Liver stiffness measurement (LSM) is a non-invasive surrogate for hepatic fibrosis that informs risk stratification and management. Vibration-controlled transient elastography (VCTE; FibroScan®) is well established. Endoscopic ultrasound–guided shear wave elastography (EUS-SWE) offers the potential to assess LSM during routine EUS; however, its diagnostic performance remains uncertain. In this prospective, single-center diagnostic accuracy study, consecutive adults without biliary obstruction who were undergoing EUS additionally underwent LSM measurement from the right hepatic lobe using EUS-SWE (Olympus ME3) and same-day VCTE. VCTE thresholds defined advanced chronic liver disease (ACLD; > 15 kPa), cirrhosis (> 12 kPa), and advanced fibrosis (> 8 kPa). EUS-SWE performance was evaluated using correlation, Bland–Altman agreement, and area under the receiver-operating characteristic curve (AUROC). Among 146 patients (median VCTE-LSM 6.05 kPa, range 3–53.3), 57, 41, and 31 had LSM ≥ 8, ≥ 12, and ≥ 15 kPa, respectively. EUS-SWE showed moderate correlation with VCTE (Spearman ρ = 0.65, p < 0.001) and reported higher values by 34.1

The present review highlights the role of computed tomography (CT), CT colonography (CTC), and magnetic resonance imaging (MRI) in the diagnosis, staging, response evaluation, and follow-up of colorectal cancer. For a CT scan, prior bowel preparation is required. This is done to enhance imaging of the colon with the use of oral or rectal contrast agents. Negative contrast like air or carbon dioxide are helpful in detecting polyps and masses by distending the colon. Virtual colonoscopy offers a lower-radiation alternative for polyp and cancer detection. Intravenous contrast administration with arterial and venous phase CT images is also important in complete staging of a known case of colon cancer and for evaluation of residual/recurrent disease. With respect to MRI, high-resolution T2-weighted images in multiple planes are important, with diffusion-weighted imaging (DWI) sequences being important for restaging. Intravenous contrast is not generally recommended. Contrast-enhanced CT and MRI are used for nodal and distant metastasis staging, with special attention to the pelvic side wall nodes. Positron emission tomography (PET) CT is to be considered for further evaluation if the findings are unclear and recurrence is suspected.

Aim and Objective Endoscopic ultrasound-guided liver biopsy (EUS-LB) is now increasingly being used across the globe as a method of liver tissue acquisition. This method is widely accepted by many professionals as it can overcome many shortcomings of percutaneous liver biopsy and transjugular liver biopsy. The aim of the study is to obtain the adequate and optimal biopsy rate associated with EUS-LB. Materials and Methods This is a retrospective observational study. Consecutive patients undergoing EUS-LB during the study period who were willing to consent were taken up for the study. Results Total 91 patients were taken up for the study. Median age of study population was 44 years out of which 39 patients were males and 52 were females (42.9 and 57.1%). Adequate biopsy rate (according to European Association for the Study of Liver Disease criteria) and optimal biopsy rate (according to American Association for the Study of Liver Diseases criteria) were 89 (81/91) and 60.4% (55/91), respectively. Rate of conclusive diagnosis was 95.6% (86/91). The commonest diagnosis encountered was nonalcoholic steatohepatitis) (23, 25.3%), followed by autoimmune hepatitis (17, 18.7%). Additional diagnostic information was obtained by endosonography during EUS-LB in 21 patients (23.1%). Gallstone disease was found in four (4.8%) patients, chronic calcific pancreatitis in two (1.9%) patients, significant abdominal lymphadenopathy defined as lymph node more than 1.5 cm in five (5.8%) patients, and esophageal or gastric varices in ten (10.6%) patients. One case of self-limiting biopsy site ooze was seen in EUS-LB and the patient was having cirrhosis. Conclusion This study showed a high diagnostic outcome and safety profile with EUS-LB technique. EUS-LB can achieve excellent histological yield when performed with optimal technique. Moreover, it is possible to obtain additional information during the procedure from diagnostic endosonography that is done as a part of EUS-LB.

