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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 115-139

Abstracts of TNISGCON 2022

Date of Web Publication5-Jul-2022

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_11_22

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How to cite this article:
. Abstracts of TNISGCON 2022. Gastroenterol Hepatol Endosc Pract 2022;2:115-39

How to cite this URL:
. Abstracts of TNISGCON 2022. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Aug 13];2:115-39. Available from: http://www.ghepjournal.com/text.asp?2022/2/3/115/349944

  Abstract No.: TNISGCON2022-01 Top

Inflammatory Bowel Disease Mimic

R. Kishore Kumar, E. Kandasamy Alias Kumar, Poppy Rejoice, Shafique, Geetha, Roshini, Ramukrishnan

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

Background and Aim: The aim is to stress the importance of endoscopic evaluation in the diagnosis of inflammatory bowel disease (IBD). Methods: This was a case series. Results: A 60-year-old male diagnosed as ileocecal tuberculosis (TB) started on anti-tuberculosis therapy (ATT) and presented to us after 6 months with a right iliac fossa mass. Colonoscopic and histopathological examination (HPE) report came as ulcerative colitis. A 15-year-old male diagnosed as TB abdomen and took ATT for 6 months. He later presented with obstructive symptoms, for which he underwent right hemicolectomy. However, no improvement in symptoms was noted. He was subjected to colonoscopy and HPE which came as Crohn's disease. Conclusion: We need to confirm the diagnosis of TB/IBD by HPE before initiation of treatment. Thereby, we can reduce the unnecessary complications related to drug and other procedures.

  Abstract No.: TNISGCON2022-02 Top

Comparison of Clinical Course and Outcome of Severe Acute Pancreatitis Alcohol versus Gallstones

G. Sandeep Kumar Reddy

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

Background and Aim: Background: Acute pancreatitis (AP) is an inflammation of the pancreas with variable etiologies. About 70%–80% of cases are caused by alcohol and gallstones. The influence of etiological factors on course and outcome is not known fully. Identification and differentiation of AP are important for management strategies. Aims: The study aims to compare the clinical course and outcomes of gallstone and alcohol-induced SAP in patients and to study the development of local and systemic complications as well as the need for minimally invasive and surgical interventions in patients with SAP, in terms of comparison of intensive care unit stay and overall morbidity and mortality. Methods: A prospective descriptive study was done on 60 patients with alcoholic and biliary SAP admitted to RGGGH. Patients presented were subjected to clinical, laboratory, and radiological investigations. Results: The percentage of alcoholic acute SAP was higher than gallstones SAP. Alcoholic SAP has higher complications, poor prognosis, and high mortality when compared to gallstone SAP. MMS in gallstones SAP was higher compared to alcoholic SAP. Conclusion: In this study, it was observed that alcoholic SAP was more common in middle-aged men and gallstone SAP in older men. Clinical course and outcomes were comparatively poor in alcoholic SAP. Patients with high modified Marshall score at presentation have long duration of hospital stay, local complications, systemic complications, and mortality rate. Clinical course and outcome were comparatively poor in alcoholic SAP. Timely interventions such as ERCP and pathophysiological differences may contribute to differences in disease severity between alcoholic and gallstone SAP.

  Abstract No.: TNISGCON2022-03 Top

Noncirrhotic Dual Portal Hypertension in Hepatic Tuberculosis

Geevarghese Prajob Prasad, Harikumar R. Nair, Jyothi Karikkanthra, Jeby Jacob

Department of Medical Gastroenterology, Apollo Adlux Hospital, Angamaly, Kerala, India

Background and Aim: Portal hypertension is divided into prehepatic, hepatic (presinusoidal, sinusoidal, and postsinusoidal), and posthepatic, of which sinusoidal portal hypertension from liver cirrhosis is the most common. We present a rare combination of sinusoidal portal hypertension from hepatic parenchymal tuberculosis (TB) and prehepatic component due to tubercular periportal lymphadenopathy causing extrahepatic portal venous obstruction. Methods: Our patient presented with variceal bleed. Although the hepatic venous pressure gradient of 7 mmHg was suggestive of sinusoidal portal hypertension, this was not clinically significant portal hypertension to result in variceal bleed. The variceal bleed was likely contributed to combination of both sinusoidal portal hypertension and prehepatic component from the lymph node compressing the portal vein at the hepatic hilum. Bridging fibrosis and hepatic granulomas were seen on liver biopsy. Necrotizing granulomatous lymphadenopathy was seen on lymph node biopsy. Polymerase chain reaction for TB from the lymph node was positive. Results: After antitubercular therapy, there was clinical, biochemical, and radiological improvement. Conclusion: Hepatic TB inducing sinusoidal and presinusoidal portal hypertension has not been reported in the published English literature.

  Abstract No.: TNISGCON2022-04 Top

Risk Factors Associated With Bleeding after Prophylactic Endoscopic Variceal Band Ligation in Liver Cirrhosis

Sudhir Kumar, Ramani Ratinavel, Kannan Mariappan, Vijaishankar Chidambaramanivasagam, P. B. Sriram

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

Background and Aim: Prophylactic endoscopic variceal band ligation (EVBL) is frequently performed in patients with liver cirrhosis. Our study aimed to identify factors associated with early upper gastrointestinal (UGI) bleeding in cirrhosis patients after prophylactic EVBL. Methods: The study was done on 100 consecutive nonemergency patients with liver cirrhosis who required prophylactic EVBL in Madurai Medical College. These patients were followed up for 1 month and observed for any early UGI bleed within 30 days of EVBL. Results: Within 30 days after EVBL, 12 UGI bleeds were observed (10 patients had minor UGI bleed and 2 patients had moderate-to-severe UGI bleed). Increased serum bilirubin level, low platelet count, and higher MELD and Child score were independently associated with UGI bleed following EVBL with statistically significant P value (P < 0.05). There was no statistically significant association between grade of varices, presence of red color sign, or increased prothrombin time and UGI bleed. No significant difference in sex, age, or cirrhosis etiology was observed between patients with or without post-EVBL UGI bleed. Conclusion: EVBL is a safe procedure, and early post-EVBL bleed is rare. Serum bilirubin, platelet count, MELD score, and Child class are associated with early UGI bleed after EVBL. Grade of esophageal varices, red color sign, and prothrombin time are not associated with UGI bleed after EVBL.

  Abstract No.: TNISGCON2022-05 Top

Fibroprogression and Cirrhosis in Living Liver Donors

Jeby Jacob, Prajob P. Geevarghese, Vijosh V. Kumar, T. P. Lakshmi1, Harikumar R. Nair

Departments of Liver and Digestive Care and 1Radiology, Apollo Adlux Hospital, Angamaly, Kerala, India

Background and Aim: Although the short-term outcomes of living donation have been described in the literature, the long-term health consequences, especially those pertaining to remnant liver, are yet to be fully understood. The current study is done to assess the prevalence of nonalcoholic fatty liver disease and to noninvasively assess remnant liver health in living liver donors. Methods: This is a retrospective observational hospital-based study, which included living liver donors who attended the liver clinic between March 2021 and October 2021. All liver donors were subjected to sonographic evaluation using ultrasound machine (Super Sonic Imagine); shear wave elastography (2D-SWE), sound speed (SSp. PLUS), attenuation (Att. PLUS), and viscosity (Vi. PLUS) were also assessed. Results: A total of 36 liver donors were included in our study. The mean APRI and FIB-4 in the total study population were 0.275 and 0.936, respectively. The mean values of 2D-SWE, Vi. PLUS, Ssp. PLUS, and Att. PLUS in the total study cohort were 7.31 kPa, 2.3 Pa.s, 1535 m/s, and 0.49 dB/cm/MHz, respectively. Significant fibrosis (>F2) was found in 11 donors, with 2 donors having 2D-SWE values in cirrhotic range. One donor with 2D-SWE value >13 kPa was extensively evaluated and was found to have biopsy-proven cirrhosis. Significant steatosis was found in 50% of donors. Conclusion: We report the first case in the published literature of cirrhosis occurring in a liver donor. Our donor cohort with a significant proportion having steatosis, inflammation, and fibroprogression underscores the importance of regular follow-up and evaluation of the remnant liver.

  Abstract No.: TNISGCON2022-06 Top

Pole of High-Density Lipoprotein in Predicting Risk of Decompensation in Chronic Liver Disease

G. Sandeep Kumar Reddy

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

Background and Aim: High-density lipoprotein (HDL) cholesterol (HDL-C) has a significant role in innate immunity to bacterial products. HDL-C has a role in modifying immune response by regulating T-cell response. Methods: This was a prospective observational study. Chronic liver disease (CLD) patients are included. Fasting lipid profile is measured. Patients are followed up for the development of decompensation. Results: A total of 71 patients were included. In the end, 57 patients had decompensation events. Mean HDL-C was significantly lower in those with decompesation. Using receiver operating characteristics, the cutoff of HDL-C of 37.2 was identified. Conclusion: HDL-C <37.2 mg/dl is a reliable marker for assessing risk of decompensation and is a useful addition to existing prognostic scores in CLD.

  Abstract No.: TNISGCON2022-07 Top

Biloma-Delayed Bile Leak in a Patient with Grade IV Blunt Liver Trauma: A Case Report and Review of the Literature

S. P. Arshiya Mubin, V. Senthil Kumar

Department of Medical Gastroenterology, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India

Background and Aim: This is a rare case with no intra- or extra-hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A literature review to highlight the incidence of delayed bile leak revealed only few reported cases. This case is to throw light on those rare cases. Methods: A 33-year-old previously healthy male presented to the trauma room following a motor vehicle collision. He was a restrained driver who hit a fixed object. This case was referred to a medical gastroenterologist due to the development of obstructive jaundice, which was increasing with each passing day. This case was followed up hence the case report. Results: We report an unusual case of delayed bile leak in a young male who presented with Grade IV blunt liver trauma following a motor vehicle collision. Although no evidence of major bile duct injury was seen initially, the patient later on developed biloma that required drainage and stenting. This could be explained by a delayed bile leak. The management of this case was based on the drainage of the biloma and ERCP stenting. Conclusion: Patients with high-grade liver injury are at risk of serious complications. In addition to a high-grade injury, centrally located liver injuries are also significant risk factors for major bile duct injury. In such type of patients, early MRCP and ERCP may be warranted to rule out a significant bile leak. Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible

  Abstract No.: TNISGCON2022-08 Top

Early Surgical Intervention in Chronic Calcific Pancreatitis

Karikal Chakaravarthi, S. Jeseanth

Department of Medical Gastroenterology, Institute of SGE and LT, Government Stanley Medical College, Chennai, Tamil Nadu, India

Background and Aim: Pancreatic ascites can occur as a complication of acute or chronic pancreatitis. In majority of cases, it is associated with pseudocyst or duct disruption. Management is initially conservative with paracentesis with nutritional support. Early surgery has been recently contemplated as primary management for pancreatic ascites. Methods: A prospective study was done over the duration of 5 years, from November 2017 to October 2021, in patients with chronic calcific pancreatitis presenting with pancreatic ascites. All patients underwent pancreatic protocol contrast-enhanced computed tomography abdomen and magnetic resonance cholangiopancreatography, duct diameter and main pancreatic duct (MPD) disruption site. Calcification and pseudocyst site were identified. After optimizing patients, early surgery was planned. Surgeries included either lateral pancreatic jejunostomy (LPJ) if MPDs were dilated. Pancreaticogastrostomy, cystogastrostomy, or cystojejunostomy, if there was pseudocyst with extraneous impression over the stomach or on mesocolon, and distal pancreatectomy (and/or) splenectomy. Results: Out of 23 cases of pancreatic ascites, six were of acute pancreatitis and conservatively managed and 17 were subjected to early primary surgery. Nine out of 17 patients underwent LPJ. 3/17 underwent pancreaticogastrostomy. 1/17 underwent cystogastrostomy and 1/17 underwent spleen preserving distal pancreatectomy. 3/17 underwent distal pancreatectomy and splenectomy. None of the patients had postoperative recurrence of pancreatic ascites. One patient developed postoperative intra-abdominal collection, which was drained. Mortality was 2/17; one died immediate postoperatively and another succumbed to pulmonary embolism on postoperative day 4. Pain scores were significantly reduced postoperatively. Conclusion: Primary early surgery directed toward primary pathology, as guided by MPD status and calcifications, in selected patients with chronic calcific pancreatitis with ascites leads to faster recovery of the patient.

  Abstract No.: TNISGCON2022-09 Top

Forgotten CBD Stents: Complications and Outcomes - A Case Series in a Tertiary Care Center

Swarna Anupama, Caroline Selvi, Aravind, Prem Kumar, Murali, Chezhian, Muthukumaran, Shubha

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

Background and Aim: Endoscopic sphincterotomy and stone extraction is the widely accepted treatment modality for CBD stones, and this procedure can clear the bile ducts in 85%–90% of patients. The biliary stenting is performed either with plastic or metal stents; studies recommend their replacement after 3–6 months to avoid complications such as occlusion, migration of the stent, or cholangitis. There are many studies about the biliary stents; however, there is a little information about the long-term stayed or forgotten biliary stents, except a few case reports. Methods: In January 2022, four patients were referred to the Department of Medical Gastroenterology, RGGGH. All the patients were admitted with complaints of recurrent episodes of upper abdominal pain, progressive jaundice, and high-colored urine. All the patients lost follow up postprocedure as they were asymptomatic. The attempts to retrieve the biliary stent endoscopically failed initially in Patient 1 because she had impacted biliary stent, and it was impossible to remove it, so a second stent was introduced to CBD to avoid biliary obstruction. Later, in the second session, stent was removed in toto. In Patient 2, broken stent (2 pieces) was seen and both were successfully removed endoscopically. In Patient 3, stent was broken in situ into multiple pieces, and in Patient 4, stent migrated into CBD and was not possible to retrieve. Hence, surgical procedures were necessary. The information collected for each patient was age, gender, clinical presentation, gallbladder stone, biochemical blood tests, ERCP findings, duration of stent stay, stent insertion, ERCP-related complications, and type of surgery. Results: There were 1 male and 3 females age ranging from 27 to 68 years (mean age 41.6 years). Patients presented with pain in the upper abdomen, jaundice, fever, abnormal liver function tests, or dilatation of the biliary tract alone or in combination. The mean duration of the patency of the stent is about 12 months. The biliary stenting is performed either with plastic or metal stents, with studies recommending their replacement after 3–6 months. Two patients with long-stayed forgotten biliary stents were treated with endoscopic removal, but two patients underwent surgical intervention. Conclusion: Endoscopic placement of the endoprosthesis is a simple and safe method; however, after insertion, all patients should be informed to be having biliary stents and the possibility of complications related to long-term endoprosthesis placement. As the stent may get impacted or broken or migrated, an endoscopic procedure may not be successful in such cases, mandating surgical removal. Such cases are treated mostly by surgical intervention. We recommend for all ERCP units provide a stent registry system that the stents placed for various procedures. There should be a definite follow-up system for patients who undergo biliary stenting.

  Abstract No.: TNISGCON2022-10 Top

Comparison of Liver Function before and after Physical Activity in Cirrhotic and Patients Admitted for Major Abdominal Surgeries - A Prospective Cohort Study

N. R. Venkatesh, A. Amudhan, T. Selvaraj, S. Jeswanth

Department of Surgical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, Tamil Nadu, India

Background and Aim: The prevalence of physical inactivity is high worldwide who are admitted for surgery. Prehabilitation initiatives aim to create sufficient physiological reserve to deal with the subsequent surgical stress response. The primary objective of this study was to assess the effect of preoperative physical activity on liver function. The secondary objectives were to assess the psychological well-being using WHOQOL BREF and to assess the liver fitness for gastrointestinal (GI) surgeries. Methods: Patients admitted to the Department of Surgical Gastroenterology, Stanley Medical College, between January 2020 and March 2021 who met the inclusion criteria were asked to walk on a ramp — distance to cover at least 2000 steps/day or the duration of the walk for 30 min/day for a week. Fitness bands and smartphone steps counter were used to calculate the steps. Results: Out of 103 patients analyzed, 82% and 69% of the study population had increase in albumin and change in INR after physical activity, which was statistically significant. Physical activity improved Child-Pugh score of cirrhotic patients. The association between physical activity and improvement in general health, energy, and fatigue in hepatobiliary, upper GI, and lower GI patients was significant, with a P = 0.013 and 0.003. Conclusion: From the study, we conclude that physical activity increases liver synthesis and function as assessed by parameters such as albumin, INR, and ALT. Furthermore, physical activity improves liver fitness which helps in decreased intensive care unit stay and early appetite.

  Abstract No.: TNISGCON2022-11 Top

A Case Series of Small Intestinal Diseases - An Enteroscopic Perspective

Kandasamy Alias Kumar, Poppy Rejoice, A. Shafique, U. Ramu Krishnan, G. Roshni, D. Geetha, K. Kishore

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

Background and Aim: A case series of small intestinal diseases - An enteroscopic perspective. Methods: A 33-year-old male presented with a mass per abdomen of 1-month duration, associated with a history of (h/o) abdominal pain and weight loss; imaging showed a mass lesion arising from the proximal jejunum; enteroscopy and biopsy were taken. A 72-year-old male presented with abdominal pain, vomiting of 3 days duration, h/o melena for 1 week, imaging showed intussusception with a mass lesion in the jejunum, and enteroscopy was done. A 52-year-old female presented with easy fatigability and melena with h/o blood transfusion. Imaging studies were normal OGD scopy and colonoscopy. Enteroscopy done discovered the culprit. Results: For Patient 1, enteroscopy revealed ulceroproliferative lesion in the distal duodenum and proximal jejunum, biopsy showed dense abnormal lymphoid infiltration, and IHC was strongly CD3+ve diagnosis of T cell lymphoma. For Patient 2, enteroscopy revealed smooth well-defined polyp with a stalk attached in the jejunum, polypectomy was done, and biopsy came as hyperplastic polyp of jejunum. For Patient 3, enteroscopy showed a bulging intraluminal mass lesion with central depression in jejunum-diagnosis of jejunal GIST was made. Conclusion: Enteroscopy is a key instrument in diagnosing small intestinal diseases with an added advantage of tissue diagnosis and endotherapy.

