Challenges of Diagnosis: Periampullary Mass-Induced Obstructive Jaundice in a Young Woman.

Periampullary cancers, which include pancreatic adenocarcinoma, ampullary cancer, distal cholangiocarcinoma, and duodenal cancer, present diagnostic and management challenges due to their aggressive nature and nonspecific symptoms. We describe a case of a female patient, age 20, who had obstructive jaundice brought on by a periampullary tumor. Despite difficulties in diagnosis and treatment, including failed endoscopic retrograde cholangiopancreatography (ERCP), the patient underwent a successful pancreaticoduodenectomy (Whipple's resection), and subsequent immunohistochemistry revealed adenocarcinoma with a mixed immunophenotype expressing duodenal and pancreatic markers. This example emphasizes the significance of taking young patients' periampullary tumors into account, the difficulties in diagnosing them, and the possibility of effective surgical surgery throughout this age range.

Acute Necrotizing Pancreatitis Presenting as Gastrocolic Fistula: A Rare Occurrence.

Tissue necrosis and ischemia are hallmarks of acute necrotizing pancreatitis, which frequently results in fatal infections. In this case, we describe a man in his 40s who had diffuse pain in the abdomen, intractable vomiting, diarrhoea, and intermittent fever. His abdominal computed tomography revealed acute pancreatitis with peripancreatic fluid collection, gastric perforation, and fistula formation between the greater curvature of the stomach and transverse colon. His upper gastrointestinal (GI) endoscopy confirmed a gastrocolic fistula.

Post-Endoscopy Parotid Swelling: A Rare Complication.

Parotid gland swelling, or parotitis, typically associated with infectious causes, can uncommonly result from non-infectious factors such as mechanical trauma following endoscopic procedures. We present a case of a 46-year-old female with liver cirrhosis who developed right parotid swelling shortly after undergoing endoscopy for evaluation of gastrointestinal symptoms. The patient's clinical course, imaging findings, and successful resolution with conservative measures are detailed. The etiology of post-endoscopy parotid swelling is multifactorial, involving potential mechanisms such as mechanical trauma, salivary gland dysfunction, infection, ductal obstruction, or allergic reactions to medications. Diagnosing this rare complication requires a comprehensive clinical evaluation, including a detailed history, symptom assessment, and imaging studies such as ultrasound. Management involves a combination of symptomatic relief, identification, and treatment of the underlying cause, emphasizing the importance of early recognition to prevent complications. In our case, warm compression provided pain relief, and the swelling subsided without the need for medical or surgical intervention. Regular follow-up evaluations and imaging studies are crucial to assess treatment response and ensure the resolution of the swelling. This case contributes to the limited literature on post-endoscopy parotid swelling, emphasizing the significance of recognizing and managing this rare complication promptly. Healthcare professionals should be vigilant, and further research is encouraged to better understand its pathophysiology and optimize management strategies in order to improve patient outcomes.

An Uncommon Encounter: A Comprehensive Case Report of an Advanced Esophageal Neuroendocrine Carcinoma.

Esophageal neuroendocrine carcinomas (E-NECs) are rare malignant tumors with unknown etiology and pathogenesis. The aggressive nature of E-NECs coupled with a tendency to metastasize and no available treatment guidelines lead to poor prognosis. Here, we report a case of a 65-year-old, previously healthy female who presented with difficulty in swallowing solids, burning sensation over the epigastric region, weight loss (>10%), and altered bowel habits for the last three months. Contrast-enhanced CT (CECT) thorax revealed asymmetric mid-esophageal wall thickening with lymphadenopathy and metastasis in both hepatic lobes. Esophageal endoscopy revealed a large circumferential ulcero-proliferative mass and umbilicated lesions. A histopathological examination revealed small cells with scant cytoplasm and pleomorphic, hyperchromatic nuclei with prominent nuclear molding, and extensive necrosis. Immunohistochemistry revealed positivity for synaptophysin, chromogranin A, and CD56. Ki-67 index was 53%. These findings suggested poorly differentiated, small cell type, high-grade E-NEC. Chemotherapy with cisplatin (30mg/m2) + irinotecan (60mg/m2) was initiated. However, following two chemotherapy cycles, the patient succumbed.

Non-invasive assessment of liver fibrosis in alcoholic liver disease.

