34 years, median disease duration at AZT initiation-3 [1] [2] [3] [4] [5] years) (Table1). Follow-up and treatment duration on AZT were 7 (4-12) years and 39.41±40.27 months respectively. Mean initiation and maintenance dose of AZT was 1.09±0.45 mg/kg and 94.82±21.29, respectively. One,3,5, and 10 years relapse free survival was 85%,79%,76%, and 64%; 87%, 82%, 79% and 72%; and 78%, 72%, 68% and 61% in overall cohort, UC and CD patients, respectively (Log-rank p=0.001 between UC and CD) ( Fig. 1 Background Fecal microbiota transplantation (FMT) has demonstrated moderate efficacy in mild-moderate ulcerative colitis (UC), and donor characteristic is a major determinant. However, there is heterogeneity on optimal donor signatures responsible for therapeutic benefit. We evaluated donor characteristics associated with better response to FMT in UC. Methods Patients with mild-moderate UC on stable doses of 5aminosalicylic acid, immunomodulators and steroids (<20 mg/day) who received FMT and anti-inflammatory diet were included. Of 36 potential donors, 13 were selected after questionnaire and investigations. FMT was freshly prepared from this pool with 2-5 donors in each batch and was administered colonoscopically every week till 6 weeks. Clinical response was decline in SCCAI>3, and remission as SCCAI<3. 16srRNA gene sequencing was done on donor stool to compare relative abundance of Firmicutes, Bacteroides, Actinobacteria, and Proteobacteria between effective and ineffective donors. For all donors, through a 2 x 2 contingency table approach, clinical response was compared between patients receiving FMT from a particular donor (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) vs. other donors, and donors associated with statistically significant higher clinical response were termed effective. Results Twenty-nine patients underwent FMT with a total of 178 sessions. Eighteen (mean age-31.1+8.8 years, males-44%, disease duration-69 [28-84] months, pancolitis-44%) had a clinical response and 11 (mean age-35.7+11.4 years, males-27%, disease duration-48 [36-96] months, pancolitis-54%) didn't. Baseline clinical, endoscopic and biochemical disease activity, and medications were similar between two groups. Of thirteen donors, numbers three (FMT with donor 3 vs. without donor 3, 69% vs. 0), six (75% vs. 33%), eight (82% vs. 33%), ten (87% vs. 36%), eleven (81% vs. 38%), and thirteen (100% vs. 47%) were effective (p<0.05 for all). Though not statistically significant, relative abundance of Firmicutes ( Introduction Unlike in Crohn's disease (CD), the role of enteral nutrition and diet in the management of ulcerative colitis (UC) hasn't been clear. Therefore, we designed this trial to evaluate efficacy of partial enteral nutrition combined with exclusion diet in patients with mild to moderate UC. Methods In this quasi-experimental study we included patients with mild to moderate UC (SCCAI) and allocated them into experimental arm which received PEN combined with exclusion diet (ED) and standard of care arm (SOC). Disease activity was measured using simple clinical colitis activity index (SCCAI) and partial mayo score (PMS). We assessed clinical remission (SCCAI ≤2) at 2 and 4 weeks. Results Out of 60 UC patients, 30 were included in PEN + ED arm and 30 were included in SOC arm. Both arms are comparable in baseline clinical and biochemical parameters like age (36.7 vs. 36.4, p=919, extent (E1, E2, E3, E2/E3: 6.7%, 15%, 36.7%, 6.7%), hemoglobin (g/L) (109 vs. 116, 0.164), SCCAI score (5 [4] [5] [6] vs. 5 [4-5.2 ], p=0.562), and PMS (4 [3-4.2] vs. 4 [3-4] , p=912) were similar between both groups except serum albumin which is higher in SOC arm (g/L) (35 vs. 40, p=0.030). Clinical remission at 2 weeks was significantly higher in SOC arm compared to PEN+ED arm. However, it was not significant at 4 weeks. A numerically higher number of patients required steroids in SOC arm compared to PEN+ED arm, but it was not significant (16.7% vs. 23.3%, p=0.748). There was a significant increase in hemoglobin in PEN+ED arm at 4 weeks (mean delta Hb:2.9g/L), whereas in SOC arm there was decrease in hemoglobin (mean delta Hb:0.45 g/L, p=0.046). However, there was no difference in delta albumin levels.

Conclusion PEN in combination with exclusion diet does not improve rate of induction of clinical remission in addition to standard medical Introduction Increasing use of abdomino-pelvic CT for various indications has greatly increased the diagnosis of bowel wall thickenings. We aim to find out the correlation between bowel thickening with subsequent colonoscopic and histopathological findings. Methods Data of patients referred for colonoscopy on basis of colonic thickening on CT were collected retrospectively between January 2020 and September 2021 and their histopathology reports were traced. Patients undergoing CT for known GI disease or known malignancy were excluded. Results A total of 122 patients were identified. Mean age of patients was 35.8 years (15-80) with male to female ratio of 0.7:1. The most common location of thickening was ileocecal (68%, n=83), followed by ascending colon (16.3%, n=20) and rectosigmoid (12.2%, n=15). Colonoscopy was normal in 35.2% (n=43) cases. More than 75% patients underage group <40 years had ileocecal thickening and 42% of them had normal colonoscopy. The most common colonoscopic abnormality found was presence of ulcers and erosions (n=38, 31.1%), followed by growth (n=15, 12.2%) and stricture (n=12, 9.8%). Other less common findings included diverticulosis, telangiectasia, pseudomelanosis coli. Nonspecific colitis was most commonly reported in patients undergoing colonoscopy (52%). Tuberculosis was diagnosed in 20.4% (n=25) mostly in pts with strictures. The diagnosis of IBD was made in 18.8% (n =23). Malignancy was found in 9% patients. Adenocarcinoma was most common (>90%) followed by lymphoma, metastatic and NET in remainder. Three patients had eosinophilic colitis. The diagnosis of malignancy was significantly more present in age group >40 years with most common site in them being rectosigmoid. Conclusion Ileocecal thickening remain the most common reported site of thickening in CT. However, a significant proportion of patients may have normal colonoscopy and many have nonspecific colitis on histopathology especially in younger age group patients.

Introduction The term inflammatory bowel diseases (IBD) encompass a spectrum of diseases, of which ulcerative colitis (UC) and Crohn's disease (CD) are the most familiar entities. Although the exact etiology is unknown, its triggering and perpetuation have been ascribed to various genetic, environmental, and immunological factors. Historically IBD was seen as the bane of Western countries, but recent reports suggest that numbers have been stealthily climbing up in Asia, special in India. We aim to study the clinical profile of IBD patients in a tertiary care hospital of north Karnataka. Methods We retrospectively analyzed the clinical profiles of IBD patients who had presented to Department of Gastroenterology over a period of 2 years from September 2019 to September 2021. Demographic profile, clinical and endoscopic findings along with management and complications were taken into consideration. Results The 145 patients, there were 139 (95.8%) patients with UC, 6 (4.2%) with CD. Chronic diarrhea (84%) and blood in stools (75.4%) were common in UC, whereas abdominal pain (60%) was common in CD. E2 (57.1%) was more common in UC, there were equal number of L2 (50%) and L3 (50%) in CD. Most of the patients had moderate to severe disease activity and responded well to pharmacotherapy. Few patients required biologicals for the remission. Conclusion In our study, we found that IBD was common in rural population of north Karnataka and UC was more common than CD. Keywords Inflammatory bowel disease, Ulcerative colitis, Crohn's disease 155 Role of cytomegalovirus infection in patients of ulcerative colitis with relapse and impact of antiviral therapy -Valganciclovir on outcome in these patients Vikas Raikwar, Sudhanshu Yadav, Shivesh Thakur, Amber Mittal, Shohini Sircar, Ajay Jain Correspondence -Ajay Jain -ajayvjain@yahoo.com Department of Gastroenterology, Choithram Hospital and Research Centre. 14, Manik Bagh Road, Indore 452 014, India Introduction High mucosal cytomegalovirus (CMV) load has been associated with failure of IV steroid therapy in patients with acute severe ulcerative colitis. A recent meta-analysis suggested that determining CMV infection assists in the selection of a proper treatment strategy. Hence, we aimed to assess the prevalence of CMV viral load in patients of ulcerative colitis who presented with relapse of symptoms in OPD and their outcome after treatment with valganciclovir. Methods Study subjects were all diagnosed patients of ulcerative colitis who presented to gastroenterology OPD from June 2020 to September 2021 with recent-onset symptoms suggestive of relapse. Relapse was defined as more than six stools per day mixed with blood and mucus and ulcerative colitis endoscopic index of severity (UCEIS) score of more than four on sigmoidoscopy. Exclusion criteria were patients with any solid organ transplantation or patients on biological therapy. Results During the study period, 90 patients of diagnosed UC came for follow-up in OPD. Out of 90 follow-up patients, 47 had relapse of symptoms. Out of these 47 patients with relapse, 14 patients (29.7%) had CMV infection proven by reverse transcription-polymerase chain reaction (RT-PCR), for CMV on tissue sample taken from the rectum, while histopathologist suspected CMV infection on H & E stain in only one patient. All patients with CMV infection proven by RT-PCR responded to oral valganciclovir given in doses of 900 mg per day for 21 days. All patients had two to three well-formed stools without any mucus or blood at the end of therapy. None of the patients with relapse treated with valganciclovir required steroids or immune-modulatory drugs or admission to hospital. Conclusions 1. The prevalence of CMV infection as a cause of relapse in this study is 29.7%. 2. All patients with CMV infection responded to oral antiviral with effective disease control without any step-up treatment for UC. Background Inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohn's disease (CD) is characterized by remitting/ relapsing course. A proportion of patients with UC, and almost all patients with CD require long-term immunosuppression to maintain endoscopic and clinical remission and prevent disease progression. The present study aimed to evaluate the long-term efficacy of thiopurines, their predictors, and the effect of the early use of thiopurines on disease outcomes in patients with IBD. Method A retrospective cohort analysis of IBD patients following up in IBD clinic at AIIMS, New Delhi, from 2004-2020. Efficacy was defined as a state of not requiring hospitalization, anti-TNF agents, surgery, and only minimum (≤ 1 steroid course in 2 years) steroid requirement during follow-up. Early thiopurine initiation was defined as commencement of thiopurines ≤2 years of disease onset. Results Of 1264 consecutive patients on thiopurines (6-MP and azathioprine), 988 (UC:720, CD:268) were considered for efficacy analysis (males:60.8%, mean age at disease onset:31.69±12.34 years and thiopurine initiation:35±13.14 years). Time to event analysis showed median efficacy rates of 79% and 72% in UC, and 68% and 61% in CD at 5 and 10 years respectively. On multivariate analysis, only male sex (HR: 1.53, 95% CI: 1.05-2.23) in UC and ileal involvement (HR: 2.361, 95% CI: 1.115-4.99; p=0.025) and occurrence of any adverse events (HR: 0.514, 95% CI: 0.313-0.844; p=0.008) in CD were having a significant predictive value for relapse. Kaplan-Meier survival analysis showed no difference between the efficacy of early and late thiopurine groups, both in UC (Log-rank p=0.72) and CD (Log-rank p=0.76). Conclusion Thiopurines still remain a viable long-term option for maintenance of remission in patients with IBD, especially in resource-limited countries. Their use can be further enhanced by optimizing their therapy and regular monitoring for adverse events. Keywords Inflammatory bowel disease, Thiopurines, Azathioprine, Efficacy Himalayan region of India with the use of CsA in patients with steroidrefractory UC. Methods The database of all UC patients, hospitalized between June 2018 to September 2021, was analyzed for the need for CsA therapy for steroid-refractory UC. Demographic and clinical characteristics, response to and complications of CsA, steroid-free remission, and the need for colectomy were reviewed for all patients. Results Of the 40 patients with moderate-severe UC, 7 patients (mean age 31.9 years; 4 women) had steroid-refractory UC. The majority (71.4%) of patients had pancolitis and remitting, relapsing course (mean number of prior exacerbations 2 (range 1-5) with mean disease duration of 3.7 years (range 0.1-13). All received intravenous CsA (2 mg/kg/day) for a mean of 5.57 days (range 5-7). The median time to clinical response (lichtiger score <10) was day 4 (range 2-6) of CsA and remission (lichtiger score <3) was achieved on a mean of 9 days (range 5-12) after CsA. All responders received oral CsA for a further 3 months followed by azathioprine. All of the patients remained steroid-free and colectomy-free for the mean follow-up period of 8.4 months (range 2-15 months). One patient each had infections (bacteremia due to klebsiella), paresthesias, and hypertrichosis with CsA therapy, but none of the patients required CsA discontinuation due to adverse events. Conclusion Our study shows that cyclosporine therapy can provide steroid-free remission and avoid colectomy in steroid-refractory moderate-severe UC without significant drug toxicity. Keywords Ulcerative colitis, Steroid refractory ulcerative colitis, Cyclosporine Cytomegalovirus (CMV) is found in 10% with ulcerative colitis (UC) and presents as a flare. However, prolonged fever is an unusual presentation of CMV in patients with UC. We present a case of UC, who got admitted with exacerbation bloody diarrhea and fever of unknown origin and was subsequently diagnosed with disseminated CMV infection. A 28-year-old male diagnosed with UC on Azathioprine and mesalamine presented with exacerbation of bloody large bowel bloody diarrhea for two months and intermittent high-grade fever for one month. An evaluation revealed deranged liver enzymes. Sigmoidoscopy revealed deep punched out ulcers in the rectum and sigmoid colon. Biopsies were taken for histopathology and immunohistochemistry for CMV. Blood CMV PCR was also sent. He was started on intravenous steroids; he remained febrile and continued to have bloody diarrhea. Awaiting histology and PCR reports, he underwent evaluation for fever, including blood cultures, computed tomography of the abdomen, echocardiography to rule out vegetations, and bone marrow biopsy, which were all non-contributory. Blood CMV PCR report was positive for CMV viremia HRCT thorax showed features of viral pneumonia. The colonic biopsy revealed CMV inclusion bodies with cytopathic changes. For elevated liver enzymes workup for hepatotropic viruses (A, B, C, and E), Wilson disease, autoimmune hepatitis was negative. Percutaneous liver biopsy showed CMV inclusion bodies, and there was no evidence of liver cirrhosis. Ganciclovir was administered for 21 days, and the patient was discharged in a stable condition with the resolution of fever and normalization of liver enzymes. Discussion CMV colitis is seen in 10% of patients with UC patients with flare. In a study, fever raised a high index of suspicion of CMV infection in IBD patients. Although CMV is a commonly identified culprit in a case of steroid-refractory UC, its presentation as a cause of prolonged fever with multi-system involvement is uncommon. Keywords Cytomegalovirus, Ulcerative colitis 159 Tofacitinib in treatment of moderate to severe steroid dependent ulcerative colitis-Indian scenario Introduction Ulcerative colitis (UC) is a chronic inflammatory condition of the large intestine. Steroids are mainstay of treatment in moderate to severe UC. But some patients become steroid dependent. Azathioprine, anti-TNF therapy and other drugs are used in steroid dependent patients for maintenance of remission. Tofacitinib is oral drug effective in UC. Aim of our study is to look for efficacy of tofacitinib in steroid dependent moderate to severe Indian UC patients. Methods An open label, single arm prospective study conducted in 19 moderate to severe steroid dependent UC patients. Patients were induced with 40 mg prednisolone OD and 10 mg to facitinib BD and were maintained on 5 mg to facitinib BD. Primary outcome was absence of rectal bleeding at 16 weeks (sub-score of 0 for rectal bleeding in Mayo score). Secondary outcome was to look for serious adverse events. Results Mean age was 38.7 years (SD=13.05 years). Median Mayo score at baseline was 9 (IQR-7,11). Median C-reactive protein (CRP) were 15.43 mg/L at baseline (IQR-9.52,22.20). At 16 weeks, primary outcome was met by 16 patients (84.21%). Median mayo score at 16 weeks was 3 (IQR-3,3) with significant reduction compared to baseline (p val-ue<0.001). Median CRP at 16 weeks were 2.56 (IQR-2.18,3.78) which also had a significant reduction compared to baseline (p value<0.001). Conclusion To facitinib is effective oral drug in treatment of steroid dependent moderate to severe UC patients. Considering cost as an issue in a developing country like India, it is a cheaper alternative to anti-TNF therapy. Keywords Tofacitinib, Steroid dependent ulcerative colitis, Moderate to severe ulcerative colitis Introduction Ulcerative colitis (UC), type of inflammatory bowel disease (IBD) is a chronic debilitating gastrointestinal disorder that markedly impair quality of life. It causes high mortality and affect about a million people in the USA with an increased proportion in cases in developing countries like India with wide variety of food and lifestyle changes in recent years. Too it adds up to the risk of colorectal cancer up to 10% and adding up to morbidity and mortality. It involves mucosa and submucosa resulting inflammation and ulcers of the colon further causing gastro-intestinal symptoms. But, there are very few studies on the morphology of myenteric ganglia specially for the change in morphology in dopaminergic neuronal type in these patients. Aim To study the morphology of the dopaminergic neurons of the myenteric plexus in the ulcerative colitis patients. Methods Samples collected-15 patients undergoing colectomy for ulcerative colitis in department of gastrointestinal surgery and 15 normal colonic tissues collected from the department of forensic medicine, All India Institute of Medical Sciences, New Delhi, after obtaining ethical clearance. Tissues were processed. Colonic tissues from the UC patients and normal specimens processed and stained by Hematoxylin and eosin staining and immunohistochemistry (IHC) done by Tyrosine hydroxylase (TH). Results H&E stained sections showed decrease in number of enteric neuronal cells and increase in the number of infiltrating polymorphic neutrophil, leukocytes and other cells in the myenteric ganglion (MG) appeared with increasing inflammation in ulcerative colitis. Shape and size of MG became spheroid and small as compared to the normal colon. There is also decrease in TH in dopaminergic neurons and increase in neuropil. Conclusion These results shows that there is decrease in neurons in myenteric plexus in UC patients which can be associated to clinical symptoms. Keywords Ulcerative colitis, Myenteric plexus, Dopaminergic neurons, Enteric nervous system Background Hepatitis E virus (HEV) is an important cause of acute liver failure (ALF) in Bangladesh with pregnant mothers being more vulnerable. Cerebral edema resulting in raised intracranial pressure (ICP) is an important cause of morbidity and mortality. Aims of the study To study the baseline characteristics and clinical outcome of HEV-induced ALF. To detect raised ICP clinically and observe response to mannitol infusion. Methods This was a prospective cohort study on baseline characteristics and clinical outcomes of 20 patients admitted to the intensive care unit (ICU) of Chattogram Maa-O-Shishu Hospital in Chattogram (Chittagong), Bangladesh with hepatitis E-induced ALF during an epidemic from June until August 2018. We diagnosed HEV infection by detecting anti-HEV IgM antibody in patients' blood. All patients were negative for hepatitis B surface antigen (HbsAg) and hepatitis A (anti-HAV) IgM antibody. Data were collected on the 5-day outcome after admission to ICU, monitoring all patients for signs of raised ICP. An intravenous bolus of 20% mannitol was administered to all patients with raised ICP. Results Twenty patients were included in the study. Ten (50%) patients, 7 (70%) females, received mannitol infusion. HE worsened in 8 (40%); 7 (87.5%) female and 3 (50%) pregnant. Glasgow Coma scores (GCS) deteriorated in 6 (30%); all (100%) females and 3 (50%) pregnant.

Worsening of hepatic encephalopathy (HE) and GCS deterioration were not significantly different between pregnant and non-pregnant subjects, nor between those who received mannitol and those who did not. Six patients (30%) met Kings College Criteria for liver transplantation: all were female and 3 (50%) pregnant with one patient dying. Conclusion Female patients developed a worse outcome than male patients. Pregnancy status was not associated with worse outcome in our cohort. Mannitol infusion was also not associated with a significant difference in outcome.

Keywords Hepatitis E, Acute liver failure, Intensive care unit, Hepatic encephalopathy 162 Management of ascites in cirrhosis, "Blanket" therapy to a "Buffet" approach: A AABHA Checklist

Correspondence -Pathik Parikh -pathik269@gmail.com Hepatology and Liver Transplant, Zydus Hospitals, Zydus Hospitals Road, Near Sola Bridge, Sarkhej -Gandhinagar Highway, Ahmedabad 380 054, India

Introduction The treatment strategy for ascites has remained a blanket therapy with consideration of different treatment options only once an individual develops refractory ascites. The concept of individualized care of ascites is recommended for early aggressive management and preventing the development of refractory ascites right from the diagnosis of ascites. Methods All patients with cirrhosis and new onset ascites were included. Patients with acute-on-chronic liver failure (ACLF), recent gastrointestinal bleed, sepsis, hepatocellular carcinoma (HCC), cardio-renal disease were excluded. All patients were started on treatment as per the "AABHA" buffet approach. These patients were followed up every 15 days for 2 months. The primary outcome was control of ascites. The secondary endpoints looked after were the development of hypotension, electrolyte imbalance, acute kidney injury, and hepatic encephalopathy. These patients were compared with a retrospective cohort of 25 patients. Results The baseline characteristics were similar between the two cohorts. At 2 months of follow-up 20/25 patients of the study group had complete response while remaining 5/25 had a partial response. In the retrospective cohort group, only 3/25 had a complete response while 18 had a partial response. The development of hyponatremia < 130 mEq/L (0/25 vs. 2/25), and acute kidney injury (0/25 vs. 3/25) were significantly higher in the retrospective cohort (p<0.05). MAP at 2 months was significantly higher in the study group (90±10 vs. 72±10, p<0.05). None developed overt hepatic encephalopathy in 2 months of follow-up. None of the patients required tolvaptan. Tapering of diuretics was possible only in the study group. Conclusion Early aggressive individualized therapy for ascites rather than a blanket therapy may be considered. More randomized controlled trials for "Buffet" approach needs to be considered. Keywords Midodrine, Refractory ascites, Diuretics, CLD Aims To study the vaccination practices in patients suffering from cirrhosis of liver using a questionnaire survey. Methods We included all patients who were willing for the study and had been seen by a gastroenterologist/hepatologist at least once. Patients offering incomplete information were excluded. Serological tests for confirmation of immunological response were not done. Details of counselling and vaccination status for hepatitis B, hepatitis A and pneumococcal infection were noted. Results A total of 305 patients (272 males, 89%) formed the study cohort. The median age was 60 years (range 27-76 years) and median duration of liver disease was 12 months (1-120 months). The median MELD was 14 (range 7-35). Only 37 (12.1%) patients reported that they had been counselled for vaccination against these infections. The rates of vaccination were very low (<10%). Conclusion Very dismal vaccination rates were noted in Indian patients with liver cirrhosis. Keywords Liver, Cirrhosis, Vaccination, Hepatitis Introduction Tuberculosis (TB) in patients being evaluated for liver transplant presents a unique challenge. There is scanty literature published on treatment of tuberculosis in such select group of patients. Most literature is on patients with early cirrhosis. There is no literature on treating Child-Turcotte-Pugh (CTP) C patients when they were being evaluated for liver transplant.

Methods In this single centre observational study, sequential patients presenting for liver transplant and diagnosed with TB were included. Results Fifteen patients were diagnosed with TB in a span of 24 months. All were males with CTP-C ethanol related cirrhosis. Median age was 41 years and median model for end-stage liver disease (MELD)-sodium was 30. Eight patients had pulmonary tuberculosis (PTB) while rest had extrapulmonary TB (EPTB) (pleural 8/20, peritoneal 4/20). The diagnosis of PTB was made by bronchoalveolar lavage (BAL), while fluid aspiration was diagnostic for EPTB. The median number of fluid aspirations required for diagnosis was 3 (range 1-5). Combination of GenXpert acidfast bacilli (AFB), adenosine deaminase (ADA), AFB staining and AFB culture was sent from each aspirated sample. Unilateral right hydrothorax was more commonly seen (4/8) as compared to bilateral effusion (3/8) and unilateral left sided effusion. All patients were treated with ethambutol and quinolone (EQ). Fifty percent patients died of complications of liver failure. Six patients (30%) recompensated after anti-tubercular treatment (ATT) and were treated with HREQ for 8 months. Their MELD sodium is now less than 15. Four patients are currently being treated with EQ >2 months and are awaiting cadaveric organs. None of the patients were transplanted after the diagnosis. Conclusion The diagnosis of tuberculosis requires battery of investigations if index of suspicion is high. EPTB is more common and history of alcoholism is a risk factor. TB in these patients have high mortality and the treatment of tuberculosis needs further randomized studies to define the best treatment strategy and timing for transplant. Keywords TB, Cirrhosis, CLD, Liver Failure 165 Long-term outcome of patients with acute severe autoimmune hepatitis

Correspondence -Pathik Parikh -pathik269@gmail.com Department of Hepatology and Liver Transplant, Zydus Hospitals, Zydus Hospitals Road, Near Sola Bridge, Sarkhej -Gandhinagar Highway, Ahmedabad 380 054, India

Background and Aim Acute severe autoimmune hepatitis (ASAIH) is a life threatening disease which often culminates into liver failure and need for urgent liver transplant. We report here long-term outcome of ASAIH patients. Methods Retrospective analysis was done for patients getting admitted for ASAIH between July 2019 to July 2020. ASAIH was defines by first presentation with INR >2 and absence of cirrhosis/bridging fibrosis on liver biopsy with no evidence of use of herbal medicines or alternative medicines.

Results Fifteen patients were classified as ASAIH. Two-third were females with a mean age of 42 years. At baseline, mean bilirubin was 18 mg/dL, mean aspartate aminotransferase (AST) was 896 IU/L, mean alanine aminotransferase (ALT) was 650 IU/L, mean immunoglobulin (IgG) level 26.34 g/L, median INR of 4.3 and mean albumin of 3.4 g/dL. Autoantibodies were present in only six patients. Histological characteristics was plasma cell, lymphocyte and neutrophilic infiltration with interface hepatitis and lobular necrosis seen in all patients. Hydrocortisone followed by prednisolone was started in all patients with a mean of 45 days after onset of jaundice. Four patients failed to respond and died due to liver failure. Remaining patients responded to steroids and had normalization of bilirubin with a median of 56 days and are under follow-up with at least 12 months. Azathioprine was introduced in all patients once bilirubin became normal. Four patients were off immunosuppression at 12 months. All patients had normalized liver function on follow-up. Conclusions Timely treatment may lead to resolution of ASAIH with excellent long-term outcomes in those who respond to steroids. Keywords AIH, Steroids, Liver failure, Autoimmune liver disease Introduction Insomnia and classically difficulty falling asleep is a common problem seen in patients of advanced liver disease. Antihistaminics (Hydroxizine) has been used with minimal success. Methods We retrospectively evaluated patients treated at our centre from January 2020 to December 2020 for advanced cirrhosis and insomnia as major complain. The treatment given and its ability to induce regular sleep at 30 days of use was considered (patient reported outcomes). Development of encephalopathy and excessive daytime somnolence (EDS) was looked for in these patients.

Thirty patients (mean age 42 years, all males) with advanced liver disease (CTP >6) had difficulty falling asleep as chief complain. Seven had nonalcoholic steatohepatitis (NASH) while remaining had alcohol related cirrhosis (ALD). Hydroxizine was used in 8 patients without any benefit. Zolpidem 10 mg was used in 24 patients for consecutive 30 days with all 7 patients of NASH while only 8/17 with ALD reported benefit with zolpidem use. Lorazepam 1 mg had been used in 10 patients with ALD with 70% reporting benefit in sleep induction. None of the patients developed encephalopathy after its use in 30 days. No Excessive daytime somnolence was reported by any patient although 5 patients reported better daytime efficiency after lorazepam use. After 30 days of regular use all 15 patients with Zolpidem use benefit reduced the usage to PRN basis while only 2/8 patients with Lorazepam use benefit reduced to PRN basis. Conclusion Although benzodiazepines and Z drugs have not been considered safe in advanced liver disease, our patients benefited with sleep induction and may need larger studies to prove safety and efficacy. Keywords EDS, Sleep induction, Liver cirrhosis 167 Case of spontaneous hemoperitoneum in a cirrhotic patient due to rupture of intra-abdominal varix Introduction Ectopic varices are dilated portosystemic collateral veins located in unusual sites other than gastroesophageal region. It constitute 1% to 5% of all variceal bleeds in patients with intrahepatic portal hypertension and 20% to 30% of those with extrahepatic portal hypertension. One of the most severe complications of ectopic varices is the rupture of intraabdominal varices leading to hemoperitoneum. Most of these patients present with hypovolemic shock, with an estimated mortality of 70%. Case Report A 49-year-old male, known case of decompensated chronic liver disease, presented with increase in abdomen distension, pain abdomen and giddiness. Examination revealed hypotension (BP-80/50 mmHg), tachycardia (HR-112 bpm), Pallor, bilateral pitting pedal edema and free fluid in abdomen. Investigations showed hemoglobin 6 g %, platelet count-90000 cells/cumm, INR-1.61. Contrast enhanced computed tomography (CECT) abdomen done showed dilated portosystemic collaterals in lower esophageal, perigastric, peripancreatic, perisplenic, umbilical region, anterior abdominal wall and in mesentery, along with splenorenal shunt, hyperdense area in pelvis measuring 12 cms x 7 cms extending up to umbilical region-suggestive of hematoma. Diagnosis of hemoperitoneum secondary to ruptured intra-abdominal varices was done, patient was treated with antibiotics and transfused with packed red blood cell (PRBC). Patient underwent TIPSS, followed by embolization of oozing superior mesenteric vein (SMV) ectopic varices at the umbilical region using coils. Preprocedure portal pressure was 37 mmHg, post-procedure portal pressure was 26 mmHg. Post coiling venogram showed no obvious contrast leak. There was no further fall in hemoglobin, patient was discharged and is on regular follow-up. Conclusion Hemorrhage from ectopic varices generally are massive and life threatening. High clinical index of suspicion is required to make the diagnosis of ectopic varices. Due to the varied locations and complex manifestations, a multimodality approach is needed, including gastroenterologists, interventional radiologists and surgeons. Keywords Ectopic varices, Hemoperitoneum, TIPSS 168 Associated risk of hepatic encephalopathy with use of proton pump inhibitors in cirrhotics: A systematic review and meta-analysis Suprabhat Giri Giri. Aditya Kale, Harish Darak, Sanjay Kumar, Akash Shukla Correspondence -Suprabhat Giri Giri -supg19167@gmail.com Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Parel, Mumbai 400 012, India

Background In patients with cirrhosis, proton pump inhibitors (PPI) overuse is common. Recently, use of long-term PPIs have associated with increased risk of complications including hepatic encephalopathy (HE), spontaneous bacterial peritonitis and mortality. However, due to study design limitations, no definite conclusions can be drawn. This metaanalysis was conducted to investigate the correlation between PPI use in cirrhosis and HE. Methods Pubmed, Google scholar and Scopus were searched from 1990 to August 2021 for research studies that described HE incidence and PPI exposure in cirrhotics including acute-on-chronic liver failure (ACLF) and patients who had undergone transjugular intrahepatic portosystemic shunt (TIPS) placement. Meeting abstracts were excluded from analysis. The odds ratios (OR) were calculated by combining the data from the identified studies using a random effects model. Results A total of ten studies were eligible for inclusion in the analysis which included four case-control and six cohort studies. Except for one study, rest all studies reported an association between use of PPI and increased risk of HE. Analysis showed that PPI users had an increased risk of HE compared with PPI non-users, with a pooled OR of 2.48 (95% CI 1.73-3.55). Statistical heterogeneity of Ors across studies was observed (Q statistic 128.60; p = 0.000; I2 = 93%). On subgroup analysis of two studies on incidence of HE after TIPS, the estimated OR was 3.191 (95% CI 2.03-5.01) without any significant heterogeneity. Begg's test and Egger's test for publication bias were not significant. Conclusion Use of PPI is associated with increased risk of HE in patients with cirrhosis, including patients with ACLF and those who underwent TIPS. Inappropriate use of PPI should be avoided in cirrhotics. However, larger prospective studies are needed to guide clinical decision making. Keywords Proton pump inhibitors, Cirrhosis, Hepatic encephalopathy 169 Correlation between serum ascites albumin gradient and esophageal varices in chronic liver disease patients with portal hypertension Chilukuru Revanth Reddy, Sudhanva Kinhal, Venkata Ranga Reddy Correspondence -Sudhanva Kinhal -sudhanvakinhal@gmail.com Department of Gastroenterology, Kurnool Medical College, Budhwarpet Road, Budhawarapeta, Kurnool 518 002, India

Background Portal hypertension is the major complication of cirrhosis and is responsible for upper gastrointestinal bleeding due to esophageal varices. High incidence of esophageal varices in patients with portal hypertension increases the burden on endoscopy units to identify esophageal varices. Endoscopy procedure is semi-invasive, costly and not widely available, hence there is a need for non-invasive, cheap and easily available method to predict the presence of esophageal varices. The SAAG (Serum Ascites Albumin Gradient) is one such method that is thought to reflect the degree of portal hypertension and esophageal varices.

Method This study was conducted in the Department of Gastroenterology, Kurnool Medical College, Kurnool. One hundred cirrhotic patients with ascites of age more than 18 years were included in the study. All underwent upper gastrointestinal endoscopy (UGIE) to verify esophageal varices and calculated the SAAG on the same day. Result Spearman's Rho coefficient was used to correlate the grade of esophageal varices with SAAG levels. Our study showed that variceal grades correlated positively (p-value <0.001) with SAAG levels. SAAG >2.1 g/dL demonstrated grade 3 esophageal varices with sensitivity and specificity of 49% and 85% respectively. Conclusion In patients with cirrhosis and ascites, SAAG could be used as a surrogate method for the presence and grading of EV, which would help to avoid multiple endoscopic procedures and reduce the cost burden.

Introduction Esophageal varices are the common complication of liver cirrhosis. Bleeding from esophageal varices increases the mortality and morbidity in cirrhotic patients. So screening of esophageal varices is essential in cirrhotic patients. Endoscopy is the gold standard method for screening and grading of esophageal varices. But endoscopy carries certain risks for patients, and it is also an invasive, expensive and uncomfortable procedure. Thus, there is a need to develop non-invasive methods to evaluate esophageal varices. Accordingly, aspartate aminotransferase to platelet ratio index (APRI) score has been developed for assessing esophageal varices. Method An observational study was conducted in patients with liver cirrhosis who underwent endoscopy over a period of 18 months during 2019-2020 in the Department of Gastroenterology, Kurnool Medical College, Kurnool, Andhra Pradesh. Fifty patients of liver cirrhosis were enrolled for the study. Grading of esophageal varices was done by endoscopy, simultaneously APRI score was also calculated. Result In this study, there was a positive correlation between esophageal varices and APRI score (p-value <0.001). APRI score >1.65 demonstrates large varices with sensitivity and specificity of 81.8% and 87.2% respectively. Conclusion APRI score can indirectly predict the presence of esophageal varices in liver cirrhosis. Keywords APRI score, Esophageal varices, Cirrhosis

Portal vein thrombosisthe common among rarities -A descriptive study from a tertiary care centre in South India In India, PVT in the absence of cirrhosis is a common cause of portal hypertension and variceal bleeding. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Acute non-cirrhotic PVT, chronic PVT (extrahepatic portal venous obstruction [EHPVO]), and PVT in cirrhosis are the three main variants of PVT with varying etiological factors and variability in presentation and management. One hundred consecutive patients with PVT were evaluated. Sixty percent of cases were males. Splenomegaly was seen in 60% of patients while 75% of patients had no clinical ascites. Varices were present in 53% of the subjects. Cirrhotics formed the major case group (63%) in our study, EHPVO was seen in 22 subjects. Fourteen patients has associated thrombosis of splenic vein and superior mesenteric vein, while 16 had associated either splenic or superior mesenteric vein thrombosis associated with PVT. Twelve patients had malignancy mostly hepatocellular carcinoma (HCC). Acquired prothrombotic states like polycythemia, antiphospholipid antibodies (APLA), homocystenemia, hyperuricemia, and Jak 2 mutation were found in our study and 4 patients had multiple prothrombotic states. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) required the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state. Transjugular intrahepatic portosystemic shunt (TIPS), transarterial radioembolization (TARE) and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Background Non-alcoholic fatty liver disease (NALFD) is the most common chronic liver disease worldwide. India and other developing countries are witnessing an unprecedented rise in prevalence of NAFLD. As part of population level strategy at primary health care, an efficient risk stratification is crucial to ensure appropriate and timely referral of individuals who require care at secondary and tertiary levels. The present study was conducted to assess the diagnostic performance of two noninvasive risk scores for liver fibrosis, FiB-4 and NFS, in Indian patients of biopsy-proven NAFLD. Methods We conducted a retrospective analysis of biopsy-proven NAFLD patients that reported to our centre between 2009 and 2015. Clinical and laboratory data were collected and two non-invasive fibrosis scores, NFS and FIB-4 score, were calculated using the original formulas. Liver biopsy was utilized as gold standard for diagnosis of NAFLD. Diagnostic performance was determined by plotting ROC (receiver operator characteristic) curves and area under the ROC curve (AUROC) was calculated for either score. Results Two hundred and seventy-two participants were included. The mean age of patients was 40 (11.85) years and 187 (79.24%) were men. We found that the AUROCs for FiB-4 score (0.634) was higher for any degree of fibrosis as compared to NFS (0.566). The AUROC for Fib-4 for advanced liver fibrosis was 0.640 (.550-.730). The performance of the scores for advanced liver fibrosis was comparable with overlapping confidence intervals for both scores.

Conclusion The present study found an average performance of Fib-4 and NFS risk scores for detecting advanced liver fibrosis in Indian population. This study highlights the need for devising novel context specific risk scores for efficient risk stratification of NAFLD patients in India.

Predictors of severity and mortality of chronic liver disease with corona virus disease 2019 Shubham Jain, Sanjay Chandnani, Pravin Rathi, Sameet Patel, Partha Debnath, Pankaj Nawghare Correspondence -Pankaj Nawghare -pankaj9ghare21@gmail.com Department of Gastroenterology, Topiwala National Medical College, B Y L Nair Ch. Hospital, Mumbai 400 008, India

Background Corona virus disease 2019 (COVID-19) has become a major health emergency worldwide. The characteristics and outcome of COVID-19 in patients with chronic liver disease (CLD) remain unclear. Aims CLD represents a major disease burden globally. Given this high burden, how different underlying liver conditions influence the outcome in patients with COVID-19 needs to be meticulously evaluated. So, we conducted this study to see the outcome of the patient and to look for predictors of severity and mortality in patients with CLD with COVID-19 infection.

Methods This was a single-center, observational study conducted at a tertiary care center. We recruit 50 consecutive patients of COVID-19 with CLD. Matched comparison group patients with CLD without COVID-19 collected retrospectively from historical data with 1:2 ratio using stratified sampling.

Results Mean age of the study population was 51 ± 12 years with the majority were male. Most patients (21/50) were presented with predominantly respiratory symptoms of which fever was the most common symptom (85%). Jaundice (70%) was the most common gastrointestinal symptom. Twenty patients had acute-on-chronic liver failure (ACLF). All patients with ACLF were having severe COVID-19 infection and succumb to multi-organ failure. Mortality was double in a patient with CLD with COVID-19 infection than historical control. Diabetes was the only comorbidity which was associated with severe infection. Patients in the severely ill subgroup had higher mortality, high creatinine, and raised D-dimer (p<0.05). CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) score on admission and Child-Turcotte-Pugh (CTP) score on admission correlates with mortality (p<0.05). Serum D-dimer level and reduced lymphocyte counts were associated with mortality on multivariate analysis. Conclusion The presence of CLD in COVID-19 patients was associated with a poor outcome. Raised D-dimer on admission can predict severe infection. Child-Pugh and CRUB-65 scores were highly associated with non-survival among these patients. Keywords COVID-19, Chronic liver disease, D-dimer 174 Non-alcoholic steatohepatitis with hepatic siderosisare we missing porphyria?

Correspondence -Vikash Prakash -vikashprakashilbs@gmail.com Department of Hepatology, D'Cosmedics Clinic, 82/A, Rash Behari Avenue, Kolkata 700 026, India A 68-years-lady with hypertension and hypothyroidism presented with fatigue and transaminitis. Physical examination was largely normal except for a firm palpable liver of 16 cms. Blood picture showing cholestasis a differential of primary biliary cholangitis, primary sclerosing cholangitis, autoimmune liver disease, infiltrative liver disease or simply non-alcoholic steatohepatitis (NASH) was kept in mind and patient evaluated further. Magnetic resonance cholangiopancreatography (MRCP) was normal. Elastography showing CAP -326 and LSM 10.8 a diagnosis of NASH with secondary iron overload was made. A liver biopsy was done to exclude differentials, assess the fibrosis and look for the amount and distribution of hepatic siderosis. Biopsy showed -NASH with secondary siderosis (Scheuer grade 2). NAS CRN activity -6. Fibrosis 1 C. SAF score -S2A4F1C. She was started on vitamin E, exercise and low-fat diet. She lost 8 kgs over 2 months from her initial weight of 90 kgs (BMI 32) however her facial darkening increased, and she developed itching on sun exposed parts. she was started on chelation with defepirone however her skin darkened further with involvement of hands and feet. She further lost 16 kgs of weight however her itching was intense and there was appearance of noninflammatory blisters and erosions on dorsum of hands and back. Patient was depressed and largely confined to home on account of poor quality of life, skin darkening and lesions on exposed parts. In view of raised ferritin an occult malignancy was looked for. Heavy metals screen was also normal. In view of all tests turning to be negative I looked back for a disease which affects both liver and skin and only one disease came to mind which is extremely rare in India namely Prophyria. We tested urinary porphyrins which was 1564 mcg/day. Thus, a diagnosis of acquired porphyria cutanea tarda was made. Cheation had failed already. Phelobotomy was chosen over hydroxychloroquine on account of severe iron overload. Keywords Porphyria, NASH, hemosiderosis Background and Aim Bone marrow (BM) is a reservoir for hematological and immune cells, and in response to injury these cells play a central role in resolution of the damage and tissue repair. Patients with liver cirrhosis have showed a progressive decline in hematopoietic stem cells (HSC) and their niche with an increase in severity of the disease. How this loss of HSC reserve affects the liver injury and regeneration is not well defined. In the current study we aim to understand the relation between bone marrow and liver regeneration in chronic liver injury. Methodology C57BL/6(J) mice were used to develop chronic liver injury through intra-peritoneal administration of carbon tetrachloride (CCl4) for 15 weeks (0.1-0.5 mL/kg). Animals were culled at different time points (n=5 each group; week-3/6/10/15) to study the changes in liver injury, regeneration, and BM-HSC reserve.

Results Histological analysis of liver tissue (Fig. 1A) showed progressive increase (p=0.0079) in Masson's trichrome (MT) positive area till week-10 with development of portal fibrosis at week-3, bridging fibrosis at week-6 and nodular fibrosis (cirrhosis) at week-10. From week 10 to week 15 while MT+ area was comparable there was significant increase (p<0.0001) in TUNEL+ hepatocyte (1D) with hepatic decompensation {ascites (SAAG 1.4 (1.1-1.7) g/dL) jaundice and rise in ammonia (p<0.001)}. With progression of liver fibrosis while number of PCNA+ hepatocyte increase till week-10, it significantly decreases from week-10 to week-15 (Fig. 1B) . Flow cytometry analysis of BM-HSCs showed significant loss of long-term (LT)-HSC (p<0.001) from week-6 to week-10 and further at week-15 while number of multipotent progenitors (MPPs) increase with increase in severity (Fig. 1C) . Conclusion During the course of chronic liver injury loss of BM-HSC reserve precedes the regeneration failure leading to hepatic decompensation. Keywords Liver cirrhosis, hepatic decompensation, Hematopoietic stem cells

Establishment of a murine model of acute-on-chronic liver failure with multi-organ dysfunction

Background and Aims Acute-on-chronic liver failure (ACLF) is a distinct clinical entity with high probability of organ failure and mortality. Since patients generally present late, experimental models are needed to understand the pathophysiology and natural course of the disease. Methodology To reproduce the syndrome of ACLF, chronic liver disease was induced in C57BL6 mice (6-8 weeks; approximately 20-24 gm weight) by intra-peritoneal administration of carbon tetrachloride (CCl4) for 10 weeks followed by an acute injury with acetaminophen (APAP) and lipopolysaccharide (LPS). Blood, ascitic fluid and organs were collected to study cell death, regeneration and fibrosis. Results At 24 hours post-APAP/LPS infusion, the liver tissue showed increased hepatocyte ballooning and endothelial cell TUNEL positivity. This was followed by progressive hepatocyte necrosis from perivascular region at day 7 to lobular region by day 11. ACLF (day 7 and day 11) animals showed increase in bilirubin (p<0.05), prothrombin time (p<0.0001), blood ammonia (p<0.001) and portal pressure post-acute hepatocellular injury similar to human ACLF. Ascites was noticed by day 11 with median serum-ascites albumin gradient of 1.2 (1.1-1.3) g/dL. In comparison to cirrhosis, ACLF group (day 7 and day 11) showed significant decrease in Sirius red (p<0.0001), collagen1 (p<0.0001) and a-SMA proportionate area (p<0.0001) with loss of hepatocytes regeneration (p<0.005). At day 11 ACLF animals also showed significant increase in serum creatinine (p<0.05) and acute tubular necrosis suggestive of organ failure, compared to cirrhosis animals. Aim To evaluate the occurrence, etiology, clinical profile, laboratory profile and outcome of hepatic dysfunction in patients admitted to the medical intensive care unit (MICU). To evaluate the effect of model for endstage liver disease (MELD) score on admission as a predictor of adverse short-term outcome in patients with hepatic dysfunction admitted in MICU.

