Richter supraumbilical hernia managed with invagination: a case report.

Introduction and importance: Richter's hernia is an incarceration of the anti-mesenteric border of a segment of bowel through an abdominal wall defect. It primarily affects elderly individuals but can occur at any age, with a slightly increased incidence in females. The increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter's hernias. Case presentation: A 40-year-old male with a history of laparoscopic cholecystectomy and kidney transplantation presented with a 4-day history of supraumbilical swelling and abdominal pain. The swelling was irreducible and accompanied by mild tenderness, and local signs of inflammation were exhibited. Intraoperatively, a 1.5 cm hernia defect was found, with the sac containing omentum and a portion of bowel segment for which invagination with serosal closure with the Mayo double-breasting technique was done. Clinical discussion: Richter's hernia presents with abdominal discomfort, bloating, nausea, and vomiting, with a notable feature being the delayed onset of symptoms due to its partial involvement of the bowel wall. Diagnosis can be achieved through a computed tomography (CT) scan or intraoperative exploration. Management of Richter hernia is contingent upon the patient's clinical condition, physical examination, and suspicion of strangulation. Conclusion: Diagnosis of Richter's hernia demands higher suspicion, particularly in patients with predisposing factors like a history of minimally invasive surgery. Prompt surgical intervention is crucial for reducing mortality and enhancing prognosis, with invagination alone being adequate if ischaemia is confined and mesh placement is unnecessary.

Comparing Feto-Maternal Outcomes in Pregnant Women With Normal and Abnormal Liver Function Tests: A Prospective Observational Study.

INTRODUCTION: Pregnant women with abnormal liver function tests (LFTs) require proper evaluation and timely management to reduce maternal and fetal morbidity and mortality. OBJECTIVE: The present study was done with the objective of determining feto-maternal outcomes in antenatal women with abnormal LFTs and comparing them with antenatal women having normal liver function. The prevalence and possible causes of derangements in LFT were also identified. METHOD: Pregnant women referred to an antenatal clinic for several reasons pertaining to abnormal liver functions, and those admitted to the labor room for delivery with abnormal LFTs were included in the study. The pregnant women with abnormal LFT were studied prospectively, and they were compared with pregnant women having normal LFT. The fetal and maternal outcomes were also noted. RESULTS:  The pregnant women attending the antenatal clinic with a history of pruritus, abdominal pain, jaundice, nausea/vomiting, hypertension ascites, etc. and delivered at our facility were evaluated. One hundred and eight women had abnormal LFT defined by criteria laid down in material and methods. Eighty-seven women with normal LFT were taken for comparison. In the abnormal LFT, the main cause was intrahepatic cholestasis of pregnancy (IHCP). There were 6 (5.5%) maternal deaths in this group and none in the normal LFTs. There were 6 (5.6%) fetal deaths and 4 (4.6%) in the other group (p-value=1). The prevalence of abnormal LFT was 9.11% throughout pregnancy. Increased bilirubin and alkaline phosphatase (ALP) were significantly correlated with maternal mortality, while gestational age at birth, presence of meconium, appearance, pulse, grimace, activity, and respiration (APGAR) score, maternal mortality, and raised alkaline phosphatase level were found to be significantly associated with fetal mortality. CONCLUSION: Patients with abnormal LFT were significantly associated with maternal morbidity and mortality. However, fetal outcomes in patients with abnormal and normal LFT were similar. Hyperbilirubinemia and raised alanine aminotransferase (ALT) were significant predictors of maternal mortality.

A Randomized Comparative Study of the Use of Individual Modality and Combination of Endoscopic Retrograde Cholangiopancreatography (ERCP) and Digital Single-Operator Cholangioscopy (DSOC) for Diagnosis of Indeterminate Biliary Strictures.

