Publications by authors named "Usha Dutta"

168 Publications

Should patients with unresectable gallbladder cancer with hilar involvement undergo unilateral or bilateral percutaneous biliary drainage in the setting of cholangitis?

Clin Exp Hepatol 2021 Mar 25;7(1):7-12. Epub 2021 Mar 25.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Aim Of The Study: This study aimed to evaluate the outcomes of patients with unresectable gallbladder cancer (GBC) with hilar involvement and cholangitis undergoing percutaneous transhepatic biliary drainage (PTBD).

Material And Methods: This retrospective study comprised consecutive patients with unresectable GBC with cholangitis who underwent PTBD. The procedures were categorized as unilateral or bilateral. Bilateral PTBD was classified as simultaneous or sequential. The mean reduction in bilirubin at two weeks was recorded. Complications and mean overall survival were also recorded.

Results: Thirty-three patients (mean age 54.5 years, 12 males) were included. Thirty patients underwent unilateral drainage. Sequential drainage of the contralateral system was performed in 11 patients. Simultaneous bilateral PTBD was performed in 3 patients. PTBD was technically successful in all patients. Mean reduction in bilirubin was 41.5% in the unilateral group. The fall of bilirubin in the simultaneous bilateral PTBD group was 39%. The mean follow-up duration was 36.5 days. No major complications were encountered. At the last follow-up, 7 patients were alive. The mean overall survival was 34.6 days.

Conclusions: Patients with unresectable GBC and cholangitis frequently require bilateral drainage. However, prospective studies should be performed to evaluate whether a sequential or simultaneous PTBD should be performed.
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http://dx.doi.org/10.5114/ceh.2021.104674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122101PMC
March 2021

Diverticular per oral endoscopic myotomy (DPOEM) for esophageal diverticular disease: a systematic review and meta-analysis.

Esophagus 2021 Jul 20;18(3):436-450. Epub 2021 Apr 20.

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.

The traditional way to tackle Zenker's diverticulum (ZD) has been flexible endoscopic septum division (FESD). Recently, the concept of per oral endoscopic myotomy has been found useful for managing diverticular diseases of the esophagus and has been termed DPOEM. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of D-POEM in diverticular disease of the esophagus and to compare it with FESD. We systematically searched PubMed and Embase, for studies reporting clinical success, technical success and adverse events in D-POEM alone or D-POEM comparing with FESD. We computed pooled prevalence for D-POEM alone and risk ratio for D-POEM vs FESD using random effect method with inverse variance approach. Subgroup analysis for ZD, non-ZD and mixed diverticulum was conducted. Totally 19 studies including 341 patients were identified reporting on D-POEM. The pooled clinical, technical success and adverse event rates for D-POEM were 87.07%, 95.19% and 10.22%, respectively. The clinical success was significantly better than FESD while the technical success, adverse event rate, procedure time and length of hospital stay were comparable with FESD. The recurrence rate was negligible for D-POEM compared to FESD. On subgroup analysis by dividing into three groups of ZD, non-ZD and mixed, there was no difference between clinical, technical success and adverse event rate among the three groups. D-POEM is an effective and safe technique among both ZD and non-ZD patients and has better clinical success than FESD.
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http://dx.doi.org/10.1007/s10388-021-00839-9DOI Listing
July 2021

Use of thiopurines in inflammatory bowel disease: an update.

Intest Res 2021 Apr 15. Epub 2021 Apr 15.

Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India.

Inflammatory bowel disease (IBD), once considered a disease of the Western hemisphere, has emerged as a global disease. As the disease prevalence is on a steady rise, management of IBD has come under the spotlight. 5-Aminosalicylates, corticosteroids, immunosuppressive agents and biologics are the backbone of treatment of IBD. With the advent of biologics and small molecules, the need for surgery and hospitalization has decreased. However, economic viability and acceptability is an important determinant of local prescription patterns. Nearly one-third of the patients in West receive biologics as the first/initial therapy. The scenario is different in developing countries where biologics are used only in a small proportion of patients with IBD. Increased risk of reactivation of tuberculosis and high cost of the therapy are limitations to their use. Thiopurines hence become critical for optimal management of patients with IBD in these regions. However, approximately one-third of patients are intolerant or develop adverse effects with their use. This has led to suboptimal use of thiopurines in clinical practice. This review article discusses the clinical aspects of thiopurine use in patients with IBD with the aim of optimizing their use to full therapeutic potential.
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http://dx.doi.org/10.5217/ir.2020.00155DOI Listing
April 2021

Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives.

Surg Laparosc Endosc Percutan Tech 2021 Mar 12. Epub 2021 Mar 12.