Methods It was a prospective observational study, conducted from December 2017 to December 2018 in a tertiary care hospital. Two hundred and two patients admitted to the MICU with liver function tests (LFTs) as per the inclusion criteria were analyzed and their short-term outcome at 7 days was studied in relation to various parameters. Results LFT abnormalities were present in 202/1126 (17.9%) of the patients admitted to MICU. Critical illness associated liver dysfunction was found in 172 (85.2%) patients, chronic liver disease (CLD) in 11 (5.4%) patients and acute viral hepatitis in 19 (9.4%) patients. Most common symptom was fever (68.3%) followed by vomiting (48.0% cases). Among LFT abnormalities, elevated transaminases, raised international normalized ratio and high MELD score on admission correlated with poor short-term outcome. Requirement for inotropes and mechanical ventilation correlated with poor short-term outcome. Mortality did not differ significantly between patients with CLD, patients with acute viral hepatitis and patients with critical illness associated hepatic dysfunction. Hepatic dysfunction in MICU was associated with poor outcome and a high short-term mortality of 114/202 (56.4%). Conclusions Liver function abnormality is common in patients who are admitted to the MICU and its presence is an indicator of poor short-term outcome, hence early intensive management is necessary. Patients with chronic liver disease have similar outcome as patients with other critical illnesses and hence need to be treated aggressively. Keywords Hepatic dysfunction, Abnormal Liver Function Test, Medical Intensive Care Unit

To study the relationship between of hepatic iron deposition and histologic severity in non-alcoholic fatty liver disease population in India. Hepatic iron overload may be present in various chronic liver diseases and associated with the risk of toxicity and severity of the liver disease. Aim is to study the relationship between hepatic iron deposition and serum iron biomarker with histologic severity in NAFLD patients. Methods It is an interim analysis of prospective study involving thirty adult subjects with metabolic syndrome and ultrasound sonography study of fatty liver with or without deranged liver function test. Other common causes of NAFLD were ruled out. These subjects underwent liver biopsy. On histopathological examination hepatic iron staining, hepatic steatosis, hepatic inflammation, ballooning degeneration, Hepatic fibrosis were seen. Serum iron biomarkers were measured prospectively. Introduction According to the BCLC protocol, transarterial chemoembolization (TACE) is the first line of treatment for intermediate-stage hepatocellular carcinoma (HCC). Predicting efficacy before TACE is important for treatment planning as it can inform the decision to conduct early repeat treatment in responders or may facilitate switching to systemic therapy or second line locoregional treatment in non-responders. Also, repeated and unnecessary TACE in non-responders can aggravate impaired hepatic function in patients with liver cirrhosis. This study aims to assess the ability of various biochemical and radiological parameters to predict TACE response, decompensation post-TACE and other post-TACE complications.

Methods Sixty patients with intermediate-stage-HCC who underwent TACE were studied for up to 6 months, factors predicting TACE response, post-TACE complications including post-embolization syndrome (PES) and decompensation were assessed. Results Sixty patients (male: female=41:19; mean age=57.95±6.48) with unresectable HCC undergoing TACE were followed-up up to a 6-month period. Twenty-seven (45%) patients achieved complete response (CR) whereas 14,12 and 7 patients had partial response, stable disease and progressive disease respectively; 4 (6.67%) had postembolization syndrome (PES); 24 (40%) decompensated during the 6month follow-up period. There was significant difference in MELD scores, AFP, HAP score, ESR, NLR, PLR, serum albumin, cumulative tumor size, number of tumours and >1 TACE sessions (p<0.05) between patients who had and hadn't achieved CR. On univariate analysis, AFP<100, MELD<10, HAP<1, NLR<2, albumin>3.5 mg/dL, tumor size <3 cm, single tumour were significantly associated with CR; HAP>1, bilirubin >2 mg/dL were significantly associated with PES, clinically significant portal hypertension (CSPH), CTP score >6, MELD>10, HAP>1, NLR>2, bilirubin>2, albumin<3.5, tumor size >3 cm, tumor number>1 were significantly associated with decompensation within 6 months post TACE. On multivariate analysis AFP (p=0.013, AUROC:0.973, 95% CI:0.79-1.00), HAP <1 (p=<0.001, AUROC:0.818, 95% CI:0.708-0.928), number of TACE sessions >1 (p=<0.001) were significant predictors of response to TACE; HAP>1 (p=0.016, AUROC:0.802, 95% CI:0.681-0.923), albumin <3.5 mg/dL (p<0.001; AUROC:0.943, 95% CI:0.1-0.168) and multilobar tumor involvement (p=0.041) were significant predictors of decompensation within 6 months post-TACE. CSPH (p=.038), bilirubin >2 mg/dL (p=0.016; AUROC:0.953, 95% CI:0.756-1), multilobar tumor involvement (p:0.041) were significant predictors of post-TACE complications including PES. Conclusion AFP<100, MELD<10, >1 TACE sessions were significantly associated with CR; patients with HAP>1, baseline Sr. albumin <3.5 mg/ dL and multilobar tumor involvement are likelier to decompensate post TACE. Patients with CSPH, Sr. bilirubin >2 mg/dL and multilobar disease are likelier to develop post-TACE complications.

Introduction Sarcopenia is a promising tool for prognostication of cirrhosis. EWGSOP2 guidelines define sarcopenia based on muscle strength, muscle quantity or quality and physical performance. Many previous studies didn't use a standardized definition of sarcopenia and was based on skeletal muscle measurement by CT or MRI. Ultrasound guided thigh muscle thickness (TMT) measurement is a validated, cost effective and easy method for assessment of muscle quantity. There is paucity of Indian studies analysing prognostic role of sarcopenia in cirrhosis. Objectives To study the predictive role of sarcopenia on mortality and complications in cirrhosis patients. Methods This was a prospective cohort study with 120 consecutive patients each in sarcopenia and no sarcopenia groups. Sarcopenia was diagnosed based on EWGSOP2 guidelines using ultrasound guided measurement of TMT. They were followed up for 6 months. Kaplan-Meier analysis with LogRank test was used to compare survival and Cox proportional hazards model was used for multivariate analysis to determine risk factors of mortality. Results Cirrhosis patients with sarcopenia (N1=120,M:F=80:40, Median age-58yrs [51-64]) and without sarcopenia (N2=120, M:F=93:27, Median age-54 yrs [46.25-60]) were enrolled. Six (month cumulative survival was 56.7% and 76.7% in sarcopenia and no sarcopenia groups respectively [p=0.001]). Six month cumulative survival in severe and non-severe sarcopenia was 23.9% and 70% respectively (p=0.001). Age, sex, nutritional status, sarcopenia status, CTP score, MELD score, bilirubin, albumin, INR and sodium were significantly associated with survival. A multivariate analysis showed sarcopenia (HR=1.283, 95% CI 1.092-2.130, p=0.031), female sex (HR=1.851, 95% CI 1.106-3.097, p=0.019), CTP class C (HR=1.447, 95% CI 1.252-1.794, p=0.002) and MELD score>15 (HR=1.116, 95% CI 1.056-2.203, p=0.05) as independent predictors of mortality. Development of complications like ascites, HE, Covid infection and UGI bleed were significantly higher in sarcopenia group, while SBP, AKI, cellulitis, UTI, HCC and ACLF were not statistically significant between two groups. Conclusion Sarcopenia is an independent prognostic marker of mortality in cirrhosis and is associated with increased risk of complications like ascites, HE, Covid infection and UGI bleed. Severe sarcopenia has even poorer outcome. It appears that addition of sarcopenia to existing scoring systems of cirrhosis will improve prognostication of patients.

The objective was to compare clinical/laboratory features (and histopathology as needed) of non-A-E hepatitis with acute viral and acute onset autoimmune hepatitis (AIH) and determine whether etiology is likely to be viral or autoimmune. Methods Cases of acute hepatitis were evaluated to segregate acute viral, autoimmune and non A-E hepatitis based upon viral markers and AIHrelated autoantibodies. Patients with negative viral serology and revised AIH score between 10-14 (probable AIH) underwent liver biopsy. Patients with post-biopsy AIH score > 15 were diagnosed as AIH. Those with negative viral serology and post-biopsy AIH score <15 were considered as non A-E hepatitis. Patients were followed up for 3 months. Results Out of 85 patients, 15 (17%) had non-A-E hepatitis, 25 (29%) AIH (acute presentations), 45 (53%) acute viral hepatitis (hepatitis A, B, E). Jaundice was the most common presentation (100%) of non-A-E hepatitis followed by anorexia (93%) and nausea (86%). Seven out of 15 (46.7%) patients with non-A-E hepatitis were males. Mean age was 39 years (range 15-55). Median total bilirubin was 10.7 mg/dL (range 6.5-15.4), aspartate and alanine aminotransferases were 512 and 670 U/L (range 450-777 and 649-1000 U/L, respectively). Five (33.3%) patients had anti-nuclear antibody and 1 (6.7%) had anti-smooth muscle antibody positive. Six (40%) had raised immunoglobulin G (mean 18.3 gm/L, range 12.2-29.0 gm/L). No patient developed liver failure or recurrent hepatitis. Bilirubin, aspartate and alanine aminotransferases, INR were not significantly different between all the groups. Non-A-E hepatitis is more likely to have albumin >3.5 gm/dL compared to autoimmune hepatitis (p=0.001). Patients with autoimmune hepatitis are more likely to have anti-nuclear and antismooth muscle antibodies (p=0.002 and <0.001, respectively), raised immunoglobulin G (p=0.003), interface hepatitis/ lymphoplasmacytic infiltration/rosette formation on histopathology (p=0.0001) as compared to non-A-E hepatitis. After 3 months, AIH patients had significantly higher bilirubin and aspartate aminotransferases (p=0.02 and 0.009, respectively). Conclusion Non-A-E hepatitis can present as a self-limiting illness. Etiology is less likely to be autoimmune. Keywords Non-A-E hepatitis, Viral hepatitis, Autoimmune hepatitis 182 Evaluate the diagnostic accuracy of a nurse-led transient elastography in liver stiffness evaluation and competency of nurse operator to stage hepatic fibrosis in chronic liver diseases patients Sanju Kumari 1 , Mini George 2 , Vinod Arora Correspondence -Sanju Kumari -sanju_ilbs19@gmail.com Department of Nursing, All India Institute of Medical Sciences, Phulwarisharif, Patna 801 505, India, and 2 Departments of Con. and Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj Road, New Delhi 110 070, India

Background Once thought to be rare, liver disease is the emerging cause of significant morbidity and mortality. Recognizing the burden of disease, a competent workforce is essential to deliver quality healthcare to patients with diagnosis of, or at risk of developing liver disease. Staging of liver diseases (liver biopsy, the gold standard) is important in-patient management. Fibroscan (transient elastography) has gained importance recently as a non-invasive modality. This study examines the diagnostic accuracy of nurses-led transient elastography in staging hepatic fibrosis in chronic liver diseases (CLD). Methods Audit of records for Fibroscan and liver biopsy done within six months of each other included 193 CLD cases in study. Data abstraction sheet and competency checklist were used. Content validity index and reliability of tool were above 0.9. Analyses was performed using SPSS V.25, with p values less than 0.05 level of significance. Diagnostic accuracy of liver stiffness evaluation (LSE) to grade hepatic fibrosis was tested against liver biopsy and a graphical plot, area under receiver operating characteristic (Figs. 1 and 2) that illustrates the diagnostic ability. Results Spearman's Rho correlation (Table 1) between LSE (by nurse-led Fibroscan) against liver biopsy was significant (p=0.01). One way ANOVA showed association between LSE and nurse competency in Fibroscan (p=0.001). Conclusion Nurse-led transient elastography showed significant diagnostic accuracy in staging of hepatic fibrosis. This study can help build hospital policies to implement nurse-led Fibroscan. Keywords Liver stiffness evaluation, Fibroscan, Nurse-led transient elastography, Liver biopsy 183 Bioenergetics failures underlie impaired monocyte function and increased mortality in acute-on-chronic liver failure Background Monocyte-macrophage plays central role in the resolution of injury and immune defense against invading pathogens. Functional exhaustion of monocytes is associated with increased susceptibility to infection and sepsis in acute-on-chronic liver failure (ACLF). Underlying mechanism of disease-associated defects in ACLF monocyte are not fully understood. We aimed to study mechanism of functional exhaustion of monocytes in ACLF and its effect on patient outcome. Methodology Monocytes were isolated from peripheral blood of ACLF patients (n=33) and matched healthy volunteers (HC, n=7). Phagocytic and oxidative burst functions were studied using commercial kits. Bioenergetics of monocytes was analysed using Xfe24 bioanalyzer. Results Compared to HC, monocytes of ACLF patients (mean-age 43 years, AARC-8.9, etiology-alcohol 64%) showed a decrease in phagocytic (p<0.0001) and oxidative burst (p<0.0001) functions. Bioenergetic analysis showed defects in oxygen consumption rate (OCR) (p<0.0001) and extracellular acidification rate (ECAR) (p<0.001) in ACLF compared to healthy (Fig. 1A) . Out of 34 patients in which monocyte bioenergetics were done at time of admission, 22 died or underwent transplant (non-survivor) and 12 were alive (survivor) in 28 days of follow-up. In comparison to survivors, monocyte of non-survivor showed reduction in both mitochondrial respiration (basal respiration [BR]-p<0.001; maximum respiration [MR]-p<0.001) and glycolysis (ECAR-p<0.0001). In univariant cox regression analysis baseline ECAR (hazard ratio [HR]=9.1), OCR (HR=4.5) and MR (HR=3.5) were significantly correlated with shortterm (28 days) mortality in ACLF patients. Patients with monocyte baseline ECAR <42.7 mpH/min (AUROC=0.901, sensitivity-86.9%, specificity-83.3%), BR <22.5 pmol/min (AUROC=0.81, sensitivity-75%, specificity-77.3%), and MR <37.9 pmol/min (AUROC=0.82, sensitivity-77.3%, specificity-75%) showed significant increase in mortality. Conclusion Bioenergetic failure drives functional exhaustion of monocytes in ACLF which may underlie increased infection and sepsis in these patients. Non-survivors show increased defects in both mitochondrial as well as glycolytic function in monocytes as compared to survivors. Together these data suggest that loss of monocyte bioenergy adversely affects the outcome of ACLF patients. Keywords Metabolism, Innate Immune Dysfunction, ACLF 184 Safety and efficacy of saroglitazar in non-diabetic non-alcoholic fatty liver disease/non-alcoholic steatohepatitis population -A 24-week, real world, single centre, retrospective study

Correspondence -Sobur Uddin Ahmed -drsobur1180@gmail.com Department of Gastroenterology, Hayat Hospital, Hayat Hospital, Guwahati 781 034, India

Background and Aims Non-alcoholic fatty liver disease (NAFLD) is a spectrum of illness from non-alcoholic fatty liver to steatohepatitis, progresses to fibrosis and ultimately leads to cirrhosis, if not managed well. Saroglitazar 4 mg is only approved therapy for NAFLD/ non-alcoholic steatohepatitis (NASH). We tried to evaluate the efficacy and safety of Saroglitazar 4 mg OD in nondiabetic NAFLD/NASH in routine clinical practice. Methods A total 40 documented NAFLD patients (Males 67.5%) prescribed on Saroglitazar 4 mg OD, were retrospectively analyzed for changes in liver biochemical parameters and lipid profile at 24 weeks. The study population was of mean age 40.6 and plusmn; 12.11 years and mean BMI 26.7 + 3.4 kg/m 2 . The mean NFS score at baseline was -1.7 + 1.2, with 52.5% (n=21) patients in intermediate NFS range. The data at baseline and 24 weeks was analyzed and statistical significance was established using paired sample T-test.

The study shows statistically significant improvements in all measured parameters from baseline. Also, there was significant improveme nt in overall NFS score by 52.7%, with 47.5% patients (n=19) in low NFS range at baseline increased to 95% (n=38), at 24 weeks. There was overall improvement in HbA1c by 0.8% (NS) from baseline, with no single episode of reported hypoglycemia. Conclusions The study shows Saroglitazar 4 mg OD as a safe and effective treatment option for nondiabetic NAFLD/NASH, with significant improvement in all liver related parameters. Keywords NAFLD, NFS Score, Saroglitazar Background and Aims Hepatitis from non-hepatotrophic virus is increasing. Dengue hepatitis is the commonest cause of hepatitis from nonhepatotrophic virus in India. Hepatitis in dengue increases mortality in dengue fever by several fold. There are no prognostic markers for patients who develop dengue hepatitis. Methods We retrospectively analyzed all patients with dengue infection admitted in two tertiary care hospitals from January 2016 to March 2021. Diagnosis of dengue fever and dengue hepatitis was confirmed by serology and standard criteria respectively Results One hundred and ninety-nine patients with dengue hepatitis were studied of which 33 patients died. Thirty-two patients had (AKI) of which 14 required hemodialysis. Forty-five patients developed acute lung injury (ALI) of which 32 required non-invasive or invasive ventilatory support. Twelve patients developed encephalopathy. Eight patients developed acute liver failure (ALF). Level of bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT) with international normalized ratio (INR), ferritin, platelet count, total leukocyte count (TLC) and AST-to-platelet ratio index (APRI); were not statistically different between survivors and non survivors. Lactate dehydrogenase (LDH) at presentation, creatinine and model for end-stage liver disease (MELD) score were higher among non survivors than survivors. When parameters peak ALT, peak AST, LDH on presentation, peak LDH, peak ferritin were divided by number of days from onset of fever (DF) they were found significantly higher in non survivors. peak LDH/df + peak ferritin/df was found to be significantly high in non survivors than survivors with area under the receiver operating curve (AUROC) of 0.854 and a value and GT; 9220 had sensitivity of 81% and specificity of 78%.

Introduction Acute kidney injury (AKI) in patients with cirrhosis is a major determinant of morbidity and mortality. Early diagnosis and management of AKI significantly influence the outcome in cirrhotic patients. We undertook this study because data on burden of AKI in hospitalized patients with cirrhosis lacks in our region. Methods A cross-sectional study was done in our setting including 128 patients hospitalized with cirrhosis. AKI was diagnosed and staged as per ICA-AKI criteria. Risk factors for incident AKI events was recorded and their association was studied by Chi-square test. Their outcome at the end of hospital stay (in terms of survived or deceased) was recorded and mortality rate was calculated. Results Prevalence of AKI among patients with cirrhosis admitted to hospital was 49.2% (63/128). Majority of patients who developed AKI had advanced decompensated cirrhosis at admission (CTP-A: 8, CTP-B: 18, CTP-C: 37) and early stages of AKI (Stage-1: 28, Stage-2: 20, Stage-3: 15) predominated in our study. Most common predisposing factors for AKI among cirrhotic patients were upper GI bleed (47.6%) and infections (33.3%; SBP-23.8%, other infections-9.5%), while diuretics (7.9%), non-steroidal anti-inflammatory drugs (NSAIDs) (3.1%) and prior large volume paracentesis (7.9%) were less common. Among patients with cirrhosis, AKI was found to be significantly associated with upper GI bleeding (Odds ratio [95% CI]: 5.000 [2.16-11.533], p-value < 0.05) and SBP (Odds ratio [95%CI]: 6.458 [1.768-23 .593], p-value <0.05). Mortality rate among hospitalized cirrhotic patients with AKI in cirrhosis were 34.92%. Acute kidney injury was identified as a risk factor for mortality among patients with cirrhosis (Odds ratio [95%CI]: 3.823 [1.549-9 .434], p-value < 0.05). Conclusion Burden of AKI (49.2% prevalence and 34.92% mortality rate) among hospitalized patients with cirrhosis is significantly high in our region. Patients with definite predisposing factors require close mon-Introduction Non-alcoholic fatty liver disease (NAFLD) is becoming a modern-day pandemic with prevalence almost 30% in Asian countries. The study was done to evaluate the efficacy of Saroglitazar 4 mg OD in lean vs. overweight/obese NAFLD patients, in routine clinical practice. Methods A total 33 NAFLD patients (Males 87.9%) diagnosed on ultrasound sonography (USG) or fibroscan imaging or elevated liver function test (LFT) along with exclusion diagnosis, and prescribed on Saroglitazar 4 mg OD, were retrospectively analyzed for changes in fibroscan LFT (n=27) and other liver related parameters. The overall improvement and improvements in lean (mean BMI 24.3 + 1.4 kg/m2) vs. overweight/obese (mean BMI 27.8 + 1.5 kg/m2) NAFLD cohort, classified as per WHO Criteria of obesity, is measured at baseline and 24 weeks. The statistical significance was established using paired sample t-test. Results The study shows significant improvements in all measured parameters from baseline in both lean vs. overweight NAFLD cohort. The overall NFS score improved by 33.4% with 69.7% (n=23) patients in low NFS range at baseline increased to 93.9% (n=31) patients after 24 weeks. Conclusions Saroglitazar 4 mg OD is found safe and equally effective in both normal weight and overweight/obese NAFLD. More studies, including well designed clinical trials will show more light on possible effect of Saroglitazar 4 mg in lean NAFLD. Upsurge in the prevalence of the non-alcoholic fatty liver disease (NAFLD) has brought up it as one of the most frequent culprits of cirrhosis worldwide and features of metabolic syndrome have been found as the most common association, influencing its prognosis and progression to liver fibrosis. Even after one-fourth of the general population being affected worldwide, diagnosed NAFLD cases are the tip of the iceberg, with less than 10% being referred to specialists. Early diagnosis of advanced liver fibrosis in NAFLD remains an uphill task in clinical practice as these are at the greatest risk of developing complications. The gold standard liver biopsy being invasive has many inherent shortcomings, favoring the non-invasive tests. Method Prospective observational study on 148 consecutive ultrasound sonography (USG) diagnosed NAFLD. Liver stiffness correlated with APRI, FIB 4, and NFS. Results 51.36% have increased stiffness (> 5.7 Kpa). FIB4 <= 1.45, between 1.45 to 3.25 and > 3.25 were seen in 66.22%, 27.03% and 6.76% respectively. Those with FIB4 > 3.25, 60% patient had F2-3 fibrosis and 20% had F1 fibrosis. NFS <= -1.45 is found in 52.7% and 47.30% had > -1.45. patients with NFS <= -1.45, 69.23% and 30.77% have normal and F1 fibrosis respectively. NFS >= 0.675 45.83% and 41.67% have F2-3 and F1 fibrosis respectively. Metabolic syndrome was the most common association with NAFLD (77.7%) and have increased risk of liver fibrosis which further increases with the increased number of component of metabolic syndrome. Past history of NAFLD had increased risk of advanced fibrosis. Conclusion APRI, FIB4, and NFS all correlate accurately in ruling out or in liver fibrosis, FIB4 and NFS in combination with USG elastography can be used for surveillance of NAFLD patients for early diagnosis of liver fibrosis and its progression to prevent complications and early referral to a specialist. Keywords Non-alcoholic fatty liver disease, Liver stiffness, FIB4

Circulating tumor cells assessment in patients with hepatocellular carcinoma by imaging flowcytometry and it`s relationship with staging -Interim analysis Introduction Circulating tumor cells are considered as potential biomarkers for the detection of hepatocellular carcinoma (HCC). It is expected to play an important role in early diagnosis and dynamic monitoring. Aim of this study was to evaluate the relationship of circulating tumor cells with HCC Barcelona Clinic Liver Cancer (BCLC) staging. Methods An imaging flowcytometry method, using immunofluorescence of cytokeratin, EpCAM (Epithelial Cell Adhesion Molecule), alphafetoprotein (AFP) together with the analysis of size, morphology and deoxyribonucleic acid (DNA) content for detection of circulating tumor cells was developed and applied to 20 HCC patients and 10 patients with cirrhosis of liver without any evidence of hepatic or extrahepatic malignancy. Results Among 20 HCC patients 17 (85%) were male. Two patients were BCLC stage A, 5 were BCLC stage B and 13 were BCLC stage C. Out of 10 cirrhotic patients 7 were Child-Turcotte-Pugh (CTP) B and 3 were CTP C. Circulating tumor cells were detected in 20 of 20 patients of HCC and none among cirrhosis of liver patients. Mean number of circulating tumor cells were 9.9 (range 1-20). Circulating tumor cells positive for EpCAM were detected in 18 patients with mean value of 4.6. Circulating tumor cells positive for cytokeratin were detected in 16 patients with mean value of 1.8. Circulating tumor cells positive for AFP were detected in all patients with mean value of 3.5. The number of circulating tumor cells were significantly associated with BCLC stage (p<0.0005) and portal vein thrombosis (p=0.025). Conclusion This study shows the potential role of circulating tumor cells as a biomarker of HCC and also a significant association between the number of circulating tumor cells with BCLC staging and portal vein thrombosis.

Introduction Patients with elevated alpha-fetoprotein (AFP) have long been associated with hepatic malignancy, but there are other benign causes of AFP elevation, especially in chronic liver disease. This case illustrates one such exemption. On the background of a previous EBV infection, patients can develop Epstein-Barr virus (EBV) hepatitis, EBV related autoimmune hepatitis, or autoimmune reaction to EBV. The history and the clinical profile of the patient is essential in directing the evaluation of these patients. Methods Case report Results The patient is a 26-year-old Asian male presenting with jaundice. He had no personal or family history of liver disease, occasional alcohol use, and denies drug or supplement use. Laboratory workup revealed hepatocellular type of liver injury (total bilirubin of 478 umol/L, direct bilirubin 401 umol/L, indirect bilirubin 77 umol/L, aspartate aminotransferase (AST) 1135 U/L, alanine transaminase (ALT) 1592 U/L, lactate dehydrogenase (LDH) 53 U/L, alkaline phosphatase (ALP) 139 u/L), elevated AFP (3337 IU/mL), elevated international normalized ratio (INR), positive autoimmune panel (ANA, anti-Sm, anti-TPO, anti-TG). Serological examinations revealed past infection with EBV and cytomegalovirus (CMV). Imaging tests did not show ductal obstruction or the presence of mass lesions. Subsequent liver biopsy demonstrated interface hepatitis. The patient was treated as a case of autoimmune hepatitis and was started on glucocorticoids with clinical and biochemical improvement including normalization of AFP levels. Conclusion This study demonstrated the low specificity of AFP as it relates to these unusually elevated levels even as compared to other studies on non-malignant cases of liver disease. In this patient with acute hepatitis, AFP elevation may represent hepatic regeneration. Keywords Case report, AFP, EBV, Acute hepatitis 191 Congenitally corrected transposition of great vessels with Crigller-Najjar syndrome type II and glucose-6-phosphate dehydrogenase deficiency-A rare association Amit Joshi, K K Sharma 1 Correspondence -Amit Joshi -dradjoshirajkot@gmail.com Departments of Gastroenterology and 1 Cardiology, Tricolour Hospitals, Vikram Sarabhai Road, Near Genda Circle, Vadodara 390 007, India

Introduction Crigler-Najjar syndrome type II is a rare disorder of bilirubin conjugation characterized by severely reduced (<10%) UGT1A1 enzyme activity. Here we present a rare case of congenitally corrected transposition of great vessels with Crigler-Najjar syndrome type II and glucose-6phosphate dehydrogenase (G6PD) deficiency. Case Report Twenty-eight-year-old male patient, known case of congenitally corrected transposition of great arteries presented with dyspnea. Patient gave history of long-standing jaundice since 10 years without any history of cholestasis, or hepatic decompensation. On examinationhe had scleral icterus and bilateral pitting pedal edema and features of cardiac failure with tender hepatomegaly. His hemogram was unremarkable. His liver biochemistry panel showed total bilirubin of 11.4 mg/dL, direct bilirubin-2.45 mg/dL, indirect bilirubin 8.99 mg/dL, serum glutamic-oxaloacetic transaminase (SGOT) -76 U/L, serum glutamic pyruvic transaminase (SGPT) -112 U/L, alkaline phosphatase 65 U/L, gamma-glutamyl transferase (GGT) -35 U/L, total protein-7.01 g/dL, serum albumin-3.71 g/dL, international normalized ratio (INR) -1.13. His ultrasound abdomen was suggestive of enlarged liver (22 cm) with normal echotexture. Baseline echocardiogram was suggestive of atrial fibrillation with high ventricular rate and echocardiography was suggestive of congenitally corrected transposition of great vessels with biventricular failure. He was found to be deficient in G6PD enzyme. His serum ceruloplasmin was normal. His UGT1A1 gene polymorphism showed 7/7 TA repeats for UGT1A1*28/*28 which was suggestive of severely reduced activity of enzyme UDP glucuronyl transferase. Patient was started with low dose phenobarbitone. The work up for raised transaminase revealed IgM anti-HAV positive. However due to his pre-existing cardiac ailment patient went into refractory cardiogenic shock and ultimately succumbed to his disease. Discussion Patient with Crigler-Najjar syndrome type II generally have indirect bilirubinemia (levels more than 5 mg/dL) with normal transaminases. As stress of congestive cardiac failure lead hyperbilirubinemia of such high levels and raised transaminases could be explained by acute hepatitis A and congestive hepatopathy secondary to congestive cardiac failure. Keywords Crigler-Najjar syndrome type II Hand grip strength: A effective bedside screening tool to detect sarcopenia and predict survival in patients with chronic liver disease Gajanan Rodge, Usha Goenka 1 , Shivaraj Afzalpurkar, Surabhi Jajodia 1 , Vikas Prakash, Mahesh Goenka Correspondence -Gajanan Rodge -grodge3@gmail.com Institute of Gastrosciences and Liver, and 1 Department of Clinical Imaging and Interventional Radiology, Apollo Multi-Speciality Hospital , 58, Canal Circular Road, Kolkata 700 054, India

Background Hand grip (HG) strength is measured by the hand grip dynamometer and is a simple bed side tool for assessment of nutritional status. L3 Psoas Muscle Index (PMI) is a CT based method for sarcopenia assessment. The aim of this study was to assess sarcopenia in cirrhotics by HG strength and its correlation with sarcopenia on CT scan. Methods The hand grip strength was measured after the patient was rested on a chair and the handle of the dynamometer was adjusted. Patients were advised to hold the instrument away from the body and table and apply possible maximal strength with the dominant hand. Three readings were noted with a gap of more than 30 sec and the highest recorded value of HG strength was recorded. Results Seventy-five consecutive patients were assessed for the HG strength and psoas muscle on CT scan. The cut off values for diagnosis of HG weakness and sarcopenia were derived from the local control group (n=75). HG weakness was seen in 41.3% (n=31) and sarcopenia assessed by PMI was seen in 36% (n=27) of the CLD patients. Fifty-three out of 75 patients completed the follow-up period of 1 year. Out of patients who succumbed to liver related illness on follow-up, 77.8% (n=7) had HG weakness, while 22.2% (n=2) without HG weakness expired during follow-up. The association of 1 year mortality and HG weakness was statistically significant (p value = 0.01). The Kappa measure of agreement between HG and sarcopenia assessment was 0.608 (good strength of agreement). The spearman's rho correlation coefficient between HG weakness and PMI sarcopenia ( Fig. 1) Autoimmune hepatitis and Wilson's disease are close differentials in middle aged female presenting with subacute hepatitis. Here we present a challenging case of autoimmune hepatitis mimicking Wilson's disease. Fifty-two-year-old female presented to outpatient department with yellowish discoloration of sclera since one week which progressed over next one month. No history of complementary and alternative medication intake. On presentation, icteric sclera and mild bipedal edema were noted besides positive shifting dullness. Total bilirubin was raised 26 mg/dL with direct: indirect 0.85 with disproportionately raised aspartate aminotransferase (AST) (655 U/L) more than alanine aminotransferase (ALT) (251 IU/L) and normal alkaline phosphatase (ALP) (127 IU/L). total protein was 5.5 gm/dL with albumin: globulin 0.77 and international normalized ratio (INR) was 1.55. ascitic fluid analysis revealed high saag low protein with no spontaneous bacterial peritonitis. viral serology were nonreactive. ana IFA was 1+(1:100), nuclear homogeneous pattern and DCT 1+(IGG). However, ana profile, anti SMA, anti LKM, anti SLA, serum ACE were negative. 24-hour urine protein was 312 mg. contrast-enhanced computed tomography (CECT) abdomen delineated hepatomegaly with mild ascites. upper GI endoscopy showed esophageal candidiasis with mild portal hypertensive gastropathy. Surprisingly serum ceruloplasmin was below 20 mg/dL with elevated urinary copper level 300 microgram. KF Ring was absent with normal brain magnetic resonance imaging (MRI) scan and magnetic resonance cholangiopancreatography (MRCP) with no evidence of cardiomyopathy on 2D echocardiography; but nerve conduction study delineated asymmetrical motor axonal neuropathy involving left lower and bilateral upper limbs. Possibility of both autoimmune hepatitis and Wilson's disease were doing rounds. Hence, she underwent liver biopsy which confirmed the findings of autoimmune hepatitis (lymphoplasmacytosis, interface hepatitis, bridging fibrosis, focal pericholangitis) with no siderosis on Perls stain and quantitative copper content 60 microgram/gram of liver. She was started on oral steroids but unfortunate she became covid positive and ultimately succumbed to death shortly. This interesting case shows the importance of rulling out the possibility of more prevalent autoimmune hepatitis before reaching diagnosis of Wilson's disease. Keywords Subacute hepatitis, Wilson disease, Autoimmune hepatitis 194 Severe hyponatremia as a prognostic indicator and mortality predictor in cirrhotic patients with refractory ascites -A prospective cohort study

Correspondence -Mithun K Unni -mithunkunni@gmail.com Department of Medical Gastroenterology, Government Medical College, 17, Mavoor Road, Kozhikode 673 008, India

Background In MELDNa score serum sodium concentrations numerically capped between 125 and 140 mmol/L. The prognostic value of severe hyponatremia (serum sodium <125 mmol/L) in cirrhotic patients with refractory ascites as an independent predictor of mortality and complications has to be studied. Aim To assess the validity of severe hyponatremia in predicting mortality and complications in cirrhotic patients with refractory ascites. Also, to assess the prevalence of severe hyponatremia in these patients. Methods One hundred and two consecutive cirrhotic patients with refractory ascites were included. They were classified into two groups A) with serum sodium < 125 meq/L and B) with serum sodium > 125 meq/L. Mortality at 3 months and 6 months were assessed. Readmissions and complications like infections, hepatic encephalopathy and hepatorenal syndrome were also studied. Results Patients with refractory ascites (n=102) (M:F 76:26, mean age 53.6 years +/-12.6 ) were followed up for a period of 6 months. At presentation, median serum sodium level was 129.5 meq/L and median MELDNa level was 29. 35.29 % patients had diuretic intractable ascites due to severe hyponatremia. Severe hyponatremia was significantly associated with early mortality and complications in patients with refractory ascites in univariate analysis. Serum sodium, MELD and CTP scores were independent predictors of mortality on multivariate analysis.

Introduction Fluid overload is the most frequent complication of endstage liver disease, regardless of its etiology. Brain natriuretic peptide (BNP) is a cardiac neurohormone that is secreted from the ventricles in response to increased pressure or volume. The major physiological effects of BNP are vasodilation and natriuresis. In this study the prognostic role of BNP as a marker of severity of liver disease will be investigated Aim of the Study Correlation of BNP with 90-day mortality, severity of disease and with number of paracentesis that the patient underwent during the 90 days period. Methods It is a prospective observational study conducted in the Department of Gastroenterology, IGIMS. Inclusion Criteria Decompensated CLD patients diagnosed clinically and radiologically and having no systolic heart failure (ef >55%). Exclusion Criteria Patients with heart failure, arrhythmia, coronary artery disease, pulmonary hypertension, chronic kidney disease. Results Out of 105 patients enrolled, 40 patients did not meet our inclusion criteria. A total of 65 patients were followed for 3 months and out of which 22 patients died. Majority of the patients were alcoholic, and cause of death were UGI bleed. Mean CTP and MELD Na levels were 11 and 24 in patients who died in 3 months and 9.8 and 20 in patients who survived. Mean number of paracenteses in alive patients were .54 and died patients were 1.16 Osmotic demylination syndrome (ODS) also called central pontine myelinosis (CPM), is defined as a acute, severe, non-inflammatory neurological disorder which is characterized by rapid destruction of myelin sheath, mainly of oligiodendritic cells with relatively well preserved axons and neuronal cell bodies. Pontis basalis is the most commonly affected site in the brain. The commonest precipitating cause of this syndrome is rapid correction of hyponatremia which results in rapid osmotic shifts and neuronal cell dehydration leading into damage of the myelin sheath. Other precipitating causes of this syndrome include chronic alcoholism especially in the withdrawal phase, patients of chronic kidney disease (CKD) and dialysis, acute liver failure and post liver transplant. Case Summary A 51-year-old male patient who had a background history of chronic alcohol consumption of more than 100 grams daily from 20 years presented with gait disturbances for 2 months and developed altered sensorium, tremors and quadriparesis needing intensive care unit (ICU) care. Magnetic resonance imaging (MRI) brain showed a well-defined focal, central trident shape area of hyperintensity T2 weighted image in the region of median pons consistent with a diagnosis of Central pontine myleinosis. Conclusion CPM is frequently underdiagnosed and underreported in clinical setting. it may mimic hepatic encephalopathy. CPM may occur in a patient with chronic alcohol intake even without rapid correction of hyponatremia. overall CPM has a dismal prognosis with high mortality or permanent neurological sequalae in 33% to 50% cases. The mechanism of CPM in a chronic alcoholic patient includes, malnutrition, dyselectrolytemia, alcohol withdrawal and nutritional deficiencies. MRI brain must be done in all patients who have a significant history of alcohol intake and present with any acute neurological symptoms Keywords Ods-osmotic demyelination syndrome Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly emerging, highly transmissible and pathogenic corona virus which has caused a pandemic with global public health emergency and financial crisis. Elderly patients, including patients with diabetes and obesity are more vulnerable to this disease. Patients with pre-existing liver disease particularly liver cirrhosis, are 4 times likely to die due to corona virus disease 2019 infection. This severe disease translates in to increased hospitalization rates with increase in ICU care and the need for ventilation and RRT which in turn leads to high mortality.

Case Summary A 53-year-old male patient with non-alcoholic steatohepatitis (NASH) related liver cirrhosis who was listed for (ldltx). One week before his scheduled liver transplant, presented to OPD with generalized weakness, oliguria and hypotension. RT-PCR for COVID -19 was positive. Patient was admitted in MICU where he developed acute-on-chronic liver failure (ACLF) grade 3. Patient needed Inotrope support and mechanical ventilation for his disease progression. Despite optimal medical intensive care, patient did not survive. Conclusions COVID-19 related mortality is significantly associated with severity of pre-existing liver cirrhosis. Majority (80%) of the patients with COVID-19 and ACLF die because of respiratory failure. COVID-19 can cause ACLF. Various mechanisms involved are -cirrhosis associated immune dysfunction, cytokine storm, persisting SIRS, multioragan damage and intestinal dysbiosis. Up to 80% of patients with cirrhosis who require ICU support will not survive. There is urgent need to prioritize patient with CLD including those who need liver transplant to get vaccinated against COVID-19. The safety and immunogenicity of mRNA and Adeno viral vector vaccines is documented.

Non-alcoholic steatohepatitis related cirrhosis, presenting as hepatic hydrothorax -Case report with literature review Nikita Sirohi, Arvind Sahni, Mohinish Chhabra, Abhishek Prasad 1 Correspondence -Mohinish Chhabra -mohinishchhabra@ fortishealthcare.com Departments of Gastroenterology, and 1 Radology, Fortis Hospital, Mohali 160 062, India Hepatic hydrothorax (HH) is rare presentation of PHTN which accounts for 2% to 3% of all pleural effusions. HH is defined as accumulation of transudative fluid more than 500 mL in pleural cavity in patients with decompensated cirrhosis after excluding cardiopulmonary and pleural diseases. The most accepted mechanism is direct passage of the fluid from the peritoneal to the pleural cavity through diaphragmatic defects. The treatment of HH is challenging and need a multidisplinary approach. Spontaneous bacterial empyema (SBE) is a complication of HH which is seen in 13% of cases. Management includes antibiotics and drainage. Liver transplant is the treatment of choice for HH and SBE. Case report A 59-year-old female diabetic patient presented with progressive shortness of breath and cough since 6 weeks with h/o ATT drugs for 1 weeks prior to hospitalization. Analysis of pleural fluid is transudative and ascitic fluid shows high SAAG. Chest imaging reveal large Rt side pleural effusion with collapse CT abdomen was consistent with liver cirrhosis and PHTN. Pleural catheter was inserted and approximately 14 litre of fluid was drained over next 2 weeks, along with low sodium diet, albumin, fluid restriction and diuretics. Patient was councelled for liver transplant and underwent a live donor liver transplant (LdLT) within 2 months of admission. Conclusion All patients of HH and SBE must be considered for liver transplant whenever feasible If transplant is not feasible TIPS should be considered. In addition to aggressive medical therapy indwelling pleural catheter have important role in management of HH and SBE. Long-term survival after liver transplant in HH and SBE is similar to patients transplanted for other indications. Keywords Hepatic hydrothorax Assessment of frailty by short physical performance battery in patients with liver cirrhosis and its ability to predict mortality and hospital re-admissions Introduction Cirrhosis of liver with its complications causes significant morbidity and mortality. Diminished physiological function and frailty can predict morbidity, hospitalizations, and mortality. Out of many frailty screening tools, short physical performance battery (SPPB) is a promising, quick, reliable, bedside tool that provides uniform, standard parameters. Aim To evaluate frailty in cirrhotic patients by SPPB and its ability to predict 90 days mortality and hospital re-admissions. Methods One hundred and three patients with liver cirrhosis presenting to OGH, Hyderabad were recruited. Clinical assessment, routine laboratory tests were performed and SPPB frailty index, CTP score, MELD-Na score were calculated on admission. Patients were followed up for rehospitalizations and mortality for 90 days. Results The mean age of patients was 44.89 ±10.02 years. Eighty-four were males and 19 were females. The most common etiology for cirrhosis was alcohol (69.69%). The mean SPPB score was 8.32 ± 2.87. 58.3% patients were frail (SPPB score <10). The SPPB score had significant positive correlation with Hb (p-0.028), mid arm circumference (p-0.004), BMI (p-0.028) and albumin (p-0.003) whereas it had significant negative correlation with age (p-0.028), CTP score (p<0.001), MELD-Na score (p<0.001). The overall 90-day mortality rate was 30.1% and readmission rate was 40.77%. The SPPB score differed significantly between survivors (9.29 ± 2.50) and non-survivors (6.06 ± 2.38) [p<0.001] as well as between re-admitted (7.83 ± 3.01) vs. non-re-admitted patients ( Accurate prediction of mortality is important in decompensated cirrhosis. At present, CTP score and MELD-Na score are mainly used to predict the mortality in patients with decompensated cirrhosis of liver, but they have certain limitations. The albumin bilirubin (ALBI) score is simple and is easily calculated using only two laboratory parameters. However, it has not been evaluated in decompensated cirrhosis in terms of mortality. Aim To evaluate the ability of ALBI score for assessing the 180 days mortality in decompensated cirrhotic patients.

Method One hundred patients with decompensated cirrhosis who presenting to the Department of Medical Gastroenterology (November 2019 to March 2021) were studied prospectively. After detailed clinical evaluation and laboratory investigations, CTP score, MELD-Na score, ALBI score and ALBI grade were calculated. We evaluated the 180 days outcome and its association with ALBI score, CTP score and MELD-Na score. Results Out of the 100 patients, 59 patients had survived for 180 days (Group-A), 21 patients had expired within 90 days (Group-B1) while 20 patients had expired between 91-180 days (Group-B2). Male predominance was seen (88% vs. 22%) and mean age was 46.39 years. Ethanol was the most common etiology of cirrhosis (79% cases). We found that mortality both at 90 days and 180 days were high in patients with higher CTP score, MELD-Na score, ALBI score and ALBI grade (p <0.05). The value of AUC was high in ALBI score (.846) as compared to CTP score (.733) and MELD-Na score (.666). At a cut off -1.04, ALBI score was 68.3% sensitive and 89.8% specific. After logistic regression analysis, we found that one unit increase in ALBI was associated with 10 times increase in mortality. Conclusion We found that ALBI score and ALBI grade predict mortality at 90 days and 180 days with high sensitivity and specificity in patients with decompensated cirrhosis. Keywords Cirrhosis, ALBI, Mortality

Challenges in liver transplantation for a special situation -Thalassemia major

Correspondence -Ronak Tate -roontate@gmail.com Department of Gastroenterology, E/204, Sukh Angan Building, Opp. S.T Depot, Nalasopara West, Palghar 401 203, India Thalassemia syndromes are associated with iron overload leading to liver cirrhosis, cardiomyopathy, heart failure, diabetes, and other endocrine abnormalities. With improved transfusion techniques and patients living longer, there is an increasing prevalence of decompensated chronic liver disease and hepatocellular carcinoma secondary to hepatitis C infection and iron overload. However, there is only one case report in literature of a combined liver and cardiac transplant in patient with thalassemia and iron overload. We present the case of a 38 years old male with thalassemia major needing weekly blood transfusions soon after birth. He had undergone a splenectomy in the past and was on iron chelation therapy. During pre-op workup was found to have hepatitis C infection was treated with Sofosbuvir based therapy and sustained virological response (SVR) was achieved. He also had severe osteoporosis and hypogonadism. Despite achieving SVR, his liver decompensated in the last few years in the form of ascites, SBP and encephalopathy. This was attributed to excess iron overload in the liver demonstrated on T2* MRI. He underwent a deceased donor liver transplant for the same. The challenges included a difficult recipient hepatectomy because of the previous splenectomy. He needed multiple PRBC which had to be leuko-depleted to reduce alloimmunisation. Postoperatively, he had tacrolimus toxicity causing hypertension and seizures. The latter resulted in a pathological radius fracture. The osteoporosis was aggravated by steroids received post-transplant. He eventually recovered well and was discharged and is doing well 5 months post-transplant. He needed lesser PRBC transfusions(twice monthly) which are leuko-depleted and iron chelation to maintain serum ferritin <1000 mg/dL. With regular monitoring of the iron overload status in addition to the routine post-transplant issues, it is possible to improve survival and quality of life in patients with thalassemia major with decompensated liver disease. Keywords Thalasemia major, Liver transplant, Hepatitis C Introduction Hepatitis C virus (HCV) infection is the most common hepatotoxic viral infection that affects patients on maintenance hemodialysis (MHD). Recommended regimens in ESRD patients are not available in India. Pangenotypic regimens containing sofosbuvir is the main stay of treatment. There is concern over safety of usage of full dose sofosbuvir in these patients as it is eliminated by kidneys. So, the aim of this study was to evaluate efficacy and safety of full dose daily sofosbuvir based DAA regimen in MHD patients with HCV infection in comparison to nonuremic patients. Methodology One hundred and six patients (50 non uremic and 56 MHD) chronic hepatitis C patients were included in the study. Before starting treatment HCV genotype, viral load, ultrasound abdomen and fibroscan were done. We started sofosbuvir (400 mg) + velpatasvir (100 mg) in patients with significant fibrosis and sofosbuvir (400 mg) + daclatasvir (60 mg) in patients without fibrosis, once daily for 12 weeks. Quantitative HCV RNA was done at 12 weeks after treatment. Results Among 56 patients on MHD 6 patients were excluded from study. Most common genotype was GT1A seen in 80% of MHD group and 88% in non-uremic group (p>0.05) followed by GT 3B in 20% of MHD patients and 12% of non-uremic group (p>0.05). Significant fibrosis was seen in 5 patients (10%) in MHD group and 15 patients (30%) in non-uremic group. SVR12 was achieved in 96% of MHD group and 98% in non-uremic group (p>0.05). Ten (20%) patients from MHD group and 8 (16%) patients in nonuremic group had minor adverse events. Nausea and headache were common adverse events observed. None of them had serious adverse Introduction Non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) is an emerging public health issue, being a major cause of liver-related morbidity and mortality worldwide. It refers to a wide spectrum of liver disease ranging from steatosis, steatohepatitis, fibrosis, cirrhosis with liver failure and hepatocellular carcinoma. This study was done to compare the real-world efficacy of saroglitazar 4 mg vs. vitamin E 400 IU in reducing AST, ALT, serum triglycerides and liver stiffness measure on Fibroscan in NASH patients. Methods This is a prospective study in which 50 patients each on saroglitazar 4 mg OD and Vitamin E 400 IU BD with USG evidence of fatty liver with abnormal LFT and or abnormal LSM were enrolled for a period of 1 year. All Patients were followed up for LFT, serum triglycerides and LSM, at an interval of 6 months and 1 year. Statistical analysis was done using paired sample t-test. Results Significant improvement was observed in LFT, Serum lipids and LSM in the group treated with saroglitazar compared to Vitamin E. Discussion The conventional knowledge that ALP rises more than AST in obstructive jaundice remains true where the jaundice is due to malignant biliary obstruction, but in obstructive stone disease, the rise in AST may equal that in ALP, or even exceed it during period of maximum jaundice.