  Abstract No.: TNISGCON2022-12 Top

An “Orphan” Disease with Crohn's Like Colitis

P. S. Kripal, T. Ravishankar P. Senthilkumar, V. Arulselvan, A. Senthilvadivu

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

Background and Aim: Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive “orphan” disease characterized by oculocutaneous albinism, bleeding diathesis, and occasionally lung fibrosis and granulomatous colitis. The estimated worldwide prevalence of HPS is 1–9 per 1,000,000. Crohn's disease (CD)-like granulomatous colitis has been described in about 20%–30% of HPS patients. Increasing documentation of monogenic defects such as HPS with IBD-like pathology can aid early clinical recognition and complement the functional understanding of the pathogenesis of IBD. This case report aims to document the clinical and therapeutic aspects of CD-like intestinal inflammation in HPS. Methods: A case report was prepared after taking informed consent and collecting relevant clinical and laboratory data. Clinical course and therapeutic response were also documented. Results: A 19-year-old male with hypopigmented skin and hair since birth was evaluated for chronic diarrhea with hematochezia and perianal lesions with purulent discharge. He was noted to have features consistent with Crohn's colitis on sigmidoscopy and biopsy. Hypopigmented iris, diminished visual acuity, nystagmus, and prolonged bleeding time were also documented. A provisional diagnosis of HPS was made based on clinical findings, and he was started on mesalamine and steroids for Crohn's like colitis. On follow-up visit, there was partial response to treatment. Conclusion: Enterocolitis with CD-like pathology is more commonly associated with HPS types 1 and 4. Earlier age of presentation, higher risk of bleeding, lower response to conventional treatment, response to anti-TNF? treatment, and a poorer prognosis are some of the important features of this rare clinical entity.

  Abstract No.: TNISGCON2022-13 Top

Sarcopenia in Liver Cirrhosis and Its Sequential Changes before and after Liver Transplantation

L. Harish Reddy, Joy Varghese, B. Mahadevan

Department of Medical Gastroenterology, Gleneagles Global Health City, Perumbakkam, Chennai, Tamil Nadu, India

Background and Aim: Sarcopenia in cirrhosis has emerged as an independent predictor of poor prognosis with an increased likelihood of adverse. Pretransplant sarcopenia is associated with longer hospitalization, longer intensive care unit stay, and even increased risk of mortality even after transplant. We indent to study psoas muscle thickness/height (PMTH) in sarcopenia using sex-specific cutoffs. We also intend to prospectively observe and compare changes of sarcopenia before and after liver transplant. Methods: This cross-sectional study was done between November 2019 and November 2021 in Gleneagles Global Health City, Chennai. 378 patients with cirrhosis who underwent computed tomography (CT) abdomen were enrolled for assessing the prevalence of sarcopenia in liver cirrhosis using handgrip strength and PMTH and 25 patients who underwent CT abdomen 6–12 months after liver transplant were included in subgroup analysis to study posttransplant changes in sarcopenia. Results: The prevalence of sarcopenia was 70.1% which is more common in males (73.35% vs. 56.75%). Sarcopenia was seen in 46.6%, 86.8%, and 82.5% of CTP A, B, and C classes, respectively. Only MELD score and presence of ascites predicted sarcopenia (P < 0.05). Sarcopenia was present in 76% of patients before and after a follow-up of 6–12 months after liver transplantation. Two patients developed de novo sarcopenia after undergoing transplantation. There was a significant association between sarcopenia and length of hospital stay after transplant surgery (20.73% vs. 13.83%; P < 0.05). Conclusion: In this single-center study, the prevalence of sarcopenia was 70.1%. Sarcopenia is common in males and worsens with the severity of the disease. Presence of ascites and high MELD score were associated with sarcopenia. Pretransplant sarcopenia is associated with increased risk of infectious, vascular complications, and prolonged hospital stay in the immediate postoperative period. Even though handgrip strength improved, PMTH decreased after transplantation. Further research is needed for better understanding, prognostication, and management of sarcopenia.

  Abstract No.: TNISGCON2022-14 Top

Biliary Interventions during COVID Pandemic: Is There Any Impact?

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

Background and Aim: Data regarding the endoscopic features and complications in patients with obstructive jaundice undergoing ERCP during the COVID-19 pandemic period are limited. The present study aims to evaluate the clinical and endoscopic features and complications in obstructive jaundice patients undergoing ERCP in our center and the impact of COVID-19 pandemic on ERCP outcomes. Methods: We retrospectively analyzed the prospectively maintained database of obstructive jaundice cases who had undergone ERCP from January 2020 to June 2021 in our center. Diagnosis was based on clinical and imaging features and laboratory parameters. Data were collected in Microsoft Excel and analyzed using SPSS version 23. Results: ERCP was performed in 103 patients during the study period. Choledocholithiasis was the most common indication. Biliary stent placement was done in 82.4% of patients. Technical success rate was >90%. The most common complication was post-ERCP pancreatitis. 79.6% of the procedures were done during the COVID-19 pandemic period. Success rate and complications were similar to those of pre-COVID period. Conclusion: The endoscopic procedure of choice for biliary decompression is ERCP. We had high success rate and low complication rate even during the COVID-19 pandemic period.

  Abstract No.: TNISGCON2022-15 Top

Hepatitis B Reactivation in Patients Receiving Anticancer Chemotherapy with Resolved Hepatitis B Infection

Kandasamy Alias Kumar, Poppy Rejoice, A. Shafique, U. Ramu Krishnan, G. Roshni, D. Geetha, K. Kishore

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

Background and Aim: The prevalence of hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg)-negative and anti-HBc-positive (resolved infection) individuals following chemotherapy for various cancers remains unknown. This research focused on investigating the prevalence and clinical features of HBV reactivation in HBsAg-negative and anti-HBc–positive patients. Methods: This is a prospective research involving cancer patients on chemotherapy who develop HBsAg positivity in a previously HBsAg-negative and hepatitis core antibody-positive patient. The analysis included 40 patients and followed up for 8 months. Results: Among 40 patients, mostly, 97.5% had a solid tumor and 3 (2.5%) patients had hematological malignancy. The majority (42.5%) received anthracycline-based therapy, and others received cisplatin plus 5 fluorouracil therapy, platinum-based therapy, and steroid therapy. Conclusion: In a patient with HBsAg positivity who was undergoing chemotherapy for cancer, antivirals were begun regardless of HBV-DNA. However, initiating antivirals in HBsAg-negative and anti-HBc-positive cancer patients undergoing chemotherapy for solid tumors other than hematological malignancy remains elusive. All guidelines suggested that HBsAg-negative and anti-HBc–positive patients must be regularly followed for HBV-DNA positivity and/or HBsAg seroconversion, and preemptive antiviral therapy must be initiated as soon as HBV reactivation is suspected. In our study, almost all patients with HBsAg-negative and HBcAb-positive patients undergoing chemotherapy for solid tumor shows HBV reactivation. Hence, antivirals may be considered in HBsAg-negative and HBcAb-positive patients undergoing chemotherapy for solid tumor regardless of HBV-DNA level and HBsAg seroconversion. However, it needs further study.

  Abstract No.: TNISGCON2022-16 Top

Management of Foreign Body Ingestion and Food Impaction in Adults and Its Complications in a Tertiary Care Center

Uday Vadicherla, Muthu Kumaran, Prem Kumar, Caroline Selvi, Aravind, Murali, Chezhian, Shubha

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

Background and Aim: Foreign body ingestions and food bolus impactions are important emergency conditions. Serious complications, such as perforations and subsequent death, can occur in both cases. In this study, we aimed to evaluate the management of patients with a history of foreign body ingestions and food impactions. Methods: A total of 76 patients were admitted with foreign body ingestion. After taking the history and performing physical examination, the initial treatment was given in the emergency department. All the patients with foreign body ingestions and food impactions underwent emergency endoscopic interventions. Results: Of 76 patients, it is most commonly seen in males (53.9%, 41) than females (46.9%, 35). It is most common in 46–55 years of age (25%, 19), followed by 36–45 years (22%, 17). Only one patient was >85 years old. Multiple foreign bodies are seen in two patients and both are taking treatment for schizophrenia. Abnormal foreign bodies such as toothbrush seen in one patient and he is also suffering with psychiatric illness. Food bolus impaction was seen in 5 (6.5%) patients; three patients having postcorrosive stricture and in two patients found to be having esophageal growth. Delay in treatment happened in two patients; in both, there was an ulcer managed conservatively. Sharp pin was found in two patients, in one patient suspected of having perforation but radiological test was negative. Conclusion: Although foreign body ingestions are rare in adults. Early endoscopic intervention leads to fewer complications. If multiple foreign bodies are found better to evaluate for psychiatric illness, care should be taken while removing sharp metallic objects.

  Abstract No.: TNISGCON2022-17 Top

An Extremely Rare Case of Primary Squamous Cell Carcinoma of Stomach - A Tumor with More Aggressive and Poor Prognosis than Adenocarcinoma Stomach

Sai Gunaranjan, Ganesh Panchapakesan, A. K. Koushik

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

Background and Aim: Squamous cell carcinoma of the stomach is a very uncommon entity, with worldwide incidence of 0.04%–0.07% of all gastric cancers. The first primary gastric squamous cell carcinoma case was described in 1895 by Rörig. Since then, fewer than 100 cases are reported in the literature. Methods: A 52-year-old male presented to the emergency department with abdominal pain in the epigastric region, burning type, nonradiating, occasionally nocturnal, increased on taking food. The patient had a history of passing black-colored stools for the past 10 days. Early satiety was present for the past 6 months. There was no history of jaundice, weight loss, fever, and altered bowels. Results: Upper gastrointestinal scopy done showed a large ulceroproliferative growth with central necrosis and overlying slough. Contrast-enhanced computed tomography (CT) abdomen done showed features suggestive of gastric malignancy (probably adenocarcinoma) with liver infiltration. Heterogeneous enhancing lesion of the left adrenal gland was also found. Biopsy report showed moderately differentiated squamous cell carcinoma [Figure 1]. Conclusion: Squamous cell carcinoma of the stomach is a extremely rare and highly aggressive tumor with poor prognosis.

  Abstract No.: TNISGCON2022-18 Top

Comparative Assessment of Noninvasive Imaging Modalities and Endoscopic Retrograde Cholangiopancreatography in Obstructive Jaundice

M. S. Revathy, Navin Kumar

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

Background and Aim: Accurate diagnosis of the cause is crucial in the management of obstructive jaundice. Noninvasive modalities such as ultrasonography (USG), multidetector computed tomography (MDCT), and magnetic resonance cholangiopancreatography (MRCP) as well as invasive modalities such as endoscopic retrograde cholangiopancreatography (ERCP) play pivotal roles in the diagnosis. Objectives: The objective of the study is to compare the diagnostic accuracy of USG, MRCP, and MDCT with ERCP in obstructive jaundice. Methods: Seventy-six patients with features suggestive of biliary obstruction were included. At least one imaging modality was used in each patient. The cause of obstruction was evaluated by each modality. Data and findings of noninvasive modalities were compared with ERCP findings. Results: The study included 76 patients (31 females and 45 males). The mean age of presentation was 48.3 years, most in the fifth decade. Predominant symptoms were jaundice (85%) and pain abdomen (59%). Most common cause of obstruction was choledocholithiasis (86.8%). Benign and malignant causes were 93.4% and 6.6%, respectively. USG, CT, and MRCP were able to diagnose accurately the cause of obstruction in 21.4%, 64%, and 97.29% of the cases, respectively, compared to ERCP findings. MRCP had better sensitivity (96.87%) than CT abdomen (73.15%) in the diagnosis of choledocholithiasis. MDCT and MRCP had similar sensitivity and specificity for the diagnosis of benign CBD stricture. For malignant causes, CT abdomen had better sensitivity (75%) than MRCP (50%) Conclusion: MRCP findings correlated most accurately with high sensitivity among noninvasive modalities with ERCP findings in diagnosis of obstructive jaundice, especially in choledocholithiasis. Noninvasive modalities may be considered the first-choice option in the diagnostic imaging of obstructive biliary disease in view of high diagnostic accuracy

  Abstract No.: TNISGCON2022-19 Top

Prevalence and Natural History of Subclinical Hepatic Encephalopathy in Cirrhosis

R. Santhosh, A. Chezian, K. Premkumar

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

Background and Aim: The natural history of subclinical hepatic encephalopathy (SHE) is unknown. The present study was conducted to study the prevalence and the natural history of SHE in patients with liver cirrhosis. Methods: One hundred and sixty-five patients with liver cirrhosis were studied. A total of nine psychometric tests (trail making and Wechsler adult intelligence scale-performance tests) were administered. SHE was present if two or more psychometric tests were abnormal. Seventy-two patients (SHE 40, without SHE 32) also underwent serial psychometric testing on follow-up visits at 6–8-week intervals. Results: SHE was present in 103 (62.4%) patients. The number and figure connection, block design, and picture completion tests were most useful in the detection of SHE. Severity of SHE, as assessed by the number of abnormal tests, was greater in patients with more severe liver disease. During follow-up, SHE tended to persist or worsen in patients with poorer liver function. Although other clinical complications were similar in different groups, overt hepatic encephalopathy developed more commonly in those patients who had SHE at entry compared to those who did not (22.6 vs. 5.6%, P = 0.044). Among the patients with SHE, the development of overt hepatic encephalopathy was more common in patients with Child's score of >6 than with Child's score of <6 (40% vs. 5%, P = 0.019). Conclusion: We conclude that SHE is common in cirrhosis. The natural history of SHE is worse in patients with advanced cirrhosis and SHE probably predisposes the cirrhotic patient to overt hepatic encephalopathy.

  Abstract No.: TNISGCON2022-20 Top

Prevalence and Type of Gastrointestinal Lesions in Upper Gastrointestinal Endoscopy of Patients with Anemia

Ramalingam Rajendiran, Senthamizhselvan Kuppusamy, Pazhanivel Mohan

Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Background and Aim: Chronic occult gastrointestinal (GI) bleeding is believed to be one of the common causes of iron deficiency anemia. Although most societies recommend bidirectional endoscopy in asymptomatic men and postmenopausal women with iron deficiency anemia, it is only a conditional recommendation in premenopausal women. This study was done to determine the frequency and the type of GI lesions in upper GI (UGI) endoscopy in patients with anemia. Methods: All patients who underwent UGI endoscopy to evaluate anemia in the Department of Gastroenterology, JIPMER, between January 2019 and December 2021 were included. Patients with iron deficiency as well as megaloblastic anemia were included. Demographic details, laboratory investigations, and endoscopic findings were collected. Results: A total of 227 patients underwent UGI endoscopy during the study. The mean age of the study population was 46.6 ± 15.4 years. 121 (55.3%) were men. Out of 227, 195 (85.9%) had iron deficiency anemia and 32 (14.1%) had megaloblastic anemia. Mean hemoglobin was 5.9 ± 1.4 g/dl. 30 (13.2%) patients had pancytopenia. UGI endoscopy was normal in 126 (55.5%) patients. The GI lesions that were identified include antral erythema (18, 7.9%), gastric polyps (11, 4.8%), gastric erosions (9, 4%), cricopharyngeal web (7, 3.1%), duodenal scalloping (7, 3.1%), duodenal polyp (7, 3.1%), deformed pyloroduodenal complex (4, 1.8%), gastric malignancy (2, 0.9%), duodenal ulcer (2, 0.9%), and gastric ulcer (1, 0.4%). Out of 81 deep duodenal biopsies performed, nonspecific duodenitis was reported in 80 and celiac disease in one patient. Helicobacter pylori-associated gastritis was reported in 14 patients (7.1%). All the gastric biopsies taken for evaluation of megaloblastic anemia evaluation showed nonspecific inflammation. Colonoscopic findings were available in 45 patients with normal UGI endoscopy. Four had adenocarcinoma of the colon, and two had a sigmoid colon polyp. In patients with iron deficiency anemia, 49 (25.1%) had eosinophilia, 7 had hookworm in stool, and in 9 patients, hookworm was demonstrated in the duodenum during endoscopy. Conclusion: In patients with anemia undergoing endoscopy, more than half had normal UGI examinations. One out of four patients with iron deficiency anemia had peripheral eosinophilia, and 9.6% had hookworms in their duodenum and stool, suggesting that parasitic infections are still a significant cause of anemia in our region.

  Abstract No.: TNISGCON2022-21 Top

Gastric Access Loop with Valve in Hepaticojejunostomy for Endoscopic Intervention: A Modified Technique Video

M. Srinivasan, M. Satish Devakumar, Jeswanth Sathyanesan

Department of Medical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, Tamil Nadu, India

Background and Aim: Access loop for hepaticojejunostomy fashioned for future endoscopic intervention for various indications. Gastric access loop is one of which approaches that has advantage over subcutaneous loop. Meanwhile, to eliminate the risk of biliary gastritis or reflux cholangitis, a valved gastric access loop to hepaticojejunostomy has been a fashioned novel approach. Methods: A 43-year-old female presented to our hospital with complaints of abdomen pain and distention postlaparoscopic cholecystectomy. She found to have bile duct and vascular injury during surgery, and she has been managed with abdominal drain for bilioma. After 2 months, the patient has undergone definitive procedure and hepaticojejunostomy. Due to high risk of anastomotic stricture associated with vascular injury, jejunal access limb has been fashioned with the stomach anterior wall. Postoperative course was uneventful. On the 3rd week postoperatively, her upper gastrointestinal (GI) endoscopy confirmed the patency of the loop by successful intubation, and upper GI contrast study confirmed the competency of the valve. Results: Access loop has been shown to be a useful tool in patients with hepaticojejunostomy for managing recurrent stones and stricture. Gastric access loop has the advantage of easy endoscopic access into the biliary system for a nonsurgical intervention. However, it is associated with risk of bile reflux gastritis and cholangitis. Our novel surgical technique eliminates both risks. Conclusion: Access jejunal limb for hepaticojejunostomy is a useful tool for nonsurgical endoscopic intervention in strictures and stones. Gastric access limb with valve is a safe modification technique that eliminates the risk of bile reflux and cholangitis.

  Abstract No.: TNISGCON2022-22 Top

QTc Prolongation in Patients of Cirrhosis and Its Relation with Severity of Cirrhosis and Cirrhotic Cardiomyopathy

Chaitanya Katragadda, M. S. Revathy

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

Background and Aim: Cardiac involvement is not uncommon in cirrhosis, and prolonged QT interval is seen in 30%–80%. Cirrhotic cardiomyopathy refers to systolic and diastolic dysfunction and impaired contractility to stress. We aim to study QTc prolongation (>440 ms) in cirrhotic patients and its relation with etiology and severity and cirrhotic cardiomyopathy. Methods: This prospective observational study was conducted in the Department of Medical Gastroenterology in Government Stanley Medical College, Chennai, between November 1, 2020, and October 31, 2021. Eighty consecutive cirrhotic patients were included. Exclusion criteria were malignancy, ischemic heart disease, cardiac arrhythmias and congenital heart defects, diabetes, hypertension, and drugs affecting QTc. All patients underwent 12-lead ECG, transthoracic ECHO, and dobutamine stress ECHO. Used Bazett's formula for QTc calculation, Montreal criteria for diagnosing cirrhotic cardiomyopathy. Results: Out of 80 patients, 53 were males with alcohol being the most common etiology (38/80) followed by chronic hepatitis B (18/80). The mean age of the patients was 49.8 years. 61 out of 80 patients (76.25%) had QTc prolongation with strong correlation with MELD >15 and CHILD PUGH scores (likelihood ratio 18.9) with the highest prevalence in CPS-C (92.3%). QTc prolongation strongly correlated with duration (likelihood ratio 9.28) but not with etiology of cirrhosis. Cirrhotic cardiomyopathy noticed in 16.25% of patients. Most patients belonged to CPS-C (12 of 13). Cirrhotic cardiomyopathy strongly correlated with high CPS (likelihood ratio 11.08) and MELD scores and prolonged history of DCLD (likelihood ratio 6.96). Conclusion: QTc prolongation was the common ECG abnormality in cirrhotic patients strongly correlating with prolonged and advanced cirrhosis. Cirrhotic cardiomyopathy prevalence is 16.25%, noted commonly in patients with prolonged and advanced cirrhosis.

