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   Table of Contents - Current issue
January-March 2019
Volume 10 | Issue 1
Page Nos. 1-73

Online since Wednesday, June 19, 2019

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Self-expanding metallic stents in malignant biliary obstruction: Do Indian patients behave differently? Highly accessed article p. 1

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Just do not stop at colonoscopy, obtain biopsies p. 3

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How effective are low-volume solutions for oral colonoscopy bowel preparation? p. 6

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Rigid sigmoidoscopic examination for rectosigmoid lesions: The older the fiddle, the sweeter the tune p. 9

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Risk of gastrointestinal bleed and endoscopic procedures on antiplatelet and antithrombotic agents Highly accessed article p. 11

The use of antiplatelet and antithrombotic agents has increased hand in hand with the number and complexity of endoscopic procedures. Hence, the endoscopists are often faced with considering endoscopy in patients on these agents. In this setting, to make informed decision, four key aspects are need to be considered. The type of antithrombotic or antiplatelet agent used and its characteristics, risk of thromboembolic events (which can lead to ischemic stroke or acute coronary syndrome, both of which carry high morbidity) due to withholding the drug, risk of bleeding (increases with invasiveness of procedure), and timing of procedure (elective or urgent) are the key factors to consider. We aim to discuss the risk of gastrointestinal bleed and endoscopic procedures on antiplatelet and antithrombotic agents focusing on Indian context based on recent Asia-pacific guidelines along with other existing guidelines.
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Antroduodenal stenting for malignant gastric outlet obstruction: Technique and outcome p. 21

Gastric outlet obstruction (GOO) is usually a late presentation of gastric cancer, pancreaticobiliary malignancy, and extrinsic lymph nodal compression. Presenting symptoms are abdominal pain, postprandial epigastric fullness, and recurrent vomiting, which lead to severe malnutrition and dehydration and poor quality of life (QoL). Endoscopic enteral stent placement has become the acceptable alternative modality for palliation of malignant GOO because it is safe, minimally invasive, and a cost-effective procedure. In addition, endoscopic stent placement leads to shorter time to resume oral diet and shorter hospital stay in comparison to surgical bypass. Endoscopic stent placement is associated with high technical as well as clinical success rates and improvement in QoL, but no survival improvement. Recurrence of symptoms occurs due to stent occlusion, or stent migration, which can be successfully managed with repeat endoscopic stent placement. Perforation and bleeding are serious but rare complications.
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Unique pattern of true foreign-body ingestion in the valley of Kashmir; Sharp foreign bodies outnumbering the blunt ones p. 28

Background and Aims: Foreign-body ingestion is a common phenomenon, especially in children. In normal adults, foreign-body ingestion is usually accidental and mostly ingestion occurs with food and impaction is a result of structural abnormalities of the upper gastrointestinal tract (UGIT). However, accidental ingestion of nonfood products is unusual; especially ingestion of pins (scarf or safety pins) and needles is unknown. We come across ingestion of these unusual/sharp foreign bodies routinely from the past few years. The aim of this study was to observe, over a period of 1 year, the spectrum of nonfood or true foreign-body ingestion in our community and to see the impact of an early endoscopy on outcome or retrieval of the ingested objects. Materials and Methods: In a prospective observational study, we studied the profile of foreign-body ingestion in normal individuals of all ages and both sexes, excluding the individuals with any structural abnormalities of the gut and the people with psychiatric ailment. Results: Of total 51 patients with foreign-body ingestion, 42 (82%) were 20 or <20 years of age with females constituting 86.3% of the total and males constituting only 13.7%. Foreign bodies ingested included 38 pins (74.5%), seven coins (13.7%), four needles (7.8%), and one denture and a nail (2%) each. Overall 26 (51%) foreign bodies were seen in UGIT (within reach of retrieval) at the time of endoscopy and all of them were retrieved. Nineteen (37.3%) patients reported within 6 h of ingestion, and majority of them (16 = 84.2%) had foreign bodies within UGIT and all of them were removed. Those patients (n = 32; 62.7%) who reported beyond 6 h, only 10 (31.25%) had foreign bodies in UGIT as a result of which the success rate of removal in these patients was only 32%. Conclusion: Most of our patients were young females and the common foreign bodies ingested were sharp including scarf pins followed by coins and needles. The success rate of retrieval was high in those who reported within 6 h of ingestion of foreign body. The rate of retrieval was 100% if foreign body was found on esophagogastroduodenoscopy. Hence, we recommend an early endoscopy in these patients and some alternative to use of scarf pins.
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Self-expanding metallic stents in malignant biliary obstruction-patency and clinical efficacy: A prospective study from north India tertiary center p. 33
Ankit Gupta, Gaurav Kumar Gupta, Atul Gawande, Manoj Kumar, Vijyant Tak, Rupesh Kumar Pokharna, Shyam Sundar Sharma, Sandeep Nijhawan
Background and Aims: Endoscopic insertion of self-expandable metallic stent (SEMS) is now accepted as first line modality of treatment for palliation in un-resectable extra-hepatic biliary obstructive jaundice. This study was done to assess the clinical efficacy and duration of patency of endoscopically inserted metallic stent in un-resectable malignant biliary obstruction. Materials and Methods: Between 2015 to 2017, 101 patients who underwent ERCP and SEMS placement for palliation of malignant biliary obstruction were included prospectively. Main outcome measures were technical success, clinical success, mean duration of SEMS patency, clinical efficacy,rate of biliary re-intervention and survival of patients. Results: Overall technical success and clinical success was achieved in 93% and 82.2% respectively. Mean duration of SEMS patency was 109 days. Analysis in subgroup of patients classified according to site of obstruction (Hilar -68, Distal CBD-33) showed that median duration of stent patency was significantly better in distal biliary stricture (135 days vs 95 days), whereas re-intervention rates were higher in higher biliary stricture than distal stricture (41% Vs 6%). Seven patients with hilar biliary stricture suffered post-SEMS insertion cholangitis. Conclusion: SEMS placement is feasible palliative method for un-resectable malignant biliary obstruction with acceptable technical and clinical success. The duration of SEMS patency and clinical efficacy is significantly better in distal biliary stricture whereas re-intervention rate is higher in hilar biliary stricture.
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Bowel cleansing agents in clinical practice: A cross-sectional study on safety, efficacy, and predictor of good bowel preparation p. 39