Aims and Objective Mortality by gastric variceal bleeding can reach up to 30%. Gastric varices can be treated by either direct endoscopic glue or endoscopic ultrasound (EUS) coiling + glue injection. Now, enough data show that EUS coil + glue is an effective option for large varices. However, it is a costlier option than direct endoscopic glue injection. In our study, after putting the coil under EUS guidance, direct endoscopic glue injection is done with a 21G sclerotherapy needle. Since the EUS needle was not used for the glue injection, it can be reused for up to three cases for deployment of the EUS coil, hence reducing the cost of the whole procedure. In short, our study aims to find the safety and efficacy of a cost-effective method of EUS coiling + glue injection in a cohort of the Indian population. Material and Methods Retrospective review of prospectively collected data on EUS coiling + direct endoscopic glue injection over a period spanning from July 2017 to December 2023 from a tertiary care center in North India. Results A total of 103 patients (gastroesophageal varices type 2, GOV2 [ n = 82] and isolated gastric varices type 1, IGV1 [ n = 21]) were taken up for the study. Among the 103 patients, 74 patients were males and 29 were females. The mean follow-up duration of the study population was 34.2 +/- 21 months. The average size of the varix was 2.3 cm. The average number of coils was 3.3 and the volume of injected glue was 3.1 mL. In our study, 4 out of 103 patients had rebleeding, but the cause of rebleeding turned out to be nonvariceal. Regarding the intraprocedural and postprocedural adverse events, 1 out of 103 patients in our study experienced abdominal pain and fever, which responded to oral analgesics and antipyretics. There was no active bleeding from the puncture site or evidence of systemic embolization. Technical success was 100% in our study. Reuse of needles was not associated with any increment in risk of infection. Conclusion EUS coiling + direct endoscopic glue injection is a safe and effective endoscopic therapy for large gastric varices with sustainable long-term beneficial effects with a negligible amount of rebleeding. Direct endoscopic injection of glue following EUS coiling with a 21G sclerotherapy needle can significantly reduce the cost of the procedure without any risk of infection.

Aim and objective: The gold standard route for liver biopsy is percutaneous liver biopsy. Endoscopic ultrasound-guided liver biopsy (EUS-LB) is now increasingly being used across the globe as a method of liver tissue acquisition. This method is widely accepted by many professionals as it can overcome many shortcomings of percutaneous liver biopsy and transjugular liver biopsy. Aim of the study is to compare the EUS-LB and percutaneous liver biopsy in terms of adequate and optimal biopsy rate.

Background: Endoscopic submucosal dissection (ESD) is a technique for resecting superficial lesions of digestive tract. First developed for early gastric cancer now its use has expanded to remove lesions from esophagus, duodenum, colon and rectum. We present our experience of ESD done for various lesions from a tertiary center in Delhi.

Background: Hepatitis B virus (HBV) infection is a significant global public health issue, with nearly 887,000 deaths annually. Public awareness and knowledge about HBV play crucial roles in preventing its spread and ensuring timely diagnosis and treatment. This study aimed to assess the general public's knowledge and vaccination status regarding hepatitis B in India.Methods: An online cross-sectional survey was conducted among 3545 participants, excluding healthcare workers and subjects below 18 years of age. The survey assessed the respondents' knowledge of HBV in four domains: knowledge about the cause of the disease and its method of spread (Domain A), knowledge about which organ gets affected by HBV and what HBV can cause (Domain B), knowledge about treatment (Domain C), and knowledge about vaccination (Domain D). The survey was scored on a scale ranging from -20 to +22 points. The survey also inquired about the vaccination status of the respondents.Results: The mean knowledge score of the respondents was 6.89 (±5.88). Only 25% of respondents demonstrated good knowledge (score ≥12), while 31% had fair knowledge (score 6-11), 40% had poor knowledge (score 0-5), and 4% had incorrect knowledge (score <0). Males, individuals aged 18-60 years, respondents with higher education levels, and urban residents had significantly higher mean knowledge scores (p <0.01). In domain-specific analysis, 47% of respondents had good knowledge in Domain B, while 43% of respondents had good knowledge in Domains C and D, respectively. Only 17% of respondents had good knowledge in Domain A. Overall, 22.7% of respondents had received all three doses of the HBV vaccine, with higher vaccination rates among males, individuals aged 18-60 years, those with higher education levels, and urban residents.Conclusion: Our study revealed limited knowledge regarding hepatitis B among the general public in India. The HBV vaccination rates are also suboptimal in India. Public health interventions, such as educational campaigns and targeted vaccination programs, are needed to improve awareness and vaccination coverage, ultimately reducing the burden of HBV infection.Funding: This work did not receive any funding.Declaration of Interest: None of the authors declare any competing interest.Ethical Approval: Participants provided informed consent before responding to the survey. The institutional ethics committee approved the study.