AIM OF THE STUDY: To assess the severity of fibrosis in patients with alcoholic liver disease (ALD) by a non-invasive method (transient elastography - TE). MATERIAL AND METHODS: A cross sectional study was conducted on 130 cases of ALD over a period of 2 years. Upper gastrointestinal (GI) endoscopy and transient elastography were done. Liver fibrosis was staged with the METAVIR system and severity of fibrosis was correlated with complications, duration of alcohol abuse, aspartate transaminase (AST) to platelet ratio index (APRI) and Child-Turcotte-Pugh (CTP) score. To establish the relationship between various parameters, Spearman's correlation coefficient (r) and their associated probability (p) were used. RESULTS: Distribution in 130 patients according to the METAVIR stage (median liver stiffness measurement [LSM]) was: F0: n = 16 (5.08 kPa); F1: n = 19 (6.6 kPa); F2: n = 9 (9.3 kPa); F3: n = 26 (16.3 kPa) and F4: n = 60 (50.5 kPa) (p < 0.0001). Liver stiffness measurement (LSM) score was significantly correlated with CTP score (r = 0.492, p < 0.0001), APRI (r = 0.435, p < 0.0001), duration of alcohol consumption (r = 0.816, p < 0.0001), presence of ascites (r = 0.756, p < 0.0001), presence of esophageal varices (r = 0.567, p < 0.0001), and presence of variceal bleeding (r = 0.383, p < 0.0001). CONCLUSIONS: TE is an inexpensive and non-invasive modality to assess the severity of liver fibrosis in ALD. It can be used as a good screening tool to identify patients with cirrhosis without the use of invasive liver biopsy, enabling better prognostication for the development of complications.

Non-invasive aspartate aminotransferase to platelet ratio index correlates well with invasive hepatic venous pressure gradient in cirrhosis.

BACKGROUND: Hepatic venous pressure gradient (HVPG) is the best recommended tool to measure portal pressure, but is invasive. HVPG helps in prognosticating cirrhosis and predict its complications. Aminotransferase to platelet ratio index (APRI) is a simple non-invasive marker of hepatic fibrosis. We aimed to correlate APRI with HVPG and to determine the usefulness of APRI in predicting complication of cirrhosis. METHODS: APRI and HVPG were measured in consecutive patients of cirrhosis aged 18 to 70 years. Spearman's rho was used to estimate their correlation; a cut-off value of APRI to predict severe portal hypertension (HVPG > 12 mmHg) was determined. RESULTS: This study, conducted between August 2011 and December 2014, included 277 patients, median age 51 (range: 16-90) years, 84% males. Etiology of cirrhosis was alcohol in 135 (49%), cryptogenic/nonalcoholic steatohepatitis (NASH) in 104 (38%), viral in 34 (12%), and others in 4 (1%). Median Child-Turcott-Pugh (CTP) and model for end-stage liver disease (MELD) scores were 7 (5-11) and 11 (6-33), respectively. Median HVPG was 17.0 (1.5-33) mmHg and median APRI was 1.09 (0.21-12.22). There was positive correlation between APRI and HVPG (Spearman's rho 0.450, p < 0.001). The area under the receiver operating characteristic (ROC) curve of APRI for predicting severe portal hypertension was 0.763 (p < 0.01). Youden's index defined the cut-off of APRI for predicting HVPG > 12 mmHg was 0.876 with a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 71%, 78%, 94%, 38%, and 73%, respectively. APRI also correlated well with CTP, variceal size, bleeding status, ascites but not with MELD. CONCLUSIONS: APRI score of 0.876 has an acceptable accuracy to predict severe portal hypertension (HVPG > 12 mmHg). High APRI also correlated with severity of cirrhosis and its complications. Thus, APRI may be used as a simple, bedside, non-invasive, and inexpensive tool for evaluating portal hypertension and complications of cirrhosis.

Dysphagia aortica: Emerging role of endoscopic ultrasound (with videos).

Dysphagia can occur due to extrinsic compression on esophagus. Dysphagia due to intrathoracic vascular causes is rare. Most reported cases of vascular etiology are due to dysphagia lusoria. Dysphagia due to any anomaly of aorta is called dysphagia aortica. In an emergency setting, endoscopic ultrasound (EUS) has been found to be superior and more sensitive for detection of abdominal aortic aneurysms over conventional radiological methods. We present a series of four cases of dysphagia aortica where the diagnosis was made by endoscopic ultrasound.