  Abstract No.: TNISGCON2022-23 Top

Demographic and Etiological Profile of Acute cholangitis: A Case Series from a Tertiary Care Center

Chittuluri Jagadeesh, A. Aravind, Caroline Selvi, K. Premkumar,

K. Muthukumaran, R. Murali

Department of Medical Gastroenterology, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

Background and Aim: Acute cholangitis (AC) is a common emergency in gastroenterology practice. We present our data of AC patients with an emphasis on etiological profile. Methods: This is a retrospective study conducted at a tertiary care center from August 2021 to January 2022. All the patients admitted in the ward or intensive care unit with AC were included. The demographic and etiological parameters were recorded. Results: 42 patients were included, comprising 19 (45.2%) males and 23 (54.8%) females. Four (9.5%) patients expired. The mean age was 44.6 ± 12.6 years. The etiology of biliary obstruction was malignant in 19 (45.2%) patients and benign in 23 (54.8%) patients. Overall, CBD stone was the most common etiology (n = 18). Conclusion: A large number of patients belonging to AC are females, and overall, CBD stone is the most common etiology.

  Abstract No.: TNISGCON2022-24 Top

Infections in End-Stage Liver Disease -The Changing Paradigm and Challenges

Nikhil Kenny Thomas, L. Venkatakrishnan, S. Mukundan, P. Thirumal, R. K. Karthikeyan, P. Arun, Ravindra Kantamneni

Department of Medical Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Background and Aim: Concerning feature of infection in end-stage liver disease (ESLD) is the growing prevalence of multidrug-resistant pathogens, which are associated with higher mortality, increased length of in-hospital stay, and higher healthcare-related costs. The aim of our study was to identify the common infections and the antimicrobial susceptibility and to analyze the risk factors in hospitalized patients with ESLD. Methods: A prospective cohort study of patients with ESLD with infections was performed at our center. Data were collected on admission vitals, disease severity (MELD, Child-Pugh, and SOFA scores), infection site, type, and antibiogram. The outcome was mortality within 30 days. Results: 542 patients (55 years, 76% men, MELD 18) were included. Urinary tract infections (52%), spontaneous bacterial peritonitis (23%), and spontaneous bacteremia (21%) formed the majority of the first infections. 127 patients (23.6%) who died within 30 days had higher admission MELD (25 vs. 18, P < 0.0001), lower serum albumin (2.4 g/dL vs. 2.8 g/dL, P = 0.004), and second infections (49% vs. 16%, P < 0.0001) but equivalent SOFA scores (9.2 vs. 9.9, P = 0.76). The case fatality rate was highest for respiratory (32.5%) and spontaneous bacteremia (25%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03), albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Multidrug resistance was seen in 26% of the study sample. Conclusion: Prompt detection of infections, especially multidrug-resistant pathogens, use of appropriate antibiotics for treatment, and prophylactic measures such as vaccinations can help improve survival in these patients.

  Abstract No.: TNISGCON2022-25 Top

Intestinal Methanogenic Overgrowth: A Neglected Microbiome

P. Arun, L. Venkatakrishnan, S. Mukundan, P. Thirumal, R. K. Karthikeyan, Ravindra

Institution: Department of Medical Gastroenterology, PSG Institute of Medical Science and Research, Coimbatore, Tamil Nadu, India

Background and Aim: Methanogenic SIBO has been renamed intestinal methanogenic overgrowth. Methane production in the human body is contributed predominantly by archaea microbe Methanobrevibacter smithii. A methane producer is identified by the detection of 10 ppm of methane anytime during lactulose breath test. The aim of this study was to identify patients with a history suggestive of SIBO for methanogenic overgrowth. Methods: Patients having symptoms of SIBO were evaluated with routine investigations, endoscopy, and breath tests, and breath test was analyzed 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 (H-SIBO) and 23 had a combination of M-SIBO and H-SIBO. Only one patient with positive hydrogen breath test did not have associated methanogenic bacterial overgrowth; the rest all had. Predominant complaints associated with methanogenic SIBO were constipation (44%), bloating (37%), and flatulence (19%). 3% of M-SIBO had 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: The incidence of methanogenic overgrowth is on the rise in South Indian population. Baseline methane levels are high in 30% of 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 the Indian population and adequately treated.

  Abstract No.: TNISGCON2022-26 Top

Clinical Implication of Post-ERCP Hyperamylasemia and Its Predictive Role in Post-ERCP Pancreatitis

Vinoth Sermadurai, Kannan Mariappan, Ramani Ratinavel, Vijai Shankar Chidambara Manivasagam

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

Background and Aim: Our aim is to identify the prevalence of post-ERCP hyperamylasemia and its role in predicting post-ERCP pancreatitis (PEP) and its association with risk factors of PEP. Methods: Our study includes 76 patients who underwent ERCP procedure in Madurai Medical College during the study period from February 1, 2021, to January 31, 2022. Serum amylase concentrations were measured 3 h and 48 h after ERCP. Results: In our study, PEP occurred in 3.9% of patients, even though hyperamylasemia was noted in 38.2% of patients. Mean serum amylase in non-PEP group at 3 h and 48 h was 86.3 ± 71.2, 70.41 ± 71 and in PEP group at 3 h and 48 h was 61.66 ± 31.07, 209 ± 123, respectively. In our study, comparison of 3 and 48 h hyperamylasemia with pancreatitis showed a significant association with 48 h amylase levels (P < 0.05). Three-hour serum amylase had no significant association with PEP. Comparing the 3 h and 48 h amylase levels with both PEP and non-PEP group, there is significant decrease in serum amylase at 48 h in non-PEP group. Bivariate logistic regression with PEP group showed that female sex, difficult cannulation, needle knife sphincterotomy, and cholangiogram had increased risk of developing PEP. Conclusion: Serum amylase levels at 48 h have more predictive role in PEP than 3 h serum amylase levels. Fall in amylase value from 3 h to 48 h excludes the chance of development of PEP. We should always suspect PEP if patient-related and procedure-related risk factors are present, even though early serum amylase is normal. Further studies are needed to know the appropriate time for measuring serum amylase for early prediction of PEP.

  Abstract No.: TNISGCON2022-27 Top

Splanchnic Thrombosis as Sequelae of Asymptomatic SARS-CoV-2 Infection

Allwin James, Alagammai Palaniyappan, Ramesh Ardhanari

Department of Medical Gastroenterology, Meenakshi Mission Hospital and Research Centre, Madurai, Tamil Nadu, India

Background and Aim: Patients with active SARS-CoV-2 infection are predisposed to venous and arterial thromboembolism; however, limited published data are available regarding mesenteric thrombosis as sequelae of SARS-CoV-2 in the convalescence period of asymptomatic infection. Here, we report a case series of patients who presented with splanchnic thrombosis as a result of recent SARS-CoV-2 infection emerging as a predominant causal factor during the pandemic era in a tertiary care hospital. Methods: All patients who presented with splanchnic thrombosis were analyzed with SARS-CoV-2 antibodies panel and for other prothrombotic states. SARS-CoV-2 IgG and SARS-CoV-2 total (IgG, IgA, and IgM) antibodies were calculated separately. A patient with SARS-CoV-2–positive antibody panel, nasopharyngeal swab RT-PCR for SARS-CoV-2 negative, and presence of splanchnic thrombosis was considered as SARS-CoV-2 sequelae-related splanchnic thrombosis. The presence of antibodies to infection defines a recent or asymptomatic infection. Diagnosis of splanchnic thrombosis was established by abdominal computed tomographic (CT) imaging. Current COVID infection was ruled out by doing CT chest. Demographic data, history of COVID infection, contact with a COVID-positive patient, COVID vaccination status, clinical presentation, management, outcome, and 30-day follow-up were analyzed in this study. Results: Six patients had SARS-CoV-2 RT-PCR negative and antibody panel positive and presented with splanchnic thrombosis. Four were males and all were more than 45 years of age. The mean age was 55 ± 9 years. All were diagnosed with splanchnic thrombosis on day 1 of admission. The mean number of hospitalization days was 5 ± 3 days. All had SARS-CoV antibody reactive and nasopharyngeal RT-PCR were negative. Total SARS-CoV-2 antibody (IgG, IgA, and IgM) was 427 ± 242 and IgG SARS-CoV-2 antibody was 9.8 ± 7.4. Diabetes was noted in five patients, and hypertension was noted in four patients. None of the patients had symptomatic COVID infection in the recent past (90 days before onset of symptoms) and were not vaccinated against SARS-CoV-2. Abdominal pain was the most common presentation seen in all patients. Two had melena as presentation and underlying chronic liver disease (CLD) was also noted; one patient had gastric ulcer and another patient had GAVE which was managed with APC. Three had underlying CLD, of which 2 were related to ethanol and 1 was attributed to NAFLD. All were compensated at presentation with CHILD A cirrhosis. Two had arterial thrombosis and four had venous thrombosis. SMA was involved in two and had ischemia, which was conservatively managed. SMV and portal vein involvement was noted in three, and isolated portal vein thrombosis was noted in one NAFLD CLD patient. CT imaging of all patients did not show any active COVID infection. All were managed conservatively with oral anticoagulation overlapped with heparin, and none required surgical management. All had successful 30-day outcome with no mortality. Conclusion: SARS-CoV-2 is emerging as a potential cause for splanchnic thrombosis. Diabetes and CLD seem to be predisposing factors. Health-care providers should be aware that following an asymptomatic SARS-CoV-2 infection, patients can present with life-threatening splanchnic thrombosis as the initial presentation.

  Abstract No.: TNISGCON2022-28 Top

Safety and Efficacy of Direct-Acting Antivirals for Chronic Hepatitis C in Patients with Chronic Kidney Disease on Maintenance Hemodialysis

M. Kannan, R. Ramani, C. Vijai Shankar, P. B. Sriram

Department of Medical Gastroenterology, Government Rajaji Hospital, Madurai Medical College, Madurai, Tamil Nadu, India

Background and Aim: Hepatitis C virus infection is common among hemodialysis (HD) patients and is associated with increased morbidity and mortality. The aim of the study is to assess the safety and efficacy of DAA regimens in patients with chronic disease on maintenance HD. Methods: In this prospective observational study, HD patients with chronic hepatitis C infection were identified and treatment was initiated with appropriate DAA regimen. Totally, 74 patients were diagnosed with chronic hepatitis C and treated with DAAs for 12 weeks. The sustained virologic response (SVR) rate obtained 12 weeks posttreatment was evaluated. Laboratory indices and adverse reactions during the treatment process were also assessed. Results: All the patients enrolled completed 12 weeks of treatment. 12 (10%) patients had underlying compensated liver disease and SVR was achieved in all the 12 patients (100%) receiving sofosbuvir/velpatasvir. 60 of 62 patients without liver disease (96.7%) who received sofosbuvir/daclatasvir without any dose alteration attained SVR without any worsening renal status. No serious adverse reactions were reported. Conclusion: DAA regimens are safe and well tolerated even in patients with chronic kidney disease on maintenance HD. Sofosbuvir/daclatasvir-based regimens without dose alteration can be used as an alternative pan-genotypic regimen in patients with chronic kidney disease on HD without worsening of renal status.

  Abstract No.: TNISGCON2022-29 Top

Comparative Risk Factor Analysis and Clinical Profile Evaluation of Esophageal and Colorectal Cancers

Kondala Rao Yedupati, Kannan Mariappan, Ramani Ratinavel, Vijai Shankar Chidambara Manivasagam, P. Sriram

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

Background and Aim: The aim is to study the comparative risk factors analysis and clinical profile of esophageal carcinoma (EC) and colorectal carcinoma (CRC) in a tertiary care center. Methods: Our study includes 30 consecutive patients with EC and CRC confirmed histopathologically. History of diabetes mellitus, behavioral factors such as tobacco use, both smoking and alcohol consumption, and dietary details were noted. Initial presenting symptoms and predominant location of tumors were also recorded. Analysis was done using appropriate statistical methods. Results: In our study, we compared 30 patients of EC, both squamous cell carcinoma and adenocarcinoma types with 30 patients of CRC of primary adenocarcinoma. The age group in the study was 25–80 years; EC is more common in younger age group of 41–55 years (43.3%) compared to CRC in around 56–70 years (46.7%), and both EC (66.7%) and CRC (56.6%) have male predominance. EC presented with dysphagia (66.7%) while CRC presented with abdomen distension (33.3%), followed by bleeding per rectum (26.7%). Smoking is more associated with EC (17 patients, 56.6%) than CRC (7 patients, 23.3%). Alcohol is a risk factor for both EC (60%) and CRC (66.6%). Red meat consumption was seen in 100% of EC and 93.3% of CRC, and 50% of EC and 50% of CRC patients had diabetes. Lower one-third of EC are predominant (28.3%) and left-sided colon cancers (23.4%) are predominant in CRC. The mean duration of presentation is earlier with EC (2.8 months) compared to CRC (5.8 months), and mortality was more with EC (56.6%) compared with CRC (30%). Conclusion: Compared with CRC, EC has more association with younger age and smoking. Although EC presents earlier, the mortality rate was higher compared to CRC.

  Abstract No.: TNISGCON2022-30 Top

Histomorphological Study of Duodenal Nodules in the First Part of Duodenum in 104 Patients in a Tertiary Care Center in South India

Bontha Vineesha, P. Ganesh, Shanmuganathan

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

Background and Aim: Duodenal nodules in the first part of the 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 these nodules. Methods: This is a retrospective study of 104 patients who had nodules in the first part of the duodenum either single or multiple during routine endoscopic procedures done between January 2019 to July 2021 which are biopsied. The morphology and its histopathology were 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. 14 patients of diagnosed neuroendocrine tumor had single 5–10 mm-sized nodule in the anterior wall. One patient had multiple nodules in the duodenum of size 1–2 mm with one predominant nodule of 8 mm size, which was neuroendocrine tumor 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.

  Abstract No.: TNISGCON2022-31 Top

Diagnostic Yield of Routine Duodenal Biopsy for Suspected Coeliac Disease in a Tertiary care centre in South India (Tamil Nadu)

Vikranth Chunduri Venkata Viswa, Ganesh Panchapakesan, Shanmuganathan Subramanyam

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

Background and Aim: Routine duodenal biopsies are taken to identify probable celiac disease (CD) in a patient presenting with anemia, diarrhea, and weight loss. The prevalence of 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. Methods: A retrospective study was conducted at Department of Gastroenterology at Sri Ramachandra Institute of Higher Education and Research, Tamil Nadu, from January 2018 to June 2021 among 516 suspected CD patients. Demographics, indications for the procedure, preoperative investigations (including complete blood count, and iron studies), and endoscopic and histologic findings were collected from medical records. Patients with iron deficiency anemia (<12 gm/dl in women and <13 gm/dl in men with low 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 517 patients are included in the study, comprising 245 (457.5%) males and females 271 (52.5%) females. The mean age was 47.6 years in males and 45.1 years in females. The predominant symptoms are only anemia in 448 (86.82%), only diarrhea in 30 (5.8%), anemia + diarrhea in 21 (4.07%), with rest of the combination of symptoms in minority. Scalloping of the duodenal mucosa is observed in 19 (3.68%) patients, but none of these patients have features of CD on microscopy. Biopsy features of CD are seen in five patients; four of them came with only anemia and one with only diarrhea. All the patients had normal duodenal endoscopy but HPE were suggestive of coeliac with Marsh stage 3. The overall yield of duodenal biopsy for identifying probable CD is 0.96%, for patients with only anemia is 0.89%, and patients with only diarrhea is 3.3%. 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.

  Abstract No.: TNISGCON2022-32 Top

Timing of Premedication with Simethicone with N-Acetyl Cysteine in Improving Mucosal Visibility during Upper Endoscopy

Gowtam Manne, Vineesha, Ganesh Panchapakesan, Shanmuganathan Subramanyam

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

Background and Aim: Upper endoscopy is the most common method for the diagnosis of upper gastrointestinal tract diseases. Simethicone was proved to be a good defoaming agent for preendoscopic usage to remove bubble and mucus. Aim: The aim is to determine the efficacy of premedication with simethicone and N-acetyl cysteine and timing of administration to improve mucosal visibility before upper endoscopy. Methods: A prospective case–control study was conducted at Department of Gastroenterology at Sri Ramachandra Institute of Higher Education and Research, Tamil Nadu. All patients above 18 years coming for endoscopy for various indications are included in the study. Patients were randomized to one of three groups simethicone (150 mg) plus N-acetyl cysteine (600 mg) with 85 ml water (15 ml emulsion of premedication + 85 ml water) 30 min before procedure (Group A); 45 min before procedure (Group B); and no preparation (Group C). A single endoscopist blinded to the patients' group assessed the gastric mucosal visibility scores (range 0–2) at the esophagus, stomach, and duodenum. The sum of the scores from the three sites was considered the total mucosal visibility score, with lower scores suggesting the best visibility. Results: A total of 150 patients were enrolled in the study. 99 (66%) were male and 51 (34%) were female. The mean mucosal visibility scores are 0.38, 0.34, and 1.76 in Groups A, B, and C, respectively. Conclusion: The mucosal visibility and detection of mucosal lesions significantly improved in simethicone group, but there was no significant difference in mucosal visibility on timing of prepreparation.

  Abstract No.: TNISGCON2022-33 Top

Sickle Cell Disease with Cholestatic Jaundice - A Case Series

Ben Xavier, T. Ravi Shankar, P. Senthil Kumar, V. Arul Selvan, A. Senthil Vadivu

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

Background and Aim: Prevalence of hepatic involvement in sickle cell disease (SCD) is 40%–80%. Sickle cell intrahepatic cholestasis (SCIC) is a rare but potentially fatal complication of SCD. In this paper, we report three SCD patients who presented with acute cholestatic injury Methods: This is a case series prepared by collecting relevant data after informed consent. Results: Case 1: An 18-year-old male with SCD presented with right abdominal pain, jaundice and fever, tenderness right hypochondrium, positive Murphy's sign, TC 14,000/mm3, TB/DB 14.2/10.5, ALT 125 U/L, AST 171 U/L, and ALP 324. MRCP - choledocholithiasis with cholelithiasis, ERCP and biliary drainage improved. Case 2: A 22-year-old male with SCD presented with pain left hip, jaundice for 5 days and fever for 3 days, afebrile, hepatosplenomegaly. Hb 5.2, TC 3000, platelet 17000, TB/DB 13.3/7.3, ALP 446, AST/ALT 76/98, RFT 19/0.9, retic count 5%, IgM dengue positive, CECT abdomen - hepatosplenomegaly, no GB or CBD stone, broad-spectrum antibiotics, partial blood exchange transfusion, rehydrated, LFT and clinical status improved. Case 3: A 19–year-old female with SCD presented with fever, right abdominal pain, and jaundice for 1 week and altered sensorium for 3 days, drowsy, tachypneic, in hypotension, hepatomegaly. TC 84,000, Hb 6.6, TB/DB 25.9/14.4, AST/ALT 723/297, ALP 944, RFT 88/1.7, PT-INR 23.2/1.83, cultures negative, USG abdomen no CBD stone. Admitted to the intensive care unit, the patient succumbed to illness on day 2 of admission. Conclusion: SCIC is a rare but severe complication of SCD. Early identification is challenging, and further studies are required to define therapeutic approaches.

