Deficiency of smooth muscle cells can lead to dysfunction and engorgement of blood vessels termed as hemangioma, arteriovenous malformations, and venous malformations (VMs). Anorectal VM is a rare disease. It can present with massive hematochezia. An optimal treatment of anorectal VMs has not been defined. Surgery is an option if the lesion can be resected completely. Endoscopic injection sclerotherapy has been reported to be effective in treating small colorectal VMs. However, it has rarely been described in the treatment of large VMs. In this study, we describe a rare case of large anorectal VMs treated with microfoam sclerotherapy.

Background: Various imaging modalities like USG, CT, Invasive cholangiography has been used since long for the evaluation of the pathology of hepato-biliary-pancreatic duct. These techniques pose some limitations either due to bowel gas and obesity in USG, distal CBD calculus and isodense calculus (isodense to bile) in CT (also not used in patient with history of contrast allergy) and post-procedural complications (followed by invasive cholangiography like ERCP and PTC). MRCP is a non-invasive diagnostic technique for the direct visualization of the biliary ducts images similar to that produced in PTC (percutaneous trans-hepatic cholangiography) and ERCP. Also, the continuous expanding spectrum of therapeutic options, including radiological interventions (for palliative and curative) for the patients with biliary tree pathology requires the accurate assessment of the lesion visualized. Aims & objectives: Comparison of sensitivity, specificity and diagnostic accuracy between the MRCP/MRI and USG in patients with pancreatic and hepato-biliary pathology and it’s related complications. Materials & methods: The study was a retrospective, single institutional study done during the last two years (January 2018 – December 2019) at IGIMS, Patna, Bihar (A tertiary care hospital). Data was collected from the departmental record for USG findings, medical record for history and PACS (Picture archiving and communicating system) for MRCP findings. Hundred patients were included in our study. All the data were entered in the MS Excel sheet and were expressed as percentage and variables as required. Vassarstats software was used for the data analysis. Results: Benign lesions were common in the age range of 46-60 years (23%), followed by 31-45 years. Most of the malignant lesions were detected in the age range of 31-45 years of age group (13%). USG detected and MRCP detected lesions were benign in 63% and 62% of the cases and malignant in 34% and 35% of the cases respectively. There were overlapping findings present in most of the cases. Pancreatitis, cholecystitis and choledochal cysts were usually associated with biliary tree calculi. Overall sensitivity, specificity and diagnostic accuracy of MRI with MRCP sequence (97%, 85% and 92.75%) is greater than that of USG (92%, 80% and 85.5%). Conclusion: MRCP combined with other MRI sequences was superior to the USG in identifying benign and malignant pathology. However, ultrasound remains the primary investigating modality of choice. However, with use of recent advances of USG like harmonic imaging there is significant improvement in the lesion characterization. MRCP is the modality of choice of imaging investigation for the characterization of the lesion especially in obese patients or to choose the patients who are ideal candidate for the MRCP. Keywords: Hepato-biliary-pancreatic pathology, MRCP

BACKGROUND:A creatinine-based estimation of the renal function lags behind the onset of disease process. Cystatin C is a new marker for acute kidney injury (AKI). However, data are limited in patients with acute-on-chronic liver failure (ACLF). We evaluated serum cystatin C as an early predictor of AKI in patients with ACLF.METHODS:In a prospective observational study, patients with ACLF and normal serum creatinine level were included in the study. Serum cystatin C was analyzed with the development of AKI and the disease outcome.RESULT:Forty-seven patients (mean age: 43.26±16.34 years; male:female: 2.35:1) were included in the study. AKI developed in 34% of patients during the hospital stay. Receiver operating characteristic (ROC) curve analysis revealed that the best cutoff for baseline cystatin C was 1.47 mg/L with a sensitivity of 0.94 and specificity of 0.68. The cystatin C ((area under the curve [AUC]=0.853) performance was better than that of the creatinine (AUC=0.699), Child-Turcotte-Pugh (CTP) (AUC=0.661), and model for end-stage liver disease-sodium (MELD-Na) (AUC=0.641). In the univariate analysis, age, platelet count, creatinine, estimated glomerular filtration rate (eGFR)-modification of diet in renal disease (MDRD), cystatin C, and estimated glomerular filtration rate-serum cystatin C (eGFRcysC) were significantly associated with AKI in ACLF patients. Cystatin C was an independent positive predictor of AKI. Cystatin C was positively correlated with the MELD-Na scores (r=0.374 and p=0.009).CONCLUSION:Our study supports previous studies reporting that serum cystatin C is a better predictor for AKI development compared to serum creatinine. Cystatin C may be used as an early marker for new-onset AKI in hospitalized patients with ACLF.