Background: A good bowel preparation for colonoscopy is the most important factor that has an impact on visualization and outcome of the procedure. Aim: The primary aim of the study was to assess the quality of bowel preparation as reported by the Boston Bowel Preparation Score (BBPS). The secondary aim of the study was to analyze the patient feedback on ease of administration, palatability, and side effects with the bowel preparation. Materials and Methods: Patients undergoing colonoscopy between March 2018 and September 2018 were enrolled in the study. Patients <18 years of age, those with the previous history of colorectal surgery, emergency procedures in an unprepared colon, and those not willing to participate were excluded from the study. Colon preparation of the patient was decided by senior consultants. A predesigned pro forma that included demography, indication for the procedure, preparation details, dietary recommendations the previous day if any, side effects, and patient's comfort to preparation was completed by two-independent observers. The BBPS was used to assess the bowel preparation. A score of <5 was deemed inadequate. P < 0.05 was considered statistically significant. Results: The study cohort consisted of 141 patients, of which 78 were male (55.3%). Eighty (56.7%) patients received oral sulfate-based preparation and 61 (43.4%) polyethylene glycol-based preparation. Nearly one third of cases reported the solution to be non palatable. 15.4% respondents reported nausea, vomiting and bloating as the major side effects of the preparation. The median duration of colonoscopy was 25 min (8–45 min). One hundred and eighteen patients (83.6%) had a BBPS score of ≥5. Sulfate preparation resulted in better bowel cleansing (P = 0.01). Age, gender, and dosing schedule of preparation, including bedtime dosing of stimulant laxative, did not alter the BBPS score. Conclusion: Sulfate- and polyethylene glycol-based preparations are commonly used for cleansing the colon. Bowel cleansing was adequate in most patients and sulfate-based yielded better bowel cleansing. Nearly 15.4% of patients reported side effects to these preparations.
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Rigid sigmoidoscopic examination, an investigation down but not out: A 5-year single-center experience on 9418 patients p. 44

Background: Rigid sigmoidoscopy (RS) in the present era of flexible sigmoidoscopies is falling out of favor although it continues to be used in some centers as an outpatient (OP) department procedure. Aims: This study aims to determine the utility of RS for diagnosis of rectosigmoidal pathologies in the OP setting with emphasis on neoplastic lesions. Methods: We retrospectively studied the RS records and histopathology reports (HPRs) of 5 years (July 2013–June 2018) done in the Department of Gastroenterology at Medical College Calicut. Results: During the study period, 9418 RS examinations were done, and a total of 6921 abnormalities were picked up, giving a diagnostic yield of 73.5%. Most common indication was bleeding per rectum (PR) (51%), followed by constipation (29%). The most common lesion found was hemorrhoids 39.8% followed by proctitis 13.7%, neoplasms 9.7%, and others 10.3% while 26.5% studies were normal. HPRs showed 7.7% to be malignant, 5.8% were adenoma, 12.2% were inflammatory bowel disease ulcerative colitis (IBD UC), 2.2% were solitary rectal ulcer syndrome, 1.2% nonspecific colitis, 1.7% nonneoplastic polyps, 2.7% were normal, and 1.4% were inconclusive. Of the 4812 patients with complaints of bleeding PR, 4739 (98.5%) had a diagnosis after RS, of which hemorrhoids (72.7%) was the most common cause followed by proctitis (14.2%), neoplasm (9%), and others (4.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of RS in detecting neoplasia was 98.2%, 96.8%, 66.1%, and 99.9%, respectively, when HPR was gold standard. RS was found to be effective for assessing activity in IBD UC. Conclusion: RS is a simple, cheap, and effective tool for diagnosing various rectosigmoid pathologies. RS can be used as an effective screening test for rectosigmoid pathologies, especially neoplasia and IBD UC.
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Histological evaluation of patients with chronic nonbloody large bowel diarrhea and normal colonoscopy p. 49