  Abstract No.: TNISGCON2022-34 Top

A Case of Acquired Tracheoesophageal Fistula with Double Stenting

Bodda Venkata Sriram, A. K. Koushik, P. Ganesh, J. C. Bose

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

Background and Aim: Acquired tracheoesophageal fistula is a rare entity and occurs as a result of malignancy, trauma, granulomatous infection, any previous surgery of trachea and esophagus. Methods: A 68-year-old male who is a known case of metastatic carcinoma of right lung cT4N2 squamous cell carcinoma diagnosed in November 2020. Endoscopy done showed a fistulous opening in the esophagus at 25 cm from incisors. Brochoscopy showed trachea esophageal fistula in the distal portion of the trachea just above the carina, with purulent secretions seen in the right lower lobe of the lung. Results: Tracheal Y stent was deployed followed by Wall flex. Esophageal-covered stent was deployed covering the defect under endoscopic and fluoroscopic guidance. Conclusion: Double stenting is a palliative approach in the case of fistula and/or malignant airway wall involvement. Preventive approach in the case of an extrinsic tracheal or bronchial compression is very helpful as a palliative procedure.

  Abstract No.: TNISGCON2022-35 Top

A Perplexing Case of Cholestatic Jaundice

S. Baraneedaran, T. Ravishankar, P. Senthil Kumar, V. Arulselvan, A. Senthil Vadivu

Department of Medical Gastroenterology, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Background and Aim: The use of complementary and alternative medicines (CAMs) to treat acute and chronic diseases is on the rise worldwide, especially in Asian countries, and mostly in China and India. Vanishing bile duct syndrome is an uncommon, acquired, but potentially serious form of chronic cholestatic liver disease, defined as a loss of the intralobular bile ducts in >50% of portal areas. Some drugs can induce alterations of the small bile ducts mimicking PBC or PSC, with bile duct damage culminating in marked ductopenia. This case report aims to discuss a case of drug-induced liver disease with ductopenia due to CAM intake. Methods: A case report was prepared after taking informed consent and collecting relevant clinical and laboratory data. Clinical course and therapeutic response were also documented. Results: A 52-year-old male with no addictions and a history of liver disease presented with cholestatic jaundice and a history of CAM intake. Initial workup viral serology and other serology markers were negative. MRCP was suggestive of sclerosing cholangitis, and he underwent ultrasound-guided liver biopsy, which suggested active cholestatic hepatitis with ductopenia due to drug-induced liver injury (DILI). Conclusion: Some patients of DILI may progress to vanishing bile duct syndrome due to drugs. This case report highlights that VBDS can occur due to CAM intake. Symptoms and liver biochemical function tests may ultimately improve; however, progressive bile duct loss can lead to cirrhosis, liver failure, and death or the need for liver transplantation.

  Abstract No.: TNISGCON2022-36 Top

Successful Endoscopic Management of Radiotherapy-Induced Tracheoesophageal Fistula with ASD Occluder Device

B. Mahadevan, Dinu Abirami Premkumar, Piyush Bawane

Department of Gastroenterology, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Background and Aim: Acquired tracheoesophageal fistula (TOF), defined by pathological communication between tracheal and esophageal lumen, usually results secondary to prolonged intubation, tracheostomy, malignancy, trauma, infections, and inhalational injury. The treatment strategies for TOF are quite complex and often require a multidisciplinary approach to alleviating patient symptoms and improving quality of life and nutrition. We report one such case of TOF secondary to radiation therapy in a patient with cervical esophageal malignancy. Methods: Case History: A 42-year-old gentleman, with good performance status, was diagnosed with locally advanced cervical esophageal squamous cell carcinoma and managed with chemoradiation. Three months following completion of radiotherapy, the patient presented with symptoms of dysphagia, cough on swallowing food, and new-onset unintentional weight loss. Evaluation for disease recurrence revealed well-controlled disease. However, further evaluation with upper gastrointestinal scopy showed fistulous opening at the upper esophagus likely to be communicating with the trachea with distal narrowing of the esophageal lumen. Diagnosis of TOF was confirmed with computed tomographic imaging, and feasible treatment options of endoscopic versus surgical techniques were considered. After multidisciplinary team discussion, atrial septal occluder device was placed from tracheal side using pediatric scope. Following endoscopic intervention, the patient is tolerating oral solid diet and symptom-free at present. Results: The principle scope behind the management of TOF is to seal the fistula and prevent spillover of gastric and oral secretions into the respiratory tract. Endoscopic interventional procedures for TOF include esophageal stenting, airway stenting, fibrin glue injections, atrial closure devices, acellular micromatrices, and bronchoscopic suturing techniques. Conclusion: Despite multiple options, our patient was successfully managed with atrial occluder device alleviating the need for surgery.

  Abstract No.: TNISGCON2022-37 Top

A Clinical Study Of Acid–Base Disturbances in Critically Ill Patients with Cirrhosis of Liver in a Tertiary Care Center

Paila Ramesh, Murali, Caroline Selvi, Prem Kumar, Shubha, Chezhian,

Muthu Kumaran, Aravind

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

Background and Aim: Liver is an important regulator of acid–base homeostasis next to the kidneys and lungs. The equilibrium of offsetting metabolic acid–base disorders in stable cirrhosis might be lost during episodes of decompensation, hemorrhage, or sepsis. The purpose of this study was to determine whether the acid–base state is destabilized in critically ill patients with cirrhosis and whether this is associated with any mortality. Methods: Sixty patients with cirrhosis were investigated in a prospective observational cohort study on admission to MGE unit of RGGH. Arterial acid–base state was assessed according to Gilfix methodology. Clinical data and hospital mortality were recorded. Results: Out of 60 patients, 45 (75%) were male and 15 (25%) were female. Severity of cirrhosis was Child-Pugh A in 5 (8%), B in 18 (30%), C in 37 (62%). Causes for hospital admission were gastrointestinal bleeding in 28 (47%), hepatic encephalopathy in 18 (30%), sepsis in 8 (13%), and renal failure in 6 (10%). Acid–base disturbances identified were respiratory alkalosis in 12 (20%), hypoalbuminemic metabolic alkalosis in 8 (13%), hyperchloremic metabolic acidosis in 8 (13%), lactic acidosis in 24 (40%), hyponatremic metabolic acidosis in 6 (10%), and mixed metabolic acidosis and respiratory alkalosis in 2 (4%). Out of 60 patients, 12 (20%) patients died during hospital stay, in which 10 (16%) had severe lactic acidosis, 1 (2%) had mixed metabolic acidosis and respiratory alkalosis, and 1 (2%) had hyponatremic metabolic acidosis. All these patients died were come under Child Pugh C severity. Conclusion: The stable equilibrium state of acid–base disorders is lost when patients with cirrhosis become critically ill. They have a high mortality rate and poor prognosis because of high prevalence of metabolic acidosis.

  Abstract No.: TNISGCON2022-38 Top

Management of Hepatic Hydrothorax with Day-Care Thoracocentesis using 16-Gauge Intranule Needle - A Single-Center Prospective Observational Study

Joy Varghese, Dinu Abirami Premkumar, P. Sugan, Premkumar, Selvakumar Malleeswaran1, Rajanikanth Patcha2, Mettu Srinivasa Reddy2

Departments of Hepatology and Transplant Hepatology, 1Liver Anaesthesia and Critical Care, 2HPB and Transplantation, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Background and Aim: The management of recurrent hepatic hydrothorax (HH) poses a major challenge in patients with end-stage liver disease awaiting liver transplantation. The aim of our study is to determine the efficacy, safety, and benefits of thoracocentesis with intranule needle in these patients. Methods: A prospective, single-center study was conducted on decompensated chronic liver disease patients who presented with symptomatic HH requiring therapeutic drainage. All these patients underwent therapeutic thoracocentesis with intranule needle and underwater seal by interventional radiologist. Results: Twenty-five decompensated chronic liver disease patients with symptomatic hydrothorax underwent 53 therapeutic thoracocentesis procedures over the period of 18 months. They were predominantly male (23, 92%) and the most common underlying liver diseases were nonalcoholic fatty liver disease and alcohol induced. Pleural fluid was drained out using 16-gauge intranule in all our patients during every episode of HH. None of them had major postprocedural complications. There was no significant association between the quantity of fluid drained and 6-month mortality. Conclusion: Thoracocentesis with 16-gauge intranule provides effective symptomatic relief and a safe procedure for all symptomatic hydrothorax in decompensated chronic liver disease patients.

  Abstract No.: TNISGCON2022-39 Top

Adequacy of Bowel Preparation using Sodium Phosphate Base for Colonoscopy and Cecal Intubation Rate While Performing Colonoscopy

Divi Videha

Background and Aim: Bowel preparation is one of the quality measures while performing colonoscopy. Success of the colonoscopy is dependent on adequate bowel preparation. Boston bowel preparation scale is used to assess adequacy of bowel preparation. One-fourth of colonoscopies are associated with inadequate bowel preparation. A score of 7/9 is considered adequate bowel preparation and is expected in >95% of all colonoscopies. Sodium phosphate preparation is being predominantly used for majority of patients. Cecal intubation is one of the quality measures while performing colonoscopy. Success of the colonoscopy is dependent on at least ≥90% departmental intubation rates. Aim: To achieve a Boston Bowel Preparation Scale (BBPS) score of 9/9 and to achieve 100% cecal intubation rate. Methods: A total of 654 patients were recruited between January 2021 and December 2021, visiting the inpatients and outpatients aged between 18 and 85 years, undergoing colonoscopy in our medical center after cleansing preparation. Type: This was a prospective study. Sodium phosphate split preparation. Results: A total of 654 patients were included, in which colonoscopy has been done, cleanliness response by sodium phosphate preparation on average of 6.91 as per BBPS, and the cecal intubation rate was 97.9% observed in those patients with good bowel preparation. Conclusion: The schedule of administration, including timing and the diet chosen, has implications for the quality of cleansing. In this study conducted by the MGE department for adequacy of bowel preparation by split preparation method and achieving cecal intubation rate, it was concluded that there is an adequate bowel preparation with this method and more than 90% cecal intubation rate is achieved.

  Abstract No.: TNISGCON2022-40 Top

Cell Therapy for Liver Disease - Bench to Bedside

Sudhagar Rengasamy, Secunda Rupert, Raghu Ramanathan, Amudhan Anbalagan, Selvaraj Thangasamy, Jeswanth Satyanesan

Department of Surgical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation and Stem Cell Research Center, Government Stanley Medical College, Chennai,

Tamil Nadu, India

Background and Aim: Cell therapy is alternative, less invasive, and potentially curative to liver transplantation. The aim is to check the regenerative ability of Wharton's jelly-derived MSCs (WJ-MSCs) in mice models for acute liver injury (ALI). The study is to assess the effect of D-galactosamine (D-GalN)-induced ALI on mouse liver extracellular matrix (ECM) after decellurization. Methods: Swiss albino mice weighing 25 ± 5 g were used. The control (Group I) received saline. Group II received DGal (800 mg/kg; i.p). Group III received WJ-MSCs (5 × 105 cells/0.5 ml) through tail vein, 24 h after D-GalN, Group IV received MSC alone, and Group V after causing ALI by D-GalN, liver was decellularized using sodium dodecyl sulfate and Triton-X 100, through portal vein. Results: A twofold elevation of AST, ALT, ALP, and bilirubin confirms hepatocellular injury, while fourfold increase in malondialdehyde and 40% fall in superoxide dismutase were indicative of oxidative stress and loss of hepatocellular membrane integrity induced by D-GalN. The above changes were restored with WJ-MSCs indicating hepatoprotective and regenerative property. The architecture components of ECM are well maintained after decellurization and not affected by D-GalN. Conclusion: The WJ-MSC treatment is able to rescue/ameliorate the hepatotoxicity induced by D-GalN in mice. ALI does not negatively alter architecture or components of ECM. Having confirmed role of WJ-MSCs in ALI in preclinical study, we have obtained license to undertake phase I/II clinical trial to study the effect of MSCs in patients with ALI and liver-based metabolic disorders. This holds much promise in future.

  Abstract No.: TNISGCON2022-41 Top

Assessment of Histological Activity in Patients with Ulcerative Colitis using Nancy Index and Its Correlation with Endoscopic Grading

Vivek Kumar Singh, Ubal Dhus, Sunil Kumar, Bhavin Davra

Department of Medical Gastroenterology, Apollo Main Hospital, Chennai,

Tamil Nadu, India

Background and Aim: Treatment targets for ulcerative colitis (UC) have changed significantly overtime to include mucosal healing as a therapeutic end point. Histological remission is associated with better outcomes as compared to endoscopy remission alone. Earlier studies using nonvalidated endoscopic and histologic indices have failed to establish a correlation between endoscopy and histology; we aim to study the correlation using validated indices. Methods: Consecutive patients with UC aged between 18 and 80 years presented to our institute undergoing endoscopic examination and biopsy from March 2020 to October 2021 were enrolled. Patients with infective colitis, toxic megacolon, perforation, hemodynamic instability, and previous colorectal surgery were excluded. Endoscopic and histologic activity was graded using UCEIS and Nancy Index into remission (UCEIS 0–1, NI 0–1), mild (UCEIS 2–4, NI 2), moderate (UCEIS 5–6, NI 3), and severe (UCEIS 7–8, NI 4). Statistical analysis was performed using Spearman's correlation coefficient using SPSS v.25.0. Results: 85 patients were enrolled. Mean age at presentation and onset of disease was 44.25 (±13.44) and 39.68 (±1.32) years, respectively. Median duration of disease was 2 (IQR — 2.5) years. M:F was 1.5. Common symptoms at the time of presentation were blood in stool (64.7%) and mucus in stool (45.9%). Endscopically, E1:E2:E3 disease was seen in 29%, 47%, and 24%, respectively. Correlation between UCEIS and NI was found to be very strong with r = 0.85(P < 0.001). 95.7% of patients in endoscopic remission also had histologic remission. No statistically significant difference was found when a UCEIS score of 0 or 1 was used to predict histological remission. Conclusion: Significant correlation was observed between validated endoscopic and histologic indices. A UCEIS score of 0/1 both predicted histological remission. Endoscopic remission can be used as surrogate marker for histological remission.

  Abstract No.: TNISGCON2022-42 Top

Title: Estrogen Receptor 1 Gene Variants in Patients with Gallstones from Southern Part of India

Y. Aishwarya, Jayanthi Venkataraman1, Solomon F. D. Paul, V. Y. Bhargav1, S. Sankar2, K. Balaji Singh3, F. Andrea Mary

Departments of Human Genetics, Biomedical Sciences and Technology, 1Hepatology, 2Surgical Gastroenterology and 3Medical Gastroenterology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Background and Aim: Regional differences in type and composition of gallstones have been reported from the Indian subcontinent. Compared to north and northeastern parts of the country, most gallstones from southern states of India are either mixed (60%) or pigment (25%). Aim: To explore the role of two genetic variants, IVS1-397 T>C (rs2234693) and IVS1-351 A>G (rs9340799) in ESR in a South Indian population with gallstones and to evaluate the hospital database for the predisposing risk factors correlating with the outcome of the study. Methods: The present case–control study recruited 40 subjects including 20 cases diagnosed with gallstones and 20 age- and gender-matched controls. Gallstones were collected from cases after cholecystectomy, and morphological analysis was performed to determine the type of gallstone (cholesterol, pigment, or mixed). Peripheral blood samples were collected, and DNA was isolated and PCR-RFLP method was used for genotyping. Representative samples were sequenced to confirm the genotypes. Furthermore, the retrospective analysis of the gallstone patients details (demographic details and biochemical parameters) was performed. Results: Majority of the stones were mixed (80%) and remaining were pigment. There were no cholesterol gallstones. On comparing the genotype frequency distribution in those with gallstone with healthy subjects, the heterozygous variant genotype, ESR1-397 TC (rs2234693) polymorphism (P = 0.0026) were risk factors for gallstone disease, and it was inferred that prevalence of cholelithiasis was more in females than males. Conclusion: The findings of the present study provide information that ESR1-397T>C (rs2234693) gene polymorphic variant could be a susceptible factor for gallstone disease in South India, and it was inferred from the retrospective details that the prevalence of cholelithiasis was more in females than males. Elevation of serum biochemical parameters could have played a major contributing role in the etiology of gallstone disease.

  Abstract No.: TNISGCON2022-43 Top

Comparison of ABC Score with AIMS65, Rockall, and Glasgow Blatchford Score for Predicting 28-Day mortalities in Patients with Upper and Lower Gastrointestinal Bleed

M. S. Revathy, S. Chitra, Jha Rakesh

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

Background and Aim: Background: Studies have shown that the Glasgow Blatchford score (GBS) can predict patients who will require hospital-based intervention with high accuracy. Implementation of GBS is associated with a 15%–20% reduction in the number of hospital admissions with upper gastrointestinal bleed (UGIB). Aim: To compare ABC score with AIMS65, Rockall, GBS score for predicting 28-day mortalities in patients with UGIB and lower gastrointestinal (GI) (LGI) bleed. Methods: Methodology: Patients were enrolled, clinical variables, blood parameters, and endoscopic findings were noted, and desired therapeutic intervention was done as per etiologies and followed up for 30 days to look for mortality. Results: 54 patients were included. Results showed that age ≥75 years, creatinine >150 μmol/L, albumin 100 beats/min, and altered mental status are associated with high mortality. The ABC score showed prediction of 28-day mortality (area under receiver operating characteristic [AUROC] [95% confidence interval] (CI) 0.81 [0.74–0.88]) in the present cohort. Based on AUROCs, the ABC score was better at predicting 28-day mortality as compared with AIMS65 (AUROC [95% CI] 0.64 [0.59–0.69]); admission Rockall score (AUROC [95% CI] 0.72 [0.69–0.75]; P < 0.001); full Rockall score (AUROC [95% CI] 0.77 [0.68–0.86]; P < 0.001); and GBS (AUROC [95% CI] 0.78 [0.74–0.82]; P < 0.001). Association between ABC score and mortality as follow patients with a score of ≤3 (62% of patients) had a very low (1.8%) risk of death within 28 days. Mortality of patients with a score 4–7 of 7.9%, and score of ≥8 had 48%. Conclusion: ABC score has better accuracy in predicting 28 days mortality for both UGIB and LGI bleed.