The displacement of spleen from its normal location to other places is known as wandering spleen (WS) and is a rare disease. The repeated torsion of WS is due to the presence of long pedicle and absence/laxity of anchoring ligaments. A WS is an extremely rare cause of left-sided portal hypertension (PHT) and severe gastric variceal bleeding. Left-sided PHT usually occurs as a result of splenic vein occlusion caused by splenic torsion, extrinsic compression of the splenic pedicle by enlarged spleen, and splenic vein thrombosis. There is a paucity of data on WS-related PHT, and these data are mostly in the form of case reports. In this review, we have analyzed the data of 20 reported cases of WS-related PHT. The mechanisms of pathogenesis, clinico-demographic profile, and clinical implications are described in this article. The majority of patients were diagnosed in the second to third decade of life (mean age: 26 years), with a strong female preponderance (M:F = 1:9). Eleven of the 20 WS patients with left-sided PHT presented with abdominal pain and mass. In 6 of the 11 patients, varices were detected incidentally on preoperative imaging studies or discovered intraoperatively. Therefore, pre-operative search for varices is required in patients with splenic torsion.

Hepatitis E virus (HEV) is an important cause of repeated waterborne outbreaks of acute hepatitis. Recently, several extrahepatic manifestations (EHMs) have been described in patients with HEV infection. Of these, neurological disorders are the most common EHM associated with HEV. The involvement of both the peripheral nervous system and central nervous system can occur together or in isolation. Patients can present with normal liver function tests, which can often be misleading for physicians. There is a paucity of data on HEV-related neurological manifestations; and these data are mostly described as case reports and case series. In this review, we analyzed data of 163 reported cases of HEV-related neurological disorders. The mechanisms of pathogenesis, clinico-demographic profile, and outcomes of the HEV-related neurological disorders are described in this article. Nerve root and plexus disorder were found to be the most commonly reported disease, followed by meningoencephalitis.

Renal failure is a common and severe complication of cirrhosis and confers poor prognosis. Serum creatinine is the most practical biomarker of renal function. Serum creatinine estimation in cirrhosis of the liver is affected by decreased formation, increased tubular secretion, increased volume of distribution, and interference by elevated bilirubin. Studies on the prognosis of cirrhotic patients using creatinine kinetics as a definition of acute kidney injury (AKI) proposed by the International Ascites Club are limited. In this single-center prospective observational study, decompensated cirrhotics with AKI defined by the International Ascites Club as the rise of serum creatinine ≥ 0.3 mg/dL within 48 h of admission or increase of serum creatinine ≥ 50% from stable baseline creatinine over the previous 3 months were followed and assessed for the development of complications during hospital course and in-hospital and 30-day mortality. AKI developed in 142 out of 499 (28.45%) patients with cirrhosis. Twenty patients were excluded. The most common etiology of cirrhosis was alcohol (n = 64, 52%), and ascites was present in 115 (94%) patients. Eighty-two (67.21%) patients presented with AKI at the time of admission. Thirty-day mortality was 46.72% (57/122 patients). Hepatorenal syndrome had the highest mortality followed by AKI related to infection. Presence of jaundice and hepatic encephalopathy (HE) was associated with poor survival with adjusted hazard ratio of 3.54 and 2.17, respectively. On bivariate logistic regression analysis, jaundice, HE, type of AKI, AKI stage at maximum creatinine, bilirubin, serum glutamic oxaloacetic transaminase (SGOT), international normalized ratio (INR), and Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were predictors of mortality (p < 0.05). Sensitivity, specificity, and accuracy of MELD > 29 and CTP score > 11 were 75.44%, 82%, and 78.70% and 66.67%, 81.54%, and 74.60%, respectively for predicting 30-day mortality. Development of AKI as defined by the International Ascites Club in cirrhosis confers high short-term mortality. Jaundice, HE, AKI stage, creatinine at enrollment, bilirubin, CTP, and MELD score were the predictors of mortality.