Conclusion Clinicians should consider the possibility of extrahepatic biliary obstruction, even when AST is the predominantly elevated enzyme.

Introduction Obesity is a known risk factor for disease progression in patients with non-alcoholic steatohepatitis (NASH); however, the body composition (BC) parameters affecting progression of NASH is not known. Introduction Methotrexate (MTX) as a DMARD, is mainstay in the treatment of variety of autoimmune diseases including psoriasis and rheumatoid arthritis (RA). Although MTX has good efficacy and safety, hepatotoxicity has been well described. Fibroscan has found to be reliable, non-invasive method for the detection of hepatic fibrosis without any side effects. The present study is conducted to assess the degree and prevalence of hepatic fibrosis in patients on MTX therapy by Fibroscan. Introduction Different leucocyte ratios like neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR) and neutrophil to monocyte ratio (NMR) have been used as markers of inflammation in various conditions. In the recent times, these ratios are being explored as markers for predicting mortality in patients with decompensated chronic liver disease (DCLD). Aim To demonstrate the usefulness of leukocyte ratios as biomarkers for mortality prediction in decompensated CLD.

Methods A retrospective analysis of decompensated CLD patients managed at our center from January 2019 -June 2021 was performed. Besides demographic and etiologic information, leukocyte ratios were calculated from the available admission investigations and comparison was done between those who survived to hospital discharge (survivors) and those who did not (non survivors Introduction Autonomic dysfunction in non-alcoholic cirrhosis is less frequently studied. Aim To assess autonomic nervous system in patients of alcohol and nonalcohol related cirrhosis. Methods This is a cross sectional study of 80 patients with cirrhosis (40 alcoholics and 40 non alcoholics). Autonomic profile included performance questionnaire and five autonomic function tests based on Ewing's test. The extent of autonomic dysfunction was determined.

Results Sixty-two of (77.5%) the cirrhotic subjects were found to have evidence of autonomic neuropathy. Of these, 10 (12.5%) patients had early parasympathetic damage, 16 (20%) had definite parasympathetic damage, and 36 (45%) had combined (that is, both parasympathetic and sympathetic) damage. 38(95%) of the alcoholics and 31 (77.5%) of the non-alcoholics had autonomic dysfunction. Autonomic dysfunction was significantly more frequent in advanced liver disease compared with early liver damage. Fortyone (73%) out of 56 cirrhotic subjects belonging to CTP B and 20 (85.7%) of the 24 patients belonging to CTP C had autonomic neuropathy.

Conclusion This study shows that autonomic neuropathy is common in cirrhotic subjects and found with comparable frequency in alcoholics and non-alcoholics. It Increases in severity with increase in extent of liver Introduction Hepatitis is a known complication during the treatment phase of leukemia but the association of abnormal liver biochemistries at initial presentation of leukemia is poorly described. Conclusion PMTH is the best nutritional assessment tool correlated with severity of cirrhosis followed by SGA. HGS, MAMC, BIA (Skeletal muscle percentage) are bedside tools for nutritional assessment in male cirrhotics. We did not find BMI, BIA (VAT, SAT) to be reliable indicators of malnutrition. Keywords Cirrhosis, Malnutrition, Nutrition assessment disrupt bile formation and present with cholestasis of hepatocellular origin. Defects in ABCB4, encoding the multi-drug resistant 3 protein (MDR3), impair biliary phospholipid secretion resulting in PFIC3. Acanthosis nigricans is a cutaneous manifestation of an underlying condition. It usually develops in in skin folds, such as the back of the neck, axilla, and groin, where it presents as velvety hyper-pigmented patches with poorly defined borders. Case Report A 12-year-old female who is known case of PFIC type 3 came for follow-up with chief complaints of pruritus and increased pigmentation over neck region and forehead. Dermatology opinion took for that and skin biopsy done which suggestive of acanthosis nigricans. Discussion Acanthosis nigricans is most commonly associated with diabetes, insulin resistance, internal malignancy, hormone disorders or with the use of certain medications like systemic glucocorticoids and oral contraceptives. The pathophysiological process behind acanthosis nigricans appears to be related to the proliferation of fibroblasts and the enhanced stimulation of epidermal keratinocytes In literature association with PFIC is not mentioned. Here we reporting a case of acanthosis nigricans in PFIC type 3 patients.

Keywords Acanthosis nigricans, PFIC

To assess response to steroids in patients with autoimmune hepatitis Introduction Autoimmune hepatitis (AIH) is an acute, or more frequently chronic, inflammatory, immune-mediated liver disease which is defined by a rise in immunoglobulin G (IgG) levels, the presence of non-organ-specific autoantibodies and characteristic histological features such as interface hepatitis and plasma cell infiltration. In autoimmune hepatitis, response to steroids and optimal timing of liver transplantation always remains controversial. Aim of study is to assess response to steroids at day 3,7,14 after starting steroids and to compare two groups responders and non responders to steroids.

Methods It is interim analysis of observational retrospective and prospective study involving 17 patients of AIH divided into acute AIH, acute severe (AS) AIH and AS-AIH with ALF (acute liver failure) . Response to steroids was assessed in these 3 groups of patients. Background Terlipressin is a commonly used drug in patients with chronic liver disease for the management of hepatorenal syndrome and hematemesis. Despite being a very useful drug, it is associated with some adverse events. However, there is not much data related to adverse events of terlipressin.

Methods We retrospectively reviewed the history, laboratory investigations, radiological investigations, medication charts, vital charts and daily progress notes of patients with cirrhosis and hepatorenal syndrome who were treated with terlipressin at our department between January 2020 and July 2021. Data recorded were age, sex, etiology of cirrhosis, diarrhea and its grading, intervention for diarrhea and spontaneous bacterial peritonitis. Results A total of 44 patients of cirrhosis with hepatorenal syndrome treated with IV terlipressin were analyzed. Diarrhea occurred in 9 (20.45%) patients among which 6 (66.66%) had severe diarrhea, 2 (22.22%) had moderate diarrhea and 1 (11.11%) had mild diarrhea. Among 6 patients of severe diarrhea, terlipressin had to be stopped in 3 (50%) and midodrine started but terlipressin was not restarted as creatinine had normalised till then. Terlipressin had to be stopped and restarted after recovery of loose stools in 2 (33.33%) patients, among them 1 (50%) patient had recurrence while the other 1 (50%) did not have recurrence of diarrhea. Terlipressin was decreased to twice a day in 1 (16.66%) patient with severe diarrhea and loose stools improved. Diarrhea was managed with racecadotril and iv fluids in patients with moderate diarrhea and terlipressin was continued.

Conclusions In our everyday clinical practice, terlipressin related adverse events are common, but often reversible. Keywords Terlipressin, Diarrhea, Cirrhosis Conclusion Tinospora cordifolia has been confirmed to be the plant consumed by the patients in our study who presented with HILI. In India, we have the capability to identify the implicated plant with a combination of morphological, microscopic, phytochemical and DNA analysis. Future studies on causality need to focus on the identification of active herb/metabolites in human blood/tissues. Reference 1. Nagral A, Adhyaru K, Rudra OS, Gharat A, Bhandare S. Herbal immune booster-induced liver injury in the COVID-19 pandemic-Introduction Non-invasive scores for assessing hepatic fibrosis in nonalcoholic fatty liver disease (NAFLD) have not been validated in Indian patients. We aimed to validate AST-platelet ratio index (APRI), Fibrosis-4 (FIB-4) and NAFLD fibrosis score (NFS) in biopsy-proven patients with NAFLD.

Methods Prospectively collected data of 129 biopsy-proven NAFLD patients was reviewed retrospectively (Males -86, mean age: 40.2 ± 10.3 years). Primary objective was to assess discriminatory ability of APRI, FIB-4 and NFS scores to detect significant (≥F2) and advanced fibrosis (≥F3) on liver histology. Secondary objectives were to assess diagnostic performance of conventional cut-offs of these scores for ruling-in and ruling-out significant and advanced fibrosis and define optimal cut-offs if required. Findings were internally validated using bootstrapping. Introduction Whether to treat patients of autoimmune hepatitis related decompensated cirrhosis with immunosuppression remains a dilemma. This observational study was conducted to look at the outcome with immunosuppressive therapy in patients with autoimmune hepatitis related decompensated cirrhosis.

Methods Retrospective data was collected from January 2017 to December 2020 of patients with autoimmune hepatitis related decompensated cirrhosis admitted at our tertiary care hospital. Patients with autoimmune hepatitis related decompensated cirrhosis were treated with steroids with/without immunomodulators using a predetermined treatment protocol and routine standard of care. Survival at the end of one year and change in MELD score (delta MELD) was calculated.

Results Thirty-five patients with autoimmune hepatitis related decompensated cirrhosis were studied. Mean age was 45.40 +/-14.5 years. 54.3% of the patients were females. Ascites was the most common form of decompensation (91.4%). Mean CTP score was 9.89 +/-1.6 and mean MELD score was 13.98 +/-4.5 at the baseline. 65.7% of the patients were treated with a combination of oral corticosteroids and immunomodulators, 14.2% were treated with oral corticosteroids alone and 20% were not started on any of the immunosuppressants. At the end of one year, resolution of ascites was seen in more than half the patients (57.1%) with five patients succumbing to their illness. Most common cause of death was sepsis. SBP (17.1%) was the most common form of infection. MELD decreased by a mean of 3.72 points from baseline in patients who survived at the end of one year. There was no significant difference in the rates of infections (p=0.5), change in MELD (p=0.9), survival (p=1) and resolution of ascites (p=0.16) between those who received immunosuppression when compared to patients who did not receive therapy. Background Ascitic fluid infection (AFI) is one of the important complications of cirrhosis which has poor prognosis. It may be classified as spontaneous bacterial peritonitis (SBP), culture negative neutrocytic ascites (CNNA) or bacteriascites. Bacterial translocation from gastrointestinal (GI) tract is considered to be the most important mechanism that leads to development of AFI. Poor oral hygiene may cause subclinical or persistent infections in cirrhotic patients may act as independent risk factor for adverse outcomes in cirrhotic patients including AFI. Aim To assess the correlation between AFI in patients with decompensated cirrhosis having poor oral hygiene. Methods All in patients of cirrhosis with ascites were examined for ascitic fluid analysis including total protein, albumin, glucose, PMN count. Fluid was also inoculated at bedside for cultures. Oral hygiene was examined for all patients by using the dental mirror. OHI-S was calculated after calculating calculus and Debris index to determine good/poor oral hygiene.

Results A total 200 patients of decompensated cirrhosis were enrolled in the study. With mean age of 50.9 + 9.85. There were 78% males with a mean BMI of 18.9 + 1.9. Alcohol was the major cause of cirrhosis (72% Introduction Mucormycosis is an opportunistic fungal infection that leads to angio-invasion causing necrosis and eschar formation in the affected areas, with cutaneous forms being extremely rare. Patients with cirrhosis are at increased risk of fungal infections due to suppressed immunity, with an increased prevalence during the corona virus disease 2019 (COVID-19) pandemic. Case Report We describe a rare case of cutaneous mucormycosis in a middle-aged male with ethanol-related chronic liver disease. He presented with symptoms of fever, breathlessness and altered mental status. On admission, he was in septic shock and acute respiratory distress syndrome (ARDS). He was noticed to have ruptured blisters in his left axilla. Although he was negative for COVID-19 RT-PCR, he had positive IgG antibodies for COVID-19. He was managed with broad-spectrum antibiotics, steroids, vasopressors as well as ventilation for ARDS. Over the course of his hospitalization, the axillary lesion progressed to a necrotizing ulcer with deep tissue invasion. Debridement and culture of the axillary ulcer revealed mucor species and therapy with antifungals was initiated. Unfortunately, he continued to deteriorate despite aggressive management and succumbed after a prolonged hospital course of 40 days. Discussion Mucormycosis is an invasive fungal infection that is most commonly seen in the rhino-orbito-cerebral region and lungs. Cutaneous presentations are rare. We believe the immune suppression due to COVID-19 exposure and co-morbid chronic liver disease led to the development of mucormycosis. The infection was diagnosed late due to its unlikely location. The addition of steroids for septic shock during hospitalization could also be contributory to the exacerbation of the infection. Background and Aim Sarcopenia is strongly associated with poor outcome in cirrhosis. There is little prospective data that sarcopenia influences outcomes in critically ill cirrhotics (CICs). Computed tomography (CT) is the gold standard for body composition assessment in the ICU, as it is independent of hydration status. Aim To assess the prevalence of sarcopenia and study its impact on clinical outcomes in CICs.

Methods In this prospective observational study, CICs admitted to the liver ICU (LICU) between January 2020 to June 2020 were enrolled, if meeting inclusion (age 18-70 years, abdominal CT scan within three months prior to ICU admission) and exclusion criteria (survival likely to be <24 hours, coexisting chronic diseases). Clinical, hemodynamic, biochemical, nutritional parameters, including length of stay (LOS), duration of mechanical ventilation (MV), development of new onset infections (NOI), and overall survival were recorded. CT images at the L3 level were analyzed using slice-o-matic V4.3 software to assess the skeletal muscle index (SMI)-expressed as skeletal muscle area (cm2)/height (m2 (Fig. 1) . EUS guided biopsy from peripancreatic and periportal lymph nodes were suggestive of necrotizing granulomatous lymphadenitis implicative of tuberculosis (Fig. 2) . His repeat scan showed a reduction of lymph node size to less than 50% of baseline size, decrease in the size of the portal vein and spleen with improvement in clinical parameters. Conclusion Involvement of periportal lymph nodes in tuberculosis is exceptional1 and there is a handful of case reports of lymph nodes compressing the portal vein at porta hepatis and manifesting as portal hypertension (PH) causing upper gastrointestinal bleeding as evidenced in our case 2. The suggested mechanism of PH in our case is compression of the portal vein by enlarged lymph nodes at the hepatic hilum. Although rare it is a treatable condition.

Correspondence -Baibaswata Nayak -baibaswat@gmail.com Department of Gastroenterology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India

Background Hepatitis B virus infection is one of leading causes of hepatocellular carcinoma. HBV genome known carry nuclear response element in the enhancer region. The corresponding nuclear response can modulate HBV replication and may promote hepatocarcinogenesis. Therefore, we designed several deletion constructs and studied protein HBx-FXR interaction to evaluate its role in carcinogenesis.

Aim To study role of nuclear receptor in HBV induced hepatocarcinogenesis Methodology The Hbx region was PCR amplified from full length HBV 1.3 mer plasmid. Full length HBx and C-terminal 14aa, 27 aa, 35 aa and 40aa deletion constructs with and without flag tag was designed cloned in pCDNA 3.1 vector. Mammalian expression of these proteins were checked by transfection using anti-HBx and anti-flag antibody. Interaction of full length HBx and DHBx with FXR was studied by coimmunoprecipitation assay. Weather binding of HBx or DHBx with FXR increases transcriptional activity will be checked by using luciferase reporter assay system. Results Cloning of HBx and DHBx in pcDNA 3.1 was carried out with sequence confirmation. Mammalian expression of full length and deleted HBx was confirmed by anti-HBx and anti-flag antibody. Expression of nuclear receptor was checked by transfecting pCMV3-NR5A2-t3 (LRH-1), pCMV3-NR0B2-HA (SHP1), pCMV3-NR1H4-t6 (FXR) using antinuclear specific antibodies and anti-HA antibody. Coimmunoprecipitation study and western blot assay found interaction. Conclusion HBx C-terminal truncation may play a significant role hepatocarcinogenesis through nuclear receptor mediated signalling. Keywords HCC, HBV, HBX, Nuclear receptor, Cancer Introduction Non-alcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease worldwide and is strongly associated with obesity and insulin resistance. NAFLD has not been extensively studied in Indian pregnant women. We studied the prevalence of NAFLD and its association with clinical and metabolic profile in Indian primigravida women. We also defined the cut-off value of homeostatic model assessment of insulin resistance (HOMA-IR) for the prediction of NAFLD in pregnant women. Methods In this cross-sectional study, consecutive primigravida women in their first trimester were screened for NAFLD using a liver ultrasound between August 2019 and March 2021. Those with preexisting diabetes, hypertension, chronic liver disease, multiple pregnancies, or a history of alcohol consumption were excluded. The association between NAFLD with clinical and biochemical markers were assessed by univariate and multiple analysis. A cut-off value of HOMA-IR for NAFLD prediction was calculated using the area under the curve. .001) and a lower serum adiponectin concentration (7.14 vs. 11.12 μg/mL, p<0.001). On multivariable logistic regression; BMI, HOMA-IR and serum adiponectin concentration were independent predictors of NAFLD in pregnancy. The HOMA-IR cut-off value of 0.9 had 71% sensitivity and 50% specificity to predict NAFLD (AUC-0.63, p<0.001). Conclusion This study reveals a silent epidemic of NAFLD affecting one in every four pregnant primigravida women. The presence of obesity, insulin resistance and low serum adiponectin concentration are independent markers for NAFLD in pregnancy Keywords Adiponectin, Insulin resistance, Non-alcoholic fatty liver disease, Obesity, Primigravida

Introduction Alcohol is the commonest etiology of cirrhosis in India and decompensation of liver cirrhosis with jaundice, ascites, variceal bleeding or hepatic is associated with increased morbidity and mortality. This study aims to analyze the outcome of patients with alcoholic cirrhosis presenting with acute decompensation (AD). Methods All patients of alcoholic cirrhosis presenting with first decompensation were included in this study and prospectively followed up for 90-days. Patients presenting as ACLF were excluded. Results A total of 167 patients were included in this study. Most common first decompensation was ascites (79.04%) followed by variceal bleeding (20.95% MELD, MELD-Na and CLIF-C AD score were significantly higher in patients who had mortality (p=0.000 for all scores). On multivariate analysis, only CLIF-C AD was an independent predictor of 90-days mortality (OR 1.206, 95% CI 1.070, 1.360, p=0.002). On analysis of the area under the ROC curve (AUROC) for predictive scores (CTP, MELD, MELD-Na, CLIF-AD), CLIF-C AD score (AUROC 0.855, 95% CI 0.792, 0.919) was the best predictor of mortality. Conclusion Alcoholic cirrhosis patients presenting with ascites as first decompensation have poorer prognosis compared to presentation with variceal bleeding. Among the prognostic scores, CLIF-C AD score was the best and the only independent predictor of mortality in patients with AD.

Introduction We investigated the prognostic implications of early hepatic dysfunction (serum bilirubin >1.2 mg/dL within 48 hours of admission) in patients with sepsis. The purpose of our study is to determine the independent association of serum bilirubin with mortality in sepsis.

Methods We conducted a prospective observational study in medical intensive care unit at the Coimbatore Medical College Hospital. We collected data from adult patients >18 years old meeting the criteria for sepsis based on sepsis-3 definition in MICU. We identified the highest serum bilirubin within first 48 hours of admission and divided patients based on the bilirubin levels into 2 groups, 0.1-1.2 mg/dL (normal) and above 1.2 mg/dL. We used multivariable logistic regression to test the independent association of various risk factors with mortality using admission bilirubin levels as our primary predictor. Results Out of 110 patients who met criteria for sepsis, 67 patients had bilirubin ≤1.2 mg/dL and 43 had a bilirubin of >1.2 mg/dL. Out of these 43 patients, 35 patients had a bilirubin >2 mg/dL. Mortality was 11.9%, 50 %, and 57.1% in persons with a bilirubin ≤1.2 mg/dL, 1.21 to 2 mg/dL, and >2 mg/dL, respectively. Compared to those with a bilirubin ≤1.2 mg/ dL, odds of mortality in patients were 8.7 (95% confidence interval 3.3-22.4) times higher in patients with bilirubin levels >1.2 mg/dL. Length of hospital stay is also significantly higher in hyperbilirubinemia group (>1.2 mg/dL) when compared to patients with normal bilirubin (≤1.2 mg/dL) with an odds ratio of 4.4 and 214atient214d214 interval 2.2-7.50. Conclusion Our study concludes that an elevated serum bilirubin on admission is independently associated with an increased risk of mortality in sepsis. Also, hyperbilirubinemia in first 48 hours is a predictor for Introduction Decompensated liver disease is a disease entity which is usually not associated with liver abscess. There are instances of liver abscess which is very rare. However we had a case of liver abscess with underlying chronic liver disease. Methods He was admitted at Max Hospital, Vaishali, Ghaziabad with complaints of fever, malaise, chills, pain abdomen in the right upper quadrant x 1 week duration. He was subjected to certain investigations which showed raised total leukocyte count and positive amebic serology and ultrasound showing liver abscess in the right lobe of the liver. He was managed with IV antibioitcs, IV fluids and IV metronidazole 800 mg thrice daily injectables x 5 days and discharged on tab metronidazole for 10 days. He responded well to the treatment and fever settled down and appetite improved. He was later discharged on tablets.

Results Forty-year-old male nondiabetic non hypertensive, euthyroid with no cardiac ailment had chronic liver disease possibly related to chronic alcohol intake presented with fever and positive amebic serology. He was treated with IV Flagyl and responded well amebic liver abscess was proven biochemically and radiologically. Although the incidence of chronic liver disease and liver abscess is unusual. Very few cases have been reported in the past.

Conclusion I am presenting a case of chronic liver disease with liver abscess who was admitted at Max Hospital, Vaishali. Although chronic liver disease and liver abscess is an unusual occurrence. There are few instances of such cases in the literature. In decompensated liver disease cases since the hepatocytes are replaced with fibroblasts and there is no space left in the liver for parasitic infection, but in this case liver abscess was seen harbouring within the liver parenchyme. It gave me immense pleasure to present this case in front of experts and so that it can be published in the literature for future reference. Keywords Decompensated liver disease, Liver abscess, Amebic serology

Peripheral blood monocyte phenotype in acute liver failure due to rat-killer poisoning Introduction Rat killer poisoning leading to acute liver failure (ALF) is increasingly seen in our hospital. Monocytes or macrophages play a significant role in the pathophysiology of ALF. In this study, we aim to study the peripheral blood monocyte phenotype and serum immune markers in ALF-RP. Classical monocytes from ALF-RP showed significantly reduced expression for surface marker HLA-DR and increased expression of CD163, CD64 and CCR2 compared to healthy controls. The phenotype noted in ALF-RP of HLA-Drlow CD163hi monocytes suggest impaired functional activity. Significantly reduced NK cell frequencies and increased serum levels of sCD163 and sCD25, noted in these patients, suggest uncontrolled macrophage activation. CD64hi monocytes and significantly increased serum IgG circulating immune complex level seen in these patients, indicate immune complex mediated injury. We also noted increase in expression of CCR-2 on monocytes and CCL2 levels in circulation, suggesting an active CCR2-CCl2 axis mediated infiltration of monocytes into inflamed liver. Conclusion Alteration noted in circulating monocyte phenotype and immune markers, suggest monocyte infiltration and macrophage activation in patients with ALF secondary to rat-killer intake. Introduction Hepatic encephalopathy (HE) and sarcopenia is one of the most important complications of chronic liver disease (CLD) that is found in approximately 40% of cirrhotic patients. Minimal hepatic encephalopathy (MHE) is considered as a preclinical stage of HE. MHE and sarcopenia impair the health-related quality of life and prognosis in patients with liver cirrhosis; however, the relationship between MHE and sarcopenia remains unclear. The aim of this study was to investigate the prevalence of sarcopenia and its relationship with MHE in cirrhotic patients.

Methods One hundred cirrhotic patients attending our OPD were enrolled after informed consent. Sarcopenia was diagnosed using Asian working group. Psoas muscle thickness was measured using plain CT at L3 level and hand grip strength was measured using handheld dynamometer. MHE was diagnosed using Psychometric hepatic encephalopathy score.

Results Out of 100 cirrhotic patient's male and females were 76 and 24. Mean age was 42±8 years. Etiology of cirrhosis was alcohol (60%), NASH (12%), HBV (16%), HCV (8%) and cryptogenic (12%). Mean MELD score was 24± 6. The prevalence of Sarcopenia was 59%, mean L3 psoas muscle index was 2.8±0.8 cm2/m2; mean hand grip strength was 18±2.6 kg. Sarcopenia was more common among CTP-C (73%). Prevalence of MHE was 42% and among patients with sarcopenia was 80%. There was a positive correlation between severity of CLD with MHE and sarcopenia (r=0.8).

Conclusion Sarcopenia and MHE are prevalent among cirrhosis, Severity increases with the severity of liver disease. MHE is more common among patients with Sarcopenia. Sarcopenia predicts MHE among cirrhotic patients.

Introduction We aimed to study reticuloendothelial activation and its association with disease severity in rodenticide induced liver injury. Here we report a case of 61 year old male who is a known case of decompensated liver disease for 8 years who had history of hemetemesis twice in past when endoscopic variceal banding was done. He was not under regular follow-up for last 4 years now he had presented with 2 weeks abdominal distension and pain along with gradually progressing type of cholestatic jaundice. Hepatocellular carcinoma or cholangiocarcinoma were the main differentials initially. On evaluation he had acute kidney injury and spontaneous bacterial peritonitis which got corrected with volume expansion and antibiotics, but his liver function continued to worsen and developed cholangitis. Tumor markers were negative ultrasound abdomen revealed dilated biliary radical on left, MRI abdomen revealed a large dilated tortuous channel of recanalized umbilical vein joining left portal vein at hepatic hilum, circling left hepatic duct proximally, causing significant mass effect on left hepatic duct proximally and upstream dilatation of left hepatic duct and intra hepatic biliary radicals. Biliary drainage was done and patient is doing well. Another interesting finding of vesical varices were also seen in the patient. Patient was asymptomatic for vesical collaterals unlike the usual presentations wherein gross hematuria might be noticed.

Introduction Hepatic sarcoidosis is a rare granulomatous disease of unknown etiology with a prevalence of 1-40:100,000. About 20% to 40% of patients have hepatomegaly or elevated liver enzymes on presentation.

Case Scenario A 36-year-old female with history of splenectomy in 2019 for refractory ITP in 2019 with diabetes mellitus, dyslipidemia and abdominal obesity as comorbidities, was evaluated in august 2021 for dragging pain in the right hypochondrium. Ultrasound abdomen was suggestive of hepatomegaly with multiple hypoechoic areas. She was managed in the line of NAFLD. But in view of rapid increase in liver size on follow-up, she was referred to our center. MRI abdomen revealed hepatomegaly with a liver span of 24.5 cm with multiple hypointense lesions, throughout the liver, suggestive of granulomatous etiology. Main differentials considered were tuberculosis and fungal granulomas, in view of immunocompromised state. Tuberculosis work up was negative. Her ACE levels were elevated and hence CT chest was taken which revealed mediastinal lymphadenopathy. For confirmation of the diagnosis she underwent liver biopsy, which showed multiple non caseating granulomas in background of macro and micro vesicular steatosis. Fungal staining was negative. In the background of elevated ACE levels and mediastinal lymphadenopathy, a diagnosis of hepatic sarcoidosis was made. However as there was no cholestasis and chronic liver disease, no specific treatment was started. She is kept under close follow-up.

Conclusion This case bring light towards the rare case scenario of hepatic sarcoidosis and the need to work up isolated hepatomegaly even in the background of metabolic syndrome.

Introduction Thalassemia patients are susceptible to hepatitis C virus (HCV) infection due to lifelong dependency on blood transfusion. This patient population is at risk of progression of fibrosis or development of cirrhosis owing to both iron overload and HCV infection. Currently there are no published data of treating hepatitis C in thalassemic children with direct acting antivirals. This study was performed to determine efficacy and safety of sofosbuvir and daclatasvir in thalssemic children and adolescent. Methods This Interventional non-randomized open label study was carried out in Hepatology Department of IPGMER, Kolkata from April 2020 to June 2021. All consecutive non-cirrhotic thalassemic patients with hepatitis C infection with detectable HCV RNA within age group of 6-18 years was treated with combination therapy with sofosbuvir-daclatasvir (200 mg+30 mg for age 6-11 years (Group-A) and 400 mg+60 mg for 12-18 years (Group-B) depending upon exclusion criteria of study. Primary efficacy endpoint of study was sustained virological response 12 weeks after completion of therapy (SVR 12 Background Refractory ascites due to cirrhosis is one of the common indications for liver transplant (LT). Ascites is expected to resolve within 2-4 weeks following orthotopic liver transplant as the reversal of hemodynamic changes occur by then. New-onset ascites after transplant has varied causes. Most common causes for the development of ascites after LT are hepatic inflow or outflow obstructions, hepatitis C, graft rejection, prolonged cold ischemia time. In addition, extrahepatic causes like infections, chronic kidney diseases, or heart failure can lead to ascites. In this retrospective study, we aimed to assess the incidence and causes of ascites in post-transplant patients during the last year. Results A total of 95 patients underwent living donor liver transplantation (LDLT) in our institution. Seven out of 95 patients developed ascites post-liver transplant. The mean age of patients was 46±18.98 years. Fifty-seven percent of patients were females. The indication of LDLT was decompensated cirrhosis in all the seven patients. Three underwent LDLT for alcohol-related liver disease, one each for non-alcoholic steatohepatitis, chronic hepatitis B, Budd-Chiari syndrome, and Wilson disease. The mean time to ascites onset was 2.9 months. All the patients had ascites prior to liver transplant out of which 5 (71%) had refractory ascites. Five (71%) of them had hepatorenal syndrome prior to transplant. Cold ischemia time was 98±19 min. Five patients were diagnosed with tubercular ascites, one had tacrolimus related proteinuria and ascites formation, and one more patient developed IgA nephropathy causing significant proteinuria and ascites. None of the patients had concomitant pulmonary tuberculosis. Rifampicin, levofloxacin, and ethambutol were initiated with gradual introduction of isoniazid over next 15 days. Conclusion Although global data suggest vascular etiologies as common cause of persistent ascites post-transplant, in Indian scenario tuberculosis should always be considered as a differential diagnosis while evaluating post-transplant patients.

Introduction Sarcopenia in cirrhosis of liver is associated with poor prognosis and more significant in Indians who have lower baseline muscle mass. We aim to establish the prevalence of sarcopenia in Indian patients with cirrhosis and its impact on their morbidity and short-term mortality.

Methods This was a prospective study of 156 consecutive patients with liver cirrhosis. The cross-sectional area of the right psoas muscle was measured at the level of L3-vertebra and Psoas muscle index (PMI) (mm2/m2) was calculated. Sarcopenia was defined based on the CT study of patients with non-specific abdominal pain (controls), as PMI less than 295 mm2/m2 and 356 mm2/m2 for females and males respectively. Results Seventy-four (47.4%) patients had sarcopenia. Sarcopenia was more common in males and with alcohol-related liver disease (ALD);70%. There was a negative correlation between the PMI and severity of liver disease as assessed by Child and MELD scores (r= -0.591 and -0.465 respectively). Patients with encephalopathy, ascites and coagulopathy had a higher prevalence of sarcopenia (Table 1) . Fifty-five patients who had sarcopenia required readmission within 6 months of follow-up as compared to those without sarcopenia (74.3% vs. 22%) (p=0.0001). 6-months mortality was higher among patients with sarcopenia (24.3% vs. 3.7%; p=0.002). MELD score and PMI were independently associated with higher mortality. PMI Cut off value for predicting mortality obtained was 305.9 mm2/m2 with a sensitivity of 76.2% and a false positivity of 22.2% (AUC was 0.805; 95% confidence interval:0.69-0.91, p=0.001). Introduction Idiopathic hypereosinophilic syndrome (HES) represents a heterogeneous group of disorders with the common features of prolonged eosinophilia of more than 1,500 eosinophils per microliter (μL) of peripheral blood for at least 6 months, with signs or symptoms of organ system dysfunction, without detectable cause. Chronic hepatitis associated with hypereosinophilia has been very rarely reported worldwide. We report a case of chronic hepatitis in a case of hypereosinophilic syndrome which responded to treatment with oral steroids. Case Summary Forty-one year old male, painter, with no prior comorbidities or addictions, presented with fatigue and yellowish discolouration of eyes. On evaluation, he had total bilirubin/direct bilirubin -6.5/3.6, SGOT/SGPT -281/417, ALP -296 (124) and absolute eosinophil count of 9960/cmm. Bone marrow aspiration and trephine biopsy showed marked increase in eosinophil precursors. Percutaneous liver biopsy showed chronic active hepatitis with mild hepatocanalicular cholestasis, mild to moderate mixed inflammation comprising of abundant eosinophils with few neutrophils and focal mild periportal fibrosis. With this, he was diagnosed to have chronic active hepatitis due to hepatic involvement in hypereosinophilic syndrome and was started on oral prednisolone with which his icterus resolved and LFT normalized. Discussion In this case report, the patient presented with clinical manifestations of active hepatitis with elevated liver enzymes and hyperbilirubinemia along with peripheral and marrow hypereosinophilia. This entity of liver involvement in HES has been mainly described at autopsy and very rarely at a patient's clinical presentation. The patient responded to treatment with oral prednisolone and is on follow-up with tapering dose of oral steroids. Conclusion In patients with hypereosinophilic syndrome, liver involvement can occur in the form of chronic hepatitis which responds to treatment with steroids.

Introduction Recent clinical data have shown that obstructive sleep apnea (OSA), through its hypoxia related consequences 3s to tissue hypoxia , thereby resulting in oxidative stress, inflammation, and sympathetic system activation, and could therefore be an independent risk factor for nonalcoholic fatty liver disease. The primary aim of this observational study is to study the effect of obstructive sleep apnoea on the degree of liver stiffness, estimated using transient elastography, a novel technique to assess liver fibrosis. Methods The study was conducted on outpatients and inpatients of a tertiary care center who are polysomnography (PSG) proven OSA patients and meet the eligibility criteria. Patients were enrolled to undergo transient elastography (fibroscan) and the following investigations -complete hemogram, liver function tests, serum lipid profile, serum fasting insulin and fasting blood sugar levels. The polysomnography, fibroscan and laboratory data was tabulated and analyzed. Results A total of 36 participants were enrolled. 4 (11.1%) participants had mild OSA, 11 (30.6%) moderate OSA and 21 (58.3%) of the participants had severe OSA. The prevalence of liver steatosis was assessed to be 83.3% (30 patients) while hepatic fibrosis was noted in 11.2% (4 patients). Oxygen desaturation events, oxygen desaturation index, apnea-hypopnea index and percentage of sleep spent below 90% oxygen saturation (T90) were significant predictors of hepatic fibrosis. Conclusion Patients with OSA have an increased risk for development of hepatic steatosis and fibrosis. The various PSG parameters can be helpful in predicting the presence of underlying liver disease and aid in screening.

The common sites of metastasis in hepatocellular carcinoma (HCC) are lung, bone and peritoneum. Rare instances of metastasis to unusual sites like nail bed, orbit and retroperitoneum have been reported as well. We report a case of metastasis of HCC in the rectovesical pouch.

Case Report A 60-year-old gentleman with chronic hepatitis B related cirrhosis on regular treatment and follow-up was diagnosed with 3.8 cm lesion in segment V consistent with HCC in 2018. He has had one session of radiofrequency ablation in 2018 and a session of transarterial chemoembolization in 2019. Subsequently, serial imaging with multiphasic magnetic resonance imaging (MRI) did not reveal any recurrence of liver lesions. Over the last 6 months, there was a gradual increase in serum alphafetoprotein (AFP) levels. The last contrast enhanced CT abdomen done 2 weeks prior to this presentation revealed a rectovesical lesion 18 mm x 16 mm which was enhancing in the arterial phase. Transrectal endoscopic ultrasound (EUS) done revealed a hypoechoic lesion~18 x14 mm in the rectovesical pouch. EUS guided fine-needle aspiration cytology was done which was suggestive of hepatocellular carcinoma. pPLEX. Number of plex sessions, flow rate and procedure time for cPLEX/ Introduction Visceral larva migrans (VLM) is a systemic manifestation of migration of second stage larvae of nematodes through the tissue of human viscera. The liver is the most common organ to be involved due to its portal venous blood supply. Presenting a case of 16 -year-old boy from a rural background presented with intermittent abdominal pain, malaise, loss of appetite and restlessness for 3 months. Method Blood investigation revealed microcytic hypochromic anemia and eosinophilia (blood eosinophil count being 27%, AEC-1610 cu/mm). Serum alkaline phosphatase raised (885 IU/L), other liver function parameters normal. Coagulation profiles were normal. Serum α-fetoprotein came normal (<0.5 IU/ mL). USG abdomen showed ill-defined hypoechoic lesions in right lobe of liver. Contrast-enhanced CT (CECT) scan of the abdomen showed large hypodense SOL with multiloculated cystic areas (5.7 x 6.4 x 7.2 cms) in segment 6/7 of liver. A provisional diagnosis of hepatic lesions associated with parasitic infestation was made. The stool examination for entamoeba histolytica, giardia and ascaris ova and cyst were negative along with their serology. The values of serum IgE levels were also high (1860 IU/L). USG guided FNAC of the lesion with Giemsa stains showed cellular smears comprising mixed inflammatory cells predominantly consisting of eosinophils with few degenerated cells were also seen. No parasites were identified in the smears. The findings were suggestive of eosinophilic abscess, thus with correlating radiological findings, a final diagnosis of visceral larva migrans was made.

Results The patient was empirically given 400 MG twice daily albendazole for 5 days. The patient was totally relieved of his symptoms and complete resolution of hepatic sol seen. Conclusion We can say in developing countries patients with peripheral eosinophilia with hepatic Sol, one must keep the differential diagnosis of parasite infestation.

In corona virus disease 2019 (COVID-19) pandemic, worsening of quality of life (QOL) in all patients is expected. Tele-consultation and online counselling became popular as patients were reluctant to visit hospitals.

Methods In a prospective single arm interventional study, QOL of 75 patients with cirrhosis was evaluated at the end of first wave of the pandemic through the SF-36 and health promoting lifestyle (HPLP-II) questionnaires. Demographics, etiology and MELD scores were documented. Patients were trained in tele-consultation and were counselled about the disease, nutrition, exercise, and psychological aspects. In second wave of COVID-19 pandemic, they were re-evaluated with same questionnaires and MELD scores, pre and post intervention scores were compared. Results Sixty-six patients (mean MELD score of 12.11+4.24) competing the study were analysed and showed significant improvement in the nutrition domain (p 0.038) in HPLP-II and in domains of role limitation due to physical health (p 0.006), emotional problems (p 0.01), emotional wellbeing (p 0.048) and general health in SF-36. In those with worsening MELD scores (n=44), there was improvement in role limitation due to emotional problems and general health in SF-36 with no significant change in health promoting behaviours (HPLP-II) while in those with improved/static MELD scores (n=22), improvement was seen in majority of the domains. Treatable cause of cirrhosis (n=46) did not show any change in health promoting behaviors (HPLP-II) while in SF-36 showed improvement in role limitation due to physical health, emotional problems and general health. Those with non-treatable causes (n=20) showed improvement in role limitation in physical activity, nutrition and overall health promotion (HPLP-II) and physical functioning, role limitation due to physical health (SF-36). Conclusion Tele-consultation and counselling significantly improved the QOL in multiple domains in patients of liver cirrhosis during the second wave of COVID-19 pandemic in Mumbai in spite of worsening of MELD scores and having an untreatable etiology of liver cirrhosis.

Introduction Thrombophilic disorders are commonly detected in patients with Budd-Chiari syndrome (BCS). BCS with multiple thrombophilic disorders in a same patient may be present up to 20% to 25% of patients. We report here a case of BCS with multiple arterial and venous thrombotic episodes.

Case A 35-year-old female presented to us in October 2021 with 1 month history of pain abdomen followed by mild abdominal distension. Previously in 2017 she had severe pain in left flank for one week. Also, she had left lower limb pain in February 2018, diagnosed as deep venous thrombosis involving left femoral and popliteal vein, received treatment for 6 months (? anticoagulation). Thrombophilia workup was not done previously. In our admission CBP revealed hemoglobin 11.8g/dL, leukocytes 5890/mm 3 , and platelets 89000/mm 3 . Liver function tests were within normal limits. Contrast enhanced computed tomography (CECT) showed non-visualization of all the three hepatic veins and compressed intrahepatic IVC with caudate lobe hypertrophy, a spleen of 10.5 cm and very minimal ascites. Also, in CECT, left kidney was contracted and chronic thrombus seen in left renal artery. Upper gastrointestinal endoscopy showed no evidence of esophageal varices. The patient's thrombophilia workup is positive for homozygous mutation in the prothrombin G20210A gene. Analysis done with allele-specific polymerase chain reaction. Also, her serum homocysteine level was 42.26 μmol/L (3.7 -13.9 μmol/L). genetic analysis for factor V mutation and Janus kinase -2 V617F were negative. protein C, protein S, antithrombin III activities were within normal limits. Patient has been started on anticoagulation and advised to follow up after one week. Response for treatment is awaited. Conclusion BCS with prothrombin gene mutation seen in 5% to 7% cases in west. In India one case report from Mumbai with heterozygous mutation. Ours is the first case in India with prothrombin gene homozygous mutation in BCS.

Keywords Budd-Chiari syndrome, Prothrombin gene G20210A homozygous mutation, Hyperhomocysteinemia

Introduction The fundamental hallmark of non-alcoholic fatty liver disease is metabolic dysregulation, which entails an inflammatory response. Lipid-induced hepatoctyte inflammation can then cause an immunemediated inflammatory cascade to go into overdrive, exacerbating fatty liver disease. The mechanisms involved in hepatocyte inflammation mitigation are poorly known. The involvement of silent information regulator 2 (SIRT2), a NAD+-dependent deacetylase and important metabolic regulator, in palmitate (PA)-induced lipoinflammation was investigated.

Method Immortalized hepatocytes and hepatoma cells were treated with palmitate and markers of inflammation were monitored by real time qPCR for IL6, IL8, TNF-α, IL1α and IL1β.NAD levels and that of its precursors such as, nicotinamide riboside (NR) and nicotinamide (NAM) were checked both in vitro and the patient plasma samples using LC-MS spectroscopy technique. Also, levels of SIRT2 were found to be reduced in presence of lipid as well as in fatty liver patient samples.

Results Hepatocytes treated with palmitate (400 μM) showed significantly higher levels of inflammatory markers IL6 (p<0.0001), IL8 (p<0.0004), IL1α (p<0.0001), IL1 β (p<0.003) but not TNFα. The mRNA levels of NAMPT, a rate limiting enzyme in NAD synthesis, were decreased in both hepatocytes cell lines (IHH and HepG2). NR and NAD levels were found to be reduced in plasma of non-alcoholic fatty liver patients. Immunoblot revealed significantly low levels of SIRT2 in palmitate treated hepatocytes (p<0.04). Decline in levels of SIRT2 was also seen in biopsy of fatty liver subjects with raised activity score (NAS >5) and increased ALT levels (>40). Overexpression of SIRT2 or its activation by NAD+ precursor nicotinamide riboside decreased lipid induced hepatocyte inflammation (Fig.1) .

Conclusion Decline in levels of NAD+ and SIRT2 is accompanied with lipoinflammation in hepatocytes. Elevating NAD+ levels by nicotinamide riboside appears promising strategy to dampen the inflamed hepatocyte.

Keywords NAFLD, NAD+, Sirtuins, Metabolomics

Comparative study of ALBI score with CTP, MELD Na, AARC score in patients of ACLF

Correspondence -Manjinder Singh -mani23111985@gmail.com Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Bailey Road, Sheikhpura, Patna 800 014, India

Objectives To compare ALBI score with Child-Pugh score, MELD Na score and AARC score in patients of ACLF to predict in hospital mortality and mortality after discharge.