  Abstract No.: TNISGCON2022-44 Top

Manometry Findings in Patients with Functional Constipation

Bhavin Davra, Usha Srinivas, Vivek Kumar Singh

Department of Medical Gastroenterology, Apollo Main Hospital, Chennai,

Tamil Nadu, India

Background and Aim: With evolving understanding of pathophysiology of chronic constipation and more insights into functional gastrointestinal disorders, newer guidelines such as ROME IV consensus are developed. A large number of patients with functional constipation (FC) have functional defecation (FDD) which requires special diagnosis and treatment beyond conventional drug-based treatment. Data on the prevalence of FDD are scarce. In this study, we intend to study the endoscopy and manometry profile of patients with FC with an objective to find the prevalence of FDD among patients with FC. Methods: Consecutive patients with FC aged between 18 and 70 years presenting to our institute and undergoing anorectal manometry (ARM) and balloon expulsion test (BET) from March 2020 to October 2021 were enrolled. Patients with mechanical obstruction or severe cardiopulmonary comorbidities were excluded. Patients with abnormal ARM and absent BET and were diagnosed as FDD and were classified into dyssynergic defecation I–IV according to Rao's classification. Results: 75 patients (M:F - 39:36) were enrolled. Mean age and mean duration were 44.59 (±13.89) years and 3.32 (±2.87) years, respectively. Common symptoms were sensation of incomplete evacuation (67%), use of manual maneuvers (55%), and excessive straining(53%). 69.2% males (27/39) had a FDD compared to 44.4% females (16/36), which was statistically significant(P = 0.037). 83% (20/24) of the patients presenting with sensation of blockage/obstruction had a FDD while 17% (4/24) had a normal manometry study which was statistically significant (P = 0.002). No other symptoms could predict an abnormal finding in endoscopy or manometry. Conclusion: A large number of patients with FC had FDD. Male patients and those presenting with symptom of sensation of obstruction/blockage were more likely to have FDD.

  Abstract No.: TNISGCON2022-45 Top

Ectopic Stomal Variceal Bleed Managed with Transjugular Intrahepatic Portosystemic Shunt

Dinu Abirami Premkumar, Joy Varghese

Department of Medical Gastroenterology, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Background and Aim: Bleeding from parastomal varices is an uncommon, but dreaded complication of portal hypertension. The management of ectopic variceal bleed poses major challenge with very few treatment options in hand. We report one such case of recurrent ileostomy site variceal bleed, which was successfully managed with transjugular intrahepatic portosystemic shunting. Methods: A 58-year-old gentleman with nonalcoholic steatohepatitis-related chronic liver disease (CLD) and history of rectal malignancy requiring total proctocolectomy with ileostomy presented with profuse bleeding from ileostomy site. He had previously presented with recurrent variceal bleeding which had been managed with variceal banding and beta-blocker therapy. Retrograde transvenous obliteration had also been performed 12 years ago for large fundal varices. Results: Clinical examination showed active ooze from stoma site, and contrast-enhanced computed tomography (CECT) revealed large ectopic stomal varices communicating with the superior mesenteric vein and right iliac vein. His liver synthetic function was well preserved with an MELD score of 9. He was initially resuscitated with blood transfusion, local compression, and terlipressin infusion. In view of stable liver function, he underwent transjugular intrahepatic portosystemic shunt procedure along with transvenous coiling of ectopic varices. Stomal bleeding settled with this treatment and CECT performed 2 months after the episode showed a patent TIPS stent with drastic reduction in size of ectopic stomal varices. Conclusion: Compression dressing, variceal suture ligation, and sclerotherapy can serve temporarily to control bleeding but are associated with high risk of rebleed. Coil embolization may serve as an alternative in patients not suitable for TIPS, but the risk of recurrence still limits its use. TIPS can be lifesaving and is the treatment of choice in compensated CLD patients complicated with bleeding stomal varices.

  Abstract No.: TNISGCON2022-46 Top

Prognosticating Acute Kidney Injury in Liver Cirrhosis: A Prospective Study

A. Deiva, M. Jayakumar, V. Y. Bhargav, Jayanthi Venkataraman

Department of Medical Gastroenterology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Background and Aim: Renal failure is a common complication in patients with chronic liver disease. 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. The aim is to determine the risk factors, clinical profile, and treatment response in cirrhotic patients with AKI. Methods: The study included 130 patients with liver cirrhosis diagnosed clinically, biochemically and confirmed with imaging (ultrasonography abdomen or computed tomography abdomen). Patient profile was noted and followed up in subsequent admissions. AKI criteria were charted based on creatinine or urine output and were 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 was noted and prognostication was 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 such as 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.

  Abstract No.: TNISGCON2022-47 Top

AST Platelet Ratio Index, Fibrosis-4, and AST/ALT Ratio Correlation with FibroScan in Predicting Severe/Not Severe Fibrosis

V. Y. Bhargav, Shaurav Khanna, S. Thamarai Selvan, Jayanthi Venkataraman

Department of Medical Gastroenterology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Background and Aim: Metabolic-associated fatty liver disease leading to fibrosis and cirrhosis of the liver is a rising global burden. Early diagnostic and screening tools which are noninvasive are required to identify the disease early. The aim is to identify a noninvasive score among Fibrosis-4 (FIB 4), AST platelet ratio index (APRI), and AST/ALT ratio that can correlate with FibroScan in predicting or excluding liver fibrosis accurately in MAFLD patients. Methods: Image diagnosed fatty liver patients underwent FibroScan and fibrosis scores were categorized into not severe fibrosis (F0, F1, and F2) and severe fibrosis (F3, F4). FIB 4, APRI, and AST/ALT ratio were measured based on the patient's laboratory data. Previously known or underlying chronic liver disease, active hepatitis, and significant alcohol consumption patients were excluded from the study. Results: 302 patients were analyzed, among which 186 (61.8%) were males, 24.9% had diabetes mellitus, 18.9% had hypertension, 18.6% had dyslipidemia. Fibrosis severity in the study showed that 127 (42.2%) had severe (F3, F4) and 174 (57.8%) had nonsevere fibrosis (F0, F1, and F2). The mean body mass index (BMI) in severe fibrosis patients was 28.9 kg/sq.m. Among the scores, FIB 4 and APRI were predictive of severe fibrosis which was statistically significant (0.005 and 0.009). FIB 4 showed a specificity of 93.7% and positive predictive value (PPV) of 74.4%, and APRI showed a specificity of 89.1% and PPV of 65.5%. Conclusion: FIB 4 and APRI were better markers in predicting severe and nonsevere fibrosis. Among both, FIB 4 had better specificity and PPV.

  Abstract No.: TNISGCON2022-48 Top

Acute Necrotizing Pancreatitis – Various Management Approaches and Their Outcome - A Prospective Study

Mohammad Riyaz, Satish Devakumar, S. Jeswanth, M. Srinivasan

Department of Medical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, Tamil Nadu, India

Background and Aim: Severe acute pancreatitis (AP) develops in 20% of patients with AP, with a historical mortality risk as high as 30%. Patients with severe AP have a high risk of multiorgan failure and prolonged intensive care unit (ICU) stays, and they need an invasive intervention for local/systemic complications. Our study aims to evaluate the efficacy of various approaches and their outcome in AP. Methods: Our study was a single-center prospective analysis on various management approaches for acute moderately severe/severe necrotizing pancreatitis classified with modified Atlanta classification from November 2019 to April 2021. Patients with mild pancreatitis were excluded. Various methods include medical/step-up/step-down (upfront surgery) approach. Results: Of 92 patients, 47 (51.1%) were managed medically without an intervention (among them 37 patients had <30% necrosis with mCTSI≤6). 23 (25%) patients underwent a step-up approach; among them, 11 required only percutaneous drain (PCD) and 12 underwent surgery followed by PCD. 22 (23.9%) patients underwent a step-down approach. The transgastric pigtail route was preferred whenever possible, to reduce the pancreatic fistula and to guide future transgastric necrosectomy. Median hospital stay was significantly reduced in the primary necrosectomy group (17 vs. 23 days) (P < 0.001). Total mortality was 11 (12.1%) with 7 patients in the step-up group, 3 patients from the medical group, and 1 patient from the step-down group (P = 0.005). Step-up group had more number of new-onset organ failure/MODS (P = 0.027) and sepsis (P = 0.001). Conclusion: Among various approaches, step-down surgery (minimally invasive/open necrosectomy) is the potential option in reducing mortality/prolonged morbidity (total hospital stay and ICU stay) in the late phase of the disease. In early disease with sepsis, pigtail drainage (step-up) preferably transgastric route provides an advantage in reducing surgical morbidity. No single approach is optimal for all patients; the best approach is multimodal and adaptable to the individual patient.

  Abstract No.: TNISGCON2022-49 Top

EUS-Guided Gastrojejunostomy For Gastric Outlet Obstruction - A Successful Story

Vishnu Abishek Raju, B. Mahadevan

Department of Medical Gastroenterology, Gleneagles Global Hospital and Health City, Chennai, Tamil Nadu, India

Background and Aim: Gastric outlet obstruction (GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum by various benign and malignant etiologies. Patient with GOO may present with nausea, vomiting, early satiety, poor intake, and weight loss. Thus, GOO associated with poor quality of life. Traditional treatment options available for GOO are surgical gastrojejunostomy (GJ), endoscopic dilatation, and endoscopic LAMS placement. The main limitation with surgery is high rates of morbidity (39%–54%) and mortality (6%–31%), and many patients are poor surgical candidates for surgery due to advanced disease, poor nutritional status, and short life expectancy. Hence, endoscopic placement of luminal uncovered SEMS is an established alternative treatment option for GOO, with clinical success of 70%–100%. The advantages of EUS-guided GJ over surgical GJ are faster resumption of oral intake, shorter hospital stay, and fewer adverse events. Case Report: A 62-year-old woman presented with abdominal pain and vomiting for 1 month and weight loss approximately 10 kg over 2 months. On evaluation, her contrast-enhanced computed tomography abdomen showed periampullary lesion measuring 3 cm × 3.3 cm × 2.9 cm. These lesion shows infiltration with suggestion of intraluminal extension in to D2, D3 segment of the duodenum. In view of poor general condition and advanced nature of the disease, she was planned for EUS-guided GJ with LAMS for palliative enteral feeds. Postprocedure, her vomiting reduced immediately. She was able to tolerating oral liquids. GOO is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum by various benign and malignant etiologies. The patient with GOO may present with nausea, vomiting, early satiety, poor intake and weight loss. Thus, GOO associated with poor quality of life. Traditional treatment options available for GOO are surgical GJ, endoscopic dilatation, and endoscopic LAMS placement. The main limitation with surgery is high rates of morbidity (39%–54%) and mortality (6%–31%), and many patients are poor surgical candidates for surgery due to advanced disease, poor nutritional status, and short life expectancy. Hence, endoscopic placement of luminal uncovered SEMS is an established alternative treatment option for GOO, with clinical success of 70%–100%. The advantages of EUS-guided GJ over surgical GJ are faster resumption of oral intake, shorter hospital stay, and fewer adverse events.

  Abstract No.: TNISGCON2022-50 Top

Does Gastric pH Have a Role in Corrosive Antral Stricture Healing?

Harshit Kamal, K. P. Govind, Jeswanth Satyanesan

Department of Surgical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India

Background and Aim: Ingested acids pool in the prepyloric area in response to corrosive-induced pylorospasm prolonged contact with prepyloric mucosa results in stricture prepyloric/antrum/body/pyloroduodenal area. Aim: To establish: Delayed healing of corrosive induced antral injury is due to persistent intrinsic gastric acid secretion. Reducing the intrinsic gastric acid secretion hastens the healing of the ulcer so that early surgery can be planned. Methods: Prospective study, January 2019 onward, 6 patients with isolated antral stricture postcorrosive ingestion in a single center endoscopy — initial injury assessment —ZARGAR scoring gastric aspirate pH measured before and after proton pump inhibitor (PPI) administration for 1 week. Results: 6 cases included and compared with historic controls pre- and post-PPI. Gastric pH of cases was 3.2, 2.8, 2.9, 3.2, 3.1, 4.1 and 5.8, 6, 5.5, 5.4, 5.8, 6.3, respectively. When comparing, gastric injury such as ulcers and erosions were absent in cases and present in controls, and the mean preoperative delay was 2.1 months in cases and 4.8 months in controls and nil postoperative complications in cases. Conclusion: Persistent intrinsic gastric acid secretion causes delayed healing of corrosive-induced antral injury. We hypothesize that, even in corrosive antral stricture, intrinsic acid secretion remains intact, causing persistent injury. This is further aggravated by the nonbuffering of acid by due to absent oral intake. Suppression of the intrinsic gastric acid secretion hastens the healing of the ulcer facilitating early surgery.

  Abstract No.: TNISGCON2022-51 Top

Clinical Characteristics of GERD among Cirrhotic Patients

Swaapnika Vemulapalli, L. Venkatakrishnan, S. Mukundan, P. Thirumal, R. K. Karthikeyan, P. Arun, Ravindra Kantamneni

Department of Medical Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Background and Aim: GERD is one of the most common diseases in modern civilization that originates from a disturbance in the structure and function of lower esophageal sphincter (LES). Many factors are involved in the GERD pathophysiology including prolonged LES relaxation, presence of hiatus hernia, low basal LES pressure, delayed esophageal clearance, and delayed gastric emptying. Asymptomatic GERD was found to be common in patients with liver failure. Liver cirrhosis with or without esophageal varices may predispose to GERD and precipitate rupture of esophageal varices. Hence, this study is essential to predict and prevent gastrointestinal (GI) bleed among cirrhotic patients. This study is aimed to study the prevalence, severity, and risk factors of GERD among cirrhotic patients. Methods: A retrospective cohort study of 870 cirrhotic patients from January 2020 till February 2022 was performed at PSG Hospital, Coimbatore. Among 870 cirrhotic patients, 60 patients have endoscopically confirmed GERD and those were included in the study. Data including demographic details, symptoms, clinical examination, laboratory parameters, Child-Pugh score, etiology of liver disease, and upper GI endoscopic findings were analyzed. Results: Total patients analyzed were 60. Of those, 83% (n = 50) were males, and predominantly, 33.3% (n = 20) belonged to 40–50 years of age group. Alcohol consumption was found to be the most common etiological factor 65% (n = 39). GERD was found to be prevalent among 50% of CTP-C (n = 30) and 31.6% of CTP-B (n = 19) patients. 55% had Grade B (n = 33) severity and 30% were noted to have Grade A (n = 18). 65% had portal hypertension (n = 39) and 50% had undergone prior variceal ligation (n = 30). Conclusion: The severity of GERD was significantly related to Child-Pugh grade. Patients with higher grades of GERD predominantly belonged to Child-Pugh B and Child-Pugh C. Portal hypertension and prior variceal ligation were noted to be predominant risk factors. Follow-up study is essential to study the effect of GERD on post-EVL ulcer and recurrent GI bleeds.

  Abstract No.: TNISGCON2022-52 Top

A Rare Case of Mesentric Ischemia Saved by Prompt Diagnosis

P. L. Alagammai, D. Allwin James

Department of Medical Gastroenterology, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India

Background and Aim: Acute mesentric ischemia is often due to arterial thrombosis/thromboembolism or venous thrombosis. These patients are managed with anticoagulation and/or antiplatelets. Rarely, mesentric ischemia can be due to gastrointestinal vasculitis. Such patients usually have systemic features of vasculitis such as skin/renal involvement or arthritis. Isolated mesentric vasculitis is rare. Methods: We report a case of isolated celiac artery polyarteritis nodosa (PAN) presenting as acute mesentric ischemia. Results: A 45-year-old male presented with acute diffuse abdominal pain. All common causes being ruled out, CECT abdomen showed wall thickening of celiac artery and branches with small splenic infarcts. ECHO was normal. There were no other clinical features of vasculitis. ANA, dsDNA, and ANCA profile were negative. While the patient was on LMWH and antiplatelets, a repeat CT after 5 days showed early microaneurysm of celiac artery which clinched the diagnosis of isolated mesentric PAN. PAN is a necrotizing vasculitis of medium-sized arteries commonly presenting with hypertension, renal failure, and neuropathy with angiography showing microaneurysms. Isolated mesenteric PAN is rare. Once diagnosed, the patient was immediately initiated on high-dose steroids and pulse cyclophosphamide to which he responded well. Thus, he was saved from intestinal gangrene and mortality. Conclusion: Consider mesentric vasculitis in the differentials in patients with acute mesentric ischemia. Early diagnosis and appropriate treatment can prevent gangrene and related complications such as sepsis and short bowel syndrome.

  Abstract No.: TNISGCON2022-53 Top

Prognostic Performance of ALBI, Child-Pugh, and MELD scores in Patients with Liver Cirrhosis Complicated with Acute Upper Gastrointestinal Variceal Bleeding

Chaitanya Katragadda, M. S. Revathy

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

Background and Aim: Acute upper gastrointestinal (UGI) variceal bleeding is a potentially lethal complication of chronic liver disease, for which CHILD-PUGH and MELD scores showed good prognostic performance. We aimed to assess the prognostic performance of the ALBI score in this clinical setting and compare it with CPS and MELD score. The secondary objective was to study the clinical profile, outcomes, and risk factors for mortality. Methods: This prospective observational study was conducted at the Medical Gastroenterology Department, Government Stanley Medical College, Chennai, between September 1, 2021, and February 20, 2022. Cirrhotic patients presenting with variceal UGI bleed were included in the study. Epidemiological profile, vital signs, clinical presentation, etiology and duration of CLD, and investigations were recorded. ALBI score calculated by âˆ'0.085 × [albumin (g/dl)] +0.66 × log[bilirubin (μmol/l)]. Results: One hundred patients were included in the study. 83 were males. Mean age was 49.35. Common etiologies were ethanol (60/100) and hepatitis B (21/100). First week mortality was 20% and 1-month mortality was 24%. Mortality strongly correlated with history of hematochezia, recurrent episodes of bleed, systolic blood pressure <90 mmHg, and hepatic encephalopathy on admission (P = 0.03). In hospital, 1-week and 30-day mortality was accurately predicted by ALBI compared with CPS and MELD score, with an area under the curve of 0.82 (95% confidence interval: 0.74–0.90, P < 0.03) for outcomes. Conclusion: ALBI score accurately predicts in-hospital, 1-week and 1-month outcome of acute variceal UGI bleeding compared with CHILD-PUGH and MELD scores. Hepatic encephalopathy was single most predictor of mortality in these patients.