Primary hepatic tuberculosis (TB) is rare, and even in endemic regions primary hepatic TB consists of 0.5% of all forms of primary TB. Hepatic tuberculomas and biliary stricture formation can rarely mimic the radiological appearance of neoplasm. Gall-bladder cancer is endemic in the Gangetic belt of India. Here, we described a case of primary hepatic TB which was initially diagnosed as gall-bladder cancer in the presence of gall-bladder wall thickening and hepatic mass lesions. Diagnosis of hepatic TB was finally confirmed after fine needle aspiration cytology from hepatic mass which showed presence of necrotising granulomatous inflammation.

Acute esophageal variceal hemorrhage (AEVH) is one of the most deadly complications of portal hypertension and a leading cause of death in decompensated cirrhotic patients. In the last two to three decades, bleeding-related deaths have decreased from approximately 50% to 15 to 20% due to the standardization of supportive treatment, use of vasoactive drugs, and advances in endotherapy and interventional radiotherapy.[1]

Colonoscopy is a widely used procedure which requires prior cleansing of the bowel. Optimal bowel cleansing is essential for a successful and accurate examination of the bowel. Inadequate bowel cleansing during colonoscopy can result in missed lesions, difficult and incomplete procedures, prolonged cecal intubation time, and increased risk of procedural complications. The adequacy of bowel cleansing mainly depends on the type of cleansing agents, volume of preparation, mode of administration (single dose vs. split dose, single day vs. two days), use of adjunct agents, the preparation-to-colonoscopy interval, and associated comorbidities in patients.[1] [2] Other factors for adequate bowel cleansing may include low residue diet, liberal fluid intake, and proper bowel preparation instructions.

In Reply Drs Goodman and Valenti raise the important issue that social spending likely affects health outcomes, and we agree.While the somewhat lower-than-average investment in social spending in the United States may not be driving higher health care spending, it is likely a driver of worse health outcomes. 1 As their letter notes, although many poor individuals in the United States may have access to excellent health care, they cannot easily access food or safe housing, factors that have a profound effect on health.Given that the United States has a much higher poverty rate than many of the other countries we studied, its lower-than-average social spending is particularly problematic for population health.Instead of justifying social spending as a way to reduce health care spending, social spending should be invested in for the most important reason of all: it likely improves health and well-being.Dr Bazemore and colleagues raise important questions about our estimates of the proportion of physicians in the United States who are practicing primary care.They rightly note that our estimates rely on numbers taken from the Kaiser Family Foundation. 2 These estimates differ from other estimates such as those of the Bureau of Labor Statistics or the AAMC.Although each approach has its strengths and weaknesses, our primary motivation was to use an approach that mirrored closely how other countries count primary care physicians.Because the Bureau of Labor Statistics excludes all self-employed physicians or physicians who are owners or partners in unincorporated practices, it likely leaves out a substantial proportion of the US physician workforce. 3Data from the other countries do not have such exclusions.The AAMC estimates that 34.8% of total active physicians were in primary care in 2015. 4However, it appears that the AAMC categorizes physicians whose specialty is not listed (n=83 637) as "other specialties." 5If we remove these unclassified physicians, the AAMC's estimate of primary care physicians is 38.5%.The AAMC recently began excluding hospitalists from its primary care categories, a reasonable decision. 5However, we chose not to do the same for purposes of comparability between countries.If we had also excluded all hospitalists, our primary care proportion would have dropped to 39%, which is nearly identical to the AAMC estimates.Of course, we then would have had to identify numbers of physicians functioning as hospitalists in other countries and excluded them as well.Those numbers were not generally available.There is no gold standard for measuring primary care, and each country does it a bit differently.Our approach was to create the most comparable set of numbers to understand how the United States compares with other countries.While the specific numbers for any one nation can be debated, if we were to take a different approach for the United States, we would have to apply the same filters and exclusions for all the other countries.Whatever approach one takes, using the lens of comparable numbers across nations, there is little evidence that the United States is an outlier in its mix of primary care and specialist physicians.

