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CONFERENCE ABSTRACT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 178-187

Abstracts of case presentations at the mid-term conference of the Tamil Nadu chapter of the Indian society of gastroenterology, September 24, 2022, christian medical college new Campus, Vellore


Date of Web Publication13-Oct-2022

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_26_22

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How to cite this article:
. Abstracts of case presentations at the mid-term conference of the Tamil Nadu chapter of the Indian society of gastroenterology, September 24, 2022, christian medical college new Campus, Vellore. Gastroenterol Hepatol Endosc Pract 2022;2:178-87

How to cite this URL:
. Abstracts of case presentations at the mid-term conference of the Tamil Nadu chapter of the Indian society of gastroenterology, September 24, 2022, christian medical college new Campus, Vellore. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Nov 27];2:178-87. Available from: http://www.ghepjournal.com/text.asp?2022/2/4/178/358478




  Hepatology Top



  Abstract – 01 Top


Hepatocellular Carcinoma in Noncirrhotic Liver in a Patient with Chronic Hepatitis B Infection and Von Willebrand Factor Deficiency

N. Amruthavarshini, Santhosh E. Kumar, Uday Zachariah, Ashish Goel, Sukesh Nair1, C. E. Eapen

Departments of Hepatology and 1Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Plasma von Willebrand factor (VWF) levels increase proportionately with severity of cirrhosis and raised VWF levels independently predict ascites, variceal bleeding, and mortality in patients with cirrhosis. Case Presentation: A 31-year-old woman, a known case of von Willebrand disease (VWF deficiency type 2) requiring frequent factor placement for the past 24 years, presented with right upper quadrant abdominal pain for 3 months and loss of appetite and weight. Clinical examination was normal. Serum total bilirubin 0.55 mg/dl, total protein 7 g/dl, albumin 4.4 g/dl, aspartate transaminase 28 U/L, alanine transaminase 15 U/L, alkaline phosphatase 11 U/L, coagulation profile: prothrombin time – 9 s, activated partial thromboplastin time – 42.1 s, platelets – 3,21,000/mm3, VWF antigen 17 IU/dl (normal: 50–150 IU/dl), VWF ristocetin activity 5.5%, VWF collagen-binding activity 2.9%. Hepatitis B surface antigen positive, hepatitis B e antigen negative, hepatitis B virus (HBV) DNA <10 IU/ml. Serum alpha-fetoprotein: 2172 IU/ml. Ultrasonography abdomen: focal liver lesion (4.2 cm × 3.8 cm sized). Gastroscopy: normal, no varices. Computed tomography abdomen: arterial phase hyperenhancing, 4 cm × 3 cm lesion with venous phase washout in segment 8, 4b of the liver suggestive of probable hepatocellular carcinoma, no features of portal hypertension or cirrhosis. She was started on tenofovir and is being considered for curative liver tumor resection. Discussion: Raised plasma VWF levels correlate with increasing severity of cirrhosis and portal hypertension in humans (PMID: 31498279). VWF gene knockout mice studies show that VWF deficiency protects against the development of cirrhosis (PMID: 28527913). In most patients with chronic HBV infection, hepatocellular carcinoma develops on the background of cirrhosis; <10% of hepatocellular carcinoma develops in noncirrhotic liver (PMID: 27693539). It is possible that in our patient with chronic hepatitis B and hepatocellular carcinoma, VWF deficiency protected against the development of cirrhosis and portal hypertension. Conclusions: Plasma VWF level is a marker of liver disease severity and may play a key role in pathogenesis of liver fibrosis and portal hypertension. In our patient, congenital VWF deficiency may have protected against the development of cirrhosis and portal hypertension.


  Abstract – 02 Top


A Rare Cause of Space-Occupying Lesion in The Liver

V. Swaapnika, Nishanth Paturi, Dhanush Thomas, L. Venkatakrishnan, S. Mukundan, P. Thirumal, R. K. Karthikeyan, P. Arun

Department of Gastroenterology, PSG Hospital, Coimbatore, Tamil Nadu, India

Background: Synovial sarcoma is a highly malignant soft tissue sarcoma of unknown histologic origin with the ability for biphasic differentiation, occurring in young adults in the vicinity of large joints of the extremities with a median age at onset of 35 years. Synovial sarcoma that originates from the liver is extremely rare. Very few cases have been reported in the domestic and international literature. Case Presentation: We present the case of an 84-year-old diabetic, hypertensive male with no addictions, who complained of dull aching right hypochondrial pain over the past 6 days. Blood investigations revealed normocytic normochromic anemia, elevated alkaline phosphatase with albumin:globulin reversal, normal blood sugar, and renal functions. Viral serology was negative. Ultrasound abdomen showed an irregular ill-defined iso-to-hyperechoic lesion, 10.6 cm × 6.6 cm sized, in the right lobe of the liver. Contrast-enhanced computed tomography abdomen revealed a large heterogeneously enhancing liver lesion, 9.7 cm × 9.3 cm × 8.1 cm sized, with centrally nonenhancing area involving segments IV, V, and VIII with washout on delayed images, with thrombosis of the middle and left hepatic veins, extending into inferior vena cava confluence and partial thrombosis of the left branch of the portal vein. Tumor markers were within normal limits. Biopsy from the liver lesion showed spindle-shaped cells arranged in sheets and fascicles which stained positive for vimentin and TLE1. Hence, pathological diagnosis was considered to be hepatic synovial sarcoma. Cytogenetic analysis confirmed the diagnosis – it revealed fusion gene SS18-SSX1. In view of elderly age and poor performance status after discussing with oncology and surgical gastroenterology teams, surgical management was deferred and decided to proceed with medical management (pazopanib). Following the initiation of treatment, the patient improved symptomatically. Conclusions: Synovial sarcoma of the liver is a rare malignancy, which is difficult to diagnose, and confirmation of diagnosis is based on histopathological assessment combined with immunohistochemical staining and if necessary cytogenetic aids.


  Abstract – 03 Top


A Case of Pregnancy Associated Liver Failure Managed with Therapeutic Plasma Exchange

Sushovan Baidya, Uday Zachariah, E. Santhosh Kumar, Kunwar Ashish Singh, C. E. Eapen, Santosh Varughese1, Dolly Daniel2, Subramani Kandasamy3, Ashish Goel

Departments of Hepatology, 1Nephrology, 2Transfusion Medicine and Immunohaematology and 3Surgical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India

Background: We present an unusual case of peripartum acute-on-chronic liver failure complicated by thrombotic microangiopathy managed successfully with therapeutic plasma exchange. Case Presentation: A 21-year-old woman (G1P1), with no history of gestational diabetes mellitus or hypertension, delivered a 3.5-kg healthy girl baby at 39 weeks by cesarean section. She was noted to have ascites during surgery and postoperatively developed a decrease in urine output, worsening ascites, along with abdominal pain and jaundice. She became hypotensive with deterioration in the sensorium. She presented to our center 1 day after delivery and had icterus, altered sensorium, ascites, and splenomegaly. Investigations showed thrombocytopenia (platelet count – 15,000/mm3), hyperbilirubinemia (serum total bilirubin – 18 mg/dl, direct bilirubin – 14.14, total protein – 3.1, albumin – 1.9, aspartate transaminase – 259, alanine transaminase – 73, and alkaline phosphatase – 46), coagulopathy (international normalized ratio – 3.5), acute kidney injury (serum creatinine – 2.5 mg/dl), and lactic acidosis. Ultrasound scan showed mildly coarse echotexture of the liver with volume redistribution, ascites, splenomegaly, attenuated portal vein replaced by collaterals, and no retained products of conception. Gastroscopy showed small esophageal varices. The presence of thrombocytopenia, kidney injury, high schistocytes (9.88%) on peripheral smear, raised lactate dehydrogenase, and low ADAMTS13 (24%) suggested thrombotic microangiopathy – probable postpartum HELLP syndrome. Etiological evaluation was negative for alternate etiology of thrombotic microangiopathy (like tropical fever syndromes, Wilsonian crisis, and sepsis). Viral serology (HBsAg, anti-HCV, HIV, IgM HAV, and IgM HEV) was negative. We considered a diagnosis of extrahepatic portal vein obstruction and postpartum HELLP syndrome. Besides supportive management, which included mechanical ventilation and renal replacement, the patient underwent five sessions of therapeutic plasma exchange. Cumulatively, plasma volume of 7300 ml was replaced with an equal volume of fresh frozen plasma over 7 days. The patient was also given broad-spectrum antibiotics with low-dose steroids. The patient showed gradual improvement in general condition and renal function and was discharged in a stable state after an in-hospital stay of 51 days, which included 25 days on ventilator and 40 days in intensive care unit. The patient remains well after 10 months of follow-up. Conclusions: Thrombotic microangiopathy can rarely present in the peripartum period and may be associated with HELLP syndrome. The case highlights the benefit of therapeutic plasma exchange in managing this condition.