Methods Clinical history, general examination, radiological examination, biochemical evaluation was done. ALBI score was calculated at admission and after discharge and compared to CTP, MELD Na and AARC score to predict in mortality and organ failure. ACLF was defined as per APASL criteria. Organ failure was defined as per EASL CLIF criteria. Statistical Analysis 1. The comparison of the variables which were quantitative in nature were analysed using independent t test. 2. The comparison of the variables which were qualitative in nature were analysed using

Fisher's exact test as atleast one cell had an expected value of less than 5. 3. Kaplan-Meier survival analysis curve was used to find out actuarial survival rate. 4. Receiver operating characteristic curve was used to predict organ failure and mortality and DeLong et al. test was used for comparison of area under curve p value of less than 0.05 was considered statistically significant. Results For predicting day 1 and day 7 mortality CTP Score has the highest AUC (0.938), for day 3 mortality AARC score had the maximum AUC (0.968). For organ failure at day 1,3,7,30 and day 90 ALBI score has the maximum AUC(1, 0.867, 0.914, 0.889, 0.74) respectively. Conclusion ALBI score is a relatively newer score. Its validated for HCC, and its role in ACLF is not well studied. As in this study ALBI Score was able to predict organ failure the best, it should be adopted widely in Background Remdesvir has been approved as an emergency drug in SARS COVID infection. One of the side effects of remdesvir was found to be drug induced liver injury. There are case reports of progression to acute liver failure in such patients. N-acetyl cysteine has been proposed in non acetaminophenan induced liver injury for the prevention of acute liver failure. The scope of N acetyl cysteine in remdesvir induced DILI has been investigated through this study. Aims: 1. Response to N-acetyl cysteine in patients with Remdesvir induced hepatotoxicity. 2. Role of N-acetyl cysteine in progression of acute liver failure in DILI patients due to Remdesvir. 3. Improvement of liver parameters after withdrawal of the drug in remdesvir induced liver injury patients. 4. Recovery from acute liver failure in NAC group. Methods Patients without prior history of liver disease who develop DILI after giving remdesvir is divided into study and control group. The study population started on inj N-acetyl cysteine 1 g twice a day for 7 days and ALT was monitored on the 7th day. The complete LFT at the time of admission, day of intitation of NAC and day 7 was recorded. The results are compared.

Results NAC is potent in reducing serum ALT (control-76.4 ± 68.7 vs. NAC-50.4 ± 19.1, p<0.0001) and AST (control -67.2 ± 44.38 vs. NAC-43.6 ± 13.8), p<0.0001) levels when compared to withdrawal group. No progression to acute liver failure was noted in both the groups. In patients with acute liver failure, the recovery was higher and more reduction in liver enzymes was noted when compared to control group. Conclusion In our study, N-acetyl cysteine was found to be effective in Remdesvir induced hepatotoxicity and found to be effective in recovery of acute liver failure.

Introduction In the natural course of chronic liver diseases (CLD), progression occurs at variable rates to cirrhosis, decompensation and finally death from complications. An intervening acute insult may lead to acuteon-chronic liver failure (ACLF) with reported high mortality. Unfortunately, there is no consensus on the definition of ACLF. Aims and Objectives To compare the three international consensus criteria for the definition of ACLF (EASL-CLIF, NACSELD and APASL) in order to (a) determine the number of patients who satisfy these definitions, and (b) determine their accuracy in predicting mortality.

Methods In this prospective observational study, 341 consecutive patients with chronic liver disease (CLD) of any etiology were enrolled and followed up. All significant clinical events and changes in laboratory data were noted in order to classify patients into the three definitions for ACLF. Primary biliary cholangitis (PBC) is a chronic, autoimmune, cholestatic disease typically occurring in elderly women and most commonly presents with pruritus, fatigue, cholestasis, and its complications. Gastric antral vascular ectasia (GAVE) is an uncommon but significant cause of upper gastrointestinal bleeding often leading to transfusion-dependent chronic iron deficiency anemia. GAVE as a first presentation of PBC is uncommon and has been rarely reported in literature.

A 59-year-old female presented with recurrent melena and transfusiondependent anemia for a year. She denied any history suggestive of jaundice, ascites or hepatic encephalopathy. Laboratory examination revealed iron deficiency anemia (hemoglobin 4.1 g/dL, 8.2% transferrin saturation, ferritin 7 ng/mL), with deranged liver function tests (total bilirubin 1.9 mg/dL, direct 1.2 mg/dL, alanine aminotransferase 67 IU/L, aspartate aminotransferase 221 U/L, alkaline phosphatase 261 U/L, total protein 7.8 g/dL and albumin level of 4.0 g/dL). Ultrasound showed a liver span of 12.6 cm with altered echotexture, mild splenomegaly (11 cm) and a dilated portal vein (13 mm). Endoscopic evaluation revealed erythematous linear stripes in the antrum suggestive of GAVE, without any esophageal or gastric varices. Fibroscan revealed a liver stiffness measurement (LSM) of 10.8 kPa (F3). Further etiological work up revealed negative viral markers for hepatitis B, C, A and E. Immunological tests were positive for antinuclear antibody (4+; 1:100), antimitochondrial antibody (4+; 1:40) and elevated IgM levels (624 mg/dL). Assessment of hepatic venous pressure gradient was suggestive of clinically significant portal hypertension (10 mmHg) while transjugular liver biopsy revealed distortion of lobular architecture with presence of portoportal bridging fibrosis, lymphocytic infiltration of bile duct epithelium with destruction of small and medium sized bile ductules, consistent with PBC. She was treated with iron supplementation and argon plasma coagulation. At 3 months of follow-up, she did not have further melena and her hemoglobin and liver function tests were normal.

Introduction The current corona virus disease 2019 (COVID-19) pandemic led to widespread consumption of various self -medications as "immunity boosters". Tinospora cordofolia (TC) was one of the common immunity booster consumed by people. We came across cases of drug induced liver injury related to it. Methods Fifty-five cases of suspected drug-induced liver injury (DILI) related to TC consumption were identified across 7 centers in India. Diagnosis of DILI was made as per the criteria of 'International DILI expert Working group' and causality assessment was done based on the Roussel Uclaf Casaulity Assessment Method. We analyzed the clinical presentation and the outcomes. 2019 (COVID-19) . However, earlier studies have shown conflicting results related to its impact on mortality. So, we aimed to study the association of fatty liver with mortality and morbidity among patients with COVID-19 pneumonia.

Methods In a retrospective case control study, patients with COVID-19 pneumonia with available CT chest with upper abdominal cuts were included. Cases (fatty liver) were those who had liver to spleen attenuation index (LAI) < 5 and controls (without fatty liver) were those with LAI >5, on non-contrast CT cuts of upper abdomen. Primary outcome measure was difference in mortality. Secondary outcome measures were difference in oxygen requirement, ventilator requirement, ICU stay and hospital stay. FIB-4 was also calculated as a non-invasive marker of liver fibrosis to analyze its impact on mortality and morbidity. Results Seventy-six patients were started on Saroglitazar. Data was analyzed for all patients at 6 months and the 55 patients who had completed 1 year of therapy. Both at 6 months and 1 year, there was a significant reduction in transaminases (18.5% and 23.6% reduction for AST, 27% and 35.4% reduction for ALT, p=0.00006). Liver stiffness came down from 11.8 kPa at baseline to 9.3 at 6 months and 8.6 at 12 months (21.5% and 28.7% reduction, respectively, p=0.000001). For those with advanced liver fibrosis at baseline (TE ≥ 9.9 kPa), the reduction in LSM was 28.2% and 36% at 6 and 12 months, respectively. Total cholesterol, LDL and triglycerides reduced significantly (14.5%, 15.3% and 18.6% respectively at 1 year). Weight reduction while on Saroglitazar was also significant (3.3% and 3.9% at 6 and 12 months, respectively). Conclusion Saroglitazar seems to be a promising option for reduction of liver stiffness and transaminitis in NAFLD. Whether there is a similar effect on liver histology has to be proven by biopsy-based studies.

quality of life parameters such as sexual life and fertility become more relevant. This study was aimed to assess the gonadal function in male patients with BCS and the effect of treatment on gonadal function.

Methods Thirty male patients with newly diagnosed BCS were prospectively assessed for the presence of gonadal dysfunction. Erectile function was assessed using standardized International Index of Erectile Function questionnaire (IIEF). Follicular stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin (SHBG), estradiol, total testosterone (TT), calculated free testosterone (cFT), calculated bioavailable testosterone (cBT), sperm count, and sperm motility were compared at baseline and at 6 months of treatment for the assessment of gonadal function.

Results Sixteen out of 30 (53.3%) patients were sexually active at the time of study and 5/16 (31%) had erectile dysfunction. Hypogonadotropic hypogonadism (HH) was the most common pattern seen in 50% cases followed by hypergonadotropic hypogonadism (HyH) in 23% cases. Twenty-seven percent patients had eugonadism. At 6 months of treatment, 60% of patients in HH group became eugondal as compared to only 14% in HyH group. Proportion of patients with erectile dysfunction reduced (6.25% vs. 31%, p=0.009) after 6 months of therapy. The improvement in sperm count and sperm motility was not significant. Prevalence of diet induced obesity has dramatically increased globally, making it essential to understand its accompanying metabolic changes in the liver. Obesity causes many health issues, both independently and in association with other chronic diseases such as diabetes, insulin resistance and non-alcoholic fatty liver disease and also considered as the major risk factor for development of non-alcoholic steatohepatitis and liver cirrhosis. In the present study we aimed to understand the molecular mechanisms underlying hepatic mitochondrial alterations in the pathophysiology of high fat diet induced obesity in rats. Early hepatic proteins profiles of normal and high fat fed induced obesity at 24 weeks were analyzed using two-dimensional difference gel electrophoresis (DIGE) and mass spectrometry for protein identification. Fifty-two protein spots were identified by MALDI-TOF and computer-assisted DIGE image software analysis showed 18 major proteins significantly differentially expressed between the comparable groups more than 2.0 to 4.0 fold changes. These proteins were modulated in response to the high-fat diet. Differentially expressed proteins were involved in important metabolic pathways including lipid metabolism, energy metabolism, detoxification, urea cycle and calcium homeostasis in the liver. Further, western blot and immunohistochemistry of liver specific Arginase-1 showed significantly over expression in high fat fed rat liver (p>0.01). Interestingly, Arginase-1 expression differentiates NASH progression. High fat in the diet might influence changes in metabolic pathways in the liver such as lipid metabolism, urea cycle and mitochondrial dysfunction could be the therapeutic targets in management of obesity related liver disease.

Introduction Implantation of donor liver grafts with severe steatosis is associated with early dysfunction of graft liver with delayed functional recovery. Appropriate donor selection optimizes both donor safety and recipient outcomes.

Methods We studied total of 101 living liver donors undergoing right hepatectomy between April 2018 to April 2020 at Indraprastha Apollo Hospital, New Delhi. We used MR spectroscopy for hepatic fat quantification and accordingly subjects were divided in 3 groups: <5%, 5% to 10% and >10% liver fat. Postoperative parameters like LFT, PT/INR, blood counts, hospital stay duration, need of blood products and complication rates were compared between the 3 groups in the early postoperative period. Kruskal-Wallis test and Chi-square test were used for quantitative and qualitative variables respectively. P-value <0.05 was considered statistically significant.

Results Total 101 donors were included, 58 with <5% liver fat, 24 with 5% to 10% liver fat and 19 with >10% steatosis. Clinical parameters like median duration of hospital stay, need for post-hepatectomy blood products transfusion (p-value <0.01), percentage of patients having postoperative bile leak (p-value <0.05) were higher in steatotic donors when comparison made across groups. Total of 25 patients (24.75%) showed post-hepatectomy complications (classified as per modified Clavien criteria), when complication rates compared across groups then showed no significant difference. No mortality was observed. Post-hepatectomy peak median levels of serum bilirubin level (p-value 0.01), ALT (p value-0.003), AST (p-value 0.009) were higher in group with >10% liver steatosis as compared to other 2 groups in the early postoperative period. However, recovery of coagulation function (INR value) and albumin levels showed no significant difference between groups (p-value >0.5).

Conclusion Degree of donor liver steatosis impacts liver function recovery and donor recovery in early post-hepatectomy period. Thus, hepatic fat quantification should be an integral part of preoperative assessment of living liver donors. Keywords Liver donor steatosis, Post-hepatectomy donor recovery efficacy after in vivo transplantations, thus limiting their clinical and regenerative applications. 3-dimensional (3D) cultures need to be optimized for their applications. In this regard, decellularized tissue matrix has emerged as a natural scaffold that is used to enhance the in-vitro properties of a variety of cell types. The primary goal of this study was to create a decellularized liver (DCL) matrix for 3-dimensional (3D) cultures of hepatic cells. Methods DCL was developed by portal vein cannulation and perfusion with detergents and characterized by histology. Enzymatically digested DCL matrix was mixed with commercially available 254atient254. Hepatocytes cell lines (Huh7) were cultured in 3D conditions with or without DCL-matrigel for 14 days. Phenotypic and functional analysis of cultured cells was done by cell morphology, gene expression, immunostaining and albumin assays at day7 and 14.

Results Huh7 cells demonstrated significantly increased proliferation in 3D conditions with DCL-matrigel than in cultures with 255atient255 alone. Gene expression of hepatocyte specific markers, asialoglycoprotein receptor 1 (ASGR-1), HNF-4a, and CK19 was increased more than 2 and 4 folds at day 7 and 14 in 3D-DCLmatrigel conditions. Liver-specific (ASGR-1) immunostaining also showed significantly enhanced expression in 3D-DCL-matrigel conditions at day14. Also, in presence of DCL-matrigel, secretion of hepatocyte marker albumin in Huh7 cells, was significantly increased in the supernatants at day7 and 14, respectively as compared to 255atient255 alone. Introduction Hepatic encephalopathy (HE) is a neuropsychiatric syndrome most often seen in the setting of cirrhosis with portal hypertension (type C). Percutaneous embolization of large portosystemic shunts (PSSs) is a rescue treatment for patients who have persistent encephalopathy or recurrent overt hepatic encephalopathy (OHE). In this case report we present a successful percutaneous embolization of portosystemic shunt. Case Report A 70-year-old female, a known case of Hep C -cirrhosis with CTP-B presented with altered sensorium, with history of recurrent episodes in the past 6 months requiring multiple admission to hospital. On examination patient had splenomegaly and asterixis. Patient was evaluated for precipitating factors of hepatic encephalopathy. Endoscopy was done and showed no esophageal varices. CT showed surface and parenchymal nodularity of the liver, narrowing of portal vein (5.5 mm) and portorenal shunt of size 16 mm. Patient underwent percutaneous embolization of portorenal shunt via a femoral vascular access and the shunt was selectively catherized and extra sling amplat wire was placed, later amplatzer vascular plug 2 was deployed into the shunt. Post

Introduction Non-alcoholic fatty liver disease (NAFLD) has historically been associated with obesity. It is considered the hepatic manifestation of the metabolic syndrome. However, recent studies have indicated that patients who are not obese can also present with NAFLD; this is known as "lean NAFLD". Cardiovascular disease remains the most common cause of all-cause mortality in NAFLD. Yet, the CV risk in lean NAFLD has not been compared till date with that of non-lean NAFLD patients. Thus, to compare the risk of atherosclerotic cardiovascular disease between patients of lean and nonlean NAFLD, by measuring CIMT and 10-year FRS-CVD risk, this study was conducted Methods A prospective observational study. Consecutive patients > 18 years age with NAFLD diagnosed according to 2018 AASLD criteria were enrolled. Those with liver cirrhosis or established CV disease (CAD, CVA, PAD) were excluded. Lean NAFLD was defined as having a BMI ≤ 23 kg/m2. CIMT was measured using standard protocol and FRS score was calculated. Results One hundred and ten patients of non-lean NAFLD and 65 patients of lean NAFLD were enrolled in the study. Age group specific analysis of CIMT and FRS-CVD risk score, by unpaired t-test, revealed no significant difference between the two arms. When patients were divided into 3 groups 18-40 years, 41-60 years and >60 years, CIMT and 10Y FRS-CVD score was seen to rise according to advancing age groups, in both the arms. Background Metabolic-associated fatty liver disease (MAFLD) leading to steatohepatitis, fibrosis, and cirrhosis of the liver is the global burden currently that is rapidly increasing in incidence. Hence early diagnostic and screening tools which are non-invasive are required to identify the disease.

Aim To identify a non-invasive score among Fibrosis-4 (FIB 4), AST platelet ratio index (APRI), and AST/ALT ratio, that can correlate with fibro scan in predicting liver fibrosis accurately in MAFLD patients. reporting complete abstinence and 51% reporting 1 or more heavy drinking days. Their severity of depression, anxiety, stress (p<0.05), and craving (p<0.08), documented relapse triggers, decreased, and the degree of mindfulness increased (p<0.05). The WPSU course was rated as a "very important" (8.7/10, SD=1.8) and "useful relapse prevention tool" (8.5/10, SD=2.1); participants reported being "very likely" to continue meditating (9.0/10, SD=1.5). "Gaining skills to reduce stress," "coping with craving," and "good group support" were the most common qualitative comments about the course value. There were no adverse events or side effects.

Conclusions Meditation may be an effective adjunctive therapy for relapse prevention in alcohol dependence. Needs revalidation in larger RCT.

Introduction Acute viral hepatitis due to hepatitis E virus (AVH-E) infection is often serious in pregnancy and could result in acute liver failure (ALF) and mortality in up to 65% cases. Better biomarkers are needed to predict the outcomes. We studied comprehensive metabolite profile to understand the pathogenesis of AVH-E and progression to ALF-E. We undertook the multivariate analysis to identify the common and specific metabolites and pathways in ALF-E and AVH-E. Methods We performed plasma metabolomics in pregnant (P) patients with AVH-E (Gr.1, =10, 4.5±2 yr), ALF-E (Gr.2, n=12, 26±2 yr) and in HC (Gr.3, n=7, 24.5±2 yr) and compared with non-pregnant (NP) acute HEV (Gr.4, n=10, 28±3 yr) , ALF-E (Gr. 5, n=8, 35±1 yr) . Common and specific metabolites and pathways associated with outcomes were identified using ultra-high performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) coupled to multivariate statistical analyses.

Results Plasma metabolomics identified a total of 278 metabolites in HEV infected patients compared to healthy controls. Multivariate principal component analysis (PCA) identified closer relationship between P-AVH-E and HC-P than ALF-E (Fig. A) . Twenty unique metabolites specific to nicotinate nicotinamide and D-glutamine-glutamate metabolism were significantly upregulated (p<0.05) in Gr.1, and 71 metabolites related to nicotinate-nicotinamide and D-arginine-D-ornithine metabolism, were upregulated in Gr.2 (Fig. B) . It was observed that 11 metabolites belonging to nicotinate and nicotinamide metabolism were significantly upregulated in both Gr.1 and Gr.2 (Fig. C) . However, the level of enrichment progressively increased from healthy pregnant to acute HEV to HEV-ALF pregnant females. We also found that D-glutamineglutamate metabolic pathway was down regulated in HEV-ALF only in pregnant women (Gr.2) . Background Rodenticide paste containing yellow phosphorous (YP) poisoning is very common in, state of Tamilnadu. Acute liver failure (ALF) occurs in 21% of such cases. PLEX is a grade 1 recommendation in the management of ALF, there have been very few studies in the context of this new intervention.

Objective The aim of this study was to study the efficacy of plasmapheresis in acute liver failure due to yellow phosphorous poisoning and to evaluate the predictive factors in determining the success of this novel method. Methods A total of 53 patients underwent plasmapheresis for ALF due to YP poisoning, over two years (December 2018-December 2020). Demographic data and biochemical parameters were recorded before and overall transplant-free survival was analyzed.

Results Of all patients, (67%) completely recovered, while 19% worsened, and referred to transplant units or while the rest expired (14%). The study showed mean difference and significant improvement in total leukocyte count (before and after -TLC mean±Std, 4638±2820 ; 6130±2274 p=<0.003*), total bilirubin (before and after -total bilirubin mean±Std were 3.7± 3; 2.2±1.9, p=0.003*), SGOT (before and after SGOT mean±Std were 252±136; 48±33, p=0.01*), prothrombin time (before and after, PT mean±Std were 56±43; 23±14 p=0.01*) and international normalized ratio (INR) (before and after INR mean±Std were 2.1± 1.4 ;1.8 ± 1.1, p=0.024*), pre and post PLEX (p < 0.05) .There was a significant association between the success of treatment and time taken to reach the hospital and quantity of toxin consumed. Interestingly, leukopenia, due to toxin-induced myelosuppression was a major early and independent predictor of mortality which preceded hepatic manifestations. Early initiation of PLEX in such patients have significant survival benefits.

Introduction Severe alcoholic hepatitis has high mortality with limited medical treatment options. As response to patients undergoing TPE procedures is variable and decision for further TPE remains empirical, we explored the utility of baseline saliva proteomics in identifying patients who are unlikely to survive or require additional TPE. Methods Saliva cotton swab from patients (n=20) undergoing TPE was collected at baseline and 24-hour after TPE. Proteins were isolated and were subjected to reduction-alkylation-trypsin digestion followed by label-free quantification using nano-HPLC coupled to high-resolution mass spectrometry. Most significant determinants in non-survivors were correlated with severity and subjected to evaluation of their diagnostic accuracy. Background and Aims Non-alcoholic fatty liver disease (NAFLD) is an increasingly prevalent and one of the fastest emerging manifestations of the metabolic syndrome worldwide. Saroglitazar 4 mg OD is only approved treatment for NAFLD associated with metabolic comorbidities and non-cirrhotic NASH. We tried to evaluate the efficacy and safety of Saroglitazar 4mg OD in NAFLD/NASH in routine clinical practice. Methods A total 50 documented NAFLD patients prescribed on Saroglitazar 4 mg OD, were retrospectively analyzed for changes in liver biochemical parameters and lipid profile at 12 weeks. The data at baseline and 12 weeks was analyzed and statistical significance was established using paired sample t-test.

The study shows statistically significant improvements in ALT by 41.9%, AST by 28.9%, serum TG by 46.5%, LDL by 21.3%, total cholesterol by 25.6% and HDL by 4.33%. Overall NFS score improved by 15.7% (p value=0.031). There was no any treatment related side effects during the study.

Conclusions The study shows Saroglitazar 4 mg OD as a safe and effective treatment option for NAFLD, with significant improvement in all liver related parameters and non-invasive NAFLD fibrosis score. 

Introduction Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The distribution of HCC vary significantly between different study populations around the world. With medical advances, early identification of HCC can be curable with resection, ablation and liver transplantation (LT). The study aims to investigate the distribution of HCC according to age ,gender and etiology, so as to identify high risk groups, that can help in better implementation of screening programmes and preventive measures. Methods This is a cross sectional study done in a tertiary care centre in south India between October 2019 to September 2021. All new cases as well as follow-up cases of HCC who attended hepatology OPD or admitted in ward/ICU were included. Data was collected and analysed. Results The total of 118 patients of HCC were identified. The most common age group of HCC was found to be 50-65 years (62.7%). The male to female ratio was 5 Background Bile acids (BA) play an inseparable role in hepatocyte proliferation and liver regeneration. In the current study, we analyzed BA pool in portal and peripheral blood in partial hepatectomy (Phx) models and studied how Bas interacted with primary liver cells to affect liver regeneration.

Methods We performed BA profiling in peripheral and portal serum by LC-MS/MS in rat models of 70% PHx at day 2 and day 5 post Phx. Primary rat hepatocytes, liver sinusoidal endothelial (LSEC) and hepatic stellate cells (HSC) were isolated by in vivo collagenase digestion. Gene and protein expression of BA receptors in primary liver cells was investigated. The effects of specific Bas were studied on liver cells by in vitro assays. Background and Aim Native extracellular matrix can affects cell viability and modulate cell functions. Keeping in mind the important role of the ECM, here we fabricated novel nanofiber scaffolds using liver extracellular matrix (LEM) to promote functions of primary hepatocytes in culture.

Methods Eight-week-old Sprague Dawley rat liver was decellularized with detergents and characterized with H&E staining and DNA content estimation. The nanofiber scaffolds were prepared by electrospinning method with PLA (Poly Lactic Acid) and powdered 10% LEM in the ratio 1:1 with HFIP (Hexafluroisopropanol) as solvent. The scaffolds were electrospun at 1.5 mL/ h at a distance of 12 cm and at 15 kv. The fabricated scaffolds were characterized by scanning electron microscopy. Primary hepatocytes were isolated using collagenase perfusion and cultured on PLA, collagen and LEM nanoscaffolds. Plated cells were characterized for viability and functions by molecular methods after two weeks of cultures.

The histology based microscopic analysis revealed a complete absence of cells in histology in the decellularized liver. Masson's Trichrome (MT) staining for collagen depicted a significant staining for this matrix protein. DNA content analysis showed complete nuclei removal and significant DNA decrease in the decellularized liver in comparison to the control liver. The pore size and fiber diameter of the newly developed LEMnanoscaffolds; (44 + 2.5 um) was similar to that of the native liver. There was an increase in viability and albumin-positivity by about 2-fold and 4-fold respectively in hepatocytes plated on LEM-nanoscaffolds as compared to those plated on collagen alone. Also the levels of secreted albumin was significantly higher in cells plated on LEM-nanoscaffolds as compared to those plated on PLA or collagen alone (P;lt; 0.05 each). Background Hepatorenal syndrome (HRS) is a serious complication of cirrhosis associated with a short survival. It is characterized by renal arterial vasoconstriction, which may precede clinically manifest renal dysfunction.

The primary aim of our study was to obtain the best cut-off value of IAP in predicting HRS occurrence in decompensated cirrhosis over 6 months. We also tried to find out other clinical and biochemical factors associated with the development of HRS. Methods A prospective follow-up study of 60 decompensated cirrhotics with tense ascites; was done. All underwent intraabdominal pressure measurement by direct method at the time of initial admission. Baseline clinical and laboratory results were obtained. Patients were followed up for 6 months to look for the development of HRS Results IAP was measured in 60 patients with tense ascites and we got values ranged from 10 cms of ascitic fluid to 25 cms of ascitic fluid with a mean value of 17.12 cms with a median value of 16 cms. ROC curve was plotted and cut off value of 17 cm (AUROC: 0.935 [0.840; 0.982]) was deriv ed, with 83.33% sensitivity and 94.44% specificity for predicting the occurrence of HRS in 6 months. Correlation of IAP with other variables was studied and found that RRI has a significant correlation with IAP (r=0.617, p 0.001). We compared the 2 groups (IAP 17 vs. IAP; 17) (n=22 vs. 38), We found that higher blood urea, higher S. creatinine, higher RRI values was more in patients with IAP; 17 (p=0.05). In multivariate analysis we found that IAP;17 cms of ascitic fluid is a significant predictor of development of HRS and mortality over a period of 6 months (p;0.005). Conclusion IAP is a novel non-invasive diagnostic screening tool to predict the development of HRS in decompensated cirrhosis. Keywords Decompensated cirrhosis, IAP, RRI, HRS.

Hepatorenal syndrome-acute kidney injury in decompensated cirrhosis versus acute-on-chronic liver failure: A comparison of response rates and predictors of response to therapy with terlipressin and albumin

Introduction A combination of terlipressin and albumin is the first-line pharmacologic treatment for hepatorenal syndrome-acute kidney injury (HRS-AKI). The early identification of patients with a low likelihood of response to treatment is crucial, as they can be fast-tracked for liver transplantation. There is limited data on the use of vasoconstrictors for HRS-AKI in acute-on-chronic liver failure (ACLF). We aimed to compare the response rates to terlipressin-albumin therapy in patients with decompensated chronic liver disease (DCLD) and ACLF and determine early predictors of treatment response. Background Renal failure is a common complication in patients with chronic liver disease and it is one of the most important risk factors associated with increased mortality. The development of acute kidney injury (AKI) in patients with cirrhosis has significant prognostic importance. Stages of AKI determine the prognosis and mortality in chronic liver disease. Aim To determine the risk factors, clinical profile and treatment response in cirrhotic patients with AKI.

The study included 130 patients with liver cirrhosis diagnosed clinically, biochemically, and confirmed with imaging (USG abdomen or CT abdomen). Patient profile was noted and followed up in subsequent admissions. AKI criteria were charted based on creatinine or urine output and was recognized. The criteria-based staging was done into AKI stages 1, 2 and 3 and treatment was given with albumin alone or with albumin + terlipressin. Response to treatment noted and prognostication done.

Results Among 130 patients with cirrhosis, 117 were males (90%); the mean age was 50.43 +10.2 years. The overall prevalence of AKI in the study was 27.7%. Complications like hepatic encephalopathy (0.020), spontaneous bacterial peritonitis (0.02), sepsis (<0.001), and shock (0.002) were significant in those with AKI and were statistically significant. Patients with stage 3 AKI were significantly older than those belonging to Stages 1 and 2 (0.043). Mortality was significantly high in those with AKI compared with no AKI (<0.001). More patients in Stage 3 required terlipressin infusion along with albumin therapy (0.0409) with a lower AKI recovery (0.008) and high mortality (0.001). Conclusion Stage 3 AKI had decreased responsiveness to terlipressin with a poor prognosis and increased mortality.

Introduction A three-year-old girl child, born out of consanguineous marriage, presented initially at the age of one-and a half years with complaints of difficulty in walking, for which she was evaluated by pediatrician, and diagnosed to have spastic paraplegia. She also had two episodes of UTI in last 4 months. Methods Her MRI brain showed delayed white matter of pons, medulla oblongata, bilateral cerebellar hemishpheres, bilateral fronto-temperoparietal and occipital lobes at subcortical and juxtaventricular regions, suggestive of dysmyelination disorder secondary to inborn errors of metabolism. She was worked up in detail, and detected to have argininemia, a urea cycle defect. Her USG abdomen showed hepatomegaly with altered echotexture. Triphasic CT abdomen showed hepatomegaly, patent hepatic arterial tree, patent splenoportal axis, and hepatic veins. It also showed bilateral pyelonephritis with focal nephrosis in left kidney. Her electrophysiological study was suggestive of multiple epilectic activity over both hemispheres, predominantly over right anterior mid temporal region. She was evaluated for liver transplantation at our centre and was deemed fit for the same after a multidisciplinary team meeting comprising of hepatologist, pediatrician, transplant surgeon, infectious disease specialist, cardiologist, nephrologist, neurologist, psychiatrist and anesthesiologist. Her father, a 32-year-old man, healthy came forward to donate a portion of his liver and was found suitable and fit. The living related donor liver transplant (left lateral segment) was undertaken.

The recipient liver was nodular, cirrhotic, with no obvious SOL. The postoperative period was uneventful, and she was discharged on D14 of the surgery. At 3 months follow-up, the graft liver (LDLT) was normal in architecture and no focal lesion. The child is doing well at 9-month follow-up. Conclusion The difficult and rare case of urea cycle defect, with multiple other co-morbidities was taken up for transplantation, and with multi-Introduction Hydatid cystis caused by Ecchinococcous granulosus and multilocularis. Humans (accidental host) get infected by eating food contaminated with dog (definitive host) feces. Liver is the most common site (70%) followed by lungs (20%), kidneys, spleen, brain and bone. One of the rare presentation is obstructive jaundice with ascites. Case Summary Sixty-nine-year-old female with prior history of carcinoma cervix treated 2 years back with chemoradiotherapy was admitted with painless progressive obstructive jaundice of 3 weeks duration and 5 days history of fever and chills. On examination there was icterus and hepatomegaly. Investigation showed Hb-11.1 gm%, TLC-14200/cumm neutrophil predominant, bilirubin (T/D)-24.5/13.1, SGOT/SGPT-132/ 100, ALP-401 (125), total protein/albumin-6.2/2.8, CRP-66 (5), blood urea/creatinine-42/1.1, tumor markers -not elevated. Ascitic fluid analysis-low SAAG (0.7), highprotein (3.8g%). Ultrasound abdomenmultiple cystic lesions in liver, IHBRD and ascites impression :-cystic metastasis and malignant ascites. MRI revealed multiple lesions markedly hyperintense on T2 with peripheral hypointense rim and the finding of cyst within cyst appearance was consistent with hydatid cyst. There was capsular breach with subdiaphragmatic extension of one cyst with rupture and moderate ascites. Another cyst was seen to compress the biliary confluence to produce bilateral IHBRD with features of cholangitis and multiple cholangitic abscesses. Confirmatory test Ecchinococcal serology (ELISA) was positive. Ascitic fluid cytology was suggestive of Hydatidosis. Antibiotics Meropenem and Tigecycline were initiated. In view of ECOG status 4, she underwent percutaneous biliary drainage. After 14 days of antibiotics along with Albendazole 400 mg BD she improved and became fit for discharge. Conclusion This case brings attention to the unique presentation of hepatic hydatid cyst from a non-endemic region causing obstructive jaundice, severe cholangitis and rupture, in the setting of previous malignancy. This underlies the need to consider other etiologies also for cystic lesions liver in a patient with malignancy. Keywords Hydatid cyst, Obstructive jaundice 331

Dinesh Background and Aim Porto-pulmonary hypertension (PoPH) is a clinical indication occurring due to portal hypertension (PHT). Endothelin (ET), thromboxane A2, glucagon, known to be associated with PoPH. The mechanisms underlying PoPH remain enigmatic due to lack of representative animal models. The present study investigated the underlying mechanism of PoPH. Methods Semaxnib (VEGFR-antagonist, 20 mg/kg) used to induce pulomary arterial hypertension. Healthy controls (Gr1), + Semaxnib (Gr2), CCl4 cirrhotic rats (Gr3), + Semaxinib (Gr4) were compared. Right ventricular systolic pressure (RVSP) and portal pressure (PP) were assessed. Heart and pulmonary artery function was monitored with 2D echocardiography, histomorphological, cellular and molecular analysis.

Results Cirrhotic animals showed significantly raised PP (15.57±0.6; +117% (Gr3), 14.97±2.0; +109% (Gr4); p=0.01, vs. 7.15±0.8 (Gr1), 8.75±0.5 mmHg (Gr2) with increased hepatic vascular resistance (HVR, p=0.001) and portal blood flow (PBF, p=0.05) in comparison to non-cirrhotics. RVSP was significantly (p=0.01) higher (36.3±3.4, +100% (Gr2), 42.72±2.6, +137% (Gr3), 40±7.9, +122% (Gr4) in comparison to Gr1 (18.2±1.73 mmHg). Echocardiography analysis revealed RV hypertrophy and dilation, confirming PoPH in Gr3, Gr4 and PAH in Gr2. Investigations indicated endothelial/smooth muscle proliferation, thickening, and narrowing of PA including pulmonary fibrosis (Gr3 and Gr4 vs. Gr1 and Gr2, p<0.05) and raised inflammatory cells infiltration.

Mechanistically, in lungs of Gr2, 3 and 4 animals, SMC specific genes were significantly upregulated (p<0.05), ET-1 (+18,+7,+21), ETAR (+5,+3,+5), CXL12 (+15,+6,+14), CXCR4 (+2,+2,+7) and its effectors, PDGF (+9,+4,+5), anti-apoptotic BCL2 (+10,+2,+10), in comparison to Gr1. The significant (p<0.05) differential expression of CD31 (+13, +9, +8) and ETBR (-3,-4,-3), confirming the endothelial dysfunction in lungs (+/-fold change). Conclusion This study demonstrated first time a raised RVSP in cirrhosis, further aggravated with VEGFR antagonist, providing an evidence for PoPH establishment with PHT. Preliminary data revealed the involvement of chemokine axis in pulmonary remodeling in the development of POPH, which needs further clinical evaluation. Keywords Portal hypertension, Pulmonary arterial hypertension, Vascular remodelling 332 A case of persistent transaminitis due to rhabdomyolysis due to entecavir in chronic hepatitis B patient with underlying chronic kidney disease

Correspondence -Viswanath Reddy Donapati -viswanathdr@yahoo.com Department of Gastroenterology, Yashoda Hospital, Alexander Road, Kummari Guda, Shivaji Nagar, Secunderabad 500 003, India

Background Oral antivirals for hepatitis B treatment are known to cause rhabdomyolysis in a small proportion of patients. We hereby describe a case of patient with chronic kidney disease who had high transaminases due to Hepatitis B and rhabdomyolysis. Methods/Case Report Fifty-two-year old male, a patient of chronic kidney disease due to diabetic nephropathy, was initiated on dialysis and in a few weeks was screened positive for hepatitis B with high viral load. Antiviral entecavir was initiated elsewhere and within 5 days presented with pain and weakness in all 4 limbs. He also complained of itching and anorexia. On evaluation, he had elevated liver enzymes, LDH and CPK levels. Entecavir was stopped and tenofovir alafenamide was initiated twice a week and the transaminases improved gradually. He was given liver supportive therapy. His transaminases took time to normalise as well as weakness which recovered more slowly.

We describe a case of drug induced rhabdomyolysis in a patient with chronic hepatitis B, presenting with hepatitis and quadriparesis. His transaminases and quadriparesis took time to improve and was doing well with change of antiviral to tenofovir alafenamide. Entecavir may be avoided in the patients with chronic kidney disease in whom tenofovir alafenamide may be safer. Background Detection and characterization of focal liver lesions (FLLs) poses a frequent challenge in clinical practice. 2D-Shear Wave elastography (2D-SWE) is a recent technique which uses acoustic radiation force to induce mechanical vibrations and assess tissue elasticity. Aims To study the elasticity characteristics of focal liver lesions by 2D shear wave elastography and to determine whether it can be used to differentiate benign from malignant lesions.

Methods All patients with FLL underwent 2D-SWE and elasticity quantification. Contrast enhanced CT or MRI findings were used as the reference method for the diagnosis of FLLs. Results Two hundred and sixteen patients with FLL were evaluated by the 2D-SWE. One hundred and thirty patients had malignant FLLs of which 90 had hepatocellular carcinoma (HCC), 20 had intrahepatic cholangiocarcinoma (IHCC) and 20 had metastatic lesions. Of the 86 benign FLL, there were 36 hemangiomas, 12 FNH, 24 simple cysts, 4 complex cysts, and 10 abscesses. Mean liver stiffness of various lesions by 2D-SWE was 65.7 (IHCC), 60.5 (HCC), 45.4 (metastases), 7.6 (hemangioma), 16.9 (FNH), 9.14 (abscess), 8.62 (simple cyst) and 2.95 (complex cyst). ROC analysis revealed that a SWE cut off of 40 kPa could distinguish between benign and malignant lesions with sensitivity of 100% and specificity of 80%. (AUROC of 0.871). Stiffness Ratio = Shear wave of lesion/Shear wave of background liver parenchyma. The lesion to background liver parenchyma stiffness ratio in cirrhotic patients was 4.81 for IHCC, 3.16 for metastasis and 1.93 for HCC. Therefore in cirrhotic patients, a lesion to liver stiffness ratio < 2 along with SWE of lesion more than 40 kpa favors HCC. However, in noncirrhotic livers, there was no statistically significant difference between stiffness ratio of various malignant focal lesions. Conclusion 2D-SWE could be a useful non -invasive method for the differentiation of benign and malignant focal lesions of liver.

Introduction Transarterial chemoembolization (TACE) can improve the overall survival of patients with intermediate-stage hepatocellular carcinoma (HCC). A modified response evaluation criterion in solid tumours (mRECIST) is used for evaluation of the treatment response in patients after TACE. We tried to evaluate the response and survival in patients after TACE. Methods Patients underwent superselective TACE with Epirubicin. The mRECIST response was calculated after 6 weeks using MRI. Predictive factors were calculated for response and survival.

Results Forty-two patients with intermediate HCC were analyzed. The mean age was 59.12 ± 8.74 years. The predominant etiology was NASH in 31% and alcohol in 23.8%. Twenty-three patients had complete response(CR), 8 patients had partial response (PR), 4 patients had stable disease (SD) and 7 patients had progressive disease (PD), as per mRECIST criteria. Objective response (OR) was defined as patients having either CR or PR and poor response (PoR) as patients having either SD or PD. 73.8% had an objective response and 26.2% had a poor response. HAP score (p=0.003) and CHILD stage (p=0.011) were the most important predictive variables for the mRECIST response. Mortality was highest among the patients with poor response, 8/11 (72.7%). 10/31 (32.2%) patients with objective response died during the follow-up period. Mean survival was significantly higher in patients with OR (25.64 months) than in patients with PoR (13.1 months), p=0.001. mRECIST response predicted survival among the patients on univariate analysis (HR=1.08, p=0.02). The independent predictors for survival were post-TACE decompensation (B-1.43, p=0.03) , ECOG performance status (B-1.41, p=0.010) , and the number of lesions (HR 2.20, p=0.017). , ascitic fluid albumin <0.7 g% (87% vs. 14.4%), PV diameter >13.7 mm (70% vs. 14.4%), PVV <12 cm/sec (73.3% vs. 13.9%) and spleen size>13.6 cm (79.3% vs. 42.9%) were significantly associated with PVT. There was no difference between CHILD B/C status or MELD Na among the 2 groups. On Logistic regression analysis, ascitic fluid albumin, SAAG, EVL sessions, PV diameter were significant risk factors for the development of PVT in DCLD (p<0.001).

Conclusion Disarray of the delicate coagulation cascade occurs in tandem with the severity of liver disease. In our study the association of low ascitic fluid albumin, high SAAG, low platelet as markers of extent of cirrhosis, low PVV indicating sluggish flow and multiple EVL sessions that trigger thrombosis in the splenoportal axis have been significantly associated with PVT in DCLD, with NASH as independent etiology. Keywords Decompenated cirrhosis, Non-tumoral portal vein thrombosis, Risk factors Background and Aim Persistence of chronic HBV infection is due to depletion and dysfunctional CD8 T cells. Eomesodermin (EOMES) is a T-box transcription factor and act as a key regulator and modulator for the expression of inhibitory molecules like PD-1, TIM3, CTLA-4, CD39.

Our aim was to investigate mechanism of immune cells exhaustion in HbsAglo and HbsAghi naive CHBV patients.

Methods We have included 36 naive CHBV (nCHBV; not on any antiviral treatment) patients with HbsAg < 2000 IU/mL (HbsAglo Gr. I, n=9) and HbsAg > 2000 IU/mL (HbsAghi) (Gr. II, n=27) , HBV DNA (<2,000 IU/mL or >2,000 IU/mL) with increased ALT/AST >1.2 x ULN, and healthy controls (HC, n=10). Blood sample was used for virological assessment, plasma analytes and high dimensional flow cytometry to analyze co-expressing inhibitory molecules and transcription factors on CD4/CD8 T and B cells.

Results Peripheral blood CD8 and CD4 T cells showed significantly (p< 0.05) high expression of PD1 in naive CHBV infected patients compared to HC. Further nCHBV patients with HbsAghi, showed significantly low expression of EOMES expressing CD8 T cells but with high BLIMP (p=0.011) and high T-bet (p=0.034), a phenotypic character of short-lived effector cells (SLEC) compared to HbsAglo patients. Additionally, cytokine bead array revealed lower levels of IFNγ, TNF-α and higher soluble PD1, TIM3, CTLA4, LAG3, PDL1, in plasma of nCHBV patients. Background and Aim Anemia is seen in nearly 70% patients with cirrhosis. It is often nonresponsive to nutritional supplements. Bone marrow (BM) in these patients shows erythroid hyperplasia with dyserythropoiesis. In this study, we aim to investigate the alterations in erythropoiesis in cirrhotic patients. Methods BM aspirates were collected from 32 cirrhotic patients (16 alcoholics, 16 non-alcoholic steatohepatitis) with mean age 50 including both male (n=22) and female (n=10) without nutritional deficiency. MELD-Na score of patients ranges from 6-40. Control sample (n=3) were taken from non-liver disease patients. Erythroid differentiation was investigated using antibodies CD34+, CD71+ (early erythroid cell marker), CD235a+ (mature erythroid cell marker) through flow cytometry. Cellular reactive oxygen species were measured by 2',7'-dichlorodihydrofluorescein diacetate fluorescent probe. The levels of genes associated with hemoglobin synthesis were measured using quantitative real time -polymerase chain reaction.

Results Total CD34+ cells population (p=0.02) was significantly reduced and early erythroid progenitors CD71+ population (ALD p=0.009, NASH p=0.002) was significantly high in cirrhotic group as compared to control. Intermediate erythroid progenitors (CD71+CD235a+) population (ALD p=0.004, NASH p=0.0003) was significantly reduced whereas matured erythroid progenitor (CD71-CD235a+) population (ALD p=0.03, NASH p<0.0001) was increased with increase in MELD-Na score (> 10), (Fig. A) . Moreover, mean flouroscence intensity (MFI) of CD235a+ marker was found to be decreased to moderate or dim with decrease level of hemoglobin (Fig. B) . ROS generation in CD34+ and erythroid progenitors was significantly increased (CD34+ p= 0.02, ROS CD34+ p=0.012, CD71+ p=0.02, CD235a+ p=0.003) in cirrhotic patients (Fig. C) . Genes associated with hemoglobin synthesis ALAS1, HMOX, BACH1 and Alfa globin1 were found to be 2-fold down regulated in cirrhotic patients than controls. Conclusion A decrease in CD71+ erythroid progenitor cell population and a defect in their maturation in the bone marrow contributes to anemia of chronic liver disease. Keywords Anemia, Cirrhosis, Erythropoiesis

Changing pattern in hepatocellular carcinoma

Correspondence -Sreevidya Pillai -drsreevidyapillai@gmail.com Department of Medical Gastroenterology, Lakeshore Hospital and Research Centre, NH 47 Byepass, Nettoor, Maradu, Ernakulam 682 040, India

Background and Aim Hepatocellular carcinoma (HCC) is a major health problem in emerging world. In recent years, the epidemiological scenario has been changing, incidence of HCC due to NAFLD is increasing worldwide. Our study is to analyse current changing pattern in HCC and to compare profile of HCC with non-alcoholic steatohepatitis (NASH) and non-NASH etiology.

Methods We did a prospective observational study of 127 newly diagnosed patient of age >18 years who came to the Department of Gastroenterology, Lakeshore Hospital during January 2019 to 283atient 2021. Statistical analysis done using Statistical Package for the Social Sciences (SPSS) and students t test. Objectives Spur cell anemia is a chronic form of anemia defined as a consequential condition in cirrhosis and generally associated with poor prognosis. the association between D-dimer and VWF in spur cell anemia has not been elucidated yet. Therefore, we aimed to evaluate the levels of VWF and D-dimer in liver cirrhosis patients with spur cell anemia.

Method Total 3 mL blood sample were collected in citrate tube from 2 subgroups of CLD patients with Child C. Total 27 CLD patients, in which without spur cells (group 1), 20 case in 7 patients in group 2 with spur cell anemia. Simultaneously, sonoclot assay were performed and then plasma was obtained by centrifugation at 3000 r·min-1 for 10 min used for VWF and D-dimer ELISA assay. Clinical and laboratory parameters including liver dysfunction and MELD-Na score were assessed. Results Spur cells <10% (group 1) and >10% (group 2) mean plasma levels of VWF were significantly ( Conclusion Elevated levels of VWF and D-dimers were noted in patients with spur cell anemia in Child C class in comparison to those without spur cell anemia. Both these factors indicates the increased probability of microvascular thrombi.