In Reply Drs Goodman and Valenti raise the important issue that social spending likely affects health outcomes, and we agree.While the somewhat lower-than-average investment in social spending in the United States may not be driving higher health care spending, it is likely a driver of worse health outcomes. 1 As their letter notes, although many poor individuals in the United States may have access to excellent health care, they cannot easily access food or safe housing, factors that have a profound effect on health.Given that the United States has a much higher poverty rate than many of the other countries we studied, its lower-than-average social spending is particularly problematic for population health.Instead of justifying social spending as a way to reduce health care spending, social spending should be invested in for the most important reason of all: it likely improves health and well-being.Dr Bazemore and colleagues raise important questions about our estimates of the proportion of physicians in the United States who are practicing primary care.They rightly note that our estimates rely on numbers taken from the Kaiser Family Foundation. 2 These estimates differ from other estimates such as those of the Bureau of Labor Statistics or the AAMC.Although each approach has its strengths and weaknesses, our primary motivation was to use an approach that mirrored closely how other countries count primary care physicians.Because the Bureau of Labor Statistics excludes all self-employed physicians or physicians who are owners or partners in unincorporated practices, it likely leaves out a substantial proportion of the US physician workforce. 3Data from the other countries do not have such exclusions.The AAMC estimates that 34.8% of total active physicians were in primary care in 2015. 4However, it appears that the AAMC categorizes physicians whose specialty is not listed (n=83 637) as "other specialties." 5If we remove these unclassified physicians, the AAMC's estimate of primary care physicians is 38.5%.The AAMC recently began excluding hospitalists from its primary care categories, a reasonable decision. 5However, we chose not to do the same for purposes of comparability between countries.If we had also excluded all hospitalists, our primary care proportion would have dropped to 39%, which is nearly identical to the AAMC estimates.Of course, we then would have had to identify numbers of physicians functioning as hospitalists in other countries and excluded them as well.Those numbers were not generally available.There is no gold standard for measuring primary care, and each country does it a bit differently.Our approach was to create the most comparable set of numbers to understand how the United States compares with other countries.While the specific numbers for any one nation can be debated, if we were to take a different approach for the United States, we would have to apply the same filters and exclusions for all the other countries.Whatever approach one takes, using the lens of comparable numbers across nations, there is little evidence that the United States is an outlier in its mix of primary care and specialist physicians.

Dieulafoy's lesion (DL) is an aberrantly dilated (up to 3-mm in diameter) and tortuous submucosal artery that protrudes through the gastrointestinal mucosa.It is a rare and potentially serious cause of gastrointestinal bleeding.The difficulty in detecting these lesions remains a major challenge.Initial endoscopy may miss diagnosis in about one thirds of cases of DL.Bleeding from DL can be intermittent and may therefore be difficult to identify.Furthermore, the bleeding point can be very small, or the lesion may be covered by blood clot.Repeat endoscopy is often rewarding in diagnosis of DL.We describe three cases of gastrointestinal bleeding due to DL; two of them were diagnosed at repeat endoscopy.

AbstractIncreasing use of button battery (BB) in household products and toys is responsible for the growing incidence of button battery ingestion (BBI). The BBI may cause life‑threatening complications. We present a series of three cases of complicated BBI (lithium cell) with delayed presentation; one of them could not survive due to tracheoesophageal fistula and sepsis. Here, we highlight the importance of early endoscopic intervention and careful follow‑up in children with lithium battery ingestion.