All ileo-cecal ulcers are not Crohn's: Changing perspectives of symptomatic ileocecal ulcers.

AIM: To investigated clinical, endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy. METHODS: Consecutive symptomatic patients undergoing colonoscopy, and diagnosed to have ulcerations in the ileocecal (I/C) region, were enrolled. Biopsy was obtained and their clinical presentation and outcome were recorded. RESULTS: Out of 1632 colonoscopies, 104 patients had ulcerations in the I/C region and were included in the study. Their median age was 44.5 years and 59% were males. The predominant presentation was lower GI bleed (55, 53%), pain abdomen ± diarrhea (36, 35%), fever (32, 31%), and diarrhea alone (9, 9%). On colonoscopy, terminal ileum was entered in 96 (92%) cases. The distribution of ulcers was as follows: Ileum alone 40% (38/96), cecum alone 33% (32/96), and both ileum plus cecum 27% (26/96). The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon. Based on clinical presentation and investigations, the etiology of ulcers was classified into infective causes (43%) and non-infective causes (57%). Fourteen patients (13%) were diagnosed to have Crohn's disease (CD). CONCLUSION: Non-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region. And if all infections are clubbed together then infection is the most common (> 40%) cause of ulcerations of the I/C region. Cecal involvement and fever are important clues to infective cause. On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers. So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn's.

Hemodynamic Response to Carvedilol is Maintained for Long Periods and Leads to Better Clinical Outcome in Cirrhosis: A Prospective Study.

BACKGROUND: Non-selective beta-blockers (NSBBs), e.g. propranolol, are recommended for prophylaxis of variceal bleeding in cirrhosis. Carvedilol, a newer NSBB with additional anti-α1-adrenergic activity, is superior to propranolol in reducing portal pressure. Repeated HVPG measurements are required to identify responders to NSBB. We aimed to determine whether a single-time HVPG measurement, using acute-hemodynamic-response-testing, is sufficient to predict long-term response to carvedilol, and whether these responders have better clinical outcome. METHODS: Consecutive patients with cirrhosis, aged 18-70 years, in whom NSBB was indicated for primary/secondary prophylaxis of variceal bleeding, and who underwent HVPG were included. Acute-hemodynamic-response was defined as a decrease in HVPG ≥10% from baseline or absolute HVPG value declining to <12 mm Hg, 1 h after 25 mg oral carvedilol. The aims of the study were to determine: the proportion of patients who achieved acute-hemodynamic-response to carvedilol; whether HVPG-response is maintained for 6 months; and clinical outcome of acute-responders to carvedilol therapy for 6 months. RESULTS: The study included 69 patients (median age 51, males 93%). Alcohol was the most common etiology; 59% patients belonged to Child-Pugh class B. NSBB was indicated for primary prophylaxis in 36% and secondary prophylaxis in 64% patients. According to the response criteria, 67% patients were found to be acute-hemodynamic-responders. At 6 months, 92% patients were found to be still maintaining their hemodynamic response to carvedilol. Using intention-to-treat analysis, 76% patients maintained their response. These acute responders, on chronic treatment with carvedilol during the 6-month period, had lesser episodes of variceal bleeding, better ascites control, and improved MELD and CTP scores, than non-carvedilol treated non-responders. However, survival remained similar in both the groups. CONCLUSIONS: A single-time HVPG measurement with acute-hemodynamic-response-testing is simple and reliable method for identifying patients who are more likely to respond to carvedilol therapy. The HVPG-response is maintained over a long period in majority of these patients and carvedilol therapy leads to better clinical outcome in these patients.

Endoscopic ultrasound in mediastinal tuberculosis.

BACKGROUND: Tubercular lymphadenitis is the commonest extra pulmonary manifestation in cervical and mediastinal locations. Normal characteristics of lymph nodes (LN) have been described on ultrasonography as well as by Endoscopic Ultrasound. Many ultrasonic features have been described for evaluation of mediastinal lymph nodes. The inter and intraobserver agreement of the endosonographic features have not been uniformly established. METHODS AND RESULTS: A total of 266 patients underwent endoscopic ultrasound guided fine needle aspiration and 134 cases were diagnosed as mediastinal tuberculosis. The endoscopic ultrasound location and features of these lymph nodes are described. CONCLUSION: Our series demonstrates the utility of endoscopic ultrasound guided fine needle aspiration as the investigation of choice for diagnosis of mediastinal tuberculosis and also describes various endoscopic ultrasound features of such nodes.