Background and Aim: Prothrombin induced by vitamin K absence-II (PIVKA-II) is an emerging biomarker for hepatocellular carcinoma (HCC) diagnosis. However, the recommended cut-off of 40 mAU/ml may not be applicable to Indian patients. This study aims to determine the optimal cut-off value for PIVKA-II in the diagnosis of HCC. Methods: This ongoing prospective observational study started in May 2022 at the Institute of Liver, Gastroenterology & Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi. Cirrhotic patients aged 18 years and above, excluding those on warfarin or with creatinine clearance <30 ml/min, were included. PIVKA-II levels were measured in all patients, followed by a triphasic CT scan of the liver. The optimal cut-off value for PIVKA-II was calculated using the receiver operating characteristic (ROC) curve. Results: Between May 2022 and April 2023, 100 cirrhotic patients were enrolled (mean age 58±11 years, 78% males). The etiologies of cirrhosis were non-alcoholic steatohepatitis (NASH) in 41% of cases, alcohol in 33%, viral causes in 20%, and other causes in 6%. HCC was present in 34% of patients. PIVKA-II levels 40 mAU/ml were found in 91% of HCC patients and 73% of non-HCC patients, resulting in a sensitivity of 91% and specificity of 27%. The area under the ROC curve for PIVKA-II in diagnosing HCC was 0.752 (95% CI 0.652, 0.853), with an optimal cut-off of 180 mAU/ml. At this cut-off, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 79%, 67%, 55%, 86%, and 71%, respectively. The sensitivity and specificity at various other cut-off levels were inferior to 180. Conclusion: The standard cut-off of PIVKA-II (40 mAU/ml) for diagnosing HCC is not suitable for Indian patients. Our study determined a more appropriate cut-off of 180 mAU/ml, which requires further validation in prospective studies conducted in India.

lipid profile FIB 4 and BARD score also improved significantly in both the groups post 24 weeks of treatment and with no difference between the groups.Conclusion: Obeticholic acid has a comparable effect with Saroglitazar in reducing Fibrosis (LSM), ALT, AST and serum Triglyceride, while it has an edge over the Saroglitazar in reducing Steatosis (CAP) Also there were no-adverse effects in terms of derranged lipd profile with Obeticholic acid as reported in previous study.

BACKGROUND:Hepatitis B virus (HBV) is a considerable public health concern in India, characterized by a significant number of chronically infected individuals. India falls into the category of an intermediate HBV endemic country, with approximately 40 million people chronically infected. Public awareness and knowledge about HBV are crucial for prevention, diagnosis, and treatment. This study aimed to assess the knowledge and vaccination status of the general public regarding hepatitis B in India.METHODS:An online cross-sectional survey was conducted with 3,545 participants, excluding healthcare workers and individuals below 18 years old. The survey evaluated knowledge in four domains: cause and spread of the disease (Domain A), organ affected and consequences (Domain B), treatment (Domain C), and vaccination (Domain D). The survey used a scoring scale from -20 to +22 points. Vaccination status was also assessed.RESULTS:The mean knowledge score of the respondents was 6.89 (±5.88). Only 25% of the respondents demonstrated good knowledge (score ≥12), while 31% had fair knowledge (score 6-11), 40% had poor knowledge (score 0-5), and 4% had incorrect knowledge (score <0). Males, individuals aged 18-60 years, respondents with higher education levels, and urban residents had significantly higher mean knowledge scores (p < 0.01). In the domain-specific analysis, 47% of the respondents had good knowledge in Domain B, while 43% of the respondents had good knowledge in Domains C and D. Only 17% of the respondents had good knowledge in Domain A. Overall, 22.7% of the respondents had received all three doses of the HBV vaccine, with higher vaccination rates among males, individuals aged 18-60 years, those with higher education levels, and urban residents.CONCLUSION:The study revealed limited knowledge about HBV among the general public in India. Vaccination rates were also suboptimal. Public health interventions, including educational campaigns and targeted vaccination programs, are needed to improve awareness and vaccination coverage, ultimately reducing the burden of HBV infection.