  Abstract No.: TNISGCON2022-54 Top

Profile of Fistulizing Crohn's Disease in a Tertiary Care Center

Dhanush, L. Venkatakrishnan, Mukundan, Kartekeyan, Arun, Ravindra

Department of Medical Gastroenterology, PSG Institute of Medical Sciences , Coimbatore, Tamil Nadu, India

Background and Aim: Fistula is a common and severe complication of Crohn's disease (CD) that affects up to 50% of patients within 20 years of initial diagnosis. It is associated with substantial morbidity and significant impairment in health-related quality of life. Aim: to analyze the profile and prevalence of fistulizing CD in a tertiary care center. Methods: A retrospective study was conducted from January 2019 to February 2022 of all patients admitted with fistulizing CD in the gastroenterology department of our hospital and they were analyzed based on the age, year from diagnosis, associated bowel involvement, type of fistula, albumin, intervention done, and number of fistula episodes. Results: The prevalence of fistulizing CD at our center during the study period was 70 patients (27%), average age at diagnosis was 34 years, isolated fistulizing CD was seen in 2 patients, small bowel involvement in the form of ileal nodularity, ulcer, and deformed IC valve was seen in 60% of the patients, and large bowel involvement was there in the form of proctosigmoiditis was there in 30%, most patients admitted had anal fistula (72.4%), rectovaginal fistula in 1%, internal fistula in 26%. The patients had diagnosis of fistulizing CD within 1 year - 10%, within 5 years - 42%, and within 10 years - 48%. Most patients had 2 fistulizing episodes on an average. Conclusion: The prevalence of fistulizing CD was 27% in our center.

  Abstract No.: TNISGCON2022-55 Top

Intrahepatic Cholestasis Secondary to Hidden Malignancy – A Case Report

Premkumar Dinu Abirami, Joy Varghese

Department of Medical Gastroenterology, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Background and Aim: Cholestatic jaundice can occur secondary to any malignancy through well-recognized mechanisms such as bile duct obstruction or widespread hepatic infiltration. The clinical entity of nonmetastatic hepatic dysfunction secondary to renal cell carcinoma was first described by Stauffer in 1961. We report one such case of intrahepatic cholestasis secondary to paraneoplastic syndrome due to Hodgkin's lymphoma. Methods: A middle-aged man presented with painless progressive jaundice for 4 months associated with pruritis, pale-colored stools, low-grade fever, and significant weight loss. Clinical examination revealed no signs of chronic liver disease and nontender hepatomegaly. His liver function tests were deranged with total bilirubin of 42.8 mg/dl, direct bilirubin of 41.7 mg/dl, and ALP of 310. He underwent detailed etiology workup for jaundice such as viral serology, autoimmune, and metabolic which were within normal limits Liver biopsy showed intrahepatic cholestasis and CECT showed multiple intra-abdominal and mediastinal lymphadenopathy. EUS-guided mediastinal lymph node biopsy showed histopathological features suggestive of Hodgkin's lymphoma. Results: He was diagnosed to have cholestatic jaundice due to paraneoplastic syndrome manifestation of Hodgkin's lymphoma - Ann Arbor Stage III S with B symptoms. The patient was started initially on oral prednisolone therapy which helped to reduce the bilirubin level followed by other chemotherapeutic medications. He recovered from jaundice and stable now. Conclusion: The proposed pathogenetic mechanism involves hyperexpression of interleukin 6 by the tumor cells. The management of cholestatic jaundice secondary to paraneoplastic syndrome is mainly directed toward the treatment of underlying malignancy, with dramatic response to treatment as in our case.

  Abstract No.: TNISGCON2022-56 Top

Profile IN Hepatitis E

Nishanth, L. Venkatakrishnan, Mukundan, Kartikayan, Arun, Ravindra

Department of Medical Gastroenterology, PSG Hospitals, Coimbatore,

Tamil Nadu, India

Background and Aim: Hepatitis E is a form of viral hepatitis caused by hepatitis E virus (HEV). It is often acute, self-limiting but can be life-threatening in certain high-risk groups such as pregnancy and alcoholic liver disease. The present study evaluated the clinical profile of acute hepatitis E cases at a tertiary care center. Methods: This is a retrospective cohort study including cases of hepatitis E done at a tertiary care center in Coimbatore from January 2020 to December 2020. A total of 50 patients diagnosed with HEV infection using IgM anti-HEV ELISA were included in the study. Results: Out of 50 patients, 26 (50%) were male, and 24 were female (48%). The mean age of the study group was 42 years. In 50 patients, 22 (44%) had underlying chronic liver disease. Furthermore, 12 (25%) presented with acute viral hepatitis, 3 (6%) with acute liver failure, and 13 (26%) with acute on chronic liver failure. A total of 46 (92%) patients survived while 4 (8%) patients expired during the course of illness. Among 4 fatal cases, all 4 presented with acute on chronic liver failure. In 50 patients, 22 (44%) patients had underlying alcoholic liver disease, 8 (16%) had NASH/NAFLD, 2 (4%) had underlying Wilson's disease, 2 (4%) were pregnant females who presented with acute liver failure but underwent plasma exchange and improved. 2 (4%) were posttransplant patients who had mild transaminase elevation and recovered. No associated underlying comorbidities or liver disease was seen in 14 (28%) of the patients. Conclusion: Preexisting chronic liver disease was significantly associated with mortality in patients suffering from viral hepatitis E. Increased bilirubin, alcohol use, and low serum albumin were also associated with increased mortality due to acute viral hepatitis E.

  Abstract no: TNISGCON2022-57 Top

Evolution of Multidrug Resistance Pattern in Spontaneous Bacterial Peritonitis during Pandemic, A Single-Center Observational Study

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

Department of Internal Medicine, Kovai Medical Center and Hospitals, 1Gastroenterology and Liver Unit, Kovai Medical Center and Hospitals, Coimbatore, India

Background and Aim: Ascites is present in 95% of Indian patients presenting with acute-on chronic liver failure (ACLF). Bacterial infection-related ACLF rate in India is 75% (43% of those infections due to spontaneous bacterial peritonitis [SBP]), with a 28-day mortality rate of 53%. Multidrug-resistant (MDR) rates in India are high, and the use of antibiotics in community had increased during the delta wave of pandemic. We aimed to analyze the MDR rates in SBP patients at our center, pre- and post-delta waves. Methods: We collected data over a period of 2 years (December 2019 to January 2022) at our center in Coimbatore, India. Patients were identified using ICD Code for Liver Disease, and 300 decompensated liver disease patients who underwent ascitic tapping were included. Bacteriological profile, resistance pattern of organisms, and outcomes were analyzed. We divided the study into two phases: Phase 1 - December 2019 to May 2021 (predelta wave); Phase 2 - June 2021 to January 2022 (postdelta wave) to analyze the impact of use of antibiotics during pandemic on the resistance pattern of organisms. Results: The incidence of SBP was 22.6% (67/300); 44 were culture-positive and 23 were culture-negative neutrophilic ascites. 47.8% (32/67) patients recovered and 52.2% (35/67) patients either died or were lost to follow-up. In patients with SBP, 71.6% (48/67) were community acquired and 28.4% (19/67) were nosocomial. Most common organisms were Escherichia coli 54.5% (24/44) and Klebsiella pneumoniae 29.4% (13/44). Extended-spectrum beta-lactamase (ESBL) was the most common resistant pattern and 2/3rd was resistant to third-generation cephalosporins. In Phase 1, multidrug-sensitive (MDS) and MDR were equal at 50% (13/26 each), but MDR organisms had increased to 73.3% (13/18) in Phase 2. Mortality rate was 46.2% in phase 1 and 55.5% in Phase 2. Conclusion: The landscape of bacterial resistance has changed at our center following the delta wave. Hence, we feel the severity of infection and the local resistance profile should guide choice of antibiotics rather than empirical use, if suspicion of SBP was to arise, for better patient outcome and de-escalate the therapy later based on sensitivity pattern.

  Abstract No.: TNISGCON2022-58 Top

An Investigation of the Relation between Plasma A Disintegrin and Metalloproteinase with a ThromboSpondin Type 1 Motif, Member 13 and Von Willebrand Factor activities, and Severity of Acute Pancreatitis - A Cross-Sectional Study

P. S. Sairam, Ajith Thomas, Anoop John, Rajeeb Jaleel, Sudipta Dhar Chowdhury, Amit Kumar Dutta, Ebby George Simon, Tulasi Geevar1, Sukesh Nair1, K. Reka2, A. J. Joseph

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

Background and Aim: Management of patients with acute pancreatitis (AP) is complicated by the difficulty in distinguishing mild from severe disease during the early stages. We aimed to compare markers of endothelial activation in patients with severe and nonsevere (mild and moderate severe) AP and correlate them with the clinical course. Methods: This was a cross-sectional observational study on patients admitted with AP within 5 days of symptom onset during December 2020 to November 2021. We measured plasma a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity, von Willebrand factor (vWF):collagen binding assay (vWF:CBA), vWF:antigen (vWF:Ag) and correlated with the disease severity, need for ventilation, and dialysis. Results: 65 patients with AP were recruited. 12 (18.5%) had severe disease; 53 (81.5%) had nonsevere disease (22 [33.8%] had mild and 31 [47.7%] had moderate severe disease]. Plasma ADAMTS13 activity In severe versus non severe AP was 38.4 ± 21.1 versus 55.90 ± 16.42 (mean ± standard deviation [SD]) (P = 0.015). In severe AP, vWF CBA was 281.67 ± 121.57, whereas in nonsevere AP, it was 206.49 ± 77.49; (P = 0.009). vWF Ag in severe versus nonsevere AP was 278.97 ± 83.76 against 271.21 ± 61.99 (P = 0.716). Of the 65 patients, 10 required ventilation and 2 required dialysis. The 10 patients who required ventilation had higher vWF CBA and vWF Ag (296.94 ± 121.16 and 277.32 ± 92.45) and lower ADAMTS13 activity (38.36 ± 18.64) than those who did not require ventilation (206.45 ± 78.02, 271.79 ± 60.92, and 55.27 ± 17.96, respectively; P = 0.003, 0.809, and 0.008, respectively). Conclusion: Endothelial activation is more pronounced in patients with greater severity of AP. Measurement of these markers may help in predicting the course of the disease. Therapies aimed at ameliorating endothelial activation may be considered in severe AP.

  Abstract No.: TNISGCON2022-59 Top

Diagnosis by Clinical Criteria Correlates Poorly With Histology In Subacute and Acute-On-Chronic Liver Failure

P. S. Sairam, Shailaja Balakumar1, Thomas Alex1, Uday Zachariah, K. Reka2, C. E. Eapen, Ashish Goel

Departments of Hepatology, 1Pathology, and 2Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India

Background and Aim: Histology may often be required to differentiate between subacute hepatic failure (SAHF) and acute-on chronic liver failure (ACLF). This study aims to assess the agreement between histology and clinical criteria in SAHF/ACLF. Methods: Patient records with hyperbilirubinemia (serum bilirubin ≥5 mg/dl) and liver failure (ascites/encephalopathy) who underwent liver biopsy from January 2017 to December 2021 were extracted. Patients with focal liver lesions, acute liver failure (ALF) and decompensated chronic liver disease (DCLD) were excluded. International Association for Study of Liver (IASL) and Asian Pacific Association for Study of Liver (APASL) criteria were applied retrospectively to classify patients as SAHF/ACLF. Liver histology reports were reclassified, based on predetermined criteria, into definite acute, definite chronic, and indeterminate liver injury. Results: Of 612 patients who underwent liver biopsy, 83 had hyperbilirubinemia and liver failure and 22 had focal liver lesions. After excluding patients with ALF (16) and DCLD (33), 34 patients were included in this study. 19 patients (males: 11; age: 33, 13–59 years; median, range; MELD: 24, 15–39])had SAHF and 15 (males: 7; age: 30, 17–46 years; MELD: 26, 17-56) had ACLF. Most common acute insult for both SAHF (21%) and ACLF (27%) was idiosyncratic drug reaction. None of SAHF (13) and 2/10 of ACLF patients had large esophageal varices. On biopsy, definite subacute injury was noted in 8 (SAHF: 6, ACLF: 2), definite chronic in 24 (SAHF: 11, ACLF: 13), and indeterminate in 2 (SAHF: 2). Clinical criteria and histology had poor agreement (kappa: 0.27). SAHF clinical criteria (sensitivity: 0.8, specificity: 0.5) and ACLF clinical criteria (sensitivity: 0.5, specificity: 0.8) were suboptimal in predicting histological liver injury (overall misclassification rate: 38% [95% confidence interval: 29%–56%]). Conclusion: Diagnostic clinical criteria are inaccurate in predicting histological pattern of liver injury in SAHF/ACLF patients.

  Abstract No.: TNISGCON2022-60 Top

Experience with Low-Volume Plasma Exchange via Centrifugal Technique using Peripheral Access in Patients with Liver Diseases

Alok Bansal, Santhosh E. Kumar1, Snehil Kumar2, Ashish Goel1, Uday Zachariah1, Sukesh Nair2, Joy Mammen2, Dolly Daniel2, C. E. Eapen

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

Background and Aim: Plasma exchange (PLEX) is an emerging therapeutic option for a wide range of liver diseases. Central venous access requires technical expertise and can be complicated by local bleed and infection. Peripheral venous access may overcome these issues. The study aims to compare the safety and efficacy of low-volume PLEX via centrifugal technique using peripheral versus central access in liver disease patients. Methods: Patients who underwent centrifugal PLEX using peripheral access (November 2019 to February 2022) and centrifugal PLEX using central access (October 2020 to June 2021) as comparator with consecutive patients of liver diseases were retrospectively studied. Patients with accessible peripheral veins underwent peripheral PLEX (pPLEX), while the rest underwent central PLEX (cPLEX) via femoral vein. Low-volume PLEX (50% of total plasma volume) with 1:1 replacement with fresh frozen plasma was done and 3 sessions were targeted. Continuous variables were expressed in median (range). Results: 40 (54%) (age 41 [16–71], males 26 [70%]) and 34 (46%) (age 37 [18–68], males 25 [73%]) patients underwent cPLEX and pPLEX, respectively. Indication for cPLEX/pPLEX were acute-on chronic liver failure (20/20), ALF (7/2), severe acute liver injury (5/3) and subacute hepatic failure(3/2), intrahepatic cholestasis(3/6), and decompensated chronic liver disease (2/1) with main etiologies of alcohol, toxin, and drugs. MELD score for cPLEX was 26.5 (12–41) and pPLEX was 28 (12–38), P = 0.4. pPLEX access was 18–gauge (n = 24/23 for inlet/return). 7 patients required access change from pPLEX to cPLEX. Targeted sessions were completed in 35(87%) cPLEX and 26 (77%) pPLEX. Number of PLEX sessions, flow rate, and procedure time for cPLEX/pPLEX was 3 (1–5)/3 (1–5), 35 (15–40)/25 (10–35) ml/min, and 75 (31–180)/100 (30–270) min, P < 0.0001. Volume processed, volume removed, plasma removal efficiency, von Willebrand factor, and bilirubin extraction efficiency for cPLEX/pPLEX were 2275 (853–4500)/2271 (490–6000) ml, 1335 (404–1857)/1237 (158–1760) ml, 55.4 (23.6–94)/50.4 (19.7–92.1)%, 17.6 (−3.9–64.1)/19.3 (−11.6–71.5)%, and 14.2 (−7.9–42)/14.7 (−25–45.4)%, P = 0.3. Complications included sepsis (1), access site bleed Clavien-Dindo grade I (1), and hypocalcemia (1) in cPLEX and access site phlebitis (2) and allergic reaction (2) in pPLEX. Conclusion: Low-volume centrifugal PLEX by peripheral venous access is feasible and appears equally efficient as central access in a spectrum of liver disease patients at significantly lower flow rates for the peripheral route.

  Abstract No.: TNISGCON2022-61 Top

Macrophage Activation and Increased Liver Recruitment Plays an Important Role in Rodenticidal Hepatotoxicity

B. Vijayalekshmi, Vijay Alexander, Anita Choudhary, Savit B. Prabhu, Anand Sharma, K. A. Balasubramanian1, Ashish Goel, Uday Zachariah, C. E. Eapen

Department of Medical Gastroenterology, Wellcome Trust Research Laboratory, Christian Medical College, 1Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India

Background and Aim: We aimed to study macrophage activation in patients with rodenticide hepatotoxicity. Methods: Retrospective Arm: From a prospectively collected database of rodenticide-hepatoxicity patients between 2018 and 2019, we analyzed markers of macrophage activation (serum ferritin, sCD163, sCD25, and macrophage activation syndrome MAS] criteria). Patients were classified into acute liver injury (ALI) and acute liver failure (ALF) based on their worst clinical status during admission. Prospective Arm: Immune cell phenotyping (done on BDFACS Aria™ III and analyzed on Flow Jo) was conducted on the peripheral blood monocytes in a subset of rodenticidal-induced ALF patients and the results were compared with healthy age-matched controls. Results: Retrospective Arm: 67 patients (23 [12–64] years; median (range), M: 25, ALI: 38, ALF: 29, MELD: 28 [7–40]) were recruited. Macrophage activation parameters were elevated in most patients – sCD163 >0.98: 88%, sCD25 72%, and ferritin >500 ng/ml: 84%. MAS criteria were noted in 61% of patients. Serum ferritin (R = 0.29), sCD163 (R = 0.6), and sCD25 (R = 0.56) levels showed significant correlation with MELD score. Prospective Arm: Seven ALF patients were recruited, and data were compared to seven healthy controls. We observed classical monocyte phenotypes associated with immunoparalysis (HLA-DR low, CD163 hi), immunocomplex-mediated injury (CD64 hi, increased circulating IgG/IgM immunocomplexes), MAS-like features (decreased NK cell frequency, increased sCD163, sCD25), and recruitment to liver (CCR2 hi, elevated serum CCL2 levels). Conclusion: Macrophage activation is seen in most patients with rodenticide hepatoxicity and markers correlate with disease severity. Peripheral monocyte phenotype changes suggest a crucial role of monocyte/macrophages including monocyte infiltration to liver in ALF patients.