  Abstract – 04 Top


A Rare Case of Congenital Afibrinogenemia with Portal Vein Thrombosis and Variceal Bleeding

Amith Viswanath, E. Santhosh Kumar1, Kunwar Ashish Singh1, Ashish Goel1, Anup Devassia2, Sukesh Nair3, Uday Zachariah1

Departments of Gastroenterology, 1Hepatology, 2Haematology and 3Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Congenital afibrinogenemia (CA) is a hereditary coagulation disorder with an incidence of 1 in million. Paradoxical arterial and venous thromboses have been reported. We present a rare complication with portal vein thrombosis and variceal bleeding. Case Presentation: A 32-year-old woman from Tamil Nadu presented to our center in 2021 with a history of hematemesis. She was initially evaluated in the Haematology Department for menorrhagia in 2013 and diagnosed with CA. She had an extensive bleeding history which included easy bruising, gum bleeding, ecchymosis, bleeding from trauma sites, and hemarthrosis from childhood. She was treated on multiple occasions with cryoprecipitate and packed cell transfusions and with fibrinogen concentrate in 2013. She was born to parents of nonconsanguineous marriage. She did not have any family member with bleeding tendency. Laboratory analysis showed undetectable fibrinogen, prothrombin time >2 min, international normalized ratio >10, and activated partial thromboplastin time >3 min. Gastroscopy, done after cryoprecipitate transfusion, showed large esophageal varices, and endoscopic variceal ligation was done. Imaging showed portal vein thrombosis with cirrhotic liver. She was started on beta-blockers. Focused next-generation sequencing showed FGA gene deletion seen in CA. She required three more sessions of variceal ligation for eradication. She did not have any further episodes of variceal bleeding. Each session of variceal ligation was done under the cover of cryoprecipitate transfusion. She did not develop any further decompensation and is on regular follow-up. Conclusions: This case highlights the role of fibrinogen in bleeding and thrombosis. Liver transplantation cures CA and has been safely performed in selected few patients.


  Abstract – 05 Top


Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, and Skin changes Syndrome? of a Different Kind

Anbu Krithigha Dharmalingam, A. K. Koushik, P. Ganesh, Shanmuganathan Subramanyam

Department of Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Background: Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a rare entity, the exact prevalence of which is unclear. It was estimated to be 0.3 in 1 lakh population in a nationwide study conducted in Japan from 2012 to 2015. As it is an indolent plasma cell dyscrasia which involves multiple systems over months to years, the diagnosis is quite challenging. Here, we present such a case of POEMS syndrome. Case Presentation: A 53-year-old male from Cuddalore presented with abdominal distension and swelling of legs over the past year and a 4-day history of diarrhea and reduced urine output. He also gave a history of significant weight loss and a history of sensory-motor axonal neuropathy, for which he was treated with high-dose steroids and mycophenolate 4 years ago. He has systemic hypertension for 7 years and coronary artery disease, coronary angioplasty done 4 years ago, for which he is on regular medications. On evaluation, he had massive ascites with high protein, high serum-ascites albumin gradient, hepatosplenomegaly with no features of cirrhosis, acute kidney injury with metabolic acidosis, hyperkalemia, primary adrenal insufficiency, hypothyroidism, sclerotic D8 vertebra, diffuse skin hyperpigmentation, and bilateral papilledema. He was suspected to have a hematological malignancy and was evaluated further. Myeloma workup done showed elevated IgA levels, M band in serum protein electrophoresis with elevated levels of IgA lambda monoclonal protein detected by immunofixation. Bone marrow biopsy findings confirmed the presence of monoclonal gammopathy. Skin biopsy showed increased pigmentation in the basal layer. As the patient had polyneuropathy, organomegaly (hepatosplenomegaly), endocrinopathy (adrenal insufficiency and hypothyroidism), monoclonal gammopathy, and skin changes along with serositis and bilateral papilledema, a diagnosis of POEMS syndrome was made. A hematologist was consulted, and the patient was started on lenalidomide and dexamethasone. On review after 2 weeks, the patient was doing well. Conclusions: POEMS syndrome is a rare disease which presents with polyneuropathy and gammopathy with osteosclerotic bone lesions. Hepatosplenomegaly and serositis being the presenting feature is very rare, as seen in this case.


  Abstract – 06 Top


Hepatic Inflammatory Pseudotumor or Tuberculosis: Mystery Unsolved

V. S. Vijesh, Vijay Alexander1, Santhosh E. Kumar1, Kunwar Ashish Singh1, Uday Zachariah1, Ashish Goel1

Departments of Gastroenterology and 1Hepatology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Tuberculosis with varied clinical and systemic presentations is a great masquerader. Case Presentation: A 43-year-old man presented with chronic cough, significant loss of weight, and loss of appetite. Evaluation elsewhere revealed an abscess in the right lobe of the liver, for which he was initiated on antibiotics. Repeat imaging revealed a focal lesion in segment VIII of the liver with capsular retraction suggestive of intrahepatic cholangiocarcinoma. Ultrasound-guided biopsy of the liver lesion showed extensive fibrosis and mixed inflammatory cells with no evidence of malignancy. He developed ascites and pleural effusions (both exudative and lymphocyte predominant) and presented to our center for further evaluation after 10 months from symptom onset. Liver function tests showed an infiltrative pattern. Differentials considered were advanced cholangiocarcinoma, tuberculosis, lymphoma, or sarcoidosis. Magnetic resonance imaging abdomen showed a T2 hyperintense lesion in the right lobe of the liver (14.5 cm × 10 cm sized) with features suggestive of cholangiocarcinoma. Repeat biopsy revealed chronic inflammation with fibroblastic tissue. Probable diagnosis of inflammatory pseudotumor of the liver was considered and was decided to keep the patient under follow-up. At 2-month follow-up, repeat imaging showed a reduction in size of the liver lesion with two focal collections suggestive of abscess. Biopsy from the lesion showed dense inflammatory-rich spindle cells. In view of the morphology and negative immunoprofile in all the biopsies, an inflammatory myofibroblastic tumor was considered. Liver resection was planned. However, the patient was lost to follow-up. He presented with progressive vomiting and cachexia after 3 months. Computed tomography (CT) scan showed innumerable discrete and confluent nodules in both lungs. CT brain showed hydrocephalus. He was started on empirical antitubercular therapy with dexamethasone. Emergency external ventricular drain was done. Cerebrospinal fluid (CSF) analysis showed 61 mg/dl protein and 65 mg/dl glucose (random blood sugar: 124 mg/dl) with 15 cells/mm3. CSF GeneXpert was low positive. He succumbed to his illness despite maximal care. MGIT culture grew mycobacterium tuberculosis after 9 weeks in CSF and after 13 weeks in endotracheal aspirate. Conclusions: Tuberculosis should be considered a strong differential for inflammatory pseudotumor of the liver. Tissue diagnosis generally helps differentiate the two. When in doubt, surgical excision should be considered.