Departments of Gastroenterology Radiodiagnosis Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Introduction: The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy.

Areas Covered: This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.
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http://dx.doi.org/10.1097/SLE.0000000000000920DOI Listing
March 2021

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.

BMJ Open 2021 02 22;11(2):e043837. Epub 2021 Feb 22.

Department of Hospital Administration, PGIMER, Chandigarh, India.

Objectives: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty.

Setting: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless.

Participants: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone.

Results: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment.

Conclusion: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.
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http://dx.doi.org/10.1136/bmjopen-2020-043837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902325PMC
February 2021

Cost concerns, not the guidelines, drive clinical care of IBD during COVID pandemic in a resource limited setting.

Expert Rev Gastroenterol Hepatol 2021 Apr 19;15(4):465-466. Epub 2021 Feb 19.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1080/17474124.2021.1890583DOI Listing
April 2021

Per Oral Endoscopic Myotomy for the Management of Large Esophageal Diverticula (D-POEM): Safe and Effective Modality for Complete Septotomy.

Dysphagia 2021 Feb 3. Epub 2021 Feb 3.

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.

With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker's while two had epiphrenic diverticulum. The median symptom duration was 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280 days (range 98-330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.
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http://dx.doi.org/10.1007/s00455-021-10252-0DOI Listing
February 2021

Splenic abscess in a tertiary care centre in India: clinical characteristics and prognostic factors.

ANZ J Surg 2020 Dec 28. Epub 2020 Dec 28.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Splenic abscess has been an uncommon entity which is now being encountered more frequently due to increased prevalence of immunodeficiency disorders and chronic illnesses. This study was aimed to audit our experience with splenic abscesses at a tertiary care centre in India highlighting usefulness of an algorithmic approach.

Methods: Retrospective analysis of data of patients (January 2014 to December 2019) with splenic abscess was done. Data were retrieved for clinical characteristics, radiological findings, organism spectra, abscess characteristics, therapeutic measures and clinical outcome.

Results: The mean age of the study population (n = 36) was 41.3 ± 19.0 years with 50% males. Comorbidities were identified in 17 (47.2%) patients, with diabetes mellitus being the commonest. Fever and abdominal pain were the most common presenting features. Multiple splenic abscesses were present in 21 (58.3%) patients. Extra-splenic abscesses in liver were seen in five (13.9%) patients while nine (25%) patients had ruptured splenic abscess. Microorganisms were identified in 24 (66.7%) patients, with Salmonella typhi being the commonest (n = 9, 25%) followed by Escherichia coli (n = 7, 19.4%) and Staphylococcus aureus (n = 4, 11.1%). Six patients received only antimicrobials, 24 were managed with percutaneous aspiration or catheter drainage and six required surgery. Five (13.9%) patients died, with highest mortality being seen in those who received only antimicrobial (50%), compared to percutaneous aspiration or catheter drainage (8.3%) and surgery (0%), P = 0.017.

Conclusion: Using percutaneous aspiration or drainage in conjunction with antibiotics, followed by surgery in non-responder, patients with splenic abscesses can be managed successfully with acceptable mortality.
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http://dx.doi.org/10.1111/ans.16517DOI Listing
December 2020

Management of gastrointestinal tuberculosis during COVID pandemic: Lessons for posterity.

Dig Liver Dis 2021 Apr 13;53(4):394-396. Epub 2020 Dec 13.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Electronic address:

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http://dx.doi.org/10.1016/j.dld.2020.11.034DOI Listing
April 2021

Adjuvant use of combination of antibiotics in acute severe ulcerative colitis: A placebo controlled randomized trial.

Expert Rev Anti Infect Ther 2020 Dec 14:1-7. Epub 2020 Dec 14.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

: Evaluation of a combination of antibiotics as an adjuvant therapy in acute severe ulcerative colitis (ASUC).: Patients with ASUC were randomized to either infusions of placebo or intravenous ceftriaxone and metronidazole in addition to standard care. Primary outcome was response on day three according to Oxford's criteria. Secondary outcome measures included changes in partial Mayo score, CRP levels, fecal calprotectin (day three), and need for second-line therapy, hospital stay, and mortality (day 28).: Fifty patients (25 in each group, median age: 33 years, 23 males) were included. The number of patients with fulminant disease in the antibiotic group were 16 (64%) as compared to 7 (28%) in the standard of care group. Complete response on day three was attained by 7 (28%) in the antibiotic and 6 (24%) standard of care group (p = 1.00). Three patients from the antibiotic group underwent colectomy and three received intravenous cyclosporine whereas four patients in the standard of care group received cyclosporine (p = 0.725). There was no significant difference in change in CRP, Partial Mayo score, and fecal calprotectin between the two groups on day three.: Combination of intravenous ceftriaxone and metronidazole did not improve outcomes in ASUC.Acronym: AAASUC trialRegistration Number: CTRI/2019/03/018196 and NCT03794765.
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http://dx.doi.org/10.1080/14787210.2021.1856656DOI Listing
December 2020

Imaging-based algorithmic approach to gallbladder wall thickening.