Background and Aim: Acute on chronic liver failure (ACLF) is a syndrome with high mortality and has few treatment options. Challenges of doing liver transplant are sick patient condition and scarcity of donor. This study aims to investigate the potential benefit of plasmapheresis in ACLF patients without transplant. Methods: This prospective study was conducted at Sir Ganga Ram Hospital. We enrolled 72 patients with ACLF (EASL CLIF criteria). In patients with no improvement in ACLF grade or MELD (after 72 hours), were evaluated for PLEX (plasma exchange) (including alcohol hepatitis patients not eligible for steroid therapy or Lille score > 0.45 after 7 days) (Group A) and rest were continued on SMT (Group B). Low volume PLEX done on alternate days as per clinical response. Results: In our study 9(40.9 %) patients underwent 2 sessions of plasmapheresis followed by 3 sessions in (27.3 %),4 in (22.7%), 1(4.5%) 5(4.5%). In PLEX (n=22) group 12 (54.5 %) patients were discharged compared to 17 (34.0%) in the SMT (n=50) group (p=0.257). 30 days survival in the PLEX group was (n=16/81.25%) compared to (n=29/68.9%) (p=.321) in SMT. 90 days survival in the PLEX group was (n=13 / 38.46%) compared to (n=20 /60%) (p=0.99) in SMT group. In PLEX group (n=12 /54.5 %) patients discharged had significant decrease in MELD Na (35.46 +/- 4.63) as compared to pre PLEX MELD (32.15 +/- 5.47) (p=.004). No PLEX related severe adverse effect seen. Conclusion: In our study patients undergoing PLEX had increased hospital survival by 20 % and increase in 30 days survival by 10 % as compared to SMT group. However these values were not statistically significant due to small sample size. Hence PLEX may be a viable therapy in patients awaiting transplant by increasing short term survival. Further randomized control trials are needed to obtain robust conclusions.

Liver stiffness measurement using transient elastography (TE-LSM) is a promising noninvasive alternative to hepatic venous pressure gradient (HVPG) for diagnosing clinically significant portal hypertension (CSPH). However, previous studies have yielded conflicting results. We evaluated the correlation between TE-LSM and HVPG and the performance of TE-LSM in diagnosing CSPH (HVPG ≥ 10 mmHg). We conducted a systematic review and meta-analysis by searching PubMed and Scopus databases for relevant literature evaluating the clinical usefulness of TE for diagnosing CSPH in patients with chronic liver disease. Twenty-six studies (4337 patients with valid TE and HVPG) met our inclusion criteria. The median correlation coefficient of TE with HVPG was 0.70 (range 0.36–0.86). The weighted mean of optimal cut-off of liver stiffness value for diagnosing CSPH was 22.8 kPa (95% CI 22.7–23.0 kPa). The summary sensitivity and specificity were 79% (95% CI 74–84%) and 88% (95% CI 84–91%), respectively. The area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.91 (95% CI 0.88–0.93) according to the bivariate model. One limitation of the study was significant heterogeneity in the results of summary sensitivity and specificity (I2 83 and 74%, respectively). The heterogeneity could be explained by the variable liver stiffness cut-offs used in studies. The meta-regression plot revealed that as the optimal cut-off increased, the sensitivity decreased, the specificity increased, and vice versa. Liver stiffness measurement using TE correlates well with HVPG, and a liver stiffness cut-off value of 22.8 kPa shows a high accuracy for diagnosing CSPH. Thus, use of TE should be integrated into clinical practice for noninvasive diagnosis of CSPH.

Helicobacter pylori (H. pylori) is implicated in the pathogenesis of functional dyspepsia (FD). There is conflicting data regarding the benefit of H. pylori eradication for symptom relief in FD. To study the benefit of eradicating H. pylori in patients with FD as compared to standard medical treatment (SMT). Secondary aims were to find efficacy of H. pylori eradication therapy, recurrence of H. pylori after eradication, and predictors of efficacy. Consecutive adult patients of FD (ROME IV) with H. pylori infection presenting in the outpatient department of our hospital were enrolled. Patients with Global Overall Symptom (GOS) scale > 2 and H. pylori infection were included. Patients were randomized into two groups: group 1 received H. pylori eradication therapy and group 2 received SMT. Treatment success was defined as symptom relief (GOS score < 2 and reduction by at least 2 points at 6 months) and H. pylori eradication was defined as stool antigen negative at 4 weeks. Of 329 participants with FD, 253 were H. pylori positive (rapid urease test and stool antigen test) (76.89%). After exclusions, 202 were randomized into two groups of 101 each. Thirty-two patients in group 1 and 31 in group 2 had treatment success (31.7% vs. 30.7%, p=1.000). The efficacy of H. pylori eradication therapy was 74.46% (70/94). H. pylori reinfection rate was 26.02% (19/73). H. pylori eradication therapy does not provide additional benefit in symptom relief in patients with FD as compared with SMT. NCT04697641 (retrospectively registered on www.clinicaltrials.gov in January 2021)