  Abstract – 07 Top


Langerhans Cell Histiocytosis with Multisystem Involvement

Ashis Kumar Choudhury, Kunwar Ashish Singh1, Uday Zachariah1, Mohammed Anwar Hussain2, Nihal Thomas2, Thomas V. Paul2, Mithun Abraham Prakash3, T. Mathu Mithra3, Biju George3, P. Janani4, Thomas Alex4

Departments of Gastroenterology, 1Hepatology, 2Endocrinology, 3Hematology and 4Pathology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Infiltrative pattern of liver disease is usually seen in diseases such as disseminated tuberculosis, lymphoma, sarcoidosis, and amyloidosis. We present a case of Langerhans cell histiocytosis with multisystem involvement which presented as infiltrative liver disease. Proper diagnosis of such cases is the most important prerequisite for correct treatment. Case Presentation: A 42-year-old male presented with nonhealing ulcers over the hard palate for 6 months with a weight loss of 11 kg. There was a history of fever for 15 days and pain over the lateral aspect of the left lower chest wall. Five years back, he had polyuria and polydipsia and was treated with desmopressin. On examination, there were two oral ulcers over the hard palate without any genital ulcer. Laboratory investigations revealed normocytic normochromic anemia, serum alkaline phosphatase 595 IU/L, and gamma-glutamyltransferase 416 U/L. Based on these findings, infiltrative liver disease with probable central diabetes insipidus was suspected. The differentials considered were sarcoidosis, tuberculosis, lymphoma, and amyloidosis. Serum calcium was 8.08 mg/dl and angiotensin-converting enzyme level was 31 U/L. There was no evidence of tuberculosis and sarcoidosis in computed tomography (CT) chest. Bone marrow biopsy was not suggestive of lymphoma. Serum electrophoresis showed a generalized increase in gamma globulins. Urine for Bence Jones protein and serum immunofixation electrophoresis were negative. Magnetic resonance imaging brain showed an intensely enhancing lesion in the proximal pituitary stalk. CT thorax and abdomen showed multiple lung nodules, fracture of the right 10th rib, and multiple hypodense rounded lesions in the liver. Magnetic resonance cholangiopancreatography abdomen showed multiple T2W hyperintense nodules studded all over the liver with normal spleen. Slide of liver biopsy performed outside revealed periportal eosinophil-rich atypical histiocytic aggregates with positive CD1a and S100 suggesting Langerhans cell histiocytosis. The patient was started on prednisolone and vinblastine, following which significant clinical improvement was seen within 5 months. Conclusions: Although Langerhans cell histiocytosis is less common in adults, it should be considered one of the differentials whenever there is an infiltrative liver disease with multisystem involvement.


  Abstract – 08 Top


A “Needle” in a Haystack

R. D. Mitul, V. Y. Bhargav, Karthikeyan Mu Ka, S. Sankar1, T. K. Anand2, Jayanthi Venkataraman

Departments of Hepatology, 1Surgical Gastroenterology and 2Medical Gastroenterology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Background: We report an unusual presentation of ampullary carcinoma masquerading as a liver abscess that was complicated by hepatobronchial fistula, refractory to medical treatment. Case Presentation: A 51-year-old male presented with dull, dragging pain in the right hypochondrium and right chest, cough with expectoration, and intermittent high-grade fever with chills for 9 months. He was diagnosed with a liver abscess in September 2021 and had percutaneous drain twice. Appetite was preserved. He had a weight loss of 2 kg. There was no history of jaundice or diarrhea. The patient was a teetotaller and nonsmoker. On examination, vitals were normal, body mass index: 23 kg/m2, no icterus. Systemic examination – Cardiovascular system normal, respiratory system: bilateral basal crepts, Per abdomen liver was palpable 4 cm; liver span 15 cm; intercostal tenderness was present; scar of drainage site noted. Hemoglobin – 9.9 g/dL; white blood cell, platelets – normal; renal function test/electrolytes – normal; blood sugar – 214 mg/dL; liver biochemistry – normal bilirubin and transaminases, albumin – 2.1 g/dL, SAP – 214 IU/L, gamma-glutamyltransferase (GGT) – 93 IU/L. Chest X-ray showed raised right hemidiaphragm. Computed tomography abdomen: a 9.2 cm × 7.7 cm × 8.8 cm ring enhanced lesion communicating with a 4.9 cm × 2.5 cm hypodense lesion in the lung in the posterior, lower lobe of the right lung was seen, suggesting a liver abscess with hepatobronchial fistula. The common bile duct (CBD) was dilated with gradual smooth tapering at its distal end with upstream dilation of the common hepatic duct and intrahepatic biliary radicles. The diagnosis of benign stricture of distal CBD was considered. In view of the raised serum alkaline phosphatase and GGT and dilated biliary system, a side-viewing endoscopy was done that showed a bulky ampulla. Biopsy confirmed moderately differentiated adenocarcinoma of the ampulla. The patient underwent Whipple procedure. Postsurgery, the drainage from the abscess cavity decreased and the pigtail was removed 2 weeks postoperatively. Histology of resected specimen: 1.5 cm ×1 cm ampullary lesion; moderately differentiated adenocarcinoma: stage pT1b pN2 margins free. Conclusions: Ampullary carcinoma needs not always present with classical features of obstructive jaundice. Liver abscess requiring repeated drainage needs screening of the distal pancreato-biliary system.


  Abstract – 09 Top


Infection in Chronic Liver Disease Is Seldom Causal

Nandhakumar Srinivasan, Arulraj Ramakrishnan, Aravindh Somasundaram, Paari Vijayaraghavan, Sibi Thooran

Gastroenterology and Liver Unit, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India

Background: We describe a man who presented with jaundice for 4 months initially felt due to Burkholderia infection but had recurrent jaundice associated with proteinuria. Intriguing features was the liver disease brought to the fore by infection but underlying liver disease still looming large. Case Presentation: A 40-year-old man presented with jaundice and itching of 4-month duration. Management initially was elsewhere with antihistamine, steroids, and native medications. Workup showed significant transaminitis and macroalbuminuria. Liver screening tests (viral and autoimmune panel) were negative but had raised 24-h urinary copper levels. Imaging showed mild rounding of liver contour without any feature of biliary obstruction. During symptomatic management in hospital for 2 weeks, he had continuous temperature spikes. Evaluation showed leukocytosis and cultures grew Burkholderia pseudomallei. Treatment with appropriate antibiotic therapy showed an improving trend, hence we attributed the clinical picture to chronic granulomatous melioidosis. During follow-up, liver functions worsened, hence he underwent liver biopsy which showed inflammation involving all portal tracts with fibrosis and early cirrhotic changes. Hepatocytes showed areas of bridging fibrosis, microvesicular stenosis, and emperipolesis. Sinusoids were dilated containing lymphomononuclear cell infiltrates. Features were suggestive of autoimmune hepatitis (modified Ishak histological activity index 11/18 and fibrosis stage 6/6). The corresponding renal biopsy was suggestive of secondary membranous nephropathy. He was started on steroids and azathioprine, in view of improving trend, on maintenance azathioprine. Albuminuria is being symptomatically managed. Currently, still he has mild transaminitis and pedal edema. Conclusion Points: It is not clear whether B. pseudomallei infection in this patient was causal or casual, whether we should have done liver biopsy earlier, and whether we are missing an overlap of autoimmune hepatitis and primary sclerosing cholangitis.


