Colonoscopy Findings of Uncomplicated Enteric Fever Mimicking Koch's Disease.

Enteric fever is a common occurrence in Southeast Asia with a myriad of presentations. Partial treatment often leads to prolonged illness. Along with this, bowel imaging often confounds the picture with tuberculosis. Colonoscopy and biopsy may help to differentiate from tuberculosis. The data on colonoscopy is scarce in enteric fever and is mostly available from case reports of gastrointestinal (GI) bleeding. We have described three cases of enteric fever with GI involvement mimicking tuberculosis. The colonoscopy picture is characteristic of pinkish-bluish ileal mucosa, with edema and decreased distensibility, along with multiple superficial ulcers. The ileocecal valve was involved in all three cases. The ascending colon was involved in two cases. There was complete resolution of lesions after treatment on follow-up. How to cite this article: Verma A, Dahale AS, Gopal P, et al. Colonoscopy Findings of Uncomplicated Enteric Fever Mimicking Koch's Disease. Euroasian J Hepato-Gastroenterol 2024;14(1):120-123.

Auto-immune pancreatitis with unusual presentations - A case series.

Auto-immune pancreatitis (AIP) is a rare benign disease commonly presented with painless obstructive jaundice and biliary obstruction with rare complications like pseudocyst. We present a case series of two patients of AIP with unusual presentations; one case presented with periorbital swelling, jaundice, and pseudocyst, and the other case presented with abdominal pain and biliary obstruction without jaundice; both showed good response with steroids.

Esophageal Lichen Planus Unusual Presentations: A Case Series.

Esophageal Lichen Planus (ELP)is a rare manifestation of Lichen Planus(LP). We present a case series of 2 patients with oral mucosal involvement who presented with dysphagia. On endoscopy, one patient revealed proximal esophageal stricture and the other patient had proximal esophageal ulcer. LP considered as a differential diagnosis in middle aged women with dysphagia.

Enhanced Liver Fibrosis Score: Is It Useful for Evaluation of Fibrosis Severity in Chronic Hepatitis C Infection?

INTRODUCTION: The assessment of liver fibrosis is important in patients with chronic hepatitis C (CHC). In recent years, non-invasive tests like enhanced liver fibrosis (ELF) have been developed as an alternative to liver biopsy for estimating the severity of liver fibrosis. Therefore, we aimed to assess whether the ELF score can be used for fibrosis severity estimation using liver biopsy as the gold standard. MATERIALS AND METHODS: Forty-nine patients with CHC were enrolled in this study. Liver biopsy, ELF assessment, and transient elastography (TE) were performed in all patients, and severity of fibrosis on histopathology was assessed by meta-analysis of histological data in viral hepatitis (METAVIR) score. In addition, the diagnostic performance of ELF was evaluated by receiver operator characteristic curve (ROC) analyses, and liver biopsy histopathology was taken as the gold standard for the severity of liver fibrosis. RESULTS: The area under receiver operator characteristic curve (AUROC) for significant fibrosis of ELF score was 0.64 (95% confidence interval {CI}, 0.48-0.79) and of TE was 0.85 (95% CI, 0.73-0.96). The AUROC for advance fibrosis of ELF was 0.77 (95% CI, 0.57-0.97) and TE was 0.98 (95% CI, 0.94-1.0). The calculated cut-offs of ELF overestimated fibrosis in 53.06% (26/49) of patients and underestimated fibrosis in 6.12% (3/49) patients. AUROC of TE was significantly better than ELF for diagnosis of significant fibrosis (p=0.004) and advanced fibrosis (p=0.034). CONCLUSION: The ELF score can be used for estimating the severity of fibrosis but it is inferior to TE in estimating liver fibrosis severity.

Endoscopic retrograde cholangiopancreaticography-related complications - Experience from tertiary care teaching centre over half a decade.

Introduction: Endoscopic retrograde cholangiopancreaticography (ERCP) is an essential therapeutic procedure with a significant risk of complications. Data regarding the complications and predictors of adverse outcomes such as mortality are scarce, especially from India and Asia. We aimed to look at the incidence and outcome of complications in ERCP patients. Materials and Methods: This study is a retrospective analysis of prospectively collected data of all the patients who underwent ERCP and had a complication from January 2012 to December 2018. Data were recorded in predesigned pro forma. The data analysis was done by appropriate statistical tests. Results: : A total of 17,163 ERCP were done. A total of 570 patients (3.3%) had complications; perforation (n = 275, 1.6%) was most common followed by pancreatitis (n = 177, 1.03%) and bleeding (n = 60, 0.35%). The majorities of perforations were managed conservatively (n = 205, 74.5%), and 53 (19%) required surgery. Overall, 69 (0.4%) patients died. Of these, 30 (10.9%) patients died with perforation. Age (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.005-1.07) and need of surgery (OR: 5.11, 95% CI: 1.66-15.77) were the predictors of mortality in patients with perforation. The majority pancreatitis were mild (n = 125, 70.6%) and overall mortality was 5.6% (n = 10). Conclusion: ERCP complications have been remained static over the years, with perforation and pancreatitis contributing the most. Most perforations can be managed conservatively with good clinical outcomes.

