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   Table of Contents - Current issue
October-December 2022
Volume 2 | Issue 4
Page Nos. 143-189

Online since Thursday, October 13, 2022

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Prediction of severity outcomes in acute pancreatitis: An odyssey in eternal evolution p. 143
Rohan Yewale, Naveen Chand, Balakrishnan S Ramakrishna
Acute pancreatitis (AP) is one of the most frequently encountered gastrointestinal emergencies in clinical practice. It has a wide clinical spectrum and a natural history which varies significantly from patient to patient as well as between two distinct episodes in a single patient. Severe AP often causes considerable morbidity and mortality with a substantial financial burden on the health-care system. The natural course and severity manifestations of AP gradually unfold and can be defined only after the initial 48–72 h of symptom onset. Early identification of patients at high risk for developing a severe course of the disease is crucial for preventing organ failure and death. A vast number of clinical, laboratory, and radiological markers and scoring systems which can predict severity outcomes of AP during this early phase, are described in literature. With a recent exploration of molecular genetics, gut microbiome analysis, and advent of artificial intelligence-derived models, these markers and scoring systems are undergoing constant evolution. Unlike the universally accepted Revised Atlanta classification for defining the severity of AP, there is no uniform consensus on the use of any particular marker or scoring system for early prediction of AP severity. Our review briefly summarizes the available literature on the early prediction of severity outcomes in AP and highlights a few recent advances in this field.
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Age cohort screening for hepatocellular carcinoma in an African population p. 152
Pantong Mark Davwar, NP David, MJ Duguru, JD Makpu, A Okwute, S McHenry, K Zawaya, I Sadiq, EN Okeke
Background: Hepatocellular carcinoma (HCC) is a disease of global and public health significance. In Africa, HCC is the fourth most common cancer and sub-Saharan Africa is a hotbed for HCC due to high prevalence of hepatitis B (HBV) and hepatitis C (HCV) virus infections. The late presentation in African patients has been well documented with attendant bad prognosis. We undertook this study to determine if there is an age-related clustering of HCC based on etiology. Methods: This was a retrospective hospital-based study from records of 425 adult patients (18 years and above) with triphasic computed tomography confirmed HCC at the Jos university teaching hospital, Jos, Nigeria. Relevant data were extracted from the database into an Excel spreadsheet with subsequent analysis based on age and risk factors of HCC. Results: Of 425 patients included in this study, 323 (76%) were male. The overall mean (± standard deviation) age for the studied population was 48.8 ± 14.6 years: 48.8 + 14.5 years for females and 48.9 + 14.6 years for males. 44.7% had HBV and 28% had HCV. There was a significant difference in the mean age of those with HBV as against HCV (43.0 ± 12.5 years vs. 54.3 ± 14.2 years; P < 0.001). Among those who had HCV as a risk factor for HCC, the majority (31.9%) were in the age group of 51–60 years while most of those with HBV (32.1%) were in the 31–40 years of age group. Conclusion: In this African cohort, HBV-related HCC presented a decade earlier than HCV-related HCC. Targeted screening strategies for HCC may take this into account.
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Prefer to avoid sedatives in patients with acute hepatotoxicity due to rodenticide ingestion: Knowledge, attitude, and practice survey of doctors from Tamil Nadu p. 156
Zachariah Thomas, Asisha Janeela, Richard Kirubakaran, Ubal Dhus, Uday Zachariah, CE Eapen, Ashish Goel
Background and Aim: While sedative drugs are not hepatotoxic, the use of sedative drugs in patients with acute liver dysfunction may lead to unrecognized sedative overdose, or trigger or aggravate encephalopathy. This study hopes to draw more attention to the need to correctly interpret and use the expert guidelines in this regard. The aim of this study was to assess the knowledge, attitude, and practice of doctors regarding sedative use in patients with acute liver dysfunction secondary to rodenticide poisoning in Tamil Nadu. Subjects and Methods: This was a cross-sectional online survey carried out between December 2021 and May 2022 among doctors in Tamil Nadu involved in the care of patients with rodenticide poisoning regarding sedative use in patients with rodenticidal hepatotoxicity. Results: Responses were obtained from 168 doctors (including 86 gastroenterologists): ([152, 90.5%] from doctors in the government sector and [16, 9.5%] from private sector). Most (96, 57.1%) respondents had managed >10 patients of rodenticide poisoning in a year. Most doctors opined that the patients they cared for did not have access to urgent liver transplantation. One hundred and fifty-one (89.9%) doctors opined that sedative use could depress sensorium further and lead to unfavorable outcomes in these patients. About 79 (47%) patients would avoid using a sedative, if possible, in patients with acute liver dysfunction. They felt the indications for sedative use were to avoid fluctuations in raised intracranial pressure (134, 79.8%) and to facilitate invasive procedures (129, 76.8%) such as endotracheal intubation. When sedative was needed, 10 doctors (6%) favored the use of a reduced dose of sedative. Conclusions: In a resource-constrained setting, where emergency liver transplantation is not easily accessible, doctors prefer to avoid sedatives in patients with rodenticidal hepatotoxicity. Increased awareness of the need to avoid sedatives or restrict the use of sedatives may improve survival in these patients.