  Abstract – 10 Top


Pregnancy-Induced Liver Failure: Role of Plasma Exchange

Nandhakumar Srinivasan, Arulraj Ramakrishnan, Aravindh Somasundaram, Paari Vijayaraghavan, Sibi Thooran

Gastroenterology and Liver Unit, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India

Background: We present a case of liver injury during the first pregnancy and acute liver failure (ALF) in subsequent pregnancy. Uniqueness is because progression remaining unabated despite termination but saved by timely plasma exchange (PLEX) without a transplant. Case Presentation: A 25-year-old primigravida presented in 2016 at 5 months of gestation with fever, high-colored urine, and purpura. Evaluation revealed hyperbilirubinemia (26.6) and transaminitis (136/55); ultrasonogram showed splenomegaly; viral and autoimmune panels were negative. Differentials considered were pregnancy-induced cholestasis and autoimmune pathology. Since there were no features of ALF, she was symptomatically managed, but lost to follow-up after successful delivery. She represented in 2020 at the 11th week of gestation with jaundice and altered sensorium for 2 days. Evaluation revealed grade 4 hepatic encephalopathy requiring intubation and blood was in keeping with ALF. She was managed with anti-encephalopathy measures, N-acetylcysteine infusion, and broad-spectrum antibiotics. Given the background and clinical scenario, she underwent termination of pregnancy followed by transplant listing. Etiological workup was positive for anti-smooth muscle antibodies (1:160), and the rest of the autoimmune panel was negative. She was started on steroids and PLEX. She had an episode of generalized seizures, and electroencephalogram showed bihemispheric dysfunction. Awaiting liver transplant in intensive care unit, she underwent six cycles of PLEX. Infection screen for fever spikes revealed multiple lung patches, and blood and bronchoalveolar lavage cultures grew Klebsiella pneumoniae requiring polymyxin B. She was extubated with improving international normalized ratio and sensorium and shifted to ward. Liver function test (LFT) again worsened but improved after starting colistin for urine and vaginal swab Klebsiella growth. After stabilization and discharge, she underwent liver biopsy during follow-up. Biopsy showed giant cell hepatitis and an acute infectious insult but no chronicity. LFT normalized with tapering steroids and low-dose maintenance for 3 months. Phone follow-up revealed current well-being. Conclusions: A role for early liver biopsy in this setting of acute liver injury remains unclear as we cannot differentiate seronegative hepatitis from cholestasis of pregnancy worsened by infection.


  Abstract – 11 Top


Looking Under the Table: An Interesting Case of Jaundice

U. Ramu Krishnan, R. Kishore Kumar, D. Geetha, A. Shafique, R. Poppy Rejoice, E. Kandaswamy Alias Kumar

Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Background: We present an interesting case of fever and jaundice that turned out to have an unexpected outcome. When a fever and jaundice present to us, it is usually either viral hepatitis or tropical infections. However rarely, there may be a bigger play in the background that may come to light on follow-up and testing. We present such a case which supports the statement “looks can be deceiving.” Case Presentation: A 15-year-old female presented with fever and jaundice of 1-week duration. She had associated symptoms of nausea, vomiting, body pain, loss of appetite, and tiredness. She had a history of menorrhagia for the past 3 months. There was no relevant history or family history. On examination, she was pale and icteric and the rest were unvaried. Investigations: She had severe microcytic hypochromic anemia and thrombocytopenia. Her liver biochemistry was altered showing elevated bilirubin more direct than indirect. Her liver transaminases were 1000 IU range, and alkaline phosphatase was normal. Renal biochemistry was normal and viral screening for hepatitis A, E, B, and C was negative. Dengue serology for IgM ELISA was positive. Her ultrasonogram of the abdomen was normal except for minimal fluid in the pouch of Douglas. A diagnosis of dengue fever with dengue hepatopathy was made. Course of Illness: The patient was treated with packed cell transfusion and supportive care including intravenous fluids and symptomatic therapy. Her serial blood works showed improving hemoglobin, platelet count, and liver biochemistry. She was discharged with hematinics. On follow-up after a week, she was found to have persistent transaminitis which was present the following week also. Antinuclear antibody ELISA was done which showed 1:40 positivity and autoimmune hepatitis profiling showed anti-smooth muscle antibody 1:100 positivity. Liver biopsy was done which showed features suggestive of autoimmune hepatitis. The patient was started on prednisolone. Conclusions: Our case had an underlying autoimmune hepatitis which was unmasked by dengue fever. Hence, this gives us a reminder that even in the most obvious of cases, anything out of the box requires further evaluation.


  Abstract – 12 Top


Association of Tuberous Sclerosis and Noncirrhotic Portal Fibrosis

R. Kishore Kumar, U. Ramakrishnan, D. Geetha, A. Shafique, R. Poppy Rejoice, E. Kandaswamy Alias Kumar

Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Background: Tuberous sclerosis can cause hepatic angiomyolipoma. No cases have been documented with noncirrhotic portal fibrosis (NCPF). Tuberous sclerosis may be another causative factor for NCPF. Case Presentation: A 46-year-old male presented with hematemesis. He was not an alcohol consumer. Physical examination revealed hyperpigmented papules over the face and hypopigmented macules over the back. Abdominal examination showed splenomegaly. He had pancytopenia. Gastroscopy revealed grade III esophageal varix. Ultrasound abdomen showed altered liver echoes with splenomegaly. Autoimmune hepatitis and Wilson workup were negative. Thrombophilia workup (protein C and S, factor V) was done; protein C levels were found to be low. Liver biopsy features showed suggestive of NCPF. Dermatology opinion was obtained for skin lesions, and he was diagnosed as a case of tuberous sclerosis. Computed tomography (CT) abdomen showed angiomyolipoma of the kidney. CT brain did not show intracerebral calcification. Conclusions: The association of tuberous sclerosis and NCPF has not been reported. NCPF needs to be considered a differential diagnosis for liver disease in patients with tuberous sclerosis.


  Abstract – 13 Top


Comparative Study of ALBI Score with Child–Turcotte–Pugh, Model of End-stage Liver Disease Na, and AARC Score in Patients with Acute-on-chronic Liver Failure

V. V. M. Sreeram, M. S. Revathy, Sathya R

Department of Medical Gastroenterology, Stanley Medical College, Chennai, Tamil Nadu, India

Background: Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by acute decompensation of chronic liver disease and often triggered by acute strikes or precipitating events. Due to the high mortality rate, accurate prognosis prediction in ACLF has always been a hot topic in liver research. Although a variety of scoring systems have been developed to assess prognosis in ACLF, most of them are based on clinical indicators at the time of diagnosis. Examples are the classic Child–Turcotte–Pugh (CTP) and Model for End-stage Liver Disease (MELD). Due to its rapidly changing nature, both initial characteristics and dynamic trends of clinical indicators are helpful to predict prognosis in ACLF. Aim: The aim of this study was to compare Albumin Bilirubin score with CTP, MELD Na, APASL aCLF Research Consortium score (AARC score) in patients with ACLF. Materials and Methods: This was an observational, descriptive, longitudinal study based on the prevalence of ACLF. All subjects meeting the eligibility criteria (acute decompensation was defined as a set of jaundice or rise in serum bilirubin levels, encephalopathy, development or increase in ascites, upper gastrointestinal bleed, increase in prothrombin time/international normalized ratio, or serum creatinine) were included in the study. These patients underwent estimation of hemogram, liver function tests, renal function tests, serum electrolytes (Na/K), viral serology (HIV/HBsAg/anti-HCV/IgM HAV/IgM HEV), urine routine/microscopic examination and culture, stool routine/microscopic examination and culture (in cases of diarrhea), blood culture, ascitic fluid analysis (if present) including culture/sensitivity, chest X-ray, and ultrasonography abdomen. Data obtained were analyzed qualitatively by Chi-square test and quantitatively by t-test. Results: Out of 40 patients, there were 29 males and 11 females with a median age of 40.2 years. Alcohol was found to be the most common etiology followed by autoimmune. A significant association was seen in ALBI score with mortality, and the mean ± standard deviation of ALBI score was −0.3 ± 0.21. A significant association was seen in ALBI score with organ failure. Conclusions: In our study, we found a statistically significant association between ALBI score and mortality. ALBI score was found to be the best score in predicting organ failure compared to other scores.