World J Gastroenterol 2020 Oct;26(40):6163-6181

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.

Gallbladder (GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma (GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities (conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.
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http://dx.doi.org/10.3748/wjg.v26.i40.6163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7596646PMC
October 2020

Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes.

Eur Radiol 2021 May 5;31(5):3439-3446. Epub 2020 Nov 5.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.

Objective: To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP).

Methods: This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated.

Results: One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3-267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively.

Conclusion: Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics.

Key Points: • Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.
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http://dx.doi.org/10.1007/s00330-020-07411-6DOI Listing
May 2021

Interventional radiological management of hepatobiliary disorders in pregnancy.

Clin Exp Hepatol 2020 Sep 30;6(3):176-184. Epub 2020 Sep 30.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Hepatobiliary disorders are common in pregnancy and pose a management challenge. Minimally invasive interventional radiological (IR) techniques allow safe and effective management of these disorders. However, the available literature is scarce. Radiological interventions in this group of patients mandate a clear understanding of the risks of radiation to the fetus. The IR physician involved in the care of these patients should be aware of the measures to minimize the exposure to ionizing radiation. Additionally, the risk-benefit ratio should be clearly defined in a multidisciplinary discussion involving IR physicians, obstetricians, and gastroenterologists. This review is an effort to address issues related to the application of IR procedures for hepatobiliary disorders in pregnant patients.
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http://dx.doi.org/10.5114/ceh.2020.99508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592089PMC
September 2020

Feasibility and safety of bedside percutaneous biliary drainage in patients with severe cholangitis.

Abdom Radiol (NY) 2021 05 23;46(5):2156-2160. Epub 2020 Oct 23.

Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India.

Purpose: To evaluate the safety and feasibility of bedside percutaneous transhepatic biliary drainage (PTBD) as a salvage procedure in patients with severe cholangitis in the intensive care unit (ICU).

Methods: This retrospective study evaluated records of consecutive patients with severe cholangitis who were admitted in the ICU. Bedside PTBD was performed using ultrasound guidance. The level and cause of biliary obstruction were recorded. The technical success of the procedure and complications were recorded.

Results: Ten patients (six males, mean age 53.8 years) underwent bedside PTBD. Six patients had distal common bile duct blockade [periampullary carcinoma (n = 2), carcinoma pancreas (n = 2), choledocholithiasis (n = 1), and benign stricture (n = 1)]. Four patients had malignant hilar stricture [cholangiocarcinoma (n = 3) and carcinoma gallbladder (n = 1)]. Technical success was achieved in all. One patient underwent bilateral PTBD. Left and right PTBD were performed in 5 and 4 patients, respectively. There were no major complications. Transient hemobilia occurred in two patients.

Conclusion: Bedside PTBD is safe and technically feasible. Prospective studies are required to establish this procedure into routine clinical practice.
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http://dx.doi.org/10.1007/s00261-020-02825-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583693PMC
May 2021

Extra-hepatic biliary obstruction due to diffuse large B-cell lymphoma: an autopsy case report with unattended yet significant pathologies.

Clin J Gastroenterol 2021 Feb 29;14(1):269-274. Epub 2020 Sep 29.

Department of Cytology and Gynaecological Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012.

Autopsy practice has been an invaluable tool to understand the pathobiology of various disease processes. We herein have given the description of a case of malignant extra-hepatic biliary obstruction secondary to a diffuse large B-cell lymphoma. The patient disease could only be adequately characterized at autopsy in the form of exact origin and subtyping of lymphoma. The autopsy revealed certain unattended and exciting, yet significant pathological findings in the form of portal vein thrombosis, neurolymphomatosis, the exact track of the lymphomatous cells from abdominal to thoracic cavity, and the terminal events which led to the patient's demise. The plausible clinical correlates of these pathological findings have been discussed. This can serve as a useful clue to the clinicians for managing such cases in the future.
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http://dx.doi.org/10.1007/s12328-020-01252-yDOI Listing
February 2021

Locally advanced gallbladder cancer: a review of the criteria and role of imaging.