Reappraisal of the Role of Ascitic Fluid Adenosine Deaminase for the Diagnosis of Peritoneal Tuberculosis in Cirrhosis.

BACKGROUNDS/AIMS: Although peritoneal tuberculosis (TB) is one of the important differential diagnoses among cirrhotic patients with ascites, a peritoneal biopsy is not always available. High ascitic fluid adenosine deaminase (ADA) has been indicative of peritoneal TB. On the other hand, studies to assess its diagnostic utility based on the confirmation of peritoneal biopsy in cirrhotic patients are scarce. METHODS: Patients with new-onset ascites were enrolled prospectively from a tertiary hospital. Peritoneal biopsy was applied according to clinical judgment when required. Based on pathology diagnosis of the peritoneum, the diagnostic efficacy of ascitic fluid ADA for peritoneal TB was evaluated in total and cirrhotic patients, respectively. RESULTS: Among 286 patients enrolled, 78 were diagnosed with peritoneal TB. One hundred and thirty-two patients had cirrhosis, and 30 of those were diagnosed with peritoneal TB. The mean ADA was 72.2 U/L and 22.7 U/L in the peritoneal and non-peritoneal TB group, respectively, among the total study population, and 64.0 U/L and 19.1 U/L in the peritoneal and non-peritoneal TB group, respectively, among the subgroup with cirrhosis. The area under the curve for ADA to diagnose peritoneal TB was 0.96 in the total study population with a cutoff value of 41.1 U/L, and 0.93 in cirrhotic patients with a cutoff value of 39.9 U/L. CONCLUSIONS: The ascitic fluid ADA measurements showed high diagnostic performance for peritoneal tuberculosis in patients with ascites regardless of cirrhosis at a similar cutoff value.

Management of scope-induced type I duodenal perforations: Over-the-scope clip versus surgery.

BACKGROUND: Scope-induced duodenal perforation is a life-threatening complication and surgery remains the standard of care. With the advent of over-the-scope clip (OTSC), scope-induced perforations are increasingly managed conservatively, though there is no study comparing this form of non-surgical treatment with surgery. We aimed to compare OTSC and surgery in the management of scope-induced perforation of the duodenum. METHODS: We retrospectively collected data of scope-induced duodenal perforation patients. Perforations identified and treated within 24 h of procedure were analyzed. Factors analyzed were spectrum, etiology, baseline parameters, perforation size, outcome, comorbidities, and duration of hospital stay. RESULTS: A total of 25 patients had type I duodenal perforations, out of whom five were excluded due to delayed diagnosis and treatment. Of the twenty, eight were treated with OTSC placement while the rest underwent surgery. Age was comparable and the majority were females. Baseline parameters and comorbidities were similar in both the groups. The median size of perforation was 1.5 cm in both the OTSC group and the surgical group. All patients were treated with standard of care according to institutional protocols. Patients in the OTSC group were started orally after 48 h of OTSC placement, while in the surgery group median time to oral intake was 7 days. Two patients in the surgical group died while there was no mortality in the OTSC group (p = 0.48). Median hospital stay was shorter in the OTSC group (2 days vs. 22 days, p = 0.003). CONCLUSIONS: OTSC is a feasible and better option in type I duodenal perforations with a shorter hospital stay.

Cystatin C and interleukin-6 for prognosticating patients with acute decompensation of cirrhosis.

BACKGROUND AND AIM: Systemic inflammation and organ dysfunction/failure can complicate acute decompensation (AD) of cirrhosis with progression to acute-on-chronic liver failure (ACLF), leading to increased mortality. There are few studies on serum biomarkers predicting renal dysfunction (RD) or ACLF in AD. Serum cystatin C (CysC) and interleukin-6 (IL-6) were evaluated for predicting RD, ACLF, and mortality in AD patients. METHODS: Consecutive AD patients seen from January 2018 to June 2019 were included. IL-6 and CysC were measured in serum at the time of index presentation. Patients were followed for 90 days or until primary (development of RD) or secondary outcomes (development of ACLF or mortality). Multivariate analysis was performed to find whether CysC and IL-6 can independently predict primary and secondary outcomes. RESULTS: A total of 124 patients were screened; 88 patients were included. On follow up, 22 (27.3%) developed RD, 11 (11/57, 19.3%) developed ACLF, and 21 (24%) died. The CysC predicted RD (odds ratio [OR] 7.97, 95% confidence interval [CI] 2.70-23.53, P = 0.001) and ACLF (OR 5.486, 95% CI 1.456-20.6, P = 0.012) development. IL-6 was not an independent predictor of RD (P = 0.315), ACLF (P = 0.168), and mortality (P = 0.225). CONCLUSION: Serum CysC can predict the development of RD and ACLF in patients of cirrhosis with AD.