Introduction: Chronic diarrhea is defined as the passage of soft or watery stool more than three times per day with or without blood and/or mucous or the passage of stool of more than 200 g per day and lasts for more than 4 weeks. Studies exploring the causes of chronic diarrhea in the developing countries are scarce and might not be generalizable from one setting to another. Aim: The aim of the study is to study the colonic and terminal ileal macroscopic and mucosal histopathological findings in chronic large bowel diarrhea patients. Methods: Eighty-six patients with chronic large bowel diarrhea were included after negative HIV status, stool analysis, and stool culture. A full-length colonoscopy with terminal ileoscopy was done. When the colon was within normal limits, randomly four biopsies each were taken from terminal ileum, ascending colon, transverse colon, and rectosigmoid region, respectively. Results: In a total of 86 patients, most of the patients (48%) were in the age group of 41–60 years. Females predominated in the present study in the ratio of 3:2. Ileal intubation was possible in all (100%) cases. Histology is normal in 35 patients. Fifty-one patients had histological changes of which 22 were diagnostic for specific disease which altered the treatment. Among 22 patients, 21 (95.4%) had histological changes in ascending colon and only 9 (40.9%) had changes in biopsy from rectosigmoid. In our study, definite diagnostic histology was obtained in 25.5% of cases. Conclusion: The yield of colonoscopy and biopsy in chronic large bowel diarrhea is moderate. Colonoscopy and biopsy have higher diagnostic yield than sigmoidoscopic biopsies.
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Dysphagia relieved by endoscopic transpapillary pancreatic duct stent placement! p. 53

Pancreatic fluid collections are usually peripancreatic in location but can be found at various atypical locations such as the mediastinum. Mediastinal pseudocysts are very rare and are very unusual cause of dysphagia. Here, we report a rare case of mediastinal pseudocyst occuring because of pancreatic duct disruption due to chronic pancreatitis and presenting as dysphagia and successfully treated with endoscopic transpapillary stent placement.
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Difficulties in diagnosing isolated IgG4-associated sclerosing cholangitis p. 56
Gábor Zsóri, Dóra Illés, László Tiszlavicz, László Czakó
The most common causes of recurrent cholangitis are biliary stones and neoplasia. Primary types of sclerosing cholangitis such as IgG4-associated sclerosing cholangitis (IgG4-SC) and primary sclerosing cholangitis (PSC) are rare causes of recurrent cholangitis. Differentiating diagnoses for IgG4-SC and PSC is essential because of the significant difference in treatment. We report a challenging case of recurrent cholangitis.
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The nowhere stone: Unusually located intrahepatic calculi in a patient with low phospholipid-associated cholelithiasis syndrome p. 60

Intrahepatic calculi or hepatolithiasis is an uncommon phenomenon which is found in relatively higher rates in eastern Asian countries. Patients usually present with features of cholangitis or intrahepatic abscess and are at risk for developing cholangiocarcinoma. Correct diagnosis and management often pose challenges. A 42-year-old female presented with a history of episodic upper abdominal pain since 8 years. Initial imaging studies showed evidence of biliary calculi, but were confounding in their localization. Magnetic resonance cholangiopancreatography showed two large calculi in the right biliary system proximal to the confluence, along with choledocholithiasis. Endoscopic retrograde cholangiopancreatography and common bile duct clearance were done; however, the patient underwent hepatic sectionectomy as a curative procedure. ABCB4 mutation was detected on DNA analysis and hence aided in making the diagnosis of low phospholipid-associated cholelithiasis. Additional imaging studies are warranted in doubtful cases. Difficult accessibility of the calculi may often limit endoscopic therapeutic options and pave the way for surgical interventions. As there is an increased risk of cholangiocarcinoma in these patients, regular follow-up is essential.
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Endoscopic biliary stenting for portal biliopathy perforating paracholedochal collateral: A rare complication p. 64

Extrahepatic portal venous obstruction (EHPVO) usually presents with upper gastrointestinal bleed in the first decade. Symptomatic portal hypertensive biliopathy is seen in minority of patients with EHPVO. With the use of endoscopic intervention, biliary drainage is maintained in these patients. Various procedural complications have been linked while performing endoscopic retrograde cholangiography and stenting; however, these are managed conservatively. Here, we are highlighting a case of EHPVO with symptomatic portal biliopathy who bled from paracholedochal collateral after biliary stenting and managed successfully with multidisciplinary approach.
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Interposed bowel loop during percutaneous endoscopic gastrostomy placement; Rare and nightmare p. 67

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Chilaiditi syndrome: An unusual cause of failed colonoscopy p. 68

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Lumen-apposing metal stent: Not the answer for every pancreatic fluid collection!! p. 70

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