Abdom Radiol (NY) 2021 03 18;46(3):998-1007. Epub 2020 Sep 18.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

Gallbladder carcinoma (GBC) is among one of the gastrointestinal malignancies with extremely dismal prognosis. This is due to the advanced stage at presentation. Majority of the patients with GBC are not considered candidates for surgery because of the locally advanced disease or metastases. However, with the accumulating evidence regarding the role of neoadjuvant chemotherapy, there is a need to correctly identify a subset of patients with locally advanced GBC who will benefit maximally from neoadjuvant chemotherapy and will be successfully downstaged to receive curative (R0) surgery. In this context, there is a lack of consensus and different groups have resorted to criteria for locally advanced disease eligible for neoadjuvant chemotherapy based on personal or institutional experiences. Imaging plays a critical role in the evaluation of patients with GBC as it helps stratify patients into resectable and unresectable. Imaging also has the potential to identify patients with locally advanced GBC and hence facilitate neoadjuvant chemotherapy and improve outcomes. In this review, we evaluate the various criteria for locally advanced GBC and the role of imaging in this scenario.
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http://dx.doi.org/10.1007/s00261-020-02756-4DOI Listing
March 2021

Development and validation of a computed tomography index for assessing outcomes in patients with acute pancreatitis: "SMART-CT" index.

Abdom Radiol (NY) 2021 04 16;46(4):1618-1628. Epub 2020 Sep 16.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

Purpose: The existing CT indices do not allow quantitative prediction of clinical outcomes in acute pancreatitis (AP). The aim of this study was to develop and validate a revised CT index using a nomogram-based approach.

Methods: This retrospective study comprised consecutive patients with AP who underwent contrast-enhanced CT between June 2017 and March 2019. 123 CT scans were randomly divided into training (n = 103) and validation groups (n = 20). Two radiologists analyzed CT scans for findings described in modified CT severity index and additional exploratory items (13 items). Seven items (pancreatic necrosis, number of collections, size of collections, ascites, pleural effusion, celiac artery involvement, and liver steatosis) found to be statistically significant were used for development of index. Synthetic minority oversampling technique (SMOTE) was employed to balance representation of minority classes and hence this index was named "SMOTE Application for Reading CT in AcuTe Pancreatitis (SMART-CT index)". Binomial logistic regression was used for development of prediction algorithm. Nomograms were then created and validated for each outcome.

Results: The new CT index had area under the curve (AUC) of 0.79 [95% CI 0.65-0.93], 0.66 (95% CI 0.54-0.77), 0.75 (95% CI 0.65-0.85), 0.83 (95% CI 0.69-0.96), 0.70 (95% CI 0.60-0.81), and 0.64 (95% CI 0.53-0.75) for mortality, intensive care unit (ICU) stay, length of hospitalization, length of ICU stay, number of admissions, and severity, respectively. The AUC of validation cohort was comparable to the training cohort.

Conclusion: The novel nomogram-based index predicts occurrence of clinical outcome with moderate accuracy.
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http://dx.doi.org/10.1007/s00261-020-02740-yDOI Listing
April 2021

Xpert MTB/RIF for diagnosis of tubercular liver abscess. A case series.

Infez Med 2020 Sep;28(3):420-424

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Hepatic involvement is an infrequent manifestation of abdominal tuberculosis and could occur in form of granulomatous hepatitis, nodular involvement or abscess formation. Tubercular liver abscess (TLA) is uncommon, and diagnosing this entity is a challenge. Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) assay has been widely used for diagnosing pulmonary tuberculosis (TB) and lymph nodal tuberculosis. Its utility in some forms of other extrapulmonary TB has also been studied. The role of Xpert MTB/RIF for diagnosis of tubercular liver abscess is not known. Here we present a series of four 4 cases of TLA, where the diagnosis was made on the basis of positive Xpert MTB/RIF assay tested on liver drained pus.
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September 2020

Diagnostic accuracy of the Xpert MTB/RIF assay for abdominal tuberculosis: a systematic review and meta-analysis.

Expert Rev Anti Infect Ther 2021 Feb 20;19(2):253-265. Epub 2020 Sep 20.

Department of Gastroenterology, Pharmacology and General Surgery, Postgraduate Institute of Medical Education and Research , Chandigarh, India.

Background: We performed a meta-analysis to determine diagnostic accuracy of Xpert MTB/RIF for diagnosis of abdominal (intestinal or peritoneal) tuberculosis (TB) in various tissues (intestinal, omental/peritoneal tissue or ascitic fluid).

