AIM:To determine long-term outcome of endoscopic management of pancreatic pseudocyst/walled-off pancreatic necrosis (WOPN) without necrosectomy.METHODS:One-hundred and sixty-five pancreatic pseudocysts/WOPN managed endoscopically over a period of 22 years were analyzed retrospectively for technical success, complications, and recurrence.RESULTS:Symptomatic 118 males and 47 females with mean age of 35.8 years were included. Alcohol was the most common etiology (41.2%). Transmural endoscopic drainage was done in 144 patients, while 21 patients underwent transpapillary drainage. All the patients were subjected to contrast computed tomography (CT) abdomen or routine/Doppler ultrasound. Endoscopic ultrasound was done in last 11 patients. One or two double pigtail 7 Fr stents were placed when clear watery fluid came out from cyst (130 patients, 78.8%), and nasocystic drainage (NCD) tubes were placed in addition to two 7 Fr stents when there were frank pus, thick dark fluid, or solid components inside the cyst (35 patients). All these patients settled on this treatment. Thirty-three of 35 patients of WOPN could be managed endoscopically without necrosectomy. Complications occurred in 9.2% of pseudocysts and 40% of WOPN. Thirty-five patients were followed up for more than 5 years (3 patients more than 10 years), and 130 patients were followed up for up to 5 years. Recurrence occurred in 8.1% of pseudocysts and 5.7% of WOPN.CONCLUSION:Majority of pancreatic pseudocysts/WOPN can be managed with endoscopic drainage without necrosectomy with high success, low complication, and recurrence rates.

A 30-years-old lady having lump in left upper abdomen for 10 years and now she presented with severe pain in same area with radiation to left shoulder for 1 week. Clinical examination revealed pallor, icterus, massive splenomegaly and a tender pulsatile lump of size 6×6 cm adjacent to spleen with a bruit. On investigations she was anemic with a hemoglobin of 8.7 g/dl (normal, 14–18 g/dl), total leukocyte count of 3800/mm3 (normal, 4000–10000/mm3), platelet count of 76000/mm3 (normal 1.5–4.5 lakhs/mm3), total bilirubin of 1.1 mg/dl (normal 0.3–1.2 mg/dl), alanine transaminase of 25 (0–40 IU/l), aspartate transaminase of 36 (0–50 IU/L), alkaline phosphatase of 125 (25–140 IU/L), albumin of 4.4 (3.5–5.0 g/dl) and globulin −2.8 (2.7–3.5 g/dl). Upper gastrointestinal endoscopy revealed small esophageal varices. Triple phase computerized tomography (CT) with angiography and magnetic resonance imaging with cholangiography (MRI with MRCP) was done as shown in Figure 1. What is your diagnosis?

Foreign body (FB) in the esophagus is a common emergency presentation in all age groups, especially in children. The immediate risk can range from a minimal one to a life-threatening scenario. Food impactions generally occur when there is altered anatomy (rings, webs or strictures) or motility disorders of the esophagus. The initial management approach includes a thorough history and physical examination followed by radiological investigations. Flexible endoscopy not only confirms the diagnosis but also is the therapeutic modality of choice for removing FBs and relieving the obstruction. This review aims to provide a comprehensive approach towards endoscopic management of esophageal FBs based on current literature and personal experience. The management problems associated with different types of FBs have also been highlighted.

Sir, We read with great interest the article “Celiac disease and chronic liver disease: Is there a relationship” published recently [1]. Association of celiac disease (CD) and chronic liver disease (CLD) has been well described [2, 3]. In this series, the mean age of patients was 28.8 years. Duration of symptoms of cirrhosis was relatively longer (83.7 months) as compared to natural history of cirrhosis and 12 % patients presented with splenomegaly [4]. Eighty percent had cryptogenic cirrhosis (CC) and most of the symptoms of CLD improved significantly on gluten-free diet (GFD). In India, noncirrhotic portal fibrosis (NCPF) is an important cause of portal hypertension (PHTN) seen in up to 18 % cases [5]. NCPF presents in the third and fourth decade and in 20 % to 30 % of cases the liver slowly undergoes parenchymal atrophy with subsequent decompensation [6, 7]. In a study of liver explants, which were initially thought to be having CC, NCPF was found to be an important cause of end-stage CLD considered for liver transplantation [8]. In a recent study, NCPF was found to be associated with CD in 12 % of cases [3]. Etiology of NCPF is largely not known; however, infection and immune mechanisms may play important roles, which have also been described in the pathogenesis of CD. We analyzed case records of CD and PHTN from January 2012 to December 2013 and nine patients were found to have both. Etiology of PHTN was EHPVO in two cases and CLD in seven cases (five cryptogenic, one hepatic venous outflow tract obstruction, and one Wilson’s disease). The mean (SD) duration of symptoms in five patients of cryptogenic cirrhosis was 77.2 months (34.1) before diagnosis, and three patients presented with massive splenomegaly. These results are similar to the series published in your journal. It may be possible that some of the cases of CC with CD, mainly those with long duration of symptoms, young age, large spleen, and responding to GFD, may actually be the cases of NCPF which needs to be studied in larger prospective studies with histology.

Squamous cell carcinomas of the base of the tongue are diagnosed often at advanced stages, especially in patients with a history of smoking and alcoholism. Metastasis of carcinoma of tongue has been described in liver, lung, bone, brain, skin, eye, soft tissue, skeletal muscle, and percutaneous endoscopic gastrostomy sites, other than cervical and axillary lymph nodes. Metastasis has also been reported after surgical treatment and radiotherapy. Obstructive jaundice in carcinoma tongue due to metastatic retroperitoneal lymph node has not been reported in literature. We report a case of obstructive jaundice due to retroperitoneal lymph node mass obstructing biliary system in a case of carcinoma base of tongue.

Background: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is done using EUS-FNA needle with an internal stylet by most of the endosonographers. There is no data to suggest that it improves the quality of cytology specimen, and it is tedious and time-consuming. Aim: To compare EUS-FNA specimens obtained with stylet and without stylet for adequacy of the specimen, amount of blood on the slide, number of passes and diagnostic yield. Materials and Methods: Patients undergoing EUS-FNA of solid lesions by one experienced endosonographer at an Indian tertiary center from October 2013 to July 2014 were included. Totally, 115 consecutive patients with 128 lesions were randomized to undergo EUS-FNA with or without stylet. Cytology slides were evaluated by a single pathologist blinded to FNA technique. Results: EUS-FNA was done with stylet in 66 lesions (Group 1) and without stylet in 62 lesions (Group 2). Site of lesion was lymph node in 67 (52.3%), pancreas in 43 (33.6%), liver in 8 (6.2%), gastrointestinal subepithelial lesion in 4 (3.1%) and others in 6 (4.9%). The average size of the lesion was 23.7 ± 14.8. When outcomes of two groups were compared, there was no statistically significant difference in adequacy of smears (P = 1.00), amount of blood on slides (P = 0.92), number of passes (P = 0.49) and diagnostic yield (P = 0.86). Conclusions: There was no significant difference in adequacy of the specimen, amount of blood on the slide, number of passes and diagnostic yield between with and without a stylet groups. The use of a stylet does not confer any advantage during EUS-FNA.