Introduction With the advancements in diagnostic and therapeutic upper gastrointestinal endoscopy (UGIE), clear mucosal visualization is essential to ensure optimal outcomes. Though routinely followed in Japan and Korea, pre-endoscopic preparation is seldom used in India. We evaluated the efficacy of a pre-endoscopic drink of N-acetylcysteine (NAC) and simethicone in improving mucosal visibility during UGIE. Patients and Methods This study was a retrospective, investigator blind study with a case–control study design. Cases included patients who received a pre-endoscopy drink of NAC and simethicone in 100 mL water administered 10 to 30 minutes prior to UGIE. Controls only had mandatory fasting for 6 to 8 hours prior to UGIE. Propensity score matching was done to ensure comparability between the groups. Digital images were taken at six standard landmarks during UGIE and stored. A blinded investigator subsequently analyzed the images and rated the mucosal visibility on a 3-point scale. The difference in the mean mucosal visibility between the cases and controls was compared. Results Mean mucosal visibility during UGIE was significantly better using NAC with simethicone as compared with no preparation at esophagus (1.14 [0.37] vs. 1.47 [0.62], p < 0.05), gastric fundus (1.10 [0.30] vs. 1.55 [0.64], p < 0.05), gastric body (1.22 [0.50] vs. 1.62 [0.73], p < 0.05), gastric antrum (1.13 [0.37] vs. 1.47 [0.62], p < 0.05), and duodenal bulb (1.13 [0.34] vs. 1.33 [0.56], p < 0.05). In distal duodenum, though visibility improved with NAC with simethicone, the difference was insignificant. There were no adverse events related to the pre-endoscopy drink. Conclusion A pre-endoscopy drink of NAC with simethicone can significantly improve mucosal visibility during UGIE. It is safe, cheap, easily available and maybe considered for routine utilization for ensuring optimal endoscopic outcomes.

Objectives: To report the diagnostic yield and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) for the evaluation of proximal bile duct lesions. Materials and methods: A retrospective analysis of data of the patients, who had undergone EUS for proximal bile duct lesions was done. FNA was performed from either the bile duct mass, enlarged node, or liver lesions. Outcome measures were the diagnostic yield of EUS FNA and adverse events. Results: From April 2011 to August 2018, 147 patients with suspected proximal bile duct malignancy underwent EUS. Mass lesion was seen in 133 (90.47%) patients. FNA was performed in 125 (85.03%) patients. The final diagnosis in patients undergoing EUS FNA was malignancy in 118, benign disease in six, and one patient was lost to follow up. EUS FNA confirmed the diagnosis in 103/118 patients with malignancy (sensitivity 87.28%); was false negative in 15/118 cases with malignancy, and was truly negative in all the six patients with benign disease (specificity 100%). Positive predictive value, negative predictive value, and the accuracy of EUS FNA were 100%, 28.57%, 87.90% respectively. No serious adverse event was reported, five patients had self-limiting pain. Conclusion: EUS FNA is a sensitive tool for the evaluation of proximal bile duct lesions. Low negative predictive value warrants further evaluation in patients with non-malignant findings on cytology.

Background and Aim: There is little information on the outcome of treatment of decompensated autoimmune liver disease (DAILD) with immunosuppressive therapy. Liver transplantation may be the only curative option as these patients are at higher risk of adverse effects. We report our experience of outcome of treatment of DAILD with steroids and azathioprine. Methods: Patients with DAILD admitted in Sir Ganga Ram Hospital since January 2011 was enrolled. DAILD was diagnosed by simplified score for autoimmune liver diseases. Comprehensive serological markers and TJLB was done in all patients. Patients with HCC and those not consenting were excluded. All patients received prednisolone (30 mg/day tapered to 10 mg/day) with or without azathioprine (50 mg/day). On follow up, response was defined as reduction in CTP score of 2. Results: 37 patients (20 females), mean age 51.9 (21 - 73) with median CTP score 9 (range, 7-12) were included. 24 patients had treatment response (15 patients from Child B to A, 3 each from C to B and C to A) after a median follow up of 49 months (1-129). Five patients met the criteria of recompensation Resolution of ascites in 21 & regression of varices in 3. 13 patients died from which 8 died because of progressive liver failure. Adverse events were noted as diabetes (n=8), sepsis (n=8) and gastrointestinal bleed (n=1). Azathiopurine was stopped in 9 patients due to cytopenia. After managing adverse events treatment was restarted or modified in all. Conclusion: In our study patients with DAILD had a transplant free survival in 24/37 (64.2%) of patients over a median follow up of 49(24-129) months. 5 patients met recompensation criteria. careful patient selection TJLB and active monitoring of side effects is needed in these patients. Sepsis, diabetes and cytopenia were seen & drugs could be restarted or modified in all patients.