Background: To determine the superiority of the combination of endoscopic retrograde cholangiopancreatography (ERCP) and digital single-operator cholangioscopy (DSOC) in the same sitting over the individual modality alone in patients with indeterminate biliary strictures. Materials and Methods: A randomized study enrolled 60 adult patients with biliary strictures who were randomized into two groups: ERCP + DSOC and ERCP/DSOC. Histopathologic or cytologic assessment was performed in terms of benign, indeterminate, or malignant nature of the strictures. Procedural adverse events were documented. Accuracy in terms of sensitivity (Sn), specificity (Sp), and predictive value [positive (PPV) and negative (NPV)] were noted. Results: As per final diagnosis, in ERCP/DSOC group, there were 12 (40%) benign cases and 18 (60%) malignant cases, and in group ERCP + DSOC, there were 8 (26.67%) benign cases and 22 (73.33%) malignant cases. ERCP/DSOC labeled 16 (53.33%) patients as benign, 8 (26.67%) as malignant, and 6 (20%) as indeterminate, while ERCP + DSOC labeled 8 (26.67%) as benign, 17 (56.67%) as malignant, and 5 (16.67%) as indeterminate. The Sn, Sp, PPV, and NPV of ERCP/DSOC were 44.4%, 75%, 100%, and 56.25%, and for ERCP + DSOC was 77.27%, 62.50%, 100%, and 62.5%, respectively (P = 0.033). Side effects were statistically similar in both the groups (P > 0.05). Conclusion: To conclude, the combination of ERCP with DSOC is safe and effective with higher diagnostic sensitivity (77.27%) in comparison to standard ERCP or DSOC alone (44.4%) for the diagnosis of biliary strictures.

How well does peripheral blood neutrophil-to-lymphocyte ratio predict the severity and prognosis of hemorrhagic Stroke.

OBJECTIVE: We explored the blood neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker and its relation with mortality and Modified Rankin Scale (mRS) score at discharge and at 3 months following ICH and also compared NLR with intracerebral hemorrhage (ICH) score, Sequential Organ Failure Assessment (SOFA) score and National Institutes of Health Stroke Scale (NIHSS) score. METHODS: The investigators calculated the NIHSS score, SOFA score, ICH score and NLR of 90 adult patients within 3 days of onset of stroke with evidence of hemorrhagic stroke in brain imaging and correlated it with in-hospital mortality, 3-month mortality and mRS at 3 months following stroke using regression analysis. RESULTS: Out of 90 individuals, there were 54 (60%) males and 36 (40%) females. The mRS score at 3 months significantly related to the admission NLR ratio >7 and SOFA score. Similarly, the in-hospital death and 3-month mortality was related to the admission NLR ratio >7 and ICH score. However, at a cut off value of NLR>3 for assessing the prognosis of the patients, we did not get significant results for mRS at 3 months following stroke and for in-hospital and 3-month mortality. CONCLUSION: A high NLR ratio >7 predicted worse outcomes in terms of mortality and morbidity at 3-months following haemorrhagic stroke. Hence, like ICH score, NLR can predict 3-month mortality following an acute haemorrhagic stroke and can also predict morbidity following 3 months of brain haemorrhage.

Effect of the SARS-CoV-2 Pandemic on Gastrointestinal Endoscopy Procedures: Experience of a Tertiary Care Center From Eastern India.

Background To contain the spread of infection and reduce the burden on healthcare infrastructure, many countries globally adopted a lockdown strategy during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Hospitals were converted to dedicated coronavirus disease 2019 (COVID-19) centers, and non-COVID-19 patients were intervened on a triage basis. During this time, only emergency procedures were performed. The impact of this lockdown strategy during the first wave of the SARS-CoV-2 pandemic on various gastrointestinal endoscopy interventions remains unknown. Methodology In this retrospective, observational study conducted in the Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar from March 25 to September 30, 2020, data related to clinical profile, indication, and endoscopic interventions performed in reverse transcriptase-polymerase chain reaction (RT-PCR)-negative patients with the use of personal protective kits were analyzed and compared with the historical controls. Results A total of 2,282 patients were admitted and 422 endoscopic procedures were performed during the six-month study period with an intervention rate of 18.49%. The most common procedure was upper gastrointestinal endoscopy (228, 58.13%), followed by endoscopic retrograde cholangiopancreatography (ERCP) (88, 22.50%). Chronic liver disease (CLD) (144 patients) followed by malignancy (111 patients) were the most common diagnosis. During the first phase of the lockdown (March to May), only 52 procedures were performed (52 vs. 506). None of the patients underwent endoscopic ultrasound. In 2019, 4,501 patients were admitted and 1,224 procedures were performed with an intervention rate of 27.19 (p < 0.0001). None of the staff of the Department of Gastroenterology developed symptomatic SARS-CoV-2 infection during this period. Conclusions There was a significant drop in endoscopic procedures during the lockdown and most of the esophagoduodenoscopy procedures were done for CLD and ERCP for biliary tract malignancy. Endoscopic procedures done on RT-PCR for COVID-19-negative patients were safe using personal protective kits.

The Psychosocial Impact of COVID-19 on an Adult Indian Population.