Introduction Autoimmune hepatitis (AIH) is characterized by selfperpetuating immune-mediated inflammatory liver damage with or without fibrosis. Corticosteroids remain the main stay of treatment. Microbiome-liver axis has been recognised as a major modulator of autoimmunity and sepsis. We investigated the presence and activity of bacterial Evs (BEVs) in plasma and their interactions with immune cells in AIH patients and their association with steroid response. and 12 non-responders [NR]) to corticosteroid therapy, and healthy controls (n=12) for BEVs (by ultracentrifugation using anti-OMPA [outer membrane protein A] and anti-LPS quantified using flow cytometry and western blot). PBMCs of AIH patients were primed with bacterial vesicles (OMVs-2 ug/mL) and (OMV+dynasore-80 uM, to block the entry of OMVs inside the cells) for 24 hour and analysed for frequency, activation of total T (CD3+CD4+CD8+) cells, mucosal associated invariant T (CD3+CD161+TCRva7.2+) cells, intracellular IL-17A and granzyme B release and B (CD19+) cells using multi-color flowcytometry.

Results Levels of systemic BEVs (OMPA+LPS+) were higher in AIH patients than controls (28.3±5.6 vs. 2.4±1.1 EV/uL; p<0.001), and were higher in moderate to severe than minimal to mild hepatic histological activity (p=0.042). At baseline, NR to corticosteroids had higher BEVs than R (39.6±10.8 EV/uL vs. 12.4±3.2; p<0.001 with AUC =0.71 CI [0.79-0.83]. Protein blots confirmed higher BEV-associated LPS and OMPA in plasma fractions of NRs than R (p=0.003). OMVs in NR PBMCs strongly stimulated the secretion of IL-17A (p=0.015) and granzyme B (p=0.052) from MAIT cells and also increased the frequency of activated MAIT cells (% MAIT+CD69+) (p=0.001) than R. Even with OMV+ dynasore treatment, no inhibition was found in cytokine release in NR, suggesting overwhelming presence of OMVs in the cells of NR and continuous cellular activation.

Conclusion Increased systemic OMPA and LPS-positive BEVs are present at baseline in AIH patients and are able to induce marked immune activation through MAITs cells, which could contribute to corticosteroid resistance. Keywords Autoimmune hepatitis, Bacterial extracellular vesicles, Ultracentrifugation

Introduction NAFLD and T2DM often coexist. Prevalence of NAFLD in patients with type 2 diabetes mellitus is more than 2-fold HIGHER than in the general population. Aims To compare various fibrosis scores (APRI, NAFLD Fibrosis score and FIB 4 score) with the results of Fibroscan and Acoustic Radiation Force Impulse imaging.

Methods Patients with overt liver disease, congestive heart failure, ascites, positive for HIV/HbsAg/HCV, alcohol intake (men who consumed >20 g and women who consumed >10 g of alcohol per day), Usage of drugs known to cause steatosis, BMI > 35 kg/m2 were excluded. Intestinal perforation is rare but potentially life-threatening complication. Case reports of duodenal perforation of displaced stents are present, but cases of duodenal perforation within situ DPT stents are extremely rare. We present 2 cases of in situ DPT plastic stent causing duodenal perforation.

A 71-year-old male, a case of advanced periampullary carcinoma with obstructive jaundice in whom biliary decompression has been done using biliary SEMS + plastic stent 10 Fr *8 cm placement, presented to emergency after the procedure with pain abdomen. ultrasonogram (USG) abdomen done which revealed stent in-situ with mild perihepatic collection. Laboratory tests revealed that the patient's white blood cell (WBC) count of 12.1 × 109/L, neutrophils (n%) was 85%, alanine aminotransferase (ALT) was 46 U/L, aspartate aminotransferase (AST) was 56 U/L, total bilirubin (TB) was 4 mg/dL, and direct bilirubin was 2.7 mg/dL. Endoscopic retrograde cholangiopancreatography (ERCP) has been done which showed the distal tip had penetrated the duodenal wall opposite the papilla. The plastic stent is successfully retracted and removed using rat tooth forceps. Perforation has been closed with 2 hemoclips, DPT 10 Fr * 8 cm plastic stent placed into metallic stent and patient recovered. A 56-year-old male underwent ERCP + DPT plastic stent placement 4 weeks back for choledocholthiasis with cholangitis, came to our centre for elective stent removal. ERCP done which revealed distal tip of plastic stent had penetrated the duodenal wall opposite the papilla. The plastic stent has been successfully retracted and removed using rat tooth forceps. One hemoclip has been applied over the duodenal perforated site. These 2 reports are rare cases of in-situ plastic stent causing perforation which has been managed endoscopically, without the need for surgical intervention. Background and Aim Billiary obstruction secondary to malignancy is a common clinical problem. Rarely, biliary obstruction is due to leukemia and obstructive jaundice in these patients usually presents late in the course of the disease. Hence, our aim of the study was to establish the diagnosis of hematological malignancy causing obstructive jaundice through biopsy and immunohistochemistry (IHC) evaluation and early starting of chemotherapy leading to complete resolution of the obstruction and normalization of liver function test (LFT). Method All the clinical data were recorded after necessary clinical examination. Clinical routine examinations were complete blood count (CBC), LFT, lactate dehydrogenase (LDH), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), ultrasonogram (USG) abdomen, magnetic resonance cholangiopancreatography (MRCP) and contrast-enhanced computed tomography (CECT) abdomen. For histopathological examination, biopsy was taken from the thigh and shoulder mass with IHC markers.

Result MRCP revealed periampullary mass lesion causing dilated common bile duct (CBD) and intrahepatic biliary radicals (IHBRs), hence endoscopic retrograde cholangiopancreatography (ERCP) with plastic stenting was done. Biopsy from shoulder lesion revealed mesenchymal tumor and IHC confirmed that the lesion as myeloid sarcoma. Following stenting after normalization of LFT, chemotherapy started.

Myeloid sarcoma is an extramedullary tumor, a subtype of acute myeloid leukemia. Myeloid sarcoma can cause biliary stricture leading to obstructive jaundice along with multiple skin nodular ulcers, even with normal hemogram report. ERCP with plastic stenting combined with early institution of chemotherapy after normalization of bilirubin may lead to complete resolution of jaundice within 3 to 4 weeks. The patient showed improvement of skin lesions and normalization of LFT after 3 weeks of chemotherapy. Keywords Acute myeloid leukemia, obstructive jaundice, myeloid sarcoma, MRCP

Background Cholangitis is one of the commonest emergencies encountered by gastroenterologists which in most of the cases warrant drainage of biliary system. Serum procalcitonin is an important biomarker of cholangitis with a potential to guide therapeutic decision.

Methods We did a retrospective analysis of prospectively maintained data of patients admitted in the hospital from March 2018 to September 2019 with a diagnosis of acute cholangitis based on Tokyo 13 guidelines (TG 13). All the demographic parameters, biochemical and hematological parameters, and the result were recorded.

Results Forty-one patients were admitted to our hospital with a mean age of 51.07±7.99 years, among which 58.5% (24/41) were females with most common etiology being choledocholithiasis (31.7%). Fever, jaundice, and abdominal pain were seen in 78% ( Cholecystocolonic fistula (CCF) is a rare, diagnosed 1 per 10,000 cholecystectomies and common in females, Mean age is 68.9 years. In only 7.9% of patients the diagnosis is made before surgery. In our case A 56-year male, newly detected type II DM with history of cholelithiasis (single episode of biliary colic 4 years back), was advised laparoscopic cholecystectomy but refused for same at that time. Now came as with history of global sensation since 3 months. Physical examination was absolutely normal. Considering past history all though he was asymptomatic, was evaluated and USG abdomen which showed grade I fatty liver with ill-defined area of hypoechogenicity in pericholecystic and GB fossa ?focal fatty sparing SOL and his routine blood investigation were within normal limit except HBA1c 8.9. Gastroscopy showed LAX LES, Grade B esophagitis. Contrast CT scan abdomen (Fig. 1 ) which was suggestive of changes of xanthogranulomatous cholecystitis with sealed off CCF or early neoplastic etiology. To confirm CCF preoperative colonoscopy was done which showed a small fistulous opening (<1 cm) seen at the level of hepatic flexure, surrounded by granulation tissue and pouring out some white cheesy material (likely pus) consistent with CCF (Fig. 2) . Patient underwent laparoscopic exploration plus cholecystectomy and primary closure of fistulous opening of colon and during surgery frozen section of fistulous margin and surgical specimen of GB showed active chronic cholecystitis with extensive Rokitansky-aschoff sinuses and follicle formation, Liver tissue was normal and no malignance was seen. Colon was viable, non-necrotic so only primary suturing of fistulous opening was performed and drain was put. Postoperative patient had no complication was discharged on Day 5. In conclusion radiologist should be aware of CCF along with other Introduction Cholecystitis is one of the most common causes of pain abdomen in the gastroenterology practice. Gallbladder (GB) perforation is a dreaded complication of acute calculous or acalculous cholecystitis with an incidence ranging from 2% to 18% and associated with high morbidity and mortality. Elderly individuals are more prone to GB perforation owing to reduced blood supply either from atherosclerosis, focal vasospasm or vasculitis.

Case A 70-year-old man, presented to us with right upper quadrant abdominal pain, jaundice and distension of abdomen for 7 days. He had comorbidities in the form of chronic obstructive pulmonary disease and hypertension. Examination revealed a distended abdomen with tenderness and guarding in the right upper quadrant. Investigations were suggestive of anemia, hyperbilirubinemia (total bilirubin-3.4 mg/dL) and raised transaminases (AST-54 IU/L, ALT-62 IU/L, ALP-171 IU/L). Ultrasound of the abdomen showed sludge filled distended GB with edematous wall thickening, septate perihepatic collection and free fluid. Contrast enhanced computed topography of the abdomen revealed a perforation of GB with associated perihepatic and subhepatic collections. Blood and ascitic fluid culture came positive for Klebsiella pneumoniae. A diagnosis of spontaneous GB perforation (type 2 according to the Niemeier classification) secondary to gangrenous acalculous cholecystitis was made and he was managed with appropriate antibiotics. Supportive treatment was continued, and ultrasound guided drainage of the collections was done. Patient had uneventful recovery and discharged with a plan for interval cholecystectomy.

Conclusion GB perforation should be considered in differential diagnosis of elderly patients presenting with abdominal pain and peritonitis. Early diagnosis and prompt treatment would help in reducing the associated Introduction The endoscopic placement of self-expanding metallic stents (SEMS) for palliation of malignant obstruction of biliary tract is an established practice. The distal end of stent may sometimes impinge on the wall of duodenum and may cause erosion of duodenal wall and subsequent bleeding.

Methods A 67-year-old male with carcinoma of gallbladder with obstruction to common bile duct (CBD) due to tumor invasion underwent biliary SEMS placement. This patient presented with melena after a week of SEMS placement. During upper gastrointestinal endoscopy (UGI) endoscopy, distal end of SEMS was seen abutting the duodenal wall and ulcerations were found on posterior and lateral wall of 2 nd part of duodenum. The distal end of SEMS was shortened by 2.0 cm using argon plasma coagulation (60 watts and 1.8L/min) to cut the meshes of SEMS, so that the lower end of SEMS is no longer in contact with duodenal wall. Stent fragment was removed using a catheter with a retrieval net. The patient experienced no complications during procedure and on follow-up. Duodenal ulceration disappeared on follow-up endoscopy.

Results Biliary SEMS trimming was successfully done using argon plasma coagulation (APC) without any untoward side effects.

Conclusion APC is an effective and safe way for trimming of metallic SEMS.

Introduction Acute cholangitis is a common complication in benign biliary strictures and choledocholithiasis. Cholangitis is rare in malignant biliary obstruction and the dilemma continues with regard to clinical presentation and management. In this study, we aimed at clinical presentation, management, and therapeutic outcome of acute cholangitis in malignant biliary obstruction.

Methods We conducted a retrospective analysis of 11 consecutive hospitalized adult patients with malignant biliary obstruction and biliary drainage confirmed-acute cholangitis between 1st September 2020 and 31st August 2021. Clinical presentation, laboratory data, and management records were collected. Outcomes were assessed in terms of postprocedure symptomatic improvement and 3-month mortality.

Results Eleven patients had malignant biliary obstruction and cholangitis. The ratio of males to females was 0.57. The mean age of presentation was 61.6 ± 8.4 years. Five patients had naïve presentation with acute cholangitis, and 6 had stent block. The etiology of biliary obstruction in those with naïve presentation was carcinoma gallbladder, hilar cholangiocarcinoma, and carcinoma head of the pancreas in 3, 1, and 1 case respectively jaundice, right hypochondrium pain, and drowsiness at presentation were found in 100%, 80%, and 80% cases respectively. No patient had fever. Recurrent hypoglycemia and hypoglycemic encephalopathy complicated 4 (100%) and 2 (50%) cases of hilar obstruction with acute cholangitis respectively. Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting, and percutaneous transhepatic biliary drainage were done in 3, and 2 cases (both Ca GB) respectively. Post-biliary drainage hypoglycemia improved in 2 cases (1 Ca GB, and 1 hilar CCA). Three-month survival was 33.3% in ERCP cases and 0% in PTBD cases (both died within 1 month and had hypoglycemic encephalopathy). Conclusion Acute cholangitis is not an uncommon naïve presentation of malignant biliary obstruction. Altered sensorium and hypoglycemia may denote underlying cholangitis sepsis in malignant hilar biliary obstruction. ERCP and biliary stent placement provide the best outcome.

Introduction Tumor suppressor gene p53 has been shown to be involved in the development and progression of gallbladder carcinoma (CAGB). The prognostic significance of p53 over-expression has been reported in CAGB. About half of the tissue samples of CAGB show over expression of p53 gene by immunohistochemical examination (IHC). Early detection of positive IHC expression for p53 gene in gallbladder tissue of chronic cholecystitis and cholelithiasis patients may be helpful for cancer prevention and early treatment. In this study we observed IHC for p53 gene of gallbladder tissues of chronic cholecystitis and cholelithiasis patients.

Method Gallbladder tissues of one hundred patients (100) in paraffin blocks with confirmed diagnosis of chronic cholecystitis (36) and cholecystitis with cholelithiasis (64) were collected. Paraffin were removed by Xylene method to isolate gallbladder tissue. IHC for p53 were performed by immunoperoxidase and diaminobenzidine staining method. Scoring was done by observing percentage of staining of cells in tissue; more than ten percent tissue staining was considered as positive.

Result Among the one hundred (100) samples, ten (10%) samples were found positive of IHC for p53 gene expression (nine samples weakly positive and one sample moderately positive). Among cholecystitis with cholelithiasis samples, nine were found weakly positive whereas one sample was moderately positive. Only one sample of chronic cholecystitis was found weakly positive. Conclusion Positive expression of p53 gene may be demonstrated by IHC method in cholecystitis with cholelithiasis. As positive expression of p53 gene predicts increased risk of development of CAGB in inflammatory conditions, risk is more in cholecystitis with cholelithiasis patients than chronic cholecystitis patients. Keywords p53, Immunohistochemistry, Cholecystitis, Cholelithiasis

Introduction Biliary drainage with T-tube after bile duct surgery has advantages. However, the use of T-tube is associated with some complications. Retained T-tube fragment is a rare complication. We present an unusual case of retained T-tube.

Case Report A 28-years-old male patient after road traffic accident presented with abdominal pain and distension. An abdominal ultrasound (USG) abdomen showed free fluid in abdomen. Diagnostic peritoneal aspiration showed bile and blood. Contrast enhanced computerized tomography (CECT) abdomen showed 7 cm size laceration in the right lobe of liver with free fluid in the abdomen and pelvis. Emergency laparotomy with cholecystectomy and choledochotomy with T-tube placement was done. On post operative day 15 patient accidentally removed T-tube. Magnetic resonance cholangiopancreatography (MRCP) done showed hepatic hyper intensity suggestive of old laceration, T tube fragment noticed in the common bile duct (CBD), fluid collection in hepatorenal pouch. Patient got discharged against medical advice. After 2 months he presented with right hypochondrial pain. MRCP showed T2 hypointense material noted with in the dilated CBD and proximal CBD dilated (8.4 mm). Endoscopic retrograde cholangiopancreatography (ERCP) cholangiogram showed Ttube in the CBD extending into the right system. Sphincterotomy with Balloon trawling done, and T-tube retained fragment removed. 7 Fr X 8 Cm stent deployed into the right system. Post procedure patient was stable and discharged after 2 days. Conclusion Retained T tube fragments is a very rare complication with few case reports. Removal can be both endoscopic and surgical, however endoscopic methods are less invasive. Hence retained T tube fragment in biliary tree should be removed as early as possible to prevent

Introduction Corona virus disease 2019 (COVID-19) is a predominantly respiratory tract infection with the ability to affect multiple organ systems. Abnormal liver tests, mainly transaminase elevations, have been reported in hospitalized patients. We describe a case of cholangiopathy in a patient who recovered from severe COVID-19 characterized by marked elevation in serum alkaline phosphatase (ALP) accompanied by evidence of bile duct injury on imaging and liver biopsy.

Case report 72-year-old male with no previous history of liver disease and history of recovery from severe cardiopulmonary COVID-19 infection 45 days back presented with history of jaundice and pruritus of 2 weeks duration. Bile duct injury was identified by abnormal liver tests with serum ALP > 3x upper limit of normal and abnormal findings on magnetic resonance cholangiopancreatography (MRCP) which showed edema around common bile duct (CBD) and intrahepatic biliary tree. Liver biopsy exhibited extensive degenerative cholangiocyte injury. His other notable labs included negative viral, tumor markers, negative autoimmune workup and bile duct brush cytology. Discussion A diagnosis of post COVID-19 cholangiopathy was made on the basis of clinical, imaging and liver biopsy findings. Patient was given symptomatic management with follow-up of gastrointestinal and liverrelated symptoms along with liver enzymes levels. Ultimately, the patients labs steadily improved and was symptom free in few days. Post-COVID-19 cholangiopathy is a special entity of liver injury that has been suggested as a variant of secondary sclerosing cholangitis in critically ill patients. It is characterized by marked cholestasis associated with ongoing jaundice that persists long after pulmonary recovery.

Conclusion Severe hospitalized COVID-19 patients are at significant risk of cholangiopathy and post COVID-19 follow-up must include regular liver functional check-up. This case is being reported to provide reference

Introduction Studies have shown an increasing incidence of sepsis with multidrug-resistant organisms (MDRO) caused by persistent contamination of duodenoscopes. Prevalent practices of scope reprocessing seem to be inadequate in completely eradicating the microbial load. The elevator tip has been shown to be a potential source for persistent contamination.

In this study, we have assessed the role of a disposable elevator tip to prevent scope contamination.

Methods This was a case-control study conducted in a high volume tertiary center. In the control group, the standard duodenoscopes (Olympus TJFQ180V) was used, while in the test group, a duodenoscope with disposable elevator tip (Pentax ED3490TK), was used. Reprocessing was carried out by dedicated trained technicians in accordance with ESGE guidelines. Bacterial contamination was confirmed by performing surveillance cultures on the scopes as per CDC guidelines. The cultures for the test group were performed after the disposal of the elevator tip. Contamination was defined as microbial growth with ≥20 CFU/20 mL of any type of microorganism (AM20). The prevalence of scope contamination, type of bacteria and procedure related cholangitis was compared between the two groups.

Results A total of 106 cultures were taken (test group -74 samples, control group -32 samples). A significantly higher proportion of contaminated scopes were seen in controls as compared to the test group (29/ 32 samples vs. 41/74 samples, p value 0.05). Six patients (10.5%) had cholangitis following procedure of which 4 patients were from the control group. Among the high priority organisms, pseudomonas aeruginosa and Klebsiella pneumoniae were the most common (10 positive samples each).

Conclusions The use of a disposable elevator tip can result in a significant reduction of bacterial contamination of the duodenoscope. Reduced bacterial contamination can lead to lower rates of post-procedure cholangitis.

Keywords Cultures, Cholangitis, Multidrug-resistant organisms Introduction Lemmel syndrome is a rare cause of the biliary mechanical compression by the juxtapapillary pseudodiverticulum, in the absence of gallstones or periampullary tumors. Most periampullary diverticula are asymptomatic. However, complications may occur in about 5%, including diverticulitis, pancreatitis, cholangitis, choledocholithiasis, enterolith, bezoar formation, intestinal obstruction, bleeding and perforation. Case Report A 60-year-old woman presented with abdominal pain, fever, and jaundice of acute onset. She was hemodynamically stable except for a fever of 101°F. Initial blood work revealed a WBC 14,500/mm 3 , ALT 118 IU/L, AST 189 IU/L, ALP 356 IU/L, T bilirubin 7.2 mg/dL. computerized tomography (CT) and magnetic resonance imaging MRI of abdomen revealed peri ampullary diverticulum compressing distal common bile duct causing proximal dilatation. Biliary findings were consistent with Lemmel syndrome. It was concluded that she had experienced a transient biliary obstruction as a result of Lemmel syndrome. Patient was managed with broad spectrum antibiotics and other supportive measures in view of cholangitis. Patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) stenting.

Patient's lab parameters improved steadily and was asymptomatic in few days. Discussion Our patient had abdominal pain associated with leukocytosis and cholangitis due to extrinsic compression of the distal CBD. Lemmel syndrome can be transient in nature as a result of a periampullary duodenal diverticulum causing extrinsic compression of the CBD. This can sometimes progress to cholangitis, as seen in our patient. Early diagnosis is necessary to avoid extensive and invasive workup. Management is often supportive, although in some cases with recurrent infection or persistent biliary obstruction, surgical diverticulectomy can be considered.

Conclusion Lemmel syndrome should be kept as a rare differential when evaluating patients with biliary obstruction.

Introduction IgG4-related sclerosing cholangitis (IgG4-SC) is the biliary manifestation of IgG4-related disease (IgG4-RD). It is a systemic fibroinflammatory condition, characterized by mass lesions and/or strictures with classical histopathological findings in involved organs. IgG4-SC is associated with type 1 autoimmune pancreatitis (AIP) in more than 90% of cases. It is challenging to diagnose IgG4-SC in the absence of associated AIP.

Case History A 32-year-old female had~6 week history of easy fatiguability, pruritus, non-significant loss of weight. At the onset, she had features of cholestatic jaundice, which on evaluation was due to midlower CBD stricture. Etiology of the stricture could not be ascertained even after cross sectional imaging (CT scan) and endoscopic biliary brushings. Patient underwent endoscopic plastic biliary stenting across the stricture and was advised for a Whipple's surgery for an indeterminate stricture. She presented to us for a second opinion. We decided to reattempt tissue diagnosis. Evaluation Endoscopic retrograde cholangiography showed single, mid to lower CBD stricture with dilated common hepatic duct and intrahepatic biliary radicals. For tissue diagnosis, single operator cholangioscopy showed a smooth fibrotic stricture, with indurated and friable margins. It showed lympho-plasmocytic infiltrate rich in IgG4 positive plasma cells (>15/HPF). Treatment As per standard of care, patient was started on oral prednisolone 0.6 mg/kg body weight/day. Discussion IgG4-SC can mimic malignancy, is steroid-responsive and has good prognosis. Inability to ascertain etiology of biliary stricture may lead to surgical resection. As per the existing data,~10% patient have a benign pathology after Whipple's surgery done for presumed malignancies. Conclusion IgG4SC is less common, but a judicious and timely use of spy cholangioscopy, which is a milestone technology helps in accurate diagnosis and may avoid major surgical procedure. Our patient could avoid Whipple's surgery which is a major surgical procedure and unnecessary for her. Background Traumatic bile leaks often results in high morbidity and prolong hospital stay that require multimodality management because of associated multiorgan injury. Data on endoscopic management of bile leaks are scarce. Aim To evaluate the efficacy of endoscopic management of a traumatic bile leak.

Methods We performed a retrospective case review of patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP) after traumatic bile duct injury secondary to blunt trauma (motor vehicle accident or fall from height) and stab wounds for management of bile leaks at our tertiary hospital. Thirty-five patients underwent ERCP, biliary sphincterotomy and stenting for the traumatic bile leak over a 11-year period. All were monitored periodically 1-2 weeks after discharge.

Endoscopic therapy was considered successful if there was no drain out. Endo biliary stent was removed after a period of 3 months.

The etiology included blunt trauma from motor vehicle accident in 22 patients, fall from height accident in 12 patients, stabbing by bull horn in one, liver injuries were grade III in 12 patients, grade IV in 23 patients. All patients were treated by biliary stent placement, and the outcome was successful in 35 of 35 cases (100%). Right hepatic duct injury in 10 (33%), left in 12 (36%), both associated with liver Laceration. CHD in 4 (12%), CBD injury in 6 (17%), GB perforation in 3 (8.5%). The mean duration of follow-up was 90 days. There were no ERCP-related complications. In our case review, endoscopic management with endo biliary stent placement was found to be successful and resulted in resolution of the bile leak in all 35 patients. Conclusion Based on our study results, ERCP should be considered as first-line therapy in the management of traumatic bile leaks.

Introduction Hepatic involvement in disseminated tuberculosis (TB) is seen in 50% to 80% cases. Isolated hepatic involvement is rare. We present a case of tuberculous distal CBD stricture presenting with obstructive jaundice.

A 15-year-old female presented with complaints of abdominal pain for 2 months and progressive jaundice for 15 days with pruritus and acholic stools. She also had intermittent fever with night sweats for 2 months and weight loss of 5 kg with poor appetite. There was a history of appendicitis at the age of 8 years and appendectomy was done. Patient's father had a history of pulmonary TB 3 years back. He was noncompliant with antituberculous therapy (ATT) and later succumbed to his illness. Ectopic opening of the common bile duct (CBD) into the gastrointestinal (GI) tract is a rare congenital anomaly. The CBD typically opens into the posteromedial aspect of the second portion of the duodenum. Ectopic openings of the CBD to other segments of the duodenum, pyloric canal and stomach have been described. During embryogenesis, disproportional elongation, and early subdivision of the primitive hepatic furrow, as it develops from the pars cystica results in ectopic opening and leads to biliary tract diseases like bile duct stones, cholangitis and acute pancreatitis.

Here we report a 56-year-old man who had presented with painless progressive obstructive jaundice, cholangitis for 1 month with associated loss of appetite. On evaluation he had elevated bilirubin, liver enzymes and tumor marker. Cross sectional imaging revealed dilated intrahepatic biliary radicles with dilated CBD showing distal smooth tapering. On endoscopic retrograde cholangiopancreatography (ERCP) periampullary bulge was noted, CBD was cannulated with difficulty but on cholangiogram the stent was noted in an unusual site. Hence, due to clinical suspicion, Magnetic resonance cholangiopancreatography (MRCP) was done on the same day, which revealed ectopic opening of CBD with distal CBD stricture but the possibility of a malignant stricture could not be ruled out. Patient underwent PTBD and brush cytology which came negative for malignancy. Due to persistent symptoms, he underwent choledochoduodenostomy. Post-surgery patient is doing well. Malfunction of the valve mechanism in the distal CBD permits influx of intestinal bacteria and gastric contents into the biliary system, which could cause a transient obstruction and recurrent subclinical cholangitis which lead to distal CBD stricture and presentation in our patient. If an ectopic opening of the CBD is suspected at endoscopy, careful inspection for bile flow, use of EUS, cautious cannulation and contrast injection can help delineate the anatomy. In conclusion, management of such cases require multidisciplinary teamwork. KeywordsEctopicopeningofCBD,PTBD,ERCP,Thirdportionofduodenum Introduction Hilar strictures can be both benign and malignant. The optimal strategies for drainage of hilar strictures are still controversial, mainly regarding the extent of drainage required and unilateral or bilateral stenting. The aim of this study was to identify predictors of successful biliary drainage mainly by liver volumetry. Methods Prospective observational study was conducted. Total 14 patients of hilar strictures of Bismuth type II, III, or IV were studied who had either endoscopic or percutaneous biliary drainage. CT volumetry of 3 main hepatic sectors (left, right anterior, and right posterior) was calculated. The liver volume drained was estimated and classified into 2 classes: less than 50% (Group A) and more than 50% (Group B) of the total volume. Main outcome measurements: Primary outcome was effective drainage which was defined as a more than 50% fall in bilirubin at day 28 post-intervention. Secondary outcomes studied include complications, reintervention, and survival and mortality rates.

Results Mean age of study population was 55 years with 78.65% females. The commonest symptom other than jaundice was weight loss (85% Conclusion Draining more than 50% of the liver volume is not required for 50% fall in bilirubin but had better survival and lesser complications.

Introduction Eosinophilic gastroenteritis (EGE) is a rare condition of unknown etiology. It is characterized by peripheral blood eosinophilia and eosinophilic infiltration of the gut wall. The presenting symptoms depend on the site and depth of intestinal involvement and varies from abdominal pain, vomiting to acute bowel obstruction, ascites. Obstructive jaundice is an uncommon symptom of EGE. Case Report We report a 47-year-old man who presented with abdominal pain, vomiting and jaundice. Investigations revealed abnormal liver tests, and peripheral blood eosinophilia. Ultrasonography of abdomen was suggestive of moderately dilated common bile duct (CBD) and intrahepatic biliary radicles due to 16 x 9 mm size calculus in distal CBD. On endoscopic retrograde cholangiopancreatography, the ampulla was irregular and bulging with stricture in the distal CBD with no obvious calculus. Biopsies from peripapillary duodenal mass showed evidence of eosinophilic gastroenteritis. Patient underwent biliary stenting and then was started on oral corticosteroids. He responded very well to that with complete resolution of the mass. Conclusion Eosinophilic gastroenteritis is a comparatively rare but treatable cause of obstructive jaundice which can masquerade as malignancy and it should be kept in mind particularly in patient with peripheral eosinophilia.

Keywords Eosinophilic gastroenteritis, Obstructive jaundice Introduction A 45-years-old male presented with acute cholangitis with progressive jaundice for 1 week. Computed tomography (CT) of abdomen showed abrupt narrowing of distal common bile duct (CBD) with dilatation of rest of CBD with mild central intrahepatic biliary dilatation (IHBD). For which he underwent endoscopic retrograde cholangiopancreatography (ERCP) and CBD stenting elsewhere. Brush cytology showed few atypical cells. As there was no improvement in liver chemistry parameters, redo ERCP was done after 2 weeks elsewhere. Based on cholangiogram they thought that it was a hilar stricture with Type III cholangiocarcinoma, hence stricture was dilated with Soehendra biliary dilation catheter (SBDC) and double pigtail biliary stent was placed ( Fig.  1) . As there was no improvement in liver chemistry even after two weeks. Came for further management.

Methods Planned for repeat ERCP and may take help of EUS for completion of the procedure.

Results ERCP was repeated for third time. On duodenoscopy CBD stent was seen in situ and removed with forceps. CBD canulation was done. Cholangiogram showed no filling of CBD and its biliary radicles-? False tract parallel to CBD (Fig. 2) . Hence ERCP was attempted in rendezvous manner with aid of endoscopic ultrasound (EUS), after entering the CBD in antegrade manner (Fig. 3) . EUS showed distal CBD stricture with IHBD. Biliary self-expandable metallic stent (SEMS) placed retrogradely (Figs. 4 and 5) .

Conclusion For complex ERCP, biliary imaging is necessary prior to procedure 1. During ERCP, good understanding of biliary anatomy is required before stenting. When in doubt, EUS can be used for better understanding of biliary anatomy in the same setting 2. Complex ERCP are better done by an expert at high volume centers. Keywords Cholangiopancreatography, Endoscopic retrograde, Endoscopic ultrasound

Comparison of ejection fraction in patients with gallstones with healthy subjects -A systematic review and meta-analysis

Introduction Gallbladder (GB) stasis is one of the contributing factors for gallstone formation. We performed a systematic review and metaanalysis to determine the gallbladder ejection fraction (GBEF) among patients with gallstones and compare it with healthy subjects. We also examined if the GBEF varied depending on the methods used to elicit GB contraction or on the imaging modality. Introduction Gallbladder (GB) stasis promotes gallstone formation. Dissolution therapy is effective only in patients without GB stasis. We studied GB contractile function using prospectively collected data in a structured format in patients with gallstone disease and compared it with normal subjects. Methods We analyzed prospectively collected data of subjects who underwent GB ejection fraction (GBEF) assessment in a tertiary care center in North India. We compared their baseline characters, demographics, symptom profile, investigations, and GBEF. GBEF was assessed 30 minutes and 60 minutes after a standard fatty meal using ultrasonography or HIDA scan. GBEF < 35% was defined as GB stasis. If the peak GB contraction was attained after 30 minutes of the meal, it was defined as sluggish GB. Both sluggish and static GB were regarded as having GB dysfunction.

Results There were 501 patients with gallstones (mean age 45.8, SD 14 years 76% females) and 85 healthy controls (mean age 36.4, SD 12 years, 35% females). The median GBEF (25th, 75th centile) among the groups were: patients with gallstone 31% (17%, 50%) and healthy subjects 54% (48%, 62%). The GBEF was significantly low in patients with gallstones when compared to normal subjects (p 0.014). Patients with gallstones more often had sluggishly contracting GBs than healthy controls (75% vs. 10%, p<0.001). 62% of the static GBs were sluggish also. Conclusion GB is static and sluggish in patients with gallstones Keywords Gallbladder ejection fraction, GBEF, Gallstone harder (3395 N vs. 3909 N, p=0 .006) stones. Mucosal tissue from GB with stones had positive cultures more often than those without stones (82% vs. 31%, p<0.001). GSD group more often had severe inflammation (94% vs. 6%, p=0.001), hyperplastic lining epithelium (51% vs. 14% p<0.001%) and metaplasia (15% vs. 0%, p=0.025) than the control group. Age more than 50 years increased the risk for metaplasia by 3 times in GSD cases. Conclusion Gallstones which were multiple, had rough surface, larger, heavier, harder, and sinking were more often associated with inflammation. Inflammation and metaplasia was more frequent in GBs with stones. Keywords Gallbladder, Gallstone, Inflammation, Metaplasia

Introduction Acute pancreatitis (AP) is a common disease which is associated with significant mortality when severe. Fatty liver disease is common in the general population and is associated with an inflammatory state. We hypothesized that the presence of fatty liver in an individual with AP may be associated with the severity of pancreatitis. The aim of this study was to investigate a possible association of fatty liver with severity of AP.

Methods Consecutive patients admitted with AP, diagnosed as per standard criteria, were enrolled in the study. Severity of AP was assigned based on the 2012 Atlanta classification. Fatty liver was defined as liver-to-spleen attenuation ratio of less than one on computed tomography scan of the abdomen. Patients were followed for outcomes including length of hospital stay, days in intensive care unit, presence of organ failure, local complications, and mortality. Results In this ongoing study, among 58 patients recruited so far, fatty liver was found in 28 (48.27%) while 30 (51.72%) had normal liver attenuation. Compared with patients without fatty liver, the severity of pancreatitis was significantly higher in fatty liver patients ( Table 1 ). The prevalence of local complications (11 vs. 6), persistent organ failure (8 vs.

2) and deaths (2 vs. 0) were higher in patients with fatty liver compared to those without. Background Acute pancreatitis (AP) is a severe and complex disease associated with significant mortality and morbidity. Several scoring systems and prognostic indicators are in use for assessing the severity of AP and predicting the outcomes, however, they have not yet proved to be accurate. We conceptualised this study to evaluate the usefulness of simple and relatively inexpensive tools: the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR)in predicting the severity and outcome of patients with AP.

Methods A prospective study was conducted in a tertiary care referral centre of Odisha from March 2020 to April 2021. One hundred and eight consecutive patients of AP were enrolled and the NLR and PLR were calculated. Severity of AP was classified as per the revised Atlanta classification.

Results The median age of patients was 38 (29,45) years with a male predominance (79%). Alcohol was most common etiology (62%) followed by biliary (30%). Mild and severe AP were seen in 52.7% (57) and 47.3 % (51) respectively (moderately severe-28; severe-23). The overall mortality was 8% (9). Median NLR and PLR were significantly higher in the severe AP as compared to mild AP 14.8] Introduction Systemic lupus erythematosus (SLE) is a multi-system disorder mostly affecting females. Gastrointestinal manifestations are known to occur in SLE and acute pancreatitis (AP) is a rare manifestation which has been reported in the range of 0.2% to 8.2%, usually in already diagnosed SLE cases. Here we describe a 40-year-old gentleman with AP as the initial manifestation of SLE.

Case report A 40-year-old man presented with fever and abdominal pain for 20 days. The pain was localized to the epigastric region with radiation to back. On examination, his vitals were stable and there were multiple oral ulcers. Abdomen was tender and other systemic examination was unremarkable. Laboratory investigations revealed anemia (7.7 g/dL), thrombocytopenia (11,040 cells/mm3), deranged kidney function (creatinine-2.61 mg/dL), elevated amylase (1088 U/L) and lipase (1841 U/L).

In view of fever, additional work up for other etiologies was done which showed negative results for malaria and dengue; sterile blood and urine cultures, and 3+ urine proteinuria. Ultrasound abdomen showed bulky pancreas with peripancreatic fat stranding. Computed tomography (CT) scan was suggestive of AP with a CT severity of 6. He was managed with intravenous fluids, analgesics and additional supportive management (naso-jejunal feeds were initiated in view of oral feed intolerance) to which he responded well. In view of oral ulcers, anemia, thrombocytopenia and proteinuria, a possibility of SLE was considered. Further investigations showed a positive anti-nuclear antibodies (3+; homogenous) and positive anti-ds DNA antibodies (2+ Introduction Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with a dismal prognosis. Statins, apart from its action as cholesterol lowering agent, have also been demonstrated to have anti-tumour effects by inhibiting angiogenesis, preventing metastasis, and inducing apoptosis. However, the efficacy of statins in improving overall survival in patients with PDAC has not been established.

Methods We conducted an observational, prospective cohort study in which all consecutive histologically proven PDAC patients between January 2016 to December 2019 were included. Statin users were defined as those who had taken statins for a minimum period of 3 months. All relevant demographics, diagnostic procedures and treatment details were recorded in pre-designed proformas. Patients were then followed up for a minimum duration of 1 year. Primary outcome of the study was overall survival. Stratified analysis was performed with respect to stage (metastatic vs. non-metastatic) and treatment modality offered (curative resection, palliative chemotherapy, palliative biliary drainage Methods 11-14 weeks old male C57BL/6J mice were administered weekly intraperitoneal injections of 9% (450 mg/100 g BW) L-Arginine hydrochloride for 6 weeks. Body weights and feed intake were monitored twice weekly. After the last injection, the mice were euthanized using intraperitoneal administration of 100 mg/kg ketamine and 10 mg/kg xylazine. Pancreata and intestines were resected aseptically, fixed in 10% formalin and processed for paraffin embedding. Fibrosis in the pancreatic tissues was assessed by H&E staining and confirmed using picro-sirius red (PSR) staining. The jejunal tissues were subjected to immunohistochemical staining for the gut barrier integrity markers ZO-1 and Caspase-3. The stained area was quantified from the total area on Image J software.

Results At the end of 6th week severe CP was induced that was characterized by adipocyte infiltration and progressive acinar cell damage in pancreatic tissues. PSR positive staining confirmed parenchymal fibrosis. From 3rd to 6th week there was a 2.33-fold increase in fibrosis, which was statistically significant (p< 0.05). Quantification of ZO-1 showed decreased staining whereas Caspase-3 showed increased staining in 6th week experimental mice than in sham controls. Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding, posing a significant diagnostic and therapeutic dilemma. The diagnostic clues are gastrointestinal bleeding associated with abdominal pain in the background of chronic pancreatitis. Hemosuccus pancreaticus secondary to gastroduodenal artery pseudoaneurysm is rarely reported in the literature. We report the case of a 28-year-old male, with a history of chronic pancreatitis on PERT, who presented with a history of abdominal pain associated with upper gastrointestinal bleeding. He had a history of three similar episodes over the past seven months. At presentation, the patient had features of anemia and postural hypotension. Blood investigations revealed hemoglobin levels of 4.5 g/dL and peripheral smear revealed hypochromic microcytic anemia. His amylase/lipase levels were normal. He was treated with whole blood transfusions. Initial esophagogastroduodenoscopy (EGD) revealed a normal study. During hospital admission, the patient developed an episode of severe abdominal pain and hematemesis. Emergency EGD done within 30 minutes revealed blood oozing from the ampulla of Vater. Abdominal contrast-enhanced computed tomography revealed features of chronic calcific pancreatitis with multiple pseudocysts. The gastroduodenal artery was seen coursing anterior to a pseudocyst of size 2.4 x 2.7 x 3.9 cm in the region of the head of the pancreas and a small (4-5 mm) proximal gastroduodenal artery pseudoaneurysm was identified. In the same setting, he underwent "sandwich method" angiographic coil embolization using 5x5 mm and 5x7 mm coils. Postprocedure, the patient had no further symptoms and was discharged. We also performed magnetic resonance spectroscopy (MRS) in a subset of patients to evaluate brain glutamate/glutamine (Glu/Glx), myoinositol, N-acetyl aspartate (NAA), creatine in the pre-frontal cortex (PFC), hippocampus (H), basal ganglia (BG), and anterior cingulate cortex (ACC), and assess the correlations with pain and QOL.

Pre-post data comparison was performed using the Wilcoxon matchedpair signed rank test, and the extended Mantel-Haenszel (MH) c2 test for linear trend, as appropriate.

Results The mean age (SD) of patients was 37.6 (12.10). There were 47 (77%) male and 25 (39%) diabetics. On follow-up, there was a significant improvement in the frequency of depression (MH χ2 linear trend-5.9; p=0.015). Significant improvement was observed in BDI II score (p=0.001), pain episodes (p=0.009) and VAS for pain (p=0.02). Significant improvement was also observed the role and emotional functions of EORTC QLQc30 (adj. p=0.008 and 0.026 respectively). The metabolites myoinositol in the right ACC and Glu/Glx in the left BG had a negative and positive correlation respectively with pain scores.

Introduction Recurrent acute pancreatitis (RAP) is defined as occurrence of two or more episodes of documented acute pancreatitis (AP) with complete resolution of symptoms and laboratory abnormalities between episodes. In this cross-sectional study we evaluate the genetic associations of idiopathic RAP. Background We earlier reported the significant differences in fecal bacteriome of chronic-pancreatitis (CP) patients with and without diabetes. In this study, we evaluate the jejunal bacterial flora in patients with CP.

Methods A well characterized 10 CP patients (diabetic=4, non-diabet-ic=6) and 1 healthy controls (HC) were recruited. 2-3 mL jejunal fluid was aspirated using sterile enteroscope, followed by fluid collection using a sterile syringe. Metagenomic DNA extraction were performed followed by V3-V4 region of 16SrDNA based on Miseq (2*250bp). The raw reads were annotated based on the Greengene database using QIIMEv1.9.1 with 95% similarity.

Results We observed significant differences in the bacterial profiles between the patients and control. There were a total of 23 phyla in the patients while 7 in HC. Additionally, 1888 bacterial species in patients and 188 in healthy control were observed. The patients with CP who had diabetes were dominated by Prevotella copri, however, the nondiabetics had more Fusobacterium nucleatum and Veillonella dispar in their jejunum. We, then studied the association among the FBS (fasting blood sugar) level and C-peptide with the patients' bacterial profile. We observed the beneficial flora viz. Faecalibacterium prausnitzii, Eubacterium rectale, and Prevotella copri to be positively associated with FBS in diabetic and negatively in non-diabetic cohorts, suggesting a possible alteration of the beneficial flora-host crosstalk in the diabetic cohort. C-peptide exhibited negative correlations with butyrate producing bacteria, Abiotrophia para-adiacens and positive correlations with Faecalibacterium prausnitzii and Eubacterium rectale in diabetic cohort. In non-diabetic patients C-peptide was found negatively associated with Eubacterium rectale, Gemella sanguinis and positively with Faecalibacterium prausnitzii.

Conclusion In this study, we are reporting for the first time the jejunal microbiome in patients with CP. Keywords Chronic pancreatitis, Jejunal microbiome, Diabetes

Introduction Differentiating between a malignant and an inflammatory head of pancreas mass often poses clinical dilemma. In this study, we aimed to explore the plasma metabolites in patients with chronic pancreatitis with head of pancreas mass (malignant and inflammatory), its potential utility in diagnostics.

Methods We recruited 84 patients and 11 healthy controls (HC) for the study and the plasma metabolites were studied on gas chromatography mass spectrometry (GCMS) platform using an untargeted approach. We performed methanol extraction, followed by pyridine-MSTFA derivatisation as sample preparation method. The differences were tested using partial least square deviation analysis ( Background Acute pancreatitis (AP) is known to result in endocrine dysfunction (prediabetes and diabetes). The objective of this study was to determine the temporal incidence of endocrine dysfunction after onset of AP and determine the risk factors in Indian patients.

In this prospective study, enrolled patients diagnosed with AP between February 2019 to May 2019 were followed at 3, 6, and 12 months. Patients with RAP, CP and pre-existing endocrine dysfunction were excluded. Demographic and disease severity (clinical, laboratory and radiological) data were recorded. Mann-Whitney U and Chi-square tests were used to compare groups. Temporal trend for development of Introduction Primary gist in the pancreas is distinctly uncommon and very few cases been reported in the literature till date. We report a case of primary pancreatic GIST with liver metastasis presenting with obstructive jaundice.

Case Report A 46-year-old diabetic female presented with complaints of painless progressive jaundice for 3 months with pruritis and claycoloured stools, along with loss of appetite and weight. She had no prior history of any abdominal surgery, no fever and no gastrointestinal bleed. On examination, patient had icterus with palpable liver having firm consistency, nodular surface, palpable 6 cm below RCS and a 4 x 5 cm vague mass in epigastrium with firm consistency. Patient's investigations showed total bilirubin-9 mg/dL, direct bilirubin-7.9 mg/dL, ALP-567 IU/L, CA 19-9: 5 IU/mL, CEA: 0.84 IU/mL, CA 125: 32 IU/mL. Ultrasound abdomen showed hypoechoic lesions in head and uncinate process of pancreas and a hypoechoic nodule in segment 8 of liver. USG guided FNAC from liver and pancreatic lesion showed atypical spindle shaped cells, which on immunohistochemistry were CD34 and CD117 positive. CECT abdomen showed hypodense lesion arising from head and uncinate process of pancreas with abrupt cut off of distal CBD and dilatation of proximal CBD and multiple hypodense lesions in right lobe of liver. As patient already had liver metastasis, curative surgery could not be done and so was managed with palliative therapy with ERCP and CBD stenting by an uncovered SEMS and was started on Tab imatinib. Conclusion Early diagnosis and treatment would save life of many patients of GIST; it requires indefinite follow-up post therapy.