  Abstract – 14 Top


A Rare Case of White Liver

D. Suryanarayana Deo, V. G. Mohan Prasad

Gastroenterology and Hepatology Unit, VGM Hospitals, Coimbatore, Tamil Nadu, India

Background: Amiodarone is a widely used anti-arrhythmic; its high iodine content accounts for 37% of the drug's molecular weight. Long-term amiodarone causes hepatotoxicity due to iodine accumulation in the liver. Here, we present a case of amiodarone-induced hepatotoxicity in a patient on long-term oral amiodarone therapy detected on nonenhanced computed tomography (CT). Case Presentation: A 71-year-old female who is a known case of hypothyroidism, diabetes mellitus, coronary artery disease, left ventricular dysfunction, and atrial fibrillation on regular medications along with amiodarone for 6 years with a cumulative dose of 4380 g, presented with abdominal distension, pedal edema, and breathlessness. In view of dyspnea, high-resolution CT thorax was done, which showed diffusely hyperdense liver (120 HU) showing attenuation values twice as expected for normal hepatic parenchyma (50 HU). The spleen had a normal baseline attenuation value of 58 HU. Consistent with a patient history of medical treatment, hyperdense liver accounts for long-term amiodarone intake. However, the patient refused any alternate therapy for atrial fibrillation and continued oral amiodarone to control atrial fibrillation and routine liver tests were advised every 3–6 months in this patient. Conclusions: Amiodarone is the most commonly used antiarrhythmic drug. Due to severe and potentially life-threatening adverse drug reactions, careful use is essential to derive optimal benefits from the drug with the least risk. Overall, amiodarone hepatotoxicity is under-recognized and is often diagnosed too late. To date, there are no evidence-based standards for monitoring amiodarone-induced hepatotoxicity. Predominant high liver density at nonenhanced CT, aided by a history of amiodarone use, helps to diagnose amiodarone liver accumulation. Further studies are required to how to monitor a patient on long-term amiodarone for hepatotoxicity.


  Gastroenterology Top



  Abstract – 01 Top


Colonic Amyloidosis

Parag Papalkar, B. S. Ramakrishna, D. Babu Vinish, Kayalvizhi R,

Rohan Yewale, Naveen Chand, P. Muthukrishnan

Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India

Background: Chronic diarrhea in adults is a common symptom with a wide range of underlying etiologies. Amyloidosis is a disease often overlooked as a cause of gastrointestinal symptoms, more specifically chronic diarrhea. Case Presentation: A 46-year-old male with no known prior comorbidities had a history of difficulty in folding fingers, pain in shoulders, and numbness in both upper limbs for which he took alternative medicines following which he developed increased frequency of stools of around eight to ten times per day associated with blood and mucus. He was evaluated for these complaints elsewhere; nonenhanced computed tomography abdomen was suggestive of circumferential wall thickening and enhancement in the colon, and colonic biopsies were reported to show chronic inflammation with focal cryptitis. He was labeled as Crohn's disease and treated with mesacol and wysolone. He was transferred to our hospital for further care as he did not respond to treatment. A review of symptoms showed that he had complaints of pedal edema, abdominal distension, generalized weakness, and a weight loss of 18 kg in 6 months. Initial laboratory investigations showed hemoglobin – 8.9 g%, serum albumin – 3.5 g%, and urine protein (3+). The patient was evaluated for proteinuria and underwent renal biopsy, and histopathology showed minimal chain disease. The previous colonic biopsy slides and blocks were reviewed in our hospital and showed extensive amyloidosis with mucosal autolysis in almost all parts of the large intestine. Further investigations showed a paraprotein band on immunofixation electrophoresis, while bone marrow aspiration and biopsy showed plasmacytosis (16% plasma cells). He was referred to the oncologists and is currently on chemotherapy bortezomib, lenalidomide, and dexamethasone. Conclusions: There is an important risk of diagnostic delay in patients whose symptoms mimic inflammatory bowel disease. In our patient, a diagnosis of inflammatory bowel disease was erroneously established before admission in the hospital. In the clinical settings, disease symptoms should be analyzed systematically, and rare diseases should be considered following the exclusion of common diseases to avoid misdiagnosis.


  Abstract – 02 Top


Strongyloidiasis Masquerading as Inflammatory Bowel Disease

Stephan Benny, Ebby Simon

Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Inflammatory bowel disease (IBD) is a relatively common cause of chronic diarrhea. It can occasionally present as subacute intestinal obstruction. Crohn's disease is managed with immunosuppression. Strongyloides stercoralis is a less common cause of worm infestation. Strongyloidiasis can rarely mimic IBD. Immunosuppression in such cases can result in larva migrans which can be fatal. It is always important to rule out Strongyloides infestation before labeling a patient as IBD and starting on immunosuppression. Case Presentation: A 40-year-old male patient, a businessman from West Bengal, presented with an 8-month history of vomiting and a 1-month history of colicky type of periumbilical pain suggestive of subacute intestinal obstruction. There were associated significant weight loss, fatigue, and anasarca. Blood investigations revealed iron-deficiency anemia and severe hypoalbuminemia. In the background of subacute intestinal obstruction, iron-deficiency anemia, and hypoalbuminemia, the possibility of Crohn's disease or abdominal tuberculosis was considered. His fecal calprotectin level was >2000 μg/mg. Gastroscopy showed gastric antral edema. Colonoscopy showed multiple patchy areas of edema and erythema from the terminal ileum to the rectum. Push enteroscopy showed duodenal and jejunal edema. Computed tomography (CT) enterogram showed skip segments of small bowel wall thickening and enhancement in the distal and mid-ileum. CT also showed mild prominence of the vasa recta. All these features were suggestive of Crohn's disease. However, the segmental biopsies taken during push enteroscopy showed foreign body granuloma and moderate active duodenitis with Strongyloides infestation. The colonoscopy segmental biopsy showed mild chronic active ileocolitis with mild eosinophilia and Strongyloides infestation. Moreover, his stool parasite special stain showed plenty of Strongyloides larva. His serum IgE level was > 1400 U/ml. He was treated with a course of tablet ivermectin. At follow-up after 3 months, there was a significant improvement in abdominal pain, anemia resolved, serum albumin level normalized, and fecal calprotectin became negative. Conclusions: It is important to rule out strongyloidiasis before labeling a patient as IBD and planning to start on immunosuppression.