BACKGROUND: Coronavirus disease (COVID-19) was a pandemic with many physical, psychological, and socioeconomic effects. COVID-19 caused a global increase in anxiety and depression because of its novelty, high infectivity, varied presentation, and unpredictable mortality. In the face of collapsing healthcare facilities, monetary setbacks, and loneliness because of lockdowns, people were anxious, and this was compounded by media sensationalism. We aimed to study the psychosocial impact of COVID-19 on the adult Indian population. METHODS: An online survey using SurveyMonkey was floated through WhatsApp messages in April 2020, using the 'chain-referral sampling' method. Responses from individuals >18 years were included, and questions included age, sex, occupation, demographics, and socioeconomic conditions. The prevalence of anxiety and depression was assessed using the Generalized Anxiety Disorder (GAD-7) and the Patient Health Questionnaire (PHQ-9) scales. Data was analyzed using IBM SPSS software, and predictors of anxiety and depression were assessed. RESULTS: A total of 2640 responses from individuals between 18 years and 81 years were analyzed, of which 39% were from females and 85% from those <50 years of age. There were students (15.6%), teachers (10.7%), healthcare workers (16.8%), homemakers (9%), and daily wage laborers (4.1%), among others. Nearly 80% lived in cities, 55% had salaried jobs, 37% were working from home, 22% were temporarily unemployed, 10% were feeling work stress, 11% had increased alcohol intake, and 7.5% saw an increase in domestic violence. The income of 50% was adversely affected. Nearly 50% of our respondents had some symptoms of anxiety, and 23% had significant anxiety (GAD ≥5). The presence of anxiety was significantly higher in females, younger adults, city dwellers, healthcare workers, unemployed people, individuals living away from home, those without fixed salaries, those with work stress, and in people whose incomes had been adversely affected by the pandemic. On logistic regression analysis, female sex, younger age, unemployment, lack of salaried jobs, work stress, being a healthcare worker, and media reports were independent predictors of anxiety. About 60% of our respondents had some symptoms of depression, with 26% having significant depression (PHQ-9 ≥5). The presence of depression was significantly higher in females, younger adults, city dwellers, unemployed people, individuals living away from home without fixed salaries, and people with work stress. On logistic regression analysis, younger age, female sex, unemployment, lack of salaried jobs, work stress, and media reports were independent predictors of depression. Among our respondents, 70% used the time during the lockdown to study, 77% caught up with their families, and 56% reconnected with hobbies. Nearly 88% of our respondents had adjusted to their changing circumstances, helped by their religious beliefs and faith, the support of family and friends, good government measures, and the assurance of healthcare. CONCLUSIONS:  Significant anxiety and depression were seen in 23% and 26% of respondents, respectively. Being a healthcare worker was an independent predictor of anxiety. Female sex, younger age, unemployment, work stress, and sensational media reports were independent predictors of both anxiety and depression.

Serum Gamma-Glutamyl Transpeptidase-to-Platelet Ratio as a Noninvasive Marker of Liver Fibrosis in Chronic Hepatitis B.

Background The gamma-glutamyl transpeptidase (GGT)-to-platelet ratio (GPR) is identified as a new model for the assessment of liver fibrosis in patients with chronic hepatitis B (CHB). We aimed to determine the diagnostic performance of GPR for the prediction of liver fibrosis in patients with CHB. Methods In an observational cohort study, patients with CHB were enrolled. The diagnostic performance of GPR was compared with transient elastography (TE), aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) scores for the prediction of liver fibrosis using liver histology as a gold standard. Results Forty-eight patients with CHB with a mean age of 33.42 ± 15.72 years were enrolled. Liver histology showed meta-analysis of histological data in viral hepatitis (METAVIR) stage F0, F1, F2, F3, and F4 fibrosis in 11, 12, 11, seven, and seven patients, respectively. The Spearman correlation of METAVIR fibrosis stage with APRI, FIB-4, GPR, and TE were 0.354, 0.402, 0.551, and 0.726, respectively (P value < 0.05). TE had the highest sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (80%, 83%, 83%, and 79%, respectively), followed by GPR (76%, 65%, 70%, and 71%, respectively) for predicting significant fibrosis (≥F2). However, TE had comparable sensitivity, specificity, PPV, and NPV with GPR (86%, 82%, 42%, and 93%, and 86%, 71%, 42%, and 92%, respectively) for predicting extensive fibrosis (≥F3). Conclusion The performance of GPR is comparable to TE in predicting significant and extensive liver fibrosis. GPR may be an acceptable, low-cost alternative for predicting compensated advanced chronic liver disease (cACLD) (F3-F4) in CHB patients.