Imaging of pancreas divisum by linear-array endoscopic ultrasonography.

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. Endoscopic ultrasound (EUS) is often performed to evaluate idiopathic pancreatitis and has been shown to have high accuracy in diagnosis of PD. The different techniques to identify PD by linear EUS have been described differently by different authors. If EUS is done with a proper technique it can be a valuable tool in the diagnosis of PD. The anatomical and technical background of different signs has not been described so far. This article summarizes the different techniques of imaging of pancreatic duct in a suspected case of PD and gives a technical explanation of various signs. The common signs seen during evaluation of pancreatic duct in PD are stack sign of linear EUS, crossed duct sign on linear EUS, the dominant duct and ventral dorsal duct (VD) transition. Few other signs are described which include duct above duct, short ventral duct /absent ventral duct, separate opening of ducts with no communication, separate opening of ducts with filamentous communication, stacking of duct of Santorini and indirect signs like santorinecele. The principles of the sign have been explained on an anatomical basis and the techniques and the principles described in the review will be helpful in technical evaluation of PD during EUS.

Adrenal insufficiency predicts early mortality in patients with cirrhosis.

BACKGROUND: Adrenal insufficiency (AI), also known as hepato-adrenal syndrome, is a well-known entity in cirrhotic patients. However, factors associated with AI and its effect on survival are still not clear. We determined the prevalence of AI in patients with cirrhosis who had no hemodynamic instability or any acute deterioration, and studied its influence on short-term survival. PATIENTS AND METHODS: In consecutive cirrhotic patients, presence of AI was determined either by total serum cortisol <18 µg/dl, 60 minutes after 250 µg synacthen injection, or when the delta-fraction (post-synacthen serum cortisol minus basal serum cortisol) was <9 µg/dl. RESULTS: A total of 120 patients were included in the study (median age 50 years (range 27-73), males 87%). The median CTP and MELD scores were 10 (range 6-13) and 20 (range 6-40). The etiology of cirrhosis was alcohol (51%), cryptogenic (28%), viral (19%) and autoimmune (2%). Sixty-nine patients (58%) had AI and the remaining 51 (42%) had normal adrenal function. Serum bilirubin was significantly higher (p < 0.05) in the AI group, and total cholesterol, HDL, LDL and hemoglobin were significantly lower (p < 0.05) in the AI group. CTP score, MELD score, and basal cortisol levels were not different between those with and without AI (p = NS). By 120 days of follow-up, 41 patients had died. Thus, the 120-day survival was 66%, and this was higher in patients without AI than in patients with AI (78% vs 56%; p = 0.019). On multivariate analysis absence of AI, low WBC and low CTP score independently predicted 120-day survival. CONCLUSIONS: AI is present in more than half of cirrhotic patients but does not parallel the severity scores of cirrhosis. Its presence predicts early mortality in these patients, and this prediction is independent of CTP or MELD scores.

Unusual cause of massive upper gastrointestinal bleeding: a pancreatic arteriovenous malformation.

CONTEXT: Upper gastrointestinal bleeding is one of the most common emergencies in gastroenterology. The common causes of the upper gastrointestinal bleeding include peptic ulcer disease, gastric erosive mucosal disease and portal hypertension. Gastrointestinal arteriovenous malformation is a less common cause of gastrointestinal bleeding and these arteriovenous malformation are most commonly located in the large and small intestine. Pancreatic arteriovenous malformation is a rare condition in which there is tumor-like formation or vascular anomaly built up via an aberrant bypass anastomosis of the arterial and venous systems in the pancreas. Splenic artery is most commonly involved (42%), followed by gastroduodenal artery (22%) and small pancreatic arteries (25%). Clinically it may present as gastrointestinal hemorrhage which is occasionally fatal. Other presentations are abdominal pain, pancreatitis, duodenal ulcer, jaundice, and portal hypertension. CASE REPORT: We present a rare case of pancreatic arteriovenous malformation presenting as massive upper gastrointestinal bleeding. CONCLUSION: Since early surgery is a life saving treatment for such cases, hence, a high index of suspicion should be maintained especially when massive bleeding is detected from the medial wall of second part of duodenum.