  Abstract – 03 Top


Double Jeopardy

Hemanth Chinthala, Sudipta Chowdhary

Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Immunoglobulin G4-related disease (IgG4-RD) is an uncommon disease with multisystem involvement. Here, we present a case of IgG4-RD complicated with tuberculosis. Case Presentation: A 60-year-old man presented with features of extrahepatic biliary obstruction. He had a 7-kg weight loss in the last 6 months. On examination, he had icterus, and there was no palpable lymphadenopathy or abdominal mass. Evaluation done at native place had raised possibility of cholangiocarcinoma. Evaluation at our center showed a cholestatic pattern of liver function test (LFT) (alkaline phosphatase: 329 IU/ml and bilirubin: 2.1 mg/dl). Serum CA 19-9 was 199 U/ml (normal: 0–33 U/ml). Imaging showed distal biliary stricture, diffuse bulky pancreas with loss of lobulation, and surrounding rind of soft tissue. IgG4 levels were 2769 mg/L (normal: <1127 mg/L). Endoscopic ultrasound (EUS) was done for assessment of the pancreas and fine-needle aspiration biopsy (FNAB). At the time of EUS, the pancreas diffusely enlarged with hypoechoic rim and a subcarinal lymph node (SLN) (7 mm × 20 mm) was noted. FNAB was done from the pancreas and subcarinal node. EUS-FNAB from the pancreas showed storiform fibrosis and moderate chronic inflammation. EUS-fine-needle aspiration cytology from SLN showed focal granulomatous inflammation. He was initiated on antitubercular therapy (ATT). At 2-month follow-up, he improved significantly and LFT normalized. Computed tomography showed a significant reduction in biliary dilatation, pancreas size, and of hypodense rim around the pancreas. ATT was continued for a total of 6 months. At the end of 6 months of ATT, LFT was normal, magnetic resonance cholangiopancreatography abdomen showed a normal common bile duct with mildly atrophic pancreas. However, he later developed Peyronie's disease, a manifestation of IgG4 disease. Conclusions: IgG4-RD is a multisystem disorder with relapsing–remitting course. It has tuberculosis, lymphoma, and other malignant disorders as close mimickers. Hence, a high index of suspicion is needed for diagnosis. Tuberculosis being a ubiquitous infection if detected warrants treatment prior to immunosuppressive therapy.


  Abstract – 04 Top


Pancreatic Cancer – “All Battles are Not Lost”

Krishna Bharadwaj, Ebby Simon

Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Primary pancreatic lymphomas (PPLs) are uncommon accounting for 0.5% of all pancreatic masses. Chemotherapy has a high complete response rate, but obtaining sample for histological diagnosis is difficult. Laparoscopic tumor biopsy can yield sufficient samples but is invasive. Although endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a less-invasive modality for tissue acquisition, the effectiveness of EUS-FNA for the diagnosis of PPLs remains unclear. Case Presentation: A 70-year-old man with no addictions and no comorbidities was evaluated for pedal edema and exertional breathlessness. His vital signs were normal, and his examination was unremarkable except for pallor and bilateral pitting pedal edema. Blood tests were within normal range except for pancytopenia and hepatitis B surface antigen positivity. His abdominal ultrasonography showed a bulky pancreas with altered echotexture. Contrast-enhanced computed tomography (CT) revealed an 8.0 cm × 4.5 cm solid hypodense mass with internal nonenhancing necrotic areas at the pancreatic head, proximal body encasing main portal vein and superior mesenteric vein. EUS revealed an 8.0 cm × 6.0 cm hypoechoic heterogeneous mass in the pancreatic head and body with multiple cystic spaces causing lower common bile duct cutoff. EUS-FNA with a 22G needle was performed and FNA smears showed dense lymphoid infiltrate of round-to-oval cells with focally elongated nuclei and scanty cytoplasm. Immunochemistry showed diffuse positivity for CD20, CD5, BCL2, and cyclin D1. With the above results, the diagnosis of pancreatic mantle cell lymphoma was made. He was started on tenofovir, and after 1 week, chemotherapy with rituximab, cyclophosphamide, vincristine, and prednisolone regimen was given for three cycles. The regimen was changed to R-miniCHOP for the next two cycles as a persistent disease was noted in CT abdomen. Further chemotherapy was done with monthly rituximab for 6 months and end-of-treatment disease assessment showed remission after 2 years. Maintenance chemotherapy was given with lenalidomide. The patient is still alive and on regular follow-up. Conclusions: PPL can be diagnosed by EUS-FNA. Accurate histology findings contributed to the selection of suitable treatment and prevented unnecessary surgery. EUS-FNA could be a useful and safe diagnostic modality in cases where the differential diagnosis of a PPL is considered.


  Abstract – 05 Top


Raw Fish Ingestion is The Clue

Jagadish Polavarapu, Ashis Choudhury, Ajith Thomas, A. J. Joseph

Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Intestinal capillariasis is a rare worm infestation caused by Capillaria philippinensis. Fish-eating birds are natural definite hosts with adult worms remaining in the intestine. Fish gets infected by bird droppings into waterbodies. Larval forms develop inside fish. Infection is acquired by eating raw, undercooked small fishes. It causes chronic diarrhea with malabsorption and electrolyte loss. If not diagnosed, this may be fatal. Case Presentation: A 19-year-old man presented with vomiting around 8–10 episodes per day for 4 months with generalized swelling of the body. The vomiting used to occur immediately after food intake. There was a history of loose stools for 1 month around ten times in a day which was small volume, not associated with blood, urgency, and tenesmus but associated with nocturnal diarrhea. This was associated with colicky periumbilical pain lasting for about 20–30 min, which used to get relieved with medication. There was a significant loss of appetite and weight. He gave a history of consuming raw fish. Physical examination revealed pallor and bilateral pitting pedal edema. Systemic examination was normal. Hemoglobin was 11.8 g/dl. Serum total protein and albumin were 4 and 1.4 g/dl, respectively. Urine examination ruled out proteinuria. Erythrocyte sedimentation rate was 8 mm and C-reactive protein was 3.3 mg/L. Serum iron, Vitamin D, B12, and folic acid were 110 μg%, 17.6 ng/ml, 2000 pg/ml, and 2.9 ng/ml, respectively. Fecal calprotectin was 2422.07 μg/g. Anti-TTG antibody was negative. Stool examination showed C. philippinensis ova. Gastroscopy was normal and segmental biopsies were nonspecific. The provisional diagnosis of malabsorption syndrome with protein-losing enteropathy was made. As capillariasis can lead to malabsorption, he was started on albendazole 400 mg one tablet daily for 2 weeks along with high-protein diet. Repeat stool examination for capillariasis was negative after 2 weeks of treatment. A review after 3 months showed normal serum protein and albumin. Conclusions: Intestinal capillariasis can be diagnosed with stool examination. However, it is undiagnosed in majority because of its rarity and lack of awareness about the existence of the parasite. Treatable infectious etiologies should be considered first in patients with chronic diarrhea and malabsorption.


  Abstract – 06 Top


A Rare Case of Immunoglobulin Light-Chain Amyloidosis Presenting with Acute Abdomen and Gastrointestinal Hemorrhage

Nishanth Paturi, V. Swaapnika, Dhanush Thomas, L. Venkatakrishnan, S. Mukundan, P. Thirumal, R. K. Karthikeyan, P. Arun

Department of Gastroenterology, PSG Hospital, Coimbatore, Tamil Nadu, India

Background: Primary systemic or amyloid light-chain (AL) amyloidosis is a multisystem disorder with myriad presentations. We chronicle here a case of AL amyloidosis involving the kidney and presenting with acute abdomen and gastrointestinal (GI) hemorrhage. Case Presentation: A 55-year-old hypothyroid female presented with epigastric pain with radiating to back and vomiting for 4 days. Examination revealed hepatosplenomegaly. She had normal complete blood count, renal function test, cholestatic pattern of liver function test, prolonged international normalized ratio, and proteinuria. Initial contrast-enhanced computed tomography (CECT) abdomen revealed hepatosplenomegaly, a 2.8 cm × 2.6 cm hypodense nodule in the periportal region, anterior to inferior vena cava (IVC) with partial compression on IVC; few small hypodense nodules in the periportal, celiac, and superior mesenteric regions with areas of soft tissue density encasing the vessels without luminal narrowing. She had a sudden increase in severity of abdominal pain and repeat CECT abdomen revealed a 15 cm × 11.2 × 10 cm hematoma in the right subhepatic region with active leak of contrast into the hematoma. Conventional angiogram showed a leak from the distal branch of the gastroduodenal artery with no evidence of aneurysm, for which coil embolization was done. Evaluation for periportal nodule revealed positive ANA-IF (1+) with nuclear speckled pattern, elevated angiotensin-converting enzyme, and beta-2-microglobulin levels. Serum protein electrophoresis was suggestive of monoclonal gammopathy of unknown significance. Urine for Bence Jones protein was negative. Serum immunofixation was positive for IgG and kappa band. Serum immunoglobulin panel showed elevated kappa and normal lambda-free light chains. Urine immunofixation was normal. Urine immunoglobulin panel revealed elevated kappa and lambda light chains. Bone marrow aspiration and biopsy showed reactive changes with no evidence of plasmacytosis. Positron emission tomography-CT was normal. Abdominal fat pad biopsy was negative. Renal biopsy revealed amorphous eosinophilic deposits in the mesangium. These deposits are Congo red positive and showed apple-green birefringence under polarized light-AL amyloid (kappa light chain). She was initiated on steroids. On follow-up, she had clinical improvement of symptoms. Conclusions: GI infiltration in systemic amyloidosis may present as nonspecific symptoms. Patients with AL amyloidosis who have initial presentations related to the GI tract should also undergo screening for cardiac and renal disease. The amyloid subtype and extent of involvement determine the therapeutic regimen and prognosis.