Methods: Electronic databases were searched for observational studies on use of Xpert MTB/RIF in ascitic fluid, peritoneal, or omental tissue for diagnosis of peritoneal and intestinal TB. We calculated the pooled sensitivity, specificity and diagnostic odds ratio of Xpert MTB/RIF for diagnosis of peritoneal TB in comparison to composite reference standard (CRS) and culture, and in comparison to CRS for intestinal TB.

Results: Twenty-five observational studies were included. The pooled sensitivity and specificity as assessed with peritoneal culture from ascites as an Index test was 64% (95% Confidence Interval [C.I.] 49-76%) and 97% (95% C.I., 95-99%) respectively and with peritoneal CRS was 30% (95% C.I., 22-40%) and 100% (95% C.I., 98-100%) respectively. In the intestinal group, the pooled sensitivity and specificity of Xpert MTB/RIF was 23% (95% C.I., 16-32%) and 100% (95% C.I., 52-100%). The AUC of peritoneal culture and intestinal tissue was 0.935 and 0.499.

Conclusion: Xpert MTB/RIF has modest sensitivity for diagnosis of peritoneal and intestinal tuberculosis but has a good specificity.

Prospero Registration: CRD42020140545.
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http://dx.doi.org/10.1080/14787210.2020.1816169DOI Listing
February 2021

Contrast-Enhanced Ultrasound is a Useful Adjunct to Doppler Ultrasound in the Initial Assessment of Patients Suspected of Budd Chiari Syndrome.

Curr Probl Diagn Radiol 2020 Jul 25. Epub 2020 Jul 25.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background: Doppler is the screening modality of choice for assessment of patients suspected of Budd Chiari syndrome (BCS). The aim of this study was to compare the diagnostic value of contrast enhanced ultrasound (CEUS) with Doppler in the initial evaluation of patients with BCS.

Methods: This was a retrospective study of patients with suspicion of BCS who underwent CEUS of the hepatic veins and inferior vena cava between July 2017 and April 2019. CEUS was performed using Sonovue. All patients underwent Doppler evaluation of the hepatic veins and inferior vena cava. The final diagnosis of BCS was based on transvenous or percutaneous digital subtraction venography. The diagnostic accuracy of CEUS was compared with Doppler.

Results: A total of 19 patients (median age, 30 years; 11 males) were evaluated with CEUS and Doppler. A final diagnosis of BCS was established on digital subtraction venography in 15 patients. CEUS was found to have a 100% sensitivity and 75% specificity. The sensitivity and specificity of Doppler was 100% and 25%. The diagnostic accuracies of CEUS and Doppler were 94.74% and 84.29%, respectively.

Conclusion: CEUS is a useful adjunct to the Doppler in the initial assessment of patients with BCS. However, further prospective studies must confirm our preliminary observations.
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http://dx.doi.org/10.1067/j.cpradiol.2020.07.004DOI Listing
July 2020

Serial measurements of faecal calprotectin may discriminate intestinal tuberculosis and Crohn's disease in patients started on antitubercular therapy.

Eur J Gastroenterol Hepatol 2021 Mar;33(3):334-338

Departments of Gastroenterology.

Background: Response to antitubercular therapy (ATT) is often used to differentiate intestinal tuberculosis (ITB) from Crohn's disease. Role of non-invasive biomarkers to predict mucosal response to ATT is unclear.

Materials And Methods: A prospective study to compare faecal calprotectin and serum C-reactive protein (CRP) levels at diagnosis, 2 and 6 months of ATT in patients with suspected ITB started on ATT was done. The patients were eventually divided into two groups: ITB or alternative diagnosis (OTH). Decline of calprotectin and CRP levels was used to compute area under the receiver operating characteristic (AUROC) to predict mucosal healing at 2 months.

Results: Thirty-seven patients (mean age: 34.95 ± 16.35 years, 23 males) were included and 28 (75.67%) were diagnosed as ITB while nine (24.32%) had alternative diagnosis (OTH). The median faecal calprotectin values of ITB and OTH groups at baseline, 2 months and 6 months were 216 and 282 µg/g (P = 0.466), 43 and 216 µg/g (P = 0.003), and 26 and 213 µg/g (P < 0.001), respectively. The median CRP values at baseline, 2 months and 6 months were 18 and 30 mg/L (P = 0.767), 4.7 and 15 mg/L (P = 0.025), and 3 and 10.85 mg/L (P = 0.068), respectively. The AUROC of percent decline in faecal calprotectin and serum CRP at 2 months for mucosal healing were 0.8287 [95% confidence inteval (CI) 0.6472-1] and 0.6018 (95% CI 0.4079-0.7957), respectively.