Addition of Nitazoxanide to Standard Clarithromycin Based Triple Therapy for 2 Weeks Effectively Eradicates Treatment-Naive Helicobacter Pylori Infection. A Single Centre prospective, open-label study.

BACKGROUND: The increasing prevalence of antibiotic-resistant strains of Helicobacter pylori (H. pylori) led to reduced success with traditional H. pylori treatments. This warrants further evaluation of other treatment options. One such treatment regimen of interest is nitazoxanide containing regimen. In this study, we evaluated the efficacy of the addition of nitazoxanide to clarithromycin-based triple therapy in patients with H. pylori infection. METHODS: In this single-center prospective observational trial, patients with H. pylori infection were treated with a regimen comprising of nitazoxanide 1000 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and esomeprazole 80 mg per day (NACE regimen) for14 days. Eradication of H. pylori infection was assessed 4 weeks after completion of therapy by using stool antigen assay. Treatment compliance and adverse effects were also evaluated. RESULTS: Out of 111 patients who entered into the study for final analysis, H. pylori eradication was achieved in 93.7% (104 out of 111) patients in per-protocol analysis and 90.4% (104 out of 115) patients in intention to treat analysis. The treatment regimen was well tolerated. CONCLUSION: The addition of nitazoxanide to standard clarithromycin-based triple therapy effectively eradicates H. pylori infection. This regimen is safe and well tolerated.

Baseline serum cystatin C as a marker of acute kidney injury in patients with acute-on-chronic liver failure.

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.

Short-term mortality in patients with cirrhosis of the liver and acute kidney injury: A prospective observational study.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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. Bullet points of the study highlights What is already known? • Renal failure is a common and severe complication of cirrhosis. • Serum creatinine is the most practical biomarker of renal function but it has many limitations in cirrhotic patients. • Creatinine kinetics-based definition of acute kidney injury (AKI) was proposed by the International Ascites Club. What is new in this study? • Short-term mortality (30 days) in decompensated cirrhotic patients with AKI as defined by the International Ascites Club using creatinine kinetics was high. • AKI due to hepatorenal syndrome (HRS) has the highest short-term (30 days) mortality followed by AKI due to infection in decompensated cirrhosis. • Detection of AKI using creatinine kinetics-based definition may prompt an early appropriate intervention. What are the future clinical and research implications of study findings? • Creatinine kinetics-based definition of AKI diagnose renal injury at an earlier stage; an appropriate intervention should be initiated at the earliest in these patients to improve patient survival.

Quantification of node importance in rain gauge network: influence of temporal resolution and rain gauge density.

Rain gauge network is important for collecting rainfall information effectively and efficiently. Rain gauge networks have been studied for several decades from a range of hydrological perspectives, where rain gauges with unique or non-repeating information are considered as important. However, the problem of quantification of node importance and subsequent identification of the most important nodes in rain gauge networks have not yet been extensively addressed in the literature. In this study, we use the concept of the complex networks to evaluate the Indian Meteorological Department (IMD) monitored 692 rain gauge in the Ganga River Basin. We consider the complex network theory-based Degree Centrality (DC), Clustering Coefficient (CC) and Mutual Information (MI) as the parameters to quantify the rainfall variability associated with all the rain gauges in the network. Multiple rain gauge network scenario with varying rain gauge density (i.e. Network Size (NS) = 173, 344, 519, and 692) and Temporal Resolution (i.e. TR = 3 hours, 1 day, and 1 month) are introduced to study the effect of rain gauge density, gauge location and temporal resolution on the node importance quantification. Proxy validation of the methodology was done using a hydrological model. Our results indicate that the network density and temporal resolution strongly influence a node's importance in rain gauge network. In addition, we concluded that the degree centrality along with clustering coefficient is the preferred parameter than the mutual information for the node importance quantification. Furthermore, we observed that the network properties (spatial distribution, DC, Collapse Correlation Threshold (CCT), CC Range distributions) associated with TR = 3 hours and 1 day are comparable whereas TR = 1 month exhibit completely different trends. We also found that the rain gauges situated at high elevated areas are extremely important irrespective of the NS and TR. The encouraging results for the quantification of nodes importance in this study seem to indicate that the approach has the potential to be used in extreme rainfall forecasting, in studying changing rainfall patterns and in filling gaps in spatial data. The technique can be further helpful in the ground-based observation network design of a wide range of meteorological parameters with spatial correlation.