  Abstract No.: TNISGCON2022-78 Top

Can We Predict The Vascular Complications in Psuedocyst or in Acute Necrotizing Pancreatitis: Based on Trypsin Fluid Analysis – A Pilot Study

M. Rohith, S. Jeswanth, J. Saravanan, K. Satishdevkumar, A. Amudhan, R. Kamalkhanan

Department of Surgical Gastroenterology, Institute of Surgical Gastroenterology and Liver Transplantation, Stanley Medical College, Chennai, Tamil Nadu, India

Background and Aim: Arterial hemorrhage may occur in up to 10% of patients with pancreatic pseudocysts/acute necrotizing pancreatitis (ANP) more ominous is the direct erosion of significant vessel by the action of pancreatic enzymes, especially elastase on vessel wall and can lead to thinning of vessel wall with aneurysm and pseudoaneurysm formation. This situation has a high mortality of 20%. Enzymatic activity in the pseudocyst or in the necrotic issue has been attributed to cause vascular complications in these patients, especially the trypsin and elastase activity. Till date, there is no study done to prove the activity of trypsin or elastase in the pseudocyst or necrotic tissue causing vascular complication. Methods: In the present study group of 32 patients, nonrandomized of whom 22 patients had vascular complications is psuedocysts or in ANP and 10 patients with normal uncomplicated pseudocysts who were treated at our institute over a period of 26 months from November 2019 to December 2021. Trypsin activity using Nα-Benzoyl-L-arginine ethyl ester (BAEE) as the substrate. The procedure is a continuous spectrophotometric rate determination (A253, Light path = 1 cm) based on the following reaction: BAEE + H2O+ Trypsin â†' Nα-Benzoyl-L-arginine + ethanol. Results: Trysin activity in psuedocystic fluid or in cases with WOPN was measured and was compared to uncomplicated psuedocysts. The mean trypsin activity was 93.63 (±SD 86.6) in the 22 complicated cases and 5.62 in uncomplicated cases (±SD 2.82), the mean difference was 88.01, and the P value by t-test is 0.001. Conclusion: Criteria for nonoperative management have been less established till date in history. The present study may guide to reduce morbidity and mortality in cases with vascular complications both in acute and chronic pancreatitis and which cases to be intervened early to prevent the vascular complications based on fluid trypsin levels.

  Abstract No.: TNISGCON2022-62 Top

Plasma exchange to Rescue Children with Rodenticidal Hepatotoxicity Who Met Listing Criteria for Urgent Liver Transplantation

T. V. Leenath, A. Goel, U. Zachariah, C. E. Eapen

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

Background and Aim: We describe our experience with low-volume plasma exchange (PLEX-LV) to treat rodenticidal hepatotoxicity in children. Methods: From prospectively collected database of patients admitted to our department with rodenticidal hepatotoxicity during 2017–2021, we retrospectively analyzed outcomes in children (≤18 years). Patients were characterized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, encephalopathy). King's college criteria and Kochi criteria (MELD score ≥36 or baseline INR ≥6 with hepatic encephalopathy) (Saraf et al. PMID: 26310868) were used to assess need for urgent liver transplantation. One-month survival was recorded. Results: Of 110 rodenticidal hepatotoxicity patients, 32 children (females: 56%; age: 16 [4.7–18] years; median, range) presented 4 (1–8) days after consumption (suicidal intent: 31, accidental: 1). Twenty patients (62%) had ALI and 12 (36%) had ALF. Nine patients with ALF fulfilled King's college and Kochi criteria for urgent liver transplantation. All patient families opted against liver transplantation. All children received standard management, including N-acetyl cysteine; ALF patients also received anticerebral edema measures. 17 patients (ALI: 6, ALF: 11) were treated with PLEX-LV (3 [1–5] sessions, volume: 26 [15–38] ml/kg body weight) and periprocedure low-dose prednisolone. At 1 month, 28 patients (88%) were alive. Of 9 children who met King's college criteria for liver transplantation (15.7 [7.4–18] years, females: 67%, MELD score: 38 [34–40], 5 (63%) survived with PLEX-LV (n = 8). Of 10 children who met Kochi criteria, 6 (67%) survived with PLEX-LV (n = 9). Conclusion: PLEX-LV shows promise as an effective nonliver transplant treatment in children with rodenticidal hepatotoxicity.

  Abstract No.: TNISGCON2022-63 Top

Study of Use of Noninvasive Biomarker, Platelet-to-Lymphocyte Ratio for the Prediction of Liver Fibrosis (on Elastography) in Patients with Hepatitis C Virus-Related Liver Disease

Indra Kishor Singh, M. S. Revathy

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

Background and Aim: Evaluation of liver fibrosis is very important for the prognosis of chronic hepatitis C patients. Liver fibrosis is a common complication of chronic hepatitis C virus (HCV) infection. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are used to assess the degree of ongoing inflammation of HCV-related chronic hepatitis. Aim: The aim of this study was to evaluate the possibility of use of the PLR and the NLR as noninvasive predictive markers of liver fibrosis. Methods: We analyzed 50 patients, 36 male patients with chronic HCV infection. Various clinical investigations were done to assess the severity of fibrosis. Transient elastography and some serological tests were performed, and the PLR and the NLR were estimated. Method evaluated the correlation between the various degrees of fibrosis and the PLR and NLR values of each patient. Results: 31 patients showed F4 fibrosis (defined by elastography) and their PLR (65.12 ± 21.15) was lower than in patients with non-F4 fibrosis (92.13 ± 45.11) (P = 0.001). The NLR was also estimated, but the difference between the 2 groups of patients was not significant statistically (P = 0.06). Conclusion: The PLR can be used as a predictive biomarker of liver fibrosis, unlike the NLR which is not predictive of this HCV-related chronic hepatitis complication.

  Abstract No.: TNISGCON2022-64 Top

Nonalcoholic Steatohepatitis: A Rapidly Increasing Indication for Liver Transplantation in India

Dinesh Jothimani, Silas Danielraj, Vaibhav Patil, Radhika Venugopal, Evangeline Simon, Mullai Ezhili, Akila Rajakumar, Kumar Palaniappan, Ashwin Rammohan, Rajesh Rajalingam, Mohamed Rela

Department of Liver Transplant, Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India

Background and Aim: There has been a considerable increase in patients with nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH). Availability of high-efficacy drugs for hepatitis B and hepatitis C infection may have changed the disease prevalence. We aimed to study the impact of this changing epidemiology in patients with end-stage liver disease (ESLD) who underwent liver transplantation (LT) over a 10-year period and reevaluate the relevance of this paradigm shift in the practice of LT. Methods: The study population was stratified in two time categories, 2009–2014 (Period 1) and 2015–2019 (Period 2). Demographics, type of transplant: LDLT or deceased donor LT (DDLT), disease etiology, and comorbidities were analyzed between the two time periods. Results: Out of 1017 adult patients, 277 in Period 1 and 740 in Period 2, there was a significant increase in NASH (85 [30.7%] and 311 [42%], P = 0.001) and decrease in hepatitis C patients (49 [17.7%] and 75 [10.1%], P = 0.002) undergoing LT between Period 1 and Period 2, respectively. There was a significant increase in hepatitis C-related hepatocellular carcinoma (HCC) (13 [26.5%] and 38 [50.7%], P = 0.009), but not NASH HCC (18 [21.2%] and 62 [19.9%], P = 0.879) or hepatitis B HCC (16 [35.6%] and 37 [35.6%], P = 1.0), respectively, between two periods. A Cox regression analysis showed a strong association between coronary artery disease (HR = 1.963) and NASH. Patients transplanted for NASH had a lower 5-year survival compared with viral hepatitis (75.9% vs. 87.4%; P = 0.03). Conclusion: Our study shows NASH as the most common indication for liver transplantation, surpassing viral hepatitis. Increase in patients with NASH undergoing LT may pose a significant challenge to the transplant team in future.

  Abstract No.: TNISGCON2022-65 Top

Vaccination Status in Patients with Inflammatory Bowel Disease

Sumanth Koppolu, Ebby George Simon, Amit Kumar Dutta, A. J. Joseph, Sudipta Dhar Chowdhury, Rajiv Zachariah

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

Background and Aim: Inflammatory bowel disease (IBD) has an increased risk of infections owing to altered cellular and humoral immunity. In all adult patients, ACG currently recommends that hepatitis A, hepatitis B, influenza, MMR, varicella, Streptococcus pneumoniae, and Tdap vaccination rates in IBD patients vary across vaccines in different populations. Aim: The study aims to find out the vaccination status in adult patients with IBD in our hospital, a tertiary care center in South India. Methods: IBD patients aged greater than 18 years 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 (Hep B, influenza, pneumococcal, and tetanus) and the 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. 73% did not receive any vaccine after diagnosis of IBD. Only 4.5% received all recommended vaccines after diagnosis of IBD. Hepatitis B (15.7%) and TdaP (21.3%) were the highest covered vaccines. Lack of knowledge (56.2%) and financial reasons (41.6%) were the main reasons for incomplete vaccination Conclusion: Vaccination appears to be underutilized in our IBD population. More effort is needed to motivate these patients to get vaccinated and reduce the risk of preventable diseases. Vaccination guidelines relevant to the Indian IBD population need to be framed for better penetration of vaccination services.

[TAG:2]Abstract No.: TNISGCON2022-66 [/TAG:2]

Transfusion-Related Lung Complications Are Uncommon in Nonventilated Liver Disease Patients undergoing Low-Volume Plasma Exchange

Vijay Alexander, Jess Elizabeth Rasalam, Snehil Kumar, Vinoi George David, Dolly Daniel, Sukesh Chandran, Kandasamy Subramani, Binila Chacko, Ebor Jacob James, Lalji Patel, Santosh Varughese, T. J. Vadivukkarasi, Kunwar Ashish Singh, Uday Zachariah, Ashish

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

Background and Aim: Plasma exchange (PLEX) is increasingly used to treat liver disease. We aimed to study transfusion-related lung complications – transfusion-related acute lung injury (TRALI) and transfusion–related circulatory overload (TACO), in patients undergoing low-volume PLEX (PLEX-LV) to treat liver disease. Methods: Prospectively accrued data of patients in our department who underwent PLEX-LV (50% of estimated plasma volume exchanged per PLEX session) for liver disease from 2016 to 2022 were retrospectively analyzed. Patients on ventilatory or oxygen support before PLEX were excluded. Incidence and cause of breathlessness during transfusion and within 6 h of cessation of the last transfusion of blood products used for PLEX were analyzed. Results: Fifty-six (baseline ventilatory or oxygenation support required: 51, COVID 19 infection: 5) of 298 liver disease patients who underwent PLEX-LV during the study period were excluded. 242 study patients (158 males; age: 38, 3–72 years; median, range, acute-on chronic liver failure: 117, acute liver failure: 74) received 5197 units of fresh frozen plasma (FFP) during 779 PLEX-LV sessions. Three patients (1.2%, TACO: 2, pulmonary hemorrhage: 1) developed breathlessness within 6 h of completion of any PLEX session. No patient had TRALI. Incidence of TACO was 0.3% (2/779) of PLEX-LV sessions and 0.04% (2/5197) of FFP units transfused during PLEX. All three patients died despite maximal supportive care. Conclusion: We found transfusion-related lung complications to be uncommon in nonventilated liver disease patients (most had liver failure) undergoing PLEX-LV. Careful attention to cumulative fluid balance may help reduce incidence of TACO further.

  Abstract No.: TNISGCON2022-67 Top

Ileal Inflammatory Fibroid Polyp: Is There an Invasive Variant?

M. N. Saravanan, M. Barathkumar, V. Vaithiswaran, P. Senguttuvan, S. Salapathy, M. Ghosh

Department of Medical Gastroenterology, Apollo Hospitals, Chennai, Tamil Nadu, India

Background and Aim: Inflammatory fibroid polyp is a rare mesenchymal lesion of the gastrointestinal tract, commonly affecting stomach followed by ileum. They are usually benign and noninvasive lesions, confined to mucosa and submucosa. We describe the unusually invasive pathology seen in a patient with an inflammatory fibroid polyp in small bowel treated surgically. Methods: This was a case report. Results: A 30-year-old gentleman presented with recurrent episodes of partial intestinal obstruction. Computed tomography abdomen showed a 7 cm × 4 cm × 3 cm intraluminal lesion in the ileum with proximal bowel dilatation and wall thickening. With preoperative differential diagnosis of gastrointestinal stromal tumor, he was taken up for surgery and underwent segmental ileal resection. The lesion was seen reaching up to serosa causing puckering on the surface and surface ulceration on the mucosal aspect. Histopathology revealed a polypoidal neoplasm with hyalinized collagenous stroma with myxoid change and stellate-shaped cells with hyperchromatic nuclei. Mitosis was rare (<1 per 10 high-power field). Stroma showed proliferation of vessels with focal onion skin appearance. Lesion involved the muscularis propria and subserosa focally (transmural involvement). Immunohistochemistry (diffusely positive for vimentin and SMA, focal pancytokeratin positivity, and negative for CD34, C-KIT, DOG1, desmin, S100, and ALK1) with histopathology favored inflammatory fibroid polyp. Ki-67 proliferation index was 0.5%. Such transmural involvement is extremely rare and very few cases are reported in the literature. This patient is symptom-free at 18 months of follow-up. Conclusion: Inflammatory fibroid polyp of the small intestine can rarely be invasive, and hence, its behavior needs to be ascertained with regular follow-up and surveillance.

  Abstract No.: TNISGCON2022-68 Top

Single-Center Experience on Outcome of Idiosyncratic Drug-Induced Liver Failure Treated with Low-Volume Plasma Exchange and Low-Dose Steroid

Kunwar Ashish Singh, Santhosh Kumar, Uday Zachariah, Vinoi David1, Dolly Daniel2, Subramani Kandasamy3, Kishore Pichamuthu3, Ashish Goel, C. E. Eapen

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

Background and Aim: We present our experience of plasma exchange (PLEX) to treat idiosyncratic-drug-induced liver injury (I-DILI) patients with liver failure. Methods: We retrospectively analyzed prospectively collected data on patients with I-DILI (diagnosed as per RUCAM score), treated with low-volume PLEX and low-dose steroid (up to 20 mg per day, with rapid taper afterward) in our department from 2016 to 2022. None of the patient opted for liver transplant. Baseline and dynamic post-PLEX parameters were compared to the worst pre-PLEX value assessed by logistic regression as predictors of 1-month outcome. Results: Forty-five I-DILI patients (probable:possible37:8; ALF:ACLF23:22, male: 25, age: 39.5, 15–84 years; median, range) underwent PLEX during the study. Causative agents were complementary and native medication (CAM, 51%), antimicrobials (24%), antiepileptics (8%), antitubercular drugs (6%), and others (11%). Twenty-six patients had encephalopathy (ALF: 23; ACLF: 3). At baseline, liver disease severity indices were serum bilirubin: 21.8 (2–48.1) mg/dl, INR was 2.4 (1.5–10), and MELD was 30 (24–43). Twenty-three ACLF patients underwent 3 (1–5) PLEX sessions with 1.2 (0.6–1.4) L of plasma exchanged per session. 22 ALF patients underwent 2 (1–6) sessions with 1.4 (0.6–1.4) L exchanged per session. Overall, 1-month survival was 32 (71%) (ALF: 57%, ACLF: 86%). Twelve (60%) of the 20 ALF patients who fulfilled King's College Criteria for liver transplantation survived with PLEX. In the entire study group, the causative agent (CAM: 87%, others: 59%; P = 0.005) was associated with 1-month survival. In ALF, none of the baseline parameters predicted survival. Drop-in von-Willebrand factor (VWF, P = 0.006) after PLEX was the only factor independent significant predictor for the 1-month outcome. On ROC analysis, AUROC for change in VWF was 0.83 (95% confidence interval [CI]: 0.64–1.0) and a 25% decrease from baseline was associated with significantly improved survival (hazard ratio: 0.28 95% CI: 0.1–0.81, P = 0.012, sensitivity: 73%, specificity: 87%). Conclusion: PLEX appears a promising treatment in I-DILI patients not opting for liver transplantation with the decrease in plasma in VWF level after PLEX predicting survival in ALF patients.

  Abstract No.: TNISGCON2022-69 Top

High-Risk Features in Appendicular Pathology: What Next?

M. N. Saravanan, V. Vaithiswaran

Department of Medical Gastroenterology, Comprehensive Advanced Surgical Team, Apollo Hospitals, Chennai, Tamil Nadu, India

Background and Aim: Appendicular neoplasm is either suspected based on initial imaging or after histopathology for appendicular resection. Detection of luminal mucin, its cellularity, and presence of invasive focus have key implications in treatment strategy, prognosis, and follow-up. We audited our experience with appendicular pathologies to assess these high-risk features. Methods: This was a retrospective audit of a prospectively maintained database from February 2020 to February 2022 to identify all appendicular specimens submitted to pathological examination for primary appendicular pathology by a single surgical unit. Clinicopathological correlation, treatment modalities, and outcomes were studied. Results: Of the 23 patients whose specimens were submitted as a part of appendectomy or extended resections, 15 showed inflammatory pathology alone (Group A). Acellular mucin limited to the appendicular lumen was observed incidentally in 3 patients who underwent laparoscopic appendectomy (Group B). Neoplasm was found in 5 patients (Group C), 2 of which showed invasive focus of adenocarcinoma and 3 had low-grade mucinous neoplasm (LAMN). Three of these patients underwent radical surgery at index presentation as there were high-risk features for neoplasm on computed tomography preoperatively (laparoscopy — 2, open — 1). One patient underwent appendectomy elsewhere with subsequent histopathology suspicious of neoplasm and underwent laparoscopic radical resection. Imaging reviewed with us showed high features in this patient. One patient who presented with perforation, sepsis, and pseudomyxoma confirmed intraoperatively underwent staged procedures. Principles of not handling appendix directly and oncological adequacy were adhered to, in line with the approach to minimally invasive colorectal cancer surgery in this high-volume unit. Margins were free in all patients with a mean lymph node yield of 12 nodes (14.5 in adenocarcinoma and 9.5 in LAMN; overall median lymph node yield - 10.5). All patients in Group C are disease-free at a mean follow-up of 8.6 months (median 4, range 3–24 months). Conclusion: Diligent reading of cross-sectional imaging can help identify patients at high risk for appendicular neoplasm. This permits radical resection promptly, including by minimally invasive technique in selected patients where expertise is available.

  Abstract No.: TNISGCON2022-70 Top

Gastroenterological Emergencies in Pregnancy: Approach

V. C. Swathika, Janani Iyer, M. N. Saravanan, V. Vaithiswaran, Senguttuvan Pandian, T. Kamalakannan

Department of Medical Gastroenterology, Apollo Hospitals, Chennai,

Tamil Nadu, India

Background and Aim: Acute abdomen in pregnancy can be challenging as it can affect fetal and maternal well-being. We reviewed our experience in gastroenterological emergencies in pregnancy. Methods: This was a retrospective review of database from November 2020 to February 2022 Results: Two patients with acute pain diagnosed with acute cholecystitis and acute appendicitis. Cholecystitis was diagnosed on ultrasound, whereas appendicitis was not evident on ultrasound and magnetic resonance imaging (MRI) abdomen clinched the diagnosis. With multidisciplinary team approach (obstetrician/surgeon/radiologist/anesthetist) weighing risk against benefits, surgery was planned by laparoscopy with appropriate precautions in port placement, minimal uterine handling, and fetal monitoring. There was no fetal loss. Conclusion: Diagnosis of acute abdomen in pregnancy is done with the aid of ultrasound or MRI abdomen. Laparoscopy is safe and feasible in expert hands with appropriate monitoring and precautions.