Conclusion: Faecal calprotectin can help in assessing response to therapy in suspected ITB patients started on empirical ATT.
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http://dx.doi.org/10.1097/MEG.0000000000001879DOI Listing
March 2021

Cytogenetic and molecular study of 370 infertile men in South India highlighting the importance of copy number variations by multiplex ligation-dependent probe amplification.

Andrologia 2020 Nov 13;52(10):e13761. Epub 2020 Aug 13.

Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India.

Male infertility is a common and severe problem affecting 7% of population. The main objective of this study is to identify the chromosomal abnormalities, Y microdeletions in infertile men and also to access the frequency of abnormal sperm count. Based on the sperm count and viability, the infertile men were grouped as Azoospermia, Asthenospermia, Oligospermia and the remaining as Idiopathic infertility. A total of 370 infertile men and 60 normal control men were recruited. Chromosomal abnormalities were identified in 3 men (3/370). The prevalence of Y microdeletions in the infertile group is 8/370 in the Azoospermia factor (AZF) region with four AZFc deletion/duplication, two AZFa deletion, one AZF b & AZFc deletion and one case of total AZF a, AZFb & AZFc deletion. However, only five cases of Y microdeletions were identified by Multiplex PCR but an additional three cases by MLPA (Multiplex ligation-dependent probe amplification). Fluorescence in situ hybridisation also confirmed the deletions. Here, we performed MLPA post-multiplex PCR, and our study revealed good yield of the Y microdeletion identification. The partial duplications which are difficult to be identified can now be easily identified by MLPA, and hence, we recommend MLPA as the choice of investigation compared to multiplex PCR for infertile men.
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http://dx.doi.org/10.1111/and.13761DOI Listing
November 2020

Unusual Sites of Necrotic Collections in Acute Necrotizing Pancreatitis: Association with Parenchymal Necrosis and Clinical Outcomes.

Dig Dis Sci 2020 Aug 10. Epub 2020 Aug 10.

Department of Gastroenterology, PGIMER, Chandigarh, 160012, India.

Background: The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than the retroperitoneum has not been systematically studied.

Aim: To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes.

Methods: This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated.

Results: A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups.

Conclusions: Mesenteric collections are frequent in ANP. The other non-retroperitoneal sites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.
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http://dx.doi.org/10.1007/s10620-020-06526-6DOI Listing
August 2020

Kissing catheter technique for percutaneous catheter drainage of necrotic pancreatic collections in acute pancreatitis.

Exp Ther Med 2020 Sep 17;20(3):2311-2316. Epub 2020 Jun 17.

Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India.

One of the critical factors for predicting the success of percutaneous catheter drainage (PCD) is the mean CT density of collection. A higher CT density suggests more necrotic solid tissue within the collection. In the present study, a novel technique for PCD of the necrotic pancreatic collection with a higher mean CT density was evaluated. It was a retrospective study of patients with acute pancreatitis (AP) who underwent PCD of pancreatic collections between May 2018 and December 2018. Patients with pancreatic collections having a CT density of >30 Hounsfield Units (HU) were considered for PCD using the kissing catheter technique. This technique involved placing two catheters side-by-side through a single cutaneous entry site, as the conventional technique of PCD may not be effective. The technical details, outcomes and complications of this technique were recorded. A total of 10 patients with a mean age of 30 years underwent PCD using this technique. All patients had severe pancreatitis with a mean CT severity index of 9 (range, 8-10). The mean CT density was 37 HU (range, 32-56). Successful management with PCD alone was achieved in 8 patients. The other 2 patients underwent surgical necrosectomy. One patient who underwent surgical necrosectomy died. Minor complications occurred in 3 patients. The kissing catheter technique allows for a higher success rate of PCD compared with that of the conventional method of PCD, in collections with a higher mean CT density.
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http://dx.doi.org/10.3892/etm.2020.8897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401886PMC
September 2020

Coronavirus disease (COVID-19) and the liver: a comprehensive systematic review and meta-analysis.

Hepatol Int 2020 Sep 4;14(5):711-722. Epub 2020 Jul 4.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Liver function derangements have been reported in coronavirus disease (COVID-19), but reported rates are variable.

Methods: We searched PubMed and Embase with terms COVID and SARS-COV-2 from December 1, 2019 till April 5, 2020. We estimated overall prevalence, stratified prevalence based on severity, estimated risk ratio (RR), and estimated standardized mean difference (SMD) of liver function parameters in severe as compared to non-severe COVID. Random effect method utilizing inverse variance approach was used for pooling the data.