Evaluation of factors associated with complications in amoebic liver abscess in a predominantly toddy-drinking population: A retrospective study of 198 cases.

BACKGROUND AND AIM: Although the mortality rate has declined in recent years, amoebic liver abscesses (ALAs) still carry a substantial risk of morbidity. Studies regarding the indicators of severity, complication, or prognosis of ALA are limited in number and heterogeneous in methodology and results. METHODS: Clinicodemographic profile, therapeutic modalities, and outcomes of indoor ALA patients admitted between January 2016 and October 2017 were analyzed. An analysis of possible prognostic factors associated with complications and interventional therapy in patients with ALA was performed retrospectively. RESULTS: Data of 198 patients with ALA (mean age: 45 ± 12.1; M:F ratio: 193:5) were analyzed. The volume of abscess (503.1 ± 391.2: 300.2 ± 305.8 mL), elevated liver enzymes, and duration of hospital stay (11.98 ± 5.75): 10.23 ± 4.1 days) were significantly (P < 0.05) higher in alcoholic, compared to nonalcoholic, individuals. On univariate analysis, older age, duration of alcohol consumption, smoking, leukocytosis, hyperbilirubinemia, hypoalbuminemia, hyponatremia, and a larger volume of abscess were found to be significantly (P < 0.05) associated with complications. On multivariate analysis, older age, duration of alcohol consumption, smoking, leukocytosis, hyperbilirubinemia, hypoalbuminemia, and hyponatremia were found to be significantly (P < 0.05) associated with complications. Male gender, hypoalbuminemia, and larger volume of abscess were significantly (P < 0.05) associated with interventional treatment. CONCLUSION: Older age, leukocytosis, hyperbilirubinemia, hypoalbuminemia, hyponatremia, chronic alcoholism, and smoking are independent factors significantly associated with complications in patients with ALA. Hypoalbuminemia, larger volume of abscess, and male gender are independent variables associated with the requirement of interventional therapy.

Comparison of concomitant therapy versus standard triple-drug therapy for eradication of Helicobacter pylori infection: A prospective open-label randomized controlled trial.

INTRODUCTION: Resistance to commonly used antibiotics against Helicobacter pylori (H. pylori) is increasing rapidly leading to lower success of traditional triple therapy to eradicate H. pylori infection. So, search for a new regimen as the first-line therapy of H. pylori infection is needed. AIM: In this study, we compared the efficacy of 14-day concomitant therapy and 14-day triple therapy for the eradication of H. pylori infection. METHOD: In this open-labeled prospective trial, patients with H. pylori infection were randomized to concomitant therapy (pantoprazole 80 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and metronidazole 1000 mg daily in divided doses) and triple therapy (pantoprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily in divided doses). Duration of treatment was 14 days. Gastric biopsy was done 10-12 weeks after completion of therapy to confirm H. pylori eradication. RESULT: The eradication rate achieved with the concomitant therapy was significantly greater than that obtained with the triple therapy. Per-protocol eradication rates of concomitant and triple therapy were 77% and 58.3% (p = 0.028), respectively. Intention-to-treat eradication rates of concomitant and triple therapy were 70.1% and 49.3% (p = 0.013), respectively. Both the treatment regimens were well tolerated. CONCLUSION: Although the rate of eradication of H. pylori infection with  concomitant therapy was higher than that with triple therapy, the rate of concomitant therapy was still less than expected.

Optimal cut-off value of fecal calprotectin for the evaluation of ulcerative colitis: An unsolved issue?

INTRODUCTION: There is variability in the fecal calprotectin (FCP) cut-off level for the prediction of ulcerative colitis (UC) disease activity and differentiation from irritable bowel disease (IBS-D). The FCP cut-off levels vary from country to country. AIMS: We aimed to assess FCP as a marker of disease activity in patients with UC. We determined the optimal FCP cut-off value for differentiating UC and IBS-D. METHODS: In a prospective study, we enrolled 76 UC and 30 IBS-D patients. We studied the correlation of FCP with disease activity/extent as well as its role in differentiating UC from IBS-D. We also reviewed literature regarding the optimal FCP cut-off level for the prediction of disease activity and differentiation from IBS-D patients. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 158 µg/g) for the prediction of complete mucosal healing (using Mayo endoscopic subscore) were 90, 85, 94.7, and 73.3%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 425 µg/g) for the prediction of inactive disease (Mayo Score ≤ 2) were 94.3, 88.7, 86.2, and 95.4%, respectively. We also found a FCP cut-off value of 188 µg/g for the differentiation of UC from IBS-D. CONCLUSIONS: The study reveals the large quantitative differences in FCP cut-off levels in different study populations. This study demonstrates a wide variation in FCP cut-off levels in the initial diagnosis of UC as well as in follow-up post-treatment. Therefore, this test requires validation of the available test kits and finding of appropriate cut-off levels for different study populations.

Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial.

BACKGROUND: Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension. METHODS: Eighty-six consecutive patients with portal hypertension and AVB were randomized to receive either continuous intravenous infusion (Group A, n = 43) or intravenous boluses of terlipressin (Group B, n = 43). Group A received 1 mg intravenous bolus of terlipressin followed by a continuous infusion of 4 mg in 24 h. Group B received 2 mg intravenous bolus of terlipressin followed by 1 mg intravenous injection every 6 h. Upper gastrointestinal (UGI) endoscopy was done within 12 h of admission. Endoscopic variceal ligation (EVL) was done using a multi-band ligator. In both groups, treatment was continued up to 5 days. The primary endpoint was rebleeding or death within 5 days of admission. RESULTS: Patients in group A had lower rate of treatment failure (4.7%) as compared to patients in group B (20.7%) (p = 0.02). Within 6 weeks, four and eight patients died in group A and B, respectively (p = 0.21). Model for end-stage liver disease sodium (MELD-Na) score and continuous infusion of terlipressin showed significant relationship with treatment failure on multivariate analysis. CONCLUSIONS: Continuous infusion of terlipressin may be more effective than intermittent infusion to prevent treatment failure in patients with variceal bleeding. There is significant relationship between MELD-Na score [Odd ratio = 1.37 (95% CI-1.16 - 1.62), p-value < 0.001] and continuous infusion of terlipressin [Odd ratio = 0.18 (95% CI-0.037 - 0.91), p-value - 0.04] with treatment failure.

Post-endoscopic retrograde cholangiopancreatography pneumothorax: Report of two cases and literature review.

Pneumothorax is a very rare complication of endoscopic retrograde cholangiopancreatography. Here, we report two cases of pneumothorax following ERCP and sphincterotomy for choledocholithiasis. Patient was treated successfully with laprotomy and repair of a rent in the posterolateral wall of the second portion of duodenum. We also review the literature.

Effect of replenishment of vitamin D on survival in patients with decompensated liver cirrhosis: A prospective study.

AIM: To assess the vitamin D (VD) deficiency as a prognostic factor and effect of replenishment of VD on mortality in decompensated cirrhosis. METHODS: Patients with decompensated liver cirrhosis were screened for serum VD levels. A total of 101 VD deficient patients (< 20 ng/mL) were randomly enrolled in two groups: Treatment group (n = 51) and control group (n = 50). Treatment group received VD treatment in the form of intramuscular cholecalciferol 300000 IU as loading dose and 800 IU/d oral as maintenance dose along with 1000 mg oral calcium supplementation. The VD level, clinical parameters and survival of both the groups were compared for 6-mo. RESULTS: Prevalence of vitamin D deficiency (VDD) in decompensated CLD was 84.31%. The mean (SD) age of the patients in the treatment group (M:F: 40:11) and control group (M:F: 37:13) were 46.2 (± 14.93) years and 43.28 (± 12.53) years, respectively. Baseline mean (CI) VD (ng/mL) in control group and treatment group were 9.15 (8.35-9.94) and 9.65 (8.63-10.7), respectively. Mean (CI) serum VD level (ng/mL) at 6-mo in control group and treatment group were 9.02 (6.88-11.17) and 29 (23-35), respectively. Over the period of time the VD, calcium and phosphorus level was improved in treatment group compared to control group. There was non-significant trend seen in greater survival (69% vs 64%; P > 0.05) and longer survival (155 d vs 141 d; P > 0.05) in treatment group compared to control group. VD level had no significant association with mortality (P > 0.05). In multivariate analysis, treatment with VD supplement was found significantly (P < 0.05; adjusted hazard ratio: 0.48) associated with survival of the patients over 6-mo. CONCLUSION: VD deficiency is very common in patients of decompensated CLD. Replenishment of VD may improve survival in patients with decompensated liver cirrhosis.