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Digital rectal examination in defecatory disorders: Is it poor man's anorectal manometry? p. 160
Pratik Sethiya, Meghraj Ingle, Mayur Gattani, Vikas Pandey, Shamshersingh Chauhan, Sneha Deshpande, Saiprasad Lad, Gaurav Kumar Singh, B Kiran, Swapnil Walke, Megha Meshram, Akash Shukla
Background and Aims: Magnetic resonance defecography (MRD) and high-resolution anorectal manometry (HR-ARM) are considered gold standards for defining pelvic floor anatomy and diagnosis of dyssynergic defecation (DD) respectively. Digital rectal examination (DRE) is a bedside test which may be used to screen for DD. The objective of the study was to evaluate the usefulness of DRE as compared with HR-ARM and MRD for detection of DD. Materials and Methods: Sixty patients of functional constipation defined by ROME-IV criteria were enrolled. After ruling out structural causes of constipation using colonoscopy, all patients were subjected to undergo DRE and subsequently HR-ARM and BET, blinded to DRE findings. MRD was reported by a radiologist who was also blinded to the findings of DRE and HR-ARM. The diagnostic yield of DRE was compared with HR-ARM and MRD. Results: Dyssynergia was diagnosed in 48/60 (80%) patients on DRE and in 44/60 (73%) patients on ARM. The sensitivity, specificity, and positive predictive value (PPV) of DRE in diagnosing DD were 95.90%, 57.14%, and 83.83%, respectively (P = 0.01). Among clinical features, only digital maneuvering while defecation correlated with DD (P = 0.019). On DRE, paradoxical anal sphincter contraction correlated with DD (P = 0.010). The presence of excessive descent on DRE correlated with excessive anorectal descent on MRD. Structural abnormalities such as rectocele, cystocele, vaginal prolapse, and uterine prolapse were associated with DD in all. Conclusion: DRE is a useful bedside test in diagnosing DD with a high sensitivity and PPV. DRE is poor in identifying structural abnormalities contributing to DD.
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Endoscopic ultrasonography-guided antegrade stenting in surgically altered anatomy: Case report and review of literature p. 166
Biswa Ranjan Patra, Sridhar Sundaram, Mohd Irtaza, Praveen Kumar Rao, Aditya Kale, Akash Shukla
Endoscopic ultrasonography-guided biliary drainage (EUS-BD) remains an alternative to Endoscopic retrograde cholangiopancreatography (ERCP) for malignant extrahepatic biliary obstruction. Biliary drainage in altered surgical anatomy remains a challenge to endoscopists. Enteroscopy-assisted ERCP (eERCP) has been utilised for biliary access in patients with altered surgical anatomy, but with suboptimal results. We report a case of 51-year-old male, a case of carcinoma stomach undergone distal D2 gastrectomy with gastrojejunostomy with distal biliary obstruction, who underwent EUS-BD antegrade approach with technical and clinical success, with a review of literature of EUS BD in altered surgical anatomy.
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Gallbladder adenocarcinoma with incidental finding of xanthogranulomatous cholecystitis and tubercular lymphadenitis: A rare case report p. 169
Syeda Iqra Usman, Zeeshan Nahid, Asfa Shams, Kafil Akhtar
Gallbladder carcinoma is the fifth most common gastrointestinal malignancy and the most common malignancy of the biliary system, with a high incidence in the Gangetic belt of India. The 5-year survival rate is nearly 19.0% because of the aggressive nature of the lesion. We report a rare case of a 35-year-old female who presented with complaints of pain in the right upper abdomen with jaundice, bloating, and intolerance to fatty food for 3 months and the lump in the right upper abdomen for 1 month. Ultrasonography and computed tomography were performed which showed a thickening in the fundic region of the gallbladder with infiltration into the liver. Extended cholecystectomy was done, and a diagnosis of well-differentiated adenocarcinoma with xanthogranulomatous cholecystitis with tubercular lymphadenitis was made.
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Epstein–Barr virus mucocutaneous ulcer: A rare cause of drug-induced lower gastrointestinal bleed p. 173
Malathi Sathiyasekaran, S Arul Prakash, Tarun J George, Lawrence D'Cruze, VY Bhargav, S Shankar, Jayanthi Venkataraman
We report a case of a young female with cirrhosis due to autoimmune hepatitis who presented with significant hematochezia. She was on azathioprine for 3 years. At colonoscopy, she had two synchronous bleeding polypoidal colonic lesions that required an emergency left hemicolectomy. Immunohistochemistry confirmed the diagnosis of Epstein–Barr virus-positive mucocutaneous ulcers (EBV-MCU).
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Abstracts of case presentations at the mid-term conference of the Tamil Nadu chapter of the Indian society of gastroenterology, September 24, 2022, christian medical college new Campus, Vellore p. 178

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Gastroenterology elsewhere p. 188
Kayalvizhi Jayaraman
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