Results: In all, 128 studies were included. The most frequent abnormalities were hypoalbuminemia [61.27% (48.24-72.87)], elevations of gamma-glutamyl transferase (GGT) [27.94% (18.22-40.27)], alanine aminotransferase (ALT) [23.28% (19.92-27.01)], and aspartate aminotransferase (AST) [23.41% (18.84-28.70)]. Furthermore, the relative risk of these abnormalities was higher in the patients with severe COVID-19 when compared to non-severe disease [Hypoalbuminemia-2.65 (1.38-5.07); GGT-2.31 (1.6-3.33); ALT-1.76 (1.44-2.15); AST-2.30 (1.82-2.90)]. The SMD of hypoalbuminemia, GGT, ALT, and AST elevation in severe as compared to non-severe were - 1.05 (- 1.27 to - 0.83), 0.76 (0.40-1.12), 0.42 (0.27-0.56), and 0.69 (0.52-0.86), respectively. The pooled prevalence and RR of chronic liver disease as a comorbidity was 2.64% (1.73-4) and 1.69 (1.05-2.73) respectively.

Conclusion: The most frequent abnormality in liver functions was hypoalbuminemia followed by derangements in gamma-glutamyl transferase and aminotransferases, and these abnormalities were more frequent in severe disease. The systematic review was, however, limited by heterogeneity in definitions of severity and liver function derangements. Graphical depiction of the summary of meta-analytic findings a) pooled prevalence of abnormalities b) Risk ratio of abnormality in severe versus non-severe COVID-19 c) standardized mean difference (SMD) between severe and non-severe group and d) pooled prevalence for parameters based on severity stratification for bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), albumin, globulin and acute hepatic injury (AHI) . Also estimates for overall/total liver disease (TLD) and chronic liver disease (CLD) amongst COVID-19 patients are depicted in a, b, d. For d) In addition to severity stratification, Overall (all studies for a particular estimate) and combined (only those studies which reported severity) estimates are provided.
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http://dx.doi.org/10.1007/s12072-020-10071-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335221PMC
September 2020

Per oral endoscopic myotomy with fundoplication is a technically feasible NOTES for achalasia cardia.

Minim Invasive Ther Allied Technol 2020 07 1:1-6. Epub 2020 Jul 1.

Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Per-oral endoscopic myotomy (POEM) has become the standard of care for the endoscopic management of achalasia but its major long-term adverse effect has been the development of reflux-associated symptoms and sequelae. This study was conducted to assess the feasibility and reproducibility of the technique of POEM with fundoplication (POEM + F), a pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedure in achalasia. Between November 2019 and January 2020, three patients with achalasia cardia were subjected to POEM + F. Various parameters such as technical feasibility, procedure time, adverse events and post-procedure follow-up were noted. POEM + F was successfully completed in all three patients. Other than intra-operative capno-peritoneum, no major adverse events were noted. On follow-up at one month, maintenance of wrap was noted.: POEM + F is a technically feasible and a reproducible pure NOTES procedure.
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http://dx.doi.org/10.1080/13645706.2020.1783320DOI Listing
July 2020

Relationship between Mayo endoscopic score and histological scores in ulcerative colitis: A prospective study.

JGH Open 2020 Jun 2;4(3):382-386. Epub 2019 Oct 2.

Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India.

Background: The Mayo endoscopic score (MES) remains the most commonly used index in clinical practice, as well as in various clinical trials. Recently, two validated histological indices (Nancy Index [NI] and Robert Histological Index [RHI]) have been developed for ulcerative colitis (UC). We aim to study the relationship between MES with NI, RHI, and the established Geboes Index (GI) in patients with UC.

Methods: This was a prospective single-center study. MES was documented from the most involved area. Biopsy was taken from the same area and reported by a single gastrointestinal histopathologist who was blinded to the endoscopic score. Histological activity was reported using GI, NI, and RHI. Statistical analysis was performed using Spearman's correlation coefficient and Cohen's kappa coefficient using SPSS version 23.

Results: Median age of patients with UC ( = 96) was 36 years. Seventeen patients were in endoscopic remission (MES 0/1). Correlation coefficient between MES and GI/NI/RHI was only weak to moderate (rho = 0.381/0.389/0.442, respectively;  < 0.001 for all three correlations). In patients with endoscopic mucosal healing ( = 17), the agreement coefficient between MES and GI/RHI was weak ( = 0.253/0.336, respectively; = 0.001 for both agreements). However, there was no significant agreement coefficient between MES and NI ( = 0.573).

Conclusion: MES moderately correlated with histological scores. RHI had the best correlation with MES among all histological indices. Endoscopic mucosal healing is not strongly correlated with histological healing. Histological examination should be performed even in patients with mucosal healing to detect ongoing histological activity.
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http://dx.doi.org/10.1002/jgh3.12260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273720PMC
June 2020

FDG-PET-CT Enterography Helps Determine Clinical Significance of Suspected Ileocecal Thickening: A Prospective Study.