Role of linear endosonography in the diagnosis of biopsy-negative malignant esophageal strictures: Exploring the unexplored.

BACKGROUND AND AIM: Endoscopic biopsy is standard for the diagnosis of esophageal malignancy. However, few cases present with smooth stricture with repetitive negative biopsy results. We aimed to use linear endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) in the diagnosis of biopsy-negative suspected malignant esophageal strictures. METHODS: We retrospectively analyzed the data from August 2017 to December 2018 of biopsy-negative esophageal strictures. All adult patients with twice-negative biopsies and with smooth overlying esophageal mucosa on endoscopy were included. Clinical, epidemiological, endoscopic, imaging, and EUS findings were noted and analyzed. RESULTS: Eighteen patients underwent EUS for suspicion of malignant esophageal stricture. Seven were excluded as they were submucosal tumors. Eleven patients showed the presence of malignancy on EUS FNA samples. Nine were males. Computed tomography showed esophageal wall thickening in eight (16-38 mm) and esophageal mass in three patients. EUS showed loss of a normal five-layered wall structure of the esophagus in all patients. Fine-needle aspiration cytology demonstrated squamous cell carcinoma (n = 4), adenocarcinoma (n = 4), poorly differentiated carcinoma (n = 2), and neuroendocrine carcinoma (n = 1). There were no complications. CONCLUSION: EUS with FNA is effective and safe for the diagnosis of biopsy-negative malignant esophageal strictures.

Endoscopic cystogastrostomy versus surgical cystogastrostomy in the management of acute pancreatic pseudocysts.

Background: Studies comparing surgical versus endoscopic drainage of pseudocyst customarily include patients with both acute and chronic pseudocysts and the endoscopic modalities used for drainage are protean. We compared the outcomes following endoscopic cystogastrostomy (ECG) and surgical cystogastrostomy (SCG) in patients with acute pseudocyst. Methods: Seventy-three patients with acute pseudocyst requiring drainage from 2011 to 2014 were analysed (18 patients excluded: transpapillary drainage n = 15; cystojejunostomy n = 3). The remaining 55 patients were divided into two groups, ECG n = 35 and SCG n = 20, and their outcomes (technical success, successful drainage, complication rate and hospital stay) were compared. Results: The technical success (31/35 [89%] vs. 20/20 [100%] P = 0.28), complication rate (10/35 [28.6%] vs. 2/20 [10%]; P = 0.17) and median hospital stay (6.5 days [range 2-12] vs. 5 days [range 3-12]; P = 0.22) were comparable in both the groups, except successful drainage which was higher in surgical group (27/35 [78%] vs. 20/20 [100%] P = 0.04). The conversion rate to surgical procedure was 17%. The location of cyst towards tail of pancreas and presence of necrosis were the main causes of technical failure and failure of successful endoscopic drainage, respectively. Conclusion: Surgical drainage albeit remains the gold standard for management of pseudocyst drainage; endoscopic drainage should be considered a first-line treatment in patients with acute pseudocyst considering the reasonably good success rate.

Tissue Xpert® MTB/RIF Assay in Peritoneal Tuberculosis: To be (Done) or Not to be (Done).

Introduction Peritoneal tuberculosis (PTB) is a paucibacillary disease with poor mycobacterial yield in ascitic fluid. The Xpert® MTB/RIF assay (Gene Xpert) is a new tool for the diagnosis of tuberculosis (TB) and has not yet been studied on peritoneal tissue. The present study aimed to investigate the yield of the Xpert® MTB/RIF assay on peritoneal tissue obtained at peritoneoscopy. Methods This is a retrospective study and the data were collected from hospital records. The patients who underwent peritoneoscopy along with Xpert® MTB/RIF assay on peritoneal tissue were included in this study. Those with proven PTB were considered as cases while those with other diagnoses as controls. Using the reference standard of TB diagnosis, sensitivity, specificity, and accuracy of Xpert® MTB/RIF assay were calculated. Results Total of 36 patients was analyzed in this study: 28 as cases and eight as controls. Peritoneoscopy was carried out for diagnosis and biopsy. Histopathology in cases revealed caseating granulomas in 16 while 11 had non-caseating granulomas. Nine patients showed acid-fast bacillus positivity on peritoneal tissue. The most common finding on peritoneoscopy was tubercles with adhesions (n = 14, 50%), followed by tubercles only (n = 12, 42.9%). Xpert® MTB/RIF assay was positive in 17 (60.7%) patients with a sensitivity of 60.71%, specificity of 100%, and an accuracy of 69.44%. Two patients expressed rifampicin resistance. Conclusion Xpert® MTB/RIF assay on peritoneal tissue has fair sensitivity and excellent specificity. The multidrug resistance and the ability to provide results rapidly make it clinically useful.