Keywords Gastrointestinal stromal tumor (GIST), Jaundice, Imatinib, CD117

Introduction Acute pancreatitis is an inflammatory condition associated with local and systemic inflammatory response. Pulmonary thromboembolism is a very rare and life-threatening complication of acute pancreatitis. Several explanations have been proposed for this like systemic inflammatory response resulting in a hypercoaguable state or inflammatory mediators causing intrinsic endothelial damage or extrinsic damage of the veins from adjacent edema, fibrosis and cellular infiltration or compression of the vein by a pseudocyst or enlarged pancreatic parenchyma.

Case A 47-years-old male, chronic alcoholic presented with complaints of pain abdomen -15 days and abdominal distension-10 days. All baseline investigations were normal except serum amylase of 793 IU/mL. USG abdomen-pancreas -obscured by bowel shadows, gross ascites. Ascitic fluid analysis-low SAAG, high protein with amylase of 7141. CECT and MRCP abdomen S/O-acute pancreatitis with pseudocyst. V.OGDpangastritis. A diagnosis of acute pancreatitis with pancreatic ascites was made and patient was planned for ERCP and PD stenting. On day 5 of admission patient complained of pain and swelling in right lower limb and Doppler was suggestive of DVT of popliteal vein. Patient was started on Inj. UFH. Next day patient developed shortness of breath. ECG sinus tachycardia with T inversion. CT chest with pulmonary angiography suggestive of pulmonary thromboembolism. Patient was thrombolysed and was started on anticoagulants. Patient underwent ERCP and PD stenting. Patient responded to treatment and is on follow-up. Conclusion Pulmonary thromboembolism in acute pancreatitis is a rare but life-threatening complication. Various risk factors have been implicated for the prothrombotic state in acute pancreatitis. Familiarity with this complication will help in its early diagnosis. Treatment with intravenous heparin followed by warfarin is effective.

Keywords Pancreatitis, Pulmonary thromboembolism, Ascites

Introduction Studies on follow-up of patients with asymptomatic walled off necrosis (WON) arscarce. This is the first prospective study for patients with asymptomatic WON. This study aims to identify infection on follow-up in these patients and its predictors. Methods: Thirty patients with acute pancreatitis with WON from November 2018 to April 2020 were enrolled. All patients were followed and patient developing complications were analyzed based on their baseline clinical, laboratory and radiological parameters to find any predictor for development of complications. Unpaired t-test or Mann-Whitney 'U' test was used for quantitative data and Chi-square or Fisher's exact was used for qualitative data. "P" value <0.05 was considered statistically significant. Introduction Acute pancreatitis (AP) is a serious gastrointestinal disorder with a wide array of etiologies. The diagnosis of AP requires 2 of the following 3 features: (1) abdominal pain characteristic of AP, (2) serum amylase and/or lipase ?3 times the upper limit of normal, and (3) characteristic findings of AP on imaging.

Alcohol is the etiological factor in 25% cases of acute pancreatitis, while hypertriglyceridemia is the third most common cause of acute pancreatitis but is relatively rare and occurs when TG levels are >1000 mg/dL. Although alcohol intake can lead to secondary hypertriglyceridemia, however which of these is the contributing etiology is difficult to ascertain. Cases We experienced 3 cases in our center who came with complaints of recent onset pain abdomen. All patients were male aged 32-48 years. One patient aged 48 years had history of familial hypertriglyceridemia and was on treatment for the last 2 years but had no regular follow-up and came with complaints of pain abdomen after binge alcohol intake with elevated triglycerides found on evaluation. 2 nd case is a known case of hypertriglyceridemia, on regular follow-up, with history of alcohol related pancreatitis in 2015. He quit alcohol after index episode but present with recent onset pain abdomen and investigations showed highly elevated triglyceride levels. Another case presented with pain abdomen after binge alcohol intake and was found to have high TG levels on evaluation. All 3 cases had mild pancreatitis and were managed with adequate intravenous fluids and insulin infusions along with other supportive treatment. All 3 patients were discharged and are on strict follow-up. These 3 cases demonstrate the need for thorough evaluation for etiology and workup of patients with acute pancreatitis in spite of obvious etiological causes based on history for better patient care.

Keywords Acute pancreatitis, Triglyceride, Alcohol

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the ongoing pandemic of corona virus disease 2019 and has caused >120,000 deaths. Although it is primarily a respiratory virus, SARS-CoV-2 also has extrapulmonary manifestations. Involvement of the pancreas is one of them.

More than 1000 patients undergone treatment for COVID-19 during period of 2020 -21 in Gandhi Hospital, Secunderabad, India. We present a series of 11 COVID 19 +ve cases presented with acute pancreatitis admitted during this period. Out of 11 cases, 7 cases were admitted with pain abdomen as presenting complaint with covid 19 symptoms (fever, cough, and breathlessness) and diagnosed as acute pancreatitis. Other 4 cases developed pain abdomen after 4 to 6 days of admission. other causes of pain abdomen were ruled out in all these patients. Other possible causes of acute pancreatitis (alcohol, gallstone, drug-induced, hypercalcemia, hypertriglyceridemia) were ruled out by history and appropriate laboratory investigations. Six of 11 patients had mild symptoms and minimal abnormal laboratory parameters related to respiratory system and pancreas, also recovered within one week. Three patients had severe respiratory involvement requiring mechanical ventilation. One of these patients had acute pancreatic necrotic collection and sepsis required higher antibiotic support. The other two patients had moderately severe acute pancreatitis with mild respiratory involvement and recovered with conservative management. Mechanism supporting COVID-19 causing pancreatitis is ACE2 mediated direct injury of the pancreas as exocrine glands and islet cells of pancreas express ACE2. Other possible mechanisms are systemic inflammatory response, circulatory proinflammatory cytokines, virus induced lipotoxicity, and microvascular injury.

Conclusion Pancreas is one of the extrapulmonary organs to involve in COVID-19 infection. It is important to consider COVID-19 infection in patients with acute pancreatitis when there is no other cause found.

Keywords COVID-19, Acute pancreatitis, COVID Designated Hospital

Introduction Squamous cell carcinoma (SCC) of the pancreas is a rare condition representing 0.5% to 5% of all pancreatic exocrine neoplasms. Its clinical presentation is similar to that of pancreatic adenocarcinoma with the majority of patients presenting with abdominal pain (78%), weight loss (57%) and jaundice (28%). To our knowledge, this is the first reported case of a pancreatic SCC presenting as acute pancreatitis (AP). Case Outline A 45-year-old lady with a history of Type 2 diabetes mellitus detected 3 months prior, presented with mild AP. Initial etiological workup for AP was inconclusive. She presented with persistent pain abdomen a month later, when a contrast enhanced computed tomography (CECT) abdomen done showed a mass lesion in the pancreaticoduodenal groove. CA19-9 level was within normal limits. Endoscopic ultrasound (EUS) confirmed a 4 x 4 cm hypoechoiec lesion in the uncinate process. EUS guided fine needle aspiration (FNA) of the pancreatic mass was performed. Histopathological examination of the pancreatic specimen revealed SCC. An extensive metastatic workup did not reveal an extrapancreatic origin for this SCC. Hence, a diagnosis of primary SCC of the pancreas was established. Discussion This is a newly reported mode of presentation of a rare pancreatic exocrine neoplasm.

Keywords Pancreas, Squamous cell carcinoma, Acute pancreatitis Introduction Early onset idiopathic chronic pancreatitis (EOICP) is a disease which affects young individuals in the prime of their lives. The present study was done with an aim to assess the pregnancy outcomes in patients with EOICP and the effect of pregnancy on the course of EOICP.

Methods Patients with EOICP who had disease onset prior to their pregnancy were recruited. All patients were interviewed using structured questionnaire. Baseline data as regards demographic variables, duration of disease, pregnancy outcomes, mode of delivery and course of illness was noted.

Results Twenty-seven patients had been diagnosed with EOICP, before pregnancy. Mean age of onset of symptoms was 19.18 (SD 6.16) years and the mean age of diagnosis was 24.47 (SD 6.19) years. Mean age at the time of childbirth was 24.2 (SD 4.73) years.

Twenty-two (81%) patients had pancreatic calcifications, 21 (78%) had pancreatic exocrine insufficiency and one patient (4%) had diabetes mellitus. There were total 40 pregnancies. Early foetal loss was recorded in 6 (15%). Thirty-one pregnancies were carried to term and 3 were preterm deliveries. Caesarean section was performed in 19 (56%). Mean foetal birth weight was 2.84 kgs. One baby required NICU admission and there was one neonatal death. Pancreatic pain during pregnancy was reported in 12 (30%) pregnancies. No patients had any complication related to chronic pancreatitis.

Conclusions The rates of early fetal loss in patients with EOICP is similar to that of healthy individuals (15-20%). The present study shows that mothers affected with EOICP have pregnancy outcomes similar to healthy women. The incidence of LSCS appeared to be higher in the present study and this needs to be explored further in subsequent longterm studies. Introduction Paraduodenal pancreatitis, also called as groove pancreatitis, is a rare entity seen in patients with recurrent pancreatitis or chronic pancreatitis. It presents with repeated vomiting, abdominal distension and pain. Gastric outlet obstruction at presentation is rare.

Methods A 50-year-old male patient presented with recurrent episodes of post-prandial non-bilious vomiting and abdominal distension since six months. The recurrent symptoms of gastric outlet obstruction led to significant weight loss of over 10-12 kilograms and malnutrition. He had history of significant alcohol consumption for 10-15 years. For the above complaints, he was admitted thrice in a span of six months. Aspiration of gastric content via nasogastric tube provided symptomatic relief. CT abdomen revealed severe mural thickening D2 causing complete luminal compromise and inhomogenous attenuation and post contrast enhancement in the groove between D2 and pancreatic head with focal hypoenhancing cystic areas. Upper gastrointestinal endoscopy revealed obstruction at junction of first and second part of duodenum (D2), and scope was not negotiable across the stricture. Endoscopic ultrasound (EUS) showed features of chronic pancreatitis and duodenal wall edema with cystic spaces and paraduodenal fat stranding s/o groove pancreatitis. EUS guided aspiration cytology was negative for malignancy.

Results After conservative measures failed and patient refused EUS guided gastrojejunal bypass stenting, patient underwent laparoscopic gastrojejunostomy. Post procedure patient was relieved of symptoms of gastric outlet obstruction. His oral intake improved, and patient started gaining weight. Conclusion Paraduodenal pancreatitis is a relatively rare and difficult condition to diagnose. Less radical surgeries like gastrojejunal bypass without pancreaticoduodenectomy can offer good symptomatic relief if malignancy is ruled out. Keywords Groove pancreatitis, Gastrojejunal bypass, Duodenal obstruction Introduction Endoscopic ultrasound (EUS) is a well-established modality for diagnosing pancreatic masses. Autoimmune pancreatitis (AIP) often masquerades as a pancreatic cancer as clinical features and imaging findings are similar in between two. Accurate differentiation amongst them may help definitive cure, prevent surgery and morbidity as well as mortality. Here we describe a challenging case series of patients presenting with obstructive jaundice and pancreatic mass diagnosed as AIP with the help of EUS.

Methods We describe case series of 3 patients presenting with pancreatic mass and obstructive jaundice for evaluation. All the patients had serum IgG4 levels tested and underwent baseline EUS with fine needle biopsy (FNB). HISORt criteria was used to diagnose the cases as AIP.

Results In clinical features jaundice and weight loss were seen in all, however pain was absent in one case. There was no lump palpable. All had elevated serum IgG4 levels. Every case underwent endoscopic retrograde cholangiopancreatography for significant jaundice. All of them were treated with tapering dose of steroids with good response. Common EUS features of autoimmune pancreatitis includes increase gland volume, echopoor mass formation, echogenic interlobular septa, narrowing with thickening of main pancreatic duct (Fig. 1) , whereas hyperechoic areas and focal enlargement is seen in pancreas cancer. Follow-up EUS was done in one which showed significant reduction in bulkiness of the pancreas, disappearance of mass formation in the head region with persistent hypoechoic coarse echotexture and hyperechoic septa (Fig. 2) .

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains one of the most serious complications after ERCP with the reported incidence ranging from 1.3% to 15.1% in most prospective series. Multiple factors can lead to the development of unpredictable PEP. Awareness of the risk factors for PEP is essential for the recognition of high-risk cases in which ERCP should be avoided if possible, or in which protective endoscopic or pharmacologic interventions should be considered. This study aimed to to study the prevalence of post-ERCP pancreatitis in our centre and to identify risk factors for it. Methods Fifty-six patients who underwent ERCP at our centre between January 2020 to August 2021 were included in this cross-sectional study. A total of 25 risk factors for PEP, either patient, procedure or operator related risk factors, were identified, and evaluated on the basis of earlier multivariate analyses from prospective studies. Prevalence of PEP was analyzed and risk factors were assessed by univariate and multivariate analysis using SPSS software. Introduction Hypercalcemia is one of the less common cause of pancreatitis. Multiple myeloma, a plasma cell malignancy can cause pancreatitis by causing hypercalcemia.

We report a case of an elderly female with multiple myeloma with pancreatitis as an index presentation.

Case We present the case of a 62-year-old female who presented to the hospital with a eight-day history of nausea, vomiting, and epigastric pain.

In the emergency department, patient was found to have Hb -4.3 gm/dL, calcium 10.4 mg/dL, albumin 2.4 gm/dL, total protein 9.2 gm/dL, creatinine 7.2 mg/dL (no baseline creatinine was available), lipase 5000 U/L, and normal liver enzymes. 24-hour urinary protein was 1200 mg/day and USG KUB was s/o bilateral increased renal echogenicity and partial loss of CMD. In light of these investigations, possibility of multiple myeloma was kept. Subsequent testing of SPEP was abnormal with a monoclonal IgA kappa spike identified. Beta 2 microglobulin was 3107 ng/mL. X-ray skull displayed lytic lesions consistent with multiple myeloma. Bone marrow biopsy confirmed the diagnosis with 46% plasma cells. Patient was managed with 2 sessions of hemodialysis and other conservative treatment. Contrast-enhanced computed tomography (CECT) whole abdomen showed foreign body with metal tecklers in transverse colon. A colonoscopy was done which showed metal mesh with tecklers and prolene sutures, which had eroded into lumen. The standard treatment of such mesh migration is surgical. But we attempted to remove the mesh endoscopically by cutting the prolene sutures with argon plasma coagulation. The mesh was folded into a roll with the help of foreign body forceps using a double channel through endoscope. The mesh was removed through anal opening successfully. Post procedure period was uneventful and patient was discharged on next day. Conclusion Endoscopic treatment for mesh migration into bowel is possible. It is a minimally invasive procedure which reduces morbidity, mortality and hospital stay for the patients as compared to surgery. Colonoscopy is a relatively safe procedure with a few, rare complications like perforation and bleeding. Complications occur more with therapeutic than diagnostic colonoscopies. It is mandatory for endoscopist to be acquainted with atypical presentations of such complications as early identification reduces morbidity and mortality. Colonic perforation is a dreaded complication of colonoscopy. Perforations can be extraperitoneal, intraperitoneal or combined. Perforation may be consequence of mechanical trauma, barotrauma, or electrocautery injury and they can be extraperitoneal, intraperitoneal or combined. The greater part of perforations are intraperitoneal. Worldwide, till date, only 11 cases of isolated extraperitoneal perforation and 22 cases of concomitant perforation have been described. Out of these reported cases only in 3 cases cecum was described as the site of perforation. We intend to report a case of extraperitoneal colonic perforation in a young lady with ileocecal tuberculosis who had presented with colicky abdominal pain in right iliac fossa for 6 months associated with evening rise of temperature, fatigue, and significant weight loss. The patient was not on any regular medication, had no comorbidities and never underwent endoscopic procedures or surgery previously. She comes from a low socioeconomic status with family history of pulmonary tuberculosis. Colonoscopy revealed loss of vascularity, erythema, edema with deep ulcers noted extending from sigmoid to ileum, deformed Bauhin's valve, ulcerated valve lip and pulled up cecum. Patient had mild epigastric pain at the time of cecal intubation, otherwise colonoscopy was uneventful. Due to minimal discomfort patient had, immediately after the procedure, abdominal X-ray was planned. Meanwhile patient developed shortness of breath and subcutaneous emphysema of the neck which was gradually progressive in nature. She underwent emergency right hemicolectomy and didn't have intra operative findings of peritonitis. Patient was started on antituberculosis treatment post-surgery and is doing well. Keywords Retroperitoneal cecal perforation, Ileocecal tuberculosis, Iatrogenic, Colonoscopy

Correlation of clinical and endoscopic profile of patients with upper gastrointestinal bleeding in a tertiary care hospital

Background Bleeding from the upper gastrointestinal tract (GIT) is about 4 times more common than bleeding from the lower GIT and is associated with significant morbidity and mortality. Early, judicious use of endoscopy can be of benefit from the standpoint of diagnosis, therapy, and prognosis. The presentation of bleeding depends on the amount and location of hemorrhage. The aim of study was to study clinical profile, etiology and correlation between clinical and endoscopic diagnosis of patient with upper gastrointestinal bleed (UGIB). Methods Eighty-six patients above the age of 18 years, irrespective of gender presented to our hospital with UGIB during the study period and were subjected to endoscopy to identify the etiology. The clinical and endoscopic profile was also analyzed.

Results Majority of the patients were between 21-40 years of age that is 47.6%. Most of them were males (82.5%) and male to female ratio was 4.7:1. The most common cause of UGIB was esophageal varices seen in 40.7% of patients, duodenal ulcer was seen in 20.9% patients, Superficial mucosal erosions in 16.2%, gastric ulcer in 9.3% patients, esophageal and gastric malignancy 6.9% and Mallory-Weiss tear was seen in 1%. The overall mortality rate was 13.9% and mortality because of UGIB was 5.8%. Conclusion In our study variceal bleed was the most common cause of UGIB, followed by duodenal ulcer bleed. caused by SARS-CoV-2 forced temporary postponement of elective endoscopic procedures but emergency procedures had to be done with the lowest possible risk of exposing patients, staff, and providers. It is widely accepted that COVID-19 is mainly spread via droplets and contact, but airborne spread is possible during aerosol-generating procedures (AGPs). Review of Literature Endoscopy is a high-risk procedure as pulmonary and gastric secretions, as well as fecal material, may contain large viral loads. Infection prevention and control measures must be implemented to enhance patient safety, avoid nosocomial outbreaks, protect HCP, and ensure rational use of limited personal protective equipment (PPE). Multiple endoscopy societies and expert groups have offered recommendations and position statements for endoscopy during the COVID-19 pandemic. Patients should be screened with a pre-procedure COVID-19 questionnaire upon arrival to the endoscopy facility. Staff should be similarly screened prior to starting each workday. Physical distancing rules need to be adhered to by patients and staff, except during intervals of close contact required by providers to prepare the patient for a procedure.

As an Endoscopist, the first mandatory thing was to clearly differentiate between the elective and emergency endoscopic procedures which wereupper or lower gastrointestinal bleed, foreign body ingestion, suspected malignancy and dysphagia. The patients requiring emergency endoscopy procedures were divided into three categories-confirmed COVID-19 cases, suspected COVID-19 cases and non Covid cases. Result In Covid suspect or non-Covid patients, emergency endoscopic procedures were not denied on basis of pending Covid testing report and procedures were done using PPE kits in case of suspected Covid patient and in gown, hairnet, face shield, goggles, N-95 face mask, double gloves and gum shoes. In total 400 procedures were done following above guidelines in which 316 (79%) were endoscopy and 84 (21%) were colonoscopy. Keywords Endoscopy, COVID-19 pandemic, PPE kits variceal bleeding. Although endoscopic cyanoacrylate glue injection is a common treatment for acute hemostasis, it has been linked to significant side effects. In the treatment of AGVB, there is limited evidence of the efficacy and relative safety of endoscopic human thrombin injection over glue injection. Methods A total of 52 AGVB patients were randomised to receive either thrombin injection (25 patients) or glue injection (27 patients). The primary outcome was the incidence of any glue or thrombin injection-related post-therapy complications. Initial hemostasis, rebleeding, and mortality were all secondary end goals. The study was approved by the ethical committee of SMS Medical College, Jaipur and registered with CTRI at No. CTRI/2020/07/026466. Results Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 100.0 % (10/10) in the thrombin group and 87.5 % (7/8) in the glue group (p=0.44). Treatment failure after 5 days occurred in two patients (6.1%) in the glue group compared to none in the thrombin group (p=0.165). Between 6 and 42 days after index bleeding, rebleeding occurred in 4 patients in the thrombin group compared to 12 patients in the glue group (p< 0.03).

In the thrombin group, none of the patients had post treatment ulcers on gastric varices compared to 14.81% (4/27) Introduction Refractory esophageal strictures are defined as an anatomic restriction because of cicatricial luminal compromise that results in dysphagia. They may occur as the result of either an inability to successfully achieve a diameter of 14 mm over 5 SG dilatation sessions at 2-week intervals (refractory) or as a result of an inability to maintain a satisfactory luminal diameter for 4 weeks once the target diameter of 14 mm has been achieved (recurrent). Treatment is difficult but dilatation combined with intralesional triamcinolone injection has been shown to reduce need of recurrent dilatations. Methods Ten patients with refractory esophageal stricture were selected for the study. All patients received triamcinolone (40 mg) injected via 23G-EST needle in a four quadrantic manner-0.5 mL each into the proximal end of the stricture and also into the stricture itself after dilatation. Patients were followed up for a period of 1 year. The intervals between dilations and frequency of dilations were calculated before and after injections. A periodic dilation index (defined as number of dilations required per month) before and after the triamcinolone injections was calculated. Results Out of the 10 patients included in the study, 3 had a post corrosive stricture, 3 were post radiation, 2 anastomotic site stricture and 2 peptic stricture. The mean number of sessions of intralesional triamcinolone was 3 with corrosive strictures requiring more sittings (average 4) and peptic strictures requiring the least (average 2). The periodic dilation index showed a decrease in all 10 patients with a mean of 1.7 prior to procedure to 0.6 after injection. The interval period between dilatations also increased. There were no major complications like bleeding or perforation in our study.

Conclusions Intralesional triamcinolone injection combined with Savary-Gilliard dilatation is a safe and effective method for management of benign refractory esophageal strictures. Background/Aims A common indication for performing an endoscopic retrograde cholangiopancreatography (ERCP) is the removal of biliary stones. Although the majority of cases are amendable to clearance of the biliary system during a single session, there remains a portion where repeated procedures are required, due to factors pertaining to the anatomy of the biliary system or the stones themselves. This study aimed to identify factors predictive of failure of ERCP in clearing common bile duct (CBD) stones during index procedure.

Methods This is a prospective study from December 2020 to September 2021. A total of 120 patients with bile duct stones confirmed on imaging were included in this study. Patients who had prior attempts at bile duct clearance were excluded. Results In our study, the factors that are associated with lower success of clearing CBD stones include-older age (>50 years, p=0.03), the presence of cholangitis (p=0.05), large stone size (>10 mm, p=0.001), larger number of filling defects (>3, p=0.002) and presence of a stricture distal to a stone (p=0.02). The use of an extraction balloon was associated with higher success of clearing the biliary system when compared to using extraction baskets (p<0.01). Other factors, including sex of the patient, shape of the stone, presence of periampullary diverticulum, CBD diameter and use of EPLBD did not significantly affect the chances of complete bile duct clearance.

Conclusion Identifying factors that might predict cases where biliary system clearance would be challenging will give the health-care provider an opportunity to allocate better resources during index procedure; provide prior information to patients about possible need for further intervention like lithotripsy or surgical exploration.

Keywords CBD stone, ERCP, Index procedure Methods The present is a double blinded randomised control study which was carried out in the Department of Gastroenterology and a total of 75 patients were taken which were divided into 2 groups as control (n=35) and study group (n=40). Two mL of normal saline and octreotide were given according to respective groups subcutaneously 1 hour before procedure followed by 6 hour and 12 hours after ERCP and serum amylase and lipase were measured along with clinical features. The following protocol was followed based on previous studies. Results: The overall mean age of the study population including study and control group was 52 years. Most common indications for ERCP was choledocholithiasis (50%) followed by malignant cause (30%), benign biliary stricture (10-15%). Clinical and ERCP related risk factors according to ESGE Guidelines were present in nearly 50% to 60%. Hyperamylasemia was present in study group in 19 patients (47.5%) and amongst control group in 16 patients (45.7%). Incidence of post ERCP pancreatitis was present in only 5% in study group and 11.4% in control group though statistically it was not significant (p=0.47) Conclusion Though, there is decrease in the incidence of post ERCP pancreatitis in the group receiving octreotide, the same was not statistically significant as compared with the control (5% vs. 11.4%). Background and Study Aim: Endoscopes have revolutionized health care by providing minimally invasive techniques for diagnosis and treatment of diseases. However, these endoscopes could be heavily contaminated with body fluids and tissues during the procedure. There is risk of transmission of infections through the endoscopes, if the disinfection process is inadequate. Current disinfection method being commonly used is high level disinfection with 2 % glutaraldehyde.

Methods We conducted a prospective, observational, single center study in a tertiary care center over a period of 18 months, to know the effectiveness of cleaning and disinfection process on the bioburden on gastrointestinal endoscopes. Random samples from GI endoscopes were cultured, one sample immediate post disinfection and the other sample after storage period. A total of 101 random samples from GI endoscopes were analyzed for microbiological growth using chrome agar medium. The pathogenic microorganisms were identified by Gram's stain and standard culture. Antibiotic susceptibility of the organism was documented.

Results Our study showed that the contamination rate of GI endoscopes is 9.9%. Mean bacteriological burden is 99 CFU/mL. Pseudomonas aeruginosa is the predominant organism identified followed by Klebsiella pneumoniae. The contamination rate of colonoscopes (16.5%), side viewing duodenoscopes (20%) and endoscopic ultrasound scopes (20%) is higher than the gastro duodenoscopes (5.5%). Immediate post disinfection contamination rate is 6.9% and after storage period is 12.8%. Conclusion Our study showed that the current disinfection method being used for cleaning of endoscopes has its limitations. Side viewing duodenoscopes and endoscopic ultrasound scopes have higher contamination rate than gastroduodenoscopes and colonoscopes. We assume that the elevator mechanism is responsible for higher contamination rate. We recommend repeat disinfection of endoscopes just before use to decrease the higher contamination rate associated with post storage period. Keywords Endoscope, Disinfection, Contamination rate

Use of a gastroscope for distal duodenal stent placement in patients with malignant obstruction

Introduction Duodenal stent placement can be 37atient372d effectively and safely by using a Gastroscope in patients with an obstruction at the level of the distal duodenum. Patients with gastrointestinal malignancies may develop an obstruction at the level of the duodenum. Stent placement is a commonly used palliative treatment because this modality is less invasive. However, stent placement in the distal part of the duodenum (second half of the horizontal part and ascending part of the duodenum) with a therapeutic gastroscope can be difficult. The main factors limiting the use of a gastroscope for distal duodenal stenting are the relatively short endoscope length, and shaft flexibility, which may cause looping of the scope into the stomach.

Method Seventy-five-year-old male, presented to us with c/o recurrent vomiting, patient was evaluated on imaging USG abdomen s/o-large lobulated soft tissue mass lesion in tail region of pancreas abutting DJ flexure/proximal jejunum, finding confirmed by gastrograffin swallow, CECT scan done s/o large pancreatic tail malignancy, infiltrating DJ flexure/proximal jejunum. USG guided FNAC s/o well differentiated adenocarcinoma. SEMS placement done and hemoclip applied to prevent stent migration, as compared to earlier cases, the approach and negotiation was much easier. The length of the stricture was determined using contrast fluoroscopy of the duodenum during the procedure. A guide wire was then introduced through the stricture and the stent was advanced over the wire. Stent length was chosen to aim at a length of 1-2 cm more than the stricture. Endoscopy and fluoroscopy were used to follow stent deployment. Immediately after the procedure, an upright abdominal X-ray was performed to assess that no perforation had occurred during the procedure.

Results Success of deployment of SEMS, easy deployment and minimal negotiation requirement. Keywords Gastric outlet obstruction (GOO) Treatment Linear echo-endoscopy was done, large fundal varices (GOV 2) 3 x 3 cm was confirmed. Coil embolization (3 coil 10 mm diameter 6*5*3 mm) and gel foam (1:1 with contrast) injected using 19 G needle. 48 hours later, re-look EUS showed complete obliteration of the varix. Discussion Traditionally, endotherapy for GV is based on injecting coils followed by cyanoacrylate. These may be associated with a long certain learning curve, systemic embolization, failed withdrawal of needle from variceal nest and deep ulceration resulting in re-bleeding. Absorbable gelatin sponge is uncommonly used in endotherapy. Unlike cyanoacrylate, it is not associated with post-injection ulcerations and damage to scopes. It is an under-utilized endoscopic intervention for the treatment of gastric varices. Keywords Gastric varices (GV)

Endoscopic ultrasound guided gallbladder drainage in high surgical risk patients -A case series

Introduction The gold standard for acute cholecystitis is cholecystectomy. Ultrasound guided gallbladder drainage (EUS-GBD) EUS-GBD is a promising alternative to cholecystectomy in surgically high-risk patients with cholecystitis or biliary obstruction. However, EUS-GBD has not been reported in surgically high-risk patients with biliary colic or choledocholithiasis in whom cholecystectomy is indicated. Here, we present a case series of four patients with high-surgical risk who underwent EUS-GBD for symptomatic gallstones.

Methods Four patients (2 males and 2 females) underwent this procedure. Average age was 84.5 (67-85) years. Comorbidities included: two patients with ischemic heart disease, one patient with hypertension, atrial fibrillation, and compensated cirrhosis, and one patient with hypertension. The indication for GBD was biliary colic in two patients and choledocholithiasis in two patients. In both patients with choledocholithiasis, EUS-GBD done after the ERCP and common bile duct clearance. All patients were considered high risk for surgery (ASA grade 3 or more).

Results Two underwent GBD with cautery enhanced lumen apposing metal stent (LAMS) and in two, a cold LAMS was placed following fistula creation and balloon dilation. The stent location was transgastric in three and transduodenal in one. All four patents tolerated the procedure well with 100% technical success rate. There were no intraprocedural or postprocedural adverse events in any patient. One patient is followed for 7 months, one for 3 months, and another two patients were followed for 2 and 1 month respectively. All patients are pain free with no complications. In three patients LAMS was removed within 4-6 weeks of procedure and was replaced with double pigtailed plastic stent for cholecystogastric fistula. One patient is awaiting follow-up.

Conclusion EUS-GBD is safe and successful in management of surgically high-risk patients with symptomatic gallstones (biliary colic and choledocholithiasis).

Keywords Gallstones, Gallbladder drainage, Endoscopic ultrasound

Efficacy and safety of Shankha Prakshalana, a yogic technique versus polyethylene glycol solution for bowel preparation in colonoscopy: A randomized controlled trial

Introduction Bowel preparation is an important part of colonoscopy. The traditional yogic technique of "Shankha Prakshalana" (SP) has been known to clean the bowel, but its efficacy for colonoscopy preparation has not been studied till date. We aimed to compare the efficacy and safety of SP with polyethylene glycol (PEG) in bowel cleaning for colonoscopy. Methods This was a single-blinded, randomized controlled trial including 94 adult patients requiring colonoscopy who were randomized into two groups: SP group (n=47) and PEG group (n=47). Patients were advised to drink 400 mL of lukewarm saline water followed by five asanas Conclusion The traditional yogic technique of "Shankha Prakshalana" is overall better than the standard PEG-electrolyte solution, as a method for colonoscopy preparation with better tolerability and less adverse effects.

Keywords Colonoscopy, Bowel preparation, Polyethylene glycol, Yoga

Introduction Ectopic varicose veins refer to varicose veins with portal hypertension different with the esophageal and gastric varices, which may exist alone or with varices in other parts. About 17% of ectopic varicose veins occur in the duodenum, and it can occur in any part of the duodenum. Duodenal variceal bleed accounts for about 5% of portal hypertension hemorrhage and can lead to a mortality rate of up to 35% to 40%. There are no standard guidelines for treatment of ectopic duodenal variceal bleed. We report a case of ectopic duodenal variceal bleed treated successfully with acrylate glue in emergency setting. CASE Presentation A 42-year-old man with a past medical history of noncirrhotic portal hypertension presented to the emergency department; with complaint of massive hematemesis and malena. Patient was initially found to be hemodynamic unstable. He was intubated in view of poor GCS and Inj. Somatostain, pantoprazole drips, Intraveous fluid and blood transfusion started as part of initial treatment. Emergent esophagoduodenoscopy (EGD) is done, showed a large varix in the second part of the duodenum. It showed evidence of recent bleeding with a red wale sign. At the time, the varix was not amenable to banding due to variceal size. A 4 mL cyanoacrylate injection was used for hemostasis. A total of 6 units packed red blood cells were transfused during his course in hospital. He was discharged uneventfully with close follow-up and advised for TIPS. Conclusion The therapies have been reported to be efficacious for duodenal variceal bleed, including endoscopic variceal ligation, endoscopic injection sclerotherapy and TIPS along with conservative management. In our case report 377atient with massive bleed treated successfully with inj. Cynoacrylate glue as emergency endoscopy treatment for primary hemostasis.

Keywords Ectopic duodenal varices, Massive bleed, Acrylate glue

Endoscopic ultrasound sonograghy guided pancreatogastrostomy in non-dilated pancreatic duct for pancreatic ascites Introduction Endoscopic retrograde pancreatography (ERP) is considered first-line therapy for management of symptomatic pancreatic duct obstruction or leaks. Technical failure with ERP occurs when the main pancreatic duct cannot be cannulated. Endoscopic ultrasound sonograghy (EUS)-guided drainage of the pancreatic duct is a minimally invasive alternative to surgery for failed conventional ERP. Here, we report a case of acute on chronic pancreatitis with pancreatic duct (PD) stricture in the head and leak from tail, which was successfully treated with EUS guided pancreaticogastrostomy.

Methods Here, we report a case of acute on chronic pancreatitis with PD stricture in the head and leak from tail, which was successfully treated with EUS guided pancreaticogastrostomy.

Conclusion In conclusion, PD stricture can be treated endoscopically using EUS guided PD drainage, and it seems to be safe and effective. However, this procedure should be performed in expert centres with interventional radiology and surgery back up.

Keywords EUS pancreatic duct (PD) stenting, Pancreatogastrostomy, Pancreatic ascites, Non-dilated PD

Novel technique of Spy-Basket guided bile duct stone extraction: First case series from India Background Peroral cholangioscopy is being increasingly used for assessment of common bile duct during endoscopic retrograde cholangiopancreatography (ERCP). Extraction of bile duct stone using SpyBasket is a novel technique and there are very few cases reported in literature.

Methods In this series we report 10 patients in whom bile duct stone extraction was done using cholangioscopy guided SpyBasket. All the patients had undergone imaging prior to the procedure to assess the bile duct diameter, location, and size of stone. Results This series includes 10 patients (80% female, 20% male) with mean age of 45.7 years (18 -63) and the mean size of the stone was 6.05 mm. Majority of the patients (8/10) had stone in the common bile duct. One patient each had stone in cystic duct and right anterior sectoral duct. In 6 patients' radiation free extraction of stone was done using cholangioscopy guided Spy-Basket and in remaining 4 patients SpyBasket was used after initial failed attempt to extract stone using extraction balloon. Conclusion All the patients had successful extraction of stone using SpyBasket with no procedure related adverse events. This is the first case series from India reporting the novel technique of SpyBasket guided bile duct stone extraction. formed from plant fibres (2). Patients who have undergone bariatric surgery are prone to bezoar formation due to reduced gastric motility, loss of pyloric function and hypoacidity (3). Bezoars can also form around a suture material which migrates intraluminally. It may be seen from months to years post operatively. Most common presentation is with post prandial pain abdomen. Other manifestations include obstruction, perforation, ulceration and gastritis (3). Endoscopic examination plays a key role in the diagnosis and management of this complication (4) . Other management options include chemical dissolution or surgical exploration (5).

Methods A 50-year-old patient who underwent RYGB 2 years back elsewhere for morbid obesity presented with pain abdomen for 20 days, aggravated on taking food. UGI endoscopy showed a phytobezoar formed around a suture material in the efferent limb causing partial lumen obstruction (Fig. 1) . The phytobezoar was made into pieces with help of rat tooth forceps and the entire bezoar was cleared with Roth net basket (Fig. 2) .

Results Contrast-enhanced computed tomography (CECT) abdomen was done the next day which showed normal calibre of both afferent and efferent limbs. No intra luminal filling defects (Fig. 3) . Patient was prescribed a syrup containing papain and fungal diastase. Advised to take low fibre diet. On follow-up he had no further episodes of pain abdomen.

Conclusion Intraluminal suture bezoar is rare complication following RYGB. High index of suspicion is needed to diagnose it. Therapeutic options include chemical dissolution, endoscopic removal and surgical exploration.

Keywords Obesity, Bezoar, Roux-en-Y gastric bypass (RYGB)

Introduction While overlapping clinical presentation between non-celiac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS) making the diagnosis difficult. Gut-microbiota has been suspected to have a role in their pathophysiology. We characterized and studied whole gut, small and large intestinal microbiota of IBS and NCGS patients at baseline and post 6-weeks of gluten-free diet (GFD) to find their role in disease development.

Methods Patients with IBS (n=493) were screened and recruited based on Rome-IV criteria, where IgA-tTG, IgA-AGA and IgG-AGA negative were, categorized as IBS and who turned-out IgA-tTG negative while IgA-AGA and/or IgG-AGA positive were categorized as likely NCGS, were put on 6-weeks GFD. Microbiome analysis was carried out for both IBS (stool=130, duodenum l=12, colon=10) and NCGS patients with baseline and follow-up samples (stool=30, duodenum=30, colon=30). Sixteen NCGS patients responded post 6-weeks GFD by claiming >30% reduction in symptoms, 14 agreed for follow-up and gluten rechallenge to check symptoms recurrence. Next-generation sequencing was performed, and data was analyzed using relevant analysis pipeline and R statistics.

Results Lower microbial diversity was observed in case of NCGS compared to controls and IBS, whereas inter-individual diversity was higher in IBS compared to NCGS. Microbiota of IBS and NCGS were significantly different especially in the duodenum, indicating gut dysbiosis. Lower abundances of common naturally occurring bacterial genera such as Alloprevotella, Succinivibrio, Lachnospira, Butyrivibrio, Blautia and higher abundances of Bacillus, Escherichia/Shigella, Pseudomonas were observed in NCGS compared to IBS. Changes in the gut microbiota were evident in duodenal microbiome as compared to colonic and whole gut microbiome. Increase in co-occurrence networking was observed after GFD in NCGS patients compared to baseline. Conclusion Significant lower microbial diversity in duodenum of NCGS compared to IBS suggests it's possible role in pathogenesis of NCGS. GFD improves symptoms, bacterial load, and taxa abundances while total diversity does not change.

Keywords Gluten related disorders, non-celiac gluten sensitivity, irritable bowel syndrome, gut Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India, and 1 Department of Pediatric Gastroenterology, Sakra Hospital, Bangalore 560 037, India

Introduction Traditionally it is believed that balloon is superior to bougie, however, there is no head-to-head comparison in children with benign esophageal strictures. We aimed to compare the efficacy and safety of endoscopic bougie and balloon dilatation for single, short esophageal strictures in children.

Methods A prospectively kept database of 188 children who presented with single short esophageal strictures between June 1994 to March 2020 was analyzed retrospectively. Comparative analysis was done for 77 cases where an exclusive bougie (n=54) or balloon (n=23) dilatation was performed. Assessment of stricture length (short if <5cm), number, and site were done at baseline by contrast esophagogram. Dilatation was considered adequate if the esophageal lumen could be dilated to 15 mm (11mm for < 2 years,12 mm between 2-5years) with complete relief of symptoms for at least 2 months.

Results The etiology of strictures (130 boys, median age 2 [0.83-4.1] years) include anastomotic 92 (48.94%) followed by corrosive stricture 42 (22.34%), peptic 20 (10.6%), congenital 18 (9.6%), post endoscopic sclerotherapy 13 (6.9%), and others 3 (1.6%). Complete data set was available for 77 cases who underwent either exclusive balloon (n=23) or bougie (n=54). Balloon dilatation was significantly better than bougie for short strictures in requiring fewer sessions to achieve adequate dilatation (4 [2-6] vs. 6 [3-9], p<0.035). There was no significant difference in perforation rates for bougie 0.35% (3/856) and balloon 0.54% (3/560) dilatation (p=0.591). Over a median follow-up of 16 (8-34) months, children who were successfully dilated showed significant improvement in their weight and height z-scores for overall as well as in both bougie and balloon groups.

Conclusion Endoscopic balloon was more effective than bougie in achieving adequate dilatation for short esophageal strictures in children. Dilatation by either bougie or balloon is safe for short strictures and resulted in significant improvement in growth on follow-up. Keywords Esophagus, Stricture, Bougie, Balloon

Introduction Non-mechanical causes of dysphagia are difficult to diagnose and manage in children, which renders it imperative to identify and profile them for appropriate treatment.

Methods Retrospective data was retrieved from a prospectively maintained motility laboratory database from July 2016 to July 2021 to identify children between 0-18 years with motor dysphagia. Clinical history, contrast esophagogram, esophagoscopy and esophageal manometry findings were noted. Manometry was performed using 36 channel water perfusion system (Medical Measurement Systems v 9.6e).

Results Nineteen children (8 male, 42%), median 14 years (1-18 y) were included. Onset of dysphagia was in 1st decade in one-thirds (36.84%). Nearly half (47%) reported dysphagia to both solids and liquids, and one fifth had documented weight loss from symptom onset. Postural maneuvers or use of liquids for bolus propulsion was seen in 15.8%. On high resolution manometry, achalasia formed the most common diagnosis ( Esophagogastric junction (EGJ) outflow obstruction was seen in 2 (10.5%), ineffective esophageal motility in 2 (10.5%), ineffective solid motility in 1 (5.3%) and no obvious abnormality in 3 (15.8%) patients. Among achalasia patients, barium swallow showed distal narrowing with dilated esophagus in 8 (73%), sigmoid esophagus in 1 (9%), and contrast hold-up on delayed films in 2 (18%). Among non-achalasia, none had a sigmoid esophagus and hold-up of contrast was seen in one patient with EGJ outflow obstruction. Among achalasia, dilated esophagus on upper endoscopy was seen in 7 (64%) and food or liquid residue in esophagus in 5 (45%). Median (range) integrated relaxation pressure was 27.9(16.1, 59.7) mm, abnormal distal latency (<4.5 seconds) seen in 71% and ineffective contraction (DCI<450 mmHg.s.cm) in 57%. No technique related adverse events were observed.

Conclusion Achalasia cardia constitutes a major proportion of esophageal motility disorders in children with motor dysphagia. Manometry is safe and an effective diagnostic tool even in young children.

Keywords Motor dysphagia, Pediatric, Achalasia

Introduction Extrahepatic portal vein obstruction (EHPVO) is the most common cause of portal hypertension in children. We studied the profile of infants and young children with EHPVO in under-five age group and compared the burden of growth failure with older children and adolescents.

Methods Data of EHPVO patients from September 2000 to September 2021 with index presentation at <5 years were analysed from a prospectiely maintained liver clinic database. Anthropometric data were compared with those presenting between 5-18 years. (32.5%) had height <3rd centile (stunted), while both stunting and wasting was seen in 12 (30%). The LBW subgroup had significantly more wasting at presentation compared to normal birth weight cohort (p=0.003).) Among 5-18 year olds, weight < 3rd centile was seen in 15.6% (vs. 40% in < 5 y, p=0.023) and height <3rd centile in 6.25% (vs. 32.5% in <5y, p= 0.006).

Conclusion EHPVO in infants and children less than 5 years has more severely affected growth indices, possibly due to early deprivation of adequate portal blood flow. A significant impairment in catch-up growth may result in infants with low birth weight developing EHPVO. Introduction Gastrointestinal bleeding (GIB) in children is a common condition with low mortality but can lead to immense anxiety in parents. These children should be timely evaluated for the etiology to decrease morbidity.

Methods We retrospectively analyed the data of children (birth to 18 years of age) referred to Pediatric Gastroenterology and Hepatology Unit in Indira Gandhi Medical College with GIB from September 2019 to August 2021, with the aim of finding out the spectrum of GIB. Those who improved on medication or did not get endoscopic evaluation were excluded.

Results Among 128 cases included, causes of upper GIB were 53.1% (n=68) and lower GIB were 46.9% (n=60). In upper GIB, non-variceal (n=58, 85%) causes were-acid peptic disease (APD) (n=47, 69.1%) and miscellaneous (n=11, 16.1%). Variceal (n=10, 14.7%) causes were-extrahepatic portal vein obstruction (n=8, 11.7%) and chronic liver disease (n=2, 3%; [1=autoimmune hepatitis, 1=Caroli's disease]). Among miscellaneous causes, 4 cases were Munchausen syndrome, 2 were Malory-Weiss tear and one each were intussusception, arteriovenous malformation, idiopathic thrombocytopenic purpura, pulmonary tuberculosis (? swallowed sputum) and hepatic artery pseudoaneurysm. Sixteen cases (34 %) of APD had H pylori infection. Among causes of lower GIB, colorectal polyps (n=24; 40%), infective diarrhea (n=9; 15 %), internal haemorrhoids (n=8, 13.3%), solitary rectal ulcer (n=6, 10%), cow milk protein allergy (n=5, 8.3%), Inflammatory bowel disease (n=4, 6.6%) and one case each of intussusception, post anastomotic ulcers, rectal prolapse and HSP were seen. One patient underwent digital subtraction angiography and coiling for hepatic artery ps eudoaneurysm. A significant bleed was seen in 25 % of the cases, while the mortality was 2.3% (3 cases). Background Approximately fifteen percent of patients with gallbladder stones also have common bile duct (CBD) stones. endoscopic retrograde cholangiopancreatography (ERCP) when combined with laparoscopic cholecystectomy (LC) for concomitant CBD stone and other complications was historically not preferred due to various technical difficulties. We aimed this study to evaluate the role of CBD milking to minimize complications and to increase probability of selective biliary cannulation in ERCPs post-LC.

