Deepu David

Multiple genetic risk factors for Crohn’s disease (CD) have been identified. However, these observations are not consistent across different populations. The protein tyrosine phosphate non-receptor type 2 (PTPN2) gene plays a role in various aspects of host defense including epithelial barrier function, autophagy, and innate and adaptive immune response. Two common polymorphisms in the PTPN2 gene (rs2542151 and rs7234029) have been associated with risk of CD in Western countries. To evaluate the association of PTPN2 gene polymorphisms with risk of CD in Indian population. We conducted a prospective case-control study. Patients with CD were recruited, and their clinical and investigation details were noted. Controls were patients without organic gastrointestinal disease or other comorbid illnesses. Two common polymorphisms in the PTPN2 gene (rs2542151 and rs7234029) were assessed. DNA was extracted from peripheral blood samples of cases and controls and target DNA was amplified using specific sets of primers. The amplified fragments were digested with restriction enzymes and the presence of polymorphism was detected by restriction fragment length polymorphism. The frequency of alleles was determined. The frequencies of genotypes and alleles were compared between cases and controls to look for significant differences. A total of 108 patients with CD (mean age 37.5 ± 12.7 years, females 42.6%) and 100 controls (mean age 39.9 ± 13.5 years, females 37%) were recruited. For the single nucleotide polymorphism (SNP) rs7234029, the overall frequency of G variant genotype (AG or GG) was noted to be significantly lower in the cases compared to controls (35.2% vs 50%, P = 0.05). For the SNP rs2542151, the overall frequency of G variant genotype (GT or GG) was noted to be similar in cases compared to controls (43.6% vs 47%, P = 0.73). There were no significant differences in minor allele (G) frequency for both polymorphisms between the cases and controls. Both the SNPs had no significant association with age of onset of illness, gender, disease location, disease behaviour, perianal disease, or extraintestinal manifestations of CD. Unlike observation form the West, polymorphisms in the PTPN2 gene (rs7234029 and rs2542151) are not associated with an increased risk of developing CD in Indian patients.

Background: Chronic pancreatitis develops in a subgroup of patients with recurrent acute pancreatitis. Detection of chronicity helps prognostication and formulation of management plan. Endoscopic ultrasonography (EUS) may detect early stages of chronic pancreatitis and hence serve as a useful diagnostic tool. Aim: To assess the frequency of chronic pancreatitis in patients with idiopathic recurrent acute pancreatitis (IRAP) using EUS. Methods: Patients with diagnosis of IRAP over a ten year period were retrospectively included. The clinical and investigation details were recorded on a structured proforma. Details of findings on EUS were recorded and proportion of patients with chronic pancreatitis was estimated. Presence of calcification and eight other parenchymal/ductal features were assessed during EUS. Presence of calcification or five of the other eight features were required for the diagnosis of chronic pancreatitis. Results: 154 patients with IRAP were included in the study. Their mean age was 31.2 + 12.5years and 77.9% were male. Thirtyeight (24.7%) patients had definitive features of chronic pancreatitis on EUS. Another 54 (35.1%) patients with 3 or 4 criteria present were considered to have intermediate probability of chronic pancreatitis. Calcification was present in 19 patients which was not detected on transabdominal imaging (ultrasound or CT). Twenty-two patients had diabetes mellitus. Conclusion: EUS detected features of chronic pancreatitis in a quarter of patients with IRAP. Hence EUS may play an important role in management of these patients.

The aim of the study was to analyze the prevalence of risk factors for non-alcoholic fatty liver disease (NAFLD) in patients with non-B non-C hepatocellular carcinoma (HCC).

Introduction Identification of pancreatic exocrine insufficiency (PEI) is important in the management of chronic pancreatitis. The 72-h stool for fecal fat estimation (FFE) has long been considered a gold standard indirect test for the diagnosis of PEI. However, the test is cumbersome for both patients and laboratory personnel alike. In this study, we aimed to assess fecal elastase 1 (FE1) as an alternate to FFE for the diagnosis of PEI. Methods In all, 87 consecutive patients diagnosed with chronic pancreatitis were included in this study. FFE and FE1 estimation was done for all the patients. For FE1, two cutoffs (<100 and <200 μg) were selected to define pancreatic exocrine insufficiency. The sensitivity, specificity, and positive and negative predictive values for the two cutoffs were estimated. Kappa statistics was used to assess degree of agreement between both tests. Results All patients completed the study and were included in the analysis. The sensitivity, specificity, and positive and negative predictive value and PABAK (prevalence and bias adjusted kappa) for FE1 <100 μg was 84.9, 47.6, 83.6, 50, and 0.52, respectively. For FE1 <200 μg, it was 90.9, 9.5, 75.95, 25, and 0.43, respectively. Conclusion FE1 is a sensitive test; however, it does not have a good agreement with FFE. FE1 may be used as screening test for PEI in patients with chronic pancreatitis.