Endoscopic Retrograde Cholangiopancreaticography in Children: A Single-center Experience From Northern India.

OBJECTIVE: To evaluate spectrum, efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) in pediatric population. METHODS: Retrospective case record review of pediatric patients (age ≤15 y) undergoing ERCP between January 2011 to June 2015 at a tertiary care referral hospital in New Delhi, India. The Indications for ERCP, cannulation success rate, procedure success rate and complications were recorded. RESULTS: The mean (SD) age of the participants were 11.5 (3) years. 164 ERCP procedures were done in 126 patients (67 males). All procedures were done under conscious sedation. The common indications for ERCP were choledocholithiasis (50, 30.5%), chronic calcific pancreatitis (38,23.2%), main pancreatic duct injury with leak (21,12.8%), and bile leak (12,7.3%). The cannulation success rate was 90.4% (114 out of 126), while procedural success rate was 86% (141 out of 164). Overall 8 complications were encountered; all were successfully managed conservatively. CONCLUSIONS: ERCP in children can be successfully performed at centers with such expertise.

Utility of cytomorphology in distinguishing solid pseudopapillary neoplasm of pancreas from pancreatic neuroendocrine tumor with emphasis on nuclear folds and nuclear grooves.

BACKGROUND: Pancreatic solid pseudopapillary tumor (SPN) and pancreatic neuroendocrine tumors (Pan-NET) have close resemblance on imaging and cytomorphology, though they differ in their prognosis and treatment strategy. SPNs are low-grade indolent tumors while Pan-NETs harbor malignant potential with propensity to metastasize. We aim to differentiate SPN from Pan-NET based on cyto-morphology; to classify nuclear membrane (NM) irregularities or nuclear folds into four grades and see whether they bear any difference with respect to the two entities. METHODS: Eighteen and ten confirmed cases of SPN and Pan-NET were included in the study. Smears were assessed for architecture, background changes, cellular, and nuclear features, which were compared between the two study groups. Nuclear folds were classified into four grades. Nuclear folds and nuclear grooves were also compared between the two groups. RESULTS: All SPN patients were females; mean age of 28 years. Pan-NET patients had equal male to female ratio; mean age of 46 years. Both SPN (78%) and Pan-NET (71%) showed predilection for pancreatic head. Mean size of lesion was 4.8 cm and 3.1 cm in SPN and Pan-NET groups. Papillary pattern, branching capillaries, degenerative background were significantly more prominent in SPN; sudden anisonucleosis and cytoplasmic granularity in Pan-NET. Metachromatic matrix, hyaline globules, and nuclear grooves were noted exclusively in SPNs. Nuclear fold grades 2 and 3 were more characteristic of SPN than Pan-NET (P = 0.041 and 0.002, respectively). CONCLUSIONS: Cytomorphology is vital in differentiating SPN from Pan-NET with nuclear folds being an important nuclear feature.

Esophageal tuberculosis: Uncommon of common.

BACKGROUND AND AIM: Esophageal involvement in tuberculosis (TB) is rare and is usually secondary. Data on esophageal TB are scarce. We aimed to analyze clinical and endoscopic features and outcomes of treatment in esophageal TB. METHODS: We retrospectively identified patients with esophageal TB from January 2014 to December 2016 at GB Pant Hospital. Well-defined granuloma with or without caseation and/or acid-fast bacilli on staining either from esophageal biopsy or the adjacent mediastinal lymph node fine-needle aspiration cytology (FNAC) specimen, along with clinical features and response to antitubercular therapy (ATT), were collectively considered to diagnose definite TB. Treatment received and response to therapy were documented and analyzed. RESULTS: A total of 19 patients had definite esophageal TB, and the median age of patients was 39 years (14-65 years) and 10 (52.6%) patients were female. The most common presenting symptom was dysphagia (n = 16, 84%) followed by odynophagia (n = 8, 42%). On endoscopy, the mid-esophagus was the most common site of involvement, and findings included ulcers (n = 17), elevated lesions (n = 9), and fistulae (n = 4) in patients. The mediastinal lymphadenopathy was present in all patients, with parenchymal lesions seen in three patients. The endoscopic mucosal biopsies were diagnostic in 11 patients, and in the remaining 8 patients, endoscopic ultrasound-guided FNAC from the mediastinal lymph nodes was diagnostic. A total of 18 patients completely responded to ATT, and 1 patient had partial response with persistent fistulae requiring additional treatment. CONCLUSION: Esophagus involvement is rare in TB; endoscopic mucosal biopsy and EUS-guided FNAC is diagnostic, and the response to ATT is excellent.