Dig Dis Sci 2021 May 1;66(5):1620-1630. Epub 2020 Jun 1.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

Background: Ileocecal thickening (ICT) on imaging could result from diverse etiologies but may also be clinically insignificant.

Aim: Evaluation of role of combined 2-deoxy-2-fluorine-18-fluoro-D-glucose(F-FDG)-positron emission tomography and computed tomographic enterography (PET-CTE) for determination of clinical significance of suspected ICT.

Methods: This prospective study enrolled consecutive patients with suspected ICT on ultrasound. Patients were evaluated with PET-CTE and colonoscopy. The patients were divided into: Group A (clinically significant diagnosis) or Group B (clinically insignificant diagnosis) and compared for various clinical and radiological findings. The two groups were compared for maximum standardized uptake values of terminal ileum, ileo-cecal valve, cecum and overall.

Results: Of 34 patients included (23 males, mean age: 40.44 ± 15.40 years), 12 (35.3%) had intestinal tuberculosis, 11 (32.4%) Crohn's disease, 3 (8.8%) other infections, 1 (2.9%) malignancy, 4 (11.8%) non-specific terminal ileitis while 3 (8.8%) had normal colonoscopy and histology. The maximum standardized uptake value of the ileocecal area overall (SUVmax-ICT-overall) was significantly higher in Group A (7.16 ± 4.38) when compared to Group B (3.62 ± 9.50, P = 0.003). A cut-off of 4.50 for SUVmax-ICT-overall had a sensitivity of 70.37% and a specificity of 100% for prediction of clinically significant diagnosis. Using decision tree model, the SUVmax-ICT with a cut-off of 4.75 was considered appropriate for initial decision followed by the presence of mural thickening in the next node.

Conclusion: PET-CTE can help in discrimination of clinically significant and insignificant diagnosis. It may help guide the need for colonoscopy in patients suspected to have ICT on CT.
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http://dx.doi.org/10.1007/s10620-020-06361-9DOI Listing
May 2021

Evaluation of gallbladder wall thickening: a multimodality imaging approach.

Expert Rev Gastroenterol Hepatol 2020 Jun 30;14(6):463-473. Epub 2020 Apr 30.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India.

Introduction: Gallbladder (GB) wall thickening is a relatively common finding on imaging. While there are clear recommendations for the management of gallstones, GB wall thickening presents a significant challenge. Despite advances in radiological as well as endoscopic techniques, the ability to characterize GB wall thickening is still limited.

Areas Covered: This review summarizes the currently available literature on various imaging investigations to characterize GB wall thickening. This review also summarizes the differences between benign and malignant GB wall thickening based on available imaging modalities. Transabdominal ultrasonography is the first-line investigation for evaluation of GB wall thickening. However, further characterization requires additional imaging tests. Magnetic resonance imaging (MRI) with the use of gadolinium and diffusion-weighted sequence is the preferred modality for GB wall characterization.

Expert Opinion: The accurate characterization of GB wall thickening is a challenging task. The available imaging criteria allow differentiation of benign and malignant GB wall thickening with moderate accuracy. The advanced imaging techniques, including contrast enhanced ultrasound, contrast-enhanced endoscopic ultrasound, and shear wave elastography, continue to evolve. There is a need for a well-designed reporting system for GB wall thickening to ensure uniformity of reporting of imaging tests, especially in regions with a high prevalence of GB cancer.
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http://dx.doi.org/10.1080/17474124.2020.1760840DOI Listing
June 2020

An unusual cause of granulomatous colitis: Behcet's disease.

JGH Open 2020 Apr 15;4(2):303-305. Epub 2019 Aug 15.

Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India.

Intestinal involvement in Behcet's disease (BD) is uncommon. Differentiating it from close mimics like Crohn's Disease is difficult. Further, in asymptomatic cases, diagnostic challenges posed is still greater. A 17-year-old boy had history of recurrent oro-genital ulcers, papulo-pustular skin eruptions, ocular lesions and had presented with recent onset perianal abscess. Fecal calprotectin was elevated, and ileo-colonoscopy showed ileocolonic ulcers of inflammatory nature. Clinical diagnosis of intestinal BD was made. Patients with BD having mucosal lesions may harbor asymptomatic intestinal lesions. Screening them with fecal calprotectin levels and if positive, with subsequent imaging and endoscopic biopsy with timely initiation of appropriate treatment in such asymptomatic cases help to control overall disease activity.
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http://dx.doi.org/10.1002/jgh3.12215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144775PMC
April 2020