  Abstract – 07 Top


A Rare Case of Agenesis of Dorsal Pancreas Presenting as Acute Abdomen

Paila Ramesh, A. Chezhian, Shubha R, Muthukumaran S, Murali A,

Prem Kumar, Caroline Selvi, Aravind A

Department of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Background: Agenesis of the dorsal pancreas is very rare with an unknown etiology and pathology, although it may be associated with autosomal dominant or X-linked dominant inheritance or retinoic acid and hedgehog signaling pathway alterations. Case Presentation: A 22-year-old male without any comorbidity presented with abdominal pain of 5 days associated with intermittent vomiting. Physical examination showed diffuse abdominal tenderness. At presentation, blood glucose levels 460 mg/dl, HbA1c 9.4%, hyperamylasemia, urine ketones were positive, arterial blood gas showed metabolic acidosis, diagnosed as type 1 diabetes with diabetic ketoacidosis (DKA) treated with intravenous fluids, insulin infusion, and potassium replacement. DKA resolved gradually after insulin therapy, but the abdominal pain continued. Computed tomography (CT) abdomen showed a normal head and uncinate process of the pancreas with completely absent neck, body, and tail of the pancreas. Magnetic resonance cholangiopancreatography (MRCP) revealed the absence of the dorsal pancreatic duct. Low-fat diet and pancreatic enzyme supplements were given with meals to facilitate the digestive process. Abdominal pain gradually resolved in 10 days of treatment. Discussion: The human pancreas develops from the foregut, and it begins with a dorsal bud followed by two ventral buds. Dorsal pancreatic agenesis can be of two types partial or complete. In partial agenesis, the minor papilla is present with a remnant of the accessory pancreatic duct with a variable degree of agenesis of the dorsal pancreas. In complete agenesis, there is no minor papilla, accessory pancreatic duct, and complete absence of the neck, body, and tail of the pancreas. Most patients with agenesis of the dorsal pancreas are asymptomatic, and abdominal pain is the most common reported symptom. In our case, we believed that abdominal pain was caused by DKA. However, the abdominal pain continued after rectifying DKA, suggesting that the pain may have been caused by dorsal pancreatic agenesis. Imaging modalities are essential to diagnose agenesis of the dorsal pancreas. Both CT and MRCP are reliable modalities to confirm the absence of the body and tail of the pancreas. ERCP can also be used to confirm the absence of the dorsal ductal system. Conclusions: Agenesis of the dorsal pancreas should be considered in a young patient diagnosed with diabetes accompanied by abdominal pain, pancreatitis, or steatorrhea.


  Abstract – 08 Top


Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, and Skin Changes Syndrome? Out of Diarrhea

Vijay Balaji, Ebby Simon

Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India

Background: Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a rare multisystem disorder of unknown pathogenesis. Gastrointestinal (GI) system disorders have not been reported among the components of the syndrome. We present a patient of POEMS syndrome who presented with GI symptoms as the major complaint. Case Presentation: A 52-year-old man presented with increased frequency of stools (6–8/day) for 2 years, bilateral pedal edema for 8 months, and weight loss of 20 kg over 8 months. He was emaciated (body mass index: 14.2) and had generalized lymphadenopathy, pandigital clubbing, papular skin lesions over the chest, and hepatosplenomegaly. He had weakness of both lower limbs proximal and distal. Laboratory evaluation revealed deranged renal functions (serum creatinine: 2.38 mg%) with proteinuria (UP/UC: 1.40). Liver function test and blood counts were normal. Stool microscopy showed Blastocystis hominis infection, for which he was treated. Gastroscopy showed gastric nodules, and biopsy showed Helicobacter pylori gastritis. Colonoscopy showed normal mucosa. Segmental biopsy showed mild chronic ileitis and colitis with telangiectasia; amyloid stain was negative. Imaging showed hepatosplenomegaly with mild ascites. Biopsy of cutaneous lesion was suggestive of hemangioma. Cervical lymph node biopsy revealed Castleman disease. Bone marrow trephine showed an increase in plasma cells including immature forms, with lambda light-chain restriction (stained with CD138), suggestive of myeloma. Serum beta-2-microglobulin was elevated (8.20). A nerve conduction study suggested a demyelinating sensory-motor neuropathy of bilateral lower and upper limbs with small-fiber involvement in lower limbs. Evaluation for endocrinopathy revealed low testosterone levels. A syndromic diagnosis of POEMS syndrome was arrived at based on the presence of polyneuropathy, monoclonal plasma cell dyscrasia, Castleman disease, organomegaly, hypogonadism, hemangiomata, clubbing, and weight loss. He was treated with three cycles of cyclophosphamide, bortezomib, and dexamethasone regimen and two cycles of VLD regimen. He is currently in remission planned for autologous stem cell transplant. Conclusions: This case highlights the atypical presentation of POEMS syndrome, importance of early diagnosis, initiation of timely therapy, and possibly better outcomes.


  Abstract – 09 Top


New Faces of an Old Foe: A Rare Cause of Upper Gastrointestinal Bleeding

C. Krishna Kumar

Department of Gastroenterology, Stanley Medical College, Tamil Nadu, India

Background: Upper gastrointestinal (GI) bleeding is a remarkably uncommon complication of splenic artery pseudoaneurysm rupture. Case Presentation: We report an interesting case of acute upper GI hemorrhage due to splenic artery pseudoaneurysm rupture. Conclusion: This presentation highlights that splenic artery pseudoaneurysm is a rare but potentially life-threatening cause of upper GI bleeds and the importance of considering it as a differential diagnosis for upper GI bleeds.

Abstract – 10

An Unusual Cause of Chronic Diarrhea in Systemic Lupus Erythematosus

R. Kishwanth, M. Kannan, R. Ramani, C. Vijaianshankar, P. B. Sriram

Department of Medical Gastroenterology, Madurai Medical College, Madurai, Tamil Nadu, India

Background: Microscopic colitis is common among the older population and usually associated with certain drug intake, but it also can be associated with autoimmune conditions such as systemic lupus erythematosus (SLE) which is yet to have proper epidemiological studies. We herein present such a case of microscopic colitis on the background of SLE in a young South Indian female. Case Presentation: The patient was 30 years old, with chronic large bowel type of diarrhea, associated with vague abdominal pain, nausea, large and small joint pains, myalgia, weight loss, and fatigability for 3 months and unilateral lower-limb swelling due to deep vein thrombosis. There was no fever, a history of any drug intake, or laxative use. She did not have any prior comorbidity nor had any substance abuse. Clinical examination revealed only pallor and mild diffuse abdominal tenderness. Laboratory investigations showed elevated erythrocyte sedimentation rate and serum protein levels with a predominant globulin fraction, nephrotic range of proteinuria with a very high urine protein-creatinine ratio, and antinuclear and multiple extractable nuclear antigen antibody positivities. Computed tomography of the abdomen showed fatty liver and diffuse wall edema of the ascending colon and cecum. After ruling out the common infectious causes of colitis, inflammatory bowel disease was suspected. At colonoscopy, no gross abnormality of the colonic mucosa was noted, but biopsies showed histopathological findings suggestive of lymphocytic colitis – microscopic colitis. Gastroscopy and biopsy did not show any gross or microscopic abnormality. Thus, the patient was diagnosed to have microscopic colitis on the background of SLE/lupus nephritis and was started on tablet prednisolone and tablet mycophenolate mofetil. The patient showed remission after 4 weeks of steroids and is being followed up. Conclusion: This case illustrates the consideration of microscopic colitis as a differential in SLE presenting with chronic diarrhea.