Method This study included all cases undergoing combined LC with ERCP as one-step procedure at GEM Hospital, Coimbatore in the period from December 2020 to August 2021. All complications and percentage of biliary or pancreatic duct (PD) cannulations were noted to compare them with conventional method of single-step procedure. Patients undergoing LC with ERCP as two-step procedure were excluded.

Result Out of total 68 cases, biliary cannulation failed in 8 patients whereas 1 failure was noted when milking of CBD was performed intra-operatively. Average anaesthesia time of 106.5 minutes in milking group was less than conventional 122.8 minutes with decreased hospital stay and lesser financial burden. Complications like retained calculi were higher in non-milking group (11 vs. 5). Postoperative pancreatitis and inadvertent PD cannulation was observed in 4 and 9 cases respectively but in 1 case each if milking was done.

Conclusion Milking of CBD although difficult in some cases of LC, has definite benefit in success rate of ERCP with reduced operative time and complication rates probably due to increased intraductal pressure effects on sphincter of Oddi. Follow-up is required to make it standardized technique in conventional one-step combined LC with ERCP. A 49-year-old male presented with complaints of weight loss 8-10 kgs since 1 year, decreased appetite, chronic diarrhea and breathlessness on exertion. Patient was taking treatment from private practitioner in view of above symptoms and on investigation found to have severe iron deficiency anemia and was kept of oral iron supplements. Patient had progressive breathlessness on exertion, and had feculent vomitus hence brought to our hospital. On examination patient had Severe pallor, tachycardia, and signs of anemic failure. Patients HB was 3.6 gm and severe iron deficiency. Patient was transfused 3 units PRBC with Lasix. CECT abdomen suggestive of Large ill-defined heterogeneously enhancing centrally necrotic mass along the greater curvature of stomach and is contiguous with transverse colon. Hence patient was posted for EGD which was suggestive of large ulcerated mass along greater curvature of stomach with feculent material oozing through fistulous tract the lesion biopsy suggestive of mixed adenocarcinoma. Colonoscopy revealed circumferential mass with luminal narrowing in descending colon, Biopsy revealed low grade adenocarcinoma. PET CT revealed FDG uptake in curvature of stomach, transverse colon and splenic flexure. IHC revealed carcinoma of gastric origin hence patient started on neoadjuvant chemotherapy with CAPEOX regime each cycle every 21 days for 4 cycles, later on posted of surgery distal gastrectomy with extended right hemicolectomy. Gastric fistula is rare presentation of both benign and malignant diseases of gastrointestinal tract. Malignant gastrocolic fistula is most commonly associated with adenocarcinoma of the transverse colon in the western world. But in our case unusual was Mixed adenocarcinoma of gastric origin causing gastro-colic fistula, which is a rare complication of gastric carcinoma. Keywords Feculent vomiting, Adenocarcinoma, Gastro-colic fistula Introduction Non-alcoholic fatty liver disease (NAFLD) has emerged as a public health problem against the backdrop of diabetes, dyslipidemias and central obesity. Lifestyle characteristics may have a major impact on liver related morbidity and mortality.

Objective To identify the lifestyle characteristics associated with NAFLD.

Methods In a hospital-based case control study a total of 320 subjects (160 per group) constituted the study population based on inclusion and exclusion criteria. Sample size was been calculated using the formula for comparing two means (Mean 1 ± SD1, Mean 2 ± SD2), with statistical power of 80% and level of significance as 5%. Lifestyle characteristics were assessed in addition to socio demographic, anthropometric, clinical, and biochemical factors. Lifestyle characteristics included assessment of nutrient intake (using 24 recall and FFQ) and dietary pattern, physical activity pattern (using GPAQ Questionnaire), sleep patterns, intake of snacks, alcohol and smoking habits by face to face interviews. We present a case of a non-alcoholic individual, who after prolonged fasting developed Wernicke's encephalopathy, which improved with prompt administration of thiamine. A 24-year-old unmarried female from the Jain community had undertaken a difficult penance of water only fasting for 30 days. Within a week of refeeding, she had vomiting 6-8 times/day, immediately after consuming any liquid or food. She was treated with iv fluids, PPI and anti-emetics but with no improvement. Electrolytes showed low serum potassium (2.9 mEq/L) which was promptly corrected. Other metabolic parameters and a sonography abdomen were normal. An upper GI endoscopy showed gastric erythema with no evidence of any ulcer or obstruction. On detailed history taking, she had complained of diplopia, difficulty in walking and maintaining balance, which she attributed to weakness due to her prolonged fasting. On clinical examination, she was fully conscious and oriented. She had bilateral 6th nerve palsy (Right>left) and horizontal gaze nystagmus with positive cerebellar signs on clinical examination, causing difficulty in walking independently. A neurologist was invoked, who after a clinical evaluation suggested an MRI brain. It showed multiple bilateral thalamic, peri aqueductal midbrain and corpus callosal altered signal intensities (T1 hypo T2 hyper intense), suggesting Wernicke's/metabolic encephalopathy. After administration of iv thiamine in the dose of 600 mg/day, she showed remarkable improvement in diplopia, gait disturbance and ataxia. Background A lifelong gluten-free diet is the only available treatment for patients with celiac disease. Nutritional quality of gluten-free food products is very important as patients consume these products for life-long.

There is paucity of data on the nutritional content and cost of GF-food products compared with their gluten containing counterparts from India and Asia.

Study After a detailed market survey, the packaged and labeled gluten-free food products (n=485) and their packaged gluten containing counterparts (n=790) from the supermarkets of Delhi (India) and e-commerce websites were included. Nutritional content and cost per 100 gram food (in US dollars) were calculated using the nutritional contents and prices mentioned on food label. Results Gluten-free food products were 232% (Range: 118%-376%) more expensive than their gluten containing counterparts. Energy content of all gluten-free food products was similar to their gluten containing counterparts, except cereal-based snacks. Both the protein and dietary fiber content were significantly lower in gluten-free pasta and macaroni products (single-grain, multigrain), cereal flours (single-grain) and nutritional-bars than their gluten containing counterparts. Gluten-free bread and confectionary items, biscuits and cookies and snacks had higher total-fats and trans-fat content than their gluten containing counterparts. Gluten-free cereal-based snack foods had higher sodium content than their gluten containing counterparts. Seventy three percent of glutenfree food products were classified as ultra-processed foods.

Conclusion Gluten-free food products are significantly more expensive than their gluten containing counterparts, thus increasing the economic burden to the patients, and potentially acting as a barrier to adherence to gluten-free diet. Majority of packaged gluten-free food products are highly processed and contain less protein and dietary fiber and higher fat, trans-fat and sodium.

Keywords Gluten-free foods, Gluten-containing food, Nutritional quality, Cost, Celiac disease 480 Barriers in the adherence to gluten-free diet in adult patients with celiac disease

Introduction Lifelong and strict adherence to gluten-free diet (GFD) is the only definite treatment for patients with celiac disease (CeD) at this point of time. Following a GFD is a challenging task for patients and families with CeD. There are many barriers in maintaining a strict adherence to GFD. The adherence to GFD is influenced by multiple factors present at various ecological levels of human-development and decision-making, including intra-personal, inter-personal, organizational, community and system-based levels. We therefore determined the factors influencing the adherence to GFD at these levels in adult patients with CeD.

Methods A questionnaire was developed based on review of literature, group discussions and expert group meetings. The questionnaire was administered to patients with CeD attending Celiac Clinic and following GFD for >1 year.

Results Overall, 545 patients (females: 335.median age: 29 years, interquartile range: 22-46 years) were included. We observed many barriers including intra-personal such as lack of a separate gluten-free flour mill at home in 165 (30.2%) patients; inter-personal barrier such as inadvertent intake of gluten-containing food products while dining-out with family/ friends in 128 (23.5%) patients; organizational barrier such as nonavailability and high cost of packaged GF-food products in nearby markets in 215 (39.2%) and 140 (25.7%) patients respectively and nonmembership of celiac support group in 248 (45.5%) patients. The barrier at the community level was non-awareness of complexity of their dietary needs in 153 (28.1%) patients. Additionally, at the system level, there is lack of appropriate infrastructure and strategy for maintenance of GF lifestyle such as inappropriate counselling by dietician and the physician in almost one third of patients. associated weight gain rather than weight loss commonly associated with malabsorption due to SIBO. When compared to H-SIBO, M-SIBO contributed to 75% of total SIBO population. Baseline methane level was elevated in 10 patients out of 34 M-SIBO patients. Conclusion Incidence of methanogenic overgrowth is on rise in South Indian population. Baseline methane levels are high in 30% patients. Further studies are needed to validate a baseline methane level for Indian population. M-SIBO is equally as important as H-SIBO and should be given priority during breath test in Indian population and adequately treated.

Introduction Posterior pharyngeal lesions constitute as one of the rare causes of dysphagia and we report a case of lethal midline granuloma presenting as dysphagia.

Case Report A 41 year old male, from middle-east without any comorbidities or addictions presented with painless progressive dysphagia to solids more than liquids and hoarseness of voice since 8 years. On examination, he was severely malnourished with severe muscle wasting. Inspiratory stridor, scarred palate and perforated anterior nasal septum were noted. All routine hematological, biochemical, virological and autoimmune investigations were normal. Nasopharyngolaryngoscopy showed scarred nasopharynx, floppy epiglottis and ankylosed cricoarytenoids. In view of stridor, computed tomography of neck and thorax were done which was not contributory. Endoscopy showed posterior pharyngeal wall ulceration and cricopharyngeal stricture which required balloon dilation (Fig. 1A, C) . Rest of the esophagus, stomach and duodenum were normal. Biopsies were obtained from the posterior pharyngeal wall. He also had vocal cord palsy. A percutaneous endoscopic gastrostomy tube was placed to improve the nutrition status. He underwent tracheostomy to relieve frequent hypoxic episodes during his sleep. Histopathology showed nonspecific granulomatous tissue with sheets of lymphocytes. Immunohistochemistry (Fig.1D ) revealed atypical lymphocytes positive for CD 20 and LCA markers and a diagnosis of lethal midline granuloma was made in consultation liaison with rheumatologist. He was started on prednisolone 1 mg/kg for 2 weeks, tapered over 8 weeks and maintenance therapy was given with Mycophenolate mofetil and hydroxychloroquine. He came for follow-up after 2 years with 11 kg weight gain, removal of tracheostomy tube and significant relief of dysphagia on MMF maintenance. Conclusion Midline granuloma is an uncommon and rare etiology that needs to be considered in differential diagnosis for persistent dysphagia. Clinical Summary A 42-year-old male presented with right upper quadrant non-colicky dull aching pain and loose stools i.e. small volume 8-10 episodes /day associated with blood in stool, not a/w urgency, tenesmus for last 3 months. He also compla ins of paresthesia and tripping of both feets during walking. He was diagnosed with bronchial asthma 1-year back. On examination vitals were stable, no pallor, no cyanosis, no clubbing, no lymphadenopathy. P/A examination was unremarkable except slight tenderness in right upper quadrant. On nervous system examination there was decreased sensation on lateral side of both lower limb and sluggish ankle reflex. On investigation Hb-13.1 g/dL, TPC -3.18 lakh/mm3 , TLC -17000/ mm 3 , DC (N-25,L -15, E-60) , AEC-8100, ESR-60 mm , Stool-pus cell-2-4/HPF, RBC-12-14/HPF. Other tests like RFT, LFT, serum electrolyte, thyroid profile were normal. Colonoscopy showed features of pancolitis, HPE-eosinophilic colitis, CT abdomen showed long segment circumferential wall thickening with submucosal edema with luminal narrowing involving ascending colon. Nerve conduction study -mononeuritis multiplex pattern with b/l asymmetric sensory motor neuropathy involving b/l common peroneal and b/l tibial nerve, HRCT thorax-patchy ground glass opacity likely indicating pulmonary infiltrate in Churg-Strauss syndrome, bone marrow study showed cellular narrow showing myeloid proliferation in all stages of maturation with increased eosinophilic precursors. Left sural nerve biopsy showed features of vasculitic neuropathy. ANA profile -normal, C ANCA -80 (N < 5 mL Background Histopathological confirmation in abdominal tuberculosis is difficult due to suboptimal non-invasive access to the involved area. Colonoscopy provide semi-invasive access to the large intestine and ileocecal area. Information on the diagnostic yield of this investigation in abdominal tuberculosis is scarce.

Objective To evaluate the role of colonoscopy in the diagnosis of abdominal tuberculosis.

Methods Between October 2020 to October 2021, patients were diagnosed to have abdominal tuberculosis on the basis of colonoscopy. The case records of these patients were still retrospectively reviewed to assess the usefulness of colonoscopy in the diagnosis of abdominal tuberculosis. Results Data for 65 consecutive patients in whom a diagnosis of intestinal tuberculosis was made during the last 1 year in hospital were reviewed. Clinical findings and the frequency of endoscopic findings were evaluated. Thirty patients had clinical symptoms (anorexia, abdominal pain and weight loss), 10 patients had only abdominal pain 10 patients had altered bowel habits, 10 patients had anorexia and 5 patients had no symptoms. Mucosal lesions were classified into 4 types: type 1, circumferential ulceration with nodules; type 2, round or irregularly shaped small ulcers, arranged circumferentially, without nodules; type 3, multiple erosions restricted to the large intestine; and type 4, small ulcers or erosions restricted to the ileum. The frequency of type 1, 2, 3, and 4 endoscopic findings was, respectively, 26,21 ;12 and 6 patients. The classical histological features are seen in only 15 patients (caseating necrosis, conglomerate epithelioid histiocytes, and disproportionate submucosal inflammation whereas presence of granulomas was seen in 50 patients. Conclusion When colonoscopy is performed in patients, it is important to be aware of subtle endoscopic findings that are characteristic for intestinal tuberculosis. Recognition of such findings may lead to a correct diagnosis of early-stage intestinal tuberculosis.

Introduction Primary eosinophilic gastroenteritis (EGE) is an uncommon inflammatory disorder of the gastrointestinal tract. Clinical presentation depends on the segment and the layer of the gastrointestinal tract affected. We present a series of cases with EGE seen over the last four years in our hospital.

Method The case records of patients seen with EGE in our hospital were retrieved and the data analyzed.

Results Among 20 patients (females 10, median age 43.5 years) diagnosed with EGE, the presenting symptoms included abdominal pain (75%), diarrhoea (30%), weight loss (5%), vomiting (20%) and abdominal fullness (20%). The diagnosis was made by endoscopic biopsies in 19 patients and by surgical biopsy in one patient. The level of involvement included esophagus in one, stomach in five, small bowel in nine, large bowel in three, and ileocolonic in six patients. Blood tests showed peripheral eosinophilia in 13 cases. Biopsies showed eosinophil counts >50/high power field in nine patients with eosinophilic cryptitis and crypt abscesses in seven patients. IgE levels were elevated in four patients. There was no evidence of systemic involvement in most patients. Most common layer involved was mucosa while five patients had muscularis and three had serosal involvement. Most of the patients were treated successfully with tapering corticosteroids and montelukast. Background and Aims This study aims to assess endoscopic findings in diabetic and non-diabetic patients presented with complaints of dyspeptic symptoms.

Methods This was a observational cross sectional study conducted in Department of Digestive Health and Disease over a period of 1 year. A total of 108 patients above the age of 18 years of which 54 patients diagnosed with DM, 54 patients with no DM with dyspeptic symptoms were included and underwent endoscopic examination of upper gastrointestinal system. Endoscopic findings of two groups were documented. Results A total of 54 patients, 24 female and 30 male in the DM group, and 54 patients, 25 female and 49 male in the non-DM group, were included in the study. Findings in DM patients in decreasing order of frequency pangastritis 35, antral gastritis 18, esophagitis 17, gastric ulcer 5, duodenal ulcer 2, duodenitis 3, hiatus hernia 2, LES dysfunction 1. Findings in non DM patients in decreasing order of frequency pangastritis 30, antral gastritis 18, esophagitis 17, gastric ulcer 2, duodenal ulcer 2, duodenitis 1, hiatus hernia 2, LES dysfunction 5. Findings such as pangastritis, gastric ulcer, duodenitis were more common in diabetic patients compared to non-diabetics. This difference was statistically significant (p=0.027). Conclusion When Endoscopic findings in patients with dyspeptic complaints were analyzed, significant difference was found between the diabetic and non-diabetic groups in terms of endoscopic findings like gastric ulcer, pangastritis, duodenitis (more common in DM We report a case of a 22-year-old female with a rare coagulation disorder, who presented to us with spontaneous hemoperitoneum, which resolved with conservative management. A 22-year-old female, a known case of Factor XIII (Fibrin Stabilizing Factor) deficiency presented to us with abdominal pain since 5 days. Pain was mild to moderate, constant, non-colicky and not related to food. She had no history of trauma over abdomen. On evaluation, hemoglobin was 5.4 g%. Platelet count, PT, and aPTT were normal. A CT abdomen was suggestive of hemoperitoneum without any laceration of internal organs. In her early childhood, she had bled profusely from the umbilicus after trauma. A surgeon took sutures on the umbilicus, but the bleed worsened. On evaluation by hematologist then, a urea solubility test was positive, confirming factor XIII deficiency. Urea solution will dissolve a clot, if the clot contains fibrin monomers. But cross-linked fibrin will not dissolve in urea. This spontaneous hemoperitoneum was probably due to ovulation. The corpus luteum cyst generally stops bleeding in normal individuals but in Factor XIII deficiency the fibrin clot is formed, but cross linking is not possible without factor XIII. Failure of secondary hemostasis, leads to late bleeding, causing hemoperitoneum. Factor XIII has a long half-life (3-4 weeks). Fresh frozen plasma or cryoprecipitate concentrate is indicated as treatment. Corifact (FXIII Concentrate) is FDA approved in USA, but unfortunately is not available in India. We treated her with blood transfusion and 2 mL/kg of FFP. We repeated the same dose every monthly for 3 months. Background Azathioprine (AZA)-induced pancreatitis is an unpredictable and dose independent adverse event affecting 2% to 7% of patients with inflammatory bowel disease (IBD) patients treated with AZA. There are no test in clinical practice to identify individuals at risk of developing pancreatitis on exposure to Aza. An association of HLA -DQA1*02:01-DRB1*07:01 with azathioprine induced pancreatitis has been described in the western literature. In this pilot study, we analysed this HLA association with the risk of development of pancreatitis. We studied an association between azathioprine induced acute pancreatitis in patients with IBD and HLA -DQA1*02:01-DRB1*07:01. Methods In this retrospective study patients who were diagnosed with IBD and developed azathioprine induced pancreatitis were recruited. Between the period 2005 and 2021 total of 1412 patients were diagnosed to have IBD and of these 222 received azathioprine and 11 patients developed pancreatitis. Risk factors for pancreatitis such as smoking, alcohol intake, steroid administration, previous history pancreatitis and duration of azathioprine intake were analysed in these patients.

Results Out of 11 patients who developed azathioprine induced pancreatitis, 10 underwent HLA typing after written informed consent. Of these 10 patients 8 had HLA association with HLA-DQA1*02-DRB1*07 (positive prevalence of 80%). Only one patient had history of smoking, and none had alcohol intake. All of them were on steroid at the time of azathioprine induction. These patients developed pancreatitis within 2 to 28 days after taking azathioprine. None had a history of pancreatitis in the past. Rechallenge in one patient resulted recurrent episode of pancreatitis. Conclusions There was significant association between azathioprine induced pancreatitis and class II HLA -DQA1*02 -DRB1*07. Additional studies are needed to decide if pre-emptive HLA typing canminimize the risk of developing pancreatitis. Keywords Immunomodulator, Pancreatitis, HLA typing

Introduction Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) are high end therapeutic endoscopic procedures performed under sedation often in high-risk settings where patients are at high risk of desaturation during procedure. Literature suggests we use the option of elective endotracheal intubation prior to the procedures particularly for those with higher ASA score. The next best option is to maintain the natural airway using Nasopharyngeal tube with oxygen through nasal prongs oxygen. We hereby describe a modification of the nasopharyngeal airway tube for giving sedation during the procedures. Aims To analyze the safety and efficacy of a modified nasopharyngeal airway for airway management during ERCP and endosonography procedures.

Methods Retrospective data of 100 patients who underwent endosonography and ERCP during a period of 3 months at Yashoda Hospital of Hyderabad was reviewed. Patient-specific and procedure specific data was extracted. Desaturation was defined by fall of pulse oximeter saturation below 90% and its relation to patient specific high riskfactors was analyzed.

Results We had 100 patients who underwent the endoscopic procedures using the modified nasopharyngeal airway. Only 10 patients had transient de-saturation below 90% without any residual sequlae. There was no interruption to the endoscopic procedure and there was no significant relation between desaturation episodes and patients higher ASA status or modified Mallampati (MMP) class. The desired optimal oxygenation and airway patency was maintained during the procedures with high degree of success using modified nasopharyngeal airway with oxygen supplementation in all patients.

Conclusions The sedation for the high end endoscopic procedures using the modification of the Nasopharyngeal airway was safe and successful in providing secure airway without any interruption of procedures.

Keywords Airway in endoscopic retrograde cholangiopancreatography, Endosonography, Anesthesia, Modified nasopharyngeal airway Background Inflamed/malignant tissues are not only visually abnormal but also physiologically abnormal in the form leaky tight junctions. This is associated with decrease in mucosal impedance (MI).

Aim The aim was to study the role of MI assessment to differentiate apparently normal region from those in inflamed/ malignant region. Methods Consecutive patients undergoing surgery at our tertiary care center were recruited after informed consent. Immediately after surgery, resected specimens were laid into tray and analyzed for MI. MI catheter was designed after multiple iterations and was validated with a commercially available impedance measuring tool. Average of three MI readings of visually uninvolved region (apparently normal) and involved region (inflamed/ malignant) were taken. Statistical analysis was done after data entry into excel sheet. Conclusions FC is raised in 9% patients with COVID-19, particularly those with symptoms, especially the GI symptoms. The rapid test was found inferior to IET for detection of FC among them.

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Mahesh Goenka Correspondence -Shivaraj Afzalpurkar -drshivaraj62@gmail.com Department of Gastroenterology, Day Care Building, Fourth Floor, Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, EM Bypass Road, 58 Canal Circular Road

11%) in transverse colon, 45 (29.41%) in left colon, 16 (10.46%) in sigmoid colon

Conclusion Incidence of colorectal polyps is significant in India though compared to western countries it is still lower. Smoking, red meat and high body mass index were predominant risk factors. Polyps were more commonly distributed in right and transverse colon. Keywords Adenoma detection, Risk factors, Adenomatous polyps, Smoking

Post Graduate Institute of Medical Sciences, 128/19, Civil Hospital Road, Rohtak 124 001, India Endoscopic glue injection versus endoscopic human thrombin injection for bleeding gastric varices -A randomized controlled trial Gireesh Dhaked, Mayank Ametha, Ashok Jhajharia, Rupesh Pokharna Correspondence -Gireesh Dhaked -dr.gireeshdhaked2210@gmail.com Department of Gastroenterology, Sawai Man Singh Medical College

Methods Retrospective review of patients with unresectable malignant hilar obstruction who underwent endoscopic bilateral SEMS insertion from 2015 to 2021 was done. Demographic details, technical success and functional success (decrease in the bilirubin value below 3 mg /dL at 4 weeks), immediate complications with 30-days mortality, requirement of re-intervention and stent patency (till re-intervention or death) were studied. Results Forty-three patients were included (Mean age 54.9 years, 51.2% females). 36/43 (83.7%) had Ca gallbladder, 5/43 (11.6%) had cholangiocarcinoma while 2/43 (4.6%) had colorectal cancer. 17/43 (39.5%) were locally advanced unresectable cancers while 26/43 (60.5%) were metastatic. Cholangitis was seen in 4/43 (9.3%)

Shitall Biradar 1 Correspondence -Harshal Gadhikar -gadhikarhp@gmail.com Shivanand Desai Centre for Digestive Disorders, Shivanand Desai Center for Digestive Disorders, and 1 Department of Pathology, Deenanath Mangeshkar Hospital and Research Center

Harsh Bapaye 1 , Sachin Palnitkar, Rajendra Pujari, Harshal Gadhikar

Department of Medicine, Byramjee Jeejeebhoy Govt. leaks, fistulas, or perforations

Abstracted data-demographics, clinical status, indication for clip application, technical success, clinical success, adverse events (Aes)

Indications -GI bleeds -11 (25.5%; duodenal ulcer-9, rectal ulcer-1, Post GJ stomal ulcer-1); acute perforations-18 (42%; esophageal-3, gastric-6, duodenal-6, recto-sigmoid-3; spontaneous-3, post-surgical-1

persistent esophageal leak post-stent placement-2, post-TB tracheaesophageal fistula-1, post-surgical recto-vaginal fistula-1; anastomotic leaks-6 [esophagojejunal-1, jejunoileal-1-3 patients (large esophageal tear -2 patients -2 clips each; esophagojejunal anastomotic dehiscence -2 clips); no procedure related Aes. Technical success-43/43 (100%), clinical success-35/43 (81.4%). Failures -rebleed-2/11 (18.1%), persistent chronic leaks/fistulas-5/14 (35.7%; 1-delayed duodenal fistula recurrence after initial sealing)

Mortality-4/43 (sepsis in postsurgical leak-1; sepsis in chronic esophageal perforation-1; hemorrhagic shock in uncontrolled GI bleed-1

Conclusion OTS clip is safe and effective for control of GI bleeds and perforation/leak/fistula closure. Outcomes are best for closure of acute perforations, moderate for bleed control, and poorest for chronic fistula or leak closure. Keywords Over the scope clips, OTSC, Perforation, Leaks

Methods Retrospective analysis of prospectively maintained database of all the patients undergoing Kaffes TM (TaeWoong NITI-STM) placement for post-surgical BBS was performed. Abstracted data -demographics, disease characteristics, prior endotherapy/percutaneous interventions, No. Of ERCPs required, complications, stent indwell time, stricture resolution/recurrence rates and follow-up was recorded. Results N=10; M:F -8:2; indication: BBS -post liver transplant -2 (1-duct -1; 2-duct -1), post cholecystectomy -8; median interval between surgery and stricture formation -5-mo (IQR 8.5); prior interventions -10/ 10 (100%; 10 -ERCP plastic stenting; 1 -PTBD + ERCP rendezvous, 1 -percutaneous stenting); mean no. of ERCPs after FCSEMS placement -2.5 (1-4); stricture resolution -8/10 (80%; external FCSEMS migration -1; lost to follow-up -1); mean stent indwell time -5.6(3 -10) m; stent removal -8; stricture recurrence -2/8 (25%; 1 -post cholecystectomy requiring surgical reconstruction, 1 -post liver transplant requiring stricture dilatation)

Conclusion FCSEMS is effective and provides long lasting stricture resolution for post-surgical benign biliary strictures with fewer endoscopic interventions. FCSEMS can be considered as first-line therapy for BBS requiring endotherapy instead of multiple plastic stents. Keywords Benign biliary strictures, BBS, FCSEMS, Postsurgical stricture Concomitant endoscopic fundoplication after per-oral endoscopic myotomy (POEM+F) for prevention of post POEM gastroesophageal reflux

United States Introduction Post per-oral endoscopic myotomy (POEM) gastroesopha-POEM+F. Abstracted data-demographics, achalasia type, pre-POEM Eckardt score (ES), procedure duration, complications and 3 monthly follow-up for 2years-post POEM Eckardt score, GerdQ scores, EGD-wrap integrity and esophagitis, pH studies. Subjective assessment -GerdQ, objective -Lyon consensus

2-adequate wrap, no esophagitis,1-adequate wrap, Gr. C esophagitis, HP gastritis)

Gr. C esophagitis-1/39 (2.5%; Wrapadequate

Keywords Endoscopic fundoplication, POEM+F, Gastroesophageal reflux, GER, post POEM GER

Methods A 67-year-old male gentleman, post esophagectomy and gastric

Vinodini Agrawal Correspondence -Mayank Jain -mayank4670@rediffmail.com Department of Gastroenterology, Arihant Hospital and Research Centre, 283-A, Gumasta Nagar

Mumbai 400 012, India Introduction High-resolution manometry (HRM) measures anal sphincter function and anorectal co-ordination. This study aims to provide normal data for HRM and evaluate the effect of gender, age, and body mass index (BMI) on anorectal functions in healthy Indian subjects. Methods HRM was performed on 93 healthy volunteers using a 20-channel, water-perfused Catheter. We evaluated anorectal pressures, rectal sensation, and balloon expulsion time

Rectal pressure (70 vs. 54 mmHg, p=0.024) and anal pressure (82 vs. 63 mmHg, p=0.008) during simulated evacuation without rectal distention, were higher in males. The threshold for the first sensation was lower in females (40 vs. 30 mL, p=0.021) but desire to defecate (105 vs. 90 ml, p=NS) and maximum tolerable volume (160 vs. 140 mL, p=NS) were not significantly different in males and females. Anal residual pressure (median 83 vs. 71 mmHg, p=0.025) was higher in subjects <40 years of age. Maximum anal squeeze pressure (185 vs. 165 mmHg, p=0.024) and maximum rectal pressure (75 vs. 62 mmHg, p=0.032) during push higher in BMI <23 kg/m2. Conclusion The present study provides normal data for the Indian population that can be used for comparison and further work. Age, gender, and BMI affect anorectal parameters in HRAM

Long-term gastrointestinal sequelae in corona virus disease 2019 infection" A prospective follow-up cohort study

Rithvik Golla 1 , Bhaskar Kante 1 , Peeyush Kumar 1 , Himanshu Narang 1 , Saurabh Kedia 1 , Govind KMakharia 1

All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi 110 029, India Introduction A novel corona virus (CoV) named '2019-nCoV' by the 3 months

7%) (M: 4, F: 8) (Mild: 8, Moderate: 5), 4 (1.4%) (M: 3, F: 1) (Mild: 3, Moderate: 1)

Mild: 3, Moderate: 2) developed FD, PI-IBS, FC, FD and FAB/D like symptoms respectively

Keywords Post prandial distress syndrome (PPDS), Post infectiousirritable bowel syndrome (PI-IBS), Functional constipation (FC), Functional diarrhea (FD), Functional abdominal bloating/distension

Moinak Sen Sarma Correspondence -Ujjal Poddar -ujjalpoddar@hotmail.com Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India Background and Aim: Clinical differentiation between intestinal tuberculosis (TB) and Crohn's disease (CD) is challenging. We aimed to document endoscopic mucosal healing and/or radiological resolution of the lesion in abdominal TB at the end of antitubercular therapy (ATT) as missing cases of other etiology like CD, multidrug resistant-TB, and gastrointestinal malignancies

Laboratory workup revealed microcytic hypochromic anaemia with hemoglobin of 9.8 g/dL, hypoalbuminemia of 1.4 g/dL, and hypoproteinaemia of 3.5 g/dL; creatinine and urinalysis were normal. Serum IgA tissue transglutaminase levels were normal. Abdominal ultrasound showed dilated bowel loops with minimal ascites. Stool levels of alpha-1-antitrypsin were significantly elevated confirming PLE. Upper gastrointestinal endoscopy revealed a large trichobezoar extending from stomach into the small bowel, thus classified as Rapunzel syndrome. Further questioning elicited a history of trichophagia. The giant trichobezoar was removed by exploratory laparotomy with anterior gastrotomy and the child subsequently tolerated advancement of the diet with improvement in serum protein levels. This signifies the rare manifestation of Rapunzel syndrome as PLE. Trichotillomania and trichophagia are more common in females who have other psychiatric comorbidities or developmental delay. This patient's presentation is unusual in many aspects including his male gender, young age, and lack of obvious developmental delay and comorbidities. Conclusion This case demonstrates the importance of considering Rapunzel syndrome in the differential diagnoses for a young patient with protein-losing enteropathy of not obvious etiology regardless of gender. Accurate history is crucial in the evaluation as delays in diagnosis are common because of its rare presentation

Lucknow 226 014, India, and 1 Department of Pediatric Gastroenterology, Sakra Hospital, Bangalore 560 037, India Introduction Endoscopic dilatation is the primary management of esophageal strictures in children, however, literature on long-term success especially on growth is lacking. Hence, we analyzed our experience on esophageal strictures, their etiology

) in children who were successfully dilated. Conclusion Endoscopic dilatation is safe and effective in the management of esophageal strictures in children with successful dilatation resulting in significant improvement in growth on follow-up

Akash Shukla Correspondence -Amrit Gopan -amrit.kem@gmail.com Department of Gastroenterology

Akash Shukla Correspondence -Amrit Gopan -amrit.kem@gmail.com Department of Gastroenterology

DAA on the pre-and posttreatment samples showed that EEN resulted in diminished Ruminococcus gnavus, Escherichia sp., Bifidobacterium longum and Enterococcus sp., while the SOC led to reduction in beneficial F. prausnitziiand enhanced Escherichia. DAA between steroid responders and steroid non-responders in the EEN group, showed significant enhancement of Veillonella, Ligilactobacillus, Limosilactobacillus, Gamella, Enterococcus and Eggerthella in the SR group

Number of hepatic encephalopathy in past

Development and validation of a digital health platform (IBD NutriCare) for telenutrition in patients with Inflammatory bowel disease Arti Gupta

Koppolu -sumanthgmc@gmail.com Department of Gastroenterology, and 1 Well Baby Clinic

After obtaining informed consent, patients underwent SARS-CoV-2 antibody testing (chemiluminescent immunoassay: Seimens kit IgG against antigen S1RBD) and information on demography, drug history, past history of COVID infection and vaccination status were noted. Patients with IBD on 5-aminosalicylic acid or not on any treatment were considered immunocompetent and those who had received steroids, thiopurines or methotrexate within 6 months of sample collection were considered immunocompromised

Conclusion Up to 1/3rd patients with IBD were seropositive for IgG SARS Cov2 antibody indicating asymptomatic COVID-19 infection. The seroprevalence was similar to healthy controls and was not different between immunocompromised and immunocompetent patients with IBD. Keywords Inflammatory bowel disease, COVID-19, SARS-CoV-2, seroprevalence, Immunosuppression, Steroids, Thiopurines 508 Acute kidney injury due to fish gallbladder ingestion: A case report Radhika Nittala, Jimmy Narayan, Manoj Sahu, Girish Pati, Debakanta Mishra Correspondence -Radhika Nittala -drnradhika@gmail.com Department of Gastroenterology, Institute of Medical Sciences and SUM Hospital

OSM-R) and IL-7 R receptor were done in mucosal biopsies. Results: One hundred and sixty-eight patients (104 CD, 64 UC) received anti-TNF therapy. The mean age at initiation of anti-TNFα agents was 34.6±13.7 years and the median disease duration before anti TNF initiation was 60 months (Range:34-108). PNR was seen in 11.5% and 23.5% and LOR was seen in 74% and 45% of patients with CD and UC respectively

In UC, no clinical, biochemical, or molecular marker was found predictive of response. Conclusion In this pilot study, anaemia and stricturing disease were predictors of PNR in patients with CD. Higher baseline expression of OSM in epithelial cells predicted LOR in patients with CD

Determinants of HRQoL were identified through multiple linear regression. Results A total of 60 IBD patients (39 UC, 21 CD) with a mean disease duration of 7.8 years were included. The mean IBDQ score was 121.8 ± 29.01. The SF36 scores were significantly lower than the population normal. There was no significant difference in the scores between UC and CD patients, whereas there was a significant difference between those with active disease vs. remission. The scores were lower when compared to the normal population even during remission. In the multiple linear regression analysis, it was found that presence of active disease (b=−0.250), Presence of EIMs (b=-0.584), and occupation status (b=0.289) were significantly associated with lower HRQoL in IBDQ scores. Conclusions HRQoL is impaired among patients with IBD, even during periods of remission when disease activity indices may be normal. Active disease, presence of EIM and unemployment due to illness, were found to be significantly associated with a reduction in HRQoL. Greater awareness of the impact of various factors on patients' HRQoL would improve the holistic management of IBD patients

India Background The aim of our study was to evaluate the prevalence and clinical relevance of oipA and babA genes of Helicobacter pylori in gastroesophageal reflux disease (GERD) and non-GERD patients. The interplay of outer membrane protein (OMP) coding genes along with virulence genes cagA vacA of H. pylori is responsible for expression of pathogenic factors in host. A group of 33 genes, the outer membrane protein coding genes (OMP) encoded by approximately 4% of the genes of H. pylori, plays a pivotal role in persistence and colonization of bacteria. Method Culture DNA of 39 H. pylori positive strains were isolated from collected GERD non-GERD samples. DNA was assayed for oipA, babA by polymerase chain reaction (PCR). cagA vacA status was also evaluated by PCR Results Out of 39 H. pylori positive samples GERD non-GERD status is 19/39 and 20/39. In 34 oipA+ve samples 50% were each GERD and non-GERD positive. In 23 babA+ve samples 68.4% had GERD while 50% were non-GERD. Cag+ve GERD/non-GERD patients were 31.5% and 60% respectively. vacs1m1/s1m2 for GERD is 21.0% and 78.9% while for non-GERD it is 55% and 45% respectively. Conclusion Our results show there were no correlation between the presence or absence of the oipA/babA and cag+ve/cag-ve in GERD and non-GERD patients. However, vacs1m1/s1m2 with p<0

Rakesh Jha Correspondence -Rakesh Jha -jharakesh2006@gmail.com Department of Medical Gastroenterology

Ravi Daswani Correspondence -Ravi Daswani -daswaniravi@yahoo.co.in Department of Gastroenterology, Midas Hospital, 10-A Racheda

Portal vein thrombosis is a potential cause of portal hypertension and its sequelae like portal cavernoma and biliopathy. Treatment of chronic portal vein thrombosis involves mainly reduction of portal hypertension and its complications. Portal vein reconstruction-transjugular intrahepatic shunt (PVR-TIPS) can reduce portal hypertension and biliopathy by restoring blood flow along portal vein. Here we report a case of 60-year-old male with chronic liver disease and chronic calcific pancreatitis with chronic portal vein thrombosis with portal cavernoma and biliopathy presented with cholangitis. MR portovenography with MRCP showed portal vein and splenic vein thrombosis with cavernoma and dilated bilateral moderate IHBR with biliopathy. Patient was treated with biliary stenting for cholangitis. PVR-TIPS was done using right IJV access and then through right hepatic vein, tract was made through hepatic parenchyma up to major collateral followed by placement of 10*80 mm Fluency graft. Under guidance it was extended till SMV by 10*100 mm Luminex bare metal stent. After reconstruction there is good hepatopetal flow through SMV-metal stent-collateral-TIPS axis. Post procedure patient developed hepatic encephalopathy which was treated conservatively with lactulose and LOLA. On follow up for 12 months, repeat cholangiogram showed resolution of biliopathy. Patient was on DOAC and no further recurrence of jaundice. In summary PVR-TIPS is a novel safe and effective approach in reducing portal pressure and biliopathy, especially when shunt surgery and conventional or trans-splenic PVR-TIPS is not feasible.Acquired immunodeficiency syndrome (AIDS) cholangiopathy is a syndrome of acalculous biliary obstruction resulting from infection-associated strictures of the biliary tract, usually seen in patients with a CD4 count well below 100/mm3. C. parvum is the most common pathogen associated with AIDS cholangiopathy. Other pathogens include cytomegalovirus (CMV), microsporidium, Cyclospora, and histoplasma. Forty-three-year-old female presented with loose stools of 3 months duration with history of significant weight loss. Patient is a known case of retroviral disease for last 10 years on combination antiretroviral therapy (cART) for 10 years . She had history of similar complaints two years ago which was treated with antibiotics. Clinical examination was unremarkable except for mild pallor and a low body mass index (BMI) of 17.6 kg/ m2. On evaluation, complete blood count (CBC) showed normocytic hypochromic anemia. Prothrombin Time and International Normalized Ratio (PT/INR) was normal. Liver function test (LFT) showed elevated alkaline phosphatase (ALP) and Gamma-glutamyl transferase (GGT). Erythrocyte sedimentation rate (ESR) was mildly elevated. Renal function test (RFT) was normal. CA 19-9 was mildly elevated. Stool routine two samples was negative for cryptosporidium and other opportunistic organisms. Serum lactate dehydrogenase (LDH) was normal. Human immunodeficiency virus (HIV) viral load was 13,400 IU/mL, CD4 count was 20. Magnetic resonance cholangiopancreatography (MRCP) showed mild to moderate dilatation of intra and extra hepatic biliary channels with abrupt cut off of terminal Common bile duct (CBD), soft tissue thickening causing luminal irregularity of the terminal CBD, prominent main pancreatic duct. Endoscopic biopsies from ileum revealed lymphoplasmacytic infiltrates with blue basophilic organisms resembling Cryptosporidium. Endoscopic retrograde cholangiopancreatography (ERCP) biopsies taken from distal CBD-revealed extensive denudation and focal ulceration covered by granulation tissue and the epithelial cell lining shows few large cells with eosinophilic nuclear and cytoplasmic inclusions and granular basophilic cytoplasm suggestive of Cytomegalovirus infection. She was managed with intravenous (IV) fluids, IV antibiotics, ursodeoxycholic acid (UDCA), proton pump inhibitors (PPIs), IV analgesics, anti-protozoal (nitazoxanide) and other supportive measures. Opportunistic infections can coexist (as in our case Cryptosporidium and Introduction World-wide prevalence of Salmonella typhi (S. typhi) chronic carrier state in gallbladder is~1-2.5% as per recent epidemiological evidence states. But the S. typhi carrier state in chronic cholecystitis and cholelithiasis patients were found much higher as per our analysis demonstrating the presence of S. typhi isolated and demonstrated from gallbladder tissues by polymerase chain reaction (PCR). Method One hundred (100) paraffinized blocks of gallbladder tissue samples of histologically proven chronic cholecystitis and cholelithiasis were collected. Among them, thirty-six (36) samples were of chronic cholecystitis (Male-6, Female-30) and sixty-four (64) were of cholecystitis with cholelithiasis (Male-9, Female-55). The samples were tested for S. typhi DNA PCR through steps of extraction of gallbladder tissues by paraffin removal, DNA extraction from it, S. typhi DNA identification, amplification and DNA sequencing and analysis. Result Seven samples were positive for S, typhi chronic carrier state (six in cholecystitis with 298atient298d298s298is samples, one in chronic cholecystitis sample); in percentage it is seven percent (7%), which is much higher than the overall prevalence of S. typhi carrier state which is only~2.5% as per present epidemiological data states.Introduction Multiple pseudoaneurysms in acute pancreatitis is a rare phenomenon. We report a case of two pseudoaneurysms in a patient, treated in two different ways. Clinical Summary A 32-year-old male with alcohol-use-disorder was admitted with dull aching, boring type of upper abdominal pain radiating backwards of 1 month duration and an episode of hematemesis 2 weeks back followed by melena. He had no comorbidities. On examination, patient had pulse: 110/minute; BP: 100/ 60 mmHg and respiratory rate: 20/minute. He was pale. Abdominal examination revealed mild epigastric tenderness without any palpable mass. Melena was noted during digital rectal examination. Serial lab investigations showed falling hemoglobin levels from 9.8 g/dL to 6.5 g/dL. Serum amylase and lipase were 1038 and 437 U/L respectively. Coagulation workup, renal and liver function tests were normal. Ultrasound abdomen showed WON of pancreas compressing body and tail. CECT abdomen showed acute necrotizing pancreatitis involving body and tail with WON (8x6.4x6.7 cm) in the left anterior sub-hepatic space. UGI endoscopy showed 0.5x0.5 cm clean based ulcer in the body of the stomach with no fresh or altered blood in the lumen. CT abdominal angiogram showed 2 aneurysms, one from proximal splenic artery and another from gastro-epiploic artery. This was confirmed by DSA. Coil embolization of right gastro-epiploic artery aneurysm was done. Covered stenting was done for splenic artery aneurysm to maintain vessel patency. Post-procedure angiogram revealed complete exclusion of the aneurysms. USG guided aspirate of WON revealed 100ml of necrotic fluid with high amylase levels, following which its walls collapsed. Patient's melena and abdominal pain subsided, and hemoglobin remained stable. CT abdomen after 2 weeks showed coils and stent in place and no intra-abdominal fluid collections. Conclusion Pseudoaneurysm in acute pancreatitis is a life-threatening situation. Early diagnosis and timely intervention is the key to saving patient's life.Pancreatic ductal adenocarcinoma (PDAC) continues to have a dismal prognosis despite treatment. Systemic inflammation (SI) has been linked to various cancers and several inflammatory mediators have been shown to be elevated in patients with PDAC. Neutrophil-lymphocyte ratio (NLR) is an easily available and inexpensive marker of SI. In our study we looked into the role of NLR as a prognostic marker in patients with PDAC. Methods Prospective observational cohort study was conducted over a period of 3 years, where all consecutive patients with histologic evidence of PDAC were included. All relevant data was recorded in a pre-designed proforma. Patients were followed up for a minimum period of 1 year. Primary outcome was overall survival. Stratified analysis was performed with respect to stage (metastatic vs non-metastatic) and treatment modality offered (curative resection, palliative chemotherapy, palliative 335atient drainage). Results A total of 161 patients with PDAC were included (mean age 62±11.91, M: F=1:4) . NLR (at cut-off 2.78) was found to have a significant association with overall survival. Moreover, on multivariate analysis, NLR (at cut-off 2.78) was found to have an independent association with overall survival (HR -2.943, 95% CI 1.23 -7.035, p value 0.015). In stratified analysis, NLR was a significant prognostic factor among both metastatic and nonmetastatic disease (p value 0.011 and 0.036 respectively). In addition, NLR also showed a significant association with overall survival in patients who were managed with palliative chemotherapy (p value 0.004). Conclusion Elevated NLR was found to be a significant, independent predictor of overall survival in our study. NLR as a prognostic factor was especially useful in patients treated with palliative chemotherapy. Objectives To study the clinical profile of patients with pancreaticopleural fistua complicating acute pancreatitis (AP). Methods All patients with acute pancreatitis diagnosed to have pancreaticopleural fistula on magnetic resonance cholangiopancreatography (MRCP) from a period of 6 months from April 2021 to September 2021 are considered for the study. Data regarding demographics, risk factors, presenting symptoms, biochemical tests, imaging and outcome were collected and analyzed. Results Male sex, alcohol abuse, severe AP and infected necrosis are risk factors for development of internal fistulae. Smoking was the additional risk factor in our study. Because of non-GI presentations, a high degree of clinical suspicion is often required to diagnose PPF. As with the other studies, dyspnea was the most common presenting symptom in 50% of patients. Most common site of duct disruption is in the body of pancreas. When the duct disruption is in the distal body, patient had bilateral effusion and when in tail, patient had left pleural effusion. A delay in diagnosis of PFs can lead to increase in length of stay, intensive care unit stay, and even in mortality. Development of fistula in acute pancreatitis is likely to extend the hospital stay, mean stay was 33.6 days in our study. Octreotide is less likely to help with internal fistula except pancreaticopleural fistula where success rates of reducing fistula output and time to fistula closure. 3 patients responded to conservative treatment, one patient improved after pancreatic duct sphincterotomy, one patient underwent laparoscopic cystogastrostomy and another patient responded to pancreatic duct stenting. Keywords Pancreaticopleural fisula, Acute pancreatitis, Chronic pancreatitis Introduction Pancreatic duct disruption is a major complication in acute and chronic pancreatitis, rarely due to trauma, results in severe symptoms, morbidity and mortality. Endotherapy in the form of pancreatic duct stenting, sphincterotomy are the main modalities in treating patients to avoid surgery. Aim To evaluate efficacy of pancreatic endotherapy as primary management in pancreatic duct disruption. Methods Twenty-five cases of pancreatic duct disruptions admitted in Osmania Hospital were studied prospectively from January2019 to August2021 and followed periodically. Results Among 25 cases, 22 males, 3 females, 12 patients are in 31-40 age group. Eighteen patients had chronic alcoholic pancreatitis, 4 had acute pancreatitis with WON, 2 due to blunt abdominal trauma, one 12 years old had MTCD. After clinical and lab assessment. All are kept on NJ feeds, antibiotics. ERCP attempted with mean duration 7-10 days. Majority of leaks noticed in genu 9 (36%), body 6 (24%), head 3 (12%) and multiple leaks in one (WON), 4 associated with portal hypertension, pancreatic duct stones in 3, pseudocyst in 3, pancreatic pleural fistula in 6 patients. Pancreatic sphincterotomy done in all patients (100%) and pancreatic duct stenting done in 20 patients (80%). In five no stenting done. One with multiple leaks and 3 with tail leaks were subjected to surgery. One responded to sphincterotomy. Twenty patients were followed periodically with symptoms improvement and USG scan. Mean duration of healing was 18 days (12 to 26 days). Eighteen patients responded after first session of endotherapy, 2 patients needed second session after 2 months for residual collection. Ninety percent patients with head and body, genu collections healed after pancreatic duct stenting, only 50% (3/6) patients with tail collections responded to endotherapy. No major complications and mortality were encountered. Conclusion Pancreatic endotherapy in the form of sphincterotomy and stenting is effective and associated with less morbidity and early recovery.Introduction Pancreatic fluid collections are seen as a sequala of pancreatitis and range from pseudocyst to walled off pancreatic necrosis. We present the pertinent clinical features as well as the management of the pancreatic fluid collections in our tertiary care centre. Aims To evaluate and study the clinical profile of cases of pancreatic fluid collections in our tertiary care centre. It was obtained by performing an audit of all patients presenting with pain abdomen in Vydehi Institute of Medical Sciences and Research Centre from 2012-2021.Method Data were collected from 1 September 2012 to 10 September 2021. All relevant investigations including CECT abdomen, EUS was done. Management of cases was done as per guidelines. Observations A total of 85 cases were enrolled in the study. Mean age of patients was 40.38 years (74 Male, 11 Female). The mean size of the fluid collection was 6.7 X 5.7 cm. Majority patients presented with abdominal pain. Fluid collections could be well detected on both contrast-enhanced computed tomography and EUS. 58 patients had pseudocysts; 17 patients had walled off pancreatic necrosis. Significant debris was seen in 17 patients. Majority of the fluid collections were in the head (48), followed by body (28), and the tail (9). Thirty-one patients were managed conservatively. Thirteen patients underwent FNAC. Thirty-nine patients were endoscopically managed (EUS guided 28 (27 cystogastrostomy and 1 cysto duodenostomy, 11 patients underwent ERCP). Twenty-seven patients were treated with transmural drainage, 11 patients were treated with trans papillary drainage alone, while combined percutaneous and trans papillary drainage was performed in 1 patient. The pancreatic fluid collections resolved in all patients within 6-16 weeks. There were no complications and no patient had recurrence of fluid collections over a follow-up period.Introduction Thalassemia major presents early between 6 and 24 months and characterized by feature of severe anemia. To maintain effective hemoglobin level of 9 to 10 mg/dL for growth, patient undergoes regular blood transfusion program leading to iron overload state. Case Report A 19-year-old male, who is known case of beta thalassemia major since 2005 underwent splenectomy in 2012 and received more than 300 unit blood transfusion. Laboratory investigation showed iron profileserum ferritin-2126 ng/mL, serum iron -46 ug/dL, TIBC-121 ug/dL. CECT abdomen suggestive ofacute cecrotizing pancreatitis with per pancreatic fluid CT severity index is 8/10 (Figs. 1 and 2). Discussion Classical thalassemia is reported to be associated with acute pancreatitis; however, the etiology is biliary as gallstones are typical in these patients. But here we report this case of acute pancreatitis in beta thalassemia which is not because of gallstones. In this patient, etiology of acute pancreatitis may be because of iron overload as iron profile study in our patient show iron overload state. So, in patients with beta thalassemia major having iron overload Introduction Pancreatic duct (PD) stents are routinely placed for various indications and are usually kept in situ for a short duration. They are subsequently removed as they can result in recurrent pancreatitis, infection, perforation, and stenosis of PD. There is paucity of data on the consequences of prolonged indwelling PD plastic stents. This study was done to retrospectively evaluate the consequences of prolonged indwelling PD plastic stents. Methods Retrospective analysis of database of 16 patients ([13 Male, median age 32 years [range 23-42]) who underwent PD stenting from 2003 to 2021 was done to identify patients who had retained nonretrievable or forgotten PD stents. The indications, duration and complications of these indwelling PD stents were retrieved from this database. Results The indications for PD stenting were external pancreatic fistula (EPF) post percutaneous drainage of acute necrotic collection in 9 (56.2%), painful chronic calcific pancreatitis (CCP) in 6 (37.5%) and PEP prophylaxis in 1 (6.3%) patient. Eleven (68.7%) patients had 5 Fr stents while 5 (31.3%) had 7 Fr stents with pancreatic sphincterotomy being done in 6 (37.5%) patients. The median duration of retained PD stents was 78 (range 48-128) months. Thirteen (81%) patients remained asymptomatic during this period. Of these 13 patients, 8 had EPF and upstream migrated stents could not be retrieved endoscopically. In 5 patients with CCP, the stent had either fragmented (n=2) or migrated inwards (n=3) and could not be removed endoscopically. Three (18.75%) patients (post EPF, PEP and CCP respectively) developed abdominal pain 36-58 months after stent insertion. Of these 3, stent was removed surgically in two patients and endoscopically in one patient. Conclusion Retained PD stents can result in complications in patients with normal PD and preserved pancreatic parenchyma. However, in advanced chronic pancreatitis and in patients with atrophied pancreatic parenchyma, retained PD stents may not result in symptoms or complications. Keywords Retained pancreatic duct stents, Prolonged indwelling PD stents, Pancreatic duct 404 Hypertriglyceridemia and alcohol -Acute pancreatits with dual etiologies -A case series Background and Aims Post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most dreaded complication of endoscopic retrograde cholangiopancreatography (ERCP). We sought to capture the various practise methods amongst advanced endoscopists regarding measures taken for prevention of PEP. Methods An anonymous online 31-item survey was sent to advanced endoscopists by digital medium like WhatsApp, Twitter, and E-mail. The responses were collected over a period of 2 weeks. Results Of the 600 endoscopists who were invited to participate, 123 responded. Thirty seven percent use intravenous hydration only in patients deemed as high risk for PEP. Majority (91.8%) use Ringer's lactate solution for the prevention of PEP. Standard hydration was the norm in using IV fluids in prevention of PEP amongst most endoscopists (67.5%). Forty percentage endoscopists put pancreatic ductal (PD) stent after more than 2 inadvertent PD cannulation. About 11 % endoscopists felt that there was no therapeutic benefit of PD stenting after inadvertent cannulation. About ninety-seven percentage endoscopists use rectal nonsteroidal anti-inflammatory drugs (NSAIDs) if there are no contraindication to use. Sixty-nine percentage endoscopists use rectal NSAIDs in high-risk patients only. About sixty percentage endoscopists use rectal NSAIDs after ERCP. Diclofenac 100 mg was the most commonly used rectal NSAID. Eighty-nine percentage of endoscopists use combined therapy for PEP. The most commonly used combination is rectal NSAID with standard hydration. If pancreatic ductal stenting is done due to inadvertent cannulation, 72 % endoscopists would still use intravenous hydration with rectal NSAID as additional mode of prophylaxis.Introduction Ascaris lumbricoides is one of the most common parasitic infestations of human gastrointestinal tract. Intestinal ascariasis is mostly asymptomatic, on rare occasions the round worm may invade the biliary tract and main pancreatic duct causing obstruction and leading to acute pancreatitis and ascending cholangitis. Here we presenting a case report of ascariasis induced acute necrotizing pancreatitis. Case Report A 53-year-old female patient known case of type 2 DM/ IHD, no addictions presented to emergency department with pancreatic type of abdominal pain for 2 days and multiple episodes of vomitings, with no h/o similar complaints in the past. The patient was hemodynamically stable, on per abdomen examination-epigastric tenderness was noted and bowel sounds were normal. Patient was treated with IV fluids/IV analgesics. On routine investigations: normal HB /total count was noted; normal liver enzymes, serum triglycerides and serum calcium with elevated serum amylase (2700 IU/L), serum lipase( 3000 IU/L) levels were noted. CECT abdomen and pelvis revealed acute necrotizing pancreatitis (CTSI-6), with no evidence of gallstones. UGI endoscopy revealed round worm in duodenum invading in to ampulla. stool testing for parasites and ova were negative. Conclusion Ascaris lumbricoides is an uncommon cause of biliary obstruction leading to complications such as cholangitis, biliary colic, acute pancreatitis. Although biliary complications are rare, these can cause severe morbidity and mortality. Therefore, early diagnosis and management are essential. Endoscopic removal of the worm is the treatment of choice, in addition to anti-helminthic medication, and supportive management.Background IgG4-related disease (IgGRD) describes a group of fibro inflammatory diseases that affecting various organs resulting in tumorlike effect and organ dysfunction. Majority of the literature is from Japan with no strong evidence to suggest a predilection for Asian populations. Data from India remains sparse. Methods Retrospective review of outpatient and inpatient database between January 2013 and July 2021 was done to identify patients having IgG4-related disease. Demographic details, details of site of disease, symptoms, mode of diagnosis and overall final management plan were noted. Results Forty-eight patients were diagnosed with IgG4-related diseases, of which 28 patients were found to have IgG4-related gastrointestinal (GI) disorders (mean age 56 ± 13 years, M:F-6:1). Among these, 19 (68%) had autoimmune pancreatitis, 4 (14%) had IgG4-related GB mass, 3 (11%) had IgG4-related retroperitoneal mass, 2 (7%) had IgG4-related liver mass. The most common mode of presentation was abdominal pain in 21 (75 %), followed by jaundice in 14 (50 %). One patient had extraabdominal involvement (IgG4-related retropharyngeal mass).18 (65%) patients were diagnosed using endoscopic ultrasound or CT-guided sampling, while 10 (35%) patients on the surgically resected specimen. Lymphoplasmacytic infiltrate with an increase in IgG4 cells and increased IgG4:IgG ratio was seen in all patients.IgG4 level is raised in 19 (68 %) patients (Median IgG4 240 mg/dL). Eighteen (64 %) patients were treated with steroids. Among these patients, 13 (72 %) showed complete response. Among partially responded patients, one underwent surgery and two responded to treatment after adding azathioprine. Among the patients who responded to steroids, 3 (23%) patients with autoimmune pancreatitis had relapsed on follow-up, who then responded to retrial with steroid and azathioprine maintenance therapy. Conclusion IgG4-related diseases are commonly misdiagnosed as malignancies. Appropriate medical management with steroids and immunomodulators is associated with optimal response in these patients. Keywords IgG4 related GI disorder, IgG4 related disease, Autoimmune pancreatitis 412 Incidence of pancreatic exocrine insufficiency following episode of acute pancreatitis -A prospective observational study Ahmad Yousuf, J C Vij, Neha Berrry, Ajay Kumar, Manaw Wadhawan, Amrish Sahney Correspondence -Ahmad Yousuf -wajeedyousuf@gmail.com Department of Gastroenterology and Hepatology, B L K Max Super Speciality Hospital, New Delhi, IndiaIntroduction AP patients may develop local, systemic complications including endocrine and exocrine insufficiency. This may persist beyond hospital admission. This study explores incidence of PEI following episode of AP and at 6 months follow-up.Methods Between December 2019 to June 2021, among 130 AP patients presenting to BLK Max Hospital, 90 were included in the study as per inclusion criteria. These were classified into mild, moderately severe or severe pancreatitis as per revised Atlanta classification. Fecal elastase, fecal sudan stain was performed at the time of discharge (in mild pancreatitis) or after restarting feeding (moderately severe or severe pancreatitis) and at follow-up time of 6 months. PEI was diagnosed if fecal elastase was <200 ug/g or a positive sudan stain. Results Ninety patients of AP were screened (mild 53, moderately severe 25, severe 12). Forty-eight (18 mild, 17 moderately severe, 12 severe) developed PEI at admission. These were followed for 6 months. Seven patients expired and 2 were lost to follow. Thirty-nine patients were included in final analysis. None among 18 patients with mild pancreatitis had PEI at follow-up. Four (23.5%) out of 17 patients with moderately severe pancreatitis persisted with PEI. Among 12 severe pancreatitis with PEI, 4 patients with PEI at the index admission persisted with PEI at follow-up. Severity of pancreatitis correlated with PEI at follow-up (p<0.001). Seven patients with necrotizing pancreatitis persisted with PEI on follow as compared to only one without necrosis (p< 0.001). Five patients with PEI had necrosis of more than 50% vs. 2 patients with 30% to 50% vs none with <30% of necrosis (p<0.001). Seven patients of ANC with local complications persisted with PEI as compared to 1 patient without any local complications (p<0.001). Conclusion PEI corelated with severity of pancreatitis, degree of necrosis and local complications. Keywords Acute pancreatitis, Pancreatic enzyme insufficiency, Acute necrotic 413 Role of endoscopic ultrasound in management of autoimmune pancreatitis Aims and Objectives To study manifestation of pancreatic exocrine and endocrine insufficiency of chronic pancreatitis presenting to tertiary care centre and to identify patients having underlying FCPD. Introduction Chronic pancreatitis is a disease involving inflammation, fibrosis, and loss of acinar and islet cells, which can manifest in unrelenting pancreatic-type abdominal pain, malnutrition, derangements in pancreatic function and visible pancreatic damage on imaging studies. Exocrine pancreatic insufficiency is defined as the presence of clinical steatorrhea and its improvement by pancreatic enzyme supplementation or fecal pancreatic elastase level <200 μg/g of stool. Pancreatic endocrine insufficiency diagnosed by fasting plasma glucose ≥126 mg%, postprandial plasma glucose ≥200 mg%, and/ or HbA1c ≥6.5%. FCPD is a subtype of tropical chronic pancreatitis comprising calcifying, non-alcoholic chronic pancreatitis affecting younger generally malnourished individuals from the tropical regions of Asia, Africa and South America particularly males. Introduction A wide variety of causes of acute pancreatitis have been reported; however, it is always difficult to be certain about the cause in a given patient. However, an attempt must be made in every patient to ascertain a cause by a thorough history, physical examination, laboratory tests, and imaging before labelling it as "idiopathic acute pancreatitis". We present a patient diagnosed to have acute pancreatitis secondary to hypercalcemia. Further work up for hypercalcemia revealed hyperparathyroidism. Methods A 47-year-old lady, teetotaller, with no previous co-morbidities was admitted with complains of pain abdomen and vomiting since 1 week. Investigations revealed serum amylase-1200 u/L and lipase-980 u/L. Fasting lipid profile was normal. Serum calcium was 15.0 mg/dL, serum albumin was 4.1 g/dL. Serum PTH was 150 pg/mL (normal range : 18.5-88 pg/mL). CECT abdomen showed diffuse peri-pancreatic fat stranding, fluid in peri-pancreatic, bilateral anterior para-renal and splenic hilar region, features suggestive of acute pancreatitis (CT Severity Index -4/10).Ultrasound neck showed heterogeneously hypoechoic lesion in relation to lower pole of left lobe of thyroid suggestive of parathyroid adenoma. Radionuclide parathyroid scan (99 mtc-sestamibi) showed hyper-functioning solitary parathyroid adenoma in pre/para tracheal region below the lower pole of the left lobe of thyroid gland. patient underwent left inferior parathyroidectomy. Postoperative period was uneventful. parathyroid biopsy revealed features suggestive of parathyroid adenoma.Results Post left inferior parathyroidectomy, serum calcium was 9.2 mg/ dL, serum PTH was 42 pg/mL (normal range : 18.5-88 pg/mL).Introduction Bone disease (osteopenia or osteoporosis) is a highly prevalent condition in society and presents a tremendous, preventable public health burden. The association of bone disease has been recognized in several diseases of the gastrointestinal tract, resulting in established guidelines for screening in patients with malabsorptive disorders such as inflammatory bowel disease and celiac disease. Increasingly, the risk of bone disease has been recognized in patients with chronic pancreatitis (CP), who share similar risk factors as patients with other gastrointestinal disorders. Methods This single-centre study was carried out in Department of Digestive Health and Diseases, Kilpauk Medical College. This study population consisted of 40 patients who were image confirmed cases of chronic pancreatitis.• History of smoking, alcohol use was taken, BMI was measured. Dual-energy x-ray absorptiometry scan was used to examine bone mineral density for the lumbar spine and bilateral femoral neck. Results Of the 40 patients, 27 were male, and 13 were female.• 12 patients were chronic smokers and 23 patients had history of significant alcohol use.• The prevalence of osteoporosis (combined estimate for femoral neck and lumbar spine) in this patient group was 30 % (12) in patients with CP compared to Indian prevalence of 18.3% in previous studies.• The prevalence of osteoporosis for the femoral neck was 18.5 % in CP, for the lumbar spine, the estimates were 16.9%. The prevalence of osteopenia was 57.5% (23) Tuberculosis of the pancreas is extremely rare, being reported in only about 0% to 4.7%. It is usually described in immunocompromised individuals. Here we describe a case of TB pancreas in a previously healthy, immunocompetent 46-year-old male, who presented to us in April 2020 with complaint of diffuse abdominal pain and weight loss. CECT showed 6.4 x 5.8 x 4.7 cm necrotic collection in mid body of pancreas with a dilated duct (4 mm) and necrotic intraabdominal lymphadenopathy. EUS showed a large bilobed collection of size 7.8 x 6.7 cm, communicating with the pancreatic duct. EUS guided FNAC was positive for TB (GeneXpert and culture). Consequently he was started on a 9 month course of AKT, to which he responded. A recent MRCP with MRI abdomen done in Oct 21 revealed complete resolution of the cystic lesion. However, atrophy of pancreatic parenchyma and pancreatic duct stricture involving body and tail was seen, with upstream dilatation of the duct (8.7 mm). No evidence of calcification was noted. The patient is asymptomatic currently with no evidence of endocrine/exocrine insufficiency. He has been prophylactically prescribed a course of pancreatic enzymes therapy. Other etiological work up of chronic pancreatitis was negative. Introduction With the rise in obesity pandemic, the number of patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) is also rising, so do the complications related to the procedure. Bezoars are collections of undigested foreign material that accumulate in the gastrointestinal tract (1) . The most common are phytobezoars, which are Introduction Telenutrition with digital health platforms is the future step towards improving patient care in patients with inflammatory bowel disease (IBD). Additionally, it offers an advantage of conducting multicenter longitudinal dietary intervention studies. Aim To develop and validate a digital health platform for patients with IBD to provide nutrition care and record longitudinal diet data on a largescale basis. Methods The development of the digital health platform was done from October 2019 -June 2021 by gastroenterologists and dieticians. For validation, patients with IBD at All India Institute of Medical Sciences, New Delhi recorded 7 days diet in the App. 24-hours diet recall for 3 days at random during the same week was also done. Energy, protein, carbohydrate, fat, fiber, cereals, fruits, vegetables, grain, legumes, milk products were compared between two methods. Results An Android and iOS-based digital health platform, IBDNutriCare; was developed in English and 7 Indian languages. This user-friendly interface can be downloaded by the patients free of cost from Google store and App store. This platform provides a recording of diet variables based on 600 Indian food recipes, patient parameters like subjective global assessment, medications, and clinical activity scores. It also provides a graphical representation of nutrient analysis, with web applications generating comprehensive reports to enable large-scale data analysis. Forty-nine patients with IBD were enrolled in a validation study comparing :IBDNutricare; based analysis with dietary recall method. The mean intake of all food groups and macronutrients was comparable between the two methods. There was a significant interclass correlation (excellent for macronutrients and all food groups except vegetables (moderate, 0.79) and Bland-Altman plot analysis showed good agreement between the two methods.Angiosarcoma is an relatively rare tumor of mesenchymal origin affecting the liver, representing between 0.1% to 2% of all primary tumours of the liver. Angiosarcoma of liver affects mainly men in their sixth or seventh decade of life and carries a high mortality. No optimal treatment protocol and follow-up are yet available. Case reports of partial and total hepatectomy with neo adjuvant therapy are providing a fair survival in recent literature. Presentation of Case A 42-year-old male, of south Indian origin living in Middle east presented with persistent high-grade fever for 2 months duration. He was diagnosed with IBS 20 years back with chronic diarrhea and was on follow-up. Investigations suggestive of a liver abscess like mass and was referred here for persisting fever despite multiple antibiotics. He was evaluated here and found to have a large liver mass with a consistency of abscess on imaging with underlying cirrhosis. Tumor markers and other sepsis and parasitic workup were negative, expect for elevated CRP. He was attempted liver aspiration which showed a blood admixture filled tissue.so further aspiration was deferred and sent for HPE, which showed prominent vascular channels with adjourning necrotic tissues. Repeat assessment and IHC with further imaging were suggestive of a primary angiosarcoma of the liver along with changes of cirrhosis. Liver cells were immunohistochemistry for neoplastic cells CD31 and CD34 were positive. Patient was deemed candidate for a partial hepatectomy and was referred to a transplant unit. He was started on reductive chemotherapy which showed only marginal benefit. In spite best efforts he succumbed to the illness within a month. Conclusion Partial hepatectomy as surgical management, followed by adjuvant therapy, for liver angiosarcoma continues to prove favorable results and prognosis compared to liver transplantation. Keywords Angiosarcoma, Liver abscess, Cirrhosis

Pankaj Tyagi 1 , Pragya Shukla 2 , Mayur Churhe 1 Correspondence -Pankaj Tyagi -drpankajtyagi@gmail.com 1 Departments of Gastroenterology, and 2 Radiation oncology, DSCI, Dilshad Garden, Delhi 110 095, IndiaIntroduction Gastrointestinal (GI) malignancies are a big burden on the society and nation. With the increasing awareness, upcoming investigations and increase in number of the hospitals there is increasing number of the malignancy patients visiting the cancer institutes. Thus, we intend to see the change in number and frequency of the GI tumors in the span of last decade. Methods Retrospectively we analyzed the frequency and the number of different tumors presenting to over tertiary cancer institute, that is Delhi state cancer institute. From the total tumor burden we also analyzed the respective GI tumors frequency and numbers. We took the patient load of 2012 and 2019. Introduction Methanogenic small intestinal bacterial overgrowth (SIBO) has been renamed as intestinal methanogenic overgrowth. Methane production in human body is contributed predominantly by archae microbe Methanobrevibacter smithii. A methane producer is identified by detection of 10 ppm of methane anytime during lactulose breath test. Methanogenic SIBO population will be having mainly bloating, constipation and weight gain. Treatment of this SIBO will be combination of Rifaximin along with Neomycin or cyclical antibiotic therapy. Methods Patients having symptoms of SIBO were evaluated with routine investigations, endoscopy and breath tests and breath test were analysed for methanogenic overgrowth. Results In our study of 45 patients suspected to have SIBO, 34 patients had intestinal methanogenic overgrowth. Twenty-four patients had hydrogen producing SIBO and 23 had combination of M-SIBO and H-SIBO. Only one patient with positive hydrogen breath test didn't have associated methanogenic bacterial overgrowth, rest all had. Predominant complaints associated with methanogenic SIBO was constipation (44%), bloating (37%), flatulence (19%). Three percent of M-SIBO had For 3 months, she was started on continuous oral contraceptive pills to avoid ovulation. At the end of 3 months, a repeat CT imaging confirmed the resolution of hemoperitoneum. Thus, this patient with spontaneous hemoperitoneum, resolved with conservative management. Keywords Factor XIII deficiency, Spontaneous hemoperitoneum, Fresh frozen plasma Mutations in the genes thiopurine S-methyltransferase (TPMT) and nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) have been identified to predispose to severe myelosuppression with AZA. We report case of a 41-year old woman with history of hypothyroidism, diagnosed as autoimmune hepatitis (AIH) in June 2021 and started on AZA 50mg per day with prednisolone 40 mg/day with tapering dose on 28th June 2021. On 2nd August 2021 she presented with hair loss, sore throat, weakness and malaise since one week. On examination she had alopecia totalis. On evaluation she found to have myelosuppression (Hb 10.1 gm/dL, total count 2402 (absolute neutrophil count 216), platelet count 234200, with normal biochemical investigations and throat swab cultures. In view of myelosuppression, AZA was kept hold and low dose steroid omnacortil 10 mg/day was continued. After 5 days she had fever so empirical antibiotics (meropenem, amikacin and fluconazole) was started as per hematologist advise. Her neutropenia was worsening as mentioned in investigation chart and she was started on granulocyte colony stimulating factor. Her genetic testing for NUDT 15 *2 or *3 (c415C>T) heterozygous detected and No TPMT mutation detected. Gradually she was improving clinically and her leukopenia improved but thrombocytopenia persisted and for same she was evaluated by bone marrow study, Immunoglobulin profile and anti PF 4 antibodies which were normal and treated with Romiplostim. To conclude simple clinical clue such as alopecia can be a predictor of severe myelosuppression in patients on AZA apart from regular hemogram (as mentioned in Table 1 ). Further it is important to look for NUDT15 mutation apart from TPMT in patients before starting AZA in Indian population. Anorexia nervosa is an eating disorder characterized by excessive restriction on food intake and irrational fear of gaining weight, often accompanied by a distorted body self-perception. We report a case of 15-year-old male who presented with complaints of anorexia, postprandial abdominal pain, constipation, insomnia and weight loss of 10 kilograms since two years. On examination, BMI was 12 kg/m2. No signs of malabsorption were present he looked cachectic, emaciated with prominent maxillary prominences (Fig. 1) . Systemic examination was unremarkable, his all blood investigations were within normal limits except mild iron deficiency anaemia Hb 11.9 gm/dl and low vitamin D3 24.6. Other investigations for weight loss evaluation like CRP, ESR, TSH, cortisol, growth hormone, testosterone, HIV, renal function test, liver function test, ANA were within normal limits. Antibody to tissue transglutaminase and anti endomysial antibody were negative. Gastroscopy, full colonoscopy, CXR, CT abdomen and ECG were within normal limits. After excluding all organic causes, we discussed with his parents, his father gave history that since last two years he is insisting on eating less he is getting irritated and short tempered. So multidisciplinary approach was considered he was diagnosed as atypical eating disorder of anorexia nervosa, he was started on olanzapine, fluoxetine, and daily counselling. He was hospitalized for 5 days and slowly his diet and calorie intake were increased under observation he was observed for refeeding syndrome by monitoring electrolytes. On follow-up after 6 months, he gained weight approximately 20 kilograms to 35 kilograms, BMI 18 kg/m2, he was now cheerful, having good appetite and taking parts in all sports in school (Fig. 2) . By reporting this case we want to create awareness among doctors which help in early diagnosis of eating disorder and prevent unnecessary investigations. Keywords Anorexia nervosa, Atypical eating disorder, Adolescent Introduction To evaluate the etiology, presentation, risk factors for rupture, management, and outcomes at 1 month in a tertiary care center for mesenteric aneurysms and pseudoaneurysms. Methods We performed retrospective analysis of data from 2017-2021 at a tertiary care centre in Western India of all the patients who were diagnosed with mesenteric aneurysms and pseudoaneurysms. Results Fifty-seven aneurysms and 48 pseudoaneurysms in 74 patients were studied. The most commonly involved vessels were splenic artery (69.5%) and gastroduodenal artery (GDA) (17.1%). About 75.6% patients were symptomatic, 51.3% had gastrointestinal bleeding (GI bleeding) and 24.3% abdominal pain. The most common etiologies noted were -chronic pancreatitis (35.1%) and decompensated cirrhosis (20.1%). Almost all patients with pseudoaneurysms were symptomatic (p<0.0001). True aneurysms were more likely to be multiple, as compared to pseudoaneurysms (1.84+1.93 vs. 1.12+0.32; p=0.009). There was no significant difference in mortality and rebleed at one month between aneurysms and pseudoaneurysms (p=0.4887 and p=0.873). Male patients were found to have a higher risk of GI bleeding, irrespective of etiology (p=0.006), whereas female patients were more likely to have complications post intervention (p=0.04). Interventional radiology guided treatment was offered in the form of angiographic coiling (40.5%), angiographic glue injection (17.6%) and angiographic glue+coiling Background and Aim Patients with inflammatory bowel disease (IBD) are at increased risk for infections owing to altered cellular and humoral immunity. Predisposing factors include age, co-morbidities, protein energy malnutrition, use of immunosuppressive medications and surgery. Various vaccine preventable diseases in IBD can be avoided by administration of the concerned vaccines. There is limited information on vaccination status in patients with IBD. We aimed to assess vaccination status in this population for the recommended vaccines. Methods IBD patients aged greater than 18 years and fulfilling inclusion criteria were included in the study after taking informed consent. We utilized a questionnaire to capture patient data which was subsequently analyzed. The prevalence of the recommended vaccines and reasons for not adhering to the vaccination schedule were assessed. Results Eighty-nine IBD patients were recruited, of which 44 (49%) patients had ulcerative colitis and 45 (51%) had Crohn's disease. Forty-five (51%) patients were on immunomodulators. Sixty-five (73%) patients were unvaccinated, 24 (27%) were partially vaccinated while only 4 (4.5%) completed the recommended vaccine schedule. Lack of knowledge (59.2%) and financial reasons (43.5%) were the most common reasons for non-adherence to the vaccine schedule. Conclusion Vaccination appears to be underutilized in our IBD population. More effort needs to be taken to motivate these patients to get vaccinated and thereby reduce the risk of preventable diseases.

Clostridoitis difficile is recognized globally as an important enteric pathogen associated with considerable morbidity and mortality. We have been experiencing increasing incidence of Clostridoitis difficile associated diarrhea (CDAD) in our hospital. To evaluate the same, we took up this study. Methods All adult patients of diarrhea, who presented to our hospital for last six months and whose samples were sent for stool testing for Clostridoitis difficile were included in the study. All demographic and clinical profile, possible risk factors and treatment response were evaluated. Clostridoitis difficile associated diarrhea (CDAD) was confirmed with detection of Toxin A or B or both with ELISA technique. Results Total of 255 patients with diarrhoea were studied. The prevalence of only toxin positive cases was 22.35% (57/255) and only glutamate dehydrogenase (GDH) antigen positive cases was 7.45% with an overall prevalence of 29.8 %. Nosocomial infection, community acquired and hospital associated comprised of 59.64% 35.08% and 5.28%, respectively. Multivariate analysis revealed that recent antibiotic use (cephalosporins and carbapenems), PPI use more than 5 days, steroid use more than 2 weeks, ICU stay and chemotherapy were independent risk factors associated with CDAD. Nasogastric intubation was observed to be a protective factor against CDAD. Response rates to vancomycin and metronidazole were 85.94%. Non-responders were treated with teicoplanin with response rate of 62.54%. Fecal microbiota transplant (FMT) was done in 3 patients, and all responded to it. The recurrence rate of CDI was 7.01%. Thirty-day mortality rate was 3.5%. Conclusion CDAD is one of the main causes of acute diarrhea, including in the community set up. PPIs, antibiotics, chemotherapy agents, steroids and ICU stay are the main risk factors for CDAD. Vancomycin and metronidazole are good first line treatment options for CDAD. Teicoplanin or FMT can be used in unresponsive cases.Introduction Malnutrition and low body weight are frequently observed in inflammatory bowel disease (IBD), especially Crohn's disease (CD). However, data on frequency of overweight/obesity IBD is limited from India. We aimed to assess the frequency of overweight/obesity in Indian patients with IBD and determine its associations with disease characteristics. Methodology The case records of patients with CD or ulcerative colitis (UC) seen in the out-patient department were retrospectively reviewed. The type of IBD (CD or UC) and clinical details including body mass index (BMI) were recorded on a structured form. The value of BMI was categorized into three groups according to the Asian-Pacific classification: Underweight (<18.5 kg/m2); Normal weight (18.5-22.9 kg/m2); Overweight/obese (>23 kg/m2). Complicated disease behaviour in CD was defined as structuring (B2) and/or penetrating (B3) and/or perianal disease (P). Statistical tests were done to assess for associations and p value of <0.05 was considered significant. Introduction Melioidosis is a systemic infectious disease caused by Burkholderia pseudomallei. Diabetes, renal disease, thalassemia, and occupational exposure to environmental contaminants are some of the risk factors for severe melioidosis. Splenic abscess is very rare, with only a few reports in the literature. We are reporting a case of splenic abscess due to B. pseudomallei infection. Case Report A HbE thalassemic 60-year-old male farmer from West Bengal with a past history of cholecystectomy in 2014 presented to our OPD with left upper abdominal pain, on and off fever and 20 kg weight loss since 2015. Patient had received multiple courses of antibiotics and also empirical ATT of 6 months with no improvement in symptoms. Abdominal examination revealed nontender moderate splenomegaly. Laboratory investigations revealed microcytic hypochromic anemia with hemoglobin-7g/dL. CECT abdomen showed splenomegaly with splenic and peri-splenic abscesses,17 mm in maximum width. USG guided perisplenic abscess aspirate showed pus with total counts >1.0 lakh/mL, predominantly neutrophilic (78%). Aspirate culture grew Burkholderia pseudomallei sensitive to ceftazidime and cotrimoxazole. The patient was treated with ceftazidime intravenously for 14 days and discharged with oral cotrimoxazole for a duration of 3 months. Patient was afebrile after 2 days of starting ceftazidime. Discussion Clinical manifestations of melioidosis include septicaemia, community-acquired pneumonia localized soft tissue lesions and visceral abscesses. Affected patients usually have well-known predisposing factor. Pre-existing thalassemia and wound inoculation during previous surgery could have hypothetically contributed to melioidosis in our patient. Conclusion B pseudomallei is a potential causative organism of splenic abscess in patients with risk factors who reside in endemic areas. A high index of suspicion is needed for diagnosis due to its varied clinical presentations. Isolation of organism from the infection site is the only diagnostic method for visceral abscess melioidosis. Appropriate antibiotics and abscess drainage contributes to a successful outcome. Introduction Percutaneous endoscopic gastrostomy (PEG) tube is an endoscopic procedure for enteral nutrition in patients unfit for per oral feeding. Indications of PEG tube include neurological conditions compromising swallow mechanism like stroke, in some post craniotomy cases, dementia etc. It is also done for maintaining nutrition in elderly debilitated individuals and in rarer instances, gastric decompression in gastric volvulus. Methods This was a retrospective analysis of a prospectively maintained data. We report the data from 01/01/2018 till 31/08/2021 of PEG tube insertion done in our center. Contraindications like active systemic infection, ascites, hemodynamic instability and bleeding diathesis were ruled out before patient selection. Written informed consent was obtained. Anticoagulants were stopped 12 hours prior to procedure. Patients were administered intravenous antibiotic Ceftriaxone 1 g 12 hours prior to procedure and post-procedural 12 hourly for 48 hours. PEG tube was placed using "pull" through technique. PEG tube feeding was started 3 hours after the procedure, and 360-degree counter-rotation manoeuvre was done 12 hours after procedure. Pre-existing PEG tube were changed if the tube was blocked or kinked after prolonged use. Results Total 88 patients underwent PEG tube insertion. Out of which, 75 were first time procedures and in 13 patients, change of pre-existing PEG tube was done from same stoma. In one patient (1.13%), PEG tube had to be removed because of stoma site infection and peritonitis. Two patients developed buried bumper syndrome (2.27%) eight-and 10-months postprocedure, for which PEG tube was changed from the same stoma site after removal of previous tube using snare polypectomy forcep. Conclusions PEG is a therapeutic procedure with high utility in maintaining enteral nutrition of patients unfit for per oral enteral feeds or requiring prolonged nasogastric feeds. Complication rates are low if done with all precautions and good care of stoma. Keywords Pull through technique, Endoscopy, Buried bumper syndrome Corona virus causes severe pneumonia in 5% cases rarely gastrointestinal (GI) problem, we present case series. Forty-nine male corona virus disease 2019 (COVID-19) pneumonia acute abdomen, WBC increased, D-dimer high, CT angiography abdomen superior mesenteric vein thrombosis, dilated inflamed jejunal ileal bowel loops, started on LMW heparin supportive care, recovered. Sixty-two years old obese, diabetic hypertensive male with severe covid, acute abdomen. CECT abdomen thrombosis of superior mesenteric artery, D-dimer high Injection Alteplase, injection Enoxaparin expired.Twenty-eight years female COVID-19 presented with acute abdomen, Ddimer 15 ng/mL, CECT abdomen confirmed portal vein thrombosis. managed with enoxapain and supportive treatment, recovered well. Thirty-seven-year-old male alcoholic liver Covid pneumonia, Covid toe, abdominal distension. Abdominal Doppler confirmed portal vein thrombosis, D-dimer 9500 ng/mL. Started on steroid, anticoagulant improved well clinically, recovered started on oral feed but developed gross GI bleed, cardiogenic shock expired. One male 55-year-old with h/o covid pneumonia 5 months back presented with acute abdomen on CECT abdomen PV and PMV thrombosis diagnosed, D-dimer 4750 ng/mL, started on anticoagulant, conservatively managed. Thrombosis in COVID-19 is due to endothelial injury by acute phase reactants, activation of tissue factor pathway, excess thrombin fibrin generation, fibrinolysis shutdown. We are first from India to reports two cases with portovein thrombosis, one case each with SMV and SMA thrombosis. We could save two young cases with low D-dimer and less severe Covid pneumonia and no comorbidities. COVID-19 can cause portal vein and SMA thrombosis, patient may present with GI emergency, awareness of these complication and timely therapy can save lives. COVID-19 induced procoagulant state can cause mesenteric artery and portal vein thrombosis, purpose of this case series is to increase awareness and diagnosis of this complication in cases with acute abdomen for timely intervention parallel to respiratory support. Background and Study Aim Variceal bleeding is a life-threatening event that has an incidence of 5% and 15 % in patients with small and large esophageal varices respectively. Endoscopic screening for esophageal varices in cirrhotic patients is mandatory. The aim was to study the role of liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) in predicting the risk of variceal bleed in patients with cirrhosis. Methods Single centre longitudinal study conducted on chronic liver disease patients (CLD) who underwent fibroscan over a period of 12 months from October 2020 to October 2022. A total of 70 patients were included in this study. LSM and SSM values of cirrhotics with history of UGI bleed (cases) were compared to those without any history of UGI bleed (controls). We report the case of a 22-year-old woman with a 5-day history of watery stool, generalized abdominal pain, repeated vomiting, and decreased urine output following the consumption of fish gallbladder for selftreatment of obesity. She was admitted and received empirical antiemetic, proton pump inhibitor, and intravenous saline treatment. Urine output reduced drastically with markedly elevated urea and creatinine, and she underwent urgent hemodialysis (HD). Based on thorough history taking and prompt biochemical investigations that showed extremely high urea and creatinine levels, we made a diagnosis of acute kidney injury (AKI) secondary to fish gallbladder poisoning. Renal function improved over a period of 5 weeks. Fish gallbladder poisoning is infrequent in India. The condition is commonly reversible, and therefore proper history taking is important and prompt biochemical investigations including blood urea and creatinine are needed to enable early diagnosis and fast institution of treatment, which may include HD.

Keywords GERD, non-GERD, Helicobacter pylori, Outer membrane protein coding genes 512 An unusual case of celiac disease with associated non-cirrhotic portal hypertension and autoimmune gastritis with squamous cell carcinoma Prasanna Gore, Dattatray Solanke Correspondence -Prasanna Gore -drprasannagore@gmail.com Department of Medical Gastroenterology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Rao Saheb, Achutrao Patwardhan Marg, Four Bungalows, Andheri West, Mumbai 400 053, India A 42-year-old male came with complaints of easy fatiguability, generalized weakness, loss of appetite, breathlessness on exertion, failure to gain weight, early satiety. Patient has history of chronic iron deficiency anemia. On examination patient had pallor, cachexia. Investigation showed severe iron deficiency anemia, hypoalbuminemia, mild deranged LFT. Patient was transfused IV iron, albumin and all the supportive medication. Patient was posted for upper GI endoscopy which revealed UES web dilated through scope, esophageal varices banded, atrophic gastric folds biopsy taken, scope (adult) could not be negotiated further to pylorus due to the stricture hence pediatric scope used and D2 had scalloping hence biopsy taken. Gastric biopsy showed autoimmune gastritis. D2 biopsy showed MARSH grade 3, simultaneously tTg-IgA levels sent which was 170. He was kept on gluten-free diet. Patient USG abdomen showed changes of liver cirrhosis with changes of portal hypertension. Patient was evaluated for cause of cirrhosis, HIV negative, HbSAg negative, anti-HCV negative, HAV and HEV IgM negative, Kayser-Fleischer (KF) ring not seen, serum ceruloplasmin normal. Hence as the cause of cirrhosis was not known patient was posted for Liver biopsy which was done and suggestive of non-cirrhotic portal hypertension. Patient later on follow-up had neck mass, fine needle aspiration cytology (FNAC) of which showed squamous cell carcinoma with unknown primary, which was operated. Unusual things in the case is non-cirrhotic portal hypertension associated celiac and autoimmune gastritis associated with celiac. Association with squamous malignancy likely due to long-term malabsorption with multivitamin deficiency. Keywords Celiac, Non-cirrhotic portal hypertension, Autoimmune gastritis 513 Online wellness programme a useful tool for irritable bowel syndrome patients Neeraj Nagaich 1 , Radha Sharma 2 Correspondence -Neeraj Nagaich -drneerajn@gmail.com 1 Department of Gastroenterology, Fortis Escorts, Jaipur 302 020, India, 2 Department of Pathology, RUHS CMS Medical College, Jaipur 302 020, IndiaObjectives Irritable bowel syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder which affects nearly 5% to 11% of the population and behavioral approaches have shown efficacy in reducing IBS symptoms. A large unmet need for non-pharmacologic tool for IBS patients. Lifestyle changes may be helpful in subgroup of patients. This prospective and retrospective study was done to evaluate efficacy of lifestyle changes implemented via wellness programme in IBS patients. Methods Wellness programme comprise of daily Swasthi sadhana, dietary and other lifestyle changes. In this study 51 patients who completed online wellness programme (5 day) and followed lifestyle changes as instructed for 8 weeks. Observations of symptoms was done a decrease was seen in GIQLI domains of core symptoms psychological symptoms and physical symptoms, there was also lesser requirement of medicine. Results In all the patients a significant decrease was reflected in the GIQLI symptoms, psychological symptoms and physical symptoms there was also lesser requirement of medicine in the patients following wellness program as compared to other patients of IBS not following life style changes of wellness programme. Conclusions Online Wellness programme is an useful approach to implement lifestyle changes and may help IBS patients. Needs revalidation in larger cohort in future studies.A 28-year-old female presented with episodic painless diarrhea 6 to 7 months associated with weight loss of 12 kgs over last 7 months. She gave H/O-"not having meals with fear of increasing loose stools". She had received two units of PRBC at native place for anemia. Her symptoms used to subside with antibiotics and metronidazole. However generalised weakness persisted. Over the last 2 -3 months she noticed tingling numbness in lower limb which had progressed to inability to walk since 2 weeks. Relatives also complained of increased irritability and refusal for admission and investigations. On examination she was cachexic, pale and had stable vitals. CNS examination revealed dysdiadokokinesia, ataxia, dysmetria, sensory neuropathy signs and power in all four limb was 5/5. Lab investigations revealed microcytic anemia with iron deficiency and normal UGI endoscopy. D2 biopsy showed nonspecific changes. I g A TTG and anti-DGP was negative. NCV revealed distal symmetrical axonal sensory polyneuropathy. Opthalmology evaluation and VEP revealed prolonged P100 latency in both eyes. MRI brain revealed B/L altered signal in dentate, dorsal pons and medulla. Cerebellum was normal What is the diagnosis?Introduction Hand grip strength (HGS) is a measure of the maximum static force that a hand can squeeze using a dynamometer. There are variations in HGS depending on race, sex, and age. HGS is measured for normal subjects and normative reference data dependent on sex and age are being used in clinical practice. We set out to establish the same amongst the Indian population. Aim To determine normal hand grip metrics in young adult population. Methods This cross-sectional descriptive study recruited 458 healthy male and female medical students between the age of 18 and above from a tertiary university hospital in Southern India. Their basic profilic data including age, gender, height, weight, food habits, place of origin(state) were collected. BMI was calculated. Hand grip strength was assessed in the dominant hand by using a Camry Hand Dynamometer with a mean of three values. Results Statistical analysis done. Mean BMI in the study group was 23.7 kg/sq.m. Age groups divided into three groups as 18-19, 20-24 and 25-30 and above among males and females. Mean value of three hand dynamometer measurements determined. Normal reference range was compared with the values obtained for weak, normal or strong hand grip strength among males and females. Conclusion BMI and dietary habits did not correlate with hand grip strength measurements. Males of age group 20-24 had highest normal range when compared with others and was statistically significant. Keywords Hand dynamometer, Hand grip strength, Body mass index 518 Real time assessment of mucosal impedance as a marker of mucosal pathology: A prospective study