To determine the efficacy and safety ultrasound-guided percutaneous catheter drainage (US-PCD) in management of various types of ruptured amebic liver abscess including free rupture (FR) with diffuse intraperitoneal fluid collections (DIFC).

Diagnosis of Trichuris trichiura infestations is usually based on identification of barrel-shaped ova in stool, but is frequently missed on stool microscopy. We describe the clinical profile of patients in whom Trichuris infection was incidentally diagnosed at colonoscopy. In a cross-sectional study, patients with colonoscopic diagnosis of trichuriasis were enrolled from the endoscopy unit in a tertiary care center. Blood and stool samples were collected from all those who were willing to participate and provide samples. Sixty-two patients participated, with mean (SD) age of 50.5 (13.6) years and male to female ratio of 40:22. Abdominal pain (61.2%) and/or altered bowel habits (32.2%) were the most common indication for colonoscopy. Most (66.6%) of the Trichuris were located in the cecum and ascending colon. Majority of the patients had live worms, either motile or adhering to the colonic mucosa. The number of worms was single or a few (<15) in 74.2% of patients. Out of 62 patients, 16 (25.8%) had relatively heavy load of parasites. Most patients had normal colonoscopic findings (80.6%). Periappendicular and/or cecal ulcerations/erosions were the most common (16.1%) abnormalities noted. Stool examination showed parasite ova only in four (6.4%) patients. In conclusion, colonoscopy was better than stool microscopy for the diagnosis of trichuriasis in our study.

There is a wide variation in the clinical presentation of chronic pancreatitis (CP) in the different parts of India. Data regarding the clinical profile of CP from eastern India are scarce. We describe the clinical and demographic profiles of patients with CP in eastern India. Consecutive patients were evaluated for the clinical presentation, etiology and complication of CP. One hundred and thirty-nine patients with CP (mean age 39.57±14.88 years; M/F 3.48:1) were included. Idiopathic CP (50.35%) was the most common etiology followed by alcohol (33.81%); 68.34% had calcific CP and 31.65% had noncalcific CP. The median duration of symptoms was 24 (1–240) months. Pain was the most common symptom, being present in 93.52% of the patients. Diabetes, steatorrhea and pseudocyst were present in 45.32%, 14.38% and 7.19% of the cases, respectively. Moderate to severe anemia was revealed in 16.53% of the patients. Benign biliary stricture was diagnosed in 19.42% of the cases (symptomatic in 6.47%). The common radiological findings were the following: pancreatic calculi (68.34%), dilated pancreatic duct (PD) (58.99%), parenchymal atrophy (25.89%) and PD stricture (23.74%). In our center, idiopathic CP followed by alcoholic CP was the most frequent form of CP. Tropical CP was distinctly uncommon.

A 55-year-old woman presented with recurrent abdominal pain, a lump in her abdomen, and vomiting.In the previous 10 years, she required multiple hospital admissions for pain.Examination revealed pallor and a lump (20 cm  15 cm) extending from left hypochondrium to left iliac region.Labs showed hemoglobin 7.8 g/dL, platelet count 5,100 cells/mm 3 , and serum protein/ albumin 6.7/3.4 g/dL; the rest of her blood parameters were normal.Ultrasound showed heterogeneous liver echo-texture, ascites, and massive splenomegaly.Esophagoduodenoscopy showed grade 2 esophageal varices.Ascetic fluid examination showed high serum ascites albumin gradient (SAAG).Etiological evaluation for chronic liver disease (CLD) was negative.Computed tomography (CT) showed a homogeneously enhanced, massively enlarged spleen in the left lower abdomen.The vascular pedicle was long, stretched, and appeared coiled (whirl sign), suggestive of torsion (Figure 1).Features of CLD with portal hypertension (PHT) were seen, including diffuse atrophy of liver parenchyma, dilated portal vein, prominent perigastric collaterals, and ascites.The patient showed symptomatic improvement with conservative treatment.