The primary aim of this study was to assess the usefulness of plasma hydrogen sulphide (H₂S) level at admission as a predictor of severity of acute pancreatitis. The secondary aims were to examine whether the level of H₂S after 48 h correlated with severity and whether level of H₂S correlated with pulmonary, renal or infectious complications. Plasma hydrogen sulphide was measured within 24 h of admission and 48 h later, in patients with acute pancreatitis. Patients were classified as having mild or severe pancreatitis, and H₂S levels in the two groups were compared. A total of 55 patients had H₂S estimation carried out within 24 h of admission. H₂S levels were similar in patients with mild (mean 31.8 ± 18.8, range 7.1 to 81.4 µmol/L) and severe pancreatitis (mean 28.2 ± 21.6, range 6.1 to 74.4 µmol/L; p = 0.339). There was no difference found between the groups after 48 h (mild n = 28, mean 26.8 ± 19.4 µmol/L, and severe n = 20, mean 34.6 ± 21.0 µmol/L; p = 0.127). There was also no difference in the levels between patients with or without lung injury, kidney injury or sepsis. Performing H2S estimation to predict severity in acute pancreatitis is not beneficial.

A 27-year-old man with unresectable periampullary neoplasm underwent a Roux-en-Y hepaticojejunostomy with gastrojejunostomy 1 year previously. He presented with a 1-month history of progressive yellowish discoloration of his eyes, abdominal pain and distension, and intermittent high fever with chills and rigors. On admission his results showed a bilirubin of 9 mg/dL, alkaline phosphatase of 1467 IU/mL, and total white blood cell (WBC) count of 28 700/mm³. A blood culture grew Escherichia coli. A contrast-enhanced computed tomography (CT) scan of the abdomen showed a grossly dilated loop of jejunum with distal obstruction, in communication with a patent hepaticojejunostomy anastomosis ([Fig. 1]). We planned to decompress the jejunal loop to relieve the cholangitis; however, the presence of a distal obstruction precluded enteroscope-assisted drainage. The distended jejunal loop was punctured with a 10-Fr cystotome (Cook Medical, Winston-Salem, North Carolina, USA) using endoscopic ultrasound (EUS) guidance ([Fig. 2 a]). The needle was removed and a 0.035-inch guidewire was placed through the inner catheter into the jejunal loop. The over-the-wire 10-Fr outer catheter of the cystotome with a diathermic ring was advanced into the jejunal loop using pure cut ([Video 1]). The cystotome was then removed. A 30-mm Niti-S Nagi stent (Taewoong Medical, Seoul, South Korea) was placed across the tract between the stomach and jejunal limb ([Fig. 2 b]), and bile was seen to drain through the gastrojejunal anastomosis ([Fig. 3 a]). To prevent migration of the stent, a 7-Fr double-pigtail plastic stent (7 cm in length) was placed across the Nagi stent ([Fig. 3 b]). After the procedure the patient’s fever subsided, his bilirubin decreased to 3.1 mg/dL, his total WBC count decreased to 15 200/mm³ and he was moved from the intensive care unit. He was discharged from hospital after 15 days. Obstruction of the jejunal loop can occur as a late complication of hepaticojejunostomy due to either adhesions or tumor recurrence. EUS-guided gastrojejunostomy for afferent-loop syndrome using a Hot Axios stent was first described by Ikeuchi et al. in 2015 [1]. Mutignani et al. recently used the Nagi stent to gain access to the jejunal loop in a patient with an hepaticojejunostomy [2]. In our patient, we used the Nagi stent to decompress the obstructed jejunal loop. The procedure appears to be a safe alternative for the management of patients with hepaticojejunostomy presenting with cholangitis secondary to jejunal loop obstruction. Endoscopy_UCTN_Code_TTT_1AS_2AD

Cerebral infarction after a viper bite is relatively uncommon. A combination of factors has been implicated in the pathophysiology of infarct following snakebite. In this case report, the clinical outcome after a posterior circulation infarct and various possibilities that could lead to such a catastrophic event are discussed. The present study stresses the need to keep hydration, blood pressure and central venous pressure optimal in all snakebite patients. Cerebral infarction should be considered a differential diagnosis, in any patient with neurological deterioration following snakebite. Prognosis of such patients with posterior circulation stroke remains poor and decompressive craniectomy has not been found to be helpful.