  Abstract No.: TNISGCON2022-79 Top

Comparison of the Results of Blood and Bile Cultures in Patients with Cholangitis

John Titus George, Rajeeb Jaleel, Amit Kumar Dutta, A. J. Joseph,

Ebby George Simon

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

Background and Aim: Blood and bile cultures aid in guiding antibiotic therapy in cholangitis. In this study, we wished to compare the microbial profile of blood and bile cultures in patients with cholangitis. Methods: In this retrospective study, patients with cholangitis from 2010 to 2020, for whom blood cultures were available, were included. Results: Among 1071 patients with cholangitis, blood cultures were positive in 373 (34.8%). 329 (84.5%) of 389 patients who had bile cultures had a positive bile culture. Among the 127 patients with both blood and bile culture positivity, complete agreement, partial agreement, and complete disagreement between the organisms cultured were noted in 47 (37%), 67 (52.7%), and 13 (10.3%), respectively. Escherichia coli (55.1%), Klebsiella (22.1%), Enterococcus (6.9%), and Pseudomonas (4.3%), were the four most common organisms isolated in the blood, which was similar to the most common organisms isolated from bile – E. coli: 31%, Enterococcus: 20.1%, Klebsiella: 18.4%, and Pseudomonas: 10.1%. ESBL+ organism was isolated in 176 (57.7%) and CRO organisms in 4 (1.3%) of the patients with positive blood cultures. While ESBL+ organism was isolated in 114 (58.8%) and CRO organisms in 25 (1.3%) of those with positive bile cultures. 118 (83.1%) of blood cultures versus 133(40.5%) of bile cultures were monomicrobial. The median number of organisms cultured in the blood and bile was 1 (IQR I≤0) and 2 (IQR - 2), respectively, which was statistically significant P I≤ 0.001. Conclusion: The yield of bile cultures is more than blood cultures in cholangitis. While bile cultures are often polymicrobial, complete or partial agreement with blood cultures is seen in nearly 80% of the patients.

  Abstract No.: TNISGCON2022-71 Top

Overweight and Obesity Is As Frequent As Underweight in Indian Patients with Inflammatory Bowel Disease

K. J. Umesh, Amit Kumar Dutta, Ajith Thomas, Anoop John, Rajeeb Jaleel, Sudipto Dhar Chowdhury, Ebby George Simon, A. J. Joseph

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

Background and Aim: 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 are limited from India. We aimed to assess the frequency of overweight/obesity in Indian patients with IBD and determine its associations with disease characteristics. Methods: The case records of patients with CD or ulcerative colitis (UC) seen in the outpatient 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); and overweight/obese (>23 kg/m2). Complicated disease behavior 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 < 0.05 was considered significant. Results: The study included 230 patients with IBD (mean age 37.5 ± 12.2 years, males 62.2%). 122 had CD (mean age 37.1 ± 13.2 years, males 63.8%) and 108 had UC (mean age 37.9 ± 11 years, males 60.2%). Overall 31.30% (95% confidence interval [CI] 25.7–37.6) of IBD patients were overweight/obese and 28.7% (95% CI 23.2-34.9) patients were underweight, suggesting a similar frequency for both categories. 35.6% women were overweight/obese compared to 28% men with IBD (P = 0.28). On evaluation of relationship with disease type, overweight/obesity was present in 35.18% ofpatients with UC and 27.86% patients with CD [Figure 1]. This difference was not significant statistically (P = 0.29). Complicated disease behaviour was noted in 53.3% of patients with CD and was not associated with overweight/obesity (P = 0.43). Conclusion: About one-third of patients with IBD are overweight/obese which is similar to the frequency of underweight patients. Overweight/obesity is frequent in both UC and CD.

  Abstract No.: TNISGCON2022-72 Top

Analysis of Coagulation Factor VIII in Liver Failure Syndromes

Sandeep Kumar, Sukesh Chandran Nair1, Uday Zachariah, Tulasi Geevar1, C. E. Eapen, Ashish Goel

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

Background and Aim: Role of factor VIII in liver failure, either as prognostic marker or as a counterbalance to other coagulation factor deficiency, is unclear. Methods: We retrospectively recruited in-patient liver failure (both acute liver failure [ALF] and acute-on chronic liver failure [ACLF]) patients with factor VIII levels (normal range: 50%–150%) tested. Other coagulation parameters (rotational thromboelastometry [ROTEM] and plasma von-Willebrand antigen [VWF]) were noted. Results: Forty-one patients (M: 20; age: 37, 16–69, median, range; MELD: 28, 8–46; VWF: 595, 103–1147 IU; ACLF: 24, acute liver injury [ALI]: 11, ALF: 6) were recruited. Most common etiology in ACLF group was alcohol (14, 58%) and in ALI/ALF was rodenticidal hepatotoxicity (9, 53%). Factor VIII levels were similarly raised in both ACLF (256%, 139%–497%) and ALI/ALF (255%,133%–728%) groups. There was no correlation of factor VIII levels with platelet count, serum fibrinogen, or prothrombin time. In ROTEM, factor VIII level negatively correlated with clotting time (r = −0.33, P = 0.04). There was no correlation of factor VIII levels to MELD score (r = −0.128, P = 0.43) but tended to correlate with plasma VWF level (r = 0.25, P = 0.10). Twenty (49%) patients underwent low-volume plasma exchange (PLEX-LV). Ten patients with adverse outcome had lower factor VIII levels (210%, 133%–728% vs. 266%,139%–522%, P = 0.1). There was a trend to lower factor VIII being a significant predictor of in-hospital outcome (AUROC: 0.7, 95% confidence interval: 0.4–0.9, P = 0.1). Conclusion: Factor VIII level is elevated in liver failure syndromes and it negatively correlates to preserved clotting time in ROTEM. Contrary to other endothelial markers (e.g., VWF), higher factor VIII levels were associated with better in-hospital outcome.

  Abstract No.: TNISGCON2022-73 Top

Effect of Biliary Plastic Stents on the Outcomes of Laparoscopic Cholecystectomy in Patients with Cholelithiasis and Choledocholithiasis

S. Siva Krishna, Pazhanivel Mohan, K. Senthamizhselvan, Kalayarasan Raja1, D. Kadambari2

Departments of Gastroenterology, 1GI Surgery and 2General Surgery, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India

Background and Aim: The manifestations of choledocholithiasis vary from being asymptomatic to the presence of biliary colic, obstructive jaundice, cholangitis, or pancreatitis. Common bile duct (CBD) stones are often secondary to gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) removal of CBD stones and laparoscopic cholecystectomy (LC) in a single session is the recommended treatment. However, LC is done at a later stage after endoscopic CBD clearance and biliary stenting in several units due to long waiting lists. The study aimed to determine the effect of CBD stent on the outcomes of LC in patients with cholelithiasis and choledocholithiasis. Methods: This was a case–controlled study between January 2020 and January 2022, wherein patients who underwent LC were included. They were divided into: Group 1, patients who underwent LC following ERCP stone retrieval and biliary stenting and Group 2, patients who underwent LC. The outcomes of LC such as conversion to open cholecystectomy (OC), biliary leak, further laparotomy for bile leak, postoperative fever, prolonged postoperative hospital stay (>3 days), and surgical site infection (SSI) were studied. Odds ratio and Chi-square test were used to compare the outcomes. Results: A total of 127 patients (Group 1 - 18 and Group 2 - 109) were studied. The frequency of patients with prolonged postoperative hospital stay (47.1% vs. 10.1%) was significantly higher in Group 1 (P < 0.05) than Group 2. Although conversion to OC (11.1% vs. 5%), postoperative fever (5.6% vs. 1.8%), and SSI (5.6% vs. 2.8%) were more in Group 1 than Group 2, they were not statistically significant. None had biliary leak. Conclusion: CBD stent placement following ERCP stone retrieval resulted in prolonged postoperative stay in patients undergoing LC.

  Abstract No.: TNISGCON2022-74 Top

Pediatric Anorectal Manometry - A Useful Endeavor?

M. Preethi

Department of Medical Gastroenterology, Apollo Hospitals, Chennai,

Tamil Nadu, India

Background and Aim: The most common indication for referral for pediatric anorectal studies is constipation. The prevalence of constipation in infants and toddlers varies from 3% to 5%. More than 90% are functional in etiology and are largely self-limiting in duration. However, persistence of symptoms, failure of response to routine laxatives and disimpaction techniques, need for prolonged therapy and social implications prompt anxious parents to seek medical consults. The utility of anorectal manometry in pediatric functional defecatory disorders and as an adjunct to select localized anorectal mechanical disorders has been steadily growing. It can be comfortably performed across all age groups and may obviate the need for further invasive tests, especially in the clinical suspicion of Hirschsprung's disease. Methods: This was a retrospective study. Data obtained from January 2019 to November 2021 were analyzed. Patients in the study were referred by pediatricians, pediatric gastroenterologists, and pediatric surgeons. The study group included all children aged 1 month up to 14 years. Informed consent had been obtained from all parents. Prior procedure, a detailed history regarding the child's bowel habits and general health was obtained by the performing doctor and/or the physician assistant. Out of the 91 parents who consented, 2 procedures were incomplete because of noncooperation. A total of 89 patients' data were analyzed. In younger children up to 7 years, only RAIR was assessed. In children older than 7 and ability to comprehend the steps, the complete test, including balloon expulsion, was performed. Results: A total of 89 procedures were analyzed, out of which 49 were males and 40 females. Three children were aged less than 1 year, 11 children were aged between 1 and 2 years, 27 children were aged between 2 and 4 years, 24 children were aged between 5 and 7 years, and 24 children were aged greater than 7 years. The most common symptoms in order of occurrence were straining at stools, abnormal postures/withholding behavior, prolonged laxative requirement, encopresis, low stool frequency, and bleed PR. Four children had undergone procedures in childhood for suspected Hirschsprung's disease. Preprocedure barium enema was available with 8 children. With respect to manometry metrics, anal canal length was 2 ± 1 cm, and the average basal anal sphincter pressures were 69.2 and squeeze pressures were 141.8. Rectal hyposensitivity was present in greater than 50 % of children who completed the procedure. RAIR was absent in 8 out of the 89 children. Out of these, two were confirmed by full thickness biopsy and three had a history of surgery. 31 children attempted the balloon expulsion step and 4 children had abnormal response suggestive of dyssynery. Conclusion: The most common cause of pediatric constipation is functional. In younger children, the onset of symptoms appears to start from the weaning period, in preschoolers during initiation of toilet training, and in older children, withholding behavior. Rectal hyposensitivity was a significant finding in older children and correlated with encopresis. RAIR absence correlated well with Hirschsprung's disease, but statistics could not be analyzed as all patients did not have histological proof of the same. Anorectal manometry is an easy and safe procedure. It can be comfortably performed across all age groups and may obviate the need for further invasive tests, especially in the clinical suspicion of Hirschsprung's disease.

  Abstract No.: TNISGCON2022-75 Top

Post-COVID Cholangiopathy: A Life-Threatening Delayed Complication!

Dinesh Jothimani, Radhika Venugopal, Mukul Vij, Evangeline Simon,

Mullai Ezhili, Rajesh Rajalingam, Ananthavadivelu Murali1, Mohamed Rela

Department of Medical Gastroenterology, Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, 1Clinicians Point, Chennai, Tamil Nadu, India

Background and Aim: COVID-19–related liver injury may occur during the illness with no sequalae. Here, we describe four patients with severe cholestatic jaundice following initial recovery from COVID-19 illness. Methods: All were men aged 50–67 years, developed COVID-19 varying from mild to severe disease. Liver function tests (LFTs) at the time of their illness did not show significant elevation. None of them had underlying known chronic liver disease. Clinical recovery from COVID-19 was complete and the patients were discharged between 7 and 21 days. All these patients developed fatigue and jaundice 4–6 weeks from their initial illness and couple of them had pruritus. Symptoms progressed with worsening hyperbilirubinemia. Peak enzymes were AST x 4–8 upper limit normal (ULN), ALT x 3–10 ULN, ALP x 4–6 ULN, and GGT x >5–15 ULN. Peak bilirubin varied between 15 and 42 mg/dl. Interestingly, none of them developed coagulopathy, ascites, or hepatic encephalopathy. Abdominal imaging showed no features of chronic liver disease and no biliary dilatation. A liver biopsy showed loss of interlobular bile ducts, degenerative features in residual ducts, hepatocanalicular bilirubinostasis, and fibrin thrombi in some vessels. Results: Out of these four patients, one died of worsening symptoms and sepsis. The second patient remained symptomatic and underwent evaluation for liver transplantation. He was found to have double vessel coronary artery disease requiring stenting. Following stent placement, he was commenced on aspirin and clopidogrel. Interestingly, there was a significant improvement in LFT within 6 weeks, deferring liver transplantation. His clinical improvement was attributed to antiplatelet drugs. The third patient developed progressive jaundice and exhaustion. He underwent auxiliary partial orthotopic liver transplantation providing provision for recovery of his native liver. Fourth patient showed a remarkable improvement with antiplatelet drugs. Conclusion: Post-COVID cholangiopathy is a poorly understood serious complication following COVID-19 with no unclear treatment.

  Abstract No.: TNISGCON2022-76 Top

“Restricted Sedative Use” Policy May Improve Survival in Patients with Rodenticide-Induced hepatotoxicity

M. Asisha Janeela, Ashish Goel, Uday George Zachariah, Kundavaram Paul Prabhakar Abhilash1, Kishore Pichamuthu2, Ebor Jacob James3, Subramani Kandasamy4, C. E. Eapen

Departments of Hepatology and 1Accident and Emergency, Christian Medical College, 2Department of Medical Gastroenterology, Medical Intensive Care Unit, Christian Medical College, 3Department of Medical Gastroenterology, Paediatric Intensive Care Unit, 4Department of Medical Gastroenterology, Surgical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India

Background and Aim: Acute liver dysfunction may affect drug metabolism in liver, lead to sedative overdose, drowsiness, and respiratory depression, and contribute to mortality. This study aims to analyze use of sedatives in patients with rodenticidal hepatotoxicity. Methods: Details of sedative use and outcomes were studied from IP charts and e-pharmacy records of patients admitted with rodenticide ingestion under the department of hepatology (2014–2021). Results: Of 85 patients with rodenticide hepatotoxicity (F: 52; age: 22 years, median; acute liver injury: 56, acute liver failure: 26), 72 (85%) consumed yellow phosphorus. All patients were managed as per standard of care including plasma exchange (41/85 patients). None underwent liver transplant. 15/85 (18%) patients received sedatives (all intravenously) – lorazepam (5 patients), dexmedetidine (5), midazolam (4), haloperidol (4), and fentanyl (4). Indications for sedative use: agitation (11/15) and endotracheal intubation (4/15). All received standard doses of sedatives. 11/15 patients who received sedatives required plasma exchange and 7/15 had worsening of oxygen saturation. 6/15 (40%) patients had worsening sensorium and died. Hospital stay was prolonged in patients who received sedatives (10.9 vs. 8.2 days). Overall, transplant-free survival was noted in 87% (74/85) patients with rodenticidal hepatoxicity. Mortality was significantly higher in patients with sedative use (6/15, 40%) as compared to patients with no sedative use (5/70, 7%; hazard ratio: 8.7, 95% confidence interval: 2.2–34.3, P = 0.003). Conclusion: Most rodenticidal hepatotoxicity patients were managed without sedatives. Sedative use was associated with worsening sensorium, prolonged hospital stay, and increased risk of death. A “restricted sedative use” policy in these patients may improve survival.

  Abstract No.: TNISGCON2022-77 Top

Trichobezoar of Small Intestine Mimicking Clinically as Acute Appendicitis

Mukund Mundra, L. Anand, S. Balakumaran

Department of Surgical Gastroenterology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: Acute abdomen has always been an interesting case scenario for clinicians and sometimes led to a diagnostic dilemma. The approach to a patient with an acute abdomen should include a thorough history and physical examination. Even in a case seems to be simple straightforward appendicitis on clinical examination, a detailed evaluation in terms of laboratory test and imaging should be done. Referring the abdomen as a “Pandora's Box,” it is not usual to come across small bowel obstruction due to a “Trichobezoar” presenting clinically as acute appendicitis. Case: A 21-year-old female presented with severe pain abdomen for 4 days, initially colicky type, gradually progressed and localized to continuous right lower abdomen pain. The patient also had nausea, vomiting, and fever. The patient had similar complaint 4 years back which was managed conservatively. On clinical examination, the patient had tachycardia (pulse rate 98/min) and per abdomen examination revealed RIF tenderness at McBurney's point with rebound tenderness (+). Laboratory parameters were normal except for raised total leukocyte count (11,600 cells/cum) and neutrophilia. Ultrasonography abdomen revealed dilated bowel loops with minimal collection in RIF along with probe tenderness. Alvarado score of the patient was 9/10 and the patient was taken up for diagnostic laparoscopy. To our surprise, terminal ileum, colon, and appendix were normal. There was an inflamed jejunal segment which adhered to RIF and was hard on palpation. Adhesions were released and small laparotomy incision was made and jejunal loop brought out. An enterotomy was done and a trichobezoar of size 10 cm × 7 cm × 5 cm removed. Postoperatively, the patient recovered well. Postoperatively, on repeated asking, the patient revealed history of trichotillomania and trichophagia. Repeat psychiatric consultation was taken and the patient was followed up. Conclusion: In the current era, a detailed preoperative evaluation should be considered in all patients, if clinical condition of patient is stable. Especially, diagnostic laparoscopy is an essential tool in surgeon's hand which prevents negative appendicectomy and accurately diagnoses the disease.

  Abstract No.: TNISGCON2022-80 Top

Intraoperative Amylase Concentration in Peripancreatic Fluid: An Independent Predictor of Postoperative Pancreatic Fistula

Aniket Payagude, L. Anand, S. Balakumaran

Department of Surgical Gastroenterology, Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: The incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy is around 5%–22% and after distal pancreaticosplenectomy (DPS) is 10%–30%. Some of the known important risk factors for the development of POPF are small-duct, soft gland, high-risk pathology, intraoperative blood loss, etc. Reuver et al. first studied the role of intraoperative amylase concentration (IOAC) in the peripancreatic fluid in predicting the POPF. Our study aims to evaluate the predictive capacity of the IOAC for the development of POPF. Methods: Prospective data, all consecutive patients – PD and DPS • August 2021– till date (n = 10). Fluid collection IOAC: standardized procedure peripancreatic fluid collected. POD 1, 3, and 5 drain fluid amylase. Standard statistical tests as appropriate are used and SPSS software was used for analysis. Results: Patient characteristics such as age, gender, ASA grade, comorbidity, diagnosis, etc., are not related. Operative details such as small duct have increased risk (not significant). Blood loss and gland consistency did not reach significant level. Mean IOAC along with POD 1 is higher in patient with POPF (grade A and B). Conclusion: IOAC correlates with increased risk of POPF. Larger prospective studies are necessaryto validate the role of IOAC as predictor of POPF, to determine optimal levels of IOAC, and to understand the pathophysiology of POPF.

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