  Abstract – 11 Top


Saved by Stoma in the Era of Biologicals: A Tale of Crohn's Disease

Nandhakumar Srinivasan, Arulraj Ramakrishnan, Aravindh Somasundaram, Paari Vijayaraghavan, Sibi Thooran

Gastroenterology and Liver Unit, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India

Background: We present a case of Crohn's disease, with challenges in management, both medically and surgically, and uncommon complications. Case Presentation: A 16-year-old girl presented in January 2021, with lower abdominal pain, weight loss, and rectal bleeding. Colonoscopy showed ileocolonic ulcers with recto-sigmoid involvement; biopsy confirmed Crohn's disease, which improved with steroids and azathioprine. She represented in November 2021 (lost to follow-up and discontinued therapy from April 2021) with abdominal pain, weight loss, and loose stools. We restarted on steroids with azathioprine. In view of persisting symptoms with development of perianal fistula, she was admitted for intravenous steroids and antibiotics. Magnetic resonance imaging (MRI) showed a fistula between anal canal and vagina. Screening sigmoidoscopy showed an active disease with recto-sigmoid thickening; biopsies confirmed active inflammatory bowel disease ruling out infections. Despite infliximab initiation, she continued to be unwell with lower abdomen pain and tenesmus. Computed tomography (CT) abdomen showed extraluminal air pockets suggesting perforation/peritonitis. We managed conservatively because of clinical stability and no collection on CT with withholding of steroids and azathioprine. After few days, due to nonimprovement, she underwent laparotomy but did not reveal any perforation, and the abdomen was closed after a peritoneal wash. Feeds were gradually started postoperatively. She had a seizure episode, a week after infliximab infusion. MRI brain was suggestive of posterior reversible encephalopathy syndrome (PRES); possibly, infliximab was induced and further therapy was stopped. She developed a collection adjacent to the surgical site. Since aspiration revealed enteric contents, she underwent loop ileostomy. We restarted steroids and azathioprine postsurgical site healing. After initiating vedolizumab, steroid was tapered but developed repeated episodes of pain with prolapse of ileostomy stoma, which she was unable to tolerate. Follow-up sigmoidoscopy showed active disease and MRI re-demonstrated fistula. Hence, ileostomy was re-fashioned to a double-barrel one. In view of weight gain with fistula healing on maintenance vedolizumab, we are planning ileostomy reversal, end of this year. Conclusions: It is debatable whether an ileostomy should have been done at initial operation, in view of CT evidence of perforation, even though laparotomy was negative. It is not clear whether i mprovement was consequent to fecal diversion, to vedolizumab, or to both.


  Abstract – 12 Top


An Uncommon Complication Following Rigid Esophagoscopy for Food Impaction in a Child

R. Ramalingam, K. Senthamizh Selvan, Pazhanivel Mohan

Department of Gastroenterology, JIPMER, Puducherry, India

Background: Flexible and rigid esophagoscopies are equally safe and effective for esophageal foreign body removal in children. The pharyngoesophageal junction and Killian's triangle are anatomically weaker regions vulnerable to injury during instrumentation. Here, we report an uncommon complication of rigid esophagoscopy in a child. Case Presentation: An 8-year-old boy presented with acute onset of dysphagia for solids and liquids along with drooling of saliva following ingestion of meat. Chest X-ray was normal and computed tomography (CT) scan revealed soft tissue density in the upper esophagus. He underwent a rigid esophagoscopy in the ENT department under general anesthesia that did not reveal any impacted food but showed mucosal erythema at the cricopharynx and upper esophagus. He developed chest pain several hours after the procedure. Clinical assessment of the neck and chest was normal. CT neck and thorax revealed a double-barrel esophagus with no sign of perforation. Flexible endoscopy showed the upper esophagus ending in a blind pouch. A careful inspection of the cricopharynx showed a thin mucosal flap. Gentle probing of the septum using a flexible tip guidewire and fluoroscopy enabled the successful passage of the wire into the stomach, which was followed with an endoscope, confirming the diagnosis of esophageal intramural dissection. The child was managed conservatively with a nasogastric tube placed over the wire and had complete recovery in 3 weeks. Conclusions: Esophageal intramural dissection is an uncommon complication of rigid esophagoscopy. Flexible endoscopes are preferred for esophageal foreign bodies owing to a lack of need for general anesthesia, overall better patient comfort, and low complication rates including postprocedure dysphagia. Moreover, the skills for performing rigid esophagoscopy have become limited among the specialists to a point that it has lost its place in recent treatment guidelines for esophageal foreign bodies. However, where expertise is available, rigid esophagoscopes can be complementary, especially in selected cases of large impacted or sharp foreign bodies in the upper esophagus.


  Abstract – 13 Top


An Uncommon Cause of a Chronic Nonhealing Perianal Ulcer

S. K. Sirasapalli, Pazhanivel Mohan, K. Senthamizh Selvan

Department of Medical Gastroenterology, JIPMER, Puducherry, India

Background: Chronic or persistent, nonhealing perianal ulcers could be due to an infection, inflammation, or a neoplasm. We present a rare case of nonhealing perianal ulcer in a middle-aged man which completely resolved with medical management. Case Presentation: A 52-year-old man presented with a painful perianal ulcer for more than a year. It started as a small nodule that ulcerated and progressively increased in size. There was no diarrhea, abdominal pain, or lump in the abdomen. He did not have fever, cough, night sweats, loss of appetite, joint pains, or redness of the eye. He had lost about 10 kg of weight in the last 6 months. There was no history of diabetes, pulmonary tuberculosis, or high-risk behavior. He had no addictions. On examination, he had a large irregular perianal ulcer measuring 10 cm × 6 cm extending around the anal opening from 2 o'clock to 6 o'clock position. The base of the ulcer showed focal areas of granulation tissue along with a few deeper areas covered with slough. Bilateral inguinal lymph nodes were enlarged, discrete, and firm with a maximum diameter of 2 cm. His complete blood counts were normal except for a mildly raised platelet count. Blood sugar, renal, and liver functions were normal. Erythrocyte sedimentation rate was 73 mm/h. Biopsy from the ulcer showed noncaseating granulomas and fine-needle aspiration cytology from the inguinal node was suggestive of granulomatous lymphadenitis. Ziehl–Neelsen stain, culture, and CBNAAT of skin biopsy were negative for MTB. Computed tomography enterography and colonoscopy were normal. Chest X-ray showed a right lung cavitary lesion with bilateral nodular opacities. CBNAAT of induced sputum was positive for MTB. There was a complete resolution of the ulcer after 1 month of starting antituberculous therapy. Conclusions: Cutaneous involvement is a rare manifestation of tuberculosis. Tuberculosis cutis orificialis is a multibacillary form of cutaneous tuberculosis involving the perianal region. Demonstration of mycobacteria in a paucibacillary form of cutaneous tuberculosis can often be challenging as was seen in our case. Hence, a high index of suspicion together with demonstration of tuberculosis infection at extracutaneous locations can help in early diagnosis and treatment.

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Conflicts of interest

There are no